 Good afternoon everybody. My name is Ina Wolbin and I'm the managing director of the Canadian Longitudinal Study on Aging, our CLSA for short and welcome to the CLSA webinar series. These are monthly online lectures to provide a forum to discuss the latest on health and aging research in Canada and internationally. So I will shortly introduce our speaker for today but just a few housekeeping items as is listed on the slide that you see right now. This webinar does not allow you to have voice interaction but you can type your questions in the chat box in the last corner of your screen and at the end of Dr. Agowal's presentation I will summarize those questions and moderate them and put them forward to the speaker and he will then answer your questions. So I want to again welcome you to our CLSA webinar series. Our speaker today is Dr. Ajay Agowal who is a clinical oncologist and visiting senior research fellow at the Institute of Cancer Policy at King's College in London. He is currently undertaking an NIHR Doctoral Research Fellowship at the London School of Hygiene and Tropical Medicine where he is investigating the impact of provider choice on outcomes for men with prostate cancer. Dr. Agowal has a master's in science of cancer from the Institute of Cancer Research and a master's in health, population and society from the London School of Economics. He has previous international experience working with the WHO in Geneva and his current research interests include cancer economics and the development of strategies for the delivery of demonstrating this with Mexico as a case study. So Dr. Agowal the floor is yours. So just in terms of an overview of the presentation I'm going to be doing I'm going to explain the study rationale which just comes down to this essential point that we know a lot about that there's going to be a lot of aging within middle income countries and that the cancer burden is going to increase but what does it mean for an elderly person in the middle income country suffering from cancer and I really wanted to do an exploratory analysis and I initially actually started this when I was at the London School of Economics and worked with collaborators at the Institute of Cancer Policy who I now do work with as well as the National Cancer Institute in Mexico. So I'll go through the methods that I used, the results of the analyses and I also have a wider discussion about the conclusions I made from this and the policy implications. So if I just start off with a study rationale, if we look back at the epidemiological transition which I know many of you were aware but essentially Omron proposed his hypothesis in the early 70s that we're shifting through a variety of stages based on our disease epidemiology, our risk factor burden and many middle income countries are moving towards the age of man-made and degenerative diseases which is caused by socioeconomic development, change in respects to infectious diseases to more non-communicable diseases caused by obesity, alcohol, smoking, etc. And this shift from communicable to non-communicable diseases varies between countries and within countries themselves with many affected by a dual burden of disease. The results of them happening in this shift is essentially that infant mortality fell, increase in life expectancy and population expansion and with the fall infertility rates as well there's a demographic transition where the proportion of elderly is increasing and expected to continue to increase. So from currently being 8% of the world's population being over 65, the majority of which in high income countries, this is going to increase to 16% by 2050 which is some 1.5 billion people. 80% will be living in low and low income countries and one of the factors to point out is that the rate of aging has been much greater in middle income countries than in high income countries where it's taken several decades for the aging process to occur and as a result the ability for social health infrastructure to manage this is very different. Just as a point to illustrate this point, between 2010 and 2030 some population projections, the percentage of over 65 is expected to increase by up to 90 to 100% in both Brazil and China, whereas in the UK and US it's expected to be about between 30 and 50% and this was a table that created from you and population data just essentially sharing over that 20 year period between 2010 and 2030 countries and the expected increase in the proportion of the population over 65. Those with a higher proportion tend to be emerging economies, middle income economies compared to those with lower rates in high income countries. But what does this mean? So we know that there's a rise in the proportion of elderly within the population of those over 65 but we know that over the time course with increasing risk factors over the life course and the accumulation of mutations that the rates of cancer is increasing as well and aging has been described as the dominant driver of this. By 2030 of the 20 million new cancer cases worldwide, currently it's 12 million new cancer cases a year, 70% will be in emerging economies and it's not just that it's the profile of the cancers themselves so whereas in the high income countries we're looking at those cancers due to behavioral risk factors such as smoking, obesity and alcohol so lung, colorectal and prostate cancers. A number of cancers within the middle income countries are due to infectious disease agents. So for instance H. pylori infection causing gastric and esophageal cancers, HPV and haploma virus for survival cancer and so the burden varies. What we also know is that the relative disability of just as life years affects low middle income countries greater than high income countries and this is due to premature mortality. When you compare the mortality to incidence ratio as a proportion, individuals who have cancer in low middle income countries have high rates of mortality relative to high income