Access Cancer Care India: affordable, integrated multi-cancer early detection to improve equitable cancer outcomes

在印度13亿人口中，超过70%的人生活在农村地区。癌症对印度农村男女造成了灾难性的影响，其中绝大多数人处于社会经济不利地位，四分之一的人生活在国家贫困线以下。研究表明，在印度农村人口中，癌症治疗的支出是所有疾病中最高的，因为癌症的表现较晚。治疗晚期和转移性疾病的费用远高于早期疾病。治疗的资金主要来自借款、出售资产以及亲友的捐助。在向私营部门求医的家庭中，超过60%的家庭产生了灾难性的自付支出。在农村，乳腺癌和口腔癌等常见癌症的死亡率也明显高于城市人口姗姗来迟，疾病费用更高，再加上刚刚起步的全民健康保险，以防止灾难性支出，这不仅是印度的“双重负担”，也是全世界的“双重负担”。改善可负担得起的癌症早期检测服务的实施，同时在提供者层面解决下游癌症途径问题，是减少这种不平等的关键。必须有一个强有力和反应灵敏的癌症卫生系统，以确保筛查阳性（有筛查规划）和/或有症状的个体能够得到及时诊断，并确保被发现患有癌症的个体能够得到适当治疗。印度农村人口在社会经济上处于不利地位，在癌症治疗方面容易受到巨大的不平等待遇我们的假设是，通过仔细调查个人、提供者和系统层面的实施障碍，以设计基于证据和具体情况的战略和政策，提高他们对癌症早期检测途径的参与，将带来更好的结果。本研究的重点是在复杂的中低收入国家印度的背景下，为癌症（二级预防）提供一种经过良好验证的综合早期检测干预方法的实施研究。该研究的三个国家提供了不同的、可比较的实施生态系统，以剖析关键问题和障碍（后勤、政治、社会和经济），以支持国家扩大规模，并为全球其他可比国家提供信息。这一干预措施针对三种特定部位的癌症——口腔癌、宫颈癌和乳腺癌——这三种癌症加在一起导致印度28%的过早死亡，全球12%的过早死亡，尤其是女性过早死亡。作为可持续发展目标3.4的一部分，扩大这些经过验证的二级预防干预措施将显著解决将过早死亡率降低三分之一的问题，我们将重点放在最脆弱人群（印度一些难以到达地区的农村人口）上，这将确保这一方法实现世卫组织将全民健康覆盖扩大到10亿人口的雄心。

Of the 1.3 billion population of India more than 70% live in the rural areas. Cancer has a catastrophic impact on the rural men and women of India, the vast majority of whom are socio-economically disadvantaged with one fourth live below national poverty line. Studies have shown that among the rural population in India expenditure on cancer treatment is among the highest for any disease due to the advanced presentation. The cost for treating advanced and metastatic disease are much higher than early stage disease. Treatment is financed mostly through borrowings, sale of assets and contributions from friends and relatives. Over 60% of the households who seek care from the private sector incur catastrophic out of pocket expenditure. Fatality rates are also significantly higher for the common cancers like breast and oral cancers in rural compared to the urban populations.2 Late presentation with more expensive disease coupled to nascent universal health coverage to protect against catastrophic expenditure typifies the 'double burden' not only in India but across the world. Improving the implementation of affordable early detection services to cancer coupled to addressing downstream cancer pathways at provider level is key to reducing such inequalities.A strong and responsive cancer health system is necessary to ensure that the screen positive (in presence of a screening programme) and/or symptomatic individuals have access to prompt diagnosis and those detected with cancer have access to appropriate treatment. Rural population in India are socio-economically disadvantaged and vulnerable to huge inequity in cancer care.3 Our hypothesis is that improving their participation to the cancer early detection pathway through careful investigation into the implementation barriers at the levels of individuals, providers and systems to design strategies and policies that are evidence and context-specific based, will lead to better outcomes.This study focuses on implementation research for a well-validated, integrated early detection interventional approach for cancer (secondary prevention) in the context of a complex lower middle- income country, India. The three states for the study provide different and comparative implementation ecosystems to dissect out critical issues and barriers (logistical, political, social and economic) to support national scale up and inform other comparable countries globally. This intervention targets three site-specific cancers - oral, cervical and breast - that, combined are responsible for 28% of premature mortality in India and 12% globally, in particular for women. Scaling up these proven secondary prevention interventions would significantly address 1/3rd reduction in premature mortality as part of SDG 3.4, and our focus on the most vulnerable populations (the rural populations in some of the hard to reach areas in India) will ensure this approach meets WHO's ambition of expanding Universal Health Coverage to a billion population.