Clinical Commissions

People with mental illness have an increased risk of physical disease, as well as reduced access to adequate health care. Physical-health disparities are observed across all mental illnesses in all countries. The high rate of physical comorbidity, which often has poor clinical management, reduces life expectancy for people with mental illness, and increases the personal, social, and economic cost of mental illness across the lifespan. This Commission summarises advances in understanding on the topic of physical health in people with mental illness, and presents clear directions for health promotion, clinical care, and future research. It aims to: (1) establish highly pertinent aspects of physical health-related morbidity and mortality that have transdiagnostic applications; (2) highlight the common modifiable factors that drive disparities in physical health; (3) present actions and initiatives for health policy and clinical services to address these issues; and (4) identify promising areas for future research that could identify novel solutions.

About 10 million people die every year from causes relating to hypertension, and elevated blood pressure is the strongest modifiable risk factor for cardiovascular disease worldwide. Despite extensive knowledge about ways to prevent as well as to treat hypertension, the global incidence and prevalence of hypertension and, more importantly, its cardiovascular complications are not reduced—partly because of inadequacies in prevention, diagnosis, and control of the disorder in an ageing world population. The aim of the Lancet Commission on hypertension is to identify key actions to improve the management of blood pressure both at the population and the individual level, and to generate a campaign to adopt the suggested actions at national levels to reduce the impact of elevated blood pressure globally.

Liver disease in the UK stands out as the one glaring exception to the vast improvements made during the past 30 years in health and life expectancy for chronic disorders such as stroke, heart disease, and many cancers. Mortality rates have increased 400% since 1970, and in people younger than 65 years have risen by almost five-times. Liver disease constitutes the third commonest cause of premature death in the UK and the rate of increase of liver disease is substantially higher in the UK than other countries in western Europe. More than 1 million admissions to hospital per year are the result of alcohol-related disorders, and both the number of admissions and the increase in mortality closely parallel the rise in alcohol consumption in the UK during the past three decades.

Progress in reducing hospital admissions and mortality in people with asthma have stalled in the past 10 years. This Lancet Commission examines where we are in the understanding of this heterogeneous syndrome and where we need to go to kickstart a new era of examining, monitoring, treating, and ultimately preventing airways diseases. The Commissioners recommend to deconstruct airway disease into component parts before planning treatment with a focus on traits that are identifiable and treatable. This approach will require a complete change in how we think about airways diseases with the goal of achieving real precision treatment with better patient outcomes. In addition, primary prevention and disease-modifying interventions need to become a more important ambition. It is unacceptable that people still die from asthma attacks in 2017.

The causes of antibiotic resistance are complex and include human behaviour at many levels of society; the consequences affect everybody in the world. Similarities with climate change are evident. Many efforts have been made to describe the many different facets of antibiotic resistance and the interventions needed to meet the challenge. However, coordinated action is largely absent, especially at the political level, both nationally and internationally.

Tremendous progress in treatment and outcomes has been achieved across the whole range of haematological malignancies in the past two decades. Although cure rates for aggressive malignancies have increased, nowhere has progress been more impactful than in the management of typically incurable forms of haematological cancer.

Collectively, China, India, and Russia account for around 40% of the world's population, experience 46% of all new cancers worldwide, and account for 52% of cancer deaths globally. However, a sizeable gap exists between disease burden and the ability of these countries to afford effective control measures, and considerable sociopolitical, cultural, and environmental factors further complicate the situation. In this Commission, and in linked Comments, a multidisciplinary team of health-care professionals, policy makers, and others address the challenges to providing cancer care in these countries and identify the critical steps needed to effect change

COPD is the third leading cause of death in the USA, affecting an estimated 28.9 million adults. The burden of disease continues to grow as the population ages and the long-term effects of smoking result in increased numbers of cases. COPD care faces many challenges including poor guideline implementation for diagnosis, suboptimal patient access to treatment, high hospital readmission rates, and extortionate co-pays for maintenance drugs. In this Commission, we summarise expert opinion from key stakeholders—patients, caregivers, and medical professionals, as well as representatives from health systems, insurance companies, and industry—to understand barriers to care delivery and to propose potential solutions.

