Regional Variation in Identified Cancer Care Needs of Early-Career Oncologists in China, India, and Pakistan

A cross-sectional survey questionnaire was distributed at clinical trial concept development workshops held at major hospitals in Beijing, Lahore, Karachi, and Mumbai to acquire information regarding home-country health conditions and needs. The respondents were predominantly early-career oncologists who identified needs for increasing clinical cancer research, public awareness of cancer, and especially professional cancer education and training.

Abstract

Background.

Cancer incidence and mortality is increasing in the developing world. Inequities between low-, middle-, and high-income countries affect disease burden and the infrastructure needs in response to cancer. We surveyed early-career oncologists attending workshops in clinical research in three countries with emerging economies about their perception of the evolving cancer burden.

Methods.

A cross-sectional survey questionnaire was distributed at clinical trial concept development workshops held in Beijing, Lahore, Karachi, and Mumbai at major hospitals to acquire information regarding home-country health conditions and needs.

Results.

A total of 100 respondents participated in the workshops held at major hospitals in the region (India = 29, China = 25, Pakistan = 42, and other = 4). Expected consensus on many issues (e.g., emergence of cancer as a significant health issue) was balanced with significant variation in priorities, opportunities, and challenges. Chinese respondents prioritized improvements in cancer-specific care and palliative care, Indian respondents favored improved cancer detection and advancing research in cancer care, and Pakistani respondents prioritized awareness of cancer and improvements in disease detection and cancer care research. For all, the most frequently cited opportunity was help in improving professional cancer education and training.

Conclusion.

Predominantly early-career oncologists attending clinical research workshops (in China, India, and Pakistan) identified needs for increasing clinical cancer research, professional education, and public awareness of cancer. Decision makers supporting efforts to reduce the burden of cancer worldwide will need to factor the specific needs and aspirations of health care providers in their country in prioritizing health policies and budgets.

Implications for Practice:

Young clinicians from Pakistan, China, and India feel that their respective countries need to address the impending challenge of rising cancer rates. They feel that improved clinical research, professional education, and service provision are major priorities for improving cancer outcomes in their region and that these are among the best ways that other countries can provide help. Nonetheless, international support needs to plan programs with local cooperation and collaboration to address country-specific needs, context, and perspectives. The results of this study suggest that oncologists in individual countries prefer focusing on their specific needs, a critical perspective for successful interaction between international efforts, local policy makers, and local cancer caregivers.

Introduction

Cancer, historically considered a disease of developed countries, is now a leading cause of death worldwide. Investment of considerable resources in developed countries has improved cancer awareness, prevention, detection, and treatment, reducing mortality. Lower-income countries are experiencing increased life expectancy and now bear an increasingly disproportionate cancer burden, with increased suffering, strain on health resources, and mortality [1, 2]. In 1970, 15% of new cancer cases were in developing countries, rising to 56% by 2008 (∼7.6 million annual deaths) [1, 2] and to an estimated 70% by 2032 [2–4]. Inequities in the cancer burden are particularly evident in large developing countries like China and India, where massive populations contribute substantially to the worldwide cancer burden, and these countries face local challenges to control cancer and treatment [1].

Juxtaposed against these trends is the small fraction of the world’s resources directed to cancer in the developing world. Although policymakers consider global and national priorities when allocating resources and balancing demands on the economy, a disproportionately small (as little as 5%) fraction of global resources are directed to cancer in developing economies, although these countries account for up to 80% of adjusted life-years lost worldwide (a disparity called “the 5/80 disequilibrium” [3, 5, 6]). This imbalance has led international agencies to advocate for increased research and cancer care in the developing world. Given the potential for international support, how might developing nations confront the cancer burden at home? Initially, countries need to prioritize these efforts based on their own unique needs.

To improve our understanding of what these needs may be and whether regional variations exist, we surveyed oncologists and other clinical care providers practicing and participating in clinical trials workshops at major hospitals in China, India, and Pakistan for their views on how the general societal trends (including health), professional/community education, and research relate to the impending burden of cancer each country faces. Many common needs were identified, but significant regional variations in priorities exist.

Materials and Methods

Predominantly early-career oncologists were surveyed after 1-day concept development workshops in December 2011: in Beijing, China, at Peking University School of Oncology, one of the major cancer centers in China, affiliated with Peking University serving high- and low-income patients; in Lahore, Pakistan, at Allama Iqbal Medical College, a general hospital affiliated with Allama Iqbal Medical College serving low-income patients; in Karachi, Pakistan, at Aga Khan University, affiliated with a general hospital serving high-, middle-, and low-income patients; and in Mumbai, India, at Tata Memorial Centre, India’s oldest and largest cancer center serving both high- and low-income patients. China, Pakistan, and India are populous countries with substantial variations in wealth and quality of health care delivery. The World Bank classifies China as an upper middle-income country, whereas both Pakistan and India are considered lower middle-income countries [7].

