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Access to cancer medications in low- and middle-income countries


Major breakthroughs have been realized in controlling cancer in the past five decades. However, for patients in low- and middle-income countries (LMICs), many of these advances are nothing but an aspiration and hope for the future. Indeed, the greatest challenge we face in oncology today is how to reconcile small, incremental and significant improvements in the management of cancer with the exponentially increasing costs of new treatments. Emerging economies are attempting to address this important issue of access to cancer medications. In this Review, we examine how LMICs are using generic and biosimilar drugs, expanding participation in clinical trials, implementing universal health-care schemes to pool resources, and using compulsory licensing schemes as well as increasing multiple-stakeholder public–private partnerships to increase access to cancer medications for their citizens. Any truly effective programme will require multiple stakeholder involvement—including governments, industry and civil society—to address the issue of access to medication. Only with the creation of a global entity to fight cancer that is supported by a global fund—for example, in the mould of the GAVI alliance and the International Finance Facility for Immunization—will we truly be able to improve cancer care in LMICs and drive down the high mortality rates in these regions.

Key Points

  • Approximately 80% of global cancer-related deaths occur in low and middle-income countries (LMICs), which might reflect poor access to oncology therapies—including drugs—in these regions

  • LMICs can drive down the costs of drugs by, for example, buying generic or biosimilar drugs, expanding their involvement in clinical trials and implementing universal health-care schemes to pool resources

  • Compulsory licensing schemes, sanctioned by the World Trade Organization, can be put in place to permit the production of generic medications while intellectual property rights are still in effect

  • Furthermore, multiple-stakeholder public–private partnerships can be leveraged to finance drug distribution schemes in LMICs

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Figure 1: The economic burden of cancer in selected countries and regions, as indicated by expenditure per patient in US dollars and as a percentage of gross national income per capita (in brackets).


  1. WHO. United Nations high level meeting on noncomunicable disease prevention and control (WHO, 2011).

  2. The General Assembly. Resolution 66/2: Political declaration of the high-level meeting of the General Assembly on the prevention and control of non-communicable diseases (United Nations, 2011).

  3. Mathers, C. D. & Loncar, D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 3, e442 (2006).

    Article  Google Scholar 

  4. LiveStrong foundation and American Cancer Society, 2012. The global economic cost of cancer. The American Cancer Society [online], (2010).

  5. National Cancer Institute. A snapshot of pediatric cancers: incidence and mortality rate trends. The American Cancer Society [online], (2011).

  6. Jemal, A., Ward, E. & Thun, M. Declining death rates reflect progress against cancer. PLoS ONE 5, e9584 (2010).

    Article  Google Scholar 

  7. Howlader, N. et al. (eds) SEER Cancer Statistics Review, 1975–2007 (Vintage 2009 Populations), National Cancer Institute [online], (2010).

    Google Scholar 

  8. Smith, T. & Hillner, B. E. Bending the cost curve in cancer care. N. Engl. J. Med. 364, 2060–2065 (2011).

    Article  CAS  Google Scholar 

  9. Economist Intelligence Unit. Breakaway: The global burden of cancer – challenges and opportunities. LIVESTRONG [online], (2009).

  10. Goss, P. et al. Cost of cancer care in Latin America and future challenges. Lancet Oncol. (in press).

  11. Lopes, G. The new front in the war on cancer. Presented at the First South East Asia Cancer Care Access Network Meeting, Singapore., (2011).

  12. Clements, B., Coady, D. & Gupta, S. The Economics of Public Health Care Reform in Advanced and Emerging Economies (International Monetary Fund, 2012).

    Google Scholar 

  13. WHO. Advancing and sustaining universal coverage. Primary health care – now more than ever. The World Health Report 2008 [online], (2009).

  14. Stuckler, D., Feigl, A. B., Basu, S. & McKee, M. The political economy of universal health coverage. Background paper for the global symposium on health systems research (WHO, 2010).

