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Breast Cancer in LMICs:Meeting the Challenge ofclosing the cancer divide
Felicia Marie KnaulFebruary 14, 2012
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From anecdote
to evidence
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January, 2008
June, 2007
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Con jf en harvard
Harvard School of Public Health
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From anecdote
to evidence
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Global Task Force on Expanded
Access to Cancer Care and
Control in Developing Countries
= global health + cancer care
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Closing the Cancer Divide:A Blueprint to Expand Access in LMICs
I: Much should be doneII: Much could be done
III: Much can be done
1: Innovative Delivery
2: Access to Affordable Medicines,
Vaccines & Technologies
3: Innovative Financing: Domesticand Global
4: Evidence for Decision-Making
5: Stewardship and Leadership
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Applies a diagonal
approach to avoid
the false dilemmasbetween disease silos
-CD/NCD- thatcontinue to plague
global health
Closing the Cancer Divide:A BLUEPRINT TO EXPAND ACCESS IN LMICs
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Challenge and disprove the
myths about cancer
M1. Unnecessary
M2. Unaffordable
M3. ImpossibleM4: Inappropriate
Should,
Could, andCan..
Expanding access to cancer care and control in
low and middle income countries:
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The divide is the result of concentrating riskfactors, preventable disease, suffering,impoverishment from ill health and deathamong poor populations.
fueled by progress in cutting-edge science andmedicine in high-income countries.
The Cancer Divide:disparities in outcomes
between poor and rich directly related to inequitiesin access and differences in underlying socio-
economic and health conditions.
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Mirrors the overall epidemiologicaltransitionprotracted and polarized*:
LMICs increasingly face both cancersassociated with infection, and all other
cancers.
Cancers that were once considered only ofthe poor, now cease to be the only cancers
of the poor. (e.g. cervical & breast cancer)
The Cancer Transition
* Frenk et al
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Cancer is a disease of both rich and poor;
yet it is increasingly the poor who suffer:
1. Exposure to risk factors2. Preventable cancers (infection)
3. Death and disability fromtreatable cancer
4. Stigma and discrimination
5. Avoidable pain and suffering
The Cancer Divide:
An Equity Imperative
Fac
ets
Ri k f t t ti
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Risk factor concentration:
Obesity Epidemic, Mexico
10
60
8
32
57
25
10
2
37
25
36 37
29
2
Malnutrition Adequate
Overweight
Obesity
1988
1999
% women 20-49 years
2006
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MortalityIncidence
Incidence and mortality of cervical cancer(adjusted rate per 100,000 women)
Incidenceratio
Mortalityratio
Russia 19.3 8.6
Central and Eastern Europe 21.3 9.0
Less developed regions 25.7 14.1
More developed regions 13.2 4.6
World 22.0 11.2
Th id i f b t
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The epidemic of breast cancer:Unforseen challenge in LDCs
Some 45% of the more than 1 million new cases of breastcancer diagnosed each year, and more than 55% of breast-
cancer-related deaths, occur in low- and middle-income
countries.*
Such countries now face the challenge of effectivelydetecting and treating a disease that previously was
considered too uncommon to merit the allocation of
precious health care dollars.
Source: Porter, P. (2007). "Westernizing Womens Risks? Breast Cancer in
Lower-Income Countries." New England Journal of Medicine 358(3):4
Curado MP, Edwards B, Shin HR, et al., eds. Cancer incidence in five continents. France: International
Agency for Research on Cancer, 2007.
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In developing regions, breast cancer
Most frequent cause of cancer-related death in developing and
developed regions
leading cause if death especially for young women
268,000 of the 458,000 deaths per year are in LIMCs: 58%
Most common cancer in developed and developing regions
4.4 million women alive (diagnosed): how many in developing
regions?
2008: 1.38 million new cases; 50% of which are from LIMCs
10.9% of all incident cancerssecond to lung
(Globocan, 2010; Boyle y Levin, 2008; Beaulieu, Bloom, y Bloom, 2009).
