Transcript No Slide Title

Presentation 100114
Cancer in the
Eastern Mediterranean Region
Common Challenges and Potentials
Mahmoud M. Sarhan, MD, MMM, CPE
King Hussein Cancer Center
Kuwait City, October 25, 2010
October Breast Cancer Program
King Hussein Cancer Center
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Presentation 091026
It is good to know that cancer is not a new disease but the
increased life expectancy and improved diagnosis has made it
more evident…
Increased
Exposure to
Carcinogens
Carcinogenic
Probably
Carcinogenic
Biological gents
Hepatitis B and C, HPV,
Helicobacter pylori, HIV,
Schistosoma
Life style
Tobacco, areca nut, alcoholic
beverages, household
combustion of coal
Radiation
Radon, solar radiation, X-and
gamma radiation
Complex
mixtures
Aflatoxins, coal-tar
Emissions from high
temperature frying
Pharmac
eutical
DES, Estrogen, progesterone,
tamoxifen, phenacetin
Androgenic steroids,
Chloramphenicol
Particles
and
fibers
Asbestos, Crystalline silica,
wood dust
Diesel engine exhaust
Metals
Arsenic, cadmium, chromium
Inorganic lead, Cobalt,
tungsten carbide
Occupati
on
Painting, chimney sweeping,
coal mining, coke production,
Petroleum refining,
hairdressing
Chemical
s
benzene, formaldehyde, vinyl
chloride
Trichloroethylene
Circadian disruption,
household combustion
of biomass fuel
(primarily wood)
+
Not a Modern Disease
+
Improved Life Expectancy
+
Better Clinical Diagnosis
Andorra
Iceland
Hong Kong
Japan
Switzerland
Australia
Sweden
Israel
Macau
Canada
New Zealand
Singapore
Norway
Spain
Cayman Islands
Italy
Netherlands
Malta
80.6
80.2
79.4
79.0
79.0
78.9
78.7
78.6
78.5
78.3
78.2
78.0
77.8
77.7
77.5
77.5
77.5
77.3
King Hussein Cancer Center
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Presentation 091026
…nevertheless, in the next 10 years, cancer worldwide will be the #1
disease claiming lives and requiring the most investment for
prevention, detection, treatment and palliative care
Projected global deaths for
selected causes (Future Health)
Cancer over time
Cancer
Ischemic
Heart
Disease
HIV/AIDS
Tuberculosis
Malaria
Million people
Stroke
Other
Infectious
Diseases
Road
Traffic
Accidents
WHO statistical highlights, 2007
King Hussein Cancer Center
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Presentation 091026
Cancer will impact the developing / low-middle income countries the
most…
Deaths in Low Income Countries
World Cancer Deaths over Time
5.3
Total Cancer Deaths in Millions
+64%
9.28
+19%
8.06
Deaths in Low Income Countries (in million)
11.94
5.0
5.0
year
Year
King Hussein Cancer Center
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Presentation 091026
>5 million from Asia
Eastern
Western
South Central
Southeastern
King Hussein Cancer Center
Source: Globocan 2000 IARC 4
Presentation 100114
It is expected that largest increase in cancer deaths within the next 15
years is likely to be in the Eastern Mediterranean region
Predicted increase in deaths from cancer over the next 15 years (WHO)4
150
100
Projection modelling predicts an increase of between 100% and 180% in
Eastern
Mediterranean
Region
India
Other parts of Asia
& Islands
Sub-saharan Africa
China
Latin America &
Caribbean
Former socialist
economy
0
Established Market
economy
50
World
Increase in death from Cancer (%)
200
projection modelling predicts
an increase of between 100%
and[Rastogiet
180% [Rastogi
al.
EMR
al.et2004]..
2004]..
Rawaf, S. et al. BMJ 2006;333:860-861
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Presentation 100114
The Eastern Mediterranean region extends from Morocco to
Pakistan and has varied income levels, health indicators and
geographies
World
Bank
Income
group
Country
Population
(in
thousands)
Expenditure
on health
per capita
in US $
Qatar
656
High
U.A.E
(Total Pop
8,219,000)
upper
Middle
(Total Pop
35,472,000)
Country
Population
(in
thousands)
Expenditure
on health
per capita
in US $
862
Jordan
5,617
177
4,210
661
Palestine
3,827
138
Kuwait
2,645
579
Tunisia
9,911
137
Bahrain
708
555
lower
middle
Iran
66,775
131
(Total Pop
231,482,000)
Morocco
30,509
72
Syria
18,200
59
Egypt
69,323
55
Djibouti
817
47
Iraq
26,503
23
Yemen
21,003
32
Low
Sudan
34,512
21
(Total Pop
238,627,000)
Pakistan
151,816
13
Afghanistan
22,998
11
Somalia
8,298
6
Lebanon
4,370
573
Saudi
Arabia
22,608
366
Oman
2,651
278
Libya
5,843
171
GINI index in many
countries varies between 28
and 42 indicating inequality
within each country
World
Bank
Income
group
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Presentation 100114
Cancer in the EMRO region is the 4th leading cause of deaths
occurring at a younger age than industrialized countries
Remarks
→ 50% of the cancers in the
Region occur before age 55
(10 – 20 years younger than
in industrialized countries).
→ The mortality/incidence
ratio is 70% indicating
significantly lower survival
rates from diagnosed cancer
(40% in America, 55% in
Europe)
.
projection modelling predicts
an increase of between 100%
and 180% [Rastogi et al.
2004]..
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Presentation 100114
Breast Cancer is the most common cancer in most of the Eastern
Mediterranean countries preceded sometimes by lung cancer
Country
Rank of
Disease
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The 3 leading causes of cancer worldwide are dominantly seen in the
region
Tobacco
Infections
 Prevalence of tobacco consumption is increasing
rapidly and is already above 30% in men in 12
countries of the Region
Top Countries Ranking (Males)
Prevalence of tobacco smoking a (%) > 40%
Country
Males > 15 years
Females > 15
Yemