The future of cancer care: Fast-tracking sustainability, access, and innovation in the Middle East
In the Middle East and North Africa, cancer is growing at an alarming rate, and – as Economist Impact notes – the region is on the cusp of a demographic transition, with UNICEF predicting the over-65s population will increase by 290% by 2050. It is well-known that age is a major risk factor for cancer, and Global Health Dynamics estimates that the cancer incidence rate in the Eastern Mediterranean region will double by 2040 – a critical issue for healthcare systems and economies.
To find out more, pharmaphorum attended an Economist Impact webinar, sponsored by BeiGene, this week. Moderator Clare Roche – manager, global health policy at Economist Impact – welcomed to the discussion: Dr Ahmed Seyam, director of health economics and health systems research at Universal Health Insurance Authority (UHIA); Majed Mohammed Ibrahim, advocacy and scientific affairs executive at Friends of Cancer Patients (FoCP); and Dr Loay Kassem, assistant professor of clinical oncology at Cairo University Hospitals.
Cancer: A growing worldwide concern and burden
The World Health Organization (WHO) projects that global cancer rates will increase by 2040, Roche told listeners, given greater exposure to risk factors, such as tobacco use, air pollution, and unhealthy diets. A whitepaper produced by Economist Impact, also supported by BeiGene, published earlier this year addressed these issues, she said, finding that strengthening end-to-end care through the healthcare system could be a central means to address the unmet needs cancer patients face even today. But how does that apply to the Middle East and Africa? Indeed, what is the biggest obstacle to sustainable oncological care in that geographic zone?
Majed Mohammed Ibrahim thinks health literacy and patient engagement and empowerment go hand in hand. Patients sometimes lack knowledge or awareness of where to go and who to seek, he said, not even knowing that they have the right to ask for help. Therefore, from a patient perspective, addressing knowledge gaps is crucial in communities.
Dr Ahmed Seyam spoke from an economist’s perspective, stating that the rapidly growing financial burden of cancer is of great concern around the world, not just in Egypt or surrounding areas. Personalised medicines and gene therapies are being spoken of, he said, but they have an extremely high price tag, requiring substantial amounts of financing. New modalities around financing will therefore need to be considered to utilise such treatments.
Dr Loay Kassem said that he thinks there is no single challenge that represents the problems faced across the whole of the Middle East and that the financial challenge is not homogenous across the area. For instance, he said, the rising incidences of cancer are not the same across different countries: an increase in bladder and liver cancer in Egypt is yet rare in other countries. But the financial challenge is, however, one challenge faced by many, as is the issue of data availability.
Long-term planning: A future oncological landscape
Referring to the whitepaper and its cancer projections over the next 20 years, Dr Kassem noted that liver cancer is largely down to infection with Hepatitis C, mentioning that a programme was implemented in Egypt to screen for this, it being a cancer that is not so much a matter of ageing or lifestyle. In breast cancer, however, lifestyle factors are hugely impactful, he said, and so too in lung cancer. Both of these present challenges that can nonetheless be addressed in the future.
Ibrahim explained that patients go through different obstacles and challenges throughout their cancer journey, no matter the geography, but financial obstacles remain a primary concern for most. Nevertheless, access to high-quality care, he said, should not be linked to the size of someone’s wallet. Aside from finance and access, it’s about awareness and preventative measures, educating the community about the signs and symptoms of various cancers and what screenings and tests are available for them. And to that end, he insisted, it is a shared responsibility of the government, healthcare systems, and other such bodies.
Ibrahim also noted that residents in the UAE need health insurance for certain treatments. While support is available from various charities, it creates a mental burden on the patient to seek such support. In general, he said, countries need to look into a strategic plan for the future that utilises resources for the long-term, rather than short-term objectives, whilst remaining realistic.
The Egyptian experience
Dr Seyam explained how Egypt has been a categorised and pluralistic system historically. A substantial proportion of the population have no health insurance whatsoever, he said, and a lot of pressure is put on households as to whether they can afford healthcare services. The vision, therefore, is to have an insurance scheme that covers the entire population by 2030 or 2032 and look to lower expenditure for this to below 30% of household income. There is yet lots of planning and coordination required between different governmental actors and bodies, but, he said, a universal health insurance scheme will provide uniformity in healthcare services once it is in place.
In response to this, Dr Kassem highlighted that one of the most important challenges that patients face is that their individual needs are not addressed very well by the healthcare system, particularly in rare diseases, where treatment access is limited. Reconstructive surgeries for breast cancer patients, for instance, he said, are considered plastic surgery and, therefore, aren’t covered from a medical perspective. Another issue, he explained, is the limited patient voice in healthcare policies. New tools to collect patient data do permit good feedback from real-world evidence (RWE), aiding clinical judgement and empowering patient voice, but it is greater access to medication that needs to be facilitated by greater access to clinical trials, also – another challenge for the future.
