Cancer Day February 4th ,2010National Cancer

Strategies

By

Dr. Asad Ramlawi

D.G.PHC & PH

Growing Burden of cancer

• The estimated number of new cases of cancer each year is expected to rise from 10 million in 2002 to 15 million by 2025.

• globally cancer as a global health problem, which by 2010 will become the leading cause of death, ahead of ischemic heart disease)

• About 60% of those cases occurring in developing countries.

Growing burden of cancer mortality

Noncommunicable diseases:

Heart disease30.2%

Cancer15.7%

Diabetes1.9%

Other chronic diseases15.7%

Infectious diseases:HIV/AIDS 4.9%

Tuberculosis 2.4%

Malaria 1.5%

OtherInfectiousDiseases

20.9%

Injuries 9.3%

Total:58Million

Deaths by cause in the world

(WHO, 2005)

Regional situation

• In EMR, cancer is the 4th ranked cause of death after cardiovascular diseases, infectious/parasitic diseases and injuries.

• Cancer kills each year in the Region, more than HIV/AIDS, tuberculosis and malaria combined.

Increase in Disease burden

• Cancer incidences are rising rapidly due to aging population and increase exposure to risk factors.

• The largest increase in cancer incidence among the WHO regions in the next 15 years is likely to be in the EM region, in which projection modelling predicts an increase of between 100% and 180% [Rastogi et al. 2004].

Increase in Deaths From Cancer In the next 15 years

180%

140%

144%

104%

0% 50% 100% 150% 200%

Middle Eastern

Sub-Saharan Africa

Latin American andCaribean

World

Estimated Causes Of Cancer Mortality in the EM Region By Gender

Top 5 cancers in some EM countries

CountriesIncidence

1st 2nd3rd4th 5th

EgyptBreastBladderNHLLiverLung

JordanBreastColonLungBladderNHL

LebanonBreastLungBladderCervixLarynx

LibyaBreastLungColonHead & NeckBladder

MoroccoBreastLung CervixProstateLymphoma

Tunisia LungBreastBladderColonNHL

Children Cancer

In the EM region, the most common children cancers are blood cancers

Incidence & Mortality of children cancer in the EM region compared to that in western countries

Can Cancer be controlled??

• 40% of cancers can be prevented

• 40% of cancers can be detected early and cured.

• 20% of cancer can be managed by palliative therapy

1 .Cancer Prevention Risk factors of cancer

Developed countries

Diet

Tobacco

Infection

ProfessionalexposuresEnvironmentalpollutionOther

Developing countries

Tobacco, Diet and Infections were responsible for 4.4 million cases globally in 2002 out of the 6.7 million

Prevalence of Smoking according to STEPwise Survey in EM countries

21.6

29

12.9

24.7

15.7

21.8

12

0

10

20

30

40

Iraq Jordan SaudiArabia

Syrian ArabRepublic

Kuwait Egypt Sudan

Prevalence of overweight and obesity

0

10

20

30

40

50

60

70

80

90

100

BMI≥25 Males

BMI≥25 Females

Prevalence of Low Physical Activity according to STEPwise Survey in EM countries

56.7

87.9

32.9

50.4

86.8

0

20

40

60

80

100

Iraq Jordan Syrian ArabRepublic

Egypt Sudan

Modifiable cancer risk factors

• Tobacco use - responsible for 1.8 million cancer deaths per year (60% of these deaths occur in low- and middle-income countries);

• Being overweight, obese or physically inactive - together responsible for 274 000 cancer deaths per year;

• harmful alcohol use - responsible for 351 000 cancer deaths per year;

• Sexually transmitted human papilloma virus (HPV) infection - responsible for 235 000 cancer deaths per year; and

• Occupational carcinogens - responsible for at least 152 000 cancer deaths per year.

Cancer Registries in the EMR Countries

• Few countries have national/sub-national cancer registry

• 11 Countries have hospital-based cancer registry and published reports.

• Data about stage at presentation, mortality, and survival are lacking in almost all countries.

• None has published survival data.• Only one (Saudi Arabia) in the EMR has

published stage data

Screening &Early Detection

Stage

of diagnosis

Breast cancerCervical cancer

U. S.EgyptU. S.Egypt

Localized 65%25.5%58% 35.9%

Regional30%58%33% 53.2%

Distant5%16.5%9% 10.9%

In the EM region, the vast majority of cancer are diagnosed at an advanced stage when cure is improbable even with the best treatment.

