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Juliet Bowater

Can cancer interventions ever be cost-effective?

With cancer costs in the USA spiralling into many tens of thousands of dollars

, and costs of some new biological treatments approaching £100,000 

, you could be forgiven for overlooking cancer interventions in developing countries as too expensive to be cost-effective.

Not so, according to the 2015 Disease Control Priorities 3rd Edition (DCP3)

cost-effective cancer intervention and treatment strategies

, offering an “Essentials Cancer Intervention Package” designed to reduce deaths from cancer, tailored to the wealth of a country and the infrastructure available. The 2011 World Health Organisation (WHO) “Best Buys” document

 also details highly cost-effective strategies for cancer intervention which could save millions of lives in the coming century, and which require relatively little infrastructure.

Cancer incidence worldwide - DCP-3 cancer report

Tobacco-related deaths are increasing rapidly, especially in low and middle income countries (LMICs)

, and tobacco use threatens to kill far more in the coming decades than it has in the past. By the middle of this century, it has been estimated that tobacco-related deaths will reach 10 million per year

With up to 2/3 of smokers dying of smoking-related diseases

 and losing, on average, 10 years of life (DCP3)

, it’s hardly surprising that both the WHO and DCP3 recommend tobacco intervention as one of their top global health priorities. In 2013, the World Health Assembly introduced a target for tobacco control 

, calling for a 1/3 reduction in use by 2025, with the aim of saving 200 million lives.

Tax boosts to increase cigarette price have been shown to reduce smoking, especially amongst young people 

. A report by the World Bank estimated that for every 10% increase in cigarette cost, tobacco consumption would drop by 4% in high income countries (HICs) and 8% in low income countries (LICs). Young people are also more likely to quit and less likely to start when prices are high

The WHO therefore recommends that excise taxes should account for 70% of cigarette cost

. A report by the Asian Development Bank stated that increasing the price of cigarettes by 50% through taxation would avert 27 million tobacco-related deaths in China, India, Thailand, the Philippines and Vietnam alone

. Price increases hit the poorest smokers in a population hardest 

but the taxes are not considered to be regressive

 since those with low income are the most likely to quit and gain the intended health benefits (for more information on this see our blog post - 

“Is Tobacco Control a “Best Buy” for the Developing World

Alongside price increases, education is also vital. The WHO Global Adult Tobacco Survey for China showed that only 23% of Chinese adults knew that smoking caused lung cancer, heart attacks and strokes

. This lack of awareness affects the poorest in a population the most, with those who are illiterate unable to read warning labels.

Pictorial warnings have been used to try and re-balance this inequality in some countries

, and there is evidence that pictorial warnings improve awareness of dangers of smoking and reduce the number of young people starting 

. Packaging controls are also important in reducing the impression that some cigarette brands are less harmful than others 

Total advertising bans have been effective in reducing cigarette consumption

, especially in low/middle income countries (LMICs)

, and bans on smoking in the workplace have also been shown to reduce consumption 

Large investments from The Bill and Melinda Gates Foundation and Bloomberg Philanthropies have gone towards increasing awareness of the dangers of tobacco, funding research and collecting data, and pushing for changes in policy to reduce tobacco use

Liver cancer has one of the highest mortality rates of any primary cancer. In 2012, it caused 746,000 deaths out of 782,000 cases 

. Highly cost-effective interventions are available to reduce the number of people who get the disease, and these interventions are recommended by both WHO and DCP3.

Hepatitis B vaccination is the first line of defence. Hep B is a cancer-causing virus responsible for around 60% of hepatocellular carcinoma (the most common type of liver cancer) in LICs 

. The virus attacks the liver, sometimes setting up an infection which can last for years. 15-45% of those with long-term infection will develop serious complications such as cirrhosis and liver cancer during their lifetime 

The majority of countries now aim to vaccinate children at birth, but coverage at birth is still low in some areas 

. Initial vaccination within 24 hours is very important in preventing mother-child transmission, which often results in dangerous long-term infection

. Increasing vaccine coverage should decrease Hep B infection rates and hence liver cancer incidence

 has more information on the cost-effectiveness of vaccination. As with 

, Giving What We Can did not find any promising vaccination funding opportunities.

Targeting other region-specific causes of liver cancer may also be cost-effective. High rates of liver fluke infection occur in some areas of eastern Asia, especially within the Mekong River Basin in Southeast Asia, where around 40 million people are infected

. The worms can infect a host for many years, causing damage to the liver’s bile ducts which can eventually lead to cancer

. Treatment with Praziquantel can clear the infection, though people in the area are often quickly reinfected by eating raw fish dishes 40.

Liver flukes are not the only parasite to play a role in cancer. Infection with Schistosoma haematobium has long been associated with bladder cancer 

, and is recognised as a cause of cancer by the IARC 

. Studies in the 1970s and 80s noted that bladder cancer was more common in areas in which Schistosoma haematobium infection was common

 and biopsies of tumours showed high incidence of schistosome infection 

. This neglected tropical disease is easily and cheaply treatable, and two of Giving What We Can’s recommended charities - the 

 - can provide treatment for around $2 per person per year.

