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National Cancer Control Programmes

Planning, implementation, monitoring and


evaluation

Dr D. Maxwell Parkin
University of Oxford, UK
Priorities in cancer control

1. Prevention
2. Early detection
3. Treatment
4. Palliative care
CANCER CONTROL PROGRAMME
A public health programme designed to reduce
the incidence and mortality of cancer and
improve the quality of life of cancer patients

It works through the systematic and equitable


implementation of evidence-based strategies
for prevention, early
detection, diagnosis, treatment, and palliation
5 steps of cancer control planning

 Assess needs and capacity


 Decide approach to planning
 Develop the plan
 Implementation
 Evaluation
NEEDS ANALYSIS: where are we now?

 identifying the health problems,


 determining priorities for preventive and curative programmes

Measuring
Burden of cancer
Past trends
Future projections
INDONESIA: Cancer cases, 2002

Lung
Males 80,000
Colon and rectum
19%
Liver

Prostate
2% Non-Hodgkin lymphoma
12%
3%
Nasopharynx
4%
5% Leukaemia
11%
6% Bladder
7% 6%
Stomach
Breast
Oral cavity & pharynx
(excl NPC) Cervix uteri

Colon and rectum

25% Ovary etc.


2% Lung
3%
Corpus uteri

Females 102,000 3% Thyroid


15%
4% Non-Hodgkin lymphoma
5% 6% Leukaemia
8% 9%
Liver
Trends in Colon Cancer Incidence: ASIA
Age Standardised Rate (World), MALES

Singapore
Chinese
Hong Kong
Osaka

Manila

Bombay
…………………
….
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….
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..
PLANNING NCCPs

I DEFINING THE MAGNITUDE OF THE PROBLEM


•Burden of cancer
•Past trends
•Future projections

II REVIEW PROFILE OF RISK FACTORS


Major causes of cancer: World 2001 (GBD 2006)

Tobacco
Infection
Bar 1
Diet H. pylori
HPV
Alcohol
Hepatitis viruses
Overweight Low fruit & veg.
Bar 6
Physical inactivity
Pollution

0 10 20 30
Percent of all cancer
PLANNING NCCPs

I DEFINING THE MAGNITUDE OF THE PROBLEM


•Burden of cancer
•Past trends
•Future projections

II REVIEW PROFILE OF RISK FACTORS

III ASSESSMENT OF CAPACITY

IV SETTING PRIORITIES FOR INTERVENTION


NCCP : intervention stategies

 Prevention
 Early detection
 Diagnosis and Treatment
 Palliative care
Activities of a Cancer Control Programme

For each:
Identify the immediate target
Estimate the impact (quantify reduction in
incidence and mortality)
Estimate the resources needed
Estimate the cost of the activity
(PRIMARY) PREVENTION
Tobacco
Infection
Avoidance
Immunisation
Treatment

Diet/Obesity/Physical exercise
Reproductive factors
Occupation

..
Percentages of all cancer cases attributable to tobacco smoking
Male Female
Eastern Africa 0.0 0.0
Middle Africa 1.7 0.0
Northern Africa 14.8 0.0
Southern Africa 18.7 3.4
Western Africa 0.0 0.0
Carribean 22.4 6.3
Central America 14.8 3.4
INDONESIA: Tobacco Use in 2005 (WHO InfoBase)
Temperate S. America 25.6 3.2
Tropical S. America 17.1 4.0
daily cigarette use 53.6% males, 2.8% females
Northern America 24.5 16.5
China 7.0 4.6
daily smoking tobacco 58.4% males 3.2% females
Japan 28.0 10.6
Other East Asia 35.4 10.8
South-Eastern Asia 27.8 7.4
South-Central Asia 13.5 0.0
Western Asia 27.9 0.2
Eastern Europe 42.3 4.1
Northern Europe 25.4 11.4
Southern Europe 36.5 3.0
Western Europe 29.4 4.4
Australia/New Zealand 17.9 8.6
Melanesia 0.7 0.0
Micronesia/Polynesia 29.7 11.1