Accessibility & Affordability of Cancer Management in the EMR

Diagnosis and treatment depend heavily on resources, including human resources which is sub-optimal in the majority of EM countries.

Radiotherapy machines and radio-oncologist /radio-technicians are not sufficient to cover the needs in many EM countries

Multidisciplinary management of cases is not instituted in all referral centres

Palliative care (PC)

• In EMR there is,

• Insufficient development of palliative care in all countries.

• Misconception in the medical community about opioids use, inappropriate concern about addiction

• No training in PC for clinicians and nurses

• Lack of awareness in the population for the possibility of pain control and peaceful death

• Inadequate policies restricting access to opioids.

• Accessibility and affordability of opioids especially oral morphine are not ensured

All patients in need of pain relief could be helped if current knowledge about pain control and palliative care were applied

Morphine consumption

0

0.5

1

1.5

2

2.5

3

3.5

mor

phio

ne c

onsu

mpt

ion

(mg/

capi

ta)

0

10

20

30

40

50

60

70

mor

phin

e co

nsum

ptio

n (m

g/ca

pita

)

Morphine consumption in western countries is around 50mg/capita

Summary of the situation

• The burden of cancer is high in the EM region and is likely to increase fast in the coming years

• There is a wide diversity among EM countries in terms of data available, programs, resources and capacities for cancer control. Many countries have already programmes, but at different levels of development.

• In almost all countries, cancers are detected late. This means increase in cost and in mortality.

• Access to treatment is limited in many countries of the Region

• There is limited access to palliative care due to misconception, health providers attitude, legislations and availability.

Cancer Control Strategy in EMR and framework for country action• WHO-EMRO has developed a regional cancer control strategy and a framework for a plan of action to assist Member States in selecting the appropriate set of interventions for cancer control.

– The strategic priorities are organised according to the level of resources available, low, middle or high.

– This strategy is in keeping with the “WHO Global Action Plan against Cancer” (GAPAC) and pursues the same goals,

– EMRO will address primarily breast cancer, tobacco related cancer and children cancer/blood cancers.

The National Strategy

1. Establish the National Cancer Control Committee (NCCC),

2. Develop and implement the NCCP, which is an integrated set of activities covering:

Primary prevention Early detection Diagnosis and treatment Palliative care Registries Research

Cont ,,,,

• raising awareness, • advocacy,• coordination with national and international

agencies, • resource mobilization, • training, • research, • identification and promotion of evidence-based

cost-effective interventions, and • development of national capacities.

A Framework for country action on cancer Control

assess national resourcescapacity

Develop policy and strategic plan

Advocacy and increase awareness

Develop information systemFor monitoring and

evaluation of programs

Multisectoral action to modifyEnvironment, mobilize resources

Implementation of the cancer control

program

Assess magnitude of the problem ,country priorities

Framework for Country Action

Situation analysis:To assess magnitude of the problem, pattern of cancer, identify gaps in knowledge, obstacles and recommend actions accordingly

Assess national capacity in prevention and control of cancer:Assess resources, management facilities, equity in distribution and accessibility of services, availability of medications and cancer registry, surveillance & database.To Strengthening of NGOs work in the field of cancer control and research availability and capacity.

Framework for Country Action/Continue

Organizational and legislative activities:

• NCC committee headed by a prominent high-level person

• Technical sub-committees for all aspects of cancer control programme.

• Alignment of the NCC Strategy with the WHO regional strategy

• Adaptation of related Global and Regional initiatives

Enabling Environment

Advocacy & Increased awareness through: Mass media, Community and religious leaders, Celebrities Other health education activities

Develop supportive activities:– Coordinate efforts of all stakeholders– Mobilize resources– Involve community at all stages of

development– Establish national network

Framework for Country Action/Continue

Preparation for implementation

• Identify the existing and required infrastructure.

• Develop the required resource & facilities plan • Integrate cancer prevention and control in PHC • Create an efficient & effective referral system• Identify and obtain required financial resources

Develop the required mechanisms for implementation

Framework for Country Action/Continue

Develop an appropriate information system for monitoring and evaluation

Promote Research: • Identify centers of excellence for research and

training• Mobilize financial resources for research• Share research findings with other countries

Encourage NGOs to join the Regional Alliance Against Cancer.

Next steps

Development of country specific National cancer control plan

Follow-up mechanisms for implementationCreating an environment for successCollaborate with regional and national

network for cancer control

THANK YOU