Felicia Marie Knaul, director of the University of Miami Institute for Advanced Study of the Americas (USA) spoke with us about the major challenges facing countries in the region in the fight against cancer.
What is the obstacle that struck you most from those found in the report?
Let’s go for parts. First the rectory. Most countries lack a national cancer program to have a registry and follow-up. So, there we have to do a lot. In the financing part, some countries have greatly innovated through reforms of their health programs towards universal coverage. Chile and Colombia, of course, but they are just a few. So, having fragmented systems where funding does not cover all of us is fostering inequity. In terms of service provision we have options to solve part, but not all, of the challenges that cancer represents. There is a wall between the third level (the specialist) and the first and second level (general practitioner and nurse) to generate a support network for the patient.
Do you have valuable stories from the region that we can all learn to overcome these obstacles?
In Mexico in 2004 with the Seguro Popular there were not enough resources and we had to choose what cure and what not, a decision that is terrible and was based on evidence on the possibility of saving lives in the most sensitive and the first thing they included was acute lymphoblastic leukemia in children. We have seen a great improvement in access to medicines and in the survival of children with cancer in the country. That is a very good example. Another is breast cancer that entered the Seguro Popular in 2007 and what we have seen are results in adherence to treatment. If in 2005 a third of women left the treatment of breast cancer because there were no resources today they are less than one percent percent. The problem is that there are many cancers not covered because there are not enough resources.
What these examples show is that if you work in a focused way, the numbers go down?
Yes, they improve a lot.
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Any examples of Colombia?
Yes, one that gives me much light and hope. Here the great challenge in Colombia was that if the constitutional access to medicines was given, the system was broken down by ineffective and very expensive drugs. The importance of setting a basic framework, an essential package and ensuring that this package is fulfilled for low-income people – because if not those people have nothing – that for me is the axis of a reform. I have no doubt that it must be expanded. I also have no doubt that there are patent medicines, such as trastuzumab, that are costly but effective and you have to see how to seek funding for them. But there are others, many, who extend life very little.
In access to pain and palliative care, what should be done?
We are about to take an article in Lancet on this subject. We are talking about the importance of offering palliative care to everyone from diagnosis when it is a disease like cancer that can kill you. No one knows, but people need to talk about those issues. With palliative care one can have a longer dignified life and with much less pain.
Many understand palliative as a resource when there is no option. Is it different now?
That should not mean that. The problem is when they tell the patient “you should choose between treatment and palliative” and that happens. They should be both at the time, but you should not invest in treatments that do not help. Another thing we have seen is out of very effective patent medicines.
And cheap …
Yes, many are old and their profit margin is low and they stop producing. I’m talking about things like morphine, in pain control. It’s cheap, worth cents, and it’s effective. I’m talking about immediate action. However, we are going to look for patches and other more expensive drugs and poor people then die in pain when there are cheap medications that can help alleviate them. In the case of children’s cancer, it is impressive because there are third-line drugs, thanks to which in Canada there is a 90 percent survival of cancer, but there are many out-of-patent chemotherapies that would help these countries reach 50 percent cent survival to 75, which is a lot. You have to do that first.
Make sure you give the basics first …
Let’s make sure we give the basics: prevention, early detection and basic treatment, but also make sure that in the basic treatment we are covering first what is effective and cheap and then we go with what is expensive. At least in terms of public funding because much can be done with out-of-patent drugs, not everything, but a lot.
How to make richer countries help us with ideas that can be applied in these poorer countries?
They can help a lot. In Canada and the United States, in breast cancer we have seen a drop in mortality between 35 and 45 percent and is for two reasons: early detection and access to treatment. So, science has advanced and there is armament to fight against breast cancer and that is thanks to science in countries like Canada and the United States. Countries like Mexico and Colombia can take advantage of this science that already exists and not everything has patent. Tamoxifen is out of patent, it is a cheap drug. Let’s talk about tele-medicine. More and more the cancer is personalized so the doctor who knows the most about my tumor with its characteristics is in China and I do not have to travel there to analyze my case.