  15. [No authors listed] Health care reform: heroes dare to cross. The Economist (21 Jul. 2012).

  16. Primanita, A. & Sagita, D. SBY plants seed for universal health care in Indonesia. The Jakarta Globe [online], (2012).

    Google Scholar 

  17. The World Bank. Health expenditure, public (percentage of total expenditure). The World Bank [online], (2012).

  18. Cavalcanti, H. Brasil tem mais de 240 mil processos na área da Saúde. Conselho Nacional de Justiça [online], (2011).

    Google Scholar 

  19. Paul, S. M. et al. How to improve R&D productivity: the pharmaceutical industry's grand challenge. Nat. Rev. Drug Discov. 9, 203–214 (2010).

    Article  CAS  Google Scholar 

  20. U.S. Food and Drug Administration. Understanding generic drugs. U.S. Food and Drug Administration [online], (2013).

  21. Generic Pharmaceutical Association. Generic Medicines. Generic Pharmaceutical Association [online], (no date listed).

  22. Kesselheim, A. S. et al. Clinical equivalence of generic and brand-name drugs used in cardiovascular disease: a systematic review and meta-analysis. JAMA 300, 2514–2526 (2008).

    Article  CAS  Google Scholar 

  23. Lopes, G. Cost comparison and economic implications of commonly used originator and generic drugs in India. Submitted for presentation at the 2013 American Society of Clinical Oncology Annual Meeting.

  24. Shrank, W. S. et al. Physician perceptions about generic drugs. Ann. Pharmacother. 45, 31–38 (2011).

    Article  Google Scholar 

  25. Alwan, F., Alshami, A., Hatim, A. & Ali, A. Impact of switching therapy from imatinib mesylate to generic copy of imatinib on hematologic response in patients with chronic phase chronic myeloid leukemia: single center study [abstract 1219]. Haematologica 96, a1219 (2011).

    Google Scholar 

  26. WHO. Medicines: Biosimilars [online], (2006).

  27. Mullard, A. Can next-generation antibodies offset biosimilar competition? Nat. Rev. Drug Discov. 11, 426–428 (2012).

    Article  CAS  Google Scholar 

  28. WHO. Trade-related aspects of intellectual property rights [online], (2013).

  29. WTO. Compulsory licensing of pharmaceuticals and TRIPS. World Trade Organization [online], (2006).

  30. WHO. Trade, foreign policy, diplomacy and health. World Health Organization [online], (2013).

  31. Berman, D. AIDS, essential medicines, and compulsory licensing. J. Int. Assoc. Physicians AIDS Care 5, 24–25 (1999).

    CAS  PubMed  Google Scholar 

  32. Mohara, A., Yamabhai, I., Chaisiri, K., Tantivess, S. & Teerawattananon, Y. Impact of the introduction of government use licenses on the drug expenditure on seven medicines in Thailand. Value Health 15 (Suppl. 1), 95–99 (2012).

    Article  Google Scholar 

  33. [No authors listed] Drugs and emerging markets: tripped up. The Economist (8 Sep. 2012).

  34. McGill, A. M. Compulsory licensing of patented pharmaceuticals: why a WTO administrative body should determine what constitutes a public health crisis under the Doha Declaration. Wake Forest Intell. Prop. L. J. 10, 69–97 (2009).

    Google Scholar 

  35. Bird, R. C. Developing nations and the compulsory license: maximizing access to essential medicines while minimizing investment side effects. J. Law Med. Ethics 37, 209–221 (2009).

    Article  Google Scholar 

  36. Yamabhai, I., Mohara, A., Tantivess, S., Chaisiri, K. & Teerawattananon, Y. Government use licenses in Thailand: an assessment of the health and economic impacts. Global Health 7, 32 (2011).

    Article  Google Scholar 

  37. BetaPharma. Welcome to BetaPharma – company information. BetaPharma [online], (2012).

  38. Sun, Y. et al. A randomized, double-blind phase III study of icotinib versus gefitinib in patients with advanced non-small cell lung cancer (NSCLC) previously treated with chemotherapy (ICOGEN) [abstract]. J. Clin. Oncol. 29 (Suppl.), a7522 (2011).

