From preventive screening to the quality of nursing care and the structure of national insurance systems, patients face multiple barriers to cancer prevention, treatment and care, said a high-level panel of experts at a side event on the margins of this week’s World Health Assembly (20-28 May).

The session, “Beyond the headlines: what will it take to address the growing cancer burden,” tread new ground in its effort by a pharma industry leader, the Roche Group, to address the charged issue of access to cancer therapies more holistically.

The company is one of the leading providers of cutting edge drugs for breast, colon and lung cancers, including new biologically-based cancer treatments that make use of the body’s  own antibodies and immune system to fight malignant growths.

However, the high cost of cancer drugs has come under intense scrutiny following the publication of a WHO report on Pricing of Cancer Medicines and Impacts, in late 2018, followed by a debate among WHO member states at the last session of the WHO Executive Board in late January.

This week’s panel took a “systems approach” to exploring solutions, which looked at perspectives from patients and health care professionals, as well as the global perspective of WHO. The session highlighted the fact that multiple barriers to access exist throughout the system – which drive up costs and limit patient access to treatment.

Patients’ Perspectives – Advance Screening and Prevention

For instance, in Brazil, which has a universal health care system, preventive services such as cancer screening that could help avert higher costs for treatment are not available, said Maira Caleffi, a breast cancer surgeon as well as founder and president of Brazilian Breast Health institutions (Femama), an umbrella organization for over 70 NGOs advocating for better access to cancer treatment.

“We have a universal health care model, but cancer is not there yet. We have some cervical cancer vaccinations but we don’t have formal screening programmes,” noted Caleffi who said that her organization is fighting for Brazil to adopt basic measures, such as a compulsory cancer registry as well as 75 percent coverage of breast cancer screening by mammograms for at-risk groups [such as women over the age of 50 and with a family history of breast cancer].

While laws have been passed to provide such measures, they have not been funded, said Caleffi. “We need to find another way to invest and fund cancer control – we need to make that as a primary care issue,” she stressed.

“Our minister only says ‘we are dealing with dengue; we are dealing with Zika; we are dealing with the primary priorities,” while cancer, she said, is still regarded as an “elite” issue – “and it is not anymore, we know that 60 percent of the cancers are going to happen in developing countries, in the very low- and middle-income populations.”

She noted that patients’ groups are fighting to advance screening so as to “make diagnosis as early as possible. We are spending a lot of the money, the few resources that we have, on advanced diseases; this is not going to save more lives. People are dying prematurely at ages 30, 40, 50-years-old. I see patients every day losing time and the opportunity to have their cancer treated and cured.”

She expressed the hope that industry forces could play a role in advocating with government and patients for more advanced screening and diagnosis, in a partnership model that focuses on win-win solutions.

“We need to open the dialogue. We have solutions, we [need to] hear the voice of the patients.”

Healthcare Providers – More Oncology Nurses Needed

Another neglected issue is the availability and quality of oncology nursing care, which is a critical link in the treatment chain, says Patsy Yates, President of the International Society of Nurses in Cancer Care and professor of nursing at Queensland University of Technology, Australia.

She noted that in countries such as Australia, there are 130 oncology nurses to every 100,000 population whereas in some low-income countries there may be no more than 3 nurses per 100,000 population.

“Nurses are really critical in terms of encouraging people to participate in treatment [early on], and giving access to screening,” noted Yates. Nurses can also mediate between patients and doctors on issues such as treatment for pain relief, improving overall quality of life, she noted, pointing to a multi-country survey that had found Australian cancer survivors had a higher quality of life than patients in other low- and middle-income countries in the region, while patients in less affluent countries also had much higher levels of chronic pain. “That’s not acceptable,” said Yates. “You cannot deliver quality cancer care if you don’t have an adequately prepared workforce. This does not necessarily add costs and it is a means for good outcomes.”

Global and Country Perspectives on Cancer Care in UHC

Noncommunicable diseases (NCDs) are now the world’s leading killers in developed as well as developing countries, with some 15 million deaths annually, noted Svetlana Axelrod, WHO’s Director of the UN Interagency Task Force and Global Coordination Mechanism on NCD Prevention and Control.

