Please mind the gap—about equity and access to care in oncology
2021; Elsevier BV; Volume: 6; Issue: 6 Linguagem: Inglês
10.1016/j.esmoop.2021.100335
ISSN2059-7029
AutoresAmelia Barcellini, Francesca Dal Mas, Paola Paoloni, Pierre Loap, Lorenzo Cobianchi, Laura D. Locati, María Rita Rodríguez‐Luna, Ester Orlandi,
Tópico(s)Palliative Care and End-of-Life Issues
ResumoHealth care disparities have been described as differences in the quality of care received by those people who have equal access to care and no difference in preferences or needs for treatment,1Torain M.J. Maragh-Bass A.C. Dankwa-Mullen I. et al.Surgical disparities: a comprehensive review and new conceptual framework.J Am Coll Surg. 2016; 223: 408-418Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar representing a serious public health concern.2Hisam B. Zogg C.K. Chaudhary M.A. et al.From understanding to action: interventions for surgical disparities.J Surg Res. 2016; 200: 560-578Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar While most literature has shown how ethnic minorities do experience health care disparities and poorer clinical outcomes,2Hisam B. Zogg C.K. Chaudhary M.A. et al.From understanding to action: interventions for surgical disparities.J Surg Res. 2016; 200: 560-578Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 3Haider A.H. Scott V.K. Rehman K.A. et al.Racial disparities in surgical care and outcomes in the United States: a comprehensive review of patient, provider, and systemic factors.J Am Coll Surg. 2013; 216: 482-492.e12Abstract Full Text Full Text PDF PubMed Scopus (216) Google Scholar, 4Elk R. Felder T.M. Cayir E. Samuel C.A. Social inequalities in palliative care for cancer patients in the United States: a structured review.Semin Oncol Nurs. 2018; 34: 303-315Crossref PubMed Scopus (12) Google Scholar inequalities are also encountered according to gender, age, socioeconomic status, sexual orientation, patients in rural areas, or the presence of disabilities.1Torain M.J. Maragh-Bass A.C. Dankwa-Mullen I. et al.Surgical disparities: a comprehensive review and new conceptual framework.J Am Coll Surg. 2016; 223: 408-418Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar While good health and well-being for all at all ages stand as one of the 17 Sustainable Development Goals promoted by the United Nations,5UN. Goal 3Ensure healthy lives and promote well-being for all at all ages. SDGs.2021https://sdgs.un.org/goals/goal3Google Scholar the abovementioned barriers are commonly fostered by geographic isolation and destitution. Such gaps represent a severe challenge in oncology, considering that cancer might be not only a cause but also a consequence of poverty. Indeed, low- and middle-income countries generally experience a high level of health care disparities with scant access to cancer screening and prevention services, vaccinations, as well as state-of-the-art oncological treatments. Particularly, a greater discrepancy is flagrant in the location of radiotherapy (RT) facilities and technologies considering that up to 70% of all the RT hubs are in high-income countries, with 30 countries, in the world, without RT.6Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries. Closing the Cancer Divide: A Blueprint to Expand Access in Low and Middle Income Countries.https://ncdalliance.org/resources/closing-the-cancer-divide-a-blueprint-to-expand-access-in-low-and-middle-income-countries-by-the-global-task-force-on-expanded-access-to-cancer-careGoogle Scholar Moreover, the chronic impairments due to cancer as well as the oncological treatment costs cast people into poverty. The recent coronavirus disease-19 (COVID-19) pandemic has sadly confirmed the trend, with the literature recording higher death rates among minority communities in wealthier countries.7Bonner S.N. Wakam G.K. Kwayke G. Scott J.W. COVID-19 and racial disparities.Ann Surg. 2020; 272: e224-e225Crossref PubMed Scopus (8) Google Scholar Moreover, of the 3.3 billion COVID-19 vaccines administered globally, thus far, only 1% of people in the low-income countries have received at least the first dose, and, dramatically, in Africa, they remain out of reach.8KFF Tracking Global COVID-19 Vaccine Equity.https://www.kff.org/global-health-policy/issue-brief/tracking-global-covid-19-vaccine-equity/Google Scholar The literature of several medical specialities reported some themes around health care disparities. For example, in surgery,1Torain M.J. Maragh-Bass A.C. Dankwa-Mullen I. et al.Surgical disparities: a comprehensive review and new conceptual framework.J Am Coll Surg. 2016; 223: 408-418Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar the dominant themes have been recognized as patient-related factors, provider-related