Transcript Education and Partnerships for Cancer Care in Developing

Cancer in Africa
Professor David Kerr
www.afrox.org ... to enable the delivery of
comprehensive cancer care to Africa
Millions of deaths in 2002
Cancer
Total TB+HIV+Mal
Malaria
HIV/AIDS
Tuberculosis
0
1
2
3
4
5
6
7
8
WHO (2003)
Worldwide annual new cases of cancer
10
16 million
in 2020
new cancer cases (millions)
9
8
developing
countries
7
6
a 50%
increase!
10 million
in 2000
5
70% will be
in the
developing
world
industrialized
countries
4
3
1990
1995
2000
2005
year
2010
2015
2020
1 million /
yr in Africa
WHO (2003)
Important Cancer Types
• Kaposi’s sarcoma
• Cervical cancer
• Hepatocellular carcinoma (HCC)
• Breast cancer
Cervical Cancer
•
•
•
•
•
•
•
•
Related to HPV
Some serotypes more important (16,18)
Serotypes vary between countries
Screening availability and uptake poor in Africa
HPV vaccines would prevent 70-80% Ca ($125)
Costs would be a problem (?large trial)
Radiation availability
Effective Palliation
Gathering the troops
A two-day meeting in London in May 2007.
– Chaired by the Rt. Hon. Alan Milburn
– Over 130 leaders in all aspects of World Health and Cancer
Control present and 23 African Health Ministers.
Download the London Declaration on Cancer Care in Africa from www.afrox.org
AfrOx aims to deliver comprehensive cancer
care to African countries where it is most
needed …
• Most Africans live in a rural areas with little access to cancer
screening, early diagnosis, treatment or palliative care (est. > 250
million people). Differential survival between blacks and whites
• Life-saving radiotherapy is available in only 21 of Africa's 53
countries, or to less than a max 20% the total population
• Over 1/3 of cancer deaths are due to preventable causes such as
viral infection, poor nutrition and widespread tobacco use
• In Africa 5% childhood cancers cured compared to 80% in developed
world
• In Africa, combination of cancer, poverty, deprivation and ID hinder
development of sustainable population and consequently a sustainable
future
The economic perspective
• Starting point: Scarce (health care) resources
• Objective: Use these to maximise health gain
• Method: Compare health interventions
– Assess their net costs
– Assess their health benefits
– Implement interventions with highest benefits in relation to
cost
• This is the cost-effectiveness approach
Resource constraints (Int. $s)
Gross National Total health
Income per
expenditure
person,
per person,
2005
2003
Tanzania
730
29
Nigeria
1,040
51
Rwanda
1,320
32
Uganda
1,500
75
Ghana
2,370
98
Botswana
10,250
375
China
UK
USA
6,600
32,690
41,950
278
2,389
5,711
Govt. health People per
expenditure
nurse,
per person,
2002
2003
16
2,703
13
588
14
2,381
23
1,639
31
1,086
238
377
101
2,047
2,548
952
83
107
Kenya: Country Profile
Location
East Africa
Total population
35, 000, 000
Gross national income per capita (PPP
international $):
1,396 US$
Total expenditure on health per capita (Intl $,
year):
8.3 US$
Total expenditure on health as % of GDP (WHO
stats):
8.1
Life expectancy at birth m/f (2000-2005):
49.9/48.7
Ministry of Health Priority List by
Expenditure- 2005/2006
ITEM
Total Annual expenditure in
Kshs’000
HIV/AIDS
13,649
Reproductive health
12,781
Child Health/MCH
12,333
Malaria control
8,085
Environmental health
STI control
5,494
TB control
2,998
2,394
EPI
2,390
Health Promotion
1,809
Rehabilitation
1,162
Dental health
858
Palliative care**
285
Mental health
136
What is good value for money?
•
•
•
•
•
•
Support for breastfeeding mothers
Community newborn care package
Measles vaccination (80% cover)
Treat smear+ tuberculosis
Cataract extraction & lens implant
Insecticide-treated bed nets (ITN)
$11 per DALY averted
$9 per DALY averted
$33 per DALY averted
$7 per DALY averted
$89 per DALY averted
$29 per DALY averted
• 2) What resources are available:
– Level of national income
– Priority given to health care
• 1) What else could be done with resources
What are the general priorities
for AfrOx?
Cancer Intelligence Units
• Partnership with IARC world leaders in the
field
• Build on hospital based registries
• Training fellowships supported by WHO
Tobacco Control
• Partnership with Gates Foundation
• Consider health economic and legal matters
Cancer Prevention
• Major development on HPV vaccine
• Current cost $125 per jab
• Will be reviewed by GAVI Summer, 2008
• Coalition of Pharma, Gates, World Bank,
WHO, AfrOx and African Health Ministries
Cancer Treatment
• Focus on curable childhood cancer
• Partner with International Society of Paeditric
Oncology
• Training fellowships
• Simplify treatment regime
Nephroblastoma in Nigeria




n = 42, 5 year survival 38%
late presentation: late referral, ignorance,
recourse to orthodox medicine after traditional
practitioners and prayer houses have failed.