The prevalence of Alzheimer’s disease (AD) and other age-related dementias is increasing dramatically with ageing populations worldwide. No treatment is yet available to halt or reverse the underlying pathology of established AD—the most common cause of dementia—and the economic and societal burdens of dementia threaten to become overwhelming as more people live into old age.

The burden of cancer is growing rapidly, and the disease is becoming a major challenge for all developed countries. This is not simply due to an increase in absolute numbers or need for optimised treatments, rather it relates to the unsustainable rate of increase in expenditure on cancer within health-care systems. What are the drivers and solutions to the so-called cancer-cost curve in developed countries? How are we going to afford to deliver high-quality and equitable care? In this Commission and the linked Comments, expert opinion from health-care professionals, policy makers, and cancer survivors has been gathered to address the barriers and solutions to delivering affordable cancer-care in high-income countries.

Every infant, child, and adolescent will experience pain at times throughout their life. Paediatric pain ranges from acute to chronic, and includes procedural, disease-related, breakthrough, and other types of pain. Despite its ubiquity, pain is often silenced and appropriate relief too infrequently given. Undertreated, unrecognised, or poorly managed pain in young people can have long-lasting negative consequences in later life, including continued chronic pain, disability, and distress. It is time for change. This Lancet Child & Adolescent Health Commission presents four transformative goals—to make pain matter, understood, visible, and better. It sets out priorities for clinicians, researchers, funders, and policy makers, and calls for cross-sector collaboration to deliver the action needed to improve the lives of children and adolescents with pain.

Updated: July 30, 2020

“Practices for the management of individual patients in settings with a high tuberculosis burden are not sufficient to prevent the emergence, amplification, and spread of drug-resistant tuberculosis” is one of the key messages from The Lancet Respiratory Medicine Commission, led by Keertan Dheda from the University of Cape Town, South Africa. The Commission focuses on multidrug-resistant, extensively drug-resistant, and incurable tuberculosis, and highlights the growing burden of disease, its implications for patient management, as well as social and legal aspects. The authors also provide practical solutions for tackling emerging resistant cases—an exponentially increasing concern in high-burden countries.

Enactment of the Cancer Moonshot within the 21st Century Cures Act in the USA arrived at a propitious moment in the advancement of knowledge, providing nearly US$2 billion of funding for cancer research and precision medicine. In 2016, the Blue Ribbon Panel (BRP) set out a roadmap of recommendations designed to exploit new advances in cancer diagnosis, prevention, and treatment. Those recommendations provided a high-level view of how to accelerate the conversion of new scientific discoveries into effective treatments and prevention for cancer.

Surgery is a fundamental modality for both curative and palliative treatment of most cancers in countries across all income settings. Yet, the global debate on cancer has mainly focused on prevention and medication, with little narrative directed towards surgery. The Lancet Oncology Commission on Global Cancer Surgery highlights cancer surgery as an integral partner in national cancer control plans as a means of addressing the overlooked role of curative surgery in cancer care. The Commission critically examines the state of global cancer surgery and the variable needs and interdependencies of surgery with other cancer treatments, such as radiotherapy. It explores the link between the needs, gaps, and opportunities and directed changes in policy to drive improvements in cancer surgery research, education, and systems of care across all income settings.

Nearly 3 billion people worldwide are exposed to the threat of household air pollution (HAP) every day from the use of solid fuel for cooking, heating, and lighting. HAP is a major contributor to global figures for morbidity and mortality, with major effects on respiratory symptoms and disease. This first Commission of The Lancet Respiratory Medicine discusses the toxic effects of HAP in low-income and middle-income countries, ways to measure pollution, and solutions to tackle the problem. While a linked Comment reminds readers that HAP can also occur in high-income countries.

While much cancer research is directed towards combating and treating cancer as a disease, much less attention is paid to a patient’s wellbeing and quality of life during the course of the disease. In a new Commission from The Lancet Oncology, Stein Kaasa and colleagues critically discuss how to integrate oncology and palliative care using standardised care pathways, referral guidelines, and collaboration to achieve the best outcomes for patient-centred care. Not only does the Commission promote integration of oncology and palliative care, it also calls for a system-level change in which the activities of professionals are coordinated to help develop and implement new educational programmes within oncology and palliative care. To succeed, effective integration must be anchored in management and policy at all levels of health care, and an integrated approach must be reflected in both international and national cancer control plans to help develop new models of care, educational and research programmes, adequate resource allocation, and sufficient investment. Hopefully, by bringing the need of palliative care into the limelight, not only does the Commission challenge the traditional, dualistic perspective of treating either the tumour or the host, it also encourages a combined approach that places the patient’s perspective at the centre of their care.