factors, system and access issues, clinical care and quality, and post-operatory care and rehabilitation.9Haider A.H. Dankwa-Mullan I. Maragh-Bass A.C. et al.Setting a national agenda for surgical disparities research recommendations from the National Institutes of Health and American College of Surgeons Summit.JAMA Surg. 2016; 151: 554-563Crossref PubMed Scopus (70) Google Scholar While many research works have tried to address several problems and efforts around each of the main topics,9Haider A.H. Dankwa-Mullan I. Maragh-Bass A.C. et al.Setting a national agenda for surgical disparities research recommendations from the National Institutes of Health and American College of Surgeons Summit.JAMA Surg. 2016; 151: 554-563Crossref PubMed Scopus (70) Google Scholar the COVID-19 crisis,7Bonner S.N. Wakam G.K. Kwayke G. Scott J.W. COVID-19 and racial disparities.Ann Surg. 2020; 272: e224-e225Crossref PubMed Scopus (8) Google Scholar with its related disruptions,10Cobianchi L. Pugliese L. Peloso A. Dal Mas F. Angelos P. To a new normal: surgery and COVID-19 during the transition ohase.Ann Surg. 2020; 272: e49-e51Crossref PubMed Scopus (33) Google Scholar,11Tseng J. Roggin K.K. Angelos P. Should this operation proceed? When residents and faculty disagree during the COVID-19 pandemic and recovery.Ann Surg. 2020; 272: e157-e158Crossref PubMed Scopus (5) Google Scholar delays in cancer diagnosis and treatment,12Bardet A. Fraslin A.M. Marghadi J. et al.Impact of COVID-19 on healthcare organisation and cancer outcomes.Eur J Cancer. 2021; 153: 123-132Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,13Hartman H.E. Sun Y. Devasia T.P. et al.Integrated survival estimates for cancer treatment delay among adults with cancer during the COVID-19 pandemic.JAMA Oncol. 2020; 6: 1881-1889Crossref PubMed Scopus (28) Google Scholar and higher mortality rate for certain communities,7Bonner S.N. Wakam G.K. Kwayke G. Scott J.W. COVID-19 and racial disparities.Ann Surg. 2020; 272: e224-e225Crossref PubMed Scopus (8) Google Scholar has proved that there is still much work to be done to limit the phenomenon of health care disparities. Several types of vulnerable patients are constantly at risk, despite the theoretical opportunity to get the same overall outcomes of those who experience more favourable conditions. The situation looks extremely complex. While we still believe that one size cannot fit all,14Cobianchi L. Dal Mas F. Angelos P. One size does not fit all—translating knowledge to bridge the gaps to diversity and inclusion of surgical teams.Ann Surg. 2021; 273: e34-e36Crossref PubMed Scopus (9) Google Scholar a call for investments, practical tools, tailored solutions, and best practices emerges.6Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries. Closing the Cancer Divide: A Blueprint to Expand Access in Low and Middle Income Countries.https://ncdalliance.org/resources/closing-the-cancer-divide-a-blueprint-to-expand-access-in-low-and-middle-income-countries-by-the-global-task-force-on-expanded-access-to-cancer-careGoogle Scholar,9Haider A.H. Dankwa-Mullan I. Maragh-Bass A.C. et al.Setting a national agenda for surgical disparities research recommendations from the National Institutes of Health and American College of Surgeons Summit.JAMA Surg. 2016; 151: 554-563Crossref PubMed Scopus (70) Google Scholar Starting from the results from the previous literature, the present work identifies some major topics with the aim to include the whole spectrum of themes that might lead to disparities in cancer care, highlighting the tentative strategies to facilitate equity and access to care for oncological patients. Under the umbrella of system-related factors, several elements have been discussed by the literature, including sociodemographic factors (like gender, culture, ethnicity), economic situation, geographic locations (low-/middle-income versus high-income countries, rural areas versus city), behaviours (lifestyle, self-monitoring abilities), and care processes (including testing, screening, and counselling services).1Torain M.J. Maragh-Bass A.C. Dankwa-Mullen I. et al.Surgical disparities: a comprehensive review and new conceptual framework.J Am Coll Surg. 2016; 223: 408-418Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar In such a scenario, social determinants of health (SDOH) play an essential role. They represent "the conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks".15Doll K.M. Investigating Black-White disparities in gynecologic oncology: theories, conceptual models, and applications.Gynecol Oncol. 