Poor food storage can also lead to higher rates of liver cancer. Aspergillus flavus and Aspergillus fumigatus can infect staple foods during cultivation, including peanuts, rice and corn

. In areas where these foods are then stored in warm, high humidity environments, the fungus is able to grow, producing the highly potent aflatoxin. This toxin causes DNA mutations and is associated with both liver and lung cancer.

In people with chronic Hep B infection, exposure to aflatoxin increases the chance of liver cancer by 30-fold. Improved grain storage and cultivation methods can reduce the amount of the toxin that people consume, and with 4.5 billion people currently exposed to aflatoxin, the potential for reducing suffering is enormous.

The final WHO “Best Buys” are designed to reduce deaths from cervical cancer. Screening and treatment for early cervical lesions have been shown to be cost-effective. Opportunistic screening with an acetic acid test is low-cost and cancerous/precancerous lesions can be removed on the same day 

Since high-risk strains of Human Papilloma Virus (HPV) are responsible for up to 98% of cervical cancer cases 

, HPV screening can also be highly effective in averting deaths from cervical cancer. Screens are low-cost and some can be done at home, so women who do not want to come to the clinic or undergo a cervical examination can still be screened 

Vaccination against HPV virus strains 16 and 18 (those most commonly associated with cervical cancer) is also highly cost-effective in some areas

. These vaccinations are included in the DCP3 recommendations, though not the WHO “Best Buys” list. HPV-16 and -18 are responsible for more than 70% of cervical cancers 

, with HPV-16 detected in 57% of cervical cancers and HPV-18 detected in 17% 

. Along with 6 less common strains, these HPV types are responsible for over 90% of cervical cancer cases.

The HPV vaccine is relatively high-cost and requires two follow-ups, so it’s not cost-effective in all areas. However, heavily subsidised vaccines, such as those offered by GAVI alliance, make vaccination much more cost-effective (vaccines at $5 per dose are available to 37 countries in Sub-Saharan Africa)

The vaccine requires a cold chain, making some areas of sub-Saharan Africa difficult to cover, but it has been estimated that 70% coverage of 9-year old girls for 5 years could avert 670,000 cases of cervical cancer in the region

Included in the DCP3, but not the WHO recommendations, is screening for breast cancer and treatment of early-stage tumours. Since presentation with advanced-stage tumour is more common in low/middle income countries

, examination by medical professionals and education in breast self-awareness may decrease death rates, as treatment earlier in the disease course is easier and has a higher success rate

A case study in Malaysia found that incidence of patients presenting with late stage breast cancer decreased from 77% to 37% after a country-wide drive to increase awareness. As part of the drive, nurses began to visit rural areas to give talks, demonstrate breast awareness and perform examinations

Finally, DCP3 also highlights the cost-effectiveness of treating some childhood cancers. The very high cure rates seen in some childhood cancers in HICs are often dependant on intensive supportive care which is not available in LICs

. However, some studies have shown less intensive treatments of certain cancers to be effective and highly cost-effective, with treatment of Burkitt’s Lymphoma, for instance, costing as little as £500 

Twinning programs, linking hospitals in LICs with specialist hospitals in HICs allow expertise to be shared, improving treatment and survival rates

. The success seen in childhood cancer can act as a strong motivator to encourage governments to pursue cancer treatment programs and give early stage patients the hope required to seek help as soon as they discover symptoms of disease3.

Despite the high cost of cancer in HICs (£5.8bn in the UK in 2010/11 - 5.4% of NHS budget

), affordable changes can be made in LICs which might avert millions of deaths over the coming century. In many cases, prevention is far more cost-effective than treatment. However, perhaps surprisingly, in cases such as cervical cancer, and potentially some childhood cancers, treating early stage disease is also highly cost effective.

For more on effective cancer interventions, see also our 

Sam Deere

If you think that altruism, equality, and helping more people rather than fewer are all important values, then you're probably on board with effective altruism.

Four Ideas You Already Agree With (That Mean You're Probably on Board with Effective Altruism)

Here are four ideas that you probably already agree with. Three are about your values, and one is an observation about the world. Individually, they each might seem a bit trite or self-evident. But taken together, they have significant implications for how we think about doing good in the world.

 — when people are in need and we can help them, we think that we should. Sometimes we think it might even be morally required: most people think that millionaires should give something back. But it may surprise you to learn that those of us on or above the median wage in a rich country are 

 — maybe we can also afford to give back too.

 — everyone has an equal claim to being happy, healthy, fulfilled and 

, whatever their circumstances. All people matter, wherever they live, however rich they are, and whatever their ethnicity, age, gender, ability, religious views, etc.

