The Lancet Oncology CommissionChallenges to effective cancer control in China, India, and Russia
Introduction
Cancer is a burgeoning health problem worldwide, and poses an increasing risk of human affliction and economic threat, particularly to emerging countries. China (1 350 695 000 people), India (1 236 686 732 people), and Russia (143 533 000 people) together account for nearly 40% of the world's population,1 and have in common vast geographies, rapidly improving economies, increasing numbers of elderly people, adoption of westernised lifestyles (eg, changes in diet and decreased physical activity), populations in rural regions and of low socioeconomic status who often face suboptimum health care, serious contamination of the environment, and rising incidences of oncogenic communicable infections.2, 3, 4 Table 1 shows comparisons of some key general and cancer-related demographics between the three countries, by contrast with those in the UK and the USA.1, 5, 6, 7, 8, 9 Although the incidences of most cancers are low in China, India, and Russia, the mortality burden from cancer is higher than in the UK and the USA; mortality-to-incidence ratios are 0·70, 0·69, and 0·60 for China, India, and Russia, respectively, compared with 0·40 in the UK and 0·33 in the USA. Despite each country's growing economy, the present financial burden per patient with cancer in China, India, and Russia is US$2202, $641, and $3784, respectively, compared with $37 836 in the UK and $86 758 in the USA (table 1).6
This Commission aims to first describe the status of overall health care and of cancer control for each country, and then emphasise specific issues and obstacles that are relevant to each: for China, access to care, contamination of the environment, and traditional medicine coupled with cancer fatalism; for India, affordability of care, provision of adequate health personnel and infrastructure, and sociocultural barriers to cancer care; and for Russia, monitoring of the burden of cancer, societal attitudes and political will towards cancer prevention, effects of inequitable treatment and access to medicine, and a need for greater international engagement.
We have endeavoured to report our findings in view of past and present improvements to health care and cancer control that are already benefiting the populations of China, India, and Russia. Our Commission has limitations; by focusing on important topics in each country we have been unable to be comprehensive in others; peer-reviewed, published evidence is often scant and at times we had to resort to an element of anecdotal evidence; and availability and access to each country's health records was often restricted. Despite these obstacles, we hope that our Commission initiates a strong debate among policy makers and other stakeholders and contributes to improved measures for cancer control in these three countries.
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Background
China is geographically the third largest country in the world with 34 provincial divisions comprising 23 provinces, five autonomous regions, four municipalities, and two special administrative regions (figure 1).10, 11 It is the largest and most populous of the low-to-middle-income countries in the world, with a population of more than 1·35 billion people.12 To address the issues that affect delivery of cancer care in China, the social, economic, and attitudinal aspects of the Chinese
Background
The increasing population of India poses substantial challenges to the government's capacity to provide consistent health-care infrastructure and delivery of care. Although communicable diseases remain a common cause of mortality, non-communicable diseases (including cancer) now account for more than 50% of deaths in India. Although overall cancer incidence is lower in India than in most high-income countries, the relative mortality rates are higher. Overall, this disparity results in a
Background
The dissolution of the Soviet Union and the formation of the Russian Federation in 1991 brought substantial social and economic instability to the region. The Russian economy experienced tremendous difficulties as it moved from a centrally planned Soviet economy to a free-market-based system. GDP fell at an accelerating rate and overinflation was a major issue. However, since 2000, the Russian economy has had sustained growth because of implementation of key economic reforms (tax, banking,
Final recommendations for China, India, and Russia
Both from a standpoint of human suffering and effects on future economies and prosperity, cancer control in China, India, and Russia is of paramount importance. To curb rising cancer incidence and disproportionately high mortality rates, steps common to all three countries need to be taken. Primary prevention, particularly reduction of tobacco use, is essential because of the mortality caused by lung and other cancers, and non-communicable diseases; tried-and-tested methods for public education
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