countries as you can see from these percentages and that's primarily when you're moving from a model which is looked at managing communicable diseases, a vertical model and then you move to cancer which is so dynamic it really exemplifies or tests the whole health system looking at prevention, screening the diagnostics, needing imaging and biopsy, histopathology services and then into the complex treatment to the surgery, radiotherapy and chemotherapy. Many countries lack the infrastructure needed to meet the current demand and in fact in managing this individuals face catastrophic financial expenditures. Another statistic was worth noting is that of the cancer research budget or the global expenditure and cancer R&D, only about 3% of this is directly relevant to low and middle income countries. So what I'm essentially trying to say is that cancer care is about systems, it's about exposure to risk factors, sustainability outcomes. So it's not just an issue of the health system, it's an issue wider than that, it's about society and political economy and it really does magnify and expose all of the strengths and weaknesses of the health system and for other chronic diseases. As a result of this, there's been a number of publications within the Lancet Oncology and here just a couple of them over the last four or five years looking at how cancer care control programs can be implemented within learning income countries and there's one just below looking at Latin America and the Caribbean which was published a couple of years ago. And things are focused on a variety of important issues. So public health strategies to manage risk factors such as smoking, improving access to screening and diagnostic investigations, looking at the individual how from the cost of diagnosis and treatment and ongoing follow up, how can it be protected from the financial cost in circumstances where they don't have any social health insurance and how can we ensure that there's inequitable availability in all parts of the country for these services. But one thing that hasn't been looked at, even though aging has been seen as the main driver, what has the impact on the elderly within these countries faced with the diagnosis of cancer? The reason why I mentioned this is that we know it has mentioned that it disproportionately affects the elderly in high income countries. But we also know that the relative survival availability is much worse compared to younger persons. So there's been a lot of research, observational work done predominantly in Europe, but there have been other studies that have found there have been a variety of issues why this gap exists and why it's continuing to widen. One aspect to the disease biology itself do elderly people have more aggressive phenotypes? Do they have more poorer functional status, so multi-morbidity making the ability to deliver aggressive treatment or delaying the presentation? There's also aspects of barriers to access in care, so uptake of screening or screening applying to these age groups, recognition of symptoms. An advanced stage of diagnosis has been a big issue, so stage for stage, it's been a big issue, so stage for stage we have to present with a more advanced stage of disease than the younger counterparts. I think a big issue is the inadequacy of treatment and whether people like to admit it or not there is an inherent ageism towards cancer care within LV populations and we know this because there's under treatment for chemotherapy, surgery particularly and also radiotherapy in men and women over the age of 70 in particular. But we have a very good understanding of cancer and aging in middle-income countries where the same issues apply to the elderly in middle-income countries. Specifically what is the current and projected cancer burden in elderly given this demographic transition? What are their outcomes from care? What are the risk factors which might impact on their access? So this might be health system effects, it might be their own socio-economic circumstance and it might be wider psychosocial cultural issues which may be either prevent the diagnosis or fear or personal support during the cancer pathway and also is there any evidence based management for the cancer in the elderly? This is often a unique population that is owned as a physiological profile in which treatments need to often be tailored for this group and it's not done so well in high-income countries with a lot of current practice of care based on younger cohorts from trials but again this is an area that needs to be looked at. So what I propose is to do an exploratory analysis in a middle-income country and I chose Mexico in many respects because it typifies much of the socio-economic demographic and epidemiological changes that are occurring in middle-income countries and I wanted to use Mexico as a case study to explore this interface within aging. Just a few stats about Mexico where it's the second-largest economy in Latin America there's an estimated population close to 120 million. Currently the population and when I say instead of elderly I mean I'm describing a population aged 65 and above is 7.5 million or close to 8 million and this represents approximately 7% of the total population. This is projected by 2030 that this is going to increase by 8.5 million to 16.2 million representing 14% of the population. So really rapid population aging that's occurring in Mexico specifically. So it faces a dual burden of disease both communicable and non-communicable diseases but predominantly non-communicable diseases as with sort of the middle-income countries in the higher-income echelons. But there is a difference in profile across the country so for instance the southern regions have lower socio-economic development and there's a two-fold increase in the number of so there's twice as many communicable disease deaths compared to the more affluent areas and also the outcomes from the non-communicable diseases are worse. What