Prevent or Treat in Latin America

• Education is the basis of prevention.
• While screening becomes more important every year, in Latin America COVID-19 has negatively affected this practice.
• In low-resource countries, there are groups of patients who do not have access to health care. Inequality in Latin America affects prevention and early detection as well as palliative care, with high costs as a result.
• We need to reduce the impact of COVID-19 on inequality.
• It is important for low- and middle-income countries to cooperate and share the innovative discoveries on the basis of reciprocity.

Cancer is a huge global health challenge. In Latin America cancer was the second leading cause of death in 2019 after cardiovascular diseases. The situation is quite serious. The most frequently diagnosed types of cancer in men are prostate (21.7%), lung (9.5%) and colorectal (8.0%); in women, the most frequent cancers are breast (25.2%), lung (8.5%) and colorectal (8.2%) (PAHO 2020).

Latin America comprises 20 countries with a total of 650 million inhabitants. Of those 20 countries, all have different health policies, different economies, and different budgets dedicated to health in general. In 2014, the countries of the region committed to investing at least 6% of their Gross Domestic Product in the health sector but very few have succeeded. Uruguay, Costa Rica and Cuba are the only countries in the region that comply with this agreement.

Oncological Challenges in Latin America

The position of the World Health Organization (WHO) is very clear: we should prevent! If we do this, the occurrence of cancer could be lowered without having to fight it. Prevention has been shown to be cost-effective for cancer care (Bray 2015). Education is the base of prevention and is necessary to achieve early diagnoses, develop friendly health systems that are receptive to the requirements of patients, and unite society.

Further to this, the states and the pharmaceutical industry should manage the rising price of treatments and make the treatment accessible to patients who need it. For example, in Latin America, cervical cancer remains one of the most common types of cancer in women and can be prevented with vaccination against the human papillomavirus (HPV), in addition to screening and treatment for precancerous lesions. Another example worth mentioning is the commitment of countries like Uruguay and Brazil to tobacco control, with measures such as designating public places and workspaces to be 100% smoke-free, printing strong messages on cigarette packs, and imposing heavy taxation of tobacco.

A big issue in Latin America is the lack of screening records that enable early detection. Screening is not appropriate for all types of cancer and, for some types, the cost makes it prohibitive in countries with lower economic development. Problems with programme structure, quality service, infrastructure, monitoring and integration with other health services prevent better use of screening (Kielstra 2017). In addition, most of the human resources and specialised equipment for cancer control continue to be concentrated in urban areas, therefore diagnosis is unlikely in rural areas. In addition, travel expenses are added to the effective cost of treatment for people living far away from the main cities.

It is necessary to mention that these issues around screening have worsened since the start of the COVID-19 pandemic. Social lockdowns and travel restrictions have had a negative impact on both screening and care for cancer patients. Screening interventions and visits were postponed from March to June 2020, leading to delayed diagnosis and late treatment of new cases. If this substantial decline in screening tests continues, there will be a related decrease in confirmed cancer cases, but only in the short term. There will, however, be an increase in cancer cases later, which will sadly entail the diagnosis of more advanced stage cancers. As a consequence, there will be an increase in cancer mortality and direct costs associated with treating patients at more advanced cancer stages (Slacom 2020)

The problem is worse for those who can neither afford private insurance nor get insurance provided by the social security system. Few countries, for example, Costa Rica, Brazil, Colombia and Uruguay, have what could be described as universal coverage of health care. Other countries generally struggle to meet the needs of the uninsured. Some countries, such as Mexico, are creating specialised insurance; others, such as Paraguay and several Argentine provinces, offer free hospital care within their public systems.

It is even more important to emphasise prevention and education of the population in these situations. If tobacco use and other key risk factors are regulated, between 30% and 50% of cancers are potentially preventable and about 30% could be cured if diagnosed early and treated in a timely and effective manner. Failure to encourage effective care policies that improve public prevention and early detection has a detrimental effect on both cancer control, social welfare and economic growth.

This inequality in Latin America affects the prevention, early detection of tumours and the stage of palliative care. Government budgets for health in Latin America are low compared to those in developed countries. According to WHO, less than 30% of cancer patients in low-income countries have access to care and treatment compared with 90% in high-income countries. Furthermore, cancer has often been a low priority in distributing such limited funds. Most countries have insufficient resources to meet current cancer needs and even less for future needs because of these budget decisions. They cannot implement active plans for needs like palliative care. There is a need for more staff in oncology; to give an example, the number of specialised oncology nurses trained in Brazil would cover only half of São Paulo’s current needs. Only Uruguay and Chile have enough radiotherapy equipment to treat all patients in the country (Goss et al. 2013).

As a result of the COVID-19 pandemic, planned operations were postponed, including chemotherapy, radiotherapy, and palliative treatment. Diagnosis at later stages will mean a significant increase in cancer care costs compared to pre-pandemic levels.

Until recently, Latin American countries had relatively few population-based cancer registries, providing information for designing effective cancer control and evaluating the impact of initiatives on cancer policies. In low-resource countries, there are groups of patients who do not have access to health care; there are people who do not get mammograms, get vaccinated, nor have access to screenings. This makes it difficult to collect proper, reliable, and unbiased data (Kielstra 2017).

What Needs to Be Done?

Urgent action should be taken to reduce the impact of the pandemic on poverty. Before the COVID-19 pandemic it was already important to establish a permanent dialogue and cooperation between healthcare systems and economy sectors, involving professionals not specialised in oncology or in the care for cancer patients. We can reduce the economic and well-being impact of cancer on patients through the effective use of communication resources, the development of care networks and the structuring of different levels of responsibility for clinical routes. A good example here is the ‘M-Tiba’ smartphone-based payment facility for health care in Kenya.

Another case is our work at Inspire2Live, a patient advocacy platform launched in the Netherlands and expanding worldwide through the development of hubs. We aim to establish a world campus with patients, researchers and clinicians working together to get cancer under control and live balanced lives in harmony with cancer.

An example of this collaboration is the ‘Teddy Bear Project’ run as part of our Latin American hub. The project is based on the promotion of photoprotection of patients with Xeroderma pigmentosum (XP). XP is an autosomal recessive disorder caused by a germinative mutation that impairs the DNA repair process. Patients with this condition are at high risk of developing skin cancer. The ‘Teddy Bear Project’ aims to provide UV-protective hats, full-face UV-protective visors, sunglasses, sunscreen and UV-protective shirts to XP patients because for them photoprotection directly leads to cancer prevention and improves the quality of life.

To be continued…

Conflict of Interest

None. 

We would like to thank Barbara and Mark Moss, patient advocates from Inspire2Live, for their assistance.