insufficient skills for diagnosis and management, high cost of
immunization against Human Papilomavirus (HPV), one of
the primary causes of cervical cancer, and socio-economic
and geographic barriers to care (7). This should serve to
highlight the scope of the challenge facing national health
systems in managing the disease.
A growing awareness of cancer incidence rates in
developing countries is paralleled by another rising rate -
mobile phone usage. By the end of 2014 the mobile
penetration rate in developing countries reached 90%, with
the total number of mobiles accounting for 78% of the global
total of 7 billion (8). The ubiquity, popularity and established
social acceptability of the mobile makes it a potential
delivery channel for communication between public health
providers and populations. Mobiles have already been used
in multiple small or medium size projects to improve
treatment adherence in specific health programmes such as
HIV Antiretroviral Therapy (9). They have also been used in
several knowledge expansion programmes for different
audiences. In Maternal and Child Health, the MAMA
Alliance and MOTECH programmes have used SMS and
voice messaging to increase knowledge of child care for
expectant or new mothers in South Africa and Ghana. They
have also been used as a confidential hub for youth
knowledge access by the U-Report application in countries
including Uganda and Zambia, where young people can
access medical information and advice on a number of
conditions which they might refrain from asking publically,
such as sexually transmitted conditions or stigmatized
diseases like HIV/AIDS. Nor has activity been restricted to
Africa; the MAMA Alliance has also implemented
programmes for maternal support in Bangladesh, and the
BBC Media Action programme Mobile Kunji has provided
similar pregnancy and neonatal support to remote
communities in the Indian state of Bihar (10).
Populations in low- and middle-income countries
frequently suffer from weak health infrastructure for
disease control: minimal clinical resources, infrequent health
worker visits, and a general apathy towards preventative
measures due to a lack of information. In cancer control this
is particularly acute. About 70% of all cancer cases are
diagnosed when the disease is already at too advanced a
stage to be cured (11). The pro-mobile arguments see
mobiles as an "enabler" to improve awareness, facilitate
access to timely screening, and ensure proper patient
follow-up, overcoming some of the commonest barriers to
cancer control.
The questions that require examination are the following.
Firstly, the validation of the appropriateness of mobile
CANCER MANAGEMENT
66 CANCER CONTROL 2015
solutions for wide-scale use in cancer control programmes
carried out in low- and middle-income settings (LMICs). This
involves looking at how to integrate mobile interventions
within the broader framework of existing health systems,
since mobile programmes working in isolation will fail to
provide these benefits. Secondly, an assessment is needed of
the exact value-add of mobile-based solutions in terms of
their evidence as effective public health tools.
The third and final question hinges on cost. A similar
validation process needs to be undertaken in order to assess
the true cost-effectiveness of mobile health (mHealth)
programmes. Excluding its return on investment in terms of
improved population health, which is difficult to calculate
accurately, the technology offers two primary areas of
quantifiable cost-effectiveness to national health services.
The first reason is that once it is built and embedded into a
public health system, the mobile platform infrastructure
used for one intervention can be used to target any number
of programmes for other diseases. The platform itself is
disease-agnostic, making it a solid investment case for
governments since the content can be constantly adapted to
target the specific health needs of a population or sub-group.
This renders the infrastructure investment for a single
programme a one-time cost for servicing needs across
communicable and noncommunicable diseases alike, as has
already been demonstrated in several mobile projects (12).
Secondly, the scale at which mobiles are able to reach and
engage patients offers a clear opportunity for economies of
scale in national programmes, via a low cost per user ratio to
render the intervention cost-effective overall. A caveat to
this is the need for a strong, sustained promotion campaign
for any new mobile-based service, in order to ensure
sufficient enrolment and uptake amongst patients and
professionals during the initial phase whilst it is normalized
as part of basic service provision.
The following article assesses existing evidence on
interventions using mobile technology to improve cancer
control in emerging health systems. It reviews existing
evidence on interventions based around prevention,
diagnosis and management of cancer, and draws some broad
conclusions on the effectiveness and suitability of
incorporating mobile-based solutions into primary healthcare
services in low-resource settings.
Interventions
In an exploration of opportunities and challenges facing
cancer management, the primary challenges were based
around four themes: patient-related challenges, health-care
providers, health facilities and management (13). These