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WHAT IF…
…everyone had equal access to cancer care?
Let’s imagine a hypothetical future in which socioeconomic barriers to cancer care no longer exist, health
systems have prioritised the full financial consequences
of cancer, and previously underserved populations
have managed to access information about early-stage
cancer symptoms. Armed with sufficient information
on symptoms, care and corresponding support, these
lower-income and vulnerable groups are now among
the first to report their symptoms to healthcare professionals. Moreover, working with patient navigators and
other health advisors, they follow their treatment regimens consistently and improve their health outcomes as
a result.
Before looking at how these barriers to equal access were overcome, we need to define what we
mean by access to care. The World Health Organisation (WHO) defines three key components of
access as follows:1
 Physical accessibility: good health services are within reasonable distance and are
organised efficiently to allow people to receive care;
 Financial affordability: people can pay for services without experiencing financial hardship;
and
 Acceptability: people are willing to seek services and are not discouraged from seeking
services, based on perceived effectiveness of services and social and cultural factors.
World Health Organization
(2013), “Universal health coverage and universal access”,
Bulletin of the World Health
Organization 013;91:546–
546A. Available at: http://
www.who.int/bulletin/volumes/91/8/13-125450.pdf
1
NN Massarweh, Y Chiang
et al, “Association Between
Travel Distance and Metastatic Disease at Diagnosis
Among Patients With Colon
Cancer”, Journal of Clinical
Oncology, March 20, 2014
Vol. 32 No. 9 942-948.
2
Understood in this way, access is not just about whether care is available. It is about whether
people are practically able to, and willing to, access it. For example, a person who has cancer
may need chemotherapy multiple times a week; consequently, there are transport costs and lost
income from time taken off work to consider—on top of treatment costs. These practical issues
can be a barrier in both high- and low-income countries. For example, a study published in 2014
in the Journal of Clinical Oncology showed that people who lived further away from healthcare
facilities were more likely to present for diagnosis at a much later stage of cancer.2
© The Economist Intelligence Unit Limited 2017
Commissioned by
1
WHAT IF…
…everyone had equal access to cancer care?
Socioeconomic status used to determine who could access care and who could not. Although
low- and middle-income countries were home to 85% of the world’s population and more than
half of the world’s new cancer cases,3 they had access to only 35% of the world’s radiotherapy
A Moten, D Schafer and M
Ferrari, “Redefining global
health priorities: Improving
cancer care in developing
settings”, Journal of Global
Health, 2014 Jun; 4(1).
3
M Samiei, “Challenges of
making radiotherapy accessible in developing countries”.
Published in: The International
Network for Cancer Treatment and Research (INCTR),
Cancer Control 2013: Cancer
care in emerging health systems, 2013, p. 86. Available
at: http://globalhealthdynamics.co.uk/cc2013/wpcontent/uploads/2013/04/8396-Samiei-varian-tpage-incldT-page_2012.pdf
4
R Luengo-Fernandez, J Leal
et al, “Economic burden of
cancer across the European
Union: a population-based
cost analysis”, The Lancet
Oncology, Vol. 14, No. 12,
pp. 1165–1174, November
2013.
5
See for example KR Yabroff
and Y Kim, “Time costs associated with informal caregiving
for cancer survivors”, Cancer,
2009;115(18 Suppl):4362-4373.
6
Office of Health Economics
and the Swedish Institute for
Health Economics, Improving
Efficiency and Resource
Allocation in Future Cancer
Care, Executive Report,
September 2016, p. 13. Available at: https://www.ohe.
org/sites/default/files/849%20
OHE-IHE%20executive%20
report%20final%20Sept%20
2016.pdf
7
R Atun, DA Jaffray et al,
“Expanding global access to
radiotherapy”, The Lancet
Oncology, Vol. 16, No. 10,
pp. 1153–1186, September
2015.
8
2
facilities.4 But regardless of where a person lived in the world, the story tended to be the same:
minority, low-income and other vulnerable populations all had the lowest cancer survival rates.
The new world of equal access to cancer care required major changes in four areas: political
will and economic considerations; physical accessibility; financial affordability; and culturally
sensitive, targeted and personalised services.
POLITICAL WILL AND ECONOMIC CONSIDERATIONS
On the path to equal access to cancer care governments first had to make cancer a bigger
priority on the policy agenda. They realised that short-term investments in boosting access to care
could have long-term societal and economic benefits.
