Cancer Burden

Due to higher life expectancy and drastic lifestyle changes, the burden of cancer is rising in low- and middle-income countries (LMICs) and is becoming an alarming public health issue (Shah et al. 2019). Disparities and inequities in healthcare access, poor education and public health policies with no preventive strategies, high cost of treatment and deprioritization of non-communicable diseases (NCDs), including cancers, are significant issues. The economic impact of premature mortality due to neoplasia, increased morbidity and low budget allocations for health also stresses an already weakened healthcare system that is not sustainable. Strengthening aspects such as education on health and lifestyle can alleviate primary prevention of neoplasia. Vaccination programmes for infectious agents such as HBV and HPV can successfully reduce cancer burden (Hussein et al. 2016), while screening programmes increase early detection of neoplasia as part of secondary prevention. Such strategies require universal healthcare access through alleviating the cost for the population, decentralization of screening and diagnosis centres and proper funding. Such policies can only be sustainable if proper treatment is given following every irregularity found in screening programmes. Facilities for cancer treatment are usually scattered in LMICs. However, resources should be made available to the population through outreach programmes, universal health insurance, collaborations with high-income countries (HICs), in parallel with infrastructure development, multidisciplinary management of oncological patients and cancer research. Supportive and survivorship care, together with palliative care, are critical and should be implemented whenever possible.

Surgical Oncology

Optimizing cancer care and surgical oncology is a crucial milestone in the integrative care of oncological patients. Surgery is essential for cancer treatment globally, but less than 25% of patients with cancer worldwide get safe, affordable or timely surgery (Sullivan et al. 2015). There have been reported wide equity gaps, and patients from rural LMIC areas are particularly at risk for lack of access to surgery, often because of economic constraints and lack of service (Sullivan et al. 2015). Considering that surgery is cost-effective and, if applied in locally confined tumours, curative, the current situation will widen the service gap instead of achieving the Sustainable Development Goal (SDG) Target 3.4 (“By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being”) because of missing SDG Target 3.8 (“Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all”).

India is the second largest country by population, and more than 70% of its population lives in rural areas with scarce resources, education and health access. In addition to disparities in healthcare access, for 2018, cancer incidence in India was estimated at more than 1.1 million new cases with an extremely high mortality to incidence ratio (Dhillon et al. 2018). Moreover, there is no central accreditation board for surgical oncology. As a result, cancer treatment facilities, already weak in infrastructure, are overcrowded, while poorly trained doctors treat patients. The cost of treatment is also extremely high due to high rates of privatization and poor social and health insurance policies, thus forcing patients to give up treatment sometimes. It is estimated that 80% of oncological patients will need surgery, making timely, optimal and affordable surgery a priority in cancer care (Sullivan et al. 2015). Steps in the right direction have been made with the implementation of the National Cancer Grid (NCG) that aims to supervise cancer care (Pramesh et al. 2014), injecting capital into healthcare with increases as high as 137% more than in previous years and through the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS).

Palliative Care

As life expectancy improves worldwide, there is also a growing need for palliative care integrated with preventive medicine, early diagnosis and optimal treatment (Palliative Care 2021). Palliative care is the multidisciplinary practice that improves the quality of life amongst patients (both adults and children) and their families who are facing issues related to a chronic or terminal illness; these may include but are not limited to identification and treatment of pain, physical, spiritual or psychosocial challenges. Early-stage symptom control is an ethical duty, and palliation is the most effective if applied early on. It reduces unnecessary hospital admissions while relieving suffering and offering dignity to patients. Health systems are responsible at a national level to include palliative care in the routine care of terminally ill or chronic patients. It is estimated that 40 million people worldwide require palliative services, while 78% live in LMIC countries. Unfortunately, only 14% of people in need of palliation receive appropriate services. This is primarily due to the lack of awareness among policymakers, inadequate funding, cultural and social barriers and perhaps unnecessarily restrictive regulations for palliative medicines. While subspeciality palliative care is a stand-alone medical speciality in many HICs, primary palliative care can be integrated at all the levels of a healthcare system even by practitioners with no former training in such practices. These services may include pain management or other physical symptoms by primary usage of pain medication, routine care of patients and care coordination. Primary palliation must be provided early on, alleviating pain and suffering and reducing care fragmentation in an empathic manner.

Iran has a population of more than 82 million. The current prevalence of cancer in Iran is more than 300,000 cases, and more than 100,000 patients add to these numbers annually. The need for palliation is palpable. While still in its infancy, palliative care in Iran can be an example of good practice. Modern practices date back to 2000 when experts in Iran collaborated with the Royal Hospital for Women in Australia and the Sydney Institute of Palliative Medicine. Training in palliative care started in the Cancer Research Center in Tehran back in 2006, while integrating palliative subspeciality training into clinical practice was established through a palliative medicine fellowship programme in 2012. One or two palliative care specialists graduate each year; however, palliation in Iran is still not well structured. This is due to a disorganized system, a shortage of trained specialists and the deprioritization of NCDs in the face of the COVID-19 pandemic. The current initiative, involving the help of the University of Ulm, Germany, and the Center for Palliative Medicine at the University Hospital of Cologne, Germany, strives to create an online educational platform in Farsi language to aid palliative care in Iran.

Paediatric Oncology

Paediatric oncology represents another challenge in integrated cancer care. HICs report over 80% survival rates for patients with paediatric neoplasias, whereas those in LMICs average at about 20% (Childhood Cancer 2021). Even though cancers are comparatively rare in children compared to cancers in adults (Cancer Statistics 2021), the burden on affected families and their grief and mental health is not to be underestimated. It is, therefore, necessary to seek solutions for the most vulnerable of society. Knowledge transfer from HICs to LMICs is desirable for strengthening collaborations and establishing a sustainable scientific exchange.