2018; 149: 78-83Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar According to the literature, most SDOH can be included in five categories, namely economic stability, education, social and community context, health and health care, neighbourhood, and built environment. A worrying gap emerges when considering the situation of developing countries. As highlighted by the Global Task Force on Expanded Access to Cancer Care and Control, five crucial points magnify the disparities in oncology between high- and low-/middle-income countries.6Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries. Closing the Cancer Divide: A Blueprint to Expand Access in Low and Middle Income Countries.https://ncdalliance.org/resources/closing-the-cancer-divide-a-blueprint-to-expand-access-in-low-and-middle-income-countries-by-the-global-task-force-on-expanded-access-to-cancer-careGoogle Scholar The first difference is represented by risk-factor prevention, which stands as one of the winning strategies for fostering lifestyles and behaviours that can prevent the onset of the disease (like avoiding smoking or unhealthy food or stimulating regular fitness activity).15Doll K.M. Investigating Black-White disparities in gynecologic oncology: theories, conceptual models, and applications.Gynecol Oncol. 2018; 149: 78-83Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar The second difference concerns preventing infection related to cancers for which there are no available treatments (human immunodeficiency virus) or for which there are currently vaccines (human papillomavirus, hepatitis B virus). The third factor is the availability of screening programs for early diagnosis (for instance, promoting tests or checks regularly, or self-assessment—like palpation for breast cancer, Pap test screenings). The fourth factor relates to the physical and psychological consequences and social matters of survivorship, which can lead to impoverishment, prejudice, and discrimination. Last but not least, low-income countries often lack the availability of treatment to face cancer-related symptoms and pain (i.e. palliative care, pain control) as well as end-of-life care.6Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries. Closing the Cancer Divide: A Blueprint to Expand Access in Low and Middle Income Countries.https://ncdalliance.org/resources/closing-the-cancer-divide-a-blueprint-to-expand-access-in-low-and-middle-income-countries-by-the-global-task-force-on-expanded-access-to-cancer-careGoogle Scholar Closing the gap in outcomes for preventable and treatable cancers requires a global effort. While low-/middle-income countries need investments in terms of adequate willingness for health care resources, knowledge, and tools to increase the number of available treatments, a general call for prevention programs emerges worldwide. Free access to counselling services, community engagement,16Kronenfeld J.P. Graves K.D. Penedo F.J. Yanez B. Overcoming disparities in cancer: a need for meaningful reform for Hispanic and Latino cancer survivors.Oncologist. 2021; 26: 443-452Crossref PubMed Scopus (5) Google Scholar,17Presch G. Dal Mas F. Piccolo D. Sinik M. Cobianchi L. The World Health Innovation Summit (WHIS) platform for sustainable development. From the digital economy to knowledge in the healthcare sector.in: Ordonez de Pablos P. Edvinsson L. Intellectual Capital in the Digital Economy. Routledge, Routledge, London2020: 19-28Crossref Google Scholar and sensitivity as well as social campaigns might be organized and tailored according to the target population, employing adequate knowledge translation tools18Dal Mas F. Biancuzzi H. Massaro M. Miceli L. Adopting a knowledge translation approach in healthcare co-production. A case study.Manag Decis. 2020; 58: 1841-1862Crossref Scopus (23) Google Scholar to ensure that citizens can understand the importance of prevention,15Doll K.M. 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Exploring the meaning of coproduction as described by patients after spinal surgery interventions.Open Nurs J. 2019; 13: 85-91Crossref Scopus (2) Google Scholar, 22Dal Mas F. Biancuzzi H. Massaro M. Barcellini A. Cobianchi L. Miceli L. Knowledge translation in oncology. a case study.Electron J Knowl Manag. 2020; 18: 212-223Crossref Scopus (10) Google Scholar in a multi-stakeholder scenario18Dal Mas F. Biancuzzi H. Massaro M. Miceli L. Adopting a knowledge translation approach in healthcare co-production. A case study.Manag Decis. 