Features
A World of
Difference
The slow march to bring high-quality hematology
and oncology care to limited-resource areas
T
he pace of progress in hematology and oncol-
ogy treatment is dizzying, but advances can
only benefit patients who have access to them.
While the U.S. and other wealthy countries
struggle with costs of treatments, most countries will
never see these new therapies, and still work to obtain
less revolutionary, cheaper treatments that have been
available elsewhere for years.
“Blood cancers and hematologic disorders aren’t con-
sidered major public health issues [in limited-resource
areas], in part because the surveillance data are not great,”
said Satish Gopal, MD, assistant professor of medicine at
the University of North Carolina (UNC) School of Medi-
cine in Chapel Hill and cancer program director at UNC
Project-Malawi, a collaboration between UNC staff and
the Malawi Ministry of Health. “So, unless you’re really
looking, these issues are sort of invisible. Even for some-
thing as seemingly basic as understanding the burden of
sickle cell disease (SCD) in sub-Saharan Africa, the data
still largely rely on mathematical modelling.”
In a Blood Advances Talks segment about the
delivery of effective care in resource-limited areas,
Ami Bhatt, MD, PhD, assistant professor of medi-
cine and genetics at Stanford University, described the
issue of global access to cancer treatments succinctly:
“For most pediatric patients [with cancer], the most
important predictor of 10-year survival is the country
in which the child was born.” 1
ASH Clinical News spoke with hematologists directly
engaged in global health to learn about their work and
explore the challenges causing this vast unmet need.
The Global Cancer Burden
“There is a misconception that people in low- and
middle-income countries (LMICs), which is approximately
80 percent of the world’s population, mostly die of infec-
tion,” Dr. Bhatt told ASH Clinical News.
Yet the data show that as populations age and as com-
municable diseases become better controlled, the cancer
burden in LMICs is growing steadily. Those countries’
health-care needs are shifting accordingly – something
that appears to have been overlooked by local governments
and international organizations alike.
According to World Health Organization estimates,
70 percent of cancer deaths occur in resource-limited
countries and, worldwide, the number of new cancer
diagnoses is expected to rise by about 70 percent over the
next two decades. 2 It is estimated that only 5 percent of
global resources for cancer are spent in LMICs.
“If people with cancer, SCD, or other non-communicable
diseases are dying and nobody knows about it, and nobody
bothers to either measure it or try to do something and then
record what happens, then how can it really change?” Dr.
Gopal asked. “Patients with cancer in places like Malawi
have been invisible to the world until recently, and even now
118
ASH Clinical News
they are barely visible.”
Over the past two decades,
UNC Project-Malawi has
operated in Malawi’s capital,
Lilongwe, to improve the health
of Malawian patients through
research, education, and efforts
to strengthen existing health
systems. One of Dr. Gopal’s
primary goals in Malawi is to
collect better data, with the
hope that once staff members
measure and establish suc-
cessful treatment protocols in
low-resource areas, local gov-
ernments and the larger global
community will expand access
to effective interventions.
“Underinsured” Is an
Understatement
Top: Satish Gopal, MD (back row, right), with health-care staff from UNC Project-Malawi.
Bottom: Signage outside of a health-care clinic in Nigeria.
Many resource-poor areas lack adequate diagnostic and
treatment facilities, not to mention trained and special-
ized staff. According to the African Cancer Registry
Network, there are only 102 cancer treatment centers
in Africa, 38 of which are located in one country, South
Africa. 3
“The challenges to providing care range from the
lack of trained staff to render a timely diagnosis, admin-
ister chemotherapy, and provide supportive treatments
such as antibiotics and anti-emetics, to [difficulties] in
obtaining a reliable and safe supply of blood products
for transfusion, to limited infrastructure within which
to provide coordinated care for these complicated patients,”
Dr. Bhatt said.
In low-income countries, access to screening and
treatment for hematologic disorders and malignancies is
often negligible, and only a small minority of these coun-
tries have health-care systems capable of delivering the
complex care required to manage readily treatable disease
– if the necessary drugs are even available.
“Drugs such as rituximab and growth factors like
granulocyte colony-stimulating factor solidly fall into a
‘luxury item’ market,” Dr. Bhatt noted.
One example of the incongruity of cancer burden be-
tween resource-poor and -rich countries is the prevalence
and consequence of Burkitt lymphoma. The malignancy
is relatively rare in Western countries but is common in
central Africa, where it comes in endemic, sporadic, and
immunodeficiency-associated forms. Untreated Burkitt
lymphoma is rapidly fatal, but with combination chemo-
therapy regimens, the response rate can reach 90 percent.
The chemotherapy regimen to treat it includes
high doses of cyclophosphamide, doxorubicin, and
methotrexate, as well as a high level of supportive care.
Because of limited access to those drugs and cultural
attitudes, more than half (55%) of parents and guardians
of children with Burkitt lymphoma in Cameroon
consult traditional healers. 4
Other diseases present additional issues: Malnutrition
underlies disorders such as iron-deficiency anemia, Dr.
Bhatt said, and for malignancies such as diffuse large
B-cell lymphomas, ac cess to anti-cancer medications and
radiation therapy is often inadequate.
On the Ground in Manila
Although health care is wholly unavailable in many low-
income countries, in middle-income countries, physician
coverage is often adequate and hospitals are usually well
resourced. A lack of widespread insurance coverage
means that access to quality care and expensive medica-
tions is limited to affluent individuals, though, and the
few others who are insured.
Emmanuel Besa, MD, has witnessed firsthand the
effects of people being uninsured in the Philippines.
Even though there are well-trained physicians and
well-equipped hospitals, health-care support from the
government is limited, he told ASH Clinical News. With-
out federal assistance, most of the population is unable
to afford the costs of care. The country is just starting to
roll out insurance for a wider swath of the population,
he said.
Dr. Besa completed his medical training at the
University of the Philippines Medical School before
doing his post-doctoral studies in hematology/oncology
at the University of Pennsylvania and, ultimately,
joining the Sidney Kimmel Cancer Center at Thomas
Jefferson University in Philadelphia.
On a recent visit to Philippine General Hospital,
December 2017