“For a long period of time we focused on communicable diseases, and we have achieved a lot,” she said. “Now we have to focus on NCDs and mental health, taking lessons learned from infectious disease control. NCDs are the biggest killers and that means cardiovascular disease, stroke, cancer, diabetes and chronic obstructive pulmonary disease (COPD).”

Axelrod said that such a commitment emerged out of the high-level political declaration on NCDs to reduce NCD mortality by one-third by 2030, which was adopted at the UN General Assembly in September of 2018, and that WHO is now engaged in advancing that goal in regions and countries.

Still, challenges are huge in light of the fact that countries are struggling just to cover the costs of primary health care services, as said half of the world’s population still lacks access to many basic health care services, said Dennis Laryea, manager of NCD control at the Ministry of Health of Ghana.

“The issues are quite different for NCDs as compared to infectious diseases,” he observed. “Malaria can be treated by the most basic of health care professionals, while you need a certain level of skills to manage things like cancers.”

Those include not only human resources but infrastructure, he stressed. Pathologists need access to diagnostic tools, chemotherapy, and surgery centres. Pharmacists are required to prepare and manage drug treatments.

“All of these are highly skilled resources,” he noted, adding that while Ghana has a reasonably good nurse-to-population ratio, oncology nurses are rare. The net result is that so far, oncology services are only available privately, in just a couple of clinics located in major cities.

Covering the Costs – Public and Private Models

Despite Ghana’s commitment to universal health care, Laryea expressed doubts as to whether Ghana could cover the costs of cancer care through public health services or public insurance models at any time in the near future. Other models of private insurance for such treatments might have to be explored, he suggested.

“In Accra there is a private oncology service for people who can afford it… We can encourage this for people who can afford it, but not use public resources.”

Robert Yates, an expert on universal health coverage (UHC) and health care finance at the London-based Chatham House, challenged that, saying that countries can set their sights higher if they enact appropriate tax measures to finance a wider range of health services.

“Ten years ago there was no talk of UHC,” he noted. “You now struggle to come to a side event [at the World Health Assembly] where people are not talking about it.”

“True universal health coverage is around shifting to a subsidized programme where the wealthier pays for services for the poor. You are seeing country after country shifting to this social health care system.

“If you look at health systems where there is a big role for private insurance companies, they have done a very poor job of keeping costs down… you get much better societal decisions when government controls those decisions.”

As long as the political will exists, investment in public health systems and insurance can be subsidized from reducing public subsidies on harmful and polluting products such diesel fuel, he added, noting that both Indonesia and Ghana have moved towards such a model, which makes subsidy reduction more politically palatable.

“Indonesia and Ghana have realized that it is much better to have UHC rather than cheap fuel,” Yates said. “Politicians are realizing that UHC can be a quick win.”

At the same time, there is no one-size-fits-all model of health system finance, said Michael Oberreiter, head of Global Access at Roche, noting that Switzerland has a hybrid public-private model of health system finance which is very different than that of France or the UK.  However, both systems offer nearly “universal” access to care. “It is critical to look in-depth at the root causes behind the lack of access to care and understand how best to support healthcare systems,” he remarked. “Often, affordability is critical; but so is capacity – not just with regards to infrastructure, but also in terms of the shortage of skills for budget planning and other processes such as patient referral. And most fundamentally, all too often healthcare is seen as just a cost, not an investment.”

Building Partnerships

What is needed is a broader partnership of government, civil society and the private sector to find solutions across the wide range of issues that provide real barriers to access, Oberreiter concluded.

“When the cost of the drug is a key barrier for a patient to get treated, then we need to do something about it, and we are doing something about it,” he said, citing “tiered pricing,” which systematically discounts drugs according to the income-level of countries, as an example.

“But people do not come close to seeing a doctor, when there is a lack of awareness or education,” so we need to develop other approaches as well. “Our drugs are completely worthless if we don’t engage the patients.”

Ultimately, said Oberreiter, healthcare companies need to work in partnership, build trust, and find solutions that are good for patients and business.

“If the solution is only good for patients, it is not going to be sustainable; if it is only good for business, then society will come and punish us. Considering the interests of patient and businesses together is a guarantee of sustainable investment,” he said adding that building trust is another essential ingredient for effective partnerships. “Leaving your ego and special interests behind, putting the patient in the centre. More trust, less ego is probably a good way forward.”

Image Credits: UnternehmerTUM/@birdyfoto.de.