2020; 58: 1841-1862Crossref Scopus (23) Google Scholar,23Cobianchi L. Dal Mas F. Massaro M. et al.Hand in hand: a multistakeholder approach for co-production of surgical care.Am J Surg. 2021; https://doi.org/10.1016/j.amjsurg.2021.07.053Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar that become more walkable when the health care resources are fairly allocated. Psycho-oncological treatment (POT) may improve patient quality of life by reducing stress allowing patients to have clear and well-based decisions. Although POT has been the standard of care in developed countries such as Austria and Germany (OnkoZert), identifying and measuring clinical distress by continuous screening tools could be challenging in countries with fewer resources.24Loth F.L. Meraner V. Holzner B. Singer S. Virgolini I. Gamper E.M. Following patient pathways to psycho-oncological treatment: identification of treatment needs by clinical staff and electronic screening.Psychooncology. 2018; 27: 1312-1319Crossref PubMed Scopus (3) Google Scholar Provider-level factors may refer to issues like implicit or unconscious biases, cultural competencies, years of training and experience, supportive hospital policies, motivation, and awareness of health disparities.1Torain M.J. Maragh-Bass A.C. Dankwa-Mullen I. et al.Surgical disparities: a comprehensive review and new conceptual framework.J Am Coll Surg. 2016; 223: 408-418Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar Even when considering this topic, worrying differences emerge when investigating different areas of the world. Seruga et al.25Seruga B. Sullivan R. Fundytus A. et al.Medical oncology workload in Europe: one continent, several worlds.Clin Oncol (R Coll Radiol). 2020; 32: e19-e26Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar reported disparities in clinical oncologist workload around Europe with a significantly higher workload of medical oncologists in Eastern European countries (EECs) than in Western European countries (WECs). This was reflected by a higher median number of annual consults (225 in EECs versus 175 in WECs, P < 0.001), daily consults (25 in EECs versus 15 in WECs, P < 0.001), and the time spent per patient (25 min per new consultation in EECs versus 45 min in WECs). In a comprehensive survey on 93 countries, 66 (71%) exceeded the optimal international standard of 150-175 annual caseload per medical oncologist.26Mathew A. Global survey of clinical oncology workforce.J Glob Oncol. 2018; 4: 1-12Google Scholar Alarmingly, in 39 (42%) countries, an oncologist would provide care for >500 patients with cancer, and in 27 (29%) countries (of which 25 in Africa and 2 in Asia), a clinical oncologist would provide care for >1000 new cases of cancers.26Mathew A. Global survey of clinical oncology workforce.J Glob Oncol. 2018; 4: 1-12Google Scholar In Honduras, there are fewer than 20 oncologists for a population of 8 million and, in Ethiopia, 4 oncologists for >80 million people.6Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries. Closing the Cancer Divide: A Blueprint to Expand Access in Low and Middle Income Countries.https://ncdalliance.org/resources/closing-the-cancer-divide-a-blueprint-to-expand-access-in-low-and-middle-income-countries-by-the-global-task-force-on-expanded-access-to-cancer-careGoogle Scholar In contrast to the data of mortality-to-incidence ratio in the high-income countries, Africa presented an exceeding >70% mortality-to-incidence ratio in 21 countries (66%) and Asia in 5 countries (26%).26Mathew A. Global survey of clinical oncology workforce.J Glob Oncol. 2018; 4: 1-12Google Scholar Available treatment options can increase the complexity of treatment decisions, inducing high psychological distress, making patients less adherent to treatment recommendations. Undoubtedly, higher capital invested in oncological health care may support low-income countries in defining better screening tools, therapies, and general oncological care.27Cavalli F. Atun R. Towards a global cancer fund.Lancet Oncol. 2015; 16: 133-134Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar The different speeds of development in high- versus middle–low-income countries concern the availability of technology. While developing nations still struggle with the absence of assigned hubs and non-qualified staff and structures, developed countries are experiencing an exciting technological revolution. New technologies like artificial intelligence, machine learning,28Loftus T.J. Filiberto A.C. Balch J. et al.Intelligent, autonomous machines in surgery.J Surg Res. 2020; 253: 92-99Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar and mixed and augmented reality29Dal Mas F. Piccolo D. Edvinsson L. Skrap M. D'Auria S. Strategy innovation, intellectual capital management and the future of healthcare. The case of Kiron by Nucleode.in: Matos F. Vairinhos V. Salavisa I. Edvinsson L. Massaro M. Knowledge, People, and Digital Transformation: Approaches for a Sustainable Future. Springer, Springer, Cham2020: 119-131Crossref Scopus (16) Google Scholar represent today the next frontier to ease and expedite cancer diagnosis30Mascagni P. Vardazaryan A. Alapatt D. et al.Artificial intelligence for surgical safety: automatic assessment of the critical view of safety in laparoscopic cholecystectomy using deep learning.Ann Surg. 2020; https://doi.org/10.1097/SLA.0000000000004351Crossref PubMed Scopus (14) Google Scholar and surgical decision-making.31Loftus T.J. Tighe P.J. Filiberto A.C. et al.Artificial intelligence and surgical decision-making.JAMA Surg. 2020; 155: 148-158Crossref PubMed Scopus (52) Google Scholar Searching for the best human–machine interaction is one of the major challenges to enjoy the benefits provided by the new technologies,32Yang G.