Cancer Research, Statistics, and Treatment

: 2018  |  Volume : 1  |  Issue : 1  |  Page : 58--62

Cancer care: Challenges in the developing world

Chepsy C Philip, Amrith Mathew, M Joseph John 
 Department of Clinical Haematology, Haemato-Oncology and Bone Marrow Transplantation, Christian Medical College and Hospital, Ludhiana, Punjab, India

Correspondence Address:
Dr. Chepsy C Philip
Christian Medical College and Hospital, Brown Road, Ludhiana - 141 008, Punjab


Objective: Cancer care in the developing world remains a challenge. Limitations in the diagnosis, poverty, and knowledge are recognized as some of the challenges. Health-care financing and treatment facilities are limitations toward availing cancer care. An assessment of the extent of the burden and strength of available infrastructure is limited. We performed an assessment to gather information from young oncologists in the developing world to identify similarities and differences among the countries. Methods: Information on services was gathered using a questionnaire from young oncologists participating in the American Society of Clinical Oncology annual meet selected to represent various developing countries. Descriptive statistics were used to report results. Results: The median doctor: outpatient ratio was 1:20 (1:2–1:80). Median: staffing ratio in an oncology ward was 1:6 (1:2–1:20). Four (22.2%) respondents reported complete social security support for health care in oncology. Stem cell transplant facility was reported as available in 8 (44.4%) centers out of 20. South Asian respondents reported the highest out-of-pocket expenditure (65%) and the least doctor: outpatient ratio at 1:20. Conclusion: Cancer care challenges appear similar in the regions surveyed. Additional strategies to improve the health-care infrastructure and provide a health security net to treat all cancer patients are required to benefit the efforts to tackle the growing burden of cancer in the developing countries.

How to cite this article:
Philip CC, Mathew A, John M J. Cancer care: Challenges in the developing world.Cancer Res Stat Treat 2018;1:58-62

How to cite this URL:
Philip CC, Mathew A, John M J. Cancer care: Challenges in the developing world. Cancer Res Stat Treat [serial online] 2018 [cited 2019 Jun 16 ];1:58-62
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Full Text


Cancer continues to remain a leading cause of morbidity and mortality. It is anticipated that the number of new cases will rise by about 70% over the next two decades and by the year 2030, about 80% of the cancer deaths are likely to occur in the developing world.[1],[2] There exist unique challenges to cancer care in the developing world. These include struggles with health-care financing, patient awareness, and treatment delivery.[3] With significant disparities in access and availability of health care, many patients in this part receive affordable rather than standard treatment.[4] The financial constraints also lead to abandonment of treatment which is disappointing despite the availability of expertise.[5],[6] The lack of knowledge in patients, delay in presenting to an expert, and poverty are well documented among the challenges in treating cancer.[7],[8] While benchmarks in oncology practices are being established in the west,[9] an assessment of the adequacy of infrastructure in the developing world is limited. It had been reported that in India, despite the availability of world-class facilities patients traveled far distances and health-care finances limited optimal cancer care.[10]

We surveyed young oncologists, representative of the developing world, in an attempt to identify challenges and measure access in the real world to cancer care in their countries.


The primary aims of the study were to compare the health-care financing by estimating the percentage of government support for cancer care in the developing countries and to understand the burden on existing facilities by estimating the number of patients, duration of patient interaction, and infrastructure availability.

The secondary aim was to compare the training programs in cancer care by estimating the years required to become an oncologist and time devoted to translational/clinical research during training and real-world practice.



The Conquer Cancer Foundations' International Development and Education Award (IDEA) Mentorship program is an effort by the American Society of Clinical Oncology to support the cancer care in the developing world by supporting the professional development of early career oncologists.[11] The participants are selected from various regions of the world representing low- and middle-income countries and are in the early stages of their career, with a potential to contribute to cancer care in their countries. We surveyed the 20 recipients for the award in 2015 to determine the cancer care facilities in their regions.


The survey gathered information in a questionnaire format on the outpatient burden on doctors, the extent of government support for treatment, and overview of services. The IDEA recipients had exclusive educational break-out sessions during the annual meet which was mandatory for all IDEA recipients to attend. The printed questionnaire (supplementary file1) was handed out in person by the first author (CCP) to the participants during the annual meet (May 29, 2015, to June 2, 2015). Those who chose not to complete the survey expressed their refusal during the handout which was followed up by a repeat request during the above period in person by the first author. Their responses were not returned. The remainder responses were handed back and collected by the first author on the last day of the meet during these mandatory sessions.