about the health system? Well it's considered to be quite inefficient and fragmented and other OEDD countries as the lowest public spending on healthcare. Social security exists for the formerly employed and when I talked about fragmentation they're a plethora of public purchaser and provider combinations as such and very fragmented private sector as well but IMSS is the largest social security funded for those formerly employed. Since 2003, Seguro Popular has been providing social security for informal sector and low-income groups to meet the eligibility criteria and it's now approximately nearly close to sort of 55-60 million people covered by this insurance screen. But the coverage by health insurance groups isn't equitable especially in its low-income groups. So when I looked at the study aid, when I prepared the study aids, I wanted to first of all look at what are the relevant research outputs related to cancer and aging in Mexico and looking at geriatric oncology, looking at the disease burden, etc. I wanted to also estimate well we know how the population is going to expand, the other population is going to expand, can we estimate what the burden of disease is within different tumor types and the proportion of which the elderly will be affected by in particular. I also wanted to assess the prevalence of socioeconomic factors that potentially impact on the access and outcomes from cancer care and investigate the health system as a role to see how within cancer care itself it's widened or reduced health inequalities from the available evidence. So in terms of methods, they use a multi-prong approach really. So a literature review, looking at whether science, pub meds and base, a bibliometric analysis of research outputs. Now I'll go into bibliometrics in a bit more detail shortly, but essentially it's there for those who are not aware. It's a way of quantifying analyzing research outputs for a given country. You can look at areas of particular research domains, the amount of international collaboration that's done funding towards different research projects. So it gives us that strategic intelligence to know where the majority of the research is being undertaken. Formally at the moment there isn't a cancer registry, or there wasn't until 2012 within Mexico. So one of the tools that I used to estimate what the incidence and the future doesn't be was this GlobalCan database, which has been produced by the International Association for Research and Cancer in France. It was a really valuable tool which I'll go through. I analyzed death certificate data that was available and also used microdata from three population level surveys. Two of which, if I go to the next slide, were nationally representative and this included a National Housing and Population Census as well as the National Survey on Nutrition and Health. There was a further survey on global aging and health, which was undertaken by the WHO, looking at six lone willing countries, including China, Mexico, South Africa, with two and a half individuals. So if I start off by going through the cancer incident projections, I said that the cancer registry wasn't available. So I was able to use this GlobalCan software to estimate changes in the incidence of cancer between 2012 and 2030. And in the absence of cancer registry data, the GlobalCan software had used death certificate data to estimate what the incidence is based on countries with similar socio-epidemiological profile and to project this accordingly. And it's estimated that by 2030, there's going to be close to 110,000 extra cases per year, which is a huge number, of which nearly 60% will be in men and women aged over 65. If we look at particular specific cancers, I've looked at incidents for lung cancer and comparing with 2080, which was the older version of the GlobalCan software in 2030. What we were finding was that there was a significant rise in the proportion of lung cancer cases, as would be expected, with this demographic transition, so close to nearly 8,000. And 75% of these cancers were in men and women over the age of 65. So lung cancer in particular is projected to be a significant burden. If we look at something like prostate cancer, which is predominates in men over the age of 65, there's going to be nearly a twofold, two to threefold increase in the number of cases, again, the majority of which will be in men over the age of 65. And I also brought in breast cancer because it's the commonest cancer type in Mexico for women, along with survival cancer. And over this period of time, there's going to be nearly 14,000 new cases and 38% of which is in the over 65. But again, there's this effect, all these different types of cancers, given that 7% going up to 14% of the population of the over 65 predominates in this age group. If we look at patterns of cancer mortality from the death registration data had in 2010, we looked at 55% of cancer deaths are in elderly men and women. It's a huge proportion given the numbers. And that the rates of deaths increase sharply over the age of 45, and currently more in men than in women. So if we look at this slide, which was based on all deaths stratified by age, looking at the number of cancer deaths per 100,000 of the population, you can see the sharp rise. And obviously, to some degree, it would be expected given that there's a greater burden in individuals over 65. But this also suggests that actually, they're not doing as well from their care. With regards to the general population, largest causes of cancer deaths are in lung cancer, so approaching 10%, nearly 10%, gasket cancer, 8%, and prostate cancer, 8%. If we look at men of all ages, prostate and lung cancer, the commonest cause of cancer death in women is breast and cervical. But if we look at this age group over 65, prostate lung hepatic cellular carcinoma, which again has got an infectious disease, etiology, and in the majority of cases from hepatitis B, hepatitis C, gastric cancer, they're