 — all else being equal, we should save more lives, help people live longer, and make more people happier. Imagine twenty sick people lining a hospital ward, who’ll die if you don’t give them medicine. You have enough medicine for everyone, and no reason to hold onto it for later: would anyone really choose to arbitrarily save only 

 of the people if it was just as easy to save 

 — even millionaires have a finite amount of money they can spend. This is also true of our time — there are never enough hours in the day. Choosing to spend money or time on one option is an implicit choice 

 (whether we think about these options or not).

I think that these four ideas are all pretty uncontroversial. I think it seems pretty intuitive that we should help people in need if we can; that we shouldn’t arbitrarily preference some groups of people over others; that we would prefer to help more people if given the option; and that we don’t have infinite time and money.

In fact I’d go further — I’d say that we’d feel pretty uncomfortable trying to 

Helping others in need isn’t morally required, important, or even that good

It’s OK to value people differently based on arbitrary differences like race, gender, ability etc.

It doesn’t matter if some people die even if it doesn’t really cost us anything extra to save their lives

We don't have infinite money, so we always need to choose which worthy cause to support.

So if we agree that these four ideas embody important values — and I think that they do — then there are big implications for how we should think about doing good. In fact, it means that the way we typically think about doing good is wrong.

In order to be true to these values, we need to think about how we can help the most people with our limited resources.

 where we can make a big impact for a small amount of money. In fact the best options are 

 — sometimes hundreds of times better. That might mean the difference between helping one person, and helping hundreds of people 

for exactly the same amount of time or money

is almost certainly not making as big an impact as the 

 (and let’s face it, many causes we choose to support tend to be the result of either random chance, or systemic factors that mean we’re only exposed to certain causes).

And this matters, because if we don’t choose well, then we’re either not giving people equal consideration (that is, implicitly discriminating against some groups of people), or we’re not helping as many people as we can (that is, allowing extra people to suffer or die, even though we could potentially help them).

So, at first, every worthy cause — from cancer research, to climate justice, to animal sanctuaries, to preventing 

 diseases in places that we'll probably never visit — should be on the table... 

 that we also think it's better to help more people and we understand that we don’t have the resources to help everyone. So we should first focus on the causes where we can help the most people for our limited time and money, 

not just on those that we happen to have already heard about

Women in Uganda holding bales of insecticide-treated bednets provided by the 

Trying to be cause-neutral can be a really hard thing to do. Most people have first-hand experience of loss: I’ve lost two relatives to leukaemia; watched as the disease consumed their bodies and the pain meds fogged their minds; lived through the shared grief of their passing. It’s entirely reasonable that this makes us want to donate to organisations trying to solve the specific problem or cure the particular disease that has robbed us of our loved ones. We’re empathetic creatures, and we don’t want other people to experience the same suffering, or for their loved ones to experience the same grief.

 equally, we should also care about treating their experiences equally. There’s not a really good reason that I should prefer averting the death, disability, and suffering caused by a particular disease (like leukaemia) any more than I should care about suffering caused by malaria, tuberculosis, traffic accidents, or anything else. What matters is that lives are cut short, parents are deprived of their children, people are living in pain. Caring about equality means treating 

 death and suffering as a tragedy, not just that caused by specific diseases that we — by cruel twists of fate that thrust them into our field of view — happen to notice.

Making these decisions is really, really hard. But there is a set of thinking tools we can use to help us. This way of thinking is called 

. It's basically the same as regular altruism (in that it emphasises the importance of helping other people) — the word 'effective' just means trying to think clearly about how your actions can help the 

I see effective altruism as a way of being able to better live up to 

This way of thinking is applicable to any way that we might want to do good — whether that be agitating for political change, choosing where we donate our money, or how to have a big impact with our careers.

In a world where there are so many worthy causes we could work on, it gives us a way out of decision paralysis, by systematically looking for ways to do the most good with our limited time and money.

It asks us to face up to some hard choices. But remember, we’re making these choices anyway, whether we think about them or not. So even though it might be hard to not donate to something that seems really important — whether for personal reasons, or because you’re convinced by a charity’s marketing pitch — remember that you’re always trading off against other worthy causes.

Here’s an example of this in action. The typical person in the UK donates around £6,700 ($9,600USD)

 over the course of their working lifetimes. For this money we could fund the distribution of 

 (likely preventing around 200children from becoming really, really sick from malaria

). However, most voluntary donations go to domestic medical charities

. The UK’s National Health Service considers it good value to save one 

. It’s highly unlikely that a domestic charity will beat this figure, so the typical donor’s impact is going to be many, many times less than it could otherwise be. Remember, 

just because we don’t think about these choices, doesn’t mean that they’re not there.

So please, think carefully about these ideas — the importance of altruism, equality, and doing as much as we can with our scarce resources — and see if they make sense to you.

If they do, then the next time you think about how to make the world a better place, give voice to these values by thinking 

Some resources for learning more about effective altruism:

Some actions you can take that we think are really effective

Blog

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