Asia's Quiet War on Lung Cancer

eden strategy institute

HEA L TH CAR E

As ia ’s Quiet War on Lung Cancer S O C I A L I N N O V A T I O N P L A Y B O O K S E R I E S

14 million people around the world are diagnosed with cancer each year

Source: Cancer Research UK 2014 eden strategy institute | 2

BACKGROUND


Lung 13%

Breast 12%

Bowel 10%

Prostate 8%

Others 57%

Most Common Cancers Worldwide

Lung cancer, the most common form of cancer, accounted for 1.8 million cases in 2012

1.8 m New Lung Cancer Cases Worldwide (2012)

BACKGROUND

This is a serious issue in Asia, with the region taking up more than 60 percent of all lung cancer cases

Source: Globocan 2012, Eden hospital interviews & analysis eden strategy institute | 4

India

Singapore

China

S.Korea

Japan

Taiwan

Hong Kong

Philippines

Laos

Vietnam

Cambodia

Thailand

Pakistan

Afghanistan

Nepal

Mongolia N.Korea

Malaysia

Sri Lanka

<499

500-‐999

1,000-‐1,999

2,000-‐5,999

6,000-‐9,999

10,000-‐19,999

20,000-‐39,999

40,000 -‐100,000

>100,000

Butan

Blangladesh

Indonesia

Myanmar

Lung Cancer Incidence within Asia (2012)

Countries with High Lung Cancer Incidence in Asia

Country Lung Cancer Incidence

China 725,359

India 145,000

Japan 94,855

Indonesia 34,695

Turkey 24,479

South Korea 22,869

Vietnam 21,844

Thailand 19,501

North Korea 13,851

Philippines 12,061

Taiwan 9,783

Others 66,418

OUR STUDY

eden strategy institute | 5

This paper draws insights from the latest developments on the ongoing baVle against lung cancer in China, Taiwan, India, and South Korea

CAUSES OF LUNG CANCER: SMOKING

Lung cancer is primarily driven by smoking, and is highly prevalent in countries such as China, India, Indonesia, and South Korea

There are one billion smokers in the world, with more than 70 percent in Asia

Source: WHO, Eden hospital interviews & analysis eden strategy institute | 6


China, for instance, consists of more than 300 million smokers, with smokers as young as two years old

Source: WSJ (2013), Photo Credit: Reuters eden strategy institute | 7

“The average age at which Chinese people start smoking is four to five years younger in 2002 compared to 1984”

Ministry of Health China


India produces 700 billion bidis annually, and consumes almost all of them locally

Source: The Times of India (2008), Photo Credit Paul Hamilton – Bidi Maker eden strategy institute | 8

“Bidi may contain lesser tobacco than cigareAes – 0.2 grams, but delivers as much or more tar and nico4ne”

Dr P C Gupta Healis Sekhsaria Ins]tute for Public Health

India


Korea has one of the highest proporYons of male smokers, despite the country’s relaYvely small populaYon

OECD

S. Korea

17 percent of teenage males is ligh]ng up a_er their daily classes

Source: OECD (2013), Photo Credit: iPark3 – Smoking talks eden strategy institute | 9

Male Smoking ProporYon

CAUSES OF LUNG CANCER: NON-‐SMOKING

Apart from smoking, non-‐smokers in Asia are also contracYng adenocarcinoma lung cancer due oncogenic mutaYon

Source: Eden hospital interviews & analysis, Photo Credit: Ed Uthman – Adenocarcinoma of lung, FNA eden strategy institute | 10

“Adenocarcinoma cancer mainly affects the terGary bronchus and bronchioles, areas which are harder to diagnose with tradiGonal methods”

Respiratory Specialist Taiwan


This is compounded with the effects of air polluYon from the different sources within Asia

Second-‐Hand Smoke Forest Fire

Asbestos & Radon gas from building materials Industrial PolluYon

Cooking Oil ParYcles

Indonesia has over 3,000 fire alerts in from 20th February to 11th March in 2014

Source: World Resources Institute (2014), The World’s Worst Pollution Problems (2012), World Health Organization’s Tobacco-Free Initiative (2010) eden strategy institute | 11

Despite the toxicity of white asbestos, China and India are sYll heavily using it for building materials

India, for example, has produced over 60,000 tons of industrial waste over the last decade

Chinese-‐style cooking contributed ~30% to indoor concentraYon of parYcles from 0.5 to 5μm

