Global Task Force On Expanding Access to Cancer Cancer and Control in Developing Countries (GTF.CCC)
Justification1: Although once considered a problem exclusive to high-income countries, cancer is a leading cause of death and disability in the developing world. Of the 7 million cancer deaths in the world today, approximately 70% occur in developing countries.2 By 2030, low and middle income countries (LMICs) will bear the brunt of an estimated 27 million new cancer cases and 17 million cancer deaths.3,4,5,6,7,8
Case fatality for the cancers that can be treated or prevented is much higher in the developing world – a result of grave inequity in the opportunity to survive the disease that has generated a cancer divide. In the case of breast cancer, the ratio of deaths to incident cases is close to 60% in low-income countries, compared to less than 25% in high-income countries. For childhood cancers the divide is especially profound: close to 90% of Canadian children diagnosed with acute lymphoblastic leukemia have hope to survive compared to only 10% of those born in one of the 25 poorest countries.
The world faces a huge and largely unperceived cost of inaction from cancer in the developing world, which calls for an immediate and large-scale global response. Only 5% of the 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.9,10 Cancer is a sorely neglected health problem and a significant cause of premature death in resource-poor settings resulting in a staggering ´5/80 cancer disequilibrium´.
Meanwhile, the world has witnessed unprecedented success in mobilizing resources for global health. New global and regional mechanisms have innovated financing and procurement schemes to guarantee access to much needed vaccines and medications. As a result, millions of lives have been saved. Lessons from these initiatives – particularly from AIDS -- can help meet the challenge of chronic conditions such as cancer.
The commonly held assumption that cancers will remain untreated in poor countries has gone largely unchallenged in public health. Skepticism about scaling up access to integrated early detection, diagnosis, treatment and palliation in poor countries is concentrated largely around the scarcity of funds and perceived obstacles to treatment and early detection. A recalibrated global response to cancer could thus prove transformative. Zero-sum debates about which life-saving interventions to deny poor patients can and should be converted through evidence garnered from experience -- by advocates as well as experts – into alternatives for mobilizing greater resources and identifying synergies between disease-specific interventions.
This agenda for action should catalyze opportunities to provide expanded cancer care and control (CCC) appropriate to the health systems of developing countries and accessible to poor patients. It is essential to develop and implement innovative health care delivery options that support rapid scale-up and parallel the application of a diagnoal approach in which resources for particular diseases are deployed in ways that stregthen entire health systems.
Global Task Force on Expanded Access to Cancer Care and Control in the Developing Countries (GTF.CCC): The Task Force, composed of 30 members, brings together leaders from the cancer and global health communities. The GTF.CCC is co-Chaired by Julio Frenk, Dean of Harvard School of Public Health and Lawrence Shulman, Chief Medical Officer and Vice President for Medical Affairs at the Dana Farber Cancer Institute. Her Royal Highness, Princess Dina Mired of the Hashemite Kingdom of Jordan and Lance Armstrong serve as Honorary co-Presidents. The Harvard Global Equity Initiative, under the direction of Felicia Knaul, serves as the Secretariat for the Task Force.
Efforts to convene the Task Force began in November of 2009 under the leadership of the Harvard Medical School, the Harvard School of Public Health, the Dana-Farber Cancer Institute and the Harvard Global Equity Initiative. The Task Force now includes leaders from institutions spanning all regions over the world including experts from academia, clinicians, civil society members and policy makers. A private sector strategy is underway to encourage participation in all facets of the Task Force.
In addition to strongly supporting efforts to prevent cancers of tomorrow by reducing cancer risk factors, especially tobacco through the WHO Framework Convention on Tobacco Control, the GTF.CCC calls for immediate action around treatment.To push forward this agenda, the GTF.CCC is applying the knowledge and ability of its members, combining expertise in global health and cancer to:
- Raise global awareness of the impact of cancer on developing countries at the global, regional and national levels through an evidence-based call-to-action.
- Define the packages of essential services and treatments needed to provide care in low-resources settings for cancers which can be cured or palliated with currently available therapies.
- Reduce human suffering from all cancers by promoting universal access to pain control and palliation and increase access to the best treatment for cancer through the procurement of affordable drugs and services in line with packages of essential elements.
