How are the lower- and middle-income countries preparing for the challenges ahead, and what does the future have in store?
by Liz Henderson
The cancer burden in Asia-Pacific is growing. Cases are projected to surge 35 per cent by 2030 due to the challenges associated with rapidly ageing populations, a growing middle class and the accompanying socioeconomic changes. Almost half of the world’s cancer cases are diagnosed here in Asia,1 and sadly, projections for cancer mortality predict an increase of 40 per cent by 2030.2 While this figure is easy to quantify numerically, it’s impossible to quantify the number of lives upended, not only of patients, but of their families and loved ones. Added to this is the emotional journey a person begins after receiving a diagnosis and the strain cancer treatment places on healthcare systems. This is especially true for emerging markets in APAC, which have different levels of development and deal with different types of cancers.
The Asia Pacific is a unique region for oncology care with one of the highest patient populations globally – home to half of the world’s population and 60 per cent of the world’s cancer patients. As Merck’s Regional VP for the Asia Pacific, I’m in the know of the challenges faced by these markets preparing for a surge in cancer diagnoses, with more than 70 per cent of these diagnoses occurring in people over the age of 65.
What has become clear to me and many other industry leaders is the difference in the challenges ahead for high-income countries that are dealing with issues relating to the quality of care, versus lower-income countries that are struggling to provide the right type of care. The question I hope to address in this piece is simple – how are the lower- and middle-income countries preparing for the challenges ahead, and what does the future have in store?
Cancer Types Vary Per Market
In the developing world, vaccine-preventable infections account for 1 in 4 cancer deaths. 3 This is a sobering statistic and highlights huge gaps in access to healthcare for some APAC markets. Thailand, Vietnam, South Korea, and China consistently rank among the top 10 countries in the world impacted by liver, stomach, and oesophagus cancers associated with hepatitis B infection. While most countries in the Asia Pacific have achieved high rates of hepatitis B immunisation, many governments are seriously lacking in HPV vaccination programmes. Lack of HPV immunisation among markets is causing the unnecessary deaths of millions of women in the region.
Urothelial carcinoma (UC), which originates in the cells lining the bladder and urinary tract, is a commonly occurring cancer. 4,5 Bladder cancer, which accounts for more than 90 per cent of cases of UC, is the 11th most common cancer worldwide and the 14th most common cancer in Asia. The proportion of upper urinary tract tumours appears to be higher in some Asian countries than in Western countries. Studies have suggested a link between this higher prevalence of upper urinary tract UC and increased exposure to environmental risk factors in Asian countries, specifically arsenic-contaminated water and aristolochic acid in Chinese traditional medicines.
In Thailand, cervical cancer is the second most common cancer in women, 6 and it is almost entirely preventable through HPV vaccination and education, given that 90 per cent of cervical cancer cases are caused by Human Papilloma Virus. In India, one woman dies of cervical cancer every 8 minutes, 7 but in contrast, Australia is set to be the first country in the world to eliminate cervical cancer after successfully implementing prevention methods since 2007 like comprehensive HPV screening, immunisation and awareness campaigns.8
Cancer types can also vary by lifestyle habits of the market in question. While lung cancers associated with high smoking rates are seen in Thailand, Vietnam, and the Philippines, Australia has a problem with colorectal (bowel) and prostate cancer. In 2019, colorectal cancer was the second most common cause of cancer death in Australia. Anyone can get bowel cancer, however, it is linked closely to lifestyle factors like smoking, being obese, 9 and having a poor diet, as well as getting older. In my view, getting older should not be a prerequisite for developing any type of cancer. It’s up to healthcare industry leaders to continue developing innovative therapies to ensure this is never the case.
When caught early, bowel cancer survival rate can be over 95 per cent, but in Australia, healthcare professionals have a difficult time trying to convince people to go for bowel cancer screening – when free home test kits are delivered to people’s doors in Australia, only 43 per cent of people actually use them, meaning millions of Australians are declining this service.10
Bladder cancer is the 14th most common cancer in Asia, with the highest incidence rate in Australia at 24 cases per 100,000 as of 2022, followed closely by New Zealand at 17 cases per 100,000. While bladder cancer can affect anyone, smoking is the single biggest risk factor.
So, as you can see, there will never be a one-size-fits-all approach to managing the increasing incidences of cancer in the Asia Pacific. Rather it takes a diversified, unique-to-market approach to understand the nuances of each country, the lifestyle habits of its citizens, and the willingness of healthcare authorities and governments to assign budgets to anti-cancer measures.