Various studies have looked at the economic costs of cancer. For example, a study published in
The Lancet in 2013 estimated the cost of cancer in the EU at €126bn (US$138bn) in 2009, including
€52bn in lost productivity (such as work missed because of sickness), €51bn in healthcare costs
(such as doctors’ time and drug costs) and €23bn in costs for informal care.5 Informal caregiving
(for example by family members and close friends) also incurs substantial costs, as studies have
shown.6
Moreover, cancer has considerable consequences for the labour market. Estimates from a joint
study by the Office of Health Economics in the UK and the Swedish Institute for Health Economics
suggest that the costs associated with this lost production could account for between one-third
and one-half of the total economic burden of cancer, depending on the country.7
Academic studies that included cost-benefit analysis started to have a stronger impact on policy.
For example, a study by Rifat Atun, professor of global health systems at Harvard University, and
others included an economic model which estimated that it would cost US$184bn to increase
access to radiotherapy across all low-income and middle-income countries by 2035, and that
over the 2015-35 period this would produce a net benefit of US$278bn and the saving of 26.9m
life years over the lifetime of the patients who received treatment.8 Moreover, the joint UK and
Swedish study calculated that a 25% reduction in smoking prevalence in nine European countries
would result in total cost savings of €6bn.9
© The Economist Intelligence Unit Limited 2017
WHAT IF…
…everyone had equal access to cancer care?
In order to reach the new reality of equal access to cancer care, governments needed to find
innovative ways to reduce financial and socioeconomic barriers. Governments embarked on
a concerted effort to improve treatment adherence and measures on information to patients
and health literacy, involving patients, carers and health professionals. This helped to reduce
medication non-adherence; in the 2010s medication non-adherence in general (not just for
cancer) cost governments in Europe an estimated €125bn and contributed to the premature
deaths of nearly 200,000 Europeans.10
As studies like these became more influential on public policy, cancer gradually became
acknowledged as a societal issue, not just a healthcare issue that was having impacts far beyond
individual patients. Once governments had started to prioritise cancer care, they began to take
more concrete steps to overcome the physical, financial and sociocultural barriers to access.
PHYSICAL ACCESSIBILITY
The lack of accessible cancer services was the first major hurdle that needed to be overcome
to secure equal access to cancer care. More resources were invested in cancer care and
organisation. This meant hiring more oncologists, nurses and support staff; employing more
oncology and other specialised equipment; and improving ways of communicating securely
with patients using electronic services. As a result of the greater availability of cancer-care
resources, the issues many patients had with transport to and from treatment centres were eased.
Oncologists can be flown in where their physical presence is needed, just as patients can be
chauffeur-driven by volunteers to where they need to be to receive care. A struggling farmer in
Uganda can have adequate access to services just as much as an affluent business owner in the
US or Europe—and enhanced telemedicine and eHealth played a key role in this development.
Health services have piloted the use of mobile-phone texts to patients and secure video and
telemedicine consultations. In a world in which everyone has equal access to cancer care these
affected by cancer to stay up-to-date with the latest advice, technology and treatment.
Office of Health Economics
and the Swedish Institute for
Health Economics, Improving
Efficiency and Resource
Allocation in Future Cancer
Care.
Everybody—not just cancer patients—has become an educated healthcare consumer.
10
services have been perfected and are used as routine. Mobile cancer services and telemedicine
coupled with mobile-phone apps can deliver instant cancer care. This can enable everyone
© The Economist Intelligence Unit Limited 2017
9
European Federation of
Pharmaceutical Industries
and Associations, “Patient
Adherence– 50% of patients
don’t take their medicine
properly”. Available at:
http://www.efpia.eu/topics/
people-health/patientadherence
3
WHAT IF…
…everyone had equal access to cancer care?
FINANCIAL AFFORDABILITY
The second major hurdle to overcome was the difficulty faced by many patients to afford cancer
services. The costs for individuals could be overbearing, including not only direct costs for cancer
treatment but also additional costs for associated healthcare problems, reduced income,
transport costs to reach healthcare facilities and higher household bills.11 Patients sometimes
faced difficult trade-offs between the cost of treatment and other financial priorities, such as a
child’s education or the medical costs of another family member.