the main ones. Breast and cervical cancer, although very important in terms of the general female population, don't have as big a burden in the over 65 population. This brought me to the bibliometric evaluation. And as I mentioned, this is a quantitative analysis publications and research activity. And you create algorithms which essentially try and pass out publications from a specific country within all journals worldwide and to estimate or understand what were the specific tumour types they were looking at and the cancer research domains. So having seen the information about where the sort of burden of disease was in terms of the cancer sites, one of the areas I wanted to look at which were what were the specific research outputs by cancer type within Mexico. So the majority were in survival and so the cancer types in the bars in pain would refer to female cancers, green men and women, men and female cancers, and blue male cancers. As you can see, the survival cancer and breast cancer have by far and away the majority of the research inputs followed by leukemia and FOMA. If we look further down, I was mentioning liver cancer, esophageal cancer, prostate cancer, they have much less research in those areas. So what we tried to do was to correlate this in a graph looking at the bone of disease related to death and the amount percentage of cancer research papers. And we looked at research papers over nearly a 25 year period from 1980 to 2012. So it's quite robust in terms of the number of papers that we were looking at. And as you can see at the top, we have survival. First of all, there's no correlation but actually survival and breast cancer relative to the burden of significantly more research into these areas. But that doesn't mean it's insufficient. I would think it suggests that actually in areas such as lung cancer in the bottom right of your screen, pancreatic prostate and esophageal cancer don't have sufficient amount of research in these areas. When we look at research types and research domains, so genetics, chemotherapy, they refer to the prognostic markers, genetic and molecular studies, chemotherapy relating to systemic treatments and then further down, looking at radiology, screening, palliative care and quality of life, they have much less. So even though, so what this tells us overall is that the specific disease sites that are getting the majority of research attention and that within the research domain, they tend to focus on more biological outputs and chemotherapy related outputs than those which may have a more public health impact such as screening and disease epidemiology. My literature review identified about 500 relevant papers but I only found 15 articles which reported on some aspects of aging and cancer. There were two or three articles which really related to the SAVE study which was a health and well-being in aging in Latin America and looked at six cities across Latin America improving Mexico City. This found that the illiterate lower educated and uninsured older men and women had lower rates of cancer, screening committee, their younger counterparts. There are also some small case theories from individual hospitals which demonstrated that there was a survival differential between elderly and younger adults for a number of disease sites such as erectile, breasts, gastric and lung cancer. But there was no articles exploring the reason for this differential between the elderly and younger cohorts or any literature exploring about the understanding of perception of cancer as an elderly adult. I mean, for instance, fear, lack of knowledge, anxiety related to cancer diagnosis have all been cited in the wider cancer literature. So in order to develop a framework for further analyses, I looked at the wider literature related to cancer and elderly cohorts within Mexico. As I pointed out previously, overwhelmingly this is predominantly in breast and survival cancer and there are a number of good studies done in this area using qualitative, often qualitative research but also some observational data. And what this found was that socioeconomic factors were strongly associated with higher rates of mortality, not just sort of poverty and low levels of literacy, but aspects of unemployment and a consequent lack of social security, rural residents, and marginalization or social isolation were particular issues that came out. Big factor was an advanced stage of diagnosis which had a major impact on survival pretty much that when patients received a diagnosis, they would either have stage 3 or stage 4 disease and they were not able to receive curative treatment. Now the predisposing facts for this are multiple but I think a big thing related to the health system itself would be limited availability of oncological services affecting access, significant delays in diagnosis and also aspects of the health insurance coverage, load screening uptake and what I wanted to do, given that these would have been looked at in sort of a different age grid cohort, was to analyze to assess the prevalence of these predisposing factors in elderly men and women from the available surveys that we had from Mexico. So it starts off with socioeconomic profiles and the educational status which I looked at from the SAVE survey those aged over 65 permanently found that actually so I've split this into rural and urban so approximately 25% of elderly men and women live in rural settings in Mexico and 75% in urban settings but actually a significant proportion had not completely had any education beyond primary school and specifically in the rural area not really had any formal education at all and this fits in with late rates of illiteracy from other studies. When you're looking at employment status the other thing that stands out so we're looking at percentage employed and this is age categories from 65 to 80 plus on the left hand column looking at percentage employed percentage non-employed they've used the term