Societal Burden of Cancer in Developing Markets Is Significant
When people die prematurely from cancer, their contribution to society is cut short, and families suffer. With the staggering projections of a 40 per cent increase in cancer mortality in APAC by 2030, my mind is brought not only to the emotional turmoil a patient feels when a new diagnosis is given, but to the loss of economic resources and opportunities for patients, families, employers, and society overall.
In Thailand, productivity loss for liver cancer-associated mortality alone accounted for THB 11,836m for men and THB 706m for women.11 In Indonesia, the cost of cancers attributed to smoking was over US$1.3bn in 2013. While cancer clearly costs economies billions of dollars, what does it cost the patient? A lot. Research published in 2012 revealed startling home truths about the financial catastrophe for patients one year after receiving a cancer diagnosis, where out of pocket medical costs exceed 30 per cent of a person’s annual household income. The ACTION study recruited almost 10,000 adult patients with a diagnosis of cancer12 and recorded the likelihood of financial catastrophe one year after diagnosis.
The study found participants in the low-income category within each country surveyed had significantly higher odds of experiencing financial catastrophe than the participants on higher income, with 50 per cent of patients overall experiencing crippling costs during, what I’m sure for many is, the toughest experience of their lives. The conclusion of the study was eye-opening. A cancer diagnosis, if you are someone who lives in Southeast Asia, is potentially disastrous – over 75 per cent of patients either died or experienced financial catastrophe within one year.
Working with a pharmaceutical company developing therapies to tackle some of the region’s most common cancers, this type of sobering research is what makes me get out of bed every morning to do my job. Imagine, what these people could go on to achieve if their lives weren’t cut short by cancer? Imagine if these countries were able to reinvest the billions of dollars lost annually on cancer treatment into reinforcing their healthcare systems so they were adequately equipped to navigate the looming cancer crisis?
This need to increase healthcare expenditure is especially true for middle-income countries, but we do see that throughout all of Asia Pacific, healthcare expenditure is simply not up to par with international standards. Only high-income countries in the Asia Pacific meet the World Health Organization’s (WHO) recommended spending levels for Universal Healthcare.
Head and Neck Cancer in Asia
Head and neck cancers are extremely common in developing countries – especially in Southeast Asia. Tobacco and alcohol use are two of the biggest risk factors for head and neck cancers, with at least 75 per cent of cases attributed to smoking and alcohol and more common in men than women due to higher rates of these lifestyle choices. The overall incidence of head and neck squamous cell carcinoma in the Asia Pacific region is approximately 300,000 new cases per year, which is more than half of the total cases worldwide.13
Patients often ignore initial symptoms for a long time. These range from persistent sore throat or nosebleeds to voice changes, earache or red and white patches in the mouth.14
Head and neck cancer can be extremely difficult for patients to deal with. It affects visible areas of the body and activities that help define who we are. By impacting eating, drinking, and speaking, it attacks the cornerstones of social life.
In Southeast Asia, the use of smokeless tobacco and areca nut is the most common cause of head and neck cancer.15 Areca nut is the seed of the areca palm. It is a confirmed carcinogen that turns the mouth bright pink, has stimulating properties, and is extremely popular in the developing economies in Asia. Although used by women and children, it is far more popular with working men who chew the nut to keep them awake during long working hours. It is incredibly sad that this habit is leading to high rates of oral cancer that are destroying the lives of so many in the region.
At Merck, we work hard to develop therapies that can prolong the lives of patients with head and neck cancer. However, if we really want to make a dent in the incidences of head and neck cancer in Asia, there needs to be a combination of preventative healthcare measures, such as raising awareness of the harms of chewing tobacco and areca nut, and effective drug therapies that can reach patients who need them.
Providing access to medicine is an important part of our work in the region. We work with local markets to ensure patients can access the medicines they need and include considerations such as the ability to implement value-based payment models, health system capacity, infrastructure, education, and unmet medical and treatment needs.
All countries in Asia have some form of cancer control plan,11 with high-income countries, like Australia and South Korea, having some of the most effective cancer registries in the region. The Philippines, however, undeniably has one of the most comprehensive plans out of the low-income markets in the region. In 2019, Philippine President Duterte signed into law the National Integrated Cancer Control Act to increase survival rates and reduce the burden of cancer on families and patients.
