Traveling Abroad for Cancer Screening, Diagnosis and Treatment - A New Paradigm Shift

The incidence of cancer is on the rise globally. Little is known about the motivations, decision-making processes, and experiences of patients who choose to seek medical care overseas. Low and middle-income countries suffer disproportionately. Established routes of travel are to high-income countries to access treatment unavailable locally or perceived as higher quality. A good example is from Kuwait and UAE to Europe and North America. There are also regionalized flows for example from Africa into South Africa, and intra-European flows from Italy to France and Austria to Germany.

There is however a new trend emerging, with people from high-income countries traveling to low and middle-income countries for cancer screening, diagnosis, and treatment. This is in part due to the rising costs of healthcare in developed nations and the availability of high-quality, affordable care in many developing countries.

A New Paradigm Shift in Medical Tourism

This new paradigm shift in medical tourism presents both challenges and opportunities. On the one hand, it is important to ensure that patients receive safe, high-quality care. On the other hand, there is potential for this to be a cost-effective way of providing access to lifesaving treatment for those who would otherwise not be able to afford it.

There is a need for more research into this phenomenon, to understand the motivations of patients and the implications for both sending and receiving countries.

• What are the motivations of patients who choose to seek cancer care abroad?
• How does this new trend impact establish patterns of medical tourism?
• What are the challenges and opportunities presented by this phenomenon?
• What are the factors that patients consider when making decisions to seek medical care overseas?

Travel decisions can often clinical networks and referral pathways between institutions in different countries which may include relationships between clinical centres conducting research or when services are unavailable in one country due to size, cost, or lack of specialization. Clinicians may also make informal suggestions to patients for further treatment options, drawing on their own experience of previous fellowships or research programmes or overseas research connections. Travel decisions may often actually go against local clinical advice. Conversely, there is also some reporting of patients choosing not to travel abroad for chemotherapy and radiotherapy despite such treatment overseas being advised by local clinicians as part of a continuous treatment pathway. Family always plays a key role in decision-making for adult cancer patients.

In the modern connected world word of mouth and acquaintance with others previously treated in a facility is always a major favour in decision-making for both screening and treatment intervention. A good experience from a patient who has recently travelled to an overseas centre provides the "5-star review" that can give the next patient the confidence to follow suit.

There are currently limited concierge services, and intermediaries within decision-making, travel, and treatment arrangements. A few insurance programs with major insurers such as BUPA offer premium global cover for the few patients able to afford international cover.

Culturally competent care is an important factor for UK patients seeking overseas treatment. There are a significant group of UK citizens of overseas origin (India, Japan etc) who will return to visit family for example in India, Japan or Korea and get scans, and check-up tests with a local doctor. The absence of any language or cultural barriers allows these patients to seek this care but travelling to a country where complex communication around results, reports of scans and treatment decisions in another language can be a daunting prospect and an obvious barrier.

The cost of medical treatment is the primary factor that attracts patients to seek care overseas. The high costs of cancer care in the United States has been well documented and is a major driver for American Medical tourists. In many cases, these high costs are driven by the fact that the US has some of the most advanced cancer treatments and technologies in the world. However, there are a growing number of developing countries that offer high-quality, affordable cancer care. These include India, Thailand, Malaysia, Mexico, and Turkey.

There are several reasons why these countries can offer high-quality, affordable cancer care. One reason is that they have lower costs of labour and overhead. They also often have lower taxes, which allows them to invest more in medical facilities and equipment. Additionally, many of these countries have a large pool of highly trained medical professionals. In fact, many of the doctors who work in these countries received their training in Western countries such as the United States, the UK, or Canada. As a result, they are familiar with the latest cancer treatments and technologies.

Another factor that contributes to the affordability of cancer care in these countries is that they often use generic drugs instead of brand-name drugs. Generic drugs are just as effective as brand-name drugs, but they cost a fraction of the price. Additionally, many of these countries have agreements with Western countries that allow them to purchase brand-name drugs at a discounted price.

When considering treatment options, patients should not only compare the cost of treatment, but also the quality of care. In general, developing countries that offer high-quality, affordable cancer care also have world-class hospitals with state-of-the-art facilities and equipment. Additionally, these hospitals tend to be staffed with experienced and highly trained medical professionals.

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Safety, Risk and Outcomes

This is probably one of the most critical factors with regard to Countries like Turkey and presents the biggest barrier for Oncotrust as a service for rapid cancer diagnosis. There is much in the popular press (many of this recent) around medical "disasters" from patient seeking dental treatment in Turkey or patients suffering complications from Bariatric Surgery. As with any medical procedure patient factors play an important role and the very patients who need complex and expensive dental restorative surgery are often those at the highest risk of complications. Compliance with aftercare, expectations, comorbidities and many other factors contribute to poor outcomes related to high-risk surgery - this does not necessarily translate into inferior care, but rather a different patient population seeking this care pathway.

Similarly, with cancer patients - those who are at the highest risk and most in need of a rapid diagnosis pathway are also the patients for whom safety and risks must be given the utmost consideration. The UK faces unprecedented pressures related to staffing and access to diagnostic services and early detection of cancer is a pivotal factor in determining survival.

There are however many treatments and procedures undertaken in developing countries which would not be considered high risk such as diagnostic scans, MRIs reporting etc and for these lower-risk services, the outcomes are often very good. Memorial Hospital is a great example of this. Having visited the Hospital myself, I would suggest the facilities, access and expertise would outperform many UK NHS Hospital given the current pressures on the NHS, which is independent of the caring and tireless work the NHS staff do day in and day out.

Quality of Care

The quality of care in developing countries that offer high-quality, affordable cancer care is generally quite good. These countries tend to have world-class hospitals with state-of-the-art facilities and equipment. Additionally, these hospitals tend to be staffed with experienced and highly trained medical professionals. The gold standard of cancer outcomes is survival and recurrence rates. Many patients in the UK are unaware how far down the European League table we are regarding cancer survival, spending on cancer drugs, the number of MRI scanners per capita and many other variables.

Why do Patients not Travel to Turkey at Scale for Cancer Diagnostic Tests Currently?

Unfortunately, despite organisation such as Memorial Hospital Antalya being centres of excellence with demonstrable high-quality outcomes, there is a perception that if the care is substantially cheaper, it must be of inferior quality, and this narrative is hard to change. Regarding cancer diagnostic services such as PET-CT scanning, Memorial Antalya Hospital is a regional centre of excellence, and standardised international reporting standards mean the quality assurance process, reliability and diagnostic sensitivity of these tests are high. It therefore follows that the advantages of rapid access to imaging and cancer diagnosis, will almost certainly outweigh the risks of travelling to Turkey for such tests, and more than offsets the risk of stage migration from an earlier stage of cancer to a later stage of cancer (with the inevitable consequence of reduced survival) which currently in now being seen in the UK population.

In summary travelling to Turkey for cancer diagnostic tests may be of significant benefit to patients to avoid late diagnosis, stage migration and improve the key outcome in Cancer that is survival.

Giles Davies, Mustafa Ozdogan on behalf of Oncotrust Medical Advisory Board