To overcome financial barriers to access to care, viable universal healthcare systems became
more widespread and common to ensure more equitable access, adequate reimbursements
and pricing based on value and patient outcomes. To ensure financial affordability of cancer
care for both individuals and health systems, healthcare policymakers subsequently adopted
models for the reimbursement and pricing of health technologies, including cancer care,
that focused increasingly on value and patient outcomes, as the notion of “value-based
healthcare”—achieving the best value for patients at the lowest possible cost—increasingly
gained traction in Europe and elsewhere.12
Based on the value-based healthcare approach, healthcare systems were reorganised to allow
funding to flow more easily from one area to another, eliminating siloes. Governments, providers
Macmillan Cancer Support,
Cancer’s hidden price tag:
revealing the costs behind
the illness. Available at:
http://www.macmillan.org.
uk/documents/getinvolved/
campaigns/costofcancer/
cancers-hidden-price-tagreport-england.pdf
11
The Economist Intelligence
Unit, Value-based healthcare
in Europe: Laying the foundation, 2016. Available at:
https://www.eiuperspectives.
economist.com/healthcare/
value-based-healthcareeurope-laying-foundation
12
Oxfam, Access to cancer
treatment: A study of
medicine pricing issues
with recommendations for
improving access to cancer
medication, 2014. Available
at: http://apps.who.int/
medicinedocs/documents/
s21758en/s21758en.pdf.
13
4
and manufacturers worked together to create healthcare systems that continuously evaluate
healthcare interventions to promote those health technologies which provide the greatest
benefit to patients, healthcare systems and wider society, and to eliminate those with less benefit,
so that the limited healthcare resources at governments’ disposal are now used more efficiently
towards greater outcomes. Systems thus reward specific desired results achieved, rather than
merely the volume of treatments sold. Patients and their health systems no longer have to opt for
less effective care because it is the more affordable choice.
Another milestone in overcoming barriers to financial affordability relates to prevention.
Policymakers, patients and health systems increasingly recognised the cost benefits of preventing
cancer from developing in the first place. Public-health programmes thus focused on preventing
key cancer triggers, such as tobacco use, sun exposure and poor diet. Another key development
was the increased use of testing for genetic dispositions. Hence, if detected, people with a
genetic disposition to develop cancer are now screened at regular intervals because early-stage
diagnosis of cancer can improve outcomes and lower the cost of treatment. Some of the most
common types of cancer can respond well to treatment when detected early.13 For example,
© The Economist Intelligence Unit Limited 2017
WHAT IF…
…everyone had equal access to cancer care?
studies on kidney cancer in England show that survival for cancers is strongly related to the stage
of the disease at diagnosis.14
Moreover, although by the mid-2010s many European countries had developed and
implemented national cancer care plans (NCCPs), 20% were found to have insufficient funds to
implement them properly.15 Hence, governments subsequently started to allocate more resources
to implementing NCCPs.
In less developed health systems—where prevention and early-detection programmes as well
as reimbursement and pricing systems remained relatively underdeveloped—donor funding still
played an important role in facilitating financial affordability of cancer care. In such countries,
life-saving treatments with a high public-health impact, such as those targeted at malaria
and maternal/infant health, for example, were often prioritised over cancer care. However,
the political will to deal with cancer gradually improved. The UN’s Sustainable Development
Goals (SDGs), adopted in 2015, included a target of reducing premature mortality from noncommunicable diseases, including cancer, by one-third by 2030. In order to reach this target,
governments, non-governmental organisations (NGOs) and other cancer advocates were
mobilised to collective action,16 supported by persistent pressure from organised groups of people
living with cancer and their support networks, including cancer charities and those who had lost
loved ones to cancer.
As a result of these initiatives, cancer patients no longer had to largely self-fund their treatment
through out-of-pocket payments—a situation that was often unsustainable for the poorest in
developing countries.
Governments also increasingly engaged with healthcare companies to lower and share costs of
assured-quality cancer treatments and pipeline research. Cancer interventions are still expensive,
but patients are benefiting from enhanced access to life-extending experimental treatments in
community-based clinical trials.17
CULTURALLY SENSITIVE, TARGETED AND PERSONALISED
SERVICES
Cancer Research UK,
Kidney cancer survival
statistics. Available at: http://
www.cancerresearchuk.
org/health-professional/
cancer-statistics/statistics-bycancer-type/kidney-cancer/
survival#heading-Three
14
Office of Health Economics
and the Swedish Institute for
Health Economics, Improving
Efficiency and Resource
Allocation in Future Cancer
Care, p. 9.