WORLD 27.9 5.9


Developed countries 30.8 9.1
Developing countries 25.2 3.1
INTERVENTIONS TO REDUCE DEMAND FOR TOBACCO
• TOBACCO TAXATION
• RESTRICTIONS ON SMOKING
• BANS ON ADVERTISING AND PROMOTING
• HEALTH INFORMATION AND COUNTER-ADVERTISING
• SMOKING CESSATION TREATMENTS

INTERVENTIONS TO REDUCE SUPPLY OF TOBACCO

FRAMEWORK CONVENTION ON TOBACCO CONTROL


LIVER CANCER & Hepatitis viruses
Indonesia
HBsAg positive ~9%
Anti-HCV positive ~2%

HBV
(45%)
HCV
(10%)
Both
(18%)
INDONESIA: Prevalence of overweight and obesity (2005)
CANCER CONTROL

Prevention

Screening & Early Detection

Treatment

Rehabilitation / Palliation
Early detection

Screening: organised efforts to detect early disease in


asymptomatic populations by mass application of simple
tests at regular intervals.

Early clinical diagnosis: detection of early clinical


stages of disease in symptomatic subjects.
Screening programmes should be undertaken only when
 their cost effectiveness has been demonstrated,
 sufficient resources are available to adequately cover the target group
with screening tests, to investigate those with positive tests, and to
provide treatment and follow-up care,
the incidence of disease is high enough to justify the efforts and costs
of screening

India
Bangladesh

Cancer of Philippines

cervix Thailand

Less developed countries


Poland

Korea, Republic

World

Indonesia
Norway

Australia

0 5 10 15 20 25 30 35
Methods of screening for breast cancer
1. Imaging: mammography

2. Physical examination

3. Self-examination
INDONESIA – a mammography screening programme?

17 million women aged 45-64.

Screening every two years would require some 6-7 million tests every year

Of these, some 3-8% (say 300,000) would require follow up investigation for an
abnormal mammogram.

Each year, there are some 7-8000 deaths from breast cancer at ages 45-
64, and 2500 over the age of 45.

A screening programme is expected to reduce mortality by ~ 20%

The maximum saving from this huge input of resources would therefore
be 2000 deaths
ALTERNATIVE:
Early clinical diagnosis:

The detection of early clinical stages of disease in


symptomatic or high-risk subjects. requires:

Increasing awareness of the population of early


warning signs of the disease

empowering them to seek early clinical attention.

orienting health personnel towards early diagnosis of


common forms of curable cancers
MANILA, PHILIPPINES
Breast cancer by stage at diagnosis 1995

In situ 1% I 4%

Unk 13%
Stage II+:
IV 8% 94%

II 50%
III 23%
Percentage of patients presented at late stage for nasopharyngeal cancer (NPC), breast and
cervix in Department of Radiotherapy and Oncology (DRO), Sarawak General Hospital (SGH)
(1991-1999) , following a programme of training of health personnel to improve their skills in early
detection of these cancers (1991-1996), and, at the same time, a public education programme to raise
awareness of these diseases, and their early signs and symptoms

Devi, B. et al. Ann Oncol 2007 18:1172-1176; doi:10.1093/annonc/mdm105


Priorities in cancer control

1. Prevention
2. Early detection
3. Treatment

Cancer therapy often relatively expensive


- making the best use of available resources
Two recommendations from the Institute of Medicine committee on
cancer control in low and medium income countries, 2006

Countries should consider establishing a government-supported cancer


“center of excellence” that provides resource-level appropriate services to
the public and acts as a reference point for national cancer control.

Resource-level specific guidelines for the overall management of major


cancers for which treatment can make a substantial difference in a
meaningful proportion of patients should be developed
Palliative Care
Concerned with QUALITY OF LIFE

Prevent & relieve suffering


through:

Management of pain

(and other
problems, physical, psychosocia
l and spiritual)
Surveillance is an essential component of a NCCP

Setting priorities
Setting objectives
Evaluating outcome
Comparing with resource inputs
EVALUATION OF

Effectiveness
Does the programme achieve its objective?

Efficiency
Costs in relation to outcome
Thank you