Statistical analysis was performed using SPSS 16.0 software (SPSS, Chicago, IL, USA). Descriptive statistics were calculated for all variables. Differences among the regions were tested using a Mann–Whitney U-test, Kruskal–Wallis test, or t-test as appropriate.


Of the 20 recipients, 18 responses were returned.

Respondent characteristics

The respondents belonged to the various World Bank regions as depicted in [Figure 1]. The majority were between 31 and 40 years (66.6%). Their further details are as tabulated in [Table 1].{Figure 1}{Table 1}

Cancer care center characteristics

All 18 (100%) centers had facilities available to provide blood components. Eight (44.4%) centers had stem cell transplantation facilities. In 4 (22.2%) countries, oncology care was completely supported by the government. The burden of patients and other features are further detailed in [Table 1].

Differences by region

South Asian respondents revealed the least share of government support, 15% (0–100) and the highest out-of-pocket expenditure by the patient, 65% (0–75). Nurse staffing ratio in the wards was the lowest in Africa at 1:14. Additional details are tabulated in [Table 2].{Table 2}


This survey illustrates some of the challenges in treating cancer in the developing world.

Health-care financing

Only four (22.2%) respondents in our survey reported on their county's complete social security net for health care. The out-of-pocket expenditure was the highest at 65% of respondents in South Asia while those from Africa reported the highest government support toward health care at 90%. Although no statistical significance was derived in the differences, it is important to recognize the importance of health-care financing. It is well reported from developing economies, where the majority of the world's poor reside that prohibitive costs of therapy represent additional challenges to effective cancer care.[5] This places an additional burden on the patient to survive the costs of cancer care along with cancer itself.[12] With lack of a social security net, patients often abandon or decline treatment.[13],[14] Government support initiatives are likely to improve outcomes through greater participation by patients in their treatment. Recent initiatives in certain countries are a step in this direction; however, the feasibility and outcomes need to be evaluated.[15],[16],[17]

Burden and extent of health-care facilities

The median number of patients that each doctor was expected to attend to during each inpatient visit in our survey was 20 (2-80). The staffing of nurses in the ward was 1 nurse for every 6 patients. These figures are possibly reflective of a burdened health-care infrastructure. The nurse ratio of 1:2 in intensive areas as supported by the American Nursing Association and the oncologist ratio of 1 in 100 requires to be compromised, to allow for more patients to be managed with the limited resources in these regions.[18],[19],[20],[21] With the developed world setting benchmarks in oncology practice and enacting laws to protect staffing ratios, these figures highlight a unique concern.[9],[20]

Oncology training

We also noted differences in the duration and pattern of oncology training and practice among the respondents. Many of them spent long hours during practice with a median of 9.5 (±3.1) hours daily. In this, the major part was spent doing clinical work with the time allocated to research limited to 10% (0–30) of the total. This possibly is a reflection of the burden of cancer patients in these centers such that very little time can be allocated for research or a lack of research capacity in these regions.[22] Possibly reflective of the percentage of hematological cancers, the share of blood cancers in daily practice was reflected by the 10% seen by the participants in their routine practice. The duration of the training period and burden on the care provider need to be addressed with efforts in building in-country expertise to cater to its population and leverage available resources.[23]

In conclusion, limited social health-care security of citizens, the high cost of cancer care and shortage of trained oncologists and support staff in the developing world need to be addressed. A lack of health security net and high out-of-pocket expenses are major hindrances to effective cancer care.[7]

Potential solution

We have noted a similarity to the challenges in cancer care in countries in the developing world. We recognize that there could be solutions from another disease which has been tackled better. A similar situation existed with respect to HIV/AIDS in the developing world. While the west was improving diagnosis and access to therapy, the burden was rising within the developing countries.[5],[24] It was proposed that the high cost of drugs and poor health infrastructure represented insurmountable obstacles. However, international pressure, focused training, and support from treatment activists enabled access to such drugs to the needy.[25] This has translated into improved treatment rates. Although HIV/AIDS is still a challenge, the situation is better than what was anticipated.[26] A similar model could assist in tackling the cancer burden.


Where benchmarks in oncology practices are being established in the west to improve patient outcomes, quality of cancer care in the developing world has much room for improvement.

A strong political will, international support, and commitment from the pharmaceutical industry are desired to improve access to treatment to tackle the growing burden of cancer in the developing world.

Limitations and strengths

Different treatment centers in these countries are likely to have different staffing resources, diagnostic facilities, costing structures, and access to trained personnel and supportive care. A larger and rigorous survey from multiple centers in these countries is required to conclusively state that the results of this study are truly representative of the developing world. This was a survey dependent on the recall of the participant experience with the known limitations of recall. However, all the respondents were either in training or within 2 years of completing their training and working in the dominant oncology centers of their nation. Despite these limitations, it is likely that these data are broadly representative of the challenges faced in many developing countries from where there are limited data. These data add on to the growing body of evidence of the burden and the need to improve quality and access to cancer care in the developing world.


