Brief: antimicrobial resistance and cancer control

Antimicrobial resistance must be addressed for better cancer treatment and care

Antimicrobial resistance (AMR), or drug resistance, poses a critical threat to global health and requires urgent attention and coordinated action. The World Health Organization (WHO) has listed AMR as one of the top 10 global public health emergencies as it is undermining recent gains in medicine, including advances in cancer treatment and care. This brief examines the issue of AMR, its profound impact on cancer control, and why it is essential for the cancer community to support comprehensive and coordinated action on AMR.

What is AMR? Antimicrobial Resistance (AMR) occurs when bacteria, viruses, fungi, and parasites no longer respond to antimicrobial medicines. As a result, antibiotics and other antimicrobial medicines become ineffective and infections become difficult or impossible to treat, increasing the risk of transmission of disease, severe illness, disability and death.

World Health Organization. Antimicrobial resistance. 2023 [accessed 27 May 2024].

Available from https://www.who.int/news-room/fact-sheets/detail/antimicrobialresistance.

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Why is AMR happening?

Although AMR is a natural phenomenon, the overuse and misuse of antimicrobial medicines have largely contributed to and accelerated its development. Examples of misuse include taking antibiotics for viral infections such as colds and flu, prematurely discontinuing a prescribed course of antibiotic treatment, physicians prescribing an inappropriate antibiotic, and when they are given to animals as growth promoters or used to prevent diseases in healthy animals.1

Why is AMR a global health threat?

Individuals with infections caused by drugresistant microbes are more likely to experience poor health outcomes. The adverse impact of AMR may include longer illness and recovery times, treatment complications, and increased mortality rates, with people dying from previously preventable causes. AMR can also complicate routine surgeries and organ transplants, in which antibiotics play a crucial role to prevent infections.

For communities, the inability or increased difficulty in treating these infections also raises the risk of transmission to others. AMR leads to longer hospital admissions and increases the costs of healthcare, thereby putting additional burden on health systems.2

Dagostar P. Antimicrobial resistance: Implications and Costs. Infect Drug Resist.

2019;12:3903-3910.

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Antimicrobial resistance must be addressed for better cancer treatment and care

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Why should the cancer community care about AMR? Over the last decades, there has been significant progress in cancer treatment and care, with key advances that have improved the effectiveness of surgery, radiotherapy, and medicines, and led to improved cancer survival outcomes.

People with cancer are more susceptible to infections due to the lowering of their immune defences caused by treatments such as chemotherapy, surgery, bone marrow transplants, and radiotherapy.

As many as 1 in 5 cancer patients undergoing treatment are hospitalised due to infection, and antimicrobial medicines are their main line of defence.3 Infections are now the second leading cause of death for cancer patients, after the cancer itself.4 This means that some individuals with a cancer that may otherwise be successfully treated are dying due to drug resistant infections. Unless AMR is urgently addressed, all the progress made in cancer treatment and care is at serious risk.

Call for national targets The recent ‘Lancet Series on Sustainable Access to Effective Antibiotics’ has identified a series of recommended national targets: Target 1: By 2030, achieve a 10% reduction in deaths from AMR Target 2: By 2030, achieve a 20% reduction in inappropriate human antibiotic use Target 3: By 2023, achieve a 30% reduction in inappropriate animal antibiotic use

Norwegian Cancer Society. What are the consequences of antibiotic resistance for cancer patients? 2020; [accessed 27 May 2024]. Available from: https://kreftforeningen.no/en/antimicrobial-resistance-amr/consequences-of-antibioticresistance/ 3

The cancer community’s five recommendations to address AMR for better cancer care AMR is a complex issue that involves the interplay of human and animal health, food and agriculture, and the environment. Given the interconnected nature of the issue, effective action requires a One Health approach that fosters collaboration between these different sectors.

By prioritising AMR as a global health imperative and implementing evidence-based interventions, stakeholders can ensure access to appropriate antimicrobials for those who may need them, preserve progress in cancer care, and improve patient outcomes globally. Every stakeholder has an integral role in addressing this crisis.

The following five recommendations address priority areas with advocacy asks for policy makers and other relevant stakeholders at the national level. These will advance critical efforts against AMR, support the implementation of the WHO Global Action Plan on AMR and the Political Declaration to be adopted at the United Nations High-Level Meeting on AMR in 2024, and contribute to better cancer treatment and care.

1. Raise knowledge and awareness Resistant bacteria are already responsible for more than 1.27 million deaths every year.5 However, knowledge and awareness of AMR’s negative impact on health outcomes, particularly on cancer treatment and care, are currently lacking among policy makers and the general public, and within the cancer community.

The critical need to address AMR alongside cancer treatment must be highlighted through awareness-raising campaigns, emphasising the detrimental impact of AMR. Furthermore, collaboration is vital and must be strengthened between the cancer and infectious diseases communities, including patient/survivor advocacy groups, to join forces and raise awareness of AMR by sharing best practices and

Nanayakkara AK. Antibiotic resistance in the patient with cancer: Escalating challenges and paths forward. CA Cancer J Clin. 2021;71(2):136-144.

5 ReAct. The threat – Antibiotic resistance [Internet]. Uppsala: ReAct - Action on Antibiotic Resistance; [accessed 27 May 2024]. Available from: https://www.reactgroup.org/antibiotic-resistance/the-threat/ 4

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resources to collectively address both challenges effectively.

therapies to manage the infection can lead to negative outcomes and increase AMR.