-Z. Cambias J. Cleary K. et al.Medical robotics. Regulatory, ethical, and legal considerations for increasing levels of autonomy.Sci Robot. 2017; 2Crossref Scopus (142) Google Scholar including fostering equity and social sustainability in the best cancer care. Indeed, developing countries lacking resources may upskill their staff and procedure through telemedicine devices6Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries. Closing the Cancer Divide: A Blueprint to Expand Access in Low and Middle Income Countries.https://ncdalliance.org/resources/closing-the-cancer-divide-a-blueprint-to-expand-access-in-low-and-middle-income-countries-by-the-global-task-force-on-expanded-access-to-cancer-careGoogle Scholar and free e-resources.33Garcia Vazquez A. Verde J.M. Dal Mas F. et al.Image-guided surgical e-learning in the post-COVID-19 pandemic era: what is next?.J Laparoendosc Adv Surg Tech. 2020; 30: 993-997Crossref PubMed Scopus (25) Google Scholar The recent literature has underlined how tele-oncology has proved to be effective to train and create collaboration between low- and high-income countries as well as mitigating the gap in access to care and clinical outcomes in developing nations,34Qaddoumi I. Mansour A. Musharbash A. et al.Impact of telemedicine on pediatric neuro-oncology in a developing country: the Jordanian-Canadian experience.Pediatr Blood Cancer. 2007; 48: 39-43Crossref PubMed Scopus (61) Google Scholar,35Hazin R. Qaddoumi I. Teleoncology: current and future applications for improving cancer care globally.Lancet Oncol. 2010; 11: 204-210Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar as reported by the Cambodian experience.36Kvedar J. Heinzelmann P.J. Jacques G. Cancer diagnosis and telemedicine: a case study from Cambodia.Ann Oncol. 2006; 17: viii37-viii42Abstract Full Text PDF PubMed Scopus (20) Google Scholar Exchange programs among hospitals and health care institutions around the world have also proved to be worthwhile to fuel human resources capability.37Cobianchi L. Dal Mas F. Peloso A. et al.Planning the full recovery phase: an antifragile perspective on surgery after COVID-19.Ann Surg. 2020; 272: e296-e299Crossref PubMed Scopus (20) Google Scholar Considering the health care staff, the literature has stressed how a diverse clinical workforce can facilitate the sensitiveness and attention towards the inequalities in care.14Cobianchi L. Dal Mas F. Angelos P. One size does not fit all—translating knowledge to bridge the gaps to diversity and inclusion of surgical teams.Ann Surg. 2021; 273: e34-e36Crossref PubMed Scopus (9) Google Scholar,38Gardner A.K. Harris T.B. Beyond numbers: achieving equity, inclusion, and excellence.Ann Surg. 2020; 271: 425-426Crossref PubMed Scopus (7) Google Scholar,39El-Deiry W.S. Giaccone G. Challenges in diversity, equity, and inclusion in research and clinical oncology.Front Oncol. 2021; 11: 1-4Crossref Scopus (2) Google Scholar Ensuring diversity in clinical staff has proved to reach higher patient satisfaction and better clinical outcomes,40Crown A. Berry C. Khabele D. et al.The role of race and gender in the career experiences of Black/African-American Academic Surgeons: a survey of the Society of Black Academic Surgeons and a call to action.Ann Surg. 2021; 273: 827-831Crossref PubMed Scopus (9) Google Scholar,41ASA Ensuring equity, diversity, and inclusion in academic surgery. American Surgical Association, Beverly, MA2018Google Scholar as professionals who are already keen on bridging the gaps with their peers14Cobianchi L. Dal Mas F. Angelos P. One size does not fit all—translating knowledge to bridge the gaps to diversity and inclusion of surgical teams.Ann Surg. 2021; 273: e34-e36Crossref PubMed Scopus (9) Google Scholar may be more willing to do so also in dealing with their patients. If diversity can support the sensitivity and engagement towards the management of different patients, knowledge and skill gaps of clinicians may remain, opening up to the topic of clinical education and training. The improvement of globally equal access to cancer treatment, vaccines, and high technologies needs financial resources, political cooperation, adequate management processes, and cost