The challenges of breast cancer care in Mexico during health-care reforms and COVID-19.

Abstract

The recent outbreak of severe acute respiratory syndrome coronavirus 2 has placed an unprecedented strain on health-care systems worldwide. Not only has the outbreak overwhelmed health-care facilities because of the sheer quantity of infected patients, but it has also forced physicians to prioritise the treatment of immediate life-threatening conditions over non-urgent ones to optimise resources and mitigate the spread of COVID-19. The stress imposed by the current pandemic has exposed health-care systems' vulnerabilities worldwide and has been particularly challenging in limited-resource settings. In the case of Mexico, more than 1 410 000 cases of COVID-19 were confirmed in 2020, with nearly 99 deaths registered per 100 000 population and a case fatality ratio of 8·8%. The COVID-19 pandemic reached Mexico during a time of profound health-care restructuring. After a historic presidential election in July, 2018, the new administration initiated a movement known as the Cuarta Transformación, or fourth transformation, of the country (the first was national independence in 1821, the second was a reform movement that culminated in 1861, and the third was the revolution in 1917). Consequently, various actions and reforms have been implemented to achieve an extensive political, economic, and social change in the country. Notably, one of the core components of this national transformation is a health reform that focuses on attaining truly universal health-care coverage. Specifically, the objectives of this new health policy are to guarantee that the uninsured sector of the population has access to free medical care, including primary care services, admission to hospitals, clinical tests, and medicines included in the National Compendium of Health Supplies; increase the efficiency, effectiveness, and quality of the national health system; increase the human and infrastructural resources available to the institutions that comprise the national health system, with a particular emphasis on highly marginalised populations; guarantee the effectiveness of public health strategies, programmes, and actions that facilitate health promotion and disease prevention; and improve nationwide health protection under a comprehensive approach that prioritises disease prevention and implementation of timely interventions. Following the announcement of these health objectives (to be achieved by 2024), a series of actions were undertaken with the goal of improving national health care. For example, a restructuring in the mechanisms related to the production, cost, and supply of medicines was initiated to demonopolise the pharmaceutical industry, eradicate corrupt activities, and reduce costs. However, some undesired consequences occurred in the short term, including a national shortage of some essential antineoplastic drugs (such as doxorubicin, cyclophosphamide, and paclitaxel) and antiretrovirals. This shortage temporarily left many around the country without access to their prescribed treatments, which in turn unleashed a series of protests in March, 2020, led by patients and their families. In what is perhaps the most ambitious component of the health reform, the 17-year-old public health-care insurance plan Seguro Popular was replaced with a new scheme known as Instituto de Salud para el Bienestar (INSABI). For context, Mexico's health-care system is fragmented into multiple insurance plans, including Seguro Popular (replaced with INSABI in January, 2020), Instituto Mexicano del Seguro Social (for formal sector workers), Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (for government workers), and the private sector. Seguro Popular was intended for all those who were not affiliated to any other insurance plan, including people from underserved communities, informal sector workers, and the self-employed. Although Seguro Popular extended health insurance to approximately 50 million Mexicans who were previously at risk of impoverishing health expenditure, it was not without shortcomings. For instance, significant patient out-of-pocket spending, elevated administrative costs, and uneven quality of care remained important concerns many years after the introduction of this plan. There were also several reports of Seguro Popular being occasionally exploited to divert federal resources. Thus, in November, 2019, the Chamber of Deputies passed a reform to replace Seguro Popular with INSABI, with the aim of delivering improved health care to the uninsured population through a more efficient system. However, some within the Senate claimed that the operational rules of INSABI were unclear and several states refused to accept this new health-care system, instead signing a non-adhesion agreement. In the states that did accept INSABI, a restructuring of federal funding to health facilities was undertaken. Hence, some private institutions that previously offered care through Seguro Popular had to refer patients to government-sanctioned centres, many of which face risks of oversaturation. All of these actions have resulted in a complex and uneven transition from Seguro Popular to INSABI throughout the country, with many patients having difficulty in maintaining access to health care and continuity of care. The arrival of the COVID-19 pandemic during the implementation of the mentioned actions and reforms has had an unprecedented impact on patients nationwide. One of the most affected populations has been that of patients with cancer, as many have had their treatments delayed, shortened, or modified. This situation has been especially worrisome for patients with breast cancer, as they make up the biggest proportion of oncology patients in the country and also lead its cancer-related mortality statistics. Furthermore, patients with breast cancer in Mexico are mostly diagnosed in advanced stages, which makes their timely and continued treatment an even more pressing issue. In response to this situation, many patients with breast cancer started reaching out to various associations to voice their concerns and publicly express the barriers they are facing to continue their treatments. Two non-governmental organisations (NGOs) dedicated to the improvement of breast cancer care in Mexico were among those frequently contacted. Hence, a collaborative initiative was started to provide these patients with a communication channel to document their concerns, with the ultimate goal of providing evidence to health policy makers regarding current obstacles to adequate breast cancer care. An online questionnaire was created to explore patients' perceptions and experiences of current access to treatments in the Mexican health-care system. The survey was developed by a team of medical oncologists, a psycho-oncologist, a clinical research fellow, and a public relations spokesperson, as well as by the leaders of both NGOs. A total of 142 responses were registered from May to August, 2020, with most originating from Mexico's three largest cities. A considerable proportion of respondents had advanced breast cancer (clinical stage III or IV), an aggressive subtype (HER2-positive or triple-negative; appendix p 1), or both. 105 (74%) of 142 patients reported an affiliation to Seguro Popular or INSABI. Through the questionnaire, 118 (83%) of respondents reported that their breast cancer treatments had been interrupted or modified at some point in the last year (13 [9%] in the last trimester of 2019, 32 [23%] in the first trimester of 2020, 54 [38%] in the second trimester of 2020, and 19 [13%] did not specify the timing), whereas nine (6%) reported not being able to start any form of treatment. The most frequently cited reasons for these two scenarios were the replacement of Seguro Popular with INSABI (76 [60%] of 127), the COVID-19 pandemic (52 [41%]), and the national shortage of antineoplastic drugs (44 [35%]). Only 50 (39%) of 127 respondents with suspended or non-initiated treatments answered that they were able to eventually resume or commence them. The median time from treatment suspension to re-initiation was 60 days (IQR 37–76). Similarly, the median time elapsed between treatment suspension and questionnaire completion in patients who had yet to resume treatment was 60 days (IQR 30–115). Furthermore, 98 (69%) of 142 respondents reported that, between October 2019 and August 2020, they had made an out-of-pocket payment for treatment regimens that were previously covered by their health insurance. The findings of this study indicate that the treatment of patients with breast cancer in Mexico has been negatively affected by the concurrent COVID-19 contingency and the process of adaptation to the new health-care policies. Now, more than ever, we urge policy makers to place patient care at the top of their priorities. Important gains have already been made in Mexico regarding breast cancer, and there is still much more to accomplish. However, we risk losing what has been achieved if we let patient care suffer during these times of global struggle. For more on COVID-19 mortality in Mexico see https://coronavirus.jhu.edu/data/mortality For more on COVID-19 mortality in Mexico see https://coronavirus.jhu.edu/data/mortality CV-G reports consultancy fees or advisory role for Roche, Novartis, Pfizer, and Eli Lilly; speaker honoraria for Roche, Myriad Genetics, and Novartis; and travel and accommodations expenses for Roche, Merck Sharpe & Dohme Oncology, and Pfizer. All other authors declare no competing interests.