Fernando Maluf: First of all, I'd like to thank Ashish's invitation. Ashish is not only my colleague, he's one of my best friends in the field, someone that I admire a lot for his leadership and the difference he's making in the bladder cancer space. And as Ashish mentioned, we are very into not only the data but using the data to try to improve the... And improving the opportunities that we do have in the developing countries in the world. And Latin America, of course, is one of the places in the world that there's a lot of improvement to be done. This is my conflict of interest and that's introduction. There is no secret to know that cancer is growing pretty fast. We will have in around five years from now, 27 million new cases per year and 17 million new deaths. It's rising in developed and developing countries, of course.
Looking at this slide, we do see that only 15% of the world belongs to developed countries of the population and 84.7% to developing countries. Most of the people in the world are living in places with severe limitations. However, when you look at the new cancer cases, we have around 40% of the new cases in developed countries and 61% in developing countries. But as a consequence and very disproportionately, despite that only 15% of people live in developed countries, the expenditures on cancer towards those countries are 93.8%. And despite 85% of people living in developing countries, only 6% of the expenditures are directed to these places. There is a huge gap and a huge disproportion.
As an example, when we do see the expenditures with medical costs, we do see that most of the costs are directed to the US, Europe, and Japan. And as a consequence, and it's not any surprise, the mortality rate in developing countries looking at cancer overall is almost double that of developed countries. And here, we can see in Brazil specifically, in Brazil, we have 220 million people living here and 3/4 are linked to the public and only 1/4 have insurance programs.
However, the expenditures to the public sector are only 40% and the expenditures to the private sector are 60%. We can imagine that the differences in mortality rate in cancer and in bladder cancer, in prostate cancer, are going to show that they are, of course, much higher in the public space than in the private space. Latin America, as we all know, is a complex region of 33 countries and 14 territories. There are huge differences between the countries. And what we can see is that the region threatens to be overwhelmed by cancer over the next two decades with significant human suffering and a sharp rise in cost. Cancer is a disease of aging people. And by 2020, Latin America had more than 100 million people over 60 years old. And by five years from now, 1.7 million new diagnoses and 1 million deaths annually. It's rising very quickly. In Latin America, cancer is less frequent than the US by many epidemiologic characteristics.
However, the mortality incidence ratio is 60% higher than in the US and most of the people are diagnosed with locally advanced or metastatic disease. We do know also that more than 50% of the people in Latin America lack adequate healthcare and at least 50 million people live in the most urban, poor, rural, or remote areas. Just to have an example of the expenditures in Latin America comparing with Europe, the US, and Japan, in Latin America, the medical expenditure per new cancer diagnosis is $8 versus $460 in the US, $243 in Japan, and $160 in the UK. It's a huge disproportionality.
There is no miracle, and what I'm showing here is, of course, what we could imagine upfront. Latin America has almost 600 million inhabitants and again, we have very difficult problems with access, with long lines for treatment, and of course with poor outcomes. Talking about that and having this as a background, we have developed a database in many places in Brazil but particularly in São Paulo, which is the place in the country where the population is concentrated most. This is a study, a retrospective study that was published in the Journal of Global Oncology evaluating more than 6,000 bladder cancer patients of different stages from one to four, which is the outcome of patients treated in the private sector... Again, private sectors represent 1/4 of the population and the public sectors are linked to the 3/4 of the population.
What's the impact of being treated in the private sector versus the public sector? And what you do see here is a huge difference between the private sector outcome and the public sector outcome. And we could see that the curves separated very quickly all along the years in the follow-up of a median of five years. When you look at this table, sorting by the stage, the chances to be alive in the private sector versus the public sector for stage two, three, or four A disease is 3.5 higher. And if you do have stage four B disease, it's almost 10 times higher. Basically, because we lack drugs, we lack surgery to be done at the correct time, we lack radiation therapy to be done at the correct time, or we even lack radiation. In Brazil, more than 70,000 people don't have radiation even when being indicated. It's a real problem. And this is another publication from our group from Fernando Korkes and myself, showing that the costs are increasing in Brazil. And we can see in this table with the introduction of many medications, as an example, the cost is increasing.
However, I have to alert that in the bladder cancer space, Ashish, there is no approval for any IO or any targeted therapy at all. The only therapy available systemically for bladder cancer in the public system is chemotherapy with platinum and gemcitabine. That's it. We can imagine the burden of this on the patient outcome. Our group also evaluated the gap in other GU malignancies. This is another trial that we conducted in almost 600 patients with prostate cancer. And in this trial, half of the patients were treated in the private, half of the patients were treated in the public system.
And this was a poster at ASCO GU, and what we can see is that the median cancer-specific survival for patients treated in the public versus in the private showed a huge difference, as you can see, with a chance of being alive in the private compared with the public almost two times. When you look at overall survival, there is also a huge difference of around 30 months between public versus private. And why is that? Because the chance of a patient in the public receiving any ARPI such as abiraterone is only 10% versus 90% in the private. Again, this is a mirror of the study that we have done in bladder cancer showing that for metastatic disease, every patient in the same disease space treated with ADT, the differences in cancer-specific survival and overall survival were huge. Again, there is a lot of space for improvement and that's what we are fighting for. Potential solutions, certainly research.
