Cancer Care In Low- And Middle-income Countries Research Articles

Global impact of antimicrobial resistance on cancer care: Challenges and strategies in low- and middle-income countries

Antimicrobial resistance (AMR) is a fast-rising global health warning that causes significant challenges to the treatment and management of infectious diseases, especially in cancer patients, who are a large number of the vulnerable populations. This work underlines the complicated problems faced by the low- and middle-income countries (LMICs) in cancer care due to AMR. The burden of both cancer and AMR is sadly high, so therefore this review sheds light into the possible potential strategies to win against these challenges and set up better cancer treatment for improved outcomes in these countries. This sheds more light and gives a deeper understanding of recent research works, epidemiological data, and relevant case studies. Furthermore, examining the interconnectivity between AMR and cancer care, narrowing it down to some particular challenges and vulnerabilities encountered by cancer patients in LMICs. The study identifies key strategies such as implementing better antimicrobial stewardship programs, improving infection prevention and control, promoting new drug development, and enhancing global interactions as important steps in reducing the effect of AMR on cancer care in LMICs. This emphasizes the urgent need for targeted interventions, context-specific solutions, building sustainable development, and global interactions to address the complex challenges posed by AMR in cancer care within LMICs.

Physician-brief advice for promoting smoking cessation among cancer patients on treatment in low and middle-income countries: a scoping review

IntroductionPhysician-brief advice has been utilized in high-income countries to promote smoking cessation among cancer patients. Empirical evidence on its effectiveness among cancer patients in low and middle-income countries (LMICs) is lacking. The gap could be due to inadequate training, and competing healthcare priorities, leading to insufficient implementation of targeted smoking cessation interventions in oncology settings. We undertook this scoping review to determine if physician-brief advice is effective in promoting smoking cessation among cancer patients in LMICs.MethodsWe conducted a literature search of all relevant articles across five databases: Cochrane Central Register of Controlled Trials, Cochrane Library (Tobacco Addiction Group trials), World Conference on Lung Cancer proceedings, PubMed, and Google Scholar up to November 2023, using pre-defined inclusion criteria and keywords. The study population was cancer survivors in LMICs, the intervention was smoking cessation advice by a physician in a clinic or oncology center during a consultation, and the outcome was the effect of smoking cessation programs in discontinuing smoking among cancer survivors in LMICs.ResultsOverall, out of every 10 cancer patients in LMICs, about seven were smokers, and one-half had received physician-brief advice for smoking cessation. Physician-brief advice was more likely to be delivered to patients with smoking-related cancer (Cohen’s d = 0.396). This means that there is a noticeable difference between patients with smoking-related cancer compared to those with cancer unrelated to smoking. Smoking cessation failure was due to the inability to cope with the symptoms of withdrawal, missed smoking cessation clinic visits, mental health disorders, limited time and resources, and minimal patient-physician contact.ConclusionThere is very little literature on the frequency of use or the efficacy of physician-brief advice on smoking cessation in LMICs. The literature suggests that cancer patients in LMICs have low self-efficacy to quit smoking, and smoking cessation is rarely part of cancer care in LMICs. Physicians in LMICs should be trained to use motivational messages and good counseling techniques to improve smoking cessation among cancer patients. Policymakers should allocate the resources to implement physician-brief advice and design training programs for physicians focusing on physician-brief advice tailored to cancer patients.

Access to Cancer Care in LMIC - Navigating Current Challenges

At the Summit on Cancer Health Disparities held in 2023, the session on Access to Cancer Care in Low- and middle- income countries (LMIC) highlighted several efforts globally. The collaborative efforts of Dana Farber Cancer Institute and the Ministry of Health in spearheading the Butaro Cancer Center of Excellence (BCCOE) in Rwanda was one such initiative. They were able to set up the BCCOE to address the unmet need of cancer care in this area and have trained nurses in East Africa to help establish other similar centers. They also serve as the single radiotherapy center for the entire of the country. Another such collaborative effort between Massachusetts General Hospital and the cancer center in Botswana in setting up sexual health education initiatives for women undergoing pelvic radiation was highlighted. They started with a quality improvement project to demonstrate the benefit of sexual health education and proper vaginal dilator use amongst women in this demographic. They were able to demonstrate that 90% of patients were able to complete an in-person 6-week workshop with clear benefits noted on a long-term basis. To highlight examples of best practice examples of equitable partnerships, examples of partnerships between Instituto Nacional de Cancerologia in Mexico City and UCSF was described. It was emphasized that for successful collaborations, equitable bidirectional partnerships are key. The thought leaders in this field also highlighted challenges associated with global oncology and the need for inclusion of minorities in clinical trials to improve cancer care for all globally.