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Breast cancer: myths and realities
It is a disease ofdeveloped countries
It is a disease ofolder women
It is of lower prioritythan cervical cancer
The majority of cases anddeaths occur in the
developing world
A large proportion of casesand deathsperhaps the
majorityhappens in
women
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~40% occur in pre-menopausal
women (55
Age of
Diagnosis
Age ofDeath
Source: Author estimates based on IARC, Globocan, 2008 and 2010.
33%
20%54%
66.6%
34.2%65%
The cancer transition in LMICs:
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Source: Knaul, Arreola, Mendez. estimates based on IHME, 2011.
The cancer transition in LMICs:
breast and cervical cancer 1980-2010
53%47%
20%24%
19%
-31%
60%
-40%
0%
40%
80%
LMICs High income
BC cases
BC deaths
CC cases
CC deaths
% Change in incidence and mortality
The cancer transition in LMICs:
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Source: Knaul Arreola Mende . estimates based on IHME 2011.
LMICs as % of global incidence and mortality
Breast
Cervical
The cancer transition in LMICs:
breast and cervical cancer 1980-2010
0%
30%
60%
90%
1980 2010 1980 2010
52%
59%
49%
63%
79%
87%82%
88%
The Cancer Transition Me ico and Costa Rica:
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Source: Knaul et al., 2008. Reproductive Health Matters, and updated byKnaul, Arreola-Ornelas and Mndez based on WHO data, WHOSIS (1955-
1978), and Ministry of Health in Mexico (1979-2006)
1995 2000 2005
Costa Rica 1995 - 2005
Breast cancer
Cervical cancerSource: Instituto Nacional de Estadstica y Censos, Ministerio de Salud,Unidad de Estadstica, Registro Nacional de Tumores de Costa Rica.
The Cancer Transition, Mexico and Costa Rica:
breast and cervical cancer, mortality time series.
0
4
8
12
16
1955
1965
1975
1985
1995
2005
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Source: Lozano, Knaul, Gmez-Dants, Arreola-Ornelas y Mndez, 2008, Tendencias en la mortalidad por cncer de Mama en Mxico, 1979-2008.
FUNSALUD, Documento de trabajo. Observatorio de la Salud.
1979
1985 1995
Nuevo Len
2008
0
Oaxaca
5
10
15
20
25
1979 1985 1995
2008
The cancer transition within Mexico:
breast and cervical cancer 1979-2008
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Adults
Breast
Cervix Prostate
Testis
HL
N HL
Leukaemia
All cancers
Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.
Children
LOW
INCOME
HIGH
INCOME
Survival
inequalityg
ap
LOW
INCOME
HIGH
INCOME
100%
The opportunity to survive (M/I)
should not be defined by income.
Yet it is.
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Stigma:
Juanita
Cancer, and
especially
reproductive
cancers, adds
a layer of
discrimination
onto gender,
ethnicity, andpoverty.
The most insidious example of
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The most insidious example of
injustice is access to pain controlNon-methadone, Morphine
Equivalent opioid consumptionper death from HIV or cancer in
pain by income level
Russia: 937 mg; ALL Developed
countries 57,041
Ch ll d di th
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Challenge and disprove the
minimalists:
myths about cancer
M1. Unnecessary NECESSARY
M2. Unaffordable: .for the poorM3. Impossible
M4: Inappropriate: either/or
Challenging cancer implies taking
resources away from other diseases of
the poor
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`5/80 Cancer Disequilibrium
Almost 80% of the DALYs (disability-adjustedlife-years) lost worldwide to cancer are in LMICs,yet these countries have only a very small share of
global resources for cancer ~ 5% or less.
Africa
1% of global spending on health64% of new cancer cases
15% of the global population.