    Article  Google Scholar 

  39. Liu, C. BIO 2012: development cost comparison, China vs. US. Bioentrepreneur [online], (2012).

    Google Scholar 

  40. Ranade, A. A. et al. A novel, cremophor-free, polymeric nanoparticle paclitaxel (do/ndr/02) multicenter study in advanced/metastatic breast cancer [abstract]. J. Clin. Oncol. 26 (Suppl.), a1115 (2008).

    Article  Google Scholar 

  41. Westphal, M. & Bach, F. Final results of a randomized phase III trial of nimotuzumab for the treatment of newly diagnosed glioblastoma in addition to standard radiation and chemotherapy with temozolomide versus standard radiation and temozolomide [abstract]. J. Clin. Oncol. 30 (Suppl.), a2033 (2012).

    Google Scholar 

  42. Rodríguez, M. et al. Nimotuzumab plus radiotherapy for unresectable squamous-cell carcinoma of the head and neck. Cancer Biol. Ther. 9, 343–349 (2010).

    Article  Google Scholar 

  43. Ahlstrom, D. & Bruton, G. D. International Management: Strategy and Culture in the Emerging World (Cengage Learning, 2010).

    Google Scholar 

  44. Glickman, S. W. et al. Ethical and scientific implications of the globalization of clinical research. N. Engl. J. Med. 360, 816–823 (2009).

    Article  CAS  Google Scholar 

  45. Garnier, J. P. Rebuilding the R&D engine in big pharma. Harv. Bus. Rev. 86, 68–76 (2008).

    PubMed  Google Scholar 

  46. Hornbeck, R. A. Price discrimination and smuggling of AIDS drugs. Top. Econ. Anal. Pol. 5, Article 16 (2005).

    Google Scholar 

  47. [No authors listed] GlaxoSmithKline launches two cancer drugs at reduced prices. The Hindu Business Line [online], (2011).

  48. Darrow, J. J. Recent developments in health law. Essential medicines: why international price discrimination may increasingly be the wrong solution to a global drug problem. J. Law Med. Ethics 39, 291–296 (2011).

    Article  Google Scholar 

  49. The Max Foundation. What is GIPAP? The Max Foundation [online], (2010).

  50. The Max Foundation. Glivec® International Patient Assistance Program (GIPAP). The Max Foundation [online], (2010).

  51. Kollewe, J. Roche to offer discounted cancer drugs in India. The Guardian (23 Mar. 2012).

    Google Scholar 

  52. Rajan, A., Gutierrez-Ibarluzea, I. & Moharra, M. Addressing issues in health technology assessment promotion: motives, enablers, and barriers. Int. J. Technol. Assess. Health Care 27, 55–63 (2011).

    Article  Google Scholar 

  53. de Souza, J. A., Polite, B. N., Manning, W. G., Fendrick, A. M. & Ratain, M. J. Value-based insurance design in oncology. Lancet Oncol. 12, 321–323 (2012).

    Article  Google Scholar 

  54. The GAVI Alliance. The GAVI Alliance [online], (2013).

  55. International Finance Facility for Immunization. IFFIm [online], (2013).

  56. The Global Fund to Fight AIDS, Tuberculosis and Malaria. The Global Fund to Fight AIDS, Tuberculosis and Malaria [online], (2013).

  57. [No authors listed] Cancer control in low and middle income countries. Facebook [online], (2013).

  58. WHO. WHO model list of essential medicines (WHO, 2011).

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All authors researched the data for the article, contributed to the discussion of the manuscript's content, wrote the manuscript and edited it before submission.

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Correspondence to Gilberto de Lima Lopes Jr.

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Lopes, G., de Souza, J. & Barrios, C. Access to cancer medications in low- and middle-income countries. Nat Rev Clin Oncol 10, 314–322 (2013).

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