Seizing the opportunity to close the cancer divide.

On which of the battles not yet won should we focus attention when reviewing the global response to the challenge of cancer? Prevention and successful treatment are possible for many of the cancers that kill poor people of all ages globally. But to respond to this opportunity, we fi rst need to dispel the myths that surround cancer and poverty. Between 1990 and 2010 the global burden of disease for cancer, as measured by disability-adjusted life-years (DALYs), increased 27·3% from around 148·1 million to 188·5 million. The cancer burden in DALYs also increased signifi cantly in the regions of the world where countries of low income and middle income are situated. Although low-income and middle-income countries account for almost 80% of the global cancer burden, they receive only 5% of global fi nancial resources for the disease, which results in a “5/80 cancer disequilibrium”. A cancer divide exists in incidence and mortality for all treatable or preventable cancers within and across countries. Cancer today is a disease of both the rich and the poor, yet the poor bear a disproportionate share of preventable death, suff ering, and pain. The weak health systems in low-income and middle-income countries are ill-prepared to meet the challenge of cancer. Most infection-associated cancers occur in lowincome and middle-income countries—these cancers disproportionately aff ect the poorest people who also have the most limited access to eff ective health care and fi nancial protection. Four myths have undermined global eff orts to address the cancer divide: that in low-income and middleincome countries interventions for cancer prevention, treatment, and care are unnecessary, unaff ordable, unattainable, and inappropriate because they divert resources from other more acute and burdensome health priorities. These erroneous arguments have plagued eff orts to develop eff ective prevention and treatment approaches for cancer in low-resource settings. Expanded access to cancer prevention, treatment, and care is possible to address the growing cancer burden. Indeed, addressing cancer in developing regions is a public health imperative. Tobacco consumption, if it continues to grow at the current pace, will kill 1 billion people in the 21st century—mostly in lowincome and middle-income countries, where 80% of smokers live. In children aged 5–14 years, cancer is among the top fi ve leading causes of death in middleincome countries and top ten causes of death in lowincome countries. Breast cancer is a leading cause of death, especially for young women, with death rates in low-income countries at least double those in highincome countries. Furthermore, each year sub-Saharan Africa consumes barely enough medicinal opioids for 85 000 patients, yet records 1·3 million deaths in pain. In addition to health benefi ts, reducing untold suff ering, and preventing families from falling into poverty, investing in cancer prevention, treatment, and care also brings economic benefi ts. The fi nancial value of productivity lost from preventable deaths from cancer outweighs the cost of prevention and treatment. Tobacco consump tion, for example, reduces global gross domes tic product (GDP) by more than 3·5% per year. The global value of productivity losses and treatmentassociated costs due to cancer is 2–4% of global GDP. Many interventions for cancer prevention, treatment, and care are much less costly than is often assumed. Reductions of up to 90% have been achieved in prices of vaccines for human papillomavirus in low-income countries. Additionally, 26 of the 29 key medicines for treating the most common cancers in low-income and middle-income countries were off patent in 2011. Cancer prevention, treatment, and care interventions have been expanded nationwide in several low-income and middle-income countries. Rwanda has successfully imple mented a national immunisation programme for human papillomavirus in conjunction with private sector partners. In El Salvador, the St Jude Children’s Research Hospital International Outreach Program has used telemedicine to strengthen local capacity and has improved survival rates for some childhood cancers from 10% to 60%. In Jordan, the King Hussein Cancer Center provides comprehensive cancer care and has achieved Joint Commission Accreditation. In Mexico, the Seguro Popular includes eff ective treat ment packages for non-Hodgkin lymphoma and for cervical, breast, prostate, testicular, and colon cancers, as well as for all cancers in children. Opportunities exist to expand cancer preven tion, treatment, and care interventions in developing regions further. Such expansion can be done by using established Published Online February 4, 2013 http://dx.doi.org/10.1016/ S0140-6736(13)60176-2