The incidence of all cancers in South Africa, boosted by ageing and population growth and measured from 2019, will almost double by 2030. This finding and the dire implications of current underfunding for cancer screening and prevention were highlighted in papers presented at the World Cancer Congress in Geneva, Switzerland yesterday, writes Chris Bateman for Medical Brief.
Actuary Dr Emma Finestone, a UCT graduate, and Dr Jodi Wishnia, a health systems researcher and Wits University PhD student, first published their findings in the SA Journal of Oncology in August. The paper, almost unknown outside of oncology circles until yesterday, was singled out as being of particular interest by the Geneva conference organisers.
Using the SA Cancer Registry and Discovery Health data, the local duo found approximately 62 000 cancer deaths in 2019 and project this mortality, based on existing trends, to 121 000 people by 2030.
The findings echo estimates by cancer researchers that cases in sub-Saharan Africa could reach 1m by 2030, almost double those from 2020.
Medical Brief previously reported that the research, published in The Lancet Oncology, looked at the prevalence and incidence of cancer in sub-Saharan Africa and showed that about 4.2% of new global cancer cases occurred in sub-Saharan Africa in 2020, according to a News24 report.
Meanwhile, Bateman writes that another local specialist duo, medical oncologist Dr Ronwyn van Eeden and Dr Mariza Tunmer, President of the SA Society of Clinical and Radiation Oncologists, told a Medtalkz online seminar last week that new cancer therapies and changes in cancer management had boosted survival odds from six months to five or six years for even late-stage local cancer patients.
However, they bemoaned the ‘financial toxicity’ of the new precision medicine drugs and scanning machines, saying they benefitted just 2% of the top tier medical aid plan beneficiaries. Those among the 84% of SA’s population who relied on the public sector had to pray their condition suited the inclusion criteria for globally funded local precision immunotherapy research trials, a rare occurrence, said Van Eeden.
Already a leading cause of mortality in South Africa, cancer accounts for 10% of national deaths annually and can be partly explained by SA having one of the most inequitable health systems in the world. Cancer now surpasses other highly prevalent local non-communicable diseases such as tuberculosis, HIV/Aids, and malaria, as previously reported in Medical Brief.
The actuarial duo said the high cancer mortality rate comes down to the inequities in prevention, screening, diagnosis and treatment, which also led to poor health outcomes.
While bemoaning the lack of recent and reliable local cancer data, (the last National Cancer Registry report was in 2017), the actuaries warn that with universal health coverage now a certainty, it has become “critical to ensure there are sufficient resources to deliver quality care for all South Africans, irrespective of socio-economic status.”
Tunmer displayed a global map showing the distribution of radiotherapy machines per million people world-wide, Africa starkly among the worst resourced continents. She singled out cervical cancer as one cancer that responded well to good quality radiotherapy. However, with HIV as a common co-factor, its prevalence was far too high and urgent lobbying for improved access to care was needed.
“In the private setting we often live in a bubble, whereas in the state sector patients present with advanced disease, and many fail at primary care level where they tell us they only got antibiotics at the clinic,” she emphasised.
Van Eeden said because many trials excluded HIV positive patients, little data existed on how to use certain drugs on such patients. “I find that difficult in terms of ethics,” she added.
She said those patients lucky enough to get into a trial were eligible for ongoing therapy as needed, including all scans, blood tests and any other associated treatment. They were also given travel money to ensure compliance and long-term follow up.
Tunmer said most scans took 15 minutes with the most highly sophisticated machines, (costing up to R70m each), taking a few hours. On a busy linear accelerator scanner, “we can usually get up to 30 or 40 patients done in a day,” she revealed.
The actuarial researchers said in their conference paper that SA’s high HIV prevalence drives a considerable amount of cancer burden, both in terms of incidence and mortality, being associated with risk of lymphoma, cervical cancer and Kaposi’s sarcoma. However, in recent years this excess risk of cancer had decreased because of antiretroviral treatment. Cervical cancer, while difficult to associated with HIV, also had worse outcomes in people living with HIV.
Being part of South Africa’s quadruple burden of disease, cancer added serious volume to the country’s rising NCD tide. Its prevention and mitigation had been hamstrung by a lack of domestic and donor funding, the conference duo said. This led to poor access to cancer prevention, screening and diagnostic services, resulting in late-stage diagnosis and poor health outcomes. As in most low and middle-income countries, South Africa has extremely low levels of access to quality cancer treatment.
Finestone and Wishnia endorsed the SA Health Department’s National Cancer Strategic Framework (2017-2022), aimed at achieving more equitable access to cancer services, saying it correctly targets common NCD factors, including tobacco use (estimated as causing 22% of cancer deaths globally), lack of physical activity, unhealthy diets and obesity. The World Health Organisation (WHO) estimates that about one-third of global cancer deaths can be attributed to these common NCD risk factors. Globally, the WHO estimates that one in nine people will develop cancer in their lifetime, the disease being the second leading cause of death world-wide.
The authors say their findings highlight the need for rapid implementation of cancer prevention strategies to reduce the number of future cases of cancer and thereby to reduce the burden on South Africa’s health system. Planning for cancer services should be evidence based to ensure that resource allocation is proportionate to the expected burden of disease and associated costs. This requires the availability of relevant, recent and reliable data.
“At present, such data are not publicly available. This highlights the need for comprehensive incidence and costing data across both the public and private sectors,” they add.
In another paper presented at the global conference, Cape Town’s Dr Salome Meyer, an SA Cancer Alliance (Access to Medicine) consultant, said there was no national cancer control plan in South Africa. The (almost-dated) Strategic Framework and policies ‘will not alleviate the current cancer care gaps as provincial Health Departments are not instructed to prioritise implementation of cancer policies in health budgets,’ she asserted.
There was no clarity on how cancer would be managed within the NHI. There was a need for a legal framework that delegated clear responsibilities, accountability against mile-stoned goals and reporting, “providing a mechanism that will enforce equitable access to cancer care between levels of care, between the public and private sectors across the cancer continuum of care, with suitable patient protections,” she said.
Meyer said six countries had so far enacted dedicated cancer Acts: The UK, the US, Japan and, most recently, three LMIC countries namely Kenya, Philippines and Chile. Against these international benchmarks, the existing South African legal health system needed analysis to determine whether a dedicated national cancer Act in South Africa would provide the necessary long term national goal setting and accountability framework to link with other legal and human rights mechanisms, to ensure equitable population-based cancer care services and appropriate patient protection.
South African Journal of Oncology: Estimating the burden of cancer in South Africa
See more from MedicalBrief archives:
Cancer Alliance: R50bn needed for cancer over next decade
Cervical cancer survival rates determined by race in SA
Cancer deaths doubling, could soar to 1m in sub-Saharan Africa by 2030
Three-pronged approach could eliminate cervical cancer within 100 years