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Winter/Spring 2007 Vol. 7 No. 1



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An Overlooked Killer

Lung cancer patient in Shanghai, People's Republic of China, ©Justin Guariglia/Corbis

Controlling Cancer in Low- and Middle-Income Countries

Nutritional deficiencies and infectious scourges rightfully demand significant shares of the attention and resources available in low- and middle-income nations where they claim so many lives. But cancer exacts a ruthless toll on these nations as well -- countries ranging from the poorest in Africa and Southeast Asia, to nations such as Brazil and India that have growing middle and upper classes. Four million deaths from cancer -- 1 million more than deaths from HIV/AIDS -- occur annually in this group of countries.

Even as these nations struggle with basic public health problems, they and the larger global community should be directing resources to developing effective cancer control programs. But cancer is generally low on or absent from the health agenda in these nations, says a new report from the Institute of Medicine. The report calls for national governments, health professionals, and the global health community to begin taking steps to develop such programs in low- and middle-income countries.

"We do not suggest a single prescription that would work in all these diverse countries, nor do we envision comprehensive cancer control being possible without significant improvements in the health care systems in these nations," said Frank A. Sloan, chair of the committee that wrote the report. "But there are global priorities and approaches to cancer control and planning that are feasible at low resource levels, and they should be applied starting now."

Oral cancer patient in Mumbai, India, photo by P. Virot, World Health Organization Prevention often is the most effective approach to cancer control. The biggest cause of cancer in low- and middle-income countries -- tobacco -- is also one of the most avoidable. Evidence is available to help curb rising smoking rates. Target countries also need financial and technical support to provide vaccinations against viruses linked to cancer, which could reduce liver and cervical cancer deaths.

Cancer care in low- and middle-income countries must be guided to a large extent by the level and type of resources available for prevention, diagnosis, and treatment. For example, early-stage breast cancer can be treated by lumpectomy and radiation therapy alone. However, radiation treatment may not be available in some nations because of cost or lack of equipment. But mastectomy and chemotherapy can still save lives in these places.

Attention should be turned toward palliative care, a crucial element of cancer treatment when patients are diagnosed late, the report urges. It suggests ways that low- and middle-income nations could ease unnecessarily strict limits on strong opioid painkillers such as morphine to make these drugs more readily available to cancer patients, who frequently suffer great pain, especially as they approach death.

Cancer control will not advance in these nations, however, without international support from the health and development communities, the report adds, and more than financial assistance is needed. Public- and private-sector organizations in the United States and other countries should provide information and technical assistance to the target nations. The report urges each low- or middle-income country to develop at least one cancer "center of excellence" that will serve as the nation's focal point of efforts to control cancer and as the international point of contact.

Established medical institutions in industrialized nations should partner with new and developing cancer centers to exchange information, provide training, and engage in other activities to help them improve, the report says. The international oncology community also should help develop programs to promote awareness of cancer and support for control efforts in the target countries. The report cautions high-income countries to resist exporting the latest, most expensive technologies that may be appropriate for wealthy countries, but for which alternatives exist that might be more feasible and cost-effective for low- and middle-income nations.   -- Christine Stencel


Cancer Control Opportunities in Low- and Middle-Income Countries. Committee on Cancer Control in Low- and Middle-Income Countries, Board on Global Health, Institute of Medicine (2007, 340 pp.; ISBN 0-309-10384-3; available from the National Academies Press, tel. 1-800-624-6242; $49.00 plus $4.50 shipping for single copies).

The committee was chaired by Frank A. Sloan, J. Alexander McMahon Professor of Health Policy and Management, and professor of economics, Center for Health Policy, Law, and Management, Duke University, Durham, N.C. The study was funded by the National Cancer Institute and the American Cancer Society.



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Copyright 2007 by the National Academy of Sciences