Table 1.

Suggested Priorities to Reduce Cancer Care Disparities Worldwide^7,10,11

Priorities	Facts	Initiatives
Tobacco control	The cost of tobacco-related cancers exceeds US$200 billion a year. The WHO estimates that by increasing tobacco taxes by 50%, there could be a reduction in the number of smokers by 49 million within the next 3 years. It has then been suggested that it would ultimately save 11 million lives, without a decrease in government revenues.	The average low- and middle-income country could, for a cost of approximately US$0.11 per capita, implement the most active control measures, including education campaigns; higher excise taxes on tobacco; smoking bans in public places; and bans on advertising, promotion, and sponsorship.
Obesity, diet, and exercise	Obesity and other diet- and physical activity–related risk factors contribute to approximately 20% of cancer cases globally and will soon be the most common modifiable causes of the disease. The Organization for Economic Cooperation and Development has predicted that the implementation of strategies to improve diets, increase physical activity, and tackle obesity in Europe would lead to gains of > 3 million years of life free of cancer over 10 years, a benefit that could increase to 11.8 million in another decade.	A recent report by McKinsey, a business consultancy, drawing on data from the United Kingdom, showed that a series of interventions to curb overweight and obesity are cost effective, costing society less than the economic benefits they bring. These included public health campaigns, portion control, and limiting media exposure and price promotions.
Vaccines	Chronic infections are responsible for approximately 15% of all cancers around the world, but in some regions, such as in sub-Saharan Africa, nearly a third of all cancers are secondary to infections, compared with < 3% in developed countries. Vaccines to prevent hepatitis B (HBV) and human papillomavirus (HPV) have a significant impact in the prevention of liver and cervical cancer, respectively. The HPV vaccine can prevent up to 70% of cervical cancers, and HBV vaccines have had a significant impact in Asian countries that implemented immunization programs in the 1980s, such as Taiwan and Singapore.	GAVI, a public-private partnership formerly known as the Global Alliance for Vaccines and Immunization, has had a major impact in reducing the price of HBV and HPV vaccines to US$0.20 and US$4.50 per dose, respectively. By providing funding and creating a working market where previously there was none, it has improved access in eligible low-income countries and potentially averted hundreds of thousands of cancer deaths.
Prevention, early detection, and treatment	The prevention, early detection, and treatment of common cancers would have a major impact worldwide. Global investment in cervical cancer prevention could save up to 230 million years of life free of disability, with an economic value of US$1 trillion in 2010. The estimated cost of new breast cancers in the same year was US$26.6 billion. As examples, the treatment of late-stage breast cancer is three times more expensive than the management of early-stage disease. The estimated cost of death and disability caused by colorectal cancer was US$99 billion in 2008, excluding direct treatment costs.	In high-resource settings, colorectal cancer screening has been shown to be a cost-effective or cost-saving measure. Worldwide, there are nearly 300,000 new cases of oral cancer every year. Studies in India, where a third of global cases occur, show that oral cancer screening by visual inspection is cost effective and that early detection can reduce the associated morbidity and mortality. Oral cancer visual inspection by trained health workers can be carried out for < US$6.00 per person. The incremental cost per life-year saved was US$835 for all individuals eligible for screening and US$156 for high-risk individuals.
Palliative care	The WHO defines palliative care as an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness through the prevention and relief of suffering by means of early identification and assessment and treatment of pain and other physical, psychosocial, and spiritual problems.	Several studies have quantified that hospital-based palliative care visits can reduce hospital costs by up to US$7,500 for patients who die during their last admission. Home-based palliative care is also important and can reduce the overall cost of care by up to US$7,500 per cancer patient.
Cancer control planning and registries	Investing in national cancer control planning is vital to plan and deliver cost-effective programs aimed at reducing cancer incidence and mortality, to improve patients' quality of life and well-being, and to decrease the economic impact of cancer globally. Cancer registries cover < 10% of the world's population, and the available ones are predominantly located in high- and middle-income countries. In Africa, < 1% of the population is covered.	The Centers for Disease Control and Prevention, in collaboration with the International Agency for Research on Cancer, is supporting research to test pilot and develop a standardized instrument—the International Cancer Registry Costing tool (InCanRegCosting tool). This project aims to systematically assess the cost of cancer registration in LMICs. Moreover, the Global Initiative for Cancer Registries, a multipartner initiative led by the International Agency for Research in Cancer, estimates that with an investment of US$15 million over 5 years, it can establish four regional capacity building hubs that would significantly improve cancer data collection around the world.
Universal health care	Aiming to improve access to health care, many LMICs in Asia and Latin America have introduced universal coverage, the fundamental element of functional health care systems because it allows pooling of resources and the provision of financial protection from the costs of illness. As an example, not just Brazil, but also Chile, Colombia, Costa Rica, Mexico, Malaysia, South Korea, Taiwan, Thailand, and others have enacted legislation creating comprehensive insurance systems over the last few decades.	A majority of LMICs, many of which are in Africa, however, still lack universal coverage programs. A study of 192 nations revealed that even though 75 of these countries had a mandate for universal access to health care, only 58 of them met stricter criteria of > 90% access of the population to skilled birth attendance (doctors, midwives, or both) and insurance. Universal coverage also brings challenges, because it often increases public expenditure (and therefore taxation) and increases bureaucratic and administrative demands. In China, for instance, public expenditure increased from 35.6% in 2001 to nearly 60% of the total health care spending in 2012. Moreover, in low-resource settings, institutions might be weaker, and problems with corruption as well as management and accountability incentives may result in underfunding and misallocation of expenditures.

Abbreviations: HBV, hepatitis B virus; HPV, human papillomavirus; LMICs, low- and middle-income countries.