Participants included junior clinicians and scientists from various disciplines involved in cancer care (medical, radiation, surgical, hematologic and pediatric oncology plus supportive care, palliative medicine, imaging, and psycho-oncology). Most participants completed their professional training within 4–10 years of completing the survey.

The survey questionnaire was originally developed for the Asia Pacific Clinical Oncology Research Development (ACORD) 6-day protocol development workshop (Queensland, Australia, September 2010) [8]. The original survey was completed using a web-based platform, but this version was paper-based to fit local capabilities. The purpose was described to workshop participants, all responses were anonymous, and a completed questionnaire indicated informed consent. Respondents replied to all questions based on conditions specific to the country where they practiced medicine. Descriptive statistics summarized the data. Differences between proportions were tested with chi-square tests where appropriate.

Results

There were 100 participants in the four workshops (India = 29, China = 25, Pakistan = 42, and other = 4); findings reflect responses from 96 completed surveys from the three primary countries. Participants were predominantly female (60%) physicians (86%) under 36 years of age (78%) who had been practicing medical oncology (55%) for 10 years or less (76%; Table 1).

Table 1.

Characteristics of respondents

Perceptions of National Issues

Health was a significant issue; ≥80% of respondents in each country cited health as their home country’s primary need (Table 2). Regional variations were evident. For example, Chinese and Pakistani respondents cited the economy most frequently, whereas Indian participants felt health was most important. Political stability was identified by significantly more respondents from India and Pakistan than China (p = .052).

Table 2.

Frequency of responses by country

The Chinese health system is funded through a nationalized health care system augmented with an additional fee for service private practice. More than 90% of cancer patients are served in public hospitals because insurance is not yet available for private clinics. In India and Pakistan, funding is almost equally divided between a nationalized system with fee for service and fee-for-service private practice, usually without private health insurance.

Perceptions of Overall Health Issues

Survey participants ranked the top five health problems in their home country. Cancer was cited by all of Chinese clinicians, whereas cardiovascular disease was identified by 93% of the clinicians from both India and Pakistan. Significantly fewer Chinese clinicians cited infectious diseases, tobacco use, and malnutrition as problems, while identifying metabolic diseases as a national issue. The country with the smallest fraction identifying cancer as a major issue was Pakistan (76%). The greatest discordance between countries was for malnutrition; Indian and Pakistanis were nearly equally concerned about malnutrition (83% and 79%, respectively) versus China (only 4%).

Respondents also ranked the top five health-related issues that they thought were increasing in their home country. Cancer was the issue identified most frequently by clinicians from China and India, yet those from Pakistan cited cardiovascular disease most frequently (closely followed by cancer). Significant regional differences were seen for malnutrition (Pakistan > India > China), tobacco use (India, Pakistan > China), and metabolic disorders (China > Pakistan, India).

Perceptions About Cancer

Respondents selected factors (from a list of six) expected to impact cancer over the next 10–15 years. The most frequently cited factor in each country was diet and lifestyle changes. Significant differences between countries were evident for their aging population and control of infectious diseases (China, India > Pakistan).

Respondents were asked to rank the top 5 (of 13) factors important to cancer care their home country needed to address. For the overall sample, four items were identified by more than 50% of the respondents: cancer screening, treatment facilities, tobacco control, and public awareness of cancer. When comparing specific needs between the three countries, significantly more participants from India cited personnel (p = .035), facilities (p = .002), and public awareness (p = .0002). Finally, participants from Pakistan wanted more access and funding for cancer services (p = .002) and access to cancer research (p = .03).

The participants were asked to rank the five best ways (from a list of nine choices) to improve cancer outcomes in their home country. The Chinese favored improved access to the latest therapies, cancer detection, and palliative care, whereas India and Pakistan cited increasing public awareness followed by, in varying order, improved cancer education and training, improved detection, and better general health care.

Perceptions of Opportunities to Help

Workshop participants were asked to rank opportunities for others to help improve local cancer outcomes in their home country. The most commonly noted opportunity was improving professional cancer education and training. Chinese respondents would welcome improvements in cancer-specific care and in palliative care. Indian clinicians favored help in improving cancer detection and advancing research in cancer care, whereas Pakistani participants would welcome raising the public’s awareness of cancer, as well as improvements in disease detection and cancer care research. Of interest was that palliative care was rated significantly higher by providers from China than from either India or Pakistan despite none of the respondents specializing in palliative care (Table 1).

