Lung cancer care in Latin America: evolution of modern therapies and challenges to overcome the existing gaps

Gustavo Werutsky, MD, Latin American Cooperative Oncology Group, Hospital São Lucas PUCRS University, Porto Alegre, Brazil

Gustavo Werutsky, MD, Latin American Cooperative Oncology Group, Hospital São Lucas PUCRS University, Porto Alegre, Brazil

What are the specific challenges that Latin American physicians and governments are facing regarding the management of lung cancer patients?
It is important to understand that Latin America is a large continent with approximately 600 million inhabitants. The four most-populated cities are Mexico City, Rio de Janeiro, São Paulo, and Buenos Aires, where the number of people living in just these four cities is equal to the total number of inhabitants of France.

Today, approximately 85,000 new cases of lung cancer are reported in Latin America per year. Smoking is increasing in Latin America in general, and especially in women, which is why we expect rising lung cancer incidence rates in the years ahead. Overall, even in the poorer countries, people in Latin America are not dying of infectious diseases any more, but rather of non-communicable disorders, such as lung cancer. It is estimated that 70 % of new cancer cases will occur in developing countries over the coming decades. Therefore, dealing with the increasing incidence of cancers in this region will be an enormous challenge for the governments in the near future, especially for lung cancer, which is the main cause of cancer deaths in Latin America. To date, Latin America is investing 10 to 20 times less money than developed countries in the fight against cancer.

About 70 % to 90 % of patients with lung cancer have advanced or metastatic disease at the time of diagnosis. In the United States, stage I lung cancer is diagnosed in approximately 15 % of cases, whereas in Brazil, this proportion is only 8 % to 9 %. This means that many patients require treatment for advanced disease, which is more costly because these patients need more assistance, drugs and hospitalisation, and the death toll is higher. This is very difficult for the economies of the Latin American countries.

Is smoking cessation being promoted?
Brazil has been conducting smoking cessation campaigns and it has been successful here. Over the last 20 years, the rate of smokers has decreased from approximately 40 % to 15 %. However, the efforts made in this area are very heterogeneous within Latin America. In some other countries, smoking continues to increase.

How is the diagnostic situation?
With respect to imaging, CT scans and PET CT scans are not widely available in Latin America. These devices are mainly Gustavo Werutsky, MD, Latin American Cooperative Oncology Group, Hospital São Lucas PUCRS University, Porto Alegre, Brazil to be found in big cities, and they are not equally distributed, as there are not sufficient numbers in public hospitals. Many patients living in rural areas do not have access to these tests, and this delays their diagnosis by a considerable degree. At the time of diagnosis, half of the patients with lung cancer have an ECOG Performance Status of 2 or higher. This affects their treatment, because many of them will not receive systemic therapy. Therefore, it is very important to raise public awareness about lung cancer and the symptoms of this disease, as well as other aspects, so that patients are encouraged to seek assistance early on. At the same time, the health authorities need to streamline and facilitate the process and the access for rapid diagnosis.

For targeted therapies, it is important to understand that their use depends on molecular diagnosis. Having access to these tests is a real challenge in Latin America. In many countries, medical care is provided either by the public health system, which is free of charge, or by the so-called private sector, where patients pay for health insurance. There is a large discrepancy between the services provided by these two systems. In Brazil, for example, the EGFR mutation testing rate in the public system ranges from 20 % to 30 %, while it is 60 % in the private sector. These numbers can basically be extrapolated to other countries. Obviously, the demand for molecular tests will depend on access to the targeted drugs. Again, there are only a few laboratories that perform these tests, as the equipment is expensive. ALK testing is not commonly requested by physicians, because ALK-targeted drugs are not approved in our countries, or have only recently been approved. ROS-1 testing is almost non-existent. Currently, tests are basically offered free of charge through voucher programmes by pharmaceutical companies.

Are there shortages concerning treatment?
The discrepancy due to the different health systems holds true for the treatment. For example, EGFR inhibitors have already been approved in the Latin American countries, but some are not available for a large proportion of patients. In an important country like Brazil, which is the sixth or seventh largest pharmaceutical market in the world, these agents were approved some years ago, but only patients in the private sector have access to them. In Brazil, for example, ALK inhibitors and immunotherapy agents will be approved this year, but again not for the patients in the public system. This means that while the technology improves at a very fast rate in Latin America, a discrepancy in access to these new agents is created at the same pace. There are huge gaps between the countries, as well as within the cities. The Latin American governments will have to face this problem rapidly and draw up strategies for lung cancer care in general, such as conducting screening programmes, optimising the diagnosis and treatment of early/ locally advanced disease stage, and facilitating access to molecular testing and treatment for metastatic disease. Enabling patients to receive the best therapies for fighting lung cancer will be the main challenge over the next 10 years.

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