optimizations. International efforts should speed up to flatten differences in screening, diagnostic, surgical, oncological, and RT willingness around the world. Indeed, high costs and scant availabilities of cancer treatments are the greater barriers in developing countries. To face this gap, an international consensus with a list of essential drugs, vaccines, and treatment technologies is needed to achieve more affordable and sustainable access to oncological care. Since 1977, the World Health Organization (WHO) created a Global Action Plan for noncommunicable diseases with the aim to cover at least 80% of essential medicines and technologies in 2025. Leading societies, such as the American Society of Clinical Oncology, the European Society of Medical Oncology, and the Union of International Cancer Control, have been involved in this outstanding task force providing a list of essential medicines for adult and paediatric oncological care. The above-reported list aimed to allow for greater access to anticancer agents fostering therapies, especially in low- and middle-income countries.42Eniu A. Torode J. Magrini N. Bricalli G. Back to the "essence" of medical treatment in oncology: the 2015 WHO Model List of Essential Medicines.ESMO Open. 2016; 1: e000030Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Even if, in the last years, the WHO improved access to antineoplastic agents worldwide,43Global Essential Medicines Countries.https://global.essentialmeds.org/dashboard/countriesGoogle Scholar accessibility in low–middle- and low-income countries remains insolvent leading to high out-pocket costs for oncological medicines on the WHO list of essential medicines.44Cherny N.I. Sullivan R. Torode J. Saar M. Eniu A. ESMO International Consortium Study on the availability, out-of-pocket costs and accessibility of antineoplastic medicines in countries outside of Europe.Ann Oncol. 2017; 28: 2633-2647Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar To note that new, more expensive targeted agents appear very infrequently available or not available at all in the middle- and low-income countries except for Brazil, Colombia, and Turkey, exposing that the WHO goal remains distant.44Cherny N.I. Sullivan R. Torode J. Saar M. Eniu A. ESMO International Consortium Study on the availability, out-of-pocket costs and accessibility of antineoplastic medicines in countries outside of Europe.Ann Oncol. 2017; 28: 2633-2647Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar Systemic therapies need sustainable costs (also considering that a more significant number of essential chemotherapy are off-patent) as well as supportive infrastructures, adequate management processes and information systems, and skilled personnel in their safe preparation and administration. Among oncological treatments, RT is indicated in ∼50% of tumours, and it is crucial for locally advanced and inoperable cancers. Still, as underlined, it remains insufficient or nonexistent in many countries. To offer safe and effective RT treatment is fundamental to provide equipment, specific structures, trained staff for treatments, and adequate maintenance of RT tools. To exemplify, in 2020, Ethiopia had only six radiation oncologists and a single cobalt-60 teletherapy machine for a population of around 100 million inhabitants. As a consequence, the median waiting time in a curative setting was around 150 days, and most RT treatments ended up as palliative.45Rick T. Habtamu B. Tigeneh W. et al.Patterns of care of cancers and radiotherapy in Ethiopia.J Glob Oncol. 2019; 5: 1-8PubMed Google Scholar In Nigeria, the average waiting time before RT could be nearly a year for prostate and breast cancers since the country only has three cobalt-60 teletherapy machines for a population of >200 million inhabitants.46Tumba N. Adewuyi S.A. Eguzo K. Adenipekun A. Oyesegun R. Radiotherapy waiting time in Northern Nigeria: experience from a resource-limited setting.Ecancermedicalscience. 2020; 14: 1097Crossref PubMed Scopus (3) Google Scholar Such delays before RT may hamper the patient's prognosis. It should be stressed that such low-income countries heavily rely on outdated RT equipment, such as cobalt-60 teletherapy machines, which may increase RT-induced toxicity compared with modern RT techniques currently available in other places of the world. Palliative and compassionate care also play a worldwide role in oncology, but above all, in the low-income countries where patients are often firstly evaluated when the tumour is advanced. In countries where most health care services are on the National Health System, the issues related to access to care may be mitigated. Still, even in developed countries, adequate access to care may be influenced by current health care and hospitals' policies and guidelines, cost containment strategies following continuous budget cuts,47Sousa M.J. Dal Mas F. Lopes Da Costa R. Advances in health knowledge management: new perspectives.Electron J Knowl Manag. 