Non-small Cell Lung Cancer
59 per cent of the world’s lung cancer cases occur in Asia, and 21 per cent of all cancer deaths in Asia are from lung cancer. It won’t surprise you to hear that smoking cigarettes is the single biggest risk factor for lung cancer. What may surprise you, is that smokers in Southeast Asia are projected to rise, albeit slightly (by 1 million), to 240 million by 2025, despite the general downwards trend seen in western economies.
Anyone can develop lung cancer, however, around 85 per cent of cases occur in people who smoke or who used to smoke. According to the WHO worldwide, tobacco use is the single greatest avoidable risk factor for cancer mortality.16 The majority of lung cancers are classified as non-small cell lung cancers, or NSCLC.
Indonesia has one of the world’s highest smoking rates at almost 40 per cent of the population, almost exclusively in men – 75 per cent versus 3 per cent of women. Research indicates the reason for this huge difference in smoking habits is due to the lack of comprehensive anti-smoking regulation combined with a message tying masculinity to smoking.17
In 1988, an Oxford epidemiologist named Sir Richard Peto predicted that 2 million Thai children would die from the effects of smoking. The Thai government since then has taken huge steps in the form of raising taxes on cigarettes, implementing bans on the sales of cigarettes to certain age groups as well as becoming the first country in the APAC region in 2018 to force cigarette manufacturers to use plain packaging.
The impact of Thailand’s anti-smoking policies is projected to save 320,000 lives by 2026. Other countries in the region like the Philippines are hiking taxes and joining Singapore and Malaysia in expanding smoke-free zones.
In China, lung cancer is the leading cause of all cancer-related deaths and it killed almost 700,000 people in 2018.18 Lung cancer prevalence is significantly higher in urban areas due to rising rates of smoking seen in the middle classes. Here in Singapore, lung cancer is the leading cause of cancer-related deaths, despite the government taking a strong anti-smoking stance.
Despite advances in the field of lung cancer, the prognosis for patients remains poor. There is a clear unmet medical need for early detection and new treatment options, which is why we are working hard to develop innovative therapies for patients with non-small cell lung cancer. The ongoing studies which evaluate MET TKI for patients with oncogenic driver mutation NSCLC (such as VISION study and INSIGHT2 study19,20), are extensively evaluated in Asia involving approximately 39-40 per cent of Asian patient recruitment vs the global pool. In Europe, our MET inhibitor has just received approval as a treatment for adults with NSCLC and we hope to see approvals/launches in the Asia Pacific this year.
What Does the Future of Cancer Care Look Like in Developing Markets?
So, what’s in store for the developing markets in the APAC region when it comes to the future of cancer care? Focusing on prevention and early diagnosis will be key. According to WHO, between 30 and 50 per cent of cancers can currently be prevented by avoiding risk factors and implementing prevention strategies – early diagnosis of cancer saves lives and significantly cuts the cost of treatment. For markets with low healthcare expenditure, identifying cancers early will be an imperative cost-saving measure.
Dedicating resources and budget to bolstering cancer registries will also make a huge impact in preparing for the inevitable increase in cancer cases. An Economist Intelligence report stated that “the urgency of developing complete cancer registries as a prerequisite for any meaningful and evidence-based long-term planning for cancer cannot be overemphasised.” This means countries like Vietnam and the Philippines need to work on securing quality data on persons with cancer to ensure optimum cancer surveillance.
Educating populations on lifestyle choices that can increase the risk of developing cancer need to continue to be a priority. We live in a world where technology can revolutionise the care of a disease like cancer, and the future looks bright for this. Digital innovations will make cancer care simpler and more streamlined, and advanced data collection methods will make it easier to develop cancer registries.
Innovative new therapies will continue to become more available, and patient outcomes will become brighter. We hope for patient-friendly policies and allocations from Governments that will assist patients and their families. As a company, we are committed to advancing better diagnosis and timely treatment options, to help improve and prolong patient lives. I look forward to a world where cancer is no longer something to dread, but something we have conquered.
- Frizberg, R. (2020, July 8). What are Asia Pacific countries getting right in the fight against cancer? World Economic Forum. Retrieved from https://www.weforum.org/agenda/2020/07/the-fight-against-cancer-in-asia-pacific-is-working-heres-why/
- Li, N., Wu, P., Shen, Y., Yang, C., Zhang, L., Chen, Y., ... & Jiang, J. (2021). Predictions of mortality related to four major cancers in China, 2020 to 2030. Cancer Communications, 41(5), 404-413.