I ti i CCC
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Investing in CCC:
We cannot afford not toHealth is an investment, not a cost
World Economic Forum: chronic disease is 1
of the 3 leading global economic risksEconomic value of lost DALYs: $921 million
VSL losses: $2.5 billion
Total economic cost of cancer, 2010
2-4% global GDP
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80% of total
75% ofbreast
95% of cervical
Avoidable cancer deaths:
1/3 to 1/2 or 2.4-3.7 million
Income Region% of all cancer deaths
considered avoidableBreast
Low income 52% 79%
Lower middle
income44% 73%
Upper middle
income33% 56%
High income 21% 40%
LMICs: Avoidable
deaths
I ti i CCC
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Investing in CCC:
we cannot afford not to
Assuming that between 50% of
deaths are avoidable
Total annual cost: $310 billionInvesting in CCC yields an annual
return on prevention and treatment of
between 1.5:1 to 3.7:1.
Economic cost of inaction, 2009
$US 2010 billion130-850
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Second-line TB Drugs
(Farmer, 2009)% Decline in price 1997-9
Amikacin 90%
Ethionamide 84%
Capreomycin 97%
Ofloxacin 98%
Reduced drug and vaccine prices
HPV vaccine in LMICs: Before 2011: from $US 30 to $US 100 per dose
PAHO Revolving Fund: decreased from US$ 32 per dose in January
2010 to US$ 14 per dose in April 2011.
GAVI: June 2011 Merck offers vaccine at US$ 5 per dose for low
income countries.
Hep B vaccine: decline from a 1982 launch price of over $100 to$0.20 a dose has enabled developing countries to dramatically increase
vaccination rates with support from GAVI
Challenge and disprove the
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Challenge and disprove the
minimalists:
myths about cancer
M1. Unnecessary
M2. Unaffordable:M3. Impossible POSSIBLE
M4: Inappropriate: either/or
Challenging cancer implies taking
resources away from other diseases of
the poor
Champions
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Harvard Breast Cancer in Develo in Countries Nov 4 `09
ChampionsNobel Amartya Sen,
Cancer survivor diagnosed in India50 years ago
Drew G. Faust
President of Harvard University22+ year BC survivor
Champions from LMICs: Mxico
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Champions from LMICs: Mxico
Successes treating other diseases:
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Successes treating other diseases:MDR-TB treatment
Source: Paul Farmer., 2009
cured
83%
abandon
therapy
2%
failed
therapy
8%
died
8%
Mitnick et al, Community-based therapy for multidrug-resistant tuberculosis in Lima, Peru. NEJM 2003; 348(2): 119-
Outcomes in MDR-TB patients in Lima,
Peru receiving at least 4 months of therapy
WHO 1997, Multidrug-resistant
tuberculosis is too expensive to treat in
poor countries; it detracts attention and
resources from treating drug-susceptible
disease.
Drug % Decline inprice 1997-9
Amikacin 90%
Ethionamide 84%
Capreomycin 97%
Ofloxacin 98%
Reduced prices of
second-line TB drugs
S i t ti l
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Mexico: cervical cancer.
Source: Knaul et al., 2008. Reproductive Health Matters, and updated by Knaul, Arreola-Ornelas and Mndez based on WHO data, WHOSIS (1955-1978), and Ministry of Health in Mexico (1979-2006)
0
4
8
12
16
1955
1965
1975
1985
1995
2005
Success in treating several cancers.
Financing innovations:
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Financing innovations:
DomesticIntegrate CCC into national insurance programs to
express previously suppressed demand, beginning
with cancers of women and children:
Mexico
Colombia
Dominican Republic
Peru
China
India
Rwanda
Taiwan
Innovations in Financing:
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Innovations in Financing:
Global
Integrated, innovative financingmechanisms that have gone to scale -
Global Fund and GAVI - can be leveragedRMNCH platforms provide models forbroad-based international partnership and
commitment-building for cancer and NCD.Recent, diagonal partnership initiatives arepromising -pink ribbon red ribbon
Challenge and disprove the
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Challenge and disprove the
minimalists:
Myths about cancer& NCD
M1. Unnecessary NECESSARY
M2.Unaffordable AFFORDABLE
M2. Impossible POSSIBLE
M4: Inappropriate: either/or
Challenging cancer implies takingresources away from other diseases of
the poor
Women and mothers in LMICs
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Women and mothers in LMICs
face many risks through the life cycle
Women 15-59, annual deaths
Diabetes
120,889
Breast
cancer
166,577
Source: Estimates based on data from WHO: Global Health Observatory, 2008 and Murray et al Lancet 2011.