2021; 18: 407-411Crossref Google Scholar data systems, and electronic records.1Torain M.J. Maragh-Bass A.C. Dankwa-Mullen I. et al.Surgical disparities: a comprehensive review and new conceptual framework.J Am Coll Surg. 2016; 223: 408-418Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar,16Kronenfeld J.P. Graves K.D. Penedo F.J. Yanez B. Overcoming disparities in cancer: a need for meaningful reform for Hispanic and Latino cancer survivors.Oncologist. 2021; 26: 443-452Crossref PubMed Scopus (5) Google Scholar Worldwide, financial mitigation policies6Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries. Closing the Cancer Divide: A Blueprint to Expand Access in Low and Middle Income Countries.https://ncdalliance.org/resources/closing-the-cancer-divide-a-blueprint-to-expand-access-in-low-and-middle-income-countries-by-the-global-task-force-on-expanded-access-to-cancer-careGoogle Scholar,16Kronenfeld J.P. Graves K.D. Penedo F.J. Yanez B. Overcoming disparities in cancer: a need for meaningful reform for Hispanic and Latino cancer survivors.Oncologist. 2021; 26: 443-452Crossref PubMed Scopus (5) Google Scholar can constitute alternative payment models and assistance programs to ensure equitable receipt of high-quality cancer care.48Patel M.I. Lopez A.M. Blackstock W. et al.Cancer disparities and health equity: a policy statement from the American Society of Clinical Oncology.J Clin Oncol. 2020; 38: 3439-3448Crossref PubMed Scopus (29) Google Scholar Clinical care and quality factors refer to patient-centredness attitudes (e.g. patient satisfaction, shared decision making,49Shay L.A. Lafata J.E. Where is the evidence? A systematic review of shared decision making and patient outcomes.Med Decis Making. 2015; 35: 114-131Crossref PubMed Scopus (476) Google Scholar and perceived quality of care50Brunoro-Kadash C. Kadash N. Time to care: a patient-centered quality improvement strategy.Leadersh Heal Serv. 2013; 26: 220-231Crossref Scopus (9) Google Scholar), the presence of supportive technology (including electronic health records), quality improvement strategies, and hospital characteristics (including regionality, volume and quality, safety, and practice variation). Therefore, clinical care and quality factors may be responsible for a large proportion of between-hospital differences in clinical outcomes.1Torain M.J. Maragh-Bass A.C. Dankwa-Mullen I. et al.Surgical disparities: a comprehensive review and new conceptual framework.J Am Coll Surg. 2016; 223: 408-418Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar In the face of treatment resource scarcity, oncological programs might be controlled from the beginning and retrospectively in order to understand the room for improvement. Policies, systems, environments, and practices that improve equitable participation in all research activities should be promoted, including clinical trials, population science, health services research, and community-based participatory research.48Patel M.I. Lopez A.M. Blackstock W. et al.Cancer disparities and health equity: a policy statement from the American Society of Clinical Oncology.J Clin Oncol. 2020; 38: 3439-3448Crossref PubMed Scopus (29) Google Scholar The Global Task Force on Expanded Access to Cancer Care and Control highlights how the research questions look different in oncology worldwide. While in the wealthier countries, oncologists are interested in studying new treatment approaches, in the low- and middle-income countries, the topics concern epidemiology, ramp-up technological services, and creation of oncological guidelines in resource-restricted settings.6Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries. Closing the Cancer Divide: A Blueprint to Expand Access in Low and Middle Income Countries.https://ncdalliance.org/resources/closing-the-cancer-divide-a-blueprint-to-expand-access-in-low-and-middle-income-countries-by-the-global-task-force-on-expanded-access-to-cancer-careGoogle Scholar Therefore, more specifically, researchers and scientists should employ recruitment strategies able to grant adequate representation of key groups at risk of disparate toxicity or mortality outcomes for the disease or treatment of interest. Individual patient factors such as socioeconomic status, race or ethnicity, and location of residence should not represent barriers in the recruitment process.48Patel M.I. Lopez A.M. Blackstock W. et al.Cancer disparities and health equity: a policy statement from the American Society of Clinical Oncology.J Clin Oncol. 