Latin America only participates in 3% to 5% of all global oncologic protocols. When you look at the number of trial sites in Latin America, per 1 million population it's only 2 versus 82 in the US, 40 times less. We have the LACOG. Ashish is a partner of the LACOG, being an advisor in many, many, many projects with us. And I thank publicly, Ashish, for that. Research is one of the ways to overcome the limitation of drug access in the public space such as we showed in bladder cancer and in prostate cancer as well. And now, we are close to publishing data from kidney cancer that's going to show similar results as in bladder, prostate, and testicular cancer as well.
And that's one of the examples of the power of research in Brazil, not only to generate access to the patients for things that they don't have in the public but also to generate really important data that is going to transform positively the lives of the patients in the trial, and hopefully patients outside of the trials after the trial results. This is one of the trials that Ashish is part of the steering committee, it's called the Redempted Trial. It's a 350-patient trial, muscle-invasive disease, cisplatin-eligible that is going to be started in four months from now, randomizing patients upfront to neoadjuvant chemoimmunotherapy with cisplatin and durvalumab, followed by radical cystectomy versus RT, followed by chemoradiation, followed by adjuvant durvalumab for both arms.
This is an important trial to try to define what's the optimal local treatment for muscle-invasive disease. And again, if it's possible to preserve the bladder, maintaining the quality of life without cystectomy. This is a trial that is one of the examples that by research, yes, we can accelerate access, we can improve access for the patients, we can treat the patients better than normally they're treated in the public space, and also generate very fine scientific data. And I stop here. And thanks again for the invitation for this talk.
Ashish Kamat: Thank you, Fernando, so much for that presentation. Again, what I really like about the way you approach things is you identify what you think is a problem, then you do the research to make sure that it is a problem. But you also find solutions, right? And I think that's a true example and a reason you're such a world leader in the field of oncology.
People that are listening in obviously are listening in from all over the globe, and you're an integral part of the International Bladder Cancer Group which is an international group. We have people from all over the world that come together, we're trying to reach people not just in North America, Latin America, but also in Africa, in Asia, in places where they really don't have resources. What's your advice to people listening in as to how they can go about doing something similar to what you've done? Obviously, you have a lot more experience and resources. But someone looking to improve the care of patients in their region, what is your advice to them?
Fernando Maluf: I think it's a great question and I think I have many answers to try to answer that. One of the things I think, again, is improving research. We know that research is very concentrated in the US, Europe, and some places in Asia. But I think it's part of the Latin American community with the LACOG, the African community, the Middle East community, the Eastern Europe community to try to join forces and try to work as closely as they can with the supporters, particularly with pharma, to try to bring trials to places with limitations in resources. That's one of the things that we're trying to do.
In parallel, Ashish, I don't know if I told you but now we are doing a capacitation of public centers that don't do research to be qualified research units. We have a social institute called Beat The Cancer. We have now qualified 20 centers in the country, high-volume centers, no research units, around 5 to 1,000 kilometers that now have research units and are participants of the trials. That's one of the things. The second thing that I think is really important is to try to do more educational programs, and we have been discussing that in the IBCG, with the same idea that we developed with Silke Gillessen based on the APCCC, a global consensus.
We have done APCCC for developing countries, posing questions and solutions when you don't have many things available, when you don't have IMRT, when you don't have an experienced surgeon to do a radical cystectomy, when you don't have durvalumab in the perioperative space, when you don't have EV in the metastatic or now perioperative space as well. That's the second thing, to try to have more data giving solutions and perspectives and guidance for people who are living in places that they know the data but they don't have access to everything they know, so they have to do the best they can with the tools they have available. Third, I think the doctors have... And I think it's really important, the doctors have to have the commitment to discuss with the agencies, with the governors, better health policies.
I think doctors are very shy to do that. I am not shy because I think it's part of my job as a physician, to take care of patients in the clinics, in the inpatient and outpatient clinics, but also to try to discuss with the government better protocols, more rational, cost-effective analysis of what we really can incorporate for a huge impact. Of course, you know that we cannot have access to everything. But there are some tools and some medications and some strategies where the cost is not that high but the impact is huge. I think we have to work more on health policies to try to improve that as well. But as you say, we can only discuss with the governors when we have the data. Now, we are providing the data to tell you there are huge gaps that we imagined that there were but now we are proving. What can we do better for our patients, improving the screening, diagnosis, treatment, and follow-up of these patients?
Ashish Kamat: That's a great answer, Fernando. Again, it's almost like you have a cookbook and people can come. And if they follow your 1, 2, 3, you can replicate this. And I would add one extra thing, I think people can then reach out to folks like yourself if they need guidance, if they need help because you truly... I know you personally, you reach out and you'll help and you're always available. Anybody listening here, if they want to reach out to you, I'm going to volunteer you on your behalf. I'm going to take that liberty.
If they need help and they want to do this, reach out to Dr. Maluf, reach out to me, reach out to us. We are always happy to help make things better for patients across the globe. Fernando, I know you're busy. In fact, I think you're in the middle of a busy clinic right now, so I want to thank you for taking the time. Always a pleasure having you onboard. And congratulations once again on something that is so, so important.
Fernando Maluf: Thank you, my dear friend. Thanks for the opportunity to share some of our work. And I'm super available to you and to any colleagues that want to discuss and to come up with some good ideas together. Thank you so much.