World Child Cancer and Students for Global Health Essay Competition Winner

Closing The Cancer Gap: Why Addressing Childhood Cancer Inequality Is A Global Priority

by Sabrina Taylor (University College London Medical Student)

The last decades have witnessed something of a renaissance in childhood cancer therapies and cure rates. However, these improvements have been unevenly distributed between high-income-countries (HICs) and low-and-middle-income-countries (LMICs). Of the estimated 200,000 children diagnosed with cancer each year, 80% live in LMIC, which accounts for around 90% of all childhood cancer deaths. [1] By highlighting the reasons for such disparities between HICs and LMICs, this article aims to confirm why addressing childhood cancer inequality should be considered a global healthcare priority.

Why is this an important issue?

A child is diagnosed with cancer every two minutes. [2] By the time this article has been read, another child has likely embarked on a demanding and life-changing journey.

Receiving such devastating news is difficult for any child and their family, but this feeling of hardship is often exacerbated for those living in LMICs. Despite advances in cancer medicine that can now treat 80% of paediatric cancers, 100,000 children still die from cancer every year, with LMICs taking the lion share of these tragedies due to a poor healthcare infrastructure. [3] As such, the harsh reality for many children is that cancer treatments are either unattainable or unaffordable simply because of where they live. This large variation in global childhood cancer burden is illustrated in Figure 1. [4] As a result, healthcare inequalities threaten the attainment of the political commitments set out in the 2030 United Nations Agenda for Sustainable Development outlined in Figure 2.

Unsurprisingly, this has sparked widespread urgency among policymakers and governments to understand the reasons for these disparities. [5]

Sabrina Taylor Child Cancer's Toll World Child Cancer
Sabrina Taylor The UN Agenda Figure 2 World Child Cancer

What are the reasons behind global childhood cancer inequalities?

In HICs, cancer represents the leading cause of death among children. Whether the same paradigm is true for LMICs remains elusive given the paucity of national cancer registry systems. It has been postulated that poor cancer survival outcomes in LMICs are dictated by:

1) limited healthcare access

2) malnutrition

3) inferior palliative care [6]

These three factors thus offer an explanation as to why most childhood cancer deaths occur in LMICs.

Firstly, limited healthcare access combined with a lack of public health awareness policies often results in delayed and underdiagnosis of cancer cases.

Retinoblastoma is a cancer type that exemplifies the association between early diagnosis and improved prognosis. In this scenario, around 90% of retinoblastoma cases in LMICs already present at an advanced metastatic stage, thereby revealing gaps in early diagnosis and referral pathways in these countries. [6]

Furthermore, LMICs present a challenge in integrating a multidisciplinary team of pathologists, surgeons, and oncologists, as well as the necessary medical resources needed to treat childhood cancers. Whereas medical spending per cancer case in HICs is 2.5  times the world average, LMICs possess only 5% of the global cancer treatment resources. [6,7] Therefore, the challenges of cancer care are disproportionately skewed towards countries that are least suited to deal with this burden, consequently, translating into suboptimal cancer care and poor survival rates for many childhood cancers.

Secondly, malnutrition is observed in 50-70% of children with cancer in LMICs and this is closely correlated with infectious complications, poorer survival, and greater toxicity during cancer treatment. [8,9] Counteracting such toxicities often requires blood donations to replenish the patients’ cells, particularly in children with acute lymphoblastic leukaemia. Most HICs have national-specific guidelines on how to manage these blood products safely. However, only 13% of LMICs have national haemovigilance systems to monitor blood transfusion, meaning that a child in an LMIC will not necessarily receive the same life-saving cancer treatment as one born in an HIC. [6]

Lastly, many children living with cancer in resource-limited countries are unfortunately destined to die, representing a need to prioritise palliative care in these countries. However, the restricted availability of pain management opiates in LMICs is a barrier in providing optimum end-of-life care for paediatric cancer patients. According to the International Narcotics Control Board, over 98% of analgesics used for pain control in 2007-08 were consumed in North America, Europe and Oceania, whereas Africa accounted for only 0.1%. [10] This inequality showcases how the distribution of fair palliative cancer care and medication is not fully met and initiatives to resolve this imbalance should be explored.

Is the cancer gap closing?

The Lancet report ‘Sustainable Care for Children with Cancer’ forecasts that 14 million children will develop cancer worldwide by 2050, and around 6 million of these cases will go underdiagnosed or untreated if efforts to enrich global healthcare systems are ignored. [11] This prediction rang alarm bells ringing for governments to collaboratively find solutions that addressed these variations in childhood cancer care.

