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

在印度13亿人口中，70%以上生活在农村地区。癌症对印度农村男女造成了灾难性的影响，其中绝大多数人在社会经济上处于不利地位，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，由于癌症的晚期表现，癌症治疗费用是所有疾病中最高的。晚期和转移性疾病的治疗费用远高于早期疾病。治疗的资金主要来自借款、销售资产以及朋友和亲戚的捐款。超过60%向私营部门寻求护理的家庭需要支付灾难性的自付费用。与城市人口相比，农村地区常见癌症（如乳腺癌和口腔癌）的死亡率也明显较高。2较晚出现的更昂贵的疾病，加上新生的全民健康保险，以防止灾难性的支出，这不仅是印度的“双重负担”，也是世界各地的“双重负担”。改善负担得起的癌症早期检测服务的实施，以及在提供者层面解决下游癌症途径，是减少这种不平等的关键。一个强大的、反应灵敏的癌症卫生系统是必要的，以确保筛查阳性（在筛查计划存在的情况下）和/或有症状的个人能够获得及时的诊断，而那些被发现患有癌症的人能够获得适当的治疗。印度的农村人口在社会经济上处于弱势地位，容易受到癌症护理方面的巨大不平等的影响。3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，以设计基于证据和特定背景的战略和政策，将导致更好的结果。这项研究的重点是在一个复杂的中低收入国家，印度的背景下，一个经过充分验证的，综合的癌症早期检测干预方法（二级预防）的实施研究。该研究的三个国家提供了不同的和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），以支持国家规模扩大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-这三种癌症加起来占印度过早死亡率的28%，占全球过早死亡率的12%，特别是妇女。作为可持续发展目标3.4的一部分，扩大这些已被证明有效的二级预防干预措施的规模，将大大降低三分之一的过早死亡率，我们对最脆弱人群（印度一些难以到达地区的农村人口）的关注将确保这一方法符合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.