Finally, the workshop participants were asked where they obtain current information about cancer care and research; multiple responses were allowed. Journals were cited most frequently by clinicians from China yet least often by those from Pakistan. The Indian respondents favored journals and professional meetings. The Pakistani caregivers favored online and electronic communications over traditional print information or meetings.

Discussion

Cancer death rates in low- and middle-income countries are now higher than that of malaria, tuberculosis and AIDs combined [9]. We sought to document the current and anticipated issues faced by young cancer caregivers actively practicing in selected low- and middle-income countries of Asia who were participating in a clinical-trials workshop held at a major hospital in their respective country. The perceptions of these early-career oncologists in China, India, and Pakistan consistently identified issues including the increasing impact of cancer in local contexts, the barriers to screening and detection, and the need for education and professional training. These observations extend our prior work surveying international oncologists attending a clinical cancer research training workshop in Australia, who were predominately from Australia and New Zealand [8] (Table 3). Despite the variations in economic conditions among these countries, respondents consistently reported significant increases in prevalence and death from cancer in their countries and the need for support in education and research.

Table 3.

Comparison of results for Australia/New Zealand and Asia

The profile of expected cancer burden differs among the three countries. For example, the Chinese clinicians viewed their country’s economy as the most pressing need followed by the environment and health. Clinicians from India ranked health as India’s greatest need followed closely by the economy and the environment. Finally, Pakistani providers agreed with their Chinese counterparts citing the economy as the primary need with health a close second followed by the environment and political stability. China is a World Bank “middle-income” country; these priorities might be expected from a country that continues to expand its economy, and the relationship between environmental concerns and some cancers supports their interest in environmental issues. India’s population density and Pakistan’s relatively low income probably influence the primary concerns facing each country. These results all were in contrast with results from Australia and New Zealand (World Bank high-income countries), where health was identified as the most important need (Table 3) [8].

Healthcare funding is heavily influenced by the local economic and political structure. A nationalized health care system supported by fee for service private practice should probably be expected in China as its market-based economy expands to become consistent with other middle-income countries [8]. India and Pakistan, however, are similar in their use of both nationalized health care supported by fee for service private practice and private payments without health insurance. A large fraction of both populations is likely unable to afford health insurance and must pay for what health care they can afford.

The health problems identified in each country likely reflect the respondent’s academic training and current clinical practice. Cancer may not be identified by the general populace of each country as a primary health concern yet, but as the burden within each country increases, poorly prepared countries will face social and economic consequences. It should not be surprising that the respondents, practicing oncologists, prioritized cancer as a national priority in China and India, whereas respondents from Pakistan expect cardiovascular disease to be their primary health issue followed closely by cancer, displacing malnutrition and infectious diseases from the list of the top three health issues.

The factors thought responsible for the rising cancer burden vary by country. Most respondents felt that diet and lifestyle changes coupled with environmental exposures are the driving primary forces. Respondents from China and India felt that their aging populations are important factors, whereas Pakistani respondents were more concerned about the increase in infections that predispose to some cancers. Overall, diet and lifestyle issues were rated by far the most important factors behind the change.

Most respondents felt that their country was ill-prepared to meet this impending challenge. More than half of all Chinese respondents felt that China needed to implement tobacco control programs, improve cancer screening, and deploy vaccines for known infectious causes of cancer. More than 50% of clinicians from India were also concerned about tobacco control [9] but would prioritize expanding infrastructure and education of professionals and the public. Pakistani providers were most concerned about cancer screening and facilities, but at least 50% also thought Pakistan needed to address infrastructure, tobacco control, and public awareness.

Respondents had suggestions to improve local cancer care. More than half of the Chinese respondents wanted to raise the public’s awareness of the disease and improve detection, prevention, and access to the latest therapies and palliative care. India and Pakistan’s physicians favored raising the public’s awareness of cancer; for example, increased awareness of breast cancer in the urban population of India has been successful in increasing the numbers of patients initiating treatment when the cancer is localized [10]. Further, they wanted improvements in professional education, general health care delivery, and better detection. Pakistani providers also felt that improved cancer care research would improve outcomes.

Workshop participants realize there are barriers to improving outcomes and expressed interest in assistance from professionals, specifically professional education. Although this factor was by far the primary request by the providers from all three countries, China would welcome help with specific care, access to the latest therapies, and better palliative care. India would benefit from better detection, research, awareness, and health care delivery. Pakistan needs help with awareness, detection, research, prevention, and access to modern therapies. Currently, all of the respondents use traditional educational sources such as journals and professional meetings, but substantial numbers of the Indian and Pakistani respondents obtain information through electronic media. A majority of Chinese respondents attend commercially sponsored educational programs.

These regional variations highlight differences in infrastructure, commitment to health, and priorities among countries considered to be low-, middle-, or high-income countries. For example, some parts of India have comprehensive palliative care services and networks for training and education that are internationally recognized, whereas other areas are less well served.