- Olivier. (2019, May 8). Cancer: An impeding health crisis in developing countries. Humanium. Retrieved from https://www.humanium.org/en/cancer/
- Chen, X. P., Xiong, G. Y., Li, X. S., Matin, S. F., Garcia, M., Fang, D., ... & Zhou, L. Q. (2013). Predictive factors for worse pathological outcomes of upper tract urothelial carcinoma: experience from a nationwide high-volume centre in C hina. BJU international, 112(7), 917-924.
- Shao, I. H., Chang, Y. H., & Pang, S. T. (2019). Recent advances in upper tract urothelial carcinomas: from bench to clinics. International Journal of Urology, 26(2), 148-159.
- Aoki, E. S., Yin, R., Li, K., Bhatla, N., Singhal, S., Ocviyanti, D., ... & Termrungruanglert, W. (2020). National screening programs for cervical cancer in Asian countries. Journal of Gynecologic Oncology, 31(3).
- National Institute of Cancer Prevention and Research (NICPR). (2021). Cancer Statistics in India. India Against Cancer. Retrieved from http://cancerindia.org.in/cancer-statistics/
- Canfell, K., Hall, M., Simms, K., Smith, M., & Saville, M. (n.d.). Australia on-track to be the first country to achieve cervical cancer elimination. HPV World. Retrieved from https://www.hpvworld.com/articles/australia-on-track-to-be-the-first-country-to-achieve-cervical-cancer-elimination/
- Mahady, S., Feletto, E., & Canfell, K. (2019, January 22). What’s behind the increase in bowel cancer among younger Australians? UNSW Newsroom. Retrieved from https://newsroom.unsw.edu.au/news/health/whats-behind-increase-bowel-cancer-among-younger-australians
- Jenkins, M. (2020, June 15). What’s gone wrong with managing bowel cancer in Australia? Pursuit. Retrieved from https://pursuit.unimelb.edu.au/articles/what-s-gone-wrong-with-managing-bowel-cancer-in-australia
- Guerrero, C. (2020). Cancer preparedness in Asia-Pacific. The Economist Intelligence Unit. Retrieved from https://worldcancerinitiative.economist.com/pdf/Roche-cancer-preparedness-in-asia/Roche_Cancer_White_paper.pdf
- ACTION Study Group [email protected] georgeinstitute. org. au. (2015). Catastrophic health expenditure and 12-month mortality associated with cancer in Southeast Asia: results from a longitudinal study in eight countries. BMC medicine, 13, 1-11.
- ESMO Asia 2016: Asian Patients With Head and Neck Squamous Cell Carcinoma Live Longer With Immunotherapy Than Overall Population. The ASCO Post. (2016, December 19). Retrieved from https://ascopost.com/News/44235
- Merck. (n.d.). Head and Neck Cancer. Merck. Retrieved from https://www.merckgroup.com/en/expertise/oncology/head-and-neck-cancer.html
- Joshi, P., Dutta, S., Chaturvedi, P., & Nair, S. (2014). Head and neck cancers in developing countries. Rambam Maimonides medical journal, 5(2).
- Merck. (n.d.). Lung Cancer. Merck. Retrieved from https://www.merckgroup.com/en/expertise/oncology/lung-cancer.html
- Schewe, E. (2017, December 30). Why Do So Many Indonesian Men Smoke? JSTOR Daily. Retrieved from https://daily.jstor.org/why-do-so-many-indonesian-men-smoke/
- AstraZeneca. (2020, May). Lung Cancer in Asia. AstraZeneca. Retrieved from https://www.astrazeneca.com/content/dam/az/our-focus-areas/Oncology/2020/lungcancer/ Lung%20Cancer%20in%20Europe%20Backgrounder_APPROVED_MAY2020.pdf
- Yang, J et al. (2022). Europe Lung Cancer Congress 2022.
- F Smit, E., Dooms, C., Raskin, J., Nadal, E., Tho, L. M., Le, X., ... & Wu, Y. L. (2022). INSIGHT 2: a Phase II study of tepotinib plus osimertinib in MET-amplified NSCLC and first-line osimertinib resistance. Future Oncology, 18(9), 1039-1054.
About the Author
Liz Henderson’s career at Merck began in 2009 and since May 2020, she has been the Regional Vice President for the Asia-Pacific Region for Merck Healthcare. She leads a team of more than 1000 colleagues and is responsible for the commercial operations for 11 countries across APAC, excluding China and Japan. She is a member of the Global Commercial Operations Leadership Team at Merck and the co-Sponsor for the Women in Leadership (WIL) Asia Council.