Cancer care for the developing world

More than four decades ago, US President Richard Nixon, inspired by early and encouraging results that showed that chemotherapy could cure diseases such as acute lymphoblastic leukemia and Hodgkin’s lymphoma, declared “war on cancer.” Since then, steady progress has been made using chemotherapy, surgery, and radiation to treat and cure an increasing number of cancer patients. But access to these life-saving advances remains elusive in low- and middle-income countries, where the majority of cancer patients reside today.

In the United States, more than 80 percent of patients with breast cancer are long-term survivors, and more than 80 percent of cancer-stricken children survive. In my nearly 40 years as an oncologist at Harvard University, I have cared for thousands of patients who would have had little chance of survival were it not for chemotherapy. Many of the patients who received treatment in the 1970s are alive and well today; their children are now productive adults.

But it was not until I began working in Rwanda in 2011 that I fully grasped the power of the tools at my disposal, by witnessing the impact of their absence. Stepping into the pediatric cancer ward at the central public referral hospital in Kigali was like traveling back in time. Outcomes among Rwandan children with Wilms’ tumor, a form of kidney cancer that rarely afflicts adults, mirrored those in the US 80 years ago, before the availability of drugs that today enable more than 90 percent of diagnosed American children to survive.

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According to Rwanda’s health minister, Agnes Binagwaho, the cancer ward in Kigali resembled the HIV/AIDS unit when she was a pediatrician at the hospital, a decade earlier. With no antiretroviral therapy, the prescription for HIV/AIDS was food and rest – meaning that infection essentially amounted to a death sentence.

At the time, some were caught, if only briefly, on the wrong side of history. In 2001, a senior US official claimed that it would be impossible to treat HIV/AIDS in Africa, owing to its “complexity” and high cost.

But he – along with the many others who shared his view – was proved wrong. Today, rates of treatment adherence in Africa among HIV-positive patients with access to drugs have long exceeded those in the US. Indeed, Rwanda was one of the first countries to achieve universal access to AIDS treatment.

Despite this experience, the prospect of effective cancer treatment in Africa has been met with similar skepticism. True, cancer therapy is complex. It requires a broad range of diagnostic and therapeutic capacities – pathology, surgery, radiation, chemotherapy, and targeted medicines – together with the knowledge and skill to safely administer these life-saving treatments.

But the Butaro Cancer Center of Excellence and others like it have proved that it is possible to treat cancer patients safely and effectively, even in poor, rural settings. Thanks to the Rwandan Ministry of Health, Partners In Health, and the Boston-based Dana-Farber Cancer Institute, the Butaro Center has treated more than 3,000 cancer patients, most of whom are referred from outside the region, since its dedication in July 2012 by former President Bill Clinton and Binagwaho. Support from the Jeff Gordon Children’s Foundation, the Breast Cancer Research Foundation, LIVESTRONG, and private donors has also been critical to this achievement.

Fortunately, some major institutions are already stepping up to bolster this effort. The World Health Organization, together with the International Union for Cancer Control, is re-examining the WHO Model List of Essential Medicines for Cancer to identify more accurately which cancers are most responsive to treatment, and which place the heaviest burdens on populations.

The most efficient approach to reducing global cancer mortality rates would be to bring existing therapies to cancer patients in developing countries. Add to that international funding for cancer treatment, like that which was mobilized for HIV/AIDS through the US President’s Emergency Plan for AIDS Relief and The Global Fund, and cancer mortality rates in developing countries could decline considerably – and quickly.

More than a decade ago, the international community decided that it would no longer accept certain death for HIV patients. We must make the same commitment today to bring life-saving cancer treatment to patients everywhere.

Lawrence N. Shulman