non-employed because this includes those working in the informal sector and also at percentage undertaking household activities. You can see that nearly in rural settings any one in four men over the age of 80 was still employed and that fits in with what we know about Mexico which out of the OECD countries is the highest effective retirement age low levels of social security so men in particular are continuing to work even sort of in the other age categories from 65 onwards both in rural and urban settings and also if you look on the far right we see the importance that female role that females play in the household with household duties all the different age groups. Looking at sources of income and this came from the housing and population census the categories were the sort of pension help from relatives outside of Mexico help from relatives within Mexico and government programs. Again there's disparities between rural and urban settings but I think the first main thing to look at with regards to pension is that in urban settings although it's not a high amount but approximately sort of 50 percent 56 percent are covered by a pension but actually that was mainly for men and women less so and also compared to the rural settings it's actually about 20 percent for males and 10 percent for females. Then if we look at the percentage support from government programs you can see that actually close to nearly 80 percent in rural settings and those above 75 were receiving support and this was less in urban settings but actually programs such as Procampo were offering assistance to elderly men and women. I think it's interesting that there is this disparity between females and males and actually you can notice this in particular with regards to the help from relatives within Mexico. It's all come on to another table shortly I think the female elderly population receiving support from elsewhere and that's partly because a number are widow less and older age which I'll show later. With regards to health insurance coverage from taking to the far right column so I've got the main insurers but the far right proportion none insured and with health insurance coverage with an urban setting about 20 percent and rural settings is close to sort of 35 percent and actually if we look at the main insurers the in the urban settings it's IMSS it's made social security which provides main health insurance coverage and in rural settings it's secure of popularity and it's about 35 percent however from more recent data it's probably up to 50-55 percent now for rural settings with the same disparity in urban settings with predominantly IMSS as the main insurer. So just back to what I was saying earlier about this aspect the social network so households headed by women age 65 and above tends to be smaller than those held by elderly men and actually from the SAGE survey nearly 50 percent of females over the age of 65 from their cohorts were widowed and this sort of points to the support that they get from relatives in terms of the income screen but also many are not enrolled within generalized insurance schemes and the risk of isolation is very much there. So this next table came related to the analysis of the health and nutrition survey and the question that was posed was a section of the paper which was only completed if the individual had received some form of care hospital care or health care within the last few weeks and after the question what would the duration see symptoms for that health for that health care issue and if we look at the far right the greater than 12 months you can see them actually compared to the sort of 20 to 64 age group of adults the duration of symptoms prior to presentation 40 to 50 percent nearly had symptoms for over 12 months suggest that there could be delays of occurring before people present although it's not possible to ascertain what those reasons might well be but also assessed using the same data set the proportion of the different types of health care facility used so IMSS and Secretary de Salu were some national health services the Secretary de Salu supplied by the Ministry of Health and IMSS the public purchaser but actually even those even despite those being the main two we can see that actually a significant proportion of elderly men and women use private facilities and pharmacies in particular with regards to out-of-the-pocket payments and this then asked the question for their last visit that they had to the clinic within that two week period that they have to pay and actually sort of one in four to one in three did have to pay an amount towards this and that depended on the health care facility that was being used so what does this all mean really well not just from the data that I presented there's been a number of studies that have happened in Mexico we can see that all the Mexicans experience more poverty than working age groups they often need additional sources of income be it from family or government programs because the low levels of social security and that findings exacerbated when you compare rural settings with urban settings the is a larger proportion in the informal sector and so they're less likely to have health insurance individuals are working to maintain it for over their to older ages in Mexico and this might affect whether they seek medical care because of the potential loss of earnings data has shown that many elderly men and women don't present to the doctor because they're trying to save up money for the test and if you imagine sort of the diagnostic process and treatment process for something like cancer care the actual burden is quite significant in terms of costs also seems to be some evidence of delayed presentation from that earlier work but we're not quite sure what the reasons are I pointed about that when beginning about the health system factors which may be exacerbating or reducing inequities or not helping with access well we first and foremost there's a significant