The UN Millennium Development Goals is an example of this initiative where governments agreed to achieve measurable improvements in the most important areas of society, including poverty, malnutrition, and diseases. [6] Arguably, these developments should indirectly improve childhood cancer care by tackling the root causes behind these inequalities in the first place.

Similarly, the World Health Organisation Global Initiative for Childhood Cancer programme also aspires to work across borders to improve outcomes for children cancer patients worldwide. Considering that only 20% of children in LMICs survive cancer, the ultimate goal behind this programme is to achieve at least a 60% survival rate for childhood cancers globally by 2030. [5] Despite disruptions to cancer treatment programmes caused by the COVID19 pandemic, this initiative has already acquired 100 expert organisations to offer strategic support plans for governments to re-build their healthcare system and improve cancer care. Ultimately, tackling childhood cancer inequality is heavily dependent on effective partnerships between government and non-government organisations to improve global healthcare. [12]

Overall, these two international initiatives already showcase a step in the right direction for closing the global cancer gap. However, this only represents a microcosm of a much larger effort in tackling childhood cancer inequalities and this global movement is expected to gain momentum over the coming years. Any proposal to improve global outcomes for paediatric cancer patients in LMICs must consider its unique characteristics, including how the disease, the patient, and the socio-economic challenges differ from adult cancer care. Therefore, initiatives aiming to improve diagnosis, treatment and survival of childhood cancers must be addressed specifically from a paediatric perspective.

Without access to the correct therapeutic and supportive care, children with cancer in LMICs will continue to suffer under a healthcare system that is not tailored to their needs. Not only does this threaten their health and survival, but inequalities in a country’s healthcare system feeds into a much wider and moral picture of denying basic human necessities. Children are tomorrow’s workforce so improving cancer healthcare in LMICs will result in a healthier population better suited to drive economic prosperity and social stability.

Improving childhood cancer is an effort that requires global solidarity, collective action, and alignment of national priorities. Although addressing only childhood cancers will not overcome the inequalities seen in other childhood diseases, this cancer gap should be prioritised as an important starting point to provide equitable healthcare for all. Only then will children all over the world be able to enjoy the chance to reach a fulfilling and rewarding adulthood with the dignity that they deserve.

References

1. Kellie SJ, Howard SC. Global child health priorities: What role for paediatric oncologists? European Journal of Cancer. 2008;44(16):2388-2396.

2. Every Two Minutes a Child is Diagnosed with Cancer. Published July 18, 2016. Accessed February 26, 2021.

3. The Lancet Cancer Campaign: Paediatric Cancer. Published 2021. Accessed February 26, 2021.

4. Institute for Health Metrics and Evaluation. Graph showing childhood cancer’s toll in lost lives and disability (0-19 years). Accessed February 26, 2021.

5. World Health Organisation (WHO). WHO GLOBAL INITIATIVE FOR CHILDHOOD CANCER: AN OVERVIEW:1-21. Accessed February 26, 2021. 

6. Carlos Rodriguez-Galindo, Paola Friedrich, Lisa Morrissey, Lindsay Frazier. Global challenges in pediatric oncology. Wolters Kluwer Health | Lippincott Williams & Wilkins. 2013;25(1):1-13.

7. Farmer P, Frenk J, Knaul FM, et al. Expansion of cancer care and control in countries of low and middle income: A call to action. The Lancet. 2010;376(9747):1186-1193.

8. Israëls T, van de Wetering MD, Hesseling P, van Geloven N, Caron HN, Molyneux EM. Malnutrition and neutropenia in children treated for burkitt lymphoma in Malawi. Pediatric Blood and Cancer. 2009;53(1):47-52.

9. Sala A, Rossi E, Antillon F, et al. Nutritional status at diagnosis is related to clinical outcomes in children and adolescents with cancer: A perspective from Central America. European Journal of Cancer. 2012;48(2):243-252.

10. International Narcotics Control Board. Report of the International Narcotics Control Board for 2010.

11. Harvard T.H.Chan School of Public Health. The moral and economic imperative of improving global cancer care for kids | News | Harvard T.H. Chan School of Public Health. Published April 1, 2020. Accessed February 28, 2021.

12. Costello A, White H. Reducing global inequalities in child health. Archives of Disease in Childhood. 2001;84(2):98-102.

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