15
WHO, World Cancer Day.
http://www.who.int/cancer/
wcd_2016/en/
16
D Dahill, “Real world studies
can be a lifeline”, Primary
Care Today, 16 June 2014.
Available at: http://www.
primarycaretoday.co.uk/
patientppi/real-world-studiescan-be-lifeline
17
While governments helped patients to overcome physical and financial barriers to accessing
cancer services, they also started to focus more on establishing patient-centred healthcare
systems to overcome issues with acceptability. Getting people more involved in their care as
© The Economist Intelligence Unit Limited 2017
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WHAT IF…
…everyone had equal access to cancer care?
partners was a central ambition that health systems achieved. This enabled them to deliver what
some healthcare strategists had called “world-class” cancer outcomes.18
By staging health fairs that were culturally sensitive to the needs of minority populations, health
services saw more people step out of their comfort zone to access treatment and support. Take,
for example, cervical-cancer screening tests. Women initially reported that they had reservations
about attending for screening because they felt fear, embarrassment and shame, or they did
not feel that they had the time to do so because of work or home commitments. Some also had
concerns about how they were treated by healthcare professionals.19 By being culturally sensitive
and sending same-sex nurse advisers into their communities to discuss key issues about cervical
screening with women it was possible to see such barriers to access break down.
Another example is lung cancer. In many European countries and the US smoking-related stigma
and distrust in the healthcare system used to be significant barriers to accessing lung-cancer
screening services.20 As screening became more widely implemented, healthcare systems
worked with patients to overcome stigma and increase patient engagement with medical care
and cancer-screening participation.
NHS England (2016).
Achieving world-class
cancer outcomes: Taking the strategy forward.
Available at: https://www.
england.nhs.uk/wp-content/
uploads/2016/05/cancerstrategy.pdf
18
LA Marlow, J Waller and J
Wardle, “Barriers to cervical
cancer screening among
ethnic minority women: a
qualitative study”, Journal of
Family Planning and Reproductive Health Care, 2015,
Oct;41(4):248-54
19
L Carter-Harris, DP Ceppa,
N Hanna and SM Rawl, “Lung
cancer screening: what do
long-term smokers know and
believe?”, Health Expectations, 23 December 2015.
20
New, targeted and personalised cancer treatments are available to everyone without barriers
to who receives treatment or where they receive it. As a precursor, standards for biomarker and
diagnostic testing accuracy were defined and guaranteed in order to optimise predictive values
for the improvement of benefits and risks. Improved genomic tools thus provide more information
to aid decision-making for greater precision, although absolute certainty remains elusive.
Nonetheless, real-world data are collected everywhere in systemic fashion, and cancer sufferers
are exceeding expectations of clinical trials and are living longer, healthier lives as a result of the
data collected. Healthcare professionals who are trained and well versed in data privacy issues
have access to electronic patient records.
As part of the international standard for treatment, cancer patients have an assigned patient
navigator to guide them through screening—where early-stage cancer or precancerous cells
can be detected—and also through their entire treatment experience. Patient navigators were
put in place following a US study showing that they helped to reduce the delays regarding
diagnosis and the start of treatment in socioeconomically disadvantaged cancer patients.21
KM Freund, TA Battaglia
et al, “Impact of patient
navigation on timely cancer
care: The Patient Navigation
Research Program”, Journal
of the National Cancer Institute, 2014 Jun 17;106(6).
21
6
© The Economist Intelligence Unit Limited 2017
WHAT IF…
…everyone had equal access to cancer care?
TOWARDS A WORLD WITH EQUAL ACCESS TO CANCER
CARE
Access to cancer care was once a universal challenge affecting countries of all income levels
and health systems. Focusing on prevention and removing physical, financial and sociocultural
barriers to access has improved cancer outcomes, thus allowing patients to return to work earlier,
be productive members of society and live longer, healthier lives.
Raising awareness in targeted and culturally sensitive ways has to some extent eradicated
certain cancers and reduced the number of people who die because their cancer is diagnosed
too late and they did not have a chance of receiving an effective treatment in time. Medical
advancements have made improved therapies available to patients. Quality of life has
improved, and cancer survivors routinely return to being economically productive citizens.
Meanwhile, caregivers are able to continue leading productive and active lives. All of this has
benefited individuals and wider society.
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© The Economist Intelligence Unit Limited 2017
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