Global Cancer Control: An Essential Duty
At NCI, we clearly recognize cancer as a global health crisis, and one for which the worldwide impact—both personal and economic—is rapidly expanding. A recent study reported that in the past 30 years the global burden of cancer, based on the incidence of new cancer cases and annual deaths, has doubled. The burden of cancer, however, is not equally distributed, and this represents a major concern. Today, 63 percent of cancer cases occur in countries less developed than ours. It has been estimated that across the globe there will be 12.9 million new cases diagnosed this year, and the worldwide toll is predicted to rise to 27 million new cancer cases and 17 million deaths by the year 2030, unless we take more pressing action.
In the United States, lung cancer is a major health problem, and in Mexico, cancers of the lung, bronchus, and trachea are also highly lethal, with a recently reported crude mortality rate of 6.5 per 100,000 people. However, cervical and uterine cancers in Mexico have an even higher crude mortality rate (recently reported at 7.6 deaths per 100,000 women), which is probably the result of inadequate screening and thus diagnosis of cancer at advanced, and more likely fatal, stages.
In Chile, the leading cause of cancer death in women is not breast or lung cancer, but cancer of the gallbladder. Both examples above, from Mexico and Chile, suggest differences in genetic susceptibility and environmental risk factors.
In China, smoking rates have skyrocketed, with an estimated 350 million current smokers. Two thirds of men in China smoke. That staggering statistic means that the rates of lung cancer and other tobacco-related cancers, such as pancreatic and bladder cancer, will increase markedly in the coming decades. An August 2009 report commissioned by the Lance Armstrong Foundation and conducted by staff at The Economist stated that, “It takes about 40 years for the increase in smoking rates to be fully reflected in cancer epidemiology statistics. As a result, the number of deaths in the developing world will continue to rise based on past activities as well as the projected increase in new lung cancer cases.”
For the United States, cancer in other countries is clearly a humanitarian and diplomatic challenge, but also a tremendous opportunity to learn through studies of genetic drivers of risk and interactions between genes and the environment. Indeed, NIH Director Dr. Francis Collins has made improving global health one of the five pillars of his directorship. Our country, he said during a recent town hall meeting with NIH employees, has been viewed of late as a “soldier to the world.” Using our scientific and medical expertise to improve global health would be a welcome display of “soft power,” he said, demonstrating that the United States can be a “doctor to the world.”
NCI’s international cancer efforts are a response to these challenges. The global economic cost in 2009 of new cancer cases—factoring medical and nonmedical costs, along with productivity losses and the cost of cancer research—is currently estimated to be at least $286 billion, according to the The Economist report, “Breakaway: The Global Burden of Cancer—Challenges and Opportunities.” A steep rise in cancer cases will only drive this economic burden higher. Such data become tangible, though, when you take a more personal perspective. In the United States, adjuvant use of the breast cancer drug tamoxifen for 5 years often costs $4,000. Meanwhile, the annual per capita income in Bangladesh is just under $600; in sub-Saharan Africa, it is about $1,100. Many of the therapies that Americans with health insurance expect to be available for their care cost at least 10 times the annual per capita income of developing nations. Yet only 5 percent of global resources for cancer are spent in that part of the world, less than $1 to $2 per day, according to the World Health Organization.
As populations move, as governments change, as environmental toxins affect great land areas, what happens to one region of the world is clearly felt in another. I believe NCI’s international duty must be, in part, to study patterns of population movement. We must also understand the impact of poverty on health and cancer rates, and we must continue to study and attempt to drive down global smoking rates. We must contemplate infectious agents as the causes of greater numbers of cancers, and we must never lose vigilance in studying the malignancies that are so often a consequence of HIV/AIDS. In short, we must employ our international research efforts to better understand the biology of cancer around the world.
Consider Bangladesh, one of the world’s poorest countries, where 162 million people live in an area the size of Iowa. With support from NCI and other organizations, Dr. Richard Love of Ohio State University is attempting to break through political and cultural barriers to save women’s lives. Dr. Love has worked with the Bangladeshi government to open free breast cancer clinics that treat hundreds of breast cancer cases, almost all of which present in late stages. In that country, where more than 30 percent of the population lives on less than $1 per day, Dr. Love is not only helping patients, he is studying populations, looking for differences in individual tumors, in the reactions of patients to medicines and treatments, in cultural traditions, and in health care systems. Dr. Love is even conducting a study in a small village to determine whether it is possible to educate women and men about breast health and breast cancer by employing a type of traditional song often performed as street theater.
Last week, I met with top health and diplomatic officials from Argentina, Brazil, Mexico, and Uruguay, who came to the NIH campus to sign letters of intent formally bringing them into the U.S.-Latin America Cancer Research Network, joining Chile, which signed a letter of intent earlier this year. For a pilot project in breast cancer, researchers from the five countries will perform molecular profiling of tumor samples from women to help identify the most common breast cancer subtypes and to improve both diagnosis and treatment. Given the growing Hispanic population in the United States, this work promises significant benefits for all of the partner countries.
In our own country, we have considerable evidence that the incidence of cancer has two principal drivers: a population that is rapidly aging, and one that is increasing in number and ethnic heterogeneity. This presents opportunities to apply what we are learning from global research programs to changing U.S. demographics.
NCI also has a long history of international population-based studies, specifically in Russia and China, to identify environmental and genetic determinants of cancer.
Healthcare, many argue, is a basic human right. The United Nations’ Universal Declaration of Human Rights from 1948 says, “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family.” When it comes to NCI and the rest of the world, I would suggest a simpler way of thinking: It is our duty to reduce cancer’s great burden for all people.
Dr. John E. Niederhuber
Director, National Cancer Institute