ASTRO 2015

Challenge of cancer in middle-income countries with an ageing population

Dr Ajay Aggarwal – London School of Hygiene and Tropical Medicine, London, UK

There was a recent paper that I submitted and was published in ecancer related to the challenge of dealing with cancer in middle income countries and this was focussing on Mexico in particular. There’s a lot published about the demographic transition, populations are surviving communicable diseases and living longer and that results in aging and naturally there’s an increase in the number of cancers that occur. But one of the things that I was interested in is what does it mean for the elderly patients in those countries who are actually getting more of those cancers. So if we take Mexico, for instance, by 2035 there’s going to be a 70% increase in the number of cancers per annum incidence. Of that 60% of those cancers are going to be in men and women over the age of 65. When you delve deeper though, there’s a social inequity so the elderly in Mexico often have poor health literacy, worse access to health services, issues with social security and being able to pay for treatment. One of the areas that we looked at in the analysis was to try and understand what were the main cancer types that elderly patients suffer from. So predominantly a lot of work had been done in cervical and breast cancer which affect a younger population cohort whereas in the elderly population lung cancer, gastric cancer and hepatocellular cancer predominate.

So we delved into this a bit deeper and actually in terms of the social security system one of the big things about Mexico is that they introduced a pattern of social health insurance called Seguro Popular which granted access to healthcare services for the poorest section of the population and financial protection, essentially, from the burden of ill health. However, not everyone is covered, especially a number of the elderly patients. Particularly for cancer care they included a number of different cancers under that social protection, however they didn’t include at the time of the study being submitted lung cancer, gastric cancer and liver cancer. So you’ve got this issue where, yes, you’ve got this aging population and they’re going to suffer from a particular set of diseases but actually they’re not accounted for within the social security system at the moment. So it was highlighting those fundamental issues and that not just Mexico alone but geriatric oncology is incredibly important and should be a political priority for those areas.

How does that then affect the resources or treatment of patients?

When you look at any of the literature in middle income countries, late presentation and advanced stage of diagnosis is one of the big issues. If you don’t understand the inherent challenges faced by men and women, elderly men and women, you can’t open up those access boundaries or educate that population as to the risk factors that they need to look out for. So actually it could have a detrimental impact on the mortality outcomes but we need more data.

What about prevention or screening?

It’s very sporadic. Actually if you take something like prostate cancer there were some studies that have been done in the elderly looking at prevention and screening and actually many are scared of having interventions such as a digital rectal examination; endoscopies and things are very expensive, mammographic screening is often dependent on how you publicise the need for mammography. And actually as part of the data that we submitted we showed that actually there was a clear gradient in age versus mammographic uptake. So there’s a lot of work that needs to be done.

What further research will you be doing in this area?

What we found useful about doing the piece of work is that it provided a marker point of where a country like Mexico is with such a vast population. Moving forward, it’s important to actually look at other countries because obviously you have to take in the population heterogeneity. But it’s also continuing to look at those elements, that it’s not just about your health system in terms of cancer care, it’s about the wider factor, the social determinants, the education that you provide, the place in society of elderly individuals and the affordability of treatment.

Who is responsible for taking action on the findings?

We had a collaborator from the National Cancer Institute in Mexico City, Karla Unger-Saldaña, and she worked on this and she’s done a lot of work in breast cancer. It has been obviously through the ecancer portal being free at the point of access, I think that’s very important for dissemination, we’ve also tried to publicise this as much as possible. But it has to be seen as a piece of background work that’s built on going forward.

Is there anything else to highlight about the research?

Interestingly, what we did look at was all the research publications from the 1990s onwards using a bibliometric analysis which was a quantitative analysis of research output using publication titles. What we found for somewhere like Mexico and its cancer care, where you do have late stage of diagnosis, prevention and screening still need some work, that actually the majority of the research being undertaken in Mexico with cancer care is still in genetics and chemotherapy and prognostic markers and very little in epidemiology, quality of life, palliative care, which is incredibly important.