There is a huge divide between the number of cancer deaths in high-income countries like the United States and those in low- and middle-income countries in Latin America. With a goal of enlisting more students, residents and faculty in the global effort to close this divide, Felicia Marie Knaul, Ph.D., a member of Sylvester Comprehensive Cancer Center, professor of public health sciences and director of the University of Miami Institute for Advanced Study of the Americas, described the successes and remaining challenges in a grand rounds presentation Jan. 31, part of a lecture series presented by Sylvester’s Global Oncology and International Programs.
The lessons from women’s cancers are particularly critical, Knaul said, because of a longtime emphasis on communicable diseases and complications of childbirth in low- and middle-income countries. Over the past three decades, maternal mortality has decreased significantly, while more complex diseases, such as breast cancer, cervical cancer and diabetes, are resulting in many more deaths.
“The message is not to stop working on maternal mortality — you have to think across a life cycle,” Knaul said. “The message is that saving a woman in that very dangerous set of days in her life, when she gives birth, is not enough. Letting her die a few years later of preventable cervical cancer or treatable breast cancer is a failure of the health system.
“I can tell you that 75 percent of breast cancer deaths in low- and middle-income countries and 95 percent of cervical cancer deaths should never have happened,” she said. “That’s a huge opportunity to evoke change, to prevent these deaths.”
Key to realizing that opportunity are earlier detection and effective advocacy. In Latin America, just over 20 percent of breast cancer cases are detected in Stage 1, and the rest are detected late. The data for the U.S. are the opposite: 80 percent are found in early stages.
A second issue is that many more breast cancer deaths in low- and middle-income countries (LMICs) are in younger women. “We don’t have a good evidence-based screening tool for women below the age of 40,” Knaul said. “So we have a lot of late diagnosis, and we have a lot of young women, so we have to figure out some solutions.”
Knaul, who is married to University of Miami President Julio Frenk, opened the presentation with the story of how she got involved in this work, showing a picture of herself 10 years ago, with her then-11-year-old daughter. “I was not trained in cancer, and in June of 2007 when you see me in this picture I was working on health system reform as a health economist. … But what I want you to focus on is that exactly 10 years ago I found myself with two children, a young mother, facing a diagnosis of invasive breast cancer.”
When she started treatment, Frenk had just completed six years as Minister of Health of Mexico.
“He would tell you that it’s one thing to lead a health system, to learn about a health system, to study a health system, but it’s very different to live a health system,” Knaul said. “We learned how hard it is to live through the long-term treatment of what is a chronic illness, and that taught us a lot about health systems that basically I think there was no other way to learn than to live it. We founded a small NGO in Mexico called Tomatelo a Pecho, and when we went to Harvard we started a global task force.”
They worked with clinicians and global health leaders to come up with systemic solutions to close the cancer divide.
Many of the answers lie in the structure of the health system, Knaul said. Through advocacy and innovative work to finance a full range of challenges, including things as complex as cancer, Frenk’s Seguro Popular program of universal coverage made it possible for Mexico to go from covering 6.5 million people to almost 55 million people.
“Not only did the number of beneficiaries increase, but also the benefits,” Knaul said. “Now we’re talking about a country where every woman has insurance to get exactly the same care I got — some of the most expensive and the most effective medicines and care you can imagine.”
Adherence to treatment has improved tremendously, Knaul said, but the gaps in early detection are a notable concern. Her research found that many women who are diagnosed with breast cancer had reported problems with the medical attention they were getting. Some told their primary care doctors they had lesions, and their doctors said they were too young to have cancer, or they didn’t know what to do about it, or they didn’t have access to mammography.
In response to this issue, Knaul and her colleagues developed a training program for about 16,000 physicians, nurses and health promoters — “a small army throughout the health system” — and increased their knowledge about breast cancer early detection.
“You can do this country by country, disease by disease,” Knaul said. “We just happen to be doing it for Mexico today for breast cancer.”
Knaul invited her audience to join the “huge opportunities to become more educated and engaged in global advocacy movements.” She praised the Mitchell Wolfson Sr. Department of Community Service (DOCS), which offers prevention and early detection in South Florida’s poorest communities.
Sylvester’s Global Oncology program and the UM Institute for Advanced Study of the Americas are offering a scholarship for three years for a student to be able to attend a global cancer conference. This year’s conference is the Toronto Global Cancer Conference March 1-3. Interested students and residents should “submit a one-page personal statement indicating your interest and what you hope to achieve by attending the conference” to firstname.lastname@example.org by Feb. 7.
Knaul said of this opportunity, “When a medical student or resident can participate in one of these young-leader cancer conferences and engage with a whole community of people who are physicians and advocates, clinicians and policy makers, it can change the way you decide to do your business for the rest of your life — not only in cancer but in terms of your engagement with the way that you can effect change around the world.”