Coordination Models for Cancer Care in Low- and Middle-Income Countries: A Scoping Review.

Background: The coordination of cancer care among multiple providers is vital to improve care quality and ensure desirable health outcomes across the cancer continuum, yet evidence is scarce of this being optimally achieved in low- and middle-income countries (LMICs). Objective: Through this scoping review, our objective was to understand the scope of cancer care coordination interventions and services employed in LMICs, in order to synthesise the existing evidence and identify key models and their elements used to manage and/or improve cancer care coordination in these settings. Methods: A detailed search strategy was conducted, aligned with the framework of Arksey and O’Malley. Articles were examined for evidence of coordination interventions used in cancer care in LMICs. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension Guidelines for Scoping Reviews, which included a checklist and explanation. The PRISMA flow diagram was utilised to report the screening of results. Data were extracted, categorised and coded to allow for a thematic analysis of the results. Results: Fourteen studies reported on coordination interventions in cancer care in LMICs. All studies reported a positive impact of cancer coordination interventions on the primary outcome measured. Most studies reported on a patient navigation model at different points along the cancer care continuum. Conclusions: An evidence-based and culturally sensitive plan of care that aims to promote coordinated and efficient multidisciplinary care for patients with suspicion or diagnosis of cancer in LMICs is feasible and might improve the quality of care and efficiency.

Factors contributing to delayed childhood cancer care in low- and middle-income countries: A systematic review protocol.

Significant disparities exist for timely access to cancer care for children, with the highest disparities in low- and middle-income countries (LMICs). This study aims to conduct a systematic review that identifies the factors contributing to delayed care of childhood cancers in LMICs. We will conduct a systematic review with search strings compliant with the PICO framework: (1) the Population-children (aged 0-18 years) from LMICs; (2) the Exposure-factors contributing to timely childhood cancer care; (3) the Outcome-delays in childhood cancer care. Our study is an essential step to guide strategic interventions to assess the myriad of factors that prevent children from accessing timely cancer care in LMICs. The results will be submitted for publication in a peer-reviewed journal and shared with institutions related to the field.

Abstract 109: A Longitudinal Telehealth Curriculum for Radiation Oncology Centers in Low and Middle-Income Countries Transitioning from 2D to 3D External Beam Radiation Therapy

Abstract Purpose: The transition from 2-dimensional (2D) to 3-dimensional (3D) external beam radiation therapy (EBRT) can dramatically improve the quality of radiotherapy in low and middle-income countries (LMICs); however, many cancer centers in LMICs lack training support to effectively make this transition. Remote training is a low-cost, accessible option to bridge this gap, and we sought to evaluate the efficacy of such a program. Methods: The nonprofit Rayos Contra Cancer identified 9 LMIC operational cancer centers in the Middle East and Northern Africa that had recently acquired technology to transition from 2D to 3D EBRT. Baseline information for each center was collected electronically, then a team of EBRT content experts developed a 12-week, 25-session continuing medical education curriculum. Each session invited live participation using Zoom video communications and lasted 1 - 2 hours. Participants were administered a Likert scale (1-5) confidence evaluation on 13 foundational topics in 3D EBRT and a 49-point knowledge-based multiple-choice examination pre- and post- curriculum. Anonymous feedback with 1-5 satisfaction scores for each session was solicited midway and at the conclusion of the curriculum. Training was provided for free. Results: Among centers, 260 participants enrolled in training, including 39 medical physicists, 36 radiation oncologists, 54 radiation therapists, 15 dosimetrists, and 116 in training or other roles. Pre- and post-curriculum average examination scores were 22.95/49 (53.4%, N = 171) and 30.76/49 (62.8%, N=87), respectively. Pre- and post-curriculum confidence evaluation showed an average of 1.4/5 (27.7%, N=260) and 3.86 (77.2%, N=74) confidence among 13 topics. Satisfaction surveys (halfway N=51, end N=48) showed high satisfaction with helpfulness (4.3/5) enjoyableness (4.2/5), and well-preparedness (4.4/5) of sessions. Conclusion: Satisfaction, confidence, and knowledge domains were all measured with favorable results. This innovative low-cost telehealth model for EBRT training is a promising vehicle for advancing cancer care in LMICs by providing educational support. Citation Format: Fei Yang, Raymond Carter, Soha Ahmed, Tia Plautz, Piotr Dubrowski, Shada Wadi-Ramahi, Sarah Ashmeg, Frank Ascoli, Daniel Wakefield, Justus Adamson, Benjamin Li. A Longitudinal Telehealth Curriculum for Radiation Oncology Centers in Low and Middle-Income Countries Transitioning from 2D to 3D External Beam Radiation Therapy [abstract]. In: Proceedings of the 9th Annual Symposium on Global Cancer Research; Global Cancer Research and Control: Looking Back and Charting a Path Forward; 2021 Mar 10-11. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2021;30(7 Suppl):Abstract nr 109.

