Global Cancer Surgery

Written by: Lou Herbert

Barts and the London School of Medicine and Dentistry

Introduction

Cancer is a major cause of morbidity and mortality globally, having become a leading cause of death in both high-income and low-income countries. Low- and middle-income countries (LMICs) face a particular challenge as the rise of non-communicable diseases such as cancer co-exist with prevalent communicable diseases, resulting in a double burden of disease (1).



Each year, around 5 million people die of cancer in LMICs, causing 10% of the 50 million deaths that occur in those countries (2). 80% of cancer cases will require surgery, as surgery plays a role in diagnosis, prevention, therapy, and palliative care of cancer management (3). However, less than 25% of cancer cases worldwide actually have access to safe and affordable surgery, with large disparities existing in LMICs in comparison to high-income countries (HICs) (3). Although HICs have higher incidence rates of cancer, mortality rates as a result of cancer are significantly higher in LMICs (4). In 2012, 65% of global cancer deaths occurred in LMICs (4).


The discourse surrounding health development in LMICs tends to prioritise issues such as infectious diseases, but has neglected noncommunicable disease treatment, including the development of surgical and anaesthetic care in these regions (5,6). There has been a call by global health practitioners for global health donors and governments to prioritise cancer treatment and to build surgical capacity in LMICs, as the burden of disease is large and continuously increasing (1). In January 2014, the Lancet established the Global Surgery Commission in order to address this gap, and formulated recommendations to improve the access to safe and affordable surgical and anaesthetic care by 2030 (5).


The cost of surgical cancer care

Cancer causes a huge economic burden. In 2008, cancer made up 1.5% of the world’s gross domestic product (GDP), around $895 billion (7). This did not include healthcare costs or the impact of disability and years of lost life as a result of cancer (7). Surgical cancers cause an estimated 2.7 million years of life lost to disability worldwide (3). As mortality as a result of cancer is higher in LMICs, especially in people aged younger than 65 years, the impact of premature mortality and lost years of productivity is large in these countries (4). As a public health issue, cancer directly threatens economic development (7).


Investing in surgery for cancer can promote the economic growth of individual countries. It is a misconception that investing in surgical and anaesthetic care is expensive, as it is now recognised that surgical treatments are some of the most cost-effective public health interventions (8). The World Health Organisation (WHO) has established a Surgical Care at the District Hospital (SCDH) manual which outlines surgical and anaesthetic interventions that are essential to provide emergency and essential surgery that can be performed in resource-poor settings (8).


On a microlevel, accessing surgery for cancer can lead to out-of-pocket payments and catastrophic health expenditure. Patients in LMICs are at greatest risk of having to make out-of-pocket payments for medical treatment (3). Worldwide, 25% of patients undergoing surgery will face catastrophic health expenditure, both from the direct costs of treatment and the indirect costs associated with accessing treatment and the loss of productivity secondary to illness (3). The risk of impoverishment as a result of cancer is highest for those who are uninsured and of a lower socioeconomic status (3).


National health insurance programs could reduce these levels of catastrophic expenditure for cancer treatment, as seen in Thailand and Malaysia where universal health coverage has helped reduce this burden (3,8). In addition, global health donors who provide funding for health programs in LMICs can help reduce the economic burden of accessing cancer care by funding noncommunicable disease programs in order to improve the quality and affordability of cancer care (8).


Integrated health systems

Improving cancer care relies on healthcare system strengthening to establish the capacity to be able to offer these services (1). Greater investment in primary and secondary healthcare services in LMICs can play a role in reducing the burden of cancer, through improved preventative cancer services such as cervical smear campaigns (1). One framework that has been suggested is the construction of Comprehensive Care Centres in LMICs, which are healthcare centres specifically dedicated to the treatment and prevention of cancer (9). These centres overlook the management of cancer nationally, acting as focal points for education and outreach of cancer services (9).


An example of a successful Comprehensive Care Centre is the King Hussein Cancer Foundation and Centre in Amman, Jordan, which is a nongovernmental, non-profit organisation that was established in 1997, that treats all forms of paediatric and adult cancers from the Middle East and North Africa (9). It has been successful in providing tertiary oncology care, establishing training posts, research programs and shaping public health policies in Jordan (9).


Comprehensive Care Centres are a framework that enable cancer treatment, including surgery, to be accessible and through funding, become affordable. The Global Surgery Commission recommends frameworks such as this as it utilises an integrated health systems approach, whereby different stakeholders, including governments and organisations, work together rather than separately in order to overcome challenges in providing surgical care and to improve overall health outcomes (3).


Conclusion

Cancer has become a global pandemic affecting both HICs and LMICs. Surgical treatment is often necessary to provide preventative, therapeutic and palliative management in the field of oncology. The global health agenda continues to focus on the treatment of communicable diseases, despite a rise in noncommunicable diseases in these regions. As a result, the establishment of adequate surgical and anaesthetic care services has fallen behind in some countries, leading to reduced access to safe and affordable surgical care for local populations. Investment in surgical care is cost-effective and can massively reduce morbidity and mortality from cancer. Through the implementation of frameworks that focus on integrated healthcare system strengthening, the access to safe and affordable cancer surgery can be established in all LMICs by 2030.


References

1. Farmer P, Frenk J, Knaul FM, Shulman LN, Alleyne G, Armstrong L, et al. Expansion of cancer care and control in countries of low and middle income: A call to action. The Lancet. 2010.

2. Countries I of M (US) C on CC in LM-I, Sloan FA, Gelband H. The Cancer Burden in Low- and Middle-Income Countries and How It Is Measured. 2007 [cited 2021 Jan 30]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK54028/

3. Sullivan R, Alatise OI, Anderson BO, Audisio R, Autier P, Aggarwal A, et al. Global cancer surgery: Delivering safe, affordable, and timely cancer surgery [Internet]. Vol. 16, The Lancet Oncology. Lancet Publishing Group; 2015 [cited 2021 Jan 23]. p. 1193–224. Available from: http://www.thelancet.com/article/S1470204515002235/fulltext

4. Shah SC, Kayamba V, Peek RM, Heimburger D. Cancer control in low- And middle-income countries: Is it time to consider screening? J Glob Oncol [Internet]. 2019 [cited 2021 Jan 30];2019(5). Available from: /pmc/articles/PMC6452918/?report=abstract

5. Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Vol. 386, The Lancet. Lancet Publishing Group; 2015. p. 569–624.

6. Ozgediz D, Jamison D, Cherian M, McQueen K. The burden of surgical conditions and access to surgical care in low- and middle-income countries. Bull World Health Organ. 2008;86:646–7

7. Sullivan R, Purushotham AD. Avoiding the zero sum game in global cancer policy: Beyond 2011 un high level summit. Eur J Cancer. 2011 Nov 1;47(16):2375–80.

8. Hedges JP, Mock CN, Cherian MN. The political economy of emergency and essential surgery in global health. World J Surg [Internet]. 2010 May 8 [cited 2021 Jan 23];34(9):2003–6. Available from: http://www.who.int/surgery/

9. Gospodarowicz M, Trypuc J, D‘Cruz A, Khader J, Omar S, Knaul F. Cancer Services and the Comprehensive Cancer Center. In: Disease Control Priorities, Third Edition (Volume 3): Cancer. 2015.

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