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Author: Bichal Jyawali, Associate Professor of Oncology and Public Health Sciences, Queen’s University, Ontario
Where should we invest today to save the largest number of lives from cancer tomorrow? This is the basic principle behind the “basic cancer” philosophy.
Annually, billions of dollars are spent on ambitious “cancer release” programs. These programs focus on discovering new drugs and technologies aimed at solving the burden of cancer. The hope is that the discovery of a new target, a new drug, or a new mechanism will help treat cancer or reduce the cancer burden.
The ambitious Cancer Moonshot Program in the United States celebrates its fifth anniversary in 2022, and sure enough, cancer remains a global problem that needs to be addressed. Some new drugs were developed in this time frame, but the percentage of patients who benefited from these new drugs remained small.
Globally, most cancer patients die not because they do not have access to these new drugs, but because they do not have access to even basic treatments.
More than 90 percent of patients in low-income countries, and more than half of patients in low- and middle-income countries, do not have access to basic radiotherapy services. More than half of the patients globally who require cancer surgery will go without services, and the services needed for an accurate cancer diagnosis are not available.
These are the interventions that help treat cancer and save the most lives, as opposed to newer drugs that marginally prolong survival or delay cancer growth. If inequalities persist in accessing proven effective interventions, newer treatment options will not reduce the global cancer burden.
I coined the term “cancer-causing cancer” in 2016 in a blog post to encourage the prioritization and research of cancer care. It’s part of the common sense revolution in oncology.
Primary cancer highlights that investing in improving access to interventions that have already proven effective saves more lives than discovering a new intervention. When patients die because surgery or an accurate diagnosis is not available, a new cancer drug won’t solve the problem.
Cervical cancer is a good example. It is perhaps the only cancer for which eliminating it is a realistic goal. HPV vaccination, cervical cancer screening, and effective treatment for early-detected cervical cancer may help eradicate this cancer.
At the same time, newer drugs such as pembrolizumab have been reported to improve 2-year survival rates in metastatic cervical cancer by 10 percentage points. Although this medical advance is not excluded, countries around the world would be wise to invest in cervical cancer screening, HPV vaccination and early treatment, rather than investing in access to pembrolizumab (the cost of this drug for one year is about 150 thousand American dollar).
In this example, the use of pembrolizumab represents a breakthrough cancer approach to cervical cancer. A focus on vaccination, screening, and early treatment is a core approach to cancer.
Costs and priorities
The cost of pembrolizumab is not unusual. Modern cancer treatments are expensive. On average, based on 2018 data, a new cancer drug costs more than $150,000 per patient per year. On the other hand, with the exception of some good medicines, the benefits provided by these medicines are not very impressive on average. For example, some new cancer drugs delay progression by only three days.
Although assessing life is an inherently impossible task, I think we as a society can agree that our resources could be better allocated than spending $16,000 per month to delay tumor growth for three days. A new study shows that these extra days of delayed tumor growth may not necessarily mean a good quality of life, either.
Primary Cancer is a philosophy that advocates prioritizing strategies in the global fight against cancer. The basic principle of cancer is that one must ensure access to interventions that have already been shown to be effective before focusing on developing new ones. We need to realign our priorities and invest in equitable access to high-value interventions.
This is not only a problem in low- and middle-income countries. There are also significant disparities in access to care within high-income countries. There are several pockets of the population in countries such as the United States and Canada, which are underserved and lack access to timely and appropriate cancer care. There are disparities in socio-economic status, levels of awareness, insurance coverage and other factors that lead to mixed outcomes, even within the same country.
Advocacy and implementation
The philosophy of the cancerous basis was detailed in a 2018 paper published in The Lancet Oncology. Since then, he has gained momentum in the world of cancer-related politics. I have talked about this in many international and national meetings, and the concept has been discussed in academia and beyond. This year at the annual meeting of the American Society of Clinical Oncology (ASCO), the largest oncology conference in the world, I will chair a session on the causes of cancer.
This recognition from ASCO will certainly add to her recognition, and hopefully it will be adopted. The session is organized into three conversations, which are also grouped into a chapter from the book:
The basis of cancer and how clinical trials fit into this philosophy.
Inequalities in low- and middle-income countries, and whether technology can help meet this challenge.
Disparities in cancer care within high-income countries.
However, the true measure of the basis of cancer is the implementation of the philosophy and the reduction of inequality in access to proven treatments. Advocacy is the first step to this end.
Bichal Gyawali receives funding from the Ontario Cancer Research Institute and the Conquering Cancer Foundation.
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