The Cancer Treatment Gap in Lower- to Middle-Income Countries

Cancer is the second leading cause of mortality globally, eclipsing the combined mortality figures for major communicable diseases (HIV, tuberculosis, and malaria). In 2018, approximately one-fifth of cancer cases and mortalities occurred in low- to middle-income countries (LMICs) [1]. Compared to high-income countries (HICs), LMICs had significantly higher total cancer-related mortality rates, which continue to rise as the rates in HICs remain stable or decrease [2]. Furthermore, the lack of high-quality cancer registries, particularly in LMICs, impacts the accuracy of these figures, suggesting that the current figures are an underestimation and that the actual data is far worse. For example, over half of cancer cases and mortalities were in Asia, yet only 6.5% of this population is covered by registries [1]. The COVID-19 pandemic has also caused further disruption to registries in LMICs [4].

Differences in cancer-related mortality rates are in part due to the significant differences in cancer care between HICs and LMICs. For example, the 5-year survival rate for lung cancer in Japan has been reported to be approximately 33%; however, this figure is just 4% for India. Similarly, the 5-year survival rate for breast cancer stands at about 90% in the USA. In contrast, in South Africa, this rate is 40%. Such inequality in outcomes can also be present within countries [1]. For example, in the USA, survival for many cancers, irrespective of the stage of diagnosis, is less favorable for black men and women, communities with lower education and income, and rural populations [5].

Disparities in care are due to several factors – in LMICs, governmental cancer care can be hampered by an unstable political environment, inadequately trained healthcare personnel, and constrained access to cancer medicines [1]. In addition, the circumstances of the patients presenting to cancer facilities can also contribute to the observed disparities. For example, a recent study in India found that oncology patients presented at a younger median age, had lower levels of education, were more likely to be financially distressed, and had to travel greater distances to seek specialized treatment [6]. Cost of care is one of the main barriers to patient treatment. In addition to the toxicity experienced during therapy, the financial costs of diagnosis, treatment, and care to the patient can be viewed as financial toxicity. A systematic review and meta-analysis by Donkor et al. [3] (2022) found that patients in LMICs experience high levels of financial toxicity. Such financial and logistical considerations are often not factored into guidelines, particularly those developed in countries with a high human development index [6].

In addressing the cancer care gap in LMICs, it is essential to recognize that most of what we currently know about cancer treatment has been based on findings obtained in HICs. As such, many of the guidelines in place may not have direct application to LMICs, given the differences in the challenges faced. For such interventions to be successful, they must incorporate the realities clinicians face in resource-constrained settings. Therefore, input from clinicians working in such locations can be invaluable when designing and implementing guidelines [7].

The World Health Organization (WHO) has identified four areas crucial for cancer control programs – risk factor modification and prevention, early diagnosis, treatment, and palliation [2]. Various strategies around these areas are being implemented to address the cancer care gap to improve access in resource-poor settings. With regards to treatment, decreasing the costs of cancer medicines by introducing biosimilars and generics can improve cost-effectiveness and overall patient access. In countries such as Bangladesh, China, and India, progress is being made, and biosimilars and generics are widely used due to their low cost, allowing for greater patient accessibility [8]. Furthermore, optimizing schedules for cancer therapy should be ongoing. If supported by data, treatment can be reduced by adopting stop-and-go strategies or using lower, less frequent doses for shorter durations. Such measures would also have the effect of increasing affordability and expanding access to treatments. Optimization can also include utilizing more convenient cancer treatment formulations, especially in LMICs, where patients often travel great distances for treatment with an intravenous infusion at specialized clinics. The availability of subcutaneous alternatives, such as subcutaneous trastuzumab, can enable local health professionals to administer these drugs, thereby making these treatments more generally available [9].

The WHO Model Lists of Essential Medicines 2013 include 25 essential cancer medications; however, cost remains a major hurdle to incorporating these treatments into national formularies [10]. In 135 countries with a per-capita gross national income of less than USD 25,000 in 2015, only 10% had all essential cancer medications, and just 37% incorporated at least twenty. The median medication count for lower-income countries (n = 28) was 9, and for lower- to middle-income countries (n = 44), this figure was 18. Only 19% of countries have incorporated trastuzumab as per the WHO Model Lists of Essential Medicines 2015. In addition, while such medications might be available in national formularies, the expense is still often for the patient, disproportionately affecting low-income countries [1]. In low-income countries, the cost of 58% of essential cancer medications is borne by the patient. This falls to 32% for low-middle-income countries and just 1.8% for upper-middle-income countries. High prices are a significant reason for hindering patient access to cancer medications. In addition, differences in prices may exist between regions; for example, the prices of essential medicines have been shown to be higher in Africa than in South America, despite comparable gross national incomes. While ensuring access to essential cancer medications is a priority, additional aspects of cancer care are crucial to bridging the cancer care gap. These include improving the quality of care by enhancing multidisciplinary management and ensuring universal access to basic therapies. For example, a recent publication by Thiagarajan et al. [11] (2023) highlights virtual tumor boards as an innovative approach to enhancing the multidisciplinary management of rare cancers and complex cases in LMICs. Furthermore, increasing access to palliative measures such as antiemetics, granulocyte colony-stimulating factor, and recombinant human erythropoietin would also be essential to closing cancer care disparities. In combination with telemedicine, these strategies could expand access to cancer care in LMICs [9].

Despite the advances being made in closing the cancer care divide, access and affordability to cancer medicines remain problems to be overcome. Moreover, given the increased burden of cancer in LMICs, this gap will only increase unless significant interventions are taken. To facilitate such interventions, incorporating the real-world experiences of LMIC oncologists when devising strategies could be crucial to closing this gap.