Ophira Ginsburg, MSc, MD FRCP (C). Scientist, Women’s College Research Institute Assistant Professor, Medicine, Public Health University of Toronto. Ophira is an innovator in the Stars in Global Health program (Round 2).
Tuesday, February 4th, is World Cancer Day. This day has special meaning for the millions of people worldwide whose lives have been touched by cancer. So it’s a good time to ask ourselves: How has cancer affected me personally? Or impacted those I love?
In Canada, one in three of us will develop cancer in our lifetime, and it will kill one in four (Canadian Cancer Society Statistics 2013). In fact, cancer is now the leading cause of death in Canada. Sad as this is, let’s take a moment today to consider the situation for a man, woman or child in a low- and middle-income country who, in the coming year, will hear the word “cancer”. In 2012, there were 14.1 million new cases, 8.2 million cancer deaths and 32.6 million people living with cancer (Globocan 2012). That’s more than HIV/AIDS, TB and malaria combined. Each year, 200,000 more women die from breast and cervical cancer than from complications during pregnancy or when a child is born. Around the world, from Bangladesh to Brazil, in low-resource countries on every continent, cancer is now among the top causes of premature death and disability. So, can any of us really say that cancer doesn’t affect all of us?
For women in the so-called “developing world”, there will be little access to prevention or early detection of cervical cancer, to a proper diagnosis or to good quality surgery for breast cancer and, for all people with advanced cancer, little or no chance to reduce pain and suffering. In many countries, myths about cancer, taboos about the female body and gender inequity create yet more barriers to seeking proper medical care if they have a breast symptom.
Far from writing this to overwhelm, demoralize or depress you, I want to share some good news. Much can be done to reduce what Felicia Knaul and others call the “cancer divide”.
In fact, there are many reasons for hope! Opportunities abound to reduce the odds of developing some cancers, to detect some common cancers early when good quality, relatively low-cost interventions such as surgery can save lives, and to reduce pain and suffering from advanced cancer. On the prevention front, taxation and other policies to help smokers quit and prevent young people from starting to smoke are effective ways to reduce the incidence of lung and other tobacco-related cancers. Similar efforts to reduce the harmful use of alcohol can lower the odds of developing many cancers, and HPV vaccination for young girls can greatly lower the risk of cervical cancer. Three of the most common cancers (breast, cervical and colorectal cancer) can be effectively and cheaply treated if detected early. For those with advanced cancer, inadequate pain control can and will become an injustice of the past. The upcoming Disease Control Priorities (DCP-3) volume on cancer will describe some of the evidence for these approaches, with specific relevance to low- and middle-income countries.
And, thanks to Grand Challenges Canada, which is funded by the government of Canada, innovators and healthcare providers in developing countries can take advantage of the Stars in Global Health program to test innovative approaches to close the cancer divide in their own settings, while offering new models for prevention, cure and care that may be of benefit for those far beyond their borders.
To cite just one example of how an award from Grand Challenges Canada can help to model solutions for cancer care and control in resource-constrained settings, I am excited to share the findings of our Grand Challenges Canada-funded project in rural Bangladesh, recently published in The Oncologist, “An mHealth Model to Increase Clinic Attendance for Breast Symptoms in Rural Bangladesh: Can Bridging the Digital Divide Help to Close the Cancer Divide?”
Over the past 18 months, our Bangladesh-based team conducted a randomized controlled population intervention trial in Khulna Division, Bangladesh, to test whether community health workers (CHWs) equipped with smart phones and our tailored “apps” could effectively and efficiently ‘case-find’ and encourage women with undiagnosed breast symptoms to go to our local clinic. Group 1 CHWs were given smart phones with our special applications to help health workers to guide interviews, show a motivational video (including testimonials by women who had been to our clinic), perform a breast examination for women who reported a current breast problem, and offer a clinic appointment for women with an abnormal breast exam. Group 2 CHWs had the same smart phones and apps, plus an extra day of “patient navigation” training to address potential social, cultural or logistical barriers to seeking care. Group 3 CHWs were the control group, without phones. They conducted the same interview and offered a breast exam as with Groups 1 and 2, but were only given a pen and paper to record the data and offer an appointment.
In June 2012, we hired and trained 30 female CHWs, young women with highschool education and good literacy skills, to conduct the door-to-door interviews and breast exams. We also hired three women with some university education and prior experience as the CHW supervisors. They, in turn, reported to our field operations management team in Bagerhat District, where the study intervention area had been already mapped, and allotted according to proximity to the clinic, socio-demographics and other factors. In only four months – two months sooner than we expected –our CHWs interviewed over 22,000 women. Compared to CHWs without smart phones (Group 3), those with smart phones (Group 1) were more efficient and effective in promoting breast health and encouraging women with a breast cancer symptom to go to the clinic or local public hospital. CHWs with extra “navigation” training (Group 2) were even more successful in encouraging women with an abnormal breast exam to attend for care.
To our knowledge, this is the first study to suggest that in places with minimal cancer control infrastructure, a locally based, multidisciplinary team can improve breast cancer care and help break down the barriers to seeking medical advice.
Now, how can we take what we’ve learned and make a bigger impact to reduce suffering and deaths from breast cancer in Bangladesh? While developing a plan to improve and adapt the model for the rest of the country, we are expanding our local partnerships and sharing our findings more broadly. In November 2013, I presented the project at the bi-annual conference of the African Organization for Research and Training in Cancer (AORTIC) in Durban, South Africa. Our model generated much discussion and enthusiasm to try similar projects in sub-Saharan Africa, and plans are now underway to assist a breast surgeon in Nairobi, Kenya, to adapt the model for her peri-urban setting.
So, in honour of all people affected by cancer wherever they live, let’s work together to dispel myths, share knowledge and make a real impact to close the cancer divide! Find out what’s happening in your community this World Cancer Day and sign the World Cancer Declaration!