Across Generations: Cancer Treatment in Developing Countries

DOI: 10.1200/JCO.2008.16.8112 During morning rounds, my young intern presented Ali Shehzad, a 17-year-old laborer with T3N1M0 colon cancer, who had to quit school after completing eighth grade because of his father’s death. He is the only son among six children; his mother and one eight-year-old sister work as maids, each earning $20 a month. My intern had recently attended our weekly journal club and knew about the superiority of fluorouracil, leucovorin, and oxaliplatin (FOLFOX) over fluorouracil. He wanted me to arrange $10,000 for Ali’s treatment. When I said funds might be difficult to obtain, he broke down and said he would not take no for an answer. We decided we would look for some donors. The next bed had a 16-year-old high school graduate, Saira, who was doing extremely well in school and had now developed acute lymphoblastic leukemia. The parents were determined to save the child, even if it meant selling all their possessions— including a small mud house and two goats. After my rounds, her father came to my office and started crying. Between sobs, he kept saying, “Doctor, please save my daughter. After Allah, you are the only one who can help me. Please take everything from me, just save her. She is such a good student and we were pinning our hopes on her to help her younger siblings after she completes her studies. I can contribute approximately 15% of the total cost of treatment over 3 years but cannot afford the full cost of treatment.” A 30-year-old mother, Leila, with locally advanced breast cancer, was sitting in the next bed with an odd mixture of hope and despondency in her eyes. Her husband had left her 2 years previously and she had a 4-year-old son who was sitting with her because there was no one at home to look after him. “I’ll go through whatever I have to,” she said. “I just want to see my son grow up. There is no one else to look after him.” We had given her first-line treatment with FAC [fluorouracil, doxorubicin, and cyclophosphamide] with a significant clinical response, but four additional cycles of taxane therapy was not feasible: at $2,000, the drug was too expensive. We decided to send her for surgery and radiation. The next patient was a young girl with dyspnea, Rukhsana, with osteogenic sarcoma who came back after 2 years with lung metastases. She had responded extremely well to chemotherapy and surgery initially, but her parents could not afford to bring her for additional treatment. Her father had now sold his motorbike to get her treated. When I explained that the cure was no longer possible, given that her disease has now spread to her lungs, he could not understand. “Do you want more money?” he asked. “You can have it as soon as I sell my house, but you must cure my daughter at all costs.” Pakistan is a third-world country. I work at a government hospital in Pakistan where more than 95% of patient incomes range from $30-$100 per month. According to official figures, nearly 44% of the population is either extremely poor, ultra poor, poor or vulnerable (ie, their monthly per-adult consumption range 659 to 1098 rupees [US $13 to $19 per month]). These patients rely on resourceconstrained government facilities for health care. For them, any state-of-the art treatment is merely a dream. Cytogenetic and flow cytometry for leukemias are a luxury the patients cannot afford; no funds for diagnostics are available. The GDP for health care is 0.51% of the total budget. Intense poverty, coupled with lack of governmental commitment to health, means that the health care situation for the poor is grim. Health insurance is only available to approximately 2% of the population. To exacerbate matters, ubiquitous illiteracy causes poor compliance with treatment. Patients are generally unaware of the impact cancer has on their health, and the consequences for their families. They fail to comprehend that delays in treatment can cause fatal complications. The department of oncology, Jinnah Hospital, is a tertiary care center located in Lahore, Pakistan’s second-largest city (population 5 million). We have a 50bed medical oncology unit with a separate radiotherapy department. These facilities cover a 300-mile radius, catering to 10,000 new cancer cases annually. Our patients receive a hospital bed, consultation, and some laboratory tests for free. A special grant from the government of approximately $66,000 forms the annual budget for medicines; an JOURNAL OF CLINICAL ONCOLOGY T H E A R T O F O N C O L O G Y: When the Tumor Is Not the Target VOLUME 26 NUMBER 30 OCTOBER 2