Building Sustainable Cancer

Control Capacity and

Infrastructure in
Developing Countries
Professor ROBERT BURTON
Monash University-Victoria Australia
IAEA-PACT Consultant
Chronic Non-communicable
Diseases-NCD

üCardiovascular
disease, mainly heart
disease and stroke
üCancer
üChronic respiratory
diseases
üDiabetes
 WHO

COMPREHENSIVE CANCER CONTROL

RESEARCH EARLY PATIENT

DETECTION WELFARE
PREVENTION TREATMENT CANCER
MONITORING

TitlQuo AD145
 A New Platform
• To join forces with other partners
• To fight cancer comprehensively
• To have an effective, efficient
and well coordinated IAEA
cancer programme that is
aligned with the work of WHO in
this area
• To mobilize new resources

International Network for Cancer Treatment and

Research

Tata
Memorial
Centre
Private
Sector

IAEA PACT July 2008 4 4

 IAEA & Cancer:
From Radiotherapy to PACT
2004 WHO calls for global action to fight the cancer epidemic
sweeping through developing countries
2005 IAEA responds and establishes PACT to address full spectrum
of cancer control, using radiotherapy as an anchor
2006 PACT Model Demonstration Sites (PMDS ) established in
Albania, Nicaragua, Sri Lanka, Tanzania, Vietnam & Yemen
2007 High level cancer control meetings Africa, Latin America
2008 US$ 23 million mobilized
to date by PACT
2009 WHO
WHO--IAEA Joint Programme
on cancer control
formally signed

Press Release WHO-IAEA, May 2009

5
 PACT:
PACT:
Its Mission
Ü To raise awareness and funds to
fight cancer in developing countries
Ü To forge partnerships with global
cancer experts including WHO,
Ministries of Health, NGOs
Ü To work with developing countries
to implement National Cancer
Control Programmes (NCCP)
Ü To accelerate IAEA’s assistance to
build infrastructure and capacity in
radiotherapy
The technology and skills already exist
to treat and often cure cancer.
People in developing countries
deserve access to them. 6
 PACT:
PACT:
Basic Strategy
Ü Move the IAEA’s cancer-
cancer-related
programmes to a public health
model
Ü Integrate radiotherapy into
National Cancer Control
Programmes
Ü Focus on prevention and
early detection to
maximise public health
benefit of investments in
treatment
7
PACT:
Priority Interventions
PACT experience in developing countries shows
urgent need for:
Screening: Cervical Radiotherapy to Palliative Care for
and Breast Treat and Cure Late Stages

Photos left to right: PMDS Albania, Nicaragua, Vietnam

8
 POPULATION CANCER
CONTROL PLANNING
UNDERTAKE A NEEDS ANALYSIS:
• Burden of Cancer & Cancer Risk Factors
• Resources of Skills & Infrastructure
• Political and Public Support
• Health Care provider Support
• Cultural Facilitators & Barriers

DECIDE THE PLANNING METHOD:

• Bottom Up
• Top down
 POPULATION CANCER
CONTROL PLANNING
THE BURDEN OF CANCER
The minimum necessary data for
planning are reliable estimates of the
incidence in the population by site for
common cancers, and the proportions
curable at diagnosis as clinical stage
(localized, regional or distant disease)
and/or mortality/incidence and/or
survival time from diagnosis.
 The BURDEN of CANCER in
INDONESIA in 2002*
TOTAL INCIDENCE 179,497 new cases

MORTALITY/INCIDENCE ratio 0.66

*Estimates from Globocan 2000, IARC, Lyon, France

*Based on data from 1 Indonesian city 1988-92 and a nearby Malay
population

#These figures have little credibility, and cannot be used for

planning: much better Indonesian data is needed
 PREVENTABILITY OF GLOBAL
CANCERS- 2000
CANCER NEW CASES PREVENTABLE FACTOR
Millions %

LUNG 1.3 80 tobacco

STOMACH 1.0 90 H.pylori / diet / tobacco
COLORECTAL 0.9 60 diet / tobacco / exercise
HEAD AND NECK 0.6 75 tobacco / alcohol
CERVIX 0.5 90 Cervical Screening/HPV
LIVER 0.5 75 HBV / HCV / alcohol
OESOPHAGUS 0.5 75 tobacco / diet
URINARY TRACT 0.5 30 tobacco
OTHER 4.3 10

