Eduardo Payet of INEN outlines the institution’s agenda for preventing advanced stages of cancer and plans to expand oncology services beyond Lima to more remote regions of Peru.
What is your assessment of the state of cancer in Peru today?
Peru is experiencing a demographic and epidemiological transition as a result of the country’s increase in GDP over the years. Improvements in the country such as better industrialization and better health system assessments have led a decrease in mortality from communicable diseases like infectious diseases. But this has increased mortality in non-communicable diseases. Cancer has become the second cause of mortality after cardiovascular diseases in Peru. Cancer, however, is the most impactful disease in terms of reducing the number of healthy years in a person’s life. We see 50,000 new cases of cancer every year, despite life expectancy growing in Peru.
The number of children getting cancer in Peru is rising too. How are you ensuring prevention of childhood cancer?
The incidence in childhood cancer has risen up to 153 new case per million, which represents a high incidence rate, and the mortality rate has decrease to 53 per million. Leukemias, Brain and spinal cord tumors and Lymphomas represent the most common malignancies. Considering all of our cases 80 percent at an advanced stage of the disease, with a late diagnosis. For many years, there has been a lack of screening programs in Peru, and diagnosis of the population has consequently been very difficult. We are now conducting a population base cancer registry, so we have identified populations risk areas, which we know are the most common tumors. Childhood cancer represents three percent of cancer in Peru. The most common cancer in Peru is gastric cancer. Among women, breast, cervical and gastric cancer are most common, and prostate, gastric and lung cancer for men.
In your opinion, how successful has Plan Esperanza been?
73 percent of the Peruvian population has an insurance health system coverage, which includes the Seguro Integral del Salud (SIS). The Plan Esperanza is a system that traduces the concept that any patient with an oncology diagnosis will receive complete medical attention. Mainly is orientated to insure those in poverty and in extreme poverty. It started covering the 6 most common malignancies, but now all our patients with any malignancy are covered. Nevertheless there are some issues to develop regarding the interventions outside Lima, due to a lack of oncology facilities and technology. We support the need of developing regional oncology institutions and units using general hospitals infrastructure. Human Resources are an important factor despite INEN has been educating specialist since its creation in 1939. 15 years ago, the big issue was how to afford the management of our cancer patients. Plan Esperanza is a unique model, in which the household out-of-pocket spending on personal care has significantly decreased.
How do you deal with the fact that cancer treatment is not readily available outside of Lima?
INEN is the only cancer hospital in Peru that depends on the Ministry of Health that can offer the complete package of treatment: diagnosis, prevention, chemotherapy, radiotherapy, surgery, etc. This is a 382-bed hospital, but Peru has 30 million people and this number increases every year. INEN offers good treatment if the patient has the opportunity to come to Lima to be treated. But patients thousands of kilometers away find difficulty in accessing INEN’s services. Hospitals outside Lima have difficulty making Plan Esperanza work in terms of logistics. This Plan is not an academic system that can be repeated easily; it is a business plan. You need logistics and administration for it to work. Hospitals outside of Lima struggle much more because they deal with more infectious diseases, maternal mortality, trauma, and then cancer. It is easy to tell patients to come to Lima, where SIS will pay for everything. But not everybody can do that. As a consequence, there we have an important waiting list.
There are plans of the Ministry of Health to increase the number of hospitals significantly in Peru this year. Will this properly address the needs of cancer patients in rural parts of the country?
Between 62 and 63 percent of new cancer patients in Peru will die in the first year of being treated. In the second year, this number increases to 78 percent and 93 percent in the fifth year. Of course, this is an issue of late diagnosis. These numbers represent the fatality index we have in Peru. This is an argument for the authorities to pay more attention on early diagnosis. Prevention is clearly better than cure, and therefore we must invest as a country in programs that can ensure prevention over treatment. There are some caveats however; gastric cancer diagnosis through endoscopy is 220 percent more expensive than treatment of this disease and is therefore not cost effective. But breast, cervical and prostate cancers are all significantly cheaper to diagnose. The question thus revolves around which preventions are most suitable possible for identifying risk patients. The Peruvian government made a program called PPR (Presupuesto Por Resultado), which is based on the “results of a program of investment directly related to your budget”. If you have good results in the treatment of your patients, we can invest more in diagnosis.
How successful has Peru’s Cancer Foundation been in its sponsorship of doctors to go abroad for studies?
The Cancer Foundation and Plan Esperanza have removed the most difficult issues we previously encountered, namely how to pay for treatments. We have changed our objectives, one of the most important being education. The Foundation has trained many young doctors who want to specialize in cancer. We have sent them to different parts of the world, mainly the US and Europe. After they have bee trained in different fields of oncology, they come back and apply their newly acquired skills in our hospitals.
Does the government understand the true impact that this work has in Peru in terms of paying for these treatments in the long-term?
I hope so! While our program focuses on treating patients, as a result of the program’s effectiveness we are also investing in promotion and prevention of the disease. Cancer control management of cancer patients is extremely important, and we have an excellent teaching school for early diagnosis of cervical and breast cancer.
Does Peru have an opportunity to be recognized at the same level as other countries in the region in terms of quality and access?
Despite the big number of cases, I think so. We think that through the establishment of a cancer hospital in Trujillo for the north, and another in Arequipa in the south, we can support the decentralization of cancer management in Peru. We need many more of these hospitals. INEN is well recognized in the cancer field in Latin America. We receive people from all over South America that come spend time as a medical resident in different parts of INEN. We have cooperative relationships and workshops and studies with American and European institutions. INEN has protocols in chemotherapy, so there is lots of cooperative work going on here. But we need to grow, as this is still a small hospital.
What are your own ambitions for the future? What do you personally want to achieve?
My vision is a country free of advanced cancer. Of course, the numbers are going to grow. We will see more cancer patients each year. Our projections are growing rapidly. We know what will happen in 2016. We have our own numbers, which identifies what will happen in 50 years in terms of which tumors will be the most common and how many cases will come up. If we continue the system we currently run, advanced tumors are going to continue. We must improve our recognition of the disease in early stages. It is not the work of this hospital, but rather its influence in universities, medical schools and health institutions.
We need to talk about cancer. We always need to think in terms of cancer; if there is pain or a lump in the body, always imagine these conditions in terms of cancer. My vision is a Peru free of advanced tumors and more institutions that can treat cancer. Because it is very difficult and expensive to build more cancer hospitals, we can use general structures of existing hospitals to create oncology units inside using healthcare professionals that have been trained properly. More cancer patients can be treated that way.
