1. Who Essential Drug List

A consensus panel discussion on the value of an Essential Drugs List (EDL) for cytotoxic drugs in developing countries (Co-Chairs: Dr. Cecilia Sepulveda, WHO and Dr. Hussein Khaled, Cairo NCI) was held during the 7th INCTR annual meeting in Sao Paulo, Brazil (March 1st - 4th, 2007). Panel members were from Argentina, (Fundaleu), UK (Cochrane Cancer Network), Mexico and India. The presentations from the panel focused on the cost, quality, and availability of cytotoxic drugs in developing countries in the current context of rising cancer incidence, continued late presentation (with its attendant increased management costs) and lack of reliable cancer registry data. The urgency of this dilemma is emphasized by the facts that, already, 70% of cancer deaths occur in developing countries and the global burden of cancer is progressively increasing, particularly in the developing countries (see President’s message).

While the cost of surgery or radiotherapy can be controlled in most developing nations, the cost of systemic therapy using pharmacologic agents often cannot. Developing countries need to be able to distinguish between those agents that are essential and those that can be used on a limited scale at high cost, because they contribute to a small or minimal degree to overall cancer treatment; in some cases the cost may be sufficiently high and the benefit sufficiently small as to make the use of particular drugs inappropriate.

WHO defines essential drugs as "Those drugs that satisfy the health care needs of the majority of the population at all times, in adequate amounts and in appropriate dosage forms, at a price the community can afford". WHO publishes EDLs that serves as a model for the selection of drugs on the basis of comparative efficacy and safety, quality and cost effectiveness. EDLs are generally updated every two years and represent influential contributions to clinical practice guidelines in developing countries. This is particularly relevant in the field of oncology where the cost differences between various cytotoxic drugs (and the same drug from different suppliers) may be substantial. Multiplied by an increasing number of patients, the cost of some individual drugs, particularly those still under patent, which may have minor benefits in particular patient subsets, could exceed the present total budget for cytotoxic agents.

The example was given of a health authority in a developing country where approximately 200 cancer patients treatable by cytotoxic drugs are diagnosed every year. The health authority has an available drug budget of 1000 currency units (cu). There are two possible drug combinations: combination A, that costs 50 cu per course and has a response rate of 60%, and combination B, costing five cu per course with a response rate of 50%. The question that faces the health authority is clear: should it treat 20 patients with regimen A and leave the remaining 180 patients untreated, or should it treat the 200 patients with regimen B with a response rate of 50% resulting in the cure of 50 patients rather than 12? It is this financial and ethical dilemma that faces health authorities and individual oncologists every day. Not surprisingly, the cytotoxic treatment regimens used vary widely from country to country from institute to institute, and from patient to patient.

In order to inform the debate on how to prioritize health care, it is crucial to have as accurate as possible a knowledge base of the quality, quantity and distribution of resources for treatment. The EDL might be conceived of as being one component of an Essential List of Treatment Resources. Unfortunately, the lack of data from developing countries, including population-based cancer registries and information on disease stage at presentation and survival rates, hinders policy makers in the process of defining the magnitude of their cancer problem, determining priorities and drawing up realistic budget estimates.

The panel felt that deciding how much of public funds (if any) should be spent on systemic therapy can only be decided in the context of the overall strategy for controlling cancer, i.e., in a national cancer control plan (NCCP). For example, drug costs might be reduced by taking measures to ensure that a higher fraction of patients is diagnosed when their disease remains localized. Information regarding the value of individual drugs – and their use in standard drug combinations - might be useful, as well, perhaps, as a supplementary list of drugs that might be considered, in some circumstances for inclusion in the national EDL – for example, drugs that are highly effective in relatively uncommon diseases.

Hussein Khaled, NCI Cairo, Egypt
Cécilia Sepulveda, WHO, Swizerland


2. Traditional Medicine

A session on Traditional Medicine, entitled, "Traditional Medical Systems: Complementary or Detrimental" Co-Chairs: Dr. Michael Wargovich, Medical University of South Carolina, Charleston, SC, USASA, and Dr. Baffour Awuah, Komfo Anokye Teaching Hospital at Kumasi, Ghana, – was held during the 2007 INCTR meeting on Saturday, March 3, 2007.