TOTAL 10.1 48

Non-Melanoma Skin
Cancers excluded PrevScreen AD196
6 Recommended Priority Actions
for Developing Countries
1. Develop population based cancer
registries.
2. Undertake Public & Health Professional
Surveys for Beliefs about Cancer & NCD
3. Develop a NCD/Cancer Control Plan
4. Plan National Workforce: 20 yrs
5. Plan National Infrastructure:10 yrs
5. Improve low technology early diagnosis of
breast and cervical cancer.
6. Develop a National Palliative Care Plan
 WHO STEPS
a tool for surveillance of major NCD risk factors
Step 1:
Behaviors
•Tobacco Use
•Physical Inactivity
•Intake fruit/veg
•Alcohol Use

Step 2:
Physical measures
•Blood Pressure
•Height /Weight

Step 3:
Blood samples
•Cholesterol
•Blood glucose/diabetes
 Men smoking
Territories are sized in proportion to the number of
men smoking cigarettes in 2005
 Unless current smokers quit, smoking
deaths will rise dramatically over the
Baseline
next 50 years
If proportion of young adults taking up smoking halves by 2020
If adult consumption halves by 2020
520
500 500
Tobacco deaths

400
340
(million)

300
220
200
190
100 70
0 0
1950 2000 Year 2025 2050

Source: Peto and Lopez, 2001

Risks are increasing
Overweight – Obesity & Cancer
USA 2003

Body Mass Index >= 25

Attributable Cancer Mortality
Women 25%
Men 14%
Calle et al NEJM 2003; 348: 1625
ACS Cohort 900,000 adults, 16 year results
World Burden of Infectious
Cancers
2000 - IARC*-1
CANCER ORGANISM NUMBER

BACTERIA
Gastric H.pylori 557,000
VIRUSES

Ano-genital & oral HPV 551,000

Liver HBV 54% 482,000

HCV 27%

*Total 10 million new cancer cases in 2000

27% of cancer in the Developing World, 9% of cancer in the Developed World
 IMMUNIZATION
AGAINST CANCER
Cancer Cause Vaccine When

Hepatoma HBV Yes 1980

Cervix HPV Yes 2008*

Stomach Helicobacter In development ?

Pylori

Nasal cancer EBV In development ?

and lymphoma

*30 million doses given by mid 2009

PrevScreen AD057
 CANCER CONTROL PLANNING

• DEVELOP THE PLAN:

• Use a Comprehensive Planning Framework
• Inclusive Stakeholder Involvement
• Criteria for Choosing Priority Actions

• IMPLEMENT THE PLAN:

• WHO Recommends that Countries Choose
and Implement Priority Actions by 4 Levels
of Resources: Very Low , Low, Medium, High

• EVALUATE THE OUTCOMES

 WHO promotes the stepwise
implementation of interventions
according to the level of resources
Example: Mammography & Pap High Level
smear breast & cervical of
cancer screening resources
Middle
Low Technology breast & cervical
level of
cancer screening Treatment of all
curable tumours resources

Awareness of early signs & symptoms of Low level of

cervical & breast cancers plus adequate resources
diagnosis and treatment
Most of the Worlds Population Very Low level
Palliative care and prevention of the most of resources
prevalent cancer risk factors (e.g. tobacco)
 REALITIES in CANCER CONTROL
PLANNING
MAJOR FORCES
• Political and Public Support
• Health Care provider Support
• Cultural Facilitators & Barriers

LOGIC VERSUS HUMAN NATURE

• Disease Advocacy Groups: breast, prostate
• Professional-Business Alliances: screening, new
pharmaceuticals, new technologies
• Barriers around sexuality: Cervical Cancer is a STD
• Personal costs and cost effectiveness

• DATA LIMITS PLANNING

• RESOURCES LIMIT ACTIONS
• Governments like BEST BUYS, BUT WHAT IS BEST?
 THANK YOU

Cape Schank-Victoria Australia