A scoping review of oncology medical education interventions in low and middle income countries.

e23004 Background: A large proportion of the global cancer burden occurs in low and middle income countries (LMICs). One of the significant barriers to adequate cancer control is the lack of an adequately trained oncology workforce. Medical education and training initiatives in oncology are necessary to tackle growing cancer incidence and mortality rates. We performed a scoping review of oncology medical education interventions in LMICs to understand the strategies used to train the global oncology workforce. Methods: We searched OVID MEDLINE and EMBASE databases between January 1, 1995 and March 4, 2020 using a standardized scoping review framework. Articles were eligible if they described an oncology medical education intervention within an LMIC with clear outcomes. Articles were classified based on the target population, the level of medical education, form of collaboration with another institution and if there was an e-learning component to the intervention. Results: Of the 806 articles screened, 25 met criteria and were eligible for analysis. The Middle East/Africa was the most common geographic area of the educational initiative (N=14/25). The majority of interventions were targeted towards physicians (n=15/25) and focused on continuing medical education (n=22/25). Twelve articles described the use of e-learning as part of the intervention. Twenty four articles described some form of collaboration, most commonly with an institution from a high-income country. Language barriers, technology, and lack of physical infrastructure and resources in the LMIC were the most common challenges described. The majority of the initiatives were funded through grants or charitable donations. Conclusions: There is a paucity of published interventions of oncology medical education initiatives in LMICs. Continued medical education initiatives and those targeted towards physicians are most common. There is a lack of collaboration between LMICs in these interventions. Further interventions are needed earlier during medical training and for non-physicians. In addition, increased use of e-learning interventions may overcome certain identified challenges. Encouragement of locally funded initiatives as well as scholarly evaluation and publication of these initiatives are important to improve cancer care in LMICs.

Implementation of breast cancer continuum of care in low- and middle-income countries during theCOVID-19 pandemic.

Breast cancer is the most common malignancy among women worldwide. The current COVID-19 pandemic represents an unprecedented challenge leading to care disruption, which is more severe in low- and middle-income countries (LMIC) due to existing economic obstacles. This review presents the global perspective and preparedness plans for breast cancer continuum of care amid the COVID-19 outbreak and discusses challenges faced by LMIC in implementing these strategies. Prioritization and triage of breast cancer patients in a multidisciplinary team setting are of paramount importance. Deescalation of systemic and radiation therapy can be utilized safely in selected clinical scenarios. The presence of a framework and resource-adapted recommendations exploiting available evidence-based data with judicious personalized use of current resources is essential for breast cancer care in LMIC during the COVID-19 pandemic.

