The Lancet Commission on cancer and health systems: harnessing synergies to achieve solutions
2021; Elsevier BV; Volume: 398; Issue: 10306 Linguagem: Inglês
10.1016/s0140-6736(21)01895-x
ISSN1474-547X
AutoresFelícia Marie Knaul, Patricia García, Mary Gospodarowicz, Beverley M. Essue, Naomi Lee, Richard Horton,
Tópico(s)Global Health and Surgery
ResumoStrong health systems require strong cancer systems and strong cancer systems strengthen health systems. This symbiotic relationship should be cultivated and leveraged to substantively advance universal health coverage. Yet, it has been largely ignored in global health.1Gelband H Jha P Sankaranarayanan R Horton S Cancer. Disease control priorities. 3rd edn. Volume 3. World Bank, Washington, DC2015Google Scholar, 2Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (806) Google Scholar The rising cancer burden—the number of cases will increase from 19·3 million to 28·4 million by 20403Sung H Ferlay J Siegel RL et al.Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.CA Cancer J Clin. 2021; 71: 209-249Crossref PubMed Scopus (10063) Google Scholar—and the availability of prevention and treatment options, demand a new vision. Meeting the challenge of cancer requires solutions that draw on innovation and seek out, build on, and promote synergies across systems. Cancer control and health-system strengthening have a shared future that is personalised and responsive to new knowledge, and nested in and integral to universal health coverage. Cancer epitomises the injustices of health-care access. A decade ago the term cancer divide was used to describe the unacceptable difference in survival rates for preventable and treatable cancers across and within countries.4Farmer P Frenk J Knaul FM et al.Expansion of cancer care and control in countries of low and middle income: a call to action.Lancet. 2010; 376: 1186-1193Summary Full Text Full Text PDF PubMed Scopus (464) Google Scholar, 5Knaul FM Gralow JR Atun R Bhadelia A Closing the cancer divide: an equity imperative. Harvard Global Equity Initiative and Harvard University Press, Cambridge, MA2012Google Scholar Now, affordable, implementable solutions exist, yet survival gaps persist, exemplified by childhood cancer: in wealthy countries, 90% of children have the likelihood of cure, while in the poorest countries only 10% can hope to survive.4Farmer P Frenk J Knaul FM et al.Expansion of cancer care and control in countries of low and middle income: a call to action.Lancet. 2010; 376: 1186-1193Summary Full Text Full Text PDF PubMed Scopus (464) Google Scholar, 6Atun R Jaffray DA Barton MB et al.Expanding global access to radiotherapy.Lancet Oncol. 2015; 16: 1153-1186Summary Full Text Full Text PDF PubMed Scopus (454) Google Scholar, 7Shannon GD Franco OH Powles J Leng Y Pashayan N Cervical cancer in Indigenous women: the case of Australia.Maturitas. 2011; 70: 234-245Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar This global health failure is perverse. For people with access to health services, science has changed many cancers into curable or liveable health conditions; where timely access to health services is lacking, survival is at best elusive. Even in high-income countries, health systems fail to offer universal access to high-quality, affordable cancer care.8Quaresma M Coleman MP Rachet B 40-year trends in an index of survival for all cancers combined and survival adjusted for age and sex for each cancer in England and Wales, 1971–2011: a population-based study.Lancet. 2015; 385: 1206-1218Summary Full Text Full Text PDF PubMed Scopus (255) Google Scholar, 9Horrill TC Linton J Lavoie JG Martin D Wiens A Schultz ASH Access to cancer care among Indigenous peoples in Canada: a scoping review.Soc Sci Med. 2019; 238112495Crossref PubMed Scopus (14) Google Scholar, 10Zavala VA Bracci PM Carethers JM et al.Cancer health disparities in racial/ethnic minorities in the United States.Br J Cancer. 2021; 124: 315-332Crossref PubMed Scopus (113) Google Scholar Despite progress, inequity in access, overdiagnosis and overtreatment, and escalating costs without achieving better outcomes demonstrate that cancer control in wealthy regions is no panacea. The new Lancet Commission on cancer and health systems (panel) proposes a diagonal approach to harness linkages and forge a synergistic and mutually symbiotic relationship to improve outcomes. Diagonal approaches to health-system strengthening12Frenk J Gómez-Dantés O Knaul FM The health systems agenda: prospects for the diagonal approach.in: Brown GW Yamey G Wamala S The handbook of global health policy. John Wiley & Sons, Chichester, UK2014: 425-439Crossref Scopus (7) Google Scholar, 13Knaul FM Bhadelia A Atun R Frenk J Achieving effective universal health coverage and diagonal approaches to care for chronic illnesses.Health Aff (Millwood). 