number of elderly that are having to pay out of pocket payments and using chronic facilities and this despite coverage by a secure popular and the actual sentence isn't quite correct so for the sort of 215 sort of approved indications secure popular does cover the costs of drugs etc but actually for the use of ministry of health services where individuals have no insurance they do have to pay out of pocket payments for drugs and in many respects especially high class cancer drugs a lot of these aren't available in the first place when I when we talk about the private facilities themselves this is a very fragmented system in itself you might one study showed that one in three didn't have a full-time doctor present they might not have diagnostic facilities and increasingly pharmacies as seen as a gateway for having access to a professional or an opinion and so one can't measure the quality of that but this isn't part borne out by a sort of low level of trust within the public system and this is not just some ministry of health this is with IMSS facilities which is the main social health insurer for those who are in formal employment often considered inferior difficult to access and plagued by excessive waiting times so two studies that looked in breast cancer found that on average the number of clinic visits required before a diagnosis of breast cancer was upwards of sort of five to eight and that the time taken from the initial presentation of symptoms to diagnosis was about six or seven months and that is completely you know that's a that changes the whole game really in that ability to get individuals or to find individuals who have potentially curated disease as opposed to those who can only need sort of control of their disease with palliative measures there's excessive bureaucracy and lack of privacy and courtesy has also been cited but what about cancer facilities in particular well there's gaps in cancer care coverage full stop so in terms of what modalities of treatment do you need for cancer care for cure well 60 percent of cure requires surgery 40 percent radiotherapy and actually five percent of cures require chemotherapy and radiotherapy is delivered with linear accelerators which is the radiotherapy machine and the whole of Mexico for 120 million people there are 20 linear accelerators for 32 states of which seven are located in the very urbanized Mexico city so this just goes to prove what essential access problems you have for such an important modality of treatment especially in rural settings although secure and popular has reduced catastrophic expenditures since it was integrated and the increasing number have enrolled into this social insurance scheme this has been at the cost of an increasing reduction in the availability of human and capital resources especially within ministry of health institutions so when I talk about human and capital resources I mean reasonable doctors less availability of drugs diagnostics within the settings another factor was that the federal fund was created to protect against catastrophic health expenditures at very high cost interventions for those who are uninsured and this included a wide range of cancers but what I find that and this up until 2012 this is still the case when I was analyzing the data I found that lung, gastric and liver cancers which both predominate in elderly cobalt and cause the majority of cancer related deaths in Mexico are not covered by this insurance scheme this was all the more worrying because there's no real screening tool for these malignancies and diagnosis and treatment are incredibly complex so if you take lung cancer you might need an ultrasound a chest x-ray a CT scan a bronchoscopy a biopsy and then treatment might be entailed four months of chemotherapy with six weeks of radiotherapy so you can see that actually if you're not protected from these expenditures that the ability to actually receive this treatment is actually probably very small or an LVR able to pay that they pay catastrophic expenditures in doing so also the symptoms associated with late diagnosis or advanced disease are huge breathless nerves bleeding etc and so this in itself highlights the need for palliative care I mean the question is because we don't know this question are there a large number of LV with this disease who are not presenting at all who are dying at home from an unknown disease this is something that really hasn't been explored whatsoever and highlights the requirement of well is there any palliative care expertise for these individuals and actually the studies that I've seen within Mexico shows that there has been not absence of policies and opioids persistent being difficult to access for pain relief so my overall conclusions from this analysis that I undertook is that first of all this is a very under-researched area and that we know that the burden of cancer will increase and that this will fall disproportionately so on elderly populations who are paid to do worse the tumor types that are being researched in Mexico I haven't looked in other countries tends to be formed before the limited research priority compared to others such as breast and cervical cancer and what was key to this is that those socioeconomic factor or predisposing factors from the Mexican literature which were associated with poor cancer outcomes such as poverty, low levels of literacy marginalization were heavily prevalent within elderly cohorts this included low levels of health insurance and the necessity to work which may result into late in presentation I think there are also wider health system factors due to the insurance scheme and the quality of service and the availability of services which are widespread issues not just for the elderly but the additional difficulties or potential difficulties in access may make it harder and there are concerns about late presentation and whether this relates to symptom recognition also as I mentioned not to give a popular