Cervical
cancer
142,744
Mortality
in
childbirth
342,900
- 35%in 30years
= 430, 210 deaths
The Diagonal Approach to
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The Diagonal Approach to
Health System Strengthening
Rather than focusing on disease-specific vertical
programs or only on horizontal system
constraints, harness synergies that provide
opportunities to tackle disease-specific priorities
while addressing systemic gaps.
Optimize available resources so that the whole is
more than the sum of the parts.
Bridge the divide as patients suffer diseases over a
lifetime, most of it chronic.
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Why diagonal?
Shared risk factors
Success and life cycle
Common need for strong healthsystems platforms
Efficiency
Economic developmentSocial justice
Di l St t i
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Diagonal Strategies:
Positive Externalities
Promoting prevention and healthy lifestyles:
Reduce risk for cancer and other diseases
Reducing stigma for womens cancers:Contributes to reducing gender discrimination.
Pain control and palliation
Reducing barriers to access is essential forcancer, for other diseases, and for surgery.
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Delivery: Harness platforms byintegrating cancer prevention,
screening and survivorshipsupport into MCH, SRH,
HIV/AIDS, social welfare andanti-poverty programs.
A Diagonal Strategy:
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Cases:
Juanita
Mexico
Mexico Seguro Popular Insurance
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g p
a diagonal strategy that includes financial
protection for catastrophic illness
Accelerated universal vertical coverage by disease
with a specified package of interventions
2004/5: ALL in children, cervical, HIV/AIDS
2006: All pediatric cancers
2007: Breast cancer
2011: Testicular cancer and NHL
Seguro Popular and cancer:
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Seguro Popular and cancer:
Evidence of impact
Since the incorporation of childhoodcancers into the Seguro Popular
30-month survival: 30% to almost 70%adherence to treatment: 70% to 95%.
Access to medicinesan anecdote
Breast cancer adherence to treatment:2005: 200/600
2010: 10/900
H i l d i l fi i l i i
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Beneficiaries: Population covered
Benefit
s:coveredinterventions
Horizontal and vertical financial protection strategies:Seguro Popular for Breast Cancer, Mexico
Catastrophic Illness
ACCELERATED VERTICAL COVERAGE: Ex: breast cancer,
Package ofessential personal
services
Community Health Services - NUTRITION
Poor Rich
M i f f t
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Mexico: summary of facts
Since 2006, breast cancer is the second leading cause ofdeath among women aged 30 to 54 years of age and the
principal cause of death due to tumors.
Seguro Popular: since 2007 all women diagnosed with
breast cancer have very complete access to treatmentwith financial protection
Only 5-10% of cases in Mexico aredetected in Stage 1 or in situ
i i
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Early Detection = survival
Stage at diagnosisSurvival rates,
US ACS
0 - 1 98%
2 - 3 84%
4 27%
Fuente: American Cancer Society. Breast Cancer Facts & Figures, 2007-2008. Atlanta, GA. : American Cancer Society, Inc.,
y Secretara de Salud. Programa de Accin: Cncer de mama. Mxico, D.F.
Mexico: 70% in late stages
IMSS M i 40 50% f
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IMSS Mxico: 40-50% of cases are
detected in stages III-IV. 85+ in II+
10%
30%
50%
1992 2002 2006
Stage I Stage II Stage III & IV
Stage at diagnosis by level of municipal
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g g y p
marginalization, Mexico, IMSS 2006(Mxico, IMSS 2006)
Source: Authors estimation based on IMSS data, 2006.
N=221(3.8%)
N=1737(30%)
N=2877(49.8%)
N=946(16.4%)
% diagnosed
in Stage 4
Late detection by state
0%
10%
20%
30%
40%
50%
Poor (High) Middle Low Very low
Stage 1 Stage 2
Stage 3 Stage 4
< low
> mid
> high
Wh ?