2015; 34: 1514-1522Crossref PubMed Scopus (39) Google Scholar leverage horizontal systemic programmes and policies, linking them with vertical, risk factor, or disease-specific interventions. Diagonalising cancer control can drive universal health coverage,14World BankHigh-performance health-financing for universal health coverage: driving sustainable, inclusive growth in the 21st century.https://documents1.worldbank.org/curated/en/641451561043585615/pdf/Driving-Sustainable-Inclusive-Growth-in-the-21st-Century.pdfDate: 2019Date accessed: June 28, 2021Google Scholar, 15Horton S Camacho Rodriguez R Anderson BO et al.Health system strengthening: integration of breast cancer care for improved outcomes.Cancer. 2020; 126: 2353-2364Crossref PubMed Scopus (8) Google Scholar, 16Levit LA Balogh E Nass SJ Ganz P Delivering high-quality cancer care: charting a new course for a system in crisis. National Academies Press, Washington, DC2013Crossref Scopus (150) Google Scholar while harnessing systemic platforms facilitates the scale-up of cancer control.PanelWhy a Commission on cancer and health systems?1Cancer is a growing, costly, and enduring health-systems challenge.2The impact of cancer varies tremendously and is highly inequitable. Setting a high standard for cancer control everywhere and for everyone can be a catalyst for more equitable health systems.3Strengthening priority setting, system efficacy, and equity for cancer can provide pathways to alleviate health-related suffering11Knaul FM Farmer PE Krakauer EL et al.Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: the Lancet Commission report.Lancet. 2018; 391: 1391-1454Summary Full Text Full Text PDF PubMed Scopus (428) Google Scholar overall.4Cancer is among the most complex of health problems and provides a prism for understanding and responding to other health-system challenges spanning prevention to palliative care. The search for solutions to cancer can reverberate diagonally and throughout health systems.5The entire health system is needed to address cancer, positioning cancer control as especially salient for building responsiveness, agility, and resilience into health systems.6Cancer control must be data as well as information driven and can provide a beacon and a vanguard for modern, digitally enabled health systems.7Integration-empowered cancer systems generate positive externalities beyond health systems.8Rapid progress in technologies for prevention, diagnostics, and treatment are potent stimuli for transformative systemic change and leap-frogging advancement, which is especially relevant in low-income and middle-income countries.9Cancer control can demonstrate how to eliminate the false dichotomies that plague health systems. Entwining research with education, linking prevention with treatment and supportive care, empowering patients to work with providers, and engaging private and public actors are emblematic of cancer control planning.10A person-centred approach is a bedrock of quality cancer control, positioning cancer as one of the few diseases with the power to mobilise patient voices and to evoke awareness and cross-cutting health-system change. 1Cancer is a growing, costly, and enduring health-systems challenge.2The impact of cancer varies tremendously and is highly inequitable. Setting a high standard for cancer control everywhere and for everyone can be a catalyst for more equitable health systems.3Strengthening priority setting, system efficacy, and equity for cancer can provide pathways to alleviate health-related suffering11Knaul FM Farmer PE Krakauer EL et al.Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: the Lancet Commission report.Lancet. 2018; 391: 1391-1454Summary Full Text Full Text PDF PubMed Scopus (428) Google Scholar overall.4Cancer is among the most complex of health problems and provides a prism for understanding and responding to other health-system challenges spanning prevention to palliative care. The search for solutions to cancer can reverberate diagonally and throughout health systems.5The entire health system is needed to address cancer, positioning cancer control as especially salient for building responsiveness, agility, and resilience into health systems.6Cancer control must be data as well as information driven and can provide a beacon and a vanguard for modern, digitally enabled health systems.7Integration-empowered cancer systems generate positive externalities beyond health systems.8Rapid progress in technologies for prevention, diagnostics, and treatment are potent stimuli for transformative systemic change and leap-frogging advancement, which is especially relevant in low-income and middle-income countries.9Cancer control can demonstrate how to eliminate the false dichotomies that plague health systems. Entwining research with education, linking prevention with treatment and supportive care, empowering patients to work with providers, and engaging private and public actors are emblematic of cancer control planning.10A person-centred approach is a bedrock of quality cancer control, positioning cancer as one of the few diseases with the power to mobilise patient voices and to evoke awareness and cross-cutting health-system change. We apply an economics of hope, which entails planning for a future that expects, embraces, and embodies scientific and systemic innovation. Hope-guided economics internalises the permeability of cost and price accounting for the fact that high now does not need to mean high later. Hope-based investment in health systems leverages past successes in combating diseases to define the future and assumes that scientific breakthroughs can be equitably distributed to strengthen health systems and economies, benefiting entire populations. By contrast, banking on a dismal today empowers an unsuccessful, inequitable tomorrow. Mobile phone technology has revolutionised opportunities for mHealth innovation even in the poorest settings.17Osei E Mashamba-Thompson TP Mobile health applications for disease screening and treatment support in low-and middle-income countries: a narrative review.Heliyon. 