but this is a catastrophic expenditure fund doesn't cover those tumor types to the greatest burden and so the elderly really are at risk of impoverishing expenditures from cancer diagnosis and delays in treatment so this is my final slide I think in terms of key research priorities I mean they're fairly obvious but again this work doesn't need to be done and it's looking at sort of cancer epidemiology in elderly populations giving out what stage they're presenting with what treatments they're receiving what their outcomes of care are what are the perceptions and barriers towards presenting with a presumed diagnosis of cancer or the understanding of cancer within elderly populations and also looking at specific health system barriers which affect elderly populations and potentially researching methods for improving general cancer awareness and education among the elderly and that completes my presentation I just wanted to say a thanks to Carla Saldana who's the National Cancer Institute who undertook this work with me where Richard Sullivan at Kings College London Grant Lewison who informed the bibliometrics research and the references would be available from a public manuscript that we published related to this which is available through this link thank you very much thank you very much Dr. Ardoral for this very comprehensive presentation if anybody in the audience has any questions please type them in the chat box and I will moderate it and present those questions to our presenter I want to start off with a very general question and you laid out very clearly you know that there will be some significant consequences in Mexico as an example of a lower to middle income country and you know you demonstrate where the gaps are in the socio-economic makeup of the country and the health systems and of course lots of research is needed to further develop policies to alleviate your predictions are there any other cancer control strategies for example that have been developed in other countries that may in the interim prevent some of your predicted outcomes it's a very good question I think a lot are in its infancy so I was involved in work in India so a couple of research projects that I was working on which essentially showed that they've developed something called the national cancer grid and they're developing good tools for epidemiological work but this aspect of inequity within provision it's very hard to overcome because as I said at the beginning this is a question it's not just related to health system that's like this is a question of some wider society in the political economy and actually where do where are elderly how are elderly perceived what are their sort of rights what is their means which they can access cancer care and I don't think there's any particularly great model that I know of that has been developed in other countries as yet and that's why I chose sort of exploratory analysis because there's no work that's been done in this area related to the elderly in these cohorts specifically and they want just to highlight some of the issues that may come about and need to be looked at okay thank you very much and I guess related to my question was a question as well from a listener you know how typical your analysis was of Mexico of other low to middle income countries or is can you make a you know does each country have specific challenges or can your results be extrapolated to many of the other low to middle income countries I think in terms of the cancer burden for middle income countries I think Mexico is very typical and I'll explain why there was a piece of work done about three or four years ago looking at the types of cancers related to the human development index which looked at GDP and education status etc and it showed that countries such as Mexico or similar countries were faced with this dual cancer burden where they were transitioning from cancers related to infectious diseases such as sort of HPV and hepatitis etc to a more risk factor driven non-communicable disease cohort also in terms of the organization of services and the integration of social health insurance schemes many countries probably haven't reached the stage that Mexico has reached but there are similar countries in that bracket in terms of trying to achieve financial protection for those most vulnerable so I would say that actually Mexico is very typical for probably more of the higher end and more developed end of middle income than other countries for instance especially those in Africa Hello Okay sorry I was talking without my talk button on thank you for your answer to that question and related to that answer and low to middle income countries there was another question of you know how will this scenario be in actual low income countries that are maybe not as well off as a country like Mexico can you make any predictions to theirs? It's very hard so I think the demographic challenge is slightly different so they're a bit further behind than middle income countries in terms of this rapid aging and so you very much have still many of these countries which face this predominantly communicable disease burden which are managed with sort of vertical structural so you know the HIV burden malaria about sort of tests and treats and various things like that and then you have this emerging counter diagnosis and then a lot of these countries so they don't actually often have a formalized cancer control program so again a lot of the work is quite exploratory almost trying I think the hardest thing and the most important thing is to actually work out how many people are suffering from cancer what types of camps and how they're presenting and that it seems very obvious but that information is missing for the vast majority of low-income countries in many respects and it has to be sort of done from survey data but no one really knows the answers to those questions Okay, thank you Another question from Dr. Kar is what role do you think