2020; 38: 3439-3448Crossref PubMed Scopus (29) Google Scholar Again, a multi-stakeholder approach, partnering with universities, other research centres, private organizations, and non-profit entities,51Cobianchi L. Dal Mas F. Piccolo D. et al.Digital transformation in healthcare. The challenges of translating knowledge in a primary research, educational and clinical centre.in: Soliman K.S. International Business Information Management Conference (35th IBIMA), 1-2- April, Seville, Spain. IBIMA, 2020Google Scholar may help overcome the inequalities in access to experimental trials,48Patel M.I. Lopez A.M. Blackstock W. et al.Cancer disparities and health equity: a policy statement from the American Society of Clinical Oncology.J Clin Oncol. 2020; 38: 3439-3448Crossref PubMed Scopus (29) Google Scholar as well as a diverse clinical workforce. Nevertheless, conducting clinical trials in developing countries is challenging both for organizational reasons, notably lack of financial resources, managerial culture, and dedicated personnel and infrastructures, and presence of diverse regulatory obstacles.52Alemayehu C. Mitchell G. Nikles J. Barriers for conducting clinical trials in developing countries—a systematic review.Int J Equity Health. 2018; 17: 37Crossref PubMed Scopus (77) Google Scholar In addition, cancers are a leading cause of mortality not only in high-income countries but also in the less developed part of the world, where although infectious disease and starvation burden remain predominant, cancer incidence and mortality rates are increasing most rapidly. Indeed, the expected progression in the following 20 years is 28.4 million cases (47% increase) with a significantly higher increase in low-income countries as compared to high-income countries (64% to 95% versus 32% to 56% respectively), placing cancer burden as the greatest health issue in developing regions.53Sung H. Ferlay J. Siegel R.L. 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 (4893) Google Scholar Post-operatory care and oncological rehabilitation pertain to patient management beyond hospital stays or after discharge. Health care disparities may arise on longer-term outcomes according to post-operative care and rehabilitation experience.1Torain M.J. Maragh-Bass A.C. Dankwa-Mullen I. et al.Surgical disparities: a comprehensive review and new conceptual framework.J Am Coll Surg. 2016; 223: 408-418Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar The long-term morbidities due to cancer as well as treatments often lead to disabilities causing a high psychological and financial cost for the patients and caregivers. Oncological patients often need to go back to their everyday life as soon as possible. If survivorship programs also using specific co-production dynamics23Cobianchi L. Dal Mas F. Massaro M. et al.Hand in hand: a multistakeholder approach for co-production of surgical care.Am J Surg. 2021; https://doi.org/10.1016/j.amjsurg.2021.07.053Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar,54Biancuzzi H. Dal Mas F. Miceli L. Bednarova R. Post breast cancer coaching path: a co-production experience for women.in: Paoloni P. Lombardi R. Gender Studies, Entrepreneurship and Human Capital. IPAZIA. Springer, Cham2019: 11-23Google Scholar is a rising standard of care in developed countries,55Bednarova R. Biancuzzi H. Rizzardo A. et al.Cancer rehabilitation and physical activity: the "Oncology in Motion" project.J Cancer Educ. 2020; (In press)https://doi.org/10.1007/s13187-020-01920-0Crossref PubMed Scopus (5) Google Scholar the equity in the access of survivorship services should be the standard in the poorest countries where disabilities related to cancer often cause further discrimination.6Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries. Closing the Cancer Divide: A Blueprint to Expand Access in Low and Middle Income Countries.https://ncdalliance.org/resources/closing-the-cancer-divide-a-blueprint-to-expand-access-in-low-and-middle-income-countries-by-the-global-task-force-on-expanded-access-to-cancer-careGoogle Scholar In his perspective, telemedicine can become precious and an effective tool to train patients, communities, and health care staff. The oncological gap worldwide stands as a painful reality, involving several aspects of health care: prevention, diagnosis, treatment, incidence, mortality, survivorship, managerial culture, and personnel training. Closing this gap is an ethical imperative. Considering that 'one size does not fit all', a realistic analysis of the long-term and short-term needs of each country is crucial to define better plans of action that should and could be adopted so that good health and well-being can be ensured to everybody.
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