A major new Commission from The Lancet and the International Society of Nephrology calls for the elimination of preventable deaths from acute kidney injury by 2025. This ambitious goal is practical and achievable according to leading medical experts. In contrast to high income countries, acute kidney injury in low and middle income countries is mainly a community-acquired disease that affects young and previously healthy individuals. Using peritoneal dialysis, acute kidney injury could be managed for as little as US$150 per patient.

Almost two-thirds of global deaths due to liver disease in 2015 occurred in the Asia-Pacific region. This Commission examines the burden of liver diseases in the Asia-Pacific region, with an in-depth review of the epidemiology and aetiology of liver disease across 11 countries and territories. Although viral hepatitis remains the most common cause of liver disease in the region, the contribution of alcohol-related liver disease and non-alcoholic fatty liver disease is rapidly increasing. The Commission concludes with suggestions for priority areas for action to tackle changing landscape of liver diseases in the Asia-Pacific region.

A Lancet Commission highlights a call from 20 professional and academic leaders for major reform in the training of doctors and other healthcare professionals for the 21st century. Changes are needed because of fragmented, outdated, and static curricula that produce ill-equipped graduates. The Commission argues for major reform across the entire medical education system, in order to produce competency-led curricula for the future.

The largest generation of adolescents and young people in human history (1·8 billion) demands more attention and action. Adolescents and young adults face unprecedented social, economic, and cultural change. The Lancet is dedicated to creating discussion around this critical topic by publishing the best research to lead to better lives for all. Adolescence is generally thought to be the healthiest time of life, and young people have therefore attracted little interest and too few resources. The 2016 Lancet Commission concluded that investing in adolescents will yield a triple benefit—today, into adulthood, and the next generation of children.

Non-communicable diseases, including cancer, are rapidly becoming the leading health-care problem in middle-income and low-income countries. In Latin America and the Caribbean, current cancer control plans vary widely between countries in this region, are largely reactionary to treating advanced cancers, and strongly favour a wealthy and educated minority. In this Commission and linked Comments, expert opinion from a multidisciplinary team of health-care professionals, policy makers, and others address the challenges to providing cancer care in this region and report on the critical steps that are required to reduce the rapidly rising human and economic burden of cancer in Latin America and the Caribbean

Cancer is one of the leading causes of mortality worldwide, and an increasing threat in low and
middle-income countries, such as those that make up Latin America and the Caribbean. In 2013, The Lancet Oncology published their first Commission on Latin America and highlighted several challenges in the region. The 2015 Commission on Latin America, Progress and remaining challenges for cancer control in Latin America and the Caribbean, explores the impact from this earlier Commission and highlights structural reforms in health care systems, new programmes for disenfranchised populations, expansion of cancer registries, cancer plans and, implementation of policies to improve primary prevention of cancer.

Psychological treatments occupy an important place in evidence-based mental health care. Now is an exciting time to fuel treatment research: a pressing demand for improvements is poised alongside new opportunities from closer links with sister scientific and clinical disciplines. The need to improve mental health treatment is great; even the best treatments do not work for everyone, treatments have not been developed for many mental disorders, and the implementation of treatments needs to address worldwide scalability. Psychological treatments have yet to benefit from numerous innovations that have occurred in science, particularly those that have emerged in the past 20 years, and arguably vice versa. This Commission, in association with mental health charity MQ, comprises ten parts that each outline an area in which an expert panel of authors sees substantial opportunity and scope for advancements that will move psychological treatments research forward.

Radiotherapy is a critical and inseparable component of comprehensive cancer treatment and care. For many of the most common cancers in low and middle income countries (LMICs), radiotherapy is essential for effective treatment. In high-income countries (HICs), radiotherapy is used to treat cancer in more than half of all cases to cure localised disease, to palliate symptoms, and to control disease in incurable cancers. Yet, in planning and building treatment capacity for cancer, radiotherapy is frequently the last resource to be considered. Consequently, worldwide access to radiotherapy is unacceptably low. We present a new body of evidence that quantifies the worldwide coverage of radiotherapy services by country.

