How To Bring Cancer Care To The World's Poorest Children

It's one of the great achievements of oncology: with advances in treatment, cure rates for children with cancer in North America now exceed 80%, up from 10% in the 1960s.

Yet for kids across the developing world, the fruits of that progress remain largely out of reach. In low- and middle-income countries, restrictive access to affordable treatment, a shortage of cancer specialists and late diagnosis dooms more than 80% of pediatric patients to die of the same illnesses.

That's one measure of what's known as the "global cancer divide"— the vast and growing gap in access to quality cancer care between wealthy and poorer countries, and the suffering and death that occurs disproportionately in the latter.

Nowhere is that divide more pronounced than among children, and it's driven in large part, experts say, by perceptions of pediatric cancer care as too costly and too complicated to deliver in low-resource settings. Those assumptions, they say, prevent policymakers from even considering pediatric oncology when setting national health priorities.

But one hospital in Rwanda is rewriting that narrative.

Built and operated by the Ministry of Health and the Boston-based charity Partners In Health, the Butaro Cancer Center of Excellence is unique in the region: a state-of-the-art medical facility providing the rural poor with access to comprehensive cancer care. And a new study shows that Butaro's pediatric cancer patients can be cared for, and cured, at a fraction of the cost in high-income countries.

"There's this myth that treating cancer is expensive," says Christian Rusangwa, a Rwandan physician with Partners In Health who worked on the study. "And that's because the data is almost all from high-income countries."

Published in 2018 in the Journal of Global Oncology, the study showed that for patients at Butaro with nephroblastoma and Hodgkin lymphoma, two common childhood cancers, a full course of treatment, follow-up and social support runs as little as $1,490 and $1,140, respectively.

Much of the savings, the authors report, comes from the low cost of labor, which for the entire cancer center amounted to less than the average annual salary for one oncologist in the United States. They also cite strong partnerships with Harvard and the Dana-Farber Cancer Institute, whose Boston-based specialists volunteer their expertise on difficult patient cases via weekly video conferences with Butaro's general practitioners.

"Most people don't think about childhood cancer in terms of return on investment," says Nickhill Bhakta, a pediatric oncologist with St. Jude Children's Research Hospital in Memphis, which has put in place similar partnerships with institutions in Singapore and China. "But there's a growing body of literature showing that, for governments, treatment is surprisingly cost-effective."

Bhakta says some of the most compelling evidence for the cost-effectiveness of care in poor countries comes from Uganda, where in March, researchers reported remarkably low costs of treating Burkitt's lymphoma, or BL. The most common childhood cancer in sub-Saharan Africa, BL is rapidly fatal, often within weeks. Yet when treated promptly, intensively and with supportive care, more than 90% of children survive the disease.

Worldwide, childhood cancers are relatively rare. But as Bhakta and colleagues reported in February in The Lancet Oncology, they're a far bigger problem than previously believed. Close to half of all children with cancer go undiagnosed and untreated, they found, suggesting that the already low survival for these cancers in low- and middle-income countries "is probably even lower."

"The naysayers will say, 'we don't have pediatric oncologists in Africa, how would we possibly address this problem?' " says Felicia Knaul, a professor of public health at the University of Miami. "And that's why partnership models, like those supported by Dana Farber and St. Jude, are so important — they've shown that you can bridge that gap and have a tremendous impact."

In 2009, Knaul, then director of the Harvard Global Equity Initiative, led a push to expand cancer care across the developing world, where a growing burden of disease had garnered little attention globally. "We challenge the public health community's assumption that cancers will remain untreated in poor countries," she and colleagues wrote in a 2010 "call to action" published in The Lancet, noting "similarly unfounded arguments" against the provision of HIV treatment.

In the early 2000s, more than 20 million people were living with HIV in sub-Saharan Africa, yet fewer than 50,000 had access to antiretroviral therapy. Though the life-saving drugs were, by then, widely available in the U.S., skeptics warned that treatment in Africa wouldn't be cost-effective.

Prevention, they asserted, was the only feasible way forward. "The two most important interventions are monogamy and abstinence," Andrew Natsios, then head of the U.S. Agency for International Development, told reporters in 2001. "The best thing to do is behave yourself."

Two decades later, echoes of that attitude reverberate in the global cancer divide; even as cancer rates continue to climb across the developing world, low and middle-income countries account for just 5% of global spending on the disease.

Still, recent years have seen important gains.

In 2017, the World Health Assembly, the World Health Organization's decision-making body, adopted a resolution on cancer that for the first time urged its member states to address childhood cancers. And in 2018, St. Jude and the WHO launched the Global Initiative on Childhood Cancer, a five-year, $15 million partnership aimed at aimed at ensuring that all children with cancer can access high-quality medicines. Their goal: to cure at least 60% of children with the six most common types of cancer by 2030.

"Here in the U.S., it was the suffering of children with acute leukemia that drove Sidney Farber to develop our first real chemotherapy drug," said Meg O'Brien, vice president for global cancer treatment at the American Cancer Society. "I don't think Dr. Farber or any of the tens of thousands of oncologists, nurses or scientists who have worked in cancer research or treatment in the years since would be content to see that what we consider one of our greatest triumphs in the battle against cancer has yet to reach children in low- and middle-income countries."

Patrick Adams is a freelance journalist based in Atlanta, GA. Find him on Twitter at @jpatadams

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