organizations such as the PIH and MSF can play in and CV care in low to middle income countries so I'm not 100% sure what those abbreviations are I believe PIH is the population Institute of Health and Medicine Health Frontier but so maybe you can elaborate the question is in the chat section Dr. Agrawal Yeah So I think there are a lot of groups working in this space as such such as the WHO the UICC who are trying to work within low-income countries work within partners there and I think there are a number of groups that have important roles to play I think it's getting that strategy right it's actually engaging with the communities and understanding the importance of where cancer is because you don't understand that many of these countries cancer is an emerging issue compared to all the other sort of cluster of diseases which they're working from I mean it's still not that widely acknowledged that rates of cervical cancer or death related to cervical cancer are often higher in low-income countries than that of HIV or malaria and the it's I think there has to be a change in our thought process towards issues related to non-communicable diseases because the amount of structural required structural change required in health systems in wider society is quite profound so I think actually it is important to get MSF and PIH involved I'm not sure of what specifically they're involved in with NCDs at the moment but there are a number of other organizations working there Okay, thank you very much There is another question where Dr. Karthus cancers aren't seen as low-hanging food for NGOs and funders how do you how do you see the private owner network to be involved? That's a very good question it's difficult to say I completely agree it isn't a low-hanging fruit at all I think there is a lot of scope but I think there's scope if it's done in a correct integrated way it can't just be about which I often hear at conferences no, let's try and fundraise so we can get 10 machines into this country but really very few machines into this country let's create two new laboratories there has to be a system and a process of initiating what the need is looking at the demand and actually dealing with the local population the workforce and planning otherwise it's not sustainable it's just too complex a disease so I think private donors are important but actually has to be of a wider strategy which knows exactly what they need to put in place step by step Okay, thank you Another question was posted to say in terms of challenges this study also found any views on women's social status and socioeconomic conditions while diagnosing and preventing disease? I'm not sure if I understand the question entirely is it asking is there sort of while diagnosing and preventing disease what I'm not entirely sure what the question means in terms of social status and socioeconomic in terms of social status and socioeconomic condition there does appear to be a disparity for women relative to men in terms of the social insurance okay, I've just seen add on to the room yes, I do think there is an issue with female empowerment and social status in particular the proportion that were formally employed that compared to the amount worth doing household duties the proportion who were more likely to be widowed the proportion who were going to be in smaller households where they were leading in I think there does appear to be a sort of a gender difference in that however, it seems that majority of the mortality is actually in elderly men a relative to elderly women but I think some entrenched social status issues for females could affect their ability to present with symptoms related to the diagnosis of cancer which does need to be explored further and I think qualitative research fits in very well to try and explore that paradigm as it has done for younger cohorts within Mexico okay, thank you there's about five minutes left if there's any more questions please cite them in the chat box I have kind of a more of a philosophical question for you Dr. Arawal our population around the globe is aging quite rapidly how optimistic are you that interventions or control strategies will catch up to avoid some of the disastrous consequences that you could predict based on your findings if I'm being honest I think it's very difficult I just I see the challenges that happen in a high income country I mean my clinical practice working as an oncologist see the sort of inequity that occurs between different social groups here and the outcomes that happen to try and recreate a comprehensive help sort of health system to manage cancer care where there's high levels of inequity in terms of income where not everyone is covered by insurance where there's a lack of availability of very high cost technologies so for instance a radiotherapy machine costs one and a half million pounds individually it's very hard to see how you can get the equivalent development and the social health coverage or protection that may require in order to keep up with this demand but that's why you know it's so important that the work that's being done and there's a lot of work that comes out in the last looking at sort of millennium development goals and looking at MCDs as a future challenge but it's so important but that's the original sort of question in terms of philosophical I think it's going to be incredibly difficult Yes, thank you so much Dr Agarwal as it was a very comprehensive presentation we really enjoyed it to look at all the different aspects and the impact on this on the future of low to middle income countries this ends our CLA Say webinar I just want to highlight our next online seminar which will be held on March 24th by Dr Bornstein from Newfoundland and Labrador and it will talk also how research can help shape our policy in practicing for the aging population in Canada so we hope to see you then as well again thank you very much for your attendance and we hope to see you in the future