Haematology in Latin America

Latin America with about 10% of the world’s population is vastly under-represented in articles in the biomedical literature concerning haematological cancers. The goal of this series is to fill this gap. Namely, we and our co-authors intend to update readers on diagnoses and therapies of haematological cancers in this important and ever-emerging region. But first some definitions and demographics.

First, what exactly is Latin America? Unfortunately, there is no precise definition. Latin America is relatively new term coined in 1856 and meant to refer to countries in the southern hemisphere with Latin languages including Spanish, Portuguese and French. This uncertainty has caused considerable confusion. For example, many consider Mexico part of North America. However, for purposes of this issue, we include Mexico, islands of the Caribbean and Central and South America under this rubric.

Latin America is big with a land mass of 19 million square kilometres, 13% of the Earth’s land surface area. It is substantially larger than Europe, 10.5 million square kilometres and similar to the USA and Canada combined, 20.5 million square kilometres.

Latin America is also populous with about 10% of the world population. The United Nations estimates the population of Latin America as 665 million, substantially larger than the European Union, 448 million and the USA and Canada, 368 million.

In contrast, Latin America is relatively poor. With a gross domestic product (GDP) of $4.7 trillion USD compared with the EU, $17.9 trillion USD and the USA and Canada, $27 trillion USD. per capita GDP of Latin America is correspondingly low ($7400 USD) compared to the EU ($33,900 USD), the USA ($63,500 USD) and Canada ($43,200 USD). It is important to consider this low amount for Latin America is substantially higher than other geospaces such as South Asia ($1800 USD) and Sub-Saharan Africa ($1500). It is also important to consider extraordinary differences in per capita GDP between Latin American countries ranging from about $9000 USD in Argentina, Brasil, Cuba and Mexico to about $2000 in Honduras and Nicaragua. Haiti has a per capita GDP of < $1000.

An important measure of the availability of medical care is the percentage of GDP spent on health care. For Latin America, this is about 8% compared with 10% for the EU, 20% for the USA and 13% for Canada.

But these data do not tell the entire story, especially in the context of haematological cancers whose diagnoses and therapies are often expensive. How are whatever available health care resources distributed? Latin America has the highest levels of income inequality in the world. The Gini coefficient or index is a statistical measure of economic inequality and income dispersion within a country. A Gini coefficient of 0 (or 0%) means a countries’ wealth is equally shared by its inhabitants whereas a coefficient of 1 (or 100%) means one person has all a countries’ wealth. Several Latin American countries such as Argentina, Chile, Bolivia and Peru have Gini coefficients of 40.0–44.9 like the USA (41.4) whereas others such as Brazil, Mexico, Paraguay and Venezuela have Gini coefficients of 45.0-49.9. Uruguay has a Gini coefficient of 39.7, better than the USA. Large EU countries such as the UK, France, Germany and Spain have lower Gini coefficients, 30.0–34.9 whereas Nordic countries such as Sweden, Denmark, Norway and Finland have coefficients of 25.0–29.9. According to the United Nations Childrens’ Fund (UNICEF), Latin America has the highest net income Gini coefficient globally at 48.3.

Another measure correlated with health care access is the Human Development Index (HDI). The HDI is a composite measurement indicating the average well-being of all people in a given country or region. A score of 0 is the poor human development and 1, the highest. The HDI of Latin America overall is about 0.76 which represents fair human development. However, scores are heterogenous with countries like Argentina and Chile with scores about 0.85 and Guyana with a score of <0.70. The HDI of EU countries is generally > 0.90 and the USA and Canada, 0.93.

The accompanying articles discuss diagnoses and therapies in people seen at expert centres. But what of the millions of undiagnosed and/or untreated people in Latin America? However, healthcare disparities are not unique to this region. They are prevalent in Southeast Asia, rural China, Sub-Saharan Africa and even the USA. 50 percent of Americans > 65 years with AML received no therapy.

Based on these data, one would expect diagnoses and therapies of haematological cancers in Latin America to lag the EU, the USA and Canada. However, it is difficult to know if this is so because there are few population-based cancer registries in Latin America as a region like the Surveillance, Epidemiology and End Results (SEER) programme of the US National Institutes of Health and similar programmes in the EU and Canada. Another important consideration are the talented Latin American haematologists and oncologists. For people diagnosed and treated for haematological cancers in the largest Latin American countries for which we have reasonable data (Argentina, Brasil and Mexico) adjusted survival outcomes seem similar to those reported in the EU, the USA and Canada. Notably, Latin American colleagues have been resourceful without access to the newest, most expensive drugs and interventions. For example, methods were developed to do haematopoietic cell transplants without needing to freeze blood or bone marrow cells. Some colleagues have re-purposed old drugs for new uses such as substituting bendamustine when melphalan is unavailable and there is development of generic versions of new, expensive drugs. Does branded pomalidomide offer a substantial survival advantage over generic lenalidomide in plasma cell myeloma (PCM)? How important is it to have midostaurin or gilteritinib for FLT3 mutated AML when survival is only modestly improved? Even more so for enasidenib and ivosidenib.

The articles which follow cover several important topics include: (1) the role of nutrition and cancer; (2) diagnoses and therapy of common haematological cancers including acute lymphoblastic and myeloid leukaemias (ALL and AML), lymphomas and PCM; and (3) the state of haematopoietic cell transplants. The contributors are, with 1 exception, distinguished Latin American colleagues. We are pleased to introduce this volume to global colleagues who may have limited knowledge about diagnoses and therapies of haematologic cancers in Latin America.

Conflict of interest

RPG is a consultant to NexImmune Inc. and Ananexa Pharma Ascentage Pharm Group, Antengene Biotech LLC, Medical Director, FFF Enterprises Inc.; partner, AZAC Inc.; Board of Directors, Russian Foundation for Cancer Research Support; and Scientific Advisory Board: StemRad Ltd.

Acknowledgment

RPG acknowledges support from the National Institute of Health Research (NIHR) Biomedical Research Centre funding scheme.