An initiative directed by HGEI, HMS, HSPH, FHCRC, UW and UW Med
Objective: The mandate of The Global Task Force on Expanded Access to Cancer Care and Control (GTF.CCC) is to design, promote and evaluate innovative, multi-stakeholder strategies for expanding access to cancer prevention, detection and care in low and middle income countries (LMICs). Working with local partners, the GTF.CCC participates in the design and implementation of innovative service delivery models to scale up access to cancer care and control (CCC), and to strengthen health systems in LMICs.
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: In Canada, almost 90% of children with acute lymphoblastic leukemia are cured, whereas the figure is the inverse in the poorest countries of the world.
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 specific health systems 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 (GTF.CCC): The GTF.CCC is directed from the Harvard Global Equity Initiative, the Harvard School of Public Health, the Harvard Medical School, the Fred Hutchinson Cancer Research Center, the University of Washington and the University of Washington Medicine. This initiative, originally convened in 2009 by four Harvard-based institutions including the Dana-Farber Cancer Institute, comprises a network of more than thirty leaders in the fields of cancer and global health from around the world. GTF.CCC also draws on more than 50 technical and strategic advisors, a private sector engagement group, a strategic advisory committee, and a dual secretariat of staff based at the Harvard Global Equity Initiative and the Fred Hutchinson Cancer Research Center. HRH Princess Dina Mired of Jordan and Lance Armstrong are the Honorary Co-Presidents of the GTF.CC, which is chaired in its second phase by Drs. Lawrence Corey and Julio Frenk.
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 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 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 many countries 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.
In October 2011, Harvard University through the Harvard Global Equity Initiative published and launched the GTF.CCC reportClosing the Cancer Divide: A Blueprint to Expand Access in Low and Middle Income Countries. This report is a product of the first two years of work of the GTF.CCC and constitutes the first phase of efforts. The report presents the evidence that supports the case for expanded access to CCC, described innovative models for achieving expanded access and provides a blueprint for future action in resource-constrained settings. The report is currently available in English and Spanish and is being translated into Arabic and Russian.
Broad dissemination of the report is underway at the global level. This work focuses on improving planning, generating stronger evidence, establishing novel programs and encouraging countries to establish multi-stakeholder groups for expanded CCC.
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 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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