Resource deficiency: 5 patients could not afford
chemotherapeutic drugs, operation was delayed
on 7 children because, they could not afford
blood and antibiotics. Poverty was largely
responsible for default from treatment.
Poor compliance to treatment regimen: 17
children could not comply. Chemotherapeutic
drugs were given only when available.
Lack of collaboration amongst clinical
community.
The cost-effectiveness plane
New treatment
more costly
New treatment more
effective but more costly
Costly & not
very effective
Maximum acceptable
cost-effectiveness ratio?
Not costly &
very effective
New treatment
more effective
Is it ethically justifiable to develop low
cost, moderately effective cancer
treatments?
• Modulated-dose oral chemo regimes for BC?
• Tamoxifen for breast lumps clinically described
as cancer?
Palliative Care
• Introduction of opiates despite cultural and
religious barriers
• Training fellowships in partnership with
Global Palliative Care fund
Afrox in Ghana
The combination of Ghana’s historic ties with Britain, its record of good governance
and the commitment of local policy-makers and clinicians to control cancer make
Ghana an excellent starting point for AfrOx to develop its work in Sub-Saharan
Africa.
Ghana has a population of 23 million which is served by only two oncology centres,
one in the capital Accra and one in Kumasi. There are only 4 oncologists in the
country and no specialist cancer nurses.
Our 5 year programme covers the spectrum of cancer control:
 Policy support for national cancer plan.
 Raising public awareness of cancer.
 Cancer prevention through screening and vaccination.
 The early diagnosis and treatment of children's cancer.
 Improvement in palliative care.
 Training and education of healthcare staff.
Our programmes in Ghana will serve as a template that could be adapted for
other African countries.
Major Achievements (1)
Public Policy Projects:
 African Cancer Reform Convention, London, 2007 (Sierra Leone, Rwanda,
Uganda, Nigeria, Burkina Faso, Cote D’Ivoire, Gambia, Egypt, Yemen, Ghana
,Tanzania, India, Cameroon, Morocco, Mozambique, Libya, Benin, Malawi, Botswana,
South Africa, Congo, Kenya, Zimbabwe, Mauritius, Zambia, Lesotho and Tunisia).
 Towards the Prevention of Cervical Cancer in Africa Conference, Oxford 2009.
Early Diagnosis and Prevention Projects:
 Cancer Awareness in Ghana: AfrOx supported the Cancer Society of Ghana (CSG)
with a capacity building grant in 2008.
Developing a Cancer Code for Africa (collaboration with ESMO and WHO).
Major Achievements (2)
Cure the Curable Projects:
 Improving Paediatric Oncology Services in Ghana: AfrOx is funding a 5-year twinning
programme between the Paediatric Cancer Unit at the Korle Bu Teaching Hospital, Accra,
Ghana and the Royal Hospital for Sick Children, Edinburgh.
Palliative Care Projects:
 Palliative Care Training: Two workshops held in January and October 2009, attended by
over 100 doctors, nurses, pharmacists and other health-workers, resulted in significant
improvement in end of life care in Ghana’s teaching hospitals.
Training and Education:
 Public lectures, Radio and TV appearances raising cancer awareness in Accra and
Kumasi; Milburn, Arbuthnott, Kerr and Roddan 2007- 2009.
 Clinician training and education workshops in Ghana, May 2009 (Sharma and Kerr):
 Workshop on Health Economics of Cancer Control, Africa Cancer Conference, 2009
(Kerr).
 E-Cancer Filming Project, Africa Cancer Conference, 2009 (Kerr).
 Practical workshop on bone marrow aspirates for children, SIOP conference, Ghana 2010
(Eden and Sharma).
AfrOx Projects
Childhood cancer Twinning project
• HPV vaccination pilot programme
• AfrOx/ AORTIC wider twinning with
NHS
• AfrOx/ESMO Cancer code and poster
campaign
•
Extend the ESMO Community
Extend ESMO’s place in the world by working to improve
cancer services in developing countries
• ESMO Developing Countries Task Force
• ESMO Cancer Prevention Working Group
• ESMO Guidelines Working Group
• ESMO Palliative Care Working Group
• ESMO National Representatives
28
The Way Forward
 The time for taking concerted action against cancer in African
and the rest of the developing world has come
 No one government, organisation or charity can tackle the
looming cancer epidemic on its own
 If the international community acts now, we have the chance
to make an extraordinary difference by preventing a major
tragedy unfolding and saving countless lives
 Only by combining our resources and skills, will we be able to
make an impact!
We hope that you will work together with us to achieve the goal of
improving cancer care in Africa.