The authors would like to thank the Conquer Cancer Foundation for support of the International Development and Education Award.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Stewart BW, Wild CP. World Cancer Report 2014. Lyons Fr: IARC International Agency for Research on Cancer (IARC), WHO Press; 2014.
2Cavalli F. The world cancer declaration: A roadmap for change. Lancet Oncol 2008;9:810-1.
3de Souza JA, Hunt B, Asirwa FC, Adebamowo C, Lopes G. Global health equity: Cancer care outcome disparities in high-, middle-, and low-income countries. J Clin Oncol 2016;34:6-13.
4Cancer in Developing Countries-INCTR – International Network for Cancer Treatment and Research. Available from: [Last accessed on 2017 Jun 14].
5Magrath I, Bey P, Shad A, Sutcliffe S. Cancer funding in developing countries: The next health-care crisis? Lancet 2010;376:1827.
6Hokland P, Cotter F. Real world data on acute myeloid leukaemia therapy from the developing world – An eye-opener. Br J Haematol 2015;170:1-2.
7Philip C, George B, Ganapule A, Korula A, Jain P, Alex AA, et al. Acute myeloid leukaemia: Challenges and real world data from India. Br J Haematol 2015;170:110-7.
8Price AJ, Ndom P, Atenguena E, Mambou Nouemssi JP, Ryder RW. Cancer care challenges in developing countries. Cancer 2012;118:3627-35.
9Balch C, Ogle JD, Senese JL. The National Practice Benchmark for oncology: 2015 report for 2014 data. J Oncol Pract 2016; 12:e437-75.
10Philip CC, Geoge B, Ganapule A, Lakshmi KM, Abubacker FN, Abraham A, et al. Acute myeloid leukemia: Challenges and real world data from India. Blood 2014;124:3685-5.
11International Development and Education Award. Conquer Cancer Foundation; 2015. Available from: [Last accessed on 2017 Jun 14].
12Global Trends: Surviving Cancer, Surviving the Cost of Cancer Care. Available from: [Last accessed on 2018 Sep 10].
13Arora RS, Pizer B, Eden T. Understanding refusal and abandonment in the treatment of childhood cancer. Indian Pediatr 2010;47:1005-10.
14Spence D, Crath R, Hibbert A, Phillips-Jackson K, Barillas A, Castagnier T, et al. Supporting cancer patients in Jamaica – A needs assessment survey. West Indian Med J 2010;59:59-66.
15Lahariya C. 'Ayushman Bharat' program and universal health coverage in India. Indian Pediatr 2018;55:495-506.
16Bagcchi S. Doctors criticise India's “ill conceived” launch of publicly funded health insurance scheme. BMJ 2018;360:k1448.
17New Plan will Help Improve Cancer Treatment and Save Lives in Nigeria. Clinton Health Access Initiative; 2018. Available from: [Last accessed on 2018 Sep 10].
18Noronha V, Tsomo U, Jamshed A, Hai M, Wattegama S, Baral R, et al. A fresh look at oncology facts on south central Asia and SAARC countries. South Asian J Cancer 2012;1:1-4.
19Effective Interprofessional Education and Collaborative Practice in Nursing Education Available from: [Last accessed on 2018 Sep 10].
20The Importance of the Optimal Nurse-to-Patient Ratio. Available from: [Last accessed on 2018 Sep 10].
21Aiken LH, Sloane DM, Cimiotti JP, Clarke SP, Flynn L, Seago JA, et al. Implications of the California nurse staffing mandate for other states. Health Serv Res 2010;45:904-21.
22Ali R, Finlayson A, Indox Cancer Research Network. Building capacity for clinical research in developing countries: The INDOX Cancer Research Network experience. Global health action 2012;5:17288.
23Chite Asirwa F, Greist A, Busakhala N, Rosen B, Loehrer PJ Sr. Medical education and training: Building in-country capacity at all levels. J Clin Oncol 2016;34:36-42.
24Grant AD, De Cock KM. The growing challenge of HIV/AIDS in developing countries. Br Med Bull 1998;54:369-81.
25Hoen E', Berger J, Calmy A, Moon S. Driving a decade of change: HIV/AIDS, patents and access to medicines for all. J Int AIDS Soc 2011;14:15.
26Ortblad KF, Lozano R, Murray CJ. The burden of HIV: Insights from the Global Burden of Disease Study 2010. AIDS 2013;27:2003-17.