Sepsis is a common and lethal syndrome: although outcomes have improved, mortality remains high. No specific anti-sepsis treatments exist; as such, management of patients relies mainly on early recognition allowing correct therapeutic measures to be started rapidly, including administration of appropriate antibiotics, source control measures when necessary, and resuscitation with intravenous fluids and vasoactive drugs when needed.

The World Health Organisation estimates that nearly one million people become infected every day with any of four curable sexually transmitted infections (STIs): chlamydia, gonorrhoea, syphilis, and trichomoniasis. Despite their high global incidence, STIs remain a neglected area of research.

The past decade has seen huge advances in the field of stem cell therapy and regenerative medicine and there is a great deal of excitement about the potential promise of these treatments. To date, however, clinical successes have mostly been achieved in small cohorts of patients, and if these therapies are to deliver substantial benefits in routine clinical practice, many challenges will need to be overcome.

The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care to meet demands of increasing need, stabilise health-care costs, and accommodate patient preference for care close to home.

Decades of progress in the care of people with cystic fibrosis mean that patients are living longer, healthier lives than ever before. However, the disease continues to limit survival and quality of life in high-income countries, and many patients in low-income and middle-income countries do not have access to integrated multidisciplinary care or affordable therapies. With a growing population of adult patients, widespread genetic testing for the diagnosis of cystic fibrosis, increased recognition of patient populations of non-European descent, and the development of potentially life-changing therapies that target the underlying cause of cystic fibrosis, an unprecedented opportunity exists for improved health outcomes. The Lancet Respiratory Medicine Commission, led by Scott Bell and Felix Ratjen, reviews the latest research advances and identifies challenges and opportunities for progress in the care of patients globally.

Psychiatry is on the cusp of major changes. It is time to look at where the specialty has been, where it is now, and to try to imagine its future. What will psychiatrists do, and how will this be delivered and financed? How will psychiatry’s relationship with society change? How must mental health laws adapt? Can psychiatry go digital? And how will psychiatrists of the future be trained?

The global burden of disease amenable to surgical intervention, such as trauma, cancer, and complications from childbirth, is substantial and growing. Despite this, there are currently gross disparities in access to safe surgical care worldwide. Surgery is an integral, indivisible component of a properly functioning health system, and all people should have access to safe, high-quality surgical and anesthesia care with financial protection when needed. The purpose of The Lancet Commission on Global Surgery is to make this vision a reality by embedding surgery within the global health agenda, catalysing political change, and defining scalable solutions for provision of quality surgical and anesthesia care for all.

Leading global health and development institutions continue to view non-communicable diseases (NCDs) predominantly through the lens of epidemiological transitions, wherein NCDs are best understood in terms of ageing, urbanisation, lifestyle choices, and affluence. This narrow framing is expressed through the so-called 5 x 5 model, favoured by WHO, of five diseases (cardiovascular disease, cancer, diabetes, chronic respiratory diseases, and mental ill-health) and five risk factors (tobacco use, unhealthy diets, physical inactivity, harmful use of alcohol, and air pollution), and is enshrined in Sustainable Development Goals target 3.4 on reducing NCD mortality.

Increasingly, people leave the countryside to pursue better opportunities in cities. Nowhere has urbanisation been more rapid and pronounced than in China. This Lancet Commission, led by Tsinghua University in Beijing, examines the particular challenges and opportunities for health in China’s cities, with regard to health risks, health promotion, environmental health, and health-care delivery. For cities to be active participants in China’s aspiration as an ecocivilisation, there needs to be increased participation in health-related activities by stakeholders, with fuller integration of health into all civic policies. From this dialogue should come shared goals that are assessed regularly, and research on interventions to improve health for people who live in cities.

Traumatic brain injury (TBI) is a public health challenge of vast, but insufficiently recognised, proportions. TBI is the leading cause of mortality in young adults and a major cause of death and disability across all ages in all countries. In high-income countries, the number of elderly people with TBI is increasing, mainly due to falls, while in low-income and middle-income countries, the burden of TBI from road traffic incidents is increasing.