Asia has one of the highest number of people exposed to secondhand smoke


China, for instance, has witnessed a rise in non-‐smoking lung cancer cases due to severe air polluYon in the past few years


“Lung cancer caused by exposure to air polluGon is increasing”

Wang Ning Deputy Director of Cancer Center

China


Taiwan, which has a generally low smoking rate, is also seeing high incidences of non-‐smoking lung cancer due to second-‐hand smoke

“ 96% of women do not smoke, but are inhaling 4 to 5 4mes a week more second-‐hand smoke at home than in the work place”

2010 Adult Smoking Behavior Survey Bureau of Health Promo]on

Taiwan 60% 80%

40%

20%

0

1000

2000

3000

4000

5000

6000

7000

Male Female Non-‐Smoking Lung Cancer Smoking related Lung Cancer

New Lung Cancer Incidence by gender and type of cancer in Taiwan (2010)

Source: Eden hospital interviews & analysis eden strategy institute | 13

LUNG CANCER DEATHS

IntervenYons for lung cancer are especially criYcal due to the high lung cancer death rates


Lung 13%

Breast 12%

Bowel 10%

Prostate 8%

Others 57%

Most Common Cancers Worldwide 14.1 million new cancer cases

Most Common Cancers Deaths Worldwide 8.2 million cancer deaths

Lung 19%

Liver 9%

Stomach 9%

Prostate 8%

Others 55%

1.8 m New Lung Cancer Cases Worldwide (2012)

1.6 m Lung Cancer Deaths Worldwide (2012)

LUNG CANCER PATIENT PATHWAY

In analyzing the drivers of lung cancer deaths, we found that most countries in Asia already have clear paYent pathways


1. IniYal Screening

v v v

Radiologists

•  Chest X-‐Ray •  Chest CT ExaminaGon •  MRI Check •  Bone Scan

Treatment with surgery

Central: Pulmonologist •  Brush & Forceps Bronchoscopy •  X-‐ray bronchoscopy (C-‐arm) •  EBUS – TBNA •  EBUS-‐Radial Peripheral: Interven]onal Radiologist •  CT-‐guided TTNA

Hard-‐to-‐reach areas: Thoracic Surgeons •  VATs •  Thoracoscopy •  MediasGnoscopy •  Wedge ResecGon

•  PET-‐CT: Radiologists •  EBUS TBNA: Pulmonologists

2. Medical Imaging

3. Biopsy

4. Staging (If unsure whether tumor has spread)

Suspected cases

Watchful waiYng •  3-‐ 6 months of watchful wai]ng

Regular follow-‐ups

PosiYve Diagnosis

Non-‐PosiYve & Inconclusive Diagnosis Non-‐cancer

False negaGve Misdiagnosis

5. Decision to Operate

Stage 1 & 2 Operable

Stage 3 & 4 Inoperable

Chemotherapy treatment

Tumor Size

>2cm •  No problem in

locaGng tumor •  PaGents may

sGll opt for surgery

•  Watchful waiGng

<1cm

3. Lab test • Pathology • Histology

•  Difficult to diagnose using non-‐surgical methods

1-‐2 cm

Exhibit: Gold Standard PaYent Pathway for Lung Cancer Diagnosis

CHALLENGES IDENTIFIED

However, high death rates remain due to lack of screening, inconsistent skill levels among doctors, and limitaYons of exisYng tools


1. IniYal Screening

v v v

Radiologists

•  Chest X-‐Ray •  Chest CT ExaminaGon •  MRI Check •  Bone Scan

Treatment with surgery

Central: Pulmonologist •  Brush & Forceps Bronchoscopy •  X-‐ray bronchoscopy (C-‐arm) •  EBUS – TBNA •  EBUS-‐Radial Peripheral: Interven]onal Radiologist •  CT-‐guided TTNA

Hard-‐to-‐reach areas: Thoracic Surgeons •  VATs •  Thoracoscopy •  MediasGnoscopy •  Wedge ResecGon