- Develop and evaluate innovative service delivery models that harness existing human, physical and technological resources in different economic and health system settings and share the lessons and evidence locally, regionally and globally.
- Expand the leadership, stewardship and evidence based for implementing the most efficient approaches to CCC in developing countries.
- Develop and support implementation of mult-stakeholder platforms for expanding access that engage all actors - public sector, private sector, civil society and researchers.
The GTF.CCC is predicated on the conviction that solutions to barriers exist and that the reasons for rapidly scaling-up cancer treatment are compelling enough to merit an invigorated global response to cancer. These solutions should be built on existing platforms, many of which stem from private sector activity.
The GTF.CCC will focus on areas that have largely been neglected, working from the perspective of health system strengthening. Specifically, the GTF.CCC focuses on developing and implementing pathways to expand coverage of: 1) existing vaccines, 2) early detection and treatment of the many cancers where cure and major improvements in life expectancy are likely, and 3) palliation to reduce human suffering.
Proposed strategies are based on a diagonal, multi-stakeholder approach designed to stregthen health systems for CCC. This approach argues that expanding cancer treatment, rather than taking resources away from other diseases, can improve the capacity of developing country health systems. Strong health systems are required for effectively treating cancers, and at the same time expanding CCC can stregthen health systems. An example is pain control - a right that is crucial for cancer palliation and for many other patient needs - but is often unavailable despite being low-cost.
The GTF.CCC plans to produce several major written outputs in 2011/2012 that follow its mandate and provide the foundation of a strategy to expand CCC strategies in the developing world. The first will be a report to be published late 2011, following the High-level Meeting of the United Nations General Assembly on the Prevention and Control of Non-communicable Diseases. The second will be a book (available both as a freely downloadable electronic version and a print version) divided into chapters and publised by the Harvard Global Equity Initiative and distributed by the Harvard University Press (HUP). The book will provide more in-depth information and detail than the report, including case study work. It will be published on-line first (freely downloadable).
Specifically, these outputs focus on providing a road-map and evidence-based recommendations for program development, local and global policy making and setting of research priorities. The recommendations will be derived from combining the knowledge and effort of leaders in both the cancer and global health communities, taking lessons from successes with diseases such as AIDS, building on initiatives and platforms such as maternal and child health and distilling evidence from examples of successful models, 'Innovation Initiatives'.
The Task Force calls for large-scaled demonstration programs to define and build new infrastructure, train health professionals and paraprofessionals, and harness the opportunities of technology and telecommunications to leapfrog over many of the on-site resource limitations. The multi-stakeholder programs seek to include government, civil society, researcher institutions and the private sector.
The GTF.CCC is contributing to the implementation of this recommendation. The focus on developing strategies at the country level to increase access to all facets of CCC has spurred partnerships in several LMICs (Mexico, Jordan, Malawi, Rwanda and Haiti) with existing, locally entrenched and independently sustainable programs. This work includes developing, designing, implementing and evaluating innovations in delivery in the areas of task shifting, infrastructure shifting, and in the use of telecommunications to enhance opportunities for telemedicine.
A multi-sectoral approach is applied in which all possible actors, both private and public, are incorporated. Carefully deisned evaluation and monitoring of these experiences will enable identification of the most effective measures to alleviate cancer burdens in different parts of the developing world and expand the volume of health services, as well as provide lessons for all health systems including those of high-income countries. These projects thus serve as 'proof of concept'.
Further, independent and sustainable in-country initiatives to take forth global recommendations and transform them into and support local action are being promoted. For example, the Rwanda Task Force on Cancer Care and Control (RTF.CCC) was convened in April of 2011, following the launch of a National Cervical Cancer Prevention Program spurred by a public-private partnership.
 This section is based on: Paul Farmer, Julio Frenk, Felicia M Knaul, Lawrence N Shulman, George Alleyne, Lance Armstrong, Rifat Atun, Douglas Blayney, Lincoln Chen, Richard Feachem, Mary Gospodarowicz, Julie Gralow, Sanjay Gupta, Ana Langer, Julian Lob-Levyt, Claire Neal, Anthony MBewu, Dina Mired, Peter Piot, K Srinath Reddy, Jeffery D Sachs, Mahmoud Sarhan, John R Seffrin. Expansion of cancer care and control in low-income and middle-income countries: call to action. Lancet 2010; 376:9747.
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