Collaborative Model for International Telehealth: High Dose Rate Brachytherapy Training for Emerging Radiation Oncology Centers in Lower- and Middle-Income Countries

PURPOSE High dose rate (HDR) brachytherapy is a critical treatment modality—both palliative and curative—for gynecologic malignancies that significantly burden low- and middle-income countries (LMICs). Many of these countries currently have limited capacity to provide necessary brachytherapy treatment. To bridge this gap in LMICs in North Africa and the Middle East, nonprofits Rayos Contra Cancer and Radiating Hope evaluated the efficacy, cost, and feasibility of a pilot HDR brachytherapy continuing medical education curriculum to selected regional cancer centers via videoconferencing. METHODS Rayos Contra Cancer and Radiating Hope recruited a global team of HDR brachytherapy content experts. They developed a 16-week curriculum and recruited 10 regional cancer center partners in LMICs throughout the Middle East, Africa, and Nepal. The curriculum included 17 sessions shared via live Zoom videoconferences. A lead correspondent was assigned for communication at each center. Attendance was taken during each call, and pre- and postsession Likert-scale (1 to 5 points) surveys were collected from participants that assessed their confidence in 15 practical competencies in HDR brachytherapy and overall confidence in their ability to provide services and teach others. RESULTS A total of 326 attendance hours was recorded during the curriculum. Among 46 participants, the average paired confidence scores increased pre- versus postcurriculum in all 15 practical competencies, with an average improvement of 1.2 out of 5 and significant P values in all 15 topics. Absolute improvements were largest for confidence in applicator commissioning (2.3 to 3.8, P = .0015), TPS commissioning (2.2 to 3.7, P = .0010), and commissioning an HDR machine (2.2 to 4.0, P = .00096). Participant confidence significantly increased in ability to provide services (3.5 to 4.2, P = .0023) and teach others (3.4 to 3.9, P = .013). There was no cost to provide this training, and more than 4,300 patients are treated annually with HDR brachytherapy at participating centers. CONCLUSION This novel low-cost telehealth model for HDR brachytherapy training is a promising vehicle for advancing cancer care in LMICs. Postcourse surveys demonstrated increased confidence in both providing care and teaching in HDR brachytherapy, and sessions were well attended. A video-based telehealth teaching platform enabled expert HDR brachytherapy providers and physicists to reach growing cancer centers worldwide.

The survival of patients enrolled in a global direct-to-patient cancer medicine donation program: The Glivec International Patient Assistance Program (GIPAP)

BackgroundThe Glivec International Patient Assistance Program (GIPAP) is a unique direct-to-patient program that provides imatinib (Glivec) at no cost to eligible patients in low- and middle-income countries (LMICs) with chronic myelogenous leukemia (CML) or gastrointestinal stromal tumor (GIST). This paper analyses the output, outcome and impact of the program between 2001 and 2014 using the data collected by the Max Foundation. MethodWe extracted data on GIPAP patients’ country of residence, sex, diagnosis, date of enrollment in GIPAP, age at enrollment, case closure date, and reason for closure from The Max Foundation database covering the period 2001 to 2014. We used Kaplan-Meier method to assess the survival rate of patients in GIPAP and used the proportional hazard regression model to estimate the effect of different variables on patients’ survival. FindingsAbout 63,000 GIPAP patients in 93 countries received over 71 million defined daily doses (DDD) of imatinib between 2001 and 2014. Our analysis showed that GIPAP patients had a 5-year survival rate of 89% which compares favorably to survival in high income countries despite the challenges of delivering cancer care in LMICs. Age at enrollment into the program, sex, duration between diagnosis and enrollment into program, year of enrollment, and patients’ diagnosis (CML vs non-CML) were factors that influenced survival. InterpretationThe GIPAP program has improved the survival of CML and GIST patients in LMICs, most of whom would not have had access to imatinib in the absence of the donation and therapeutic support of the program. FundingThis work was funded as part of Access Accelerated case studies. Access Accelerated is an initiative of more than 20 global biopharmaceutical companies in partnership with the World Bank and Union of International Cancer Control that seeks to reduce barriers to prevention, treatment and care for non-communicable diseases in LMICs.

Patient navigation services for cancer care in low-and middle-income countries: A scoping review.

BackgroundNearly 70% of all cancer deaths occur in low- and middle-income countries (LMICs) and many of these cancer deaths are preventable. In high-income countries (HICs), patient navigation strategies have been successfully implemented to facilitate the patient’s journey at multiple points along the cancer care continuum. The purpose of this scoping review is to understand and describe the scope of patient navigation interventions and services employed in LMICs.MethodsA systematic search of published articles was conducted including Medline, Biosis, Embase, Global Health, and Web of Science. Articles were examined for evidence of patient navigation interventions used in cancer care in LMICs. Evidence was synthesized by navigation service provided and by type of outcome.ResultsFourteen studies reported on patient navigation interventions in cancer care in low-income and middle-income countries in Asia, South America, and Africa. Most studies reported on women’s cancers and included navigation interventions at most points along the cancer care continuum i.e. awareness, education, screening participation, adherence to treatment and surveillance protocols.ConclusionFew studies report on cancer patient navigation in LMICs. With the use of an implementation science framework, patient navigation research can explore a broader range of outcomes to better evaluate its potential role in improving cancer control in LMICs.