On this point, Ibrahim agreed, but added that he doesn’t understand how working in the interests of a patient doesn’t often involve having the patient on the table. A Gulf Survivors Forum was begun a few years ago to help in this regard, he said. It invites patients to the platform to share their concerns and what they expect from the government, pharma, and healthcare, permitting them to state what they need that is as yet unmet by those authoritative bodies. This circumvents the lack of patient voice to an extent, he admitted, but patients must be brought more into decision-making.
However, resource constraints are currently a worldwide issue, as Dr Seyam reminded the panel. It is, he said, about balance, incentivising innovation to be available and accessible for patients, while managing limited resources and budgets worldwide. It is the difference between paying for products and paying for outcomes, and it depends on evidence-based decision-making and questioning the value. He explained that, in Egypt, they are currently interested in engaging the patient voice in the HTA process and gathering patient-reported outcomes.
But there remains the question of the affordability of innovation, as Dr Kassem commented, and he shared a case study on overcoming this issue: in Egypt, breast cancer patients had limited access to innovative medications due to the cost before, but now advancements have resulted in major conversations with big pharma to reprice for greater access. At the end of the day, patient compliance for a treatment programme relies on patients being able to see the pathway ahead of them. Within that context, negotiations with pharma companies were therefore made and a revision was implemented, so that many targeted therapies became available in early and advanced cancers at a more affordable price. It’s a positive example of putting the whole spectrum of care on the table for beneficial results, he said.
COVID’s impact on cancer care in the EMEA region
The pandemic was a global experience of multiple horrors, but it was also a period from which many learnings have been taken, particularly by the pharma and healthcare sectors. For his part, Dr Seyam posited that it had a silver lining, bringing health to the top of the priority list for governments worldwide. It helped the industry to understand that there are many solutions and technology can help in that and in managing patients. During the pandemic itself, lots of cancer patients faced a multitude of issues when it came to being able to access care and facilities or following up with physicians to dispense their medications, but, on the bright side, technology was shown to be able to provide tangible solutions and that digital platforms provide value to patients.
Ibrahim agreed that Covid was, as a learning experience, a ‘blessing in disguise’. In the UAE, he explained, the effects were not as severe as in some neighbouring countries. However, during that time, in terms of cancer patients, they were working on a framework for cancer prevention, and one discussion with a health figure in a neighbouring country resulted in a refusal to talk about anything besides COVID during the pandemic – a detrimental response for cancer patients.
Health literacy and overcoming barriers to screening
In order to improve health literacy and surmount obstacles to early diagnosis and treatment, Ibrahim believes work must be done on three important ‘pillars’: patient support, community awareness, and advocacy. His organisation has, for many years, been working to limit the misinformation surrounding cancer. However, despite government investment in the region, people still look at cancer as a death sentence and retain misconceptions – that it is a sin, that it is the Devil. He urged that citizens need to know that it is but a disease, like many other diseases out there, and that many people overcome it. So, working towards addressing stigma remains a challenging aspect.
From a public health perspective, social behaviour change is very challenging, Ibrahim explained. One example is that men are not willing to discuss prostate cancer; with female cancers, there is the worry in certain communities that a woman won’t be suitable for marriage if she receives a diagnosis. In short, it’s about dispelling myths, he said, and that requires a multi-faceted approach, including lived experiences and voices from the community who can influence.
In Egypt, the breast cancer screening programme has been a major success, Dr Kassem said. Prevention programmes always include the question of community uptake, of course, he admitted, but what might have helped in this regard was that it was decided that an annual clinical breast exam would be undertaken by a female doctor only. In Egypt, this has been a very successful decision. Mammography is the gold-standard of screening for Western countries, he said, but in Egypt and other countries in the Middle East, this just isn’t possible. Therefore, they’ve adopted the WHO-suggested screening programme in the first instance, so that the number who are referred to mammograms is reduced, minimising costs.
How health authorities can use data
Digital technologies have made life much easier in the past few years, Dr Seyam noted. Without data, it is a case of navigating blindly in a minefield, so there is great dedication to investment in and implementation of digital health technologies, particularly in Egypt, at the moment in the region.
However, Dr Kassem returned to one of the major challenges regarding cancer care in the Middle East: localised clinical trials. Most clinical trial data comes from the United States and Western Europe, he explained, and the population and the data gathered is completely different from the Middle East. Specifics of culture, too, might preclude acceptance of innovations, he said. Therefore, clinical trials in the Middle East are needed, and a new structure of oversight of these needs to be put in place.
Data helps everyone, he said: “Lack of data is like sailing an uncharted sea: everyone needs data to make valuable decisions, in order to really make a difference in the patient journey.”
To conclude, the panellists highlighted that the need for high-quality communication and tangible action, effected by collaboration, remains. There is no one solution for cancer care in the Middle East and Africa, Dr Seyam said, but it is a matter of blending holistic solutions: “Finance reforms, evidence-based decision making, incentivising clinical trials as a means of early access to specific treatments: all of these will converge to provide benefit for patients, both in cancer and in other diseases.”