The responses regarding the role of research in improving professional knowledge to improve care and outcomes were interesting. Lower-income countries have scarce public money for research, and few respondents feel that research funding is an important priority for their country to address, yet they recognize that improved research activities would be important to improve outcomes and would welcome support from others to help in that regard. Consequently, investments in a local country’s ability to conduct research should be specific to that country’s needs, thereby elevating the importance of research training to prioritize local outcomes using scientific rigor and integrity. This suggests that one approach could be to prioritize clinical research on cost-effective strategies in cancer care.

Healthcare systems face unique challenges to improve cancer prevention, treatment, and outcomes. Clinicians from Australia and New Zealand felt the best way to improve outcomes was to improve general health care delivery [8]. In contrast, the most frequently cited way to improve outcomes by the Asian clinicians was to improve detection. All three countries in this report also believe the best way to achieve their goals is for others to help improve professional education and training to improve patient care. Support for improving cancer care in developing countries must consider local conditions first so that support meets actual and perceived needs of each locale. Unfortunately, low- and middle-income countries may have limited academic, financial, and infrastructure resources required to achieve the same success currently experienced in higher-income nations.

Our study has some limitations. Most respondents were a highly select group of practicing oncologists and researchers who were attending a clinical trial workshop at a major hospital in their country. Therefore, they are not representative of the general health care professionals in their respective countries. Although their perceptions and opinions of the cancer care challenges helped us learn what their priorities are, health care providers with a more general perspective might have differing views. Further, our sample size was too small to address differences in clinical subgroups or clinicians in a variety of practice settings, serving both low- and high-income patients. Finally, future studies should address patients and their families about their disease burden, what is lacking, and their priorities to compare with what the respondents have prioritized.

Conclusion

Clinicians from Pakistan, China, and India feel that improved clinical research, professional education, and service provision are major priorities for improving cancer outcomes in their region and that these are among the best ways that other countries can provide help. International support needs to plan programs with local cooperation and collaboration to address country-specific needs, context, and perspectives. A profile of specific needs is likely preferred than a single model universal approach. Farmer et al. [3] suggest a focus on cancers “that can be prevented . . . cured . . . or palliated,” and others have suggest that a research perspective was also a priority [6]. Our results suggest that oncologists in individual countries prefer focusing on their specific needs, a critical perspective for successful interaction between international efforts, local policy makers, and local cancer caregivers.

Author Contributions

Conception/Design: H. Kim Lyerly, Amy P. Abernethy

Provision of study material or patients: Zeba Aziz, Reena Nair, C.S. Pramesh, Rozmin Jamal, Azizunissa Irumnaz, Jun Ren

Collection and/or assembly of data: H. Kim Lyerly, Zeba Aziz, Reena Nair, C.S. Pramesh, Rozmin Jamal, Azizunissa Irumnaz, Jun Ren

Data analysis and interpretation: H. Kim Lyerly, Maria R. Fawzy, Martin R. Stockler, Amy P. Abernethy

Manuscript writing: H. Kim Lyerly, Maria R. Fawzy, Zeba Aziz, Reena Nair, C.S. Pramesh, Vani Parmar, Purvish M. Parikh, Rozmin Jamal, Azizunissa Irumnaz, Jun Ren, Martin R. Stockler, Amy P. Abernethy

Final approval of manuscript: H. Kim Lyerly, Maria R. Fawzy, Zeba Aziz, Reena Nair, C.S. Pramesh, Vani Parmar, Purvish M. Parikh, Rozmin Jamal, Azizunissa Irumnaz, Jun Ren, Martin R. Stockler, Amy P. Abernethy

Disclosures

Amy P. Abernethy: Bristol-Myers Squibb, ACORN Research (C/A), Agency for Healthcare Research and Quality, Alexion Pharmaceuticals, Alliance for Clinical Trials in Oncology, American Cancer Society, DARA, Celgene, Helsinn, Dendreon, GlaxoSmithKline, Bristol-Myers Squibb, Kanglaite, Pfizer, Galena, Insys, Biovex, MiCo, Lilly, Amgen (RF), Flatiron Health, Inc., athenahealth, Inc., Advoset, LLC, Orange Leaf Associates, LLC (E); Reena Nair: Roche India Pvt. Ltd., Novartis (C/A, RF), Intas Pharmaceuticals, Ltd. (C/A). The other authors indicated no financial relationships.

(C/A) Consulting/advisory relationship; (RF) Research funding; (E) Employment; (ET) Expert testimony; (H) Honoraria received; (OI) Ownership interests; (IP) Intellectual property rights/inventor/patent holder; (SAB) Scientific advisory board