An Educational Intervention and Feasibility Assessment of Breast Ultrasound in Rural South Africa

Purpose Breast cancer is the leading cause of cancer death in women worldwide, with a strikingly high mortality in low- and middle-income countries (LMICs) as a result of the scarcity of detection, diagnosis, and treatment. With mammography unavailable, ultrasound (US) offers a viable alternative. The literature reports successful training in various domains, but a curriculum focused on the breast is novel. We assessed the feasibility—knowledge acquisition, perceived utility, and self-efficacy—of a breast US training program for the detection of breast cancer by nonphysician providers. Methods Training was implemented for 12 providers, including professional nurses, nursing assistants, and lay counselors, at Hlokomela clinic in Hoedspruit, South Africa, over 3 weeks. Didactic presentations and example cases were followed by a presurvey (n = 12) that characterized providers’ initial attitudes toward early detection and a pretest (n = 12) that determined immediate retention of knowledge and areas for focused training. All providers received hands-on training with nurses as models. Five providers trained with patients. A post-test (n = 12) assessed overall knowledge retention and acquisition, and a postsurvey (n = 10) gauged program acceptance and provider self-efficacy with breast US. Results Pretest to post-test averages improved by 68% overall and in four competencies—foundational knowledge, descriptive categories, benign versus malignant, and lesion identification. On the postsurvey, providers expressed the belief that US could significantly affect breast cancer detection (9.1/10), treatment (7.9/10), and survival (8.7/10) in their communities and endorsed moderate confidence in their scanning (6.3/10) and interpreting abilities (5.6/10). Conclusion There is a pressing need for a paradigm shift in breast cancer care in LMICs, with early detection critical to improving outcomes. Our research supports the feasibility of breast US training as part of a breast education program in LMICs. Pretest and post-test results and observed proficiency indicate that training nonphysician providers is achievable. Postsurvey responses indicate program acceptance, provider self-efficacy with US, and community-based ownership of a breast cancer screening and awareness initiative. Follow-up work that is focused on quality improvement and sustainability is ongoing. Future work may show that breast US is viable for early detection when mammography is unavailable. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . Susan C. Harvey Consulting or Advisory Role: IBM Watson, Hologic Inc Research Funding: IBM Watson

Lessons From Pediatric HIV: A Case for Curative Intent in Pediatric Cancer in LMICs.

* Abbreviations: ALL — : acute lymphoblastic leukemia ARV — : antiretroviral medication BL — : Burkitt lymphoma CLHIV — : children living with HIV HIC — : high-income country LMIC — : low- and middle-income country Antiretroviral medications (ARVs) are now being provided to nearly 50% of children living with HIV (CLHIV) in low- and middle-income countries (LMICs), an increase of 30% in the past 5 years.1 The provision of ARVs in LMICs demonstrates that effective therapy can be delivered to children with complex medical issues. An estimated 96% of CLHIV and 80% of children <15 years of age living with cancer reside in LMICs, where 94 900 pediatric AIDS deaths and 120 000 pediatric cancer deaths occur annually.2,3 The health system infrastructure gains in the fight against HIV and other communicable diseases represent a promising platform for long-overdue, transformational cancer care in LMICs. Similar to combination antiretroviral therapy in the context of pediatric HIV, the advent of combination chemotherapy in the mid-1960s revolutionized pediatric cancer treatment. Before chemotherapy, pediatric cancer was uniformly fatal, and care was focused on palliation. By the 1970s, over half of children diagnosed with cancer in high-income countries (HICs) were cured. … Address correspondence to Henry Miller, Office of HIV/AIDS, United States Agency for International Development, 1300 Pennsylvania Ave, NW, Washington, DC 20523. E-mail: hmiller{at}usaid.gov

Making the invisible visible: Oncology nursing efforts of NCI-designated cancer centers in LMICs

