cancer, treatment, access, chemotherapy, radiotherapy, lmics, usa, global health

Despite of all declarations about efforts and plans of governments, international organizations like United Nations (UN), World Health Organization (WHO), International Atomic Energy Agency (IAEA) and the big cancer societies and unions in the world , it is needless to say the gap between the required and the available cancer drugs and radiotherapy services increased in the last decade in the low and middle income countries (LMICs).^1–3 In an article published in 2015 the contributors from different affiliations and including the IAEA replied a critical question about “Have we made a progress regarding global access to radiotherapy services in the past decade?”. They emphasized that it remains a deficit of more than 7,000 radiotherapy machines in the world and the gap between the required and the supply is rising particularly in LMICs.⁴ In May, 2013, WHO declared and published a global action for the prevention and control of non-communicable diseases for the next 7 years till the year 2020. This plan implies 80% affordability of essential cancer drugs and medicine by the year 2020 worldwide.⁵ Today in 2017, after 4 years of the 7 years plans, there is no sign of any remarkable progress toward achievement of the objective.

If the movement continue in the same way of reports, conferences, commissions, task forces , that end with reporting the tragic situation and data, with calls and plans of actions to improve the picture by 2020 0r 2025, but without focused and globally coordinated scientific works to explore unlimited approaches to resource sparing and cost effective care and with shortage of practical tactics that consider the incentives and interests of all stakeholders and mobilisation of every possible resources ; financial and human resources and allies in win-win scenarios that cope with the real world, then it is expected that the problem will tragically escalate in the upcoming 10 years particularly in LMICs.⁶ In addition to the lack of foreseen remarkable increase of radiotherapy and medical oncology services, there are -among others causes- the increase in cancer incidence and prevalence in LMICs partially due to increase in population, increase of life expectancy , lower mortality due to communicable in comparison to non-communicable diseases and change of life style.^7,8

In this editorial, based on the notions of the win-win initiative,⁹ a brain storming proposal is presented to save the expenses paid by pharmaceuticals and radiotherapy manufactures for the travels of oncologists from LMICs to attend international conferences. The saved sum could be one of resources to increase cancer care services in some underserved regions.

In December, 2007, The Win-Win scientific initiative was first proposed by Experts in cancer without borders of the International Campaign for Establishment and Development of Oncology Centres (ICEDOC).^6,10 In 29 April, 2016, The Win-Win Initiative joined Harvard Global Health Catalyst GHC and becomes one of its activities. The first wing of the initiative aims at the increase of affordability of value based cancer treatment in the world by exploring scientific avenues that result in cost saving and scientific allocation of resources without compromising the overall outcome and quality of life of patients.^6,9

In fact, the problem of skyrocketing increase in cost and lack of access of cancer care is touching high income countries too. There are frightful predictions for the future of cancer care in the USA.^11,12 Hence, The win-win initiative has global scientific approaches. Some of the scientific published works with the win-win notions are about brain storming directions on how to lessen the problem of shortage of essential cancer drugs and generics in the USA.^13,14 Moreover, in other published works, it tackled how could LMICs contribute scientifically in global enhancement of value based cancer care and in relevant researches.¹⁵

To be realistic, the interests and incentives of all the stakeholders are considered, hence, all would win but with emphasis on decreasing the burden on cancer patients and their families as a main goal. This also aims at progress of science and flourishing the business of pharmaceutical companies and manufacturers of radiotherapy equipment and medical devices without ruining a country or individuals economies.⁶

The second wing of the initiative regards the catalyst action and the professional advice to increase enormously the rate of establishment of services of clinical oncology worldwide starting with the part of most difficult challenges that is Africa. The initiative is not a funding body. The challenges are enormous, so, as a facilitator, the win-win initiatives encourage collaboration, coordination and partnership to mobilize all potential local and international resources and allies in order to serve the cause of making a real remarkable increase in cancer care services in the next 10 years. Hence, the win-win initiative and notions are not competing or replacing any society, organization, body, governmental or private efforts or individuals in the world.⁹ As stated in the webs of ICEDOC “ It is a message of scientific based cooperation in fields of global cancer care and control and a message of love for all the humanity, translated into constructive and hand in hand actions”.¹⁰

The numbers of attendees from LMICS in the big annual conferences of big oncology organizations like American Society of Clinical Oncology (ASCO), European Society of Medical Oncology (ESMO), and American Society for Radiation Oncology (ASTRO) and European Society for Radiotherapy and Oncology compose of around 20%-30 % of the total number of attendance. The cost of travel, accommodation and side expenses of the attendees from LMICs are paid mostly by pharmaceutical companies and a less number by radiotherapy and medical devices manufactures. The costs are increasing. By rough estimation; the total cost could be around 40-50 million USD annually. This estimation could be more; therefore, subjected for more accurate calculation ad updates by further studies. The objective of the present editorial is to raise the idea and not to study the very accurate estimation of costs per year for every big conference around the world.