The session included five presentations commencing with an overview of the use of traditional medicine in the prevention of cancer; Dr. Wargovich reported that chronic, unresolved, asymptomatic inflammation is now considered to be a critical step in the development of common cancers. Botanical compounds that relieve inflammation are being found to have efficacy in inhibiting cellular proliferation of a number of human tumor cells in vitro. Dr. Wargovich illustrated his ongoing collaborative studies with examples, e.g., the use of traditional medicinal plants in the Republic of Guinea (West Africa) and semi-tropical fruits in Brazil.

Dr. Awuah then gave an overview of traditional medicine systems in West Africa. He observed that until recently there had been a conscious, or perhaps unconscious, ignorance of the impact of traditional medicine practitioners in the effort to manage cancer patients with curative intent. In medical practice the practitioner whom a patient first consults contributes immensely to the final outcome of the disease. In many developing countries the majority of the population still lives in rural communities where access to orthodox medical practitioners is nonexistent. For these populations the first point of consultation is usually the traditional healer who resides within the community. However, there is a huge difference between the orthodox and traditional medical concepts with respect to perceptions of diseases, their causation and treatment. Orthodox or 'Western' medicine regards physical and infectious agents and genetic abnormalities to be the causes of many diseases, whereas in traditional medicine spiritual and supernatural powers, among other factors, are widely thought to be among the causes of disease. From the orthodox perspective the usual reasons given for the abysmal outcome of cancer patients from the developing world are ignorance, poverty, and the low level of cancer awareness due to lack of education. As a result cancer control strategies generally ignore the traditional healers, even though they play a major role in health service delivery in rural populations. There is therefore an urgent need to look at the role of traditional medicine practitioners in our effort to control cancers in the developing world.

Dr. Zeba Aziz (Hospital, Lahore, Pakistan) presented an overview of traditional medicine systems in Pakistan. The use of complementary and alternative medicine (CAM) prior to, during and after treatment with standard therapy for cancer is increasing in cancer patients both in developed and developing countries. In Pakistan the most commonly used CAM practices are: acupuncture, Aryuvedic medicine, homeopathy, and the use of faith healers. However, quite often the use of CAM results in delayed diagnosis and advanced disease. Dr. Aziz reported that there are no randomized trials to support the use of CAM.

Presenting a summary of traditional medicine and its use in East Africa Dr. Twalib Ngoma (Ocean Road Cancer Institute, Dar Es Salaam, Tanzania) explored the significance of the fact that many patients in the developing world see a traditional healer first. He suggested that this has two possible outcomes. Firstly, if the patient finds relief of symptoms, or is cured of their ailment, verification is difficult since the patient has not entered an allopathic care system. Secondly, many patients spend too long in the care of a traditional healer, delaying diagnosis and treatment; a delay that otherwise might have allowed for a successful medical intervention.

Dr. Yaoping Wang, (Shanghai Children’s Cancer Centre, Shanghai China). presented an overview of Asian Traditional Medicine and cited the long history of the use of such practices in China. Based on an understanding of energy flow throughout the body, traditional Chinese medicine (TCM) uses a combination of energy practices and herbal medicine to bring the body into a state of harmony, and is often at variance with the more disease-focused practices of Western Medicine.

After these presentations there was a lively discussion on the role of INCTR in furthering research on Traditional Medicine Systems. The panel of speakers agreed that the integration of traditional medicine practices with allopathic practices might be a worthy goal. Dr. Magrath suggested that the concept of a "polyclinic" be developed where both types of approaches could be available to the patient, under the same roof. The panel concluded that the topic of Traditional Medicine be expanded and made a permanent part of the scientific sessions of future INCTR annual meetings. Further, it was suggested that a formal working group of interested individuals in the area of traditional medicine be formed within INCTR for future planning of research strategies.

Michael Wargowich, Medical University of South Carolina, USA
Baffour Awuah, Komfo Anokye Teaching Hospital, Ghana