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Why?
Social and health systems
barriers to early detectionand
non-price barriers totreatment
Vignette: a series of Missed Opportunities:
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g ppJuanita
(patient journey analysis)42; left breast substantially larger than right; arrived at Morelos
Womens Hospital bc she could not move her swollen arm; father of
children abandoned household at diagnosis
History 1:
- 5 children aged 7-18; breast fed all
- Cartilla de la mujer: regular PAP and clinic visits
- Has Oportunidadesattends regular community health platicas
History 2:
Felt a breast lump 4 years priorfear kept her from saying anything
Lump grewlast year asked doctor-pasante at local clinic and given anti-b
w/out bc
Is entitled to Seguro Popular and free care
Cannot travel to Mexico City so seeking care locally and paying out of pocket
J it
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br
Juanita:Advanced metastatic breast
cancer is the result of a series ofmissed opportunities
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Barrier 1: financing
Barrier 2: myth and machismo
Barrier 3: Inequity in addition to lack
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0%
10%
20%
30%
+ Poorest
Q1 Q2 Q 3 Q 4Least poor
QV
16%
21% 22%24%
28%
Fuente: ENSANUT, 2006
q y
of overall access and utilization
Only 1 in 5women 40-69
report a
preventivehealth visit
including
mamography2006
B i 4 P lit i
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Barrier 4: Poor quality services
women diagnosed with bc reported problems withproviders when seeking diagnosis.
In routine, annual repro health/OBGYN visit/ PAP
screening, there was no BCE
Physician insisted woman was overreacting and sent herhome with no diagnosis
Health professionals and first-level care providers
report lack of sensitivity of health personnel relating to
the requests of women regarding breast health
Results from a national qualitative studynigenda et al, 2009
a series of missed opportunities
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a series of missed opportunities
Nurse and midwife
Works on MCH, SRH and HIV/AIDS
locally
Has participated in global advocacy andtraining conferences
Undertakes research and field surveys
.has never considered including NCD or
cancerbcthere is no treatment
available or it is not a problem
Policy maker in MOHoffice down the
hall from women and cancer Manages the cash-transfer, family
planning program
Information on NCD and cancers are not a
topic that is covered in the discussions
bc it is not a problem and there are no
materials
Breast cancer advocate, runs an
international NGO. Concerned about funding for
treatment but does not participate
in debate about health care reform
Patients are surviving to suffer
other diseases (diabetes?), but her
group cannot offer assistance
they have no linkages to other
groups
Does not participate in advocacy
about women and health more
broadly, yet one of the mainbarriers to early detection of her
patients is machismo and gender
discrimination
Programs to reduce
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Programs to reduce
barriers
Core project components
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Core project components1) Expand potential for early detection
Harness anti-poverty and MCH Oportunidades programTraining of health promoters
Improved referral system
Training of primary care-level physicians and nurses
2) Expand potential for care and treatment in secondary level
hospitalsSupervision and capacity building from tertiary to secondary
district hospitals
Centers for chemotherapy and survivorshipsecondary and
primary levelAcreditation of secondary centers so SPSS can finance
3) Increase data-for-decision-making, evaluation and monitoring
Improved or new registries
Evaluation and monitoring
P ti i ti i tit ti
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Participating institutions:
Seguro Popular and MOH MexicoMinistry of Health of Jalisco, Morelos, Nuevo Leon, Puebla,
Sinaloa.
National Cancer Institute of Mexico
National Institute of Public Health
Cncer de mama: Tmatelo a pecho
Mexican Health Foundation
The Global Task Force on Expanded Cancer Care and Control inDeveloping Countries through the Secretariat based at the
Harvard Global Equity Initiative and Seattle Cancer Care Alliance
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Challenge and disprove the
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g pminimalists:
Myths about breast cancer,cancer& NCD
M1. Unnecessary NECESSARYM2. Impossible POSSIBLE
M3.Unaffordable AFFORDABLE
M4. Inappropriate : APPROPRIATE
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Be anoptimist
optimalist
Expanding access to cancer care and control in
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