Armenia is the perfect example that succeeded in overcoming the unmet needs of children with cancer. In 1994, the survival rate of children with acute lymphocytic leukaemia (ALL) was 0.7%, while in 2019, it was 73.3% after implementing standardized protocols (Krmoyan et al. 2019). Good practices were disseminated through collaborations with cancer centres in the USA, Germany, Taiwan, Austria and Belgium. Collective efforts founded the Armenian Association of Hematology and Oncology (AAHO), created a united Pediatric Cancer and Blood Disorders Center of Armenia (PCBDCA), only to start, in 2019, a three-year fellowship for paediatric haematology-oncology. While having to overcome issues like the government not subsidizing some cancer treatments, Armenia proved that LMICs could meet the needs of paediatric cancer patients with the help of and through collaborative projects with HICs.

Quality Assurance in Oncology

The administration of procedures like chemotherapy, radiation therapy, surgery and all imaging modalities happens with the provision that these are safe. Analyses by one of the leading scientific societies in oncology have shown that adherence to standards is less stringent the longer a physician practises her/his speciality (Blayney et al. 2020). Moreover, quality control should be carried out regularly to ensure optimal care for all cancer patients. The American Society of Clinical Oncology (ASCO) developed a quality programme called the Quality Oncology Practice Initiative (QOPI), wich has been open for worldwide registration since 2016 (Blayney et al. 2020). Such programmes warrant a proper assessment of patients and ensure high-quality outpatient practices with the aim of constant self-actualization of the treatment team and the applied pathways. With oncology as a rapidly evolving discipline, this self-actualization is essential for providing services that meet the patients’ und the physicians’ highest standards while ensuring organizational and financial safety and thus sustainability.

A group of practising oncologists in Brazil officially obtained the QOPI Certification Program (QCP) accreditation in February 2020 and is an eloquent example that implementing quality cancer care at international standards can be feasible in more places. This experience will be described in the chapter “Quality Oncology Practice Improvement (QOPI) in Brazil: A Successful Knowledge Transfer Under the Auspices of the American Society of Clinical Oncology (ASCO)”.

Comprehensive Cancer Centres

Through the centuries, cancer centres have evolved in places with high incidence, subsequently becoming also research facilities. The cancer centre I am directing was founded over 90 years ago and had already incorporated an epidemiological approach to oncology thereby paving the way to possible treatments of these ailments. In France, cancer centres integrating basic research were founded after World War II, and in the USA, the National Cancer Act of 1971 led to the foundation of cancer centres and, subsequently, the Comprehensive Cancer Centres (CCCs).

Research, education and outreach and multidisciplinary management are significant features of a Comprehensive Cancer Centre (CCC), as a model borrowed from the USA, currently adopted by other countries like Germany (Comprehensive Cancer Center Ulm (CCCU) | Universitätsklinikum Ulm 2021). CCCs are expected to conduct and initiate clinical trials, sustain basic and translational research and provide quality management of such activities. Tumour boards with regular meetings should give recommendations for every patient, while multidisciplinary teams provide timely, optimal and affordable state-of-the-art cancer management. Therefore, many challenges arise while running a CCC, including but not limited to providing adequate infrastructure that can sustain all of the requirements above, funding, finding an optimal quality management system that can ensure proper adherence to international quality standards, outreach programmes, palliative care and many more.

COVID-19-Related Service Disruption

One of the most recent struggles for healthcare systems worldwide is the COVID-19 pandemic. While the first cases were recorded in 2019 in Wuhan City, China, the disease spread easily and was characterized quickly as a pandemic (Coronavirus disease (COVID-19) – World Health Organization 2021), taking by surprise even the most prepared healthcare systems, now having to face a new disease, with no evidence-based treatment with a shortage of protective gear, ICU beds and ventilators. Quick reallocation of human, logistic and financial resources towards a new crisis meant that NCDs were no longer a priority. Therefore, many preventive programmes for neoplasia were deferred, slowing down or coming to a complete halt (Richards et al. 2020). Meanwhile, government officials issued many restrictions, including lockdowns and sanitary measures that, together with natural immunization and later on through vaccination, led to a decrease of the COVID-19 disease burden. Various resources became available for physicians worldwide in hopes of aiding medical specialists in staying up to date with the latest medical news, such as (How I Treat COVID-19 | Management of the COVID-19 Pandemic 2021). However, slowly restarting screening programmes brought up a new challenge in the form of excess diagnosis (Jones et al. 2020; Yong et al. 2020; Marine et al. 2020).

It became quickly apparent that harvesting the COVID-19 momentum is a fundamental turning point moving forward in most healthcare systems and public health policies worldwide. Appropriate simulation models can estimate optimal catching-up strategies for mitigating the deferred preventive services (Creating et al. 2021; Castanon et al. 2021a,b) while evaluating the feasibility of deploying different models like age-related risk stratification (Castanon et al. 2021a), since triaging and prioritizing patients is a must moving forward. As healthcare systems proved to be very reactive to change, some strategies seem like they are here to stay, like telemedicine and other uses of technology such as self-sampling for HPV. Vaccination facilities worldwide can be further capitalized on for HBV or HPV vaccination, borrowing strategies previously used in the COVID-19 pandemic such as vaccination marathons and intensive media coverage with proper funding and guidance. Elective surgery should be restarted responsibly (Anaesthesia 2021) as further challenges such as providing COVID-19-free pathways for NCDs, cancers included, arise.

To summarize, NCDs, neoplasias included, have a considerable impact on all levels of society. Cancer patients should not be neglected despite the current epidemiological, financial or logistical challenges a healthcare system faces, while timely, affordable and safe cancer management should always be provided.