An increasing majority of new cancer cases and mortality occur in low- and middle-income countries (LMICs). Nurses provide most cancer care in LMICs, yet receive limited, if any, oncology education and training. To better understand the efforts taking place to address this need, the Center for Global Health (CGH) at the US National Cancer Institute (NCI) undertook a study of global oncology nursing projects at NCI-designated cancer centers. The 62 comprehensive and clinical NCI-designated cancer centers were surveyed about the nature and scope of their efforts in strengthening oncology nursing internationally. We received responses from 43 of the 62 cancer centers, with 21centers reporting a total of 29 projects. Twenty-three of 29 projects had involvement in an LMIC. The most common types of projects were research studies and short-term intensive trainings, most of which were for discrete tasks. Unsurprisingly, of the projects that had specific foci, most focused on breast or cervical cancer, and palliative care. Of the 22 projects that reported project costs, almost 90% were under $200,000 USD, suggesting that strengthening the global cancer workforce can be done with limited expense. While this study is limited to efforts of NCI-designated cancer centers, the findings reveal limited engagements in education and training of oncology nurses, who provide most of the cancer care in LMICs, but also provide tangible areas for strengthening this workforce and improving oncology care delivery.

The Role of Affordable, Point-of-Care Technologies for Cancer Care in Low- and Middle-Income Countries: A Review and Commentary.

As the burden of non-communicable diseases such as cancer continues to rise in low- and middle-income countries (LMICs), it is essential to identify and invest in promising solutions for cancer control and treatment. Point-of-care technologies (POCTs) have played critical roles in curbing infectious disease epidemics in both high- and low-income settings, and their successes can serve as a model for transforming cancer care in LMICs, where access to traditional clinical resources is often limited. The versatility, cost-effectiveness, and simplicity of POCTs warrant attention for their potential to revolutionize cancer detection, diagnosis, and treatment. This paper reviews the landscape of affordable POCTs for cancer care in LMICs with a focus on imaging tools, in vitro diagnostics, and treatment technologies and aspires to encourage innovation and further investment in this space.

Balancing Equity and Advancement: The Role of Health Technology Assessment in Radiotherapy Resource Allocation

Radiotherapy is an essential modality for effective cancer control, yet enormous inequalities in access in low- and middle-income countries (LMICs) have created one of the largest global technology gaps in medicine today. The Global Task Force on Radiotherapy for Cancer Control quantified this gap and showed that over half of patients worldwide do not have access to treatment. Governments, policy makers and the global health community have ignored this crisis due to the complexity of radiotherapy technology and its seemingly high upfront costs. However, understanding the cost of treatment in the context of a dramatic clinical benefit could help to demonstrate the feasibility of radiotherapy in diverse income settings. When there are scarce resources, such analysis is essential in order to set priorities and provide high-value interventions to large populations. Here we explore the current status of economic evaluation tools in LMICs and some of the barriers to their use. We describe how the concepts of health technology assessment, value-based care and investment frameworks can be applied to the global crisis of radiotherapy availability to guide appropriate capacity building and resource utilisation. The development of local expertise in these health economic tools can be a powerful level to improve cancer care in LMICs and to build universal global access to radiotherapy.

Access to cancer medications in low- and middle-income countries

Major breakthroughs have been realized in controlling cancer in the past five decades. However, for patients in low- and middle-income countries (LMICs), many of these advances are nothing but an aspiration and hope for the future. Indeed, the greatest challenge we face in oncology today is how to reconcile small, incremental and significant improvements in the management of cancer with the exponentially increasing costs of new treatments. Emerging economies are attempting to address this important issue of access to cancer medications. In this Review, we examine how LMICs are using generic and biosimilar drugs, expanding participation in clinical trials, implementing universal health-care schemes to pool resources, and using compulsory licensing schemes as well as increasing multiple-stakeholder public-private partnerships to increase access to cancer medications for their citizens. Any truly effective programme will require multiple stakeholder involvement-including governments, industry and civil society-to address the issue of access to medication. Only with the creation of a global entity to fight cancer that is supported by a global fund-for example, in the mould of the GAVI alliance and the International Finance Facility for Immunization-will we truly be able to improve cancer care in LMICs and drive down the high mortality rates in these regions.