Most attendees from of LMICs are from regions that have increasing problem of shortage of affordability of cancer drugs and radiotherapy care to serve their increasing numbers of cancer patients. We suggest that the sum of 40-50 million USD - or whatever the sum would be- is better spent by companies-better without intermediary- as follows: 1) The big fraction would be for providing cancer drugs , either free or at lower price , or to assist in increasing radiotherapy services in selected certain locations every year. 2) The other fraction could be for: a) after arrangement, companies would cover fees for special registrations for online live attendance using information and communications technology (ICT) to be held in local universities or local hospitals, where local attendees could send some questions or comments in some interactive sessions, in addition to the online access to all sessions. It could be a privilege by companies for LMICs unless the attendee pays for him/herself. Hence, once again, it is win-win approach as more attendees from LMICs would effectively participate (without long travels, shopping , excursions and without the usual scene of thousands persons out- and not in- the lecture halls) , The distinguished big cancer society’s will achieve more of their scientific goals, while the organizers of big conferences will still gain money of group and individuals online registrations b) To support some annual short fellowships for older or short training for the younger oncologists in some institutes or departments in USA or Europe. It could be also for some South to South short scientific visits Or C) to support some selected research projects in LMICS or to support in training of local staff in order to conduct valid research and to participate in clinical trials.

All these, would be more beneficial than what could be called as a sort of “Onco-Tourism” in the occasions of big conferences. In fact, if we look deeply, then the real financial burden from “Onco- Tourism” may mostly come from exhausting resources of patients or their countries. This should be re- seen with ethical considerations and as a violation of human rights by unnecessary financial abuse and may be also physical hurts to cancer patients by some non- value based interventions. Hence, more attention should be paid for researches, training and scientific works on how to get better value cancer care.^16,17

Pharmaceuticals companies and radiotherapy and medical equipment manufactures would be free to select in what of the above –or more- purposes to spend directly by them or via their access of care or social departments. So, no extra-cost for overhead are required. The roles of The Win-Win initiative or similar endeavours could be as volunteer advisers or to coordinate as catalysts.

To not to be taken as theoretical dreamer, one of the recent examples is that a pharmaceutical company responded to the win-Win notion by agreeing to fund the building a radiotherapy bunker in the new project of West Kenya Cancer Centre in Kisumu, Kenya. The same company funds fellowship cancer care training in Tata Memorial Centre, India for candidates from Africa from Africa. Recently, this leading pharmaceutical company is negotiating an agreement to fund the post graduate studies of the Master Degree in Clinical Oncology in Alexandria University, Egypt for a number of medical graduates from different African countries. Hence, they will be qualified clinical Oncologists with skills to run or to contribute in running radiation and medical oncology service and palliative care.¹⁸

No one could imagine that the annual sum of 40-50 million USD would solve the immense problems, but it could help. We ask for mobilisation of every possible international and local resource to increase affordability of better value cancer care for more human beings in the real world via win-win scientific approaches in which no one would lose.

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The authors declare that there is no conflict of interest.

1. Farmer P, Frenk J, Knaul FM, et al. (2010) Expansion of cancer care and control in countries of low and middle income: a call to action. Lancet. 2010;376:1186–1193  
2. Cazap E, Magrath I, Kingham P, et al. Structural Barriers to Diagnosis and Treatment of Cancer in Low- and Middle-Income Countries: The Urgent Need for Scaling Up. J Clin Oncol. 2016;34(1):14–19.  
3. Atun R, Jaffray DA, Barton MB, et al. Expanding global access to radiotherapy. Lancet Oncol. 2015;16(10):1153–1186.
4. Yap ML, Zubizarreta E, Bray F, et al. Global access to radiotherapy services: have we made progress during the past decade?. Journal of Global Oncology. 2015;2(4):207–215.  
5. Collingridge D, Sullivan R. Affordable cancer care: pipedream or achievable reality?. Lancet Oncol. 2014;15(3):257–258.
6. Elzawawy A. Science and Affordability of Cancer Drugs and Radiotherapy in the World - Win-Win Scenarios. In: Ravinder Mohan (Ed.), Advances in Cancer Management. InTech. 2012;255–278.
7. Ferlay I, Soerjomataram M, Ervik D, et al. GLOBOCAN 2012 v1.0 Cancer incidence and mortality worldwide: IARC Cancer Base No. 11. International Agency for Research on Cancer, Lyon, France. 2013.
8. Stewart B, Wild C. World Cancer Report. IARC, Lyon, France. 2014.
9. The Win-Win scientific initiative.
10. International Campaign for establishment and development of oncology centres & ICEDOC's Experts in cancer without borders (ICEDOC).
11. Medscape. ASCO Makes Dire Predictions for the Future of US Cancer Care. 2014.
12. Medscape. State of US Cancer Care: Like a Dickens Novel? Medscape. 2016.
13. Elzawawy AM, Kerr DJ. Variation in the availability of cancer drug generics in the United States of America. Ann Oncol Suppl. 2013;5:v17–v22.
14. Elzawawy A. The Shortage of Essential Cancer Drugs and Generics in the United States of America: Global Brain Storming Directions for the World. Int J Cancer Clin Res. 2015;2(2):016.
15. Elzawawy AM. Could African and Low- and Middle-Income Countries Contribute Scientifically to Global Cancer Care?. J Glob Oncol. 2015;1(2):49–53.
16. Brook RH. The end of the quality improvement movement. Long live improving Value. JAMA. 2010;304(16):1831–1832.
17. Muir Gray JA, Kerr DJ. How to Get Better Value Cancer Care. Offox Press Ltd, Oxford, UK. 2013.
18. Western Kenya Cancer Care Centre (WKCCC) Project. December 2016 Newsletter.