As we commemorate World Cancer Day on 4 February, we are once again reminded of the stark realities and difficult journeys that cancer patients, their families, friends and loved ones navigate and traverse in order to find the hope that we so often talk of when faced with a cancer diagnosis.

In this first year of a new three-year rolling campaign themed “Close the Care Gap” by the Union for International Cancer Control (UICC), built to inspire change and mobilise action, we reflect, acknowledge and recognise that the continued battle against cancer is not a singular effort, and a unified response is mandatory to ensure a path to victory. We need to continue strengthening our partnerships and consolidating efforts with the continued understanding that every single individual can inspire change and make a difference in reducing the global impact of cancer.

Cancer: A global public health burden

Cancer continues to impact as a major public health problem globally and remains a formidable adversary. One in five men and one in six women worldwide develop cancer during their lifetime, and one in eight men and one in 11 women die from the disease. Unless greater efforts are placed into altering the course of the disease, this number is expected to rise to close to 30 million new cases by 2040.

With South Africa’s growing population of approximately 60 million and an ageing population, the caseload is expected to double by 2040 as well. Cancer remains the fifth main cause of mortality in South Africa and the latest data from the National Cancer Registry reveals that in 2019, just over 85,000 cases were diagnosed. Cancers of the breast, cervix and prostate continue to dominate with a similar profile extending into Africa.

It is important to note that about 30% of cancer deaths are due to the five leading behavioural and dietary risks, ie high body mass index, low fruit and vegetable intake, lack of physical activity, tobacco use and alcohol use. Many cancers can be prevented by avoiding exposure to these common risk factors.

In addition, a significant proportion of cancers can be cured, by surgery, radiotherapy or chemotherapy, especially if they are detected early. There is an urgent need to increase early-stage cancer detection, screening, and diagnosis to significantly improve cancer patients’ chances of survival and quality of life.

Universally, the majority of cancers are amenable to early detection. When a cancer is detected at an early stage — and when coupled with appropriate treatment — the chance of survival beyond five years is dramatically higher than when detected at a later stage when the tumour has spread, and the disease is more advanced.

Furthermore, early diagnosis can also reduce the cost of treatment. Despite this, millions of cancer cases are found late, leading to expensive and complex treatment options, diminished quality of life, and avoidable deaths.

Despite our advances, disparities and inequalities remain

We must acknowledge that survival rates have substantially improved over the last decades for most cancer sites. Nonetheless, not all patients benefit from these advances. Barriers exist at the individual, health system, and government level, which prevent millions of people globally from receiving an early diagnosis and better treatment.

There are huge disparities in health resources (infrastructure, human resources, access to treatment, good governance, etc) that make populations in Africa, including South Africa, extremely vulnerable to developing and treating cancer. Health system-related barriers such as increased awareness among healthcare workers to detect cancer early, especially at the primary care level, and lack of an efficient and timely referral for testing and diagnosis leads to needless delays in treatment.

Therefore, continued efforts in strengthening the capacity of the health sector, improving access to treatments and supportive services remain core to curbing the rising epidemic of cancer.

Geographical, economic, and societal barriers also lead to huge inequities as populations navigate the cancer care continuum of cancer prevention, detection/diagnosis, and management/treatment. More than 70% of the world’s total new annual cases occur in Africa, Asia, and Central and South America. These regions account for more than 60% of the world’s cancer deaths.

In low and middle-income countries, treatment for cancer is not widely available. Health systems are often not equipped to deal with detection and treatment of cancers. Prevention and early detection programmes are often weak or non-existent. This situation is exacerbated in some cases by the high cost of treatment and, in particular, the high cost of newer cancer medication. The unsustainability of cancer medication pricing has increasingly become a global issue creating access challenges in low-and middle-income countries.

While death rates from cancer in wealthy countries are slightly declining because of early diagnosis and the availability of treatment, this is not the case in low- and middle-income countries. For example, over 80% of children diagnosed with cancer in high-income countries will be cured of the disease, in contrast to rates as low as 10% among children diagnosed with cancer in low- and middle-income countries, which, despite having almost 80% of the burden, have less than 5% share of global resources for combating cancer.

According to the Global Task Force on Expanded Access to Cancer Care and Control, only 5% of global resources for cancer are spent in the developing world, yet these countries account for almost 80% of disability-adjusted years of life lost to cancer globally. In developing countries, governments and individuals struggle to pay for products that are priced at several times the level of their per capita GDP. Particularly in a situation where the product has no competitors, buyers are at the mercy of a single provider, often the patent holder of the product.

In 2018, the World Health Organization (WHO) released its technical report on pricing of cancer medicines and its impacts. It was found that pricing of cancer drugs is disproportionately higher than other types of pharmaceuticals and therapies. In 2017, estimated global expenditure on medicines for cancer and related supportive care amounted to $133-billion. Despite these huge costs, a systematic evaluation of 68 cancer medicines approved by the European Medicines Agency (EMA) in 2009–2013 showed that only 35% had established evidence of prolonged survival at the time of approval. Similarly, only 10% of the 68 medicines had evidence of improvement in the quality of life at the time of approval.

In addition to the high costs, some medicines may present higher risk of toxicities to patients, with evidence of high rates of deaths related to treatment (toxic deaths) and high chances of patients discontinuing treatment due to intolerance.

By way of example, an editorial published in the South African Medical Journal reported that the provision of new-generation immunotherapy drugs such as ipilimumab costs around R1-million, and trastuzumab (breast cancer drug) costs R25,000 per treatment while a mastectomy plus trastuzumab costs approximately R500,000. These exorbitant costs threaten the provision of robust cancer programmes and medical aid limits are increasingly unable to cover older-generation therapies, let alone more targeted interventions.

It has been consistently observed that socioeconomically disadvantaged populations have higher cancer rates and worse survival outcomes, and this socioeconomic gap has widened over time. Yet, socioeconomic status, a function of income, education and occupation, does not itself cause cancer or poor outcomes. Rather, it is a marker for the underlying physical and social factors that cause the disease, its recurrence and its eventual outcome. Lower socioeconomic status can lead to access problems along the entire spectrum of care, starting from early detection issues to delays in diagnosis after the appearance of initial symptoms.

Apart from logistical barriers to access, people of lower socioeconomic status are more likely to remain uninformed about early detection programmes and disease management, including the early signs, symptoms and availability of cancer treatment. Value-based care is important for any country. It should not be limited to drug-price controls but should encompass affordable pathways and universal health coverage. Value-based care is a core solution. Many countries now recognise the importance of looking beyond technologies in delivering equality in care and outcomes.

We often hear that efforts to expand cancer care are not affordable and will divert resources from higher priorities, as was the case during the Covid-19 epidemic. A similar view was once held with respect to the HIV/Aids epidemic, which prohibited progress. Yet we have seen remarkable success expanding access to HIV and Aids services. Many lessons can be learnt from which we can draw inspiration and we can do the same for cancer. Closing the care gap would be a broad investment in the health, as well as the economic and social wellbeing of our citizens.

In our efforts to minimise the cancer burden, the African Cancer Institute at the Faculty of Medicine and Health Sciences, Stellenbosch University, has become a key player in the global fight against cancer through its commitment to research excellence, committed and inspired faculty and robust partnerships with world-renowned research and training institutions as well as advocacy and support groups. These partnerships have ensured that the best minds work cohesively in bringing hope to cancer patients and their families worldwide. DM

Professor Vikash Sewram is the Director of the African Cancer Institute in the Faculty of Medicine and Health Sciences at Stellenbosch University.

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