Policy makers and relevant stakeholders should carry out national public awareness campaigns on AMR using simple and easy-to-understand messages, through multiple channels and engagement of communities. These campaigns should target different audiences and parts of society working in the human and animal health, agriculture and environment sectors.

Policy makers and relevant stakeholders should: •

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2. Address AMR in national cancer control plans with focus on infection prevention and control and access to appropriate essential medicines National cancer control plans (NCCPs) guide countries in addressing their cancer burden.

Given the impact of AMR on cancer outcomes, these plans must be updated to include priority actions on: Infection prevention and control measures The number of fatal outcomes among patients with drug-resistant infections is at least two to three times higher than with patients infected with sensitive pathogens.6 Infection prevention and control is evidence-based practice that prevents patients and health workers from being affected by avoidable infections.7 Strong infection prevention and control measures reduce the risk of healthcare-associated infections and must be a priority.

Sustainable access to timely and effective treatments for infections in cancer patients The lack of sustainable access to antimicrobial treatment for infections is also a driver of AMR. Some of the reasons for the lack of access include challenges with supply chain and regulatory capacity, limited availability of source materials, low rate of registrations of novel antimicrobials in developing markets, and a fragile pipeline for the research and development of new antimicrobials. Furthermore, fragmented access to diagnostics, clinical guidelines for infection management not adapted to the cancer centre, and suboptimal

World Health Organization. Global report on infection prevention and control; 2022.

Geneva: World Health Organization. ISBN: 978-92-4-005116-4.

7 World Health Organization. (n.d.). Infection prevention and control. [cited May 28, 2024]. Available from https://www.who.int/health-topics/infection-prevention-andcontrol#tab=tab_1 6

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include AMR in national cancer control plans and incorporate robust and sustainable infection prevention and control measures at both the national and facility levels to reduce the spread of drug-resistant infections; put in place resources and pathways to update guidelines for infection prevention and control, and the management of infections; ensure sustainable access to qualityassured essential medicines (as per the WHO Model List of Essential Medicines8) and effective infectious disease diagnostics for cancer patients.

3. Improve data and surveillance According to a recent study by the AMR and Cancer Consortium, the incidence of drugresistant infections was 1.5 to 2 times higher in cancer patients compared to non-cancer patients.9 Despite such studies, data on the impact of AMR on cancer care is still scarce, with data gaps especially in low- and middle-income countries (LMICs), thus emphasising the need to expand microbiology laboratory capacity and data collection systems to improve knowledge on the extent of AMR in cancer treatment.10 This is essential in ensuring optimal care and in making evidence-based decisions – especially on infection prevention and control programmes and the use of essential antimicrobials.9

Policy makers and relevant stakeholders should: • •

strengthen national diagnostics and microbiology laboratory infrastructure; provide resources for the cancer and infectious diseases sectors to collaborate on collecting data on the prevalence and negative impact of resistant infections on cancer patients to inform evidencebased and location-specific interventions and policies.

World Health Organization. WHO Model List of Essential Medicines - 23rd list, 2023.

Geneva: World Health Organization; [accessed 27 May 2024]. Available from: https://www.who.int/publications/i/item/WHO-MHP-HPS-EML-2023.01 9 Cancer and AMR Consortium (forthcoming in 2024).

10 Murray, C. JL, et al. “Global Burden of Bacterial Antimicrobial Resistance in 2019: a Systematic Analysis.” The Lancet, vol. 399, no. 10325, Elsevier, 2022, pp. P629–655.

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4. Mobilise sustainable financing

5. Engage cancer care providers

Like national cancer control plans for cancer control, national action plans (NAPs) on AMR help countries address AMR. However, in 2023 only 27% of countries reported implementing their NAPs effectively, and only 11% had allocated national budgets to do so.

Unfortunately, despite the clear evidence between AMR and cancer outcomes, AMR is currently not a priority for the health workforce for cancer. In contrast, it is a higher priority issue for infectious diseases colleagues. This siloed approach needs to change.

Securing sufficient investment is critical for the effective and successful implementation of NAPs aimed at addressing AMR, especially in LMICs. Increased investment and international support are urgently needed for countries to deliver on NAPs to effectively address AMR.

Training and education on AMR for the health workforce for cancer is a crucial first step. This should encompass the critical importance of infection prevention and control, the rational use of antimicrobials, clinical guidelines for the management of infections, and the need to promote responsible antimicrobial stewardship practices and interventions to reduce AMR. The infectious diseases community and cancer community must join forces to address AMR effectively.

Policy makers and relevant stakeholders should: • •

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mobilise sustainable funding for the implementation of national action plans (NAPs) on AMR; consider additional mechanisms to improve sustainable funding, such as engagement with international donors and public private partnerships, taxation options, and engage with multilateral development banks to review lending conditions in order to facilitate more investments in health; include AMR across programmes and plans (such as universal health coverage, health emergencies, and NCCPs) to support NAP activities.

Policy makers and relevant stakeholders should: •

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include the health workforce for cancer and patients in governance structures and decision-making processes related to AMR and cancer treatment (including in committees for treatment guidelines and antimicrobial stewardship, etc) to ensure their expertise and perspectives are considered in a holistic rather than siloed approach to care. ensure that AMR is an integral part of preservice and in-service training and education of the health workforce for cancer.

Tackling AMR is not just about saving lives today, it is also about safeguarding the future of cancer care. Without effective antimicrobials, our ability to treat infections in cancer patients, manage complications, and ensure successful outcomes diminishes.

Professor Jeff Dunn AO, President of UICC

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