2021; 7e06639Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 18Wallis L Blessing P Dalwai M Shin SD Integrating mHealth at point of care in low- and middle-income settings: the system perspective.Glob Health Action. 2017; 101327686Crossref PubMed Scopus (62) Google Scholar Global, out-of-the-box thinking has helped make several vaccines affordable and available even in the poorest countries, without stifling innovation.19Chokshi DA Kesselheim AS Rethinking global access to vaccines.BMJ. 2008; 336: 750-753Crossref PubMed Google Scholar The Lancet Commission on cancer and health systems is timely given this is a pandemic year. Health and health systems are still defined by COVID-19, but the challenges of cancer and strengthening health systems will outlive and outgrow the pandemic. COVID-19 deaths and excess mortality from cancer will be layered and concentrated in low-income and middle-income countries. Late diagnosis and impoverishment will leave families unable to afford health care, and weakened or devastated health systems will have less capacity to manage complex diseases such as cancer.20Jazieh AR Akbulut H Curigliano G et al.Impact of the COVID-19 pandemic on cancer care: a global collaborative study.JCO Glob Oncol. 2020; 6: 1428-1438Crossref PubMed Scopus (88) Google Scholar Our task is to identify pathways that improve access to technology and innovations that support better and more equitable cancer control, spanning prevention to palliation, while strengthening health systems to be more prepared for other health challenges, including future pandemics. COVID-19 presents opportunities to leap-frog by harnessing communication technology breakthroughs through telemedicine. The data science revolution makes it affordable to develop, digitalise, synthesise, analyse, store, and share vast quantities of information that anchor machine learning. Additionally, artificial intelligence could improve health-care quality and efficiency in all resource settings, alleviating workforce and equipment shortages, and facilitating clinical decision support tools and remote technical and quality assurance.6Atun R Jaffray DA Barton MB et al.Expanding global access to radiotherapy.Lancet Oncol. 2015; 16: 1153-1186Summary Full Text Full Text PDF PubMed Scopus (454) Google Scholar, 21Hosny A Aerts HJWL Artificial intelligence for global health.Science. 2019; 366: 955-956Crossref PubMed Scopus (40) Google Scholar The Commissioners (appendix) comprise disciplinary, thematic, experiential, and scientific expertise into intellectual bridges that aim to transcend the false dichotomies that characterise the worlds of cancer and health systems.22Frenk J Gómez-Dantés O False dichotomies in global health: the need for integrative thinking.Lancet. 2017; 389: 667-670Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar Commissioners include cancer clinicians and scientists, health-system stewards, global health leaders, primary care providers, economists, and patient advocates in a gender-balanced group that spans world regions. COVID-19 is a catalyst for disruptive innovation that cancer control must harness to absorb and radiate new energy for systemic change. We are confronted with both a challenge and an opportunity to raise the bar for cancer control for everyone, everywhere, and to shake health systems out of an equilibrium of apathy through which some have access to ever-improving treatment and prevention, while many—mostly the poor—do not have even pain relief and palliative care.11Knaul FM Farmer PE Krakauer EL et al.Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: the Lancet Commission report.Lancet. 2018; 391: 1391-1454Summary Full Text Full Text PDF PubMed Scopus (428) Google Scholar Our Commission takes up the gauntlet. FMK reports grants to Tómatelo a Pecho, a Mexican non-profit organisation, from Merck Sharp & Dohme, Roche, Higia, Novartis, and Pfizer; grants to the Mexican Health Foundation from Fundación Gonzalo Río Arronte; and consulting fees unrelated to this research paper from Merck EMD Serono for work on gender equity in leadership. BME reports consulting fees unrelated to this topic area from the University of Miami, Miami, FL, USA, from a research grant provided by Merck for work on gender equity and the health workforce. All other authors declare no competing interests. The authors acknowledge David Jaffray for providing critical insight for this Comment and Renu Sara Nargund for excellent research assistance. Download .pdf (.22 MB) Help with pdf files Supplementary appendix
Referência(s)