•  PET-‐CT: Radiologists •  EBUS TBNA: Pulmonologists

2. Medical Imaging

3. Biopsy

4. Staging (If unsure whether tumor has spread)

Suspected cases

Watchful waiYng •  3-‐ 6 months of watchful wai]ng

Regular follow-‐ups

PosiYve Diagnosis

Non-‐PosiYve & Inconclusive Diagnosis Non-‐cancer

False negaGve Misdiagnosis

5. Decision to Operate

Stage 1 & 2 Operable

Stage 3 & 4 Inoperable

Chemotherapy treatment

Tumor Size

>2cm •  No problem in

locaGng tumor •  PaGents may

sGll opt for surgery

•  Watchful waiGng

<1cm

3. Lab test • Pathology • Histology

•  Difficult to diagnose using non-‐surgical methods

1-‐2 cm

Inconsistent skill levels and

misdiagnosis

Limita]ons of exis]ng methods & equipment

Lack of awareness and early screening

leading Exhibit: Gold Standard PaYent Pathway for Lung Cancer Diagnosis

Due to the lack of noYceable symptoms, many paYents usually get diagnosed and treated at a late stage of lung cancer



leading

Inconsistent skill levels and misdiagnosis


Country % of Late Stage Cancer

Average 77.8

China 80.0

Taiwan 80.0

India 85.0

Korea 66.0


Free screening for lung cancer remains unavailable in Asia for the public, unlike screening for breast and cervical cancer




CHINA

TAIWAN INDIA S. KOREA

Free Lung Cancer Health Screening

No No No No

Free Breast Cancer Screening

Yes Yes Yes Yes

Free Cervical Cancer Screening

Yes Yes Yes Yes

Countries Studied


leading


In addiYon, the level of skills among doctors appears to be inconsistent across countries, and even within the same country



leading



“There is a limitaGon to how far we can go in to the lung using CT-‐guided TTNA. It’s usually only 5cm from chest wall”

Respiratory Specialist

Taiwan

“If the radiologist is experienced enough, then every posiGon is possible. ComplicaGon would not be serious”

Respiratory Specialist Taiwan

Different level of skills with CT-‐guided TTNA

Different amount of Yme required to conduct biopsy

“Doctor can find the tumor using EBUS usually within ten seconds. The enGre procedure will be completed within ten minutes”

Pulmonologist Taiwan

“We take around 30 to 40 minutes per EBUS-‐TBNA test”

Pulmonologist Korea


In developing markets like India, lung cancer is commonly misdiagnosed as tuberculosis, leading to late treatment



leading



Symptoms of Pulmonary Tuberculosis •  Persistent cough that brings up phlegm, which may be bloody

•  Mild to significant breathlessnessXD •  Lack of appe]te and weight loss •  High temperature of 38ºC (100.4ºF) or above •  Night Sweat •  Extreme ]redness or fa]gue, accompanied with pain

*Symptoms in common with lung cancer

Misdiagnosis of Lung Cancer as Tuberculosis “66% of the lung cancer paGents get treated for TB”

Pulmonologis India – Delhi

“Most paGents are diagnosed with TB and come to the pulmonologists at a later stage, by when their condiGon has already worsened”

Pulmonologist, India -‐ Mumbai


ExisYng medical imaging tools are limited in their ability to detect early stage lung cancer



leading



Chest CT Scan PET CT Scan Chest X-‐Ray MRI Scan Bone Scan


Method Uses electromagne]c radia]on to generate images of ]ssues and structures inside the body

Creates 3D picture of the inside of the body with mul]ple x-‐ray

Uses magne]c fields to produce detailed images of the body

Radioac]ve glucose injected into body to find tumors

Uses a radioac]ve tracer to look at the inside of the bone

Func]on Ini]al test to detect abnormal shadowing within lungs

To provide precise informa]on about size, shape and posi]on of any lung tumors/enlarged lymph nodes

Metastasis detec]on for brain

Typically used for staging. Full body tes]ng for cancer

Metastasis detec]on for bones

Strengths Quick, simple & cheap Ability to spot very small lung tumors, and help determine exact loca]on and extent of tumors

Ability to see size and loca]on of lung cancer metastases

Ability to test for metastasis

Ability to test for metatasis

Limita]ons Unable to detect small lung tumors

Insufficient to confirm cancer

Rarely used for lungs as lung is always moving

Costly. High false posi]ve for tuberculosis pa]ents

Replaced by PET CT scan to find lung cancer that has spread to the bones

TradiYonal biopsy tools are olen only able to reach up to terYary bronchi, with problems accessing parts near the nerves and heart



leading



Primary & Secondary Bronchus can be reached with tradiYonal biopsy tools

Lung regions that are difficult to access

TerYary Bronchus, that can be reached with bronchoscopes & EBUS RP

TradiYonal Bronchoscopy

EBUS radial probe (RP)

EBUS radial probe (RP): Blind



SOLUTION SPACE

Successfully tackling lung cancer requires close collaboraYon among governments, hospitals, and various stakeholders for shared benefits

Government Hospitals

Doctors Medical Device Companies

NGOs

Insurance Companies COUNTRY

LUNG CANCER STRATEGY

•  Raising awareness of lung cancer and its links with smoking

•  Advoca]ng / subsidizing free screening for high risk individuals

•  Raising awareness on risk of smoking and benefits of early screening

•  Assessing healthcare economics of subsidizing lung cancer diagnosis and treatment

•  Capacity building to ensure consistency of skills and reduce cases of misdiagnosis

•  Conference s to share best prac]ce cases

•  Working with hospitals and government to provide comprehensive coverage for lung cancer screening

•  Sharing of knowledge and training •  Con]nual learning and upgrading of skills

•  R&D on improving lung cancer biopsy and treatment

Medical Schools

•  Collabora]ng with medical device companies to conduct research

•  Consistent method of providing training to doctors

Source: Want China Times (2012) Taipei Times (2012), Ministry of Health and Welfare (2014) Photo Credit: Taiwan Health Promotion Administration (2012) eden strategy institute | 24

The government in Taiwan, for instance, has worked together with hospitals and clinics in local communiYes on a series of smoking cessaYon campaigns through educaYon and support

“Thanks to the program, an es4mated NT$900 million (US$30.1million) in medical expenditure will be save in the short term and a much greater amount in the long term”

Taiwan Former Premier Jiang Yi-‐Huah

SOLUTION SPACE

EducaYon Regulatory Changes

Support & Counseling Financial IncenYve •  First smoke-‐free hospital

network in the Asia-‐Pacific region in 2010, with 113 ins]tu]ons joining

•  2,151 hospitals providing new Quit Smoking Services

Impact (Since 2012) •  Served 630,000 people •  Helped more than 160,000 people to quit

•  “Quit Smoking, Smoke-‐free Taipei Program” provides 4 weeks of free medica]on and medical advise

•  Program funding by Na]onal Health Insurance scheme

•  Extended smoke-‐free areas to include most enclosed work-‐places and public places

•  Adding graphic health warnings to cigarese packages and banning of tobacco adver]sements

•  Media campaigns on public awareness and secondhand smoke exposure

Source and Photo Credit: Norwalk Hospital (2014) eden strategy institute | 25

Norwalk hospital, in the US, also offers free low-‐dose lung CT screening for high risk paYents to encourage early diagnosis

Qualifying criteria •  Aged between 55 and 80 •  Have smoked within the last 15 years •  Have a 30+ pack year smoking history

“Researchers found that screening with low-‐dose lung CT screening significantly reduced the mortality rate from lung cancer by 20 percent”

Norwalk Hospital (2014)

Free Lung Cancer Screening Program Includes: •  Low-‐dose lung CT screening •  Scan of the coronary arteries •  Three personalized smoking cessa]on

classes for current smokers who wish to quit

SOLUTION SPACE

Source: Eden medical device company and hospital interviews & analysis eden strategy institute | 26

Breakthroughs in lung cancer biopsy technologies can also address the limitaYon of exisYng methods Employing EBUS radial probe together with ENB as a safer and more comfortable early stage peripheral diagnosis tools

Primary & Secondary Bronchus can be reached with tradiYonal biopsy tools

Lung regions that are difficult to access

TerYary Bronchus, which can be reached with bronchoscopes & EBUS RP

TradiYonal Bronchoscopy

ENB

EBUS radial probe (RP)

EBUS radial probe (RP): Blind

ENB (Blind)

Bronchioles, which can be reached with EBUS RP and ENB

Endobrochial Ultrasound Bronchoscopy Radial Probe (EBUS RP)

Electromagne]c Naviga]on Bronchoscopy (ENB)

SOLUTION SPACE

Source: NY Daily News (2014), Photo Credit: American Friends of Tel Aviv University eden strategy institute | 27

The possibility of a breathalyzer for lung cancer diagnosis is also in its research and development stage

SOLUTION SPACE

Preventable deaths from lung cancer can be reduced with widespread awareness-‐building smoking and early screening, subsidized lung cancer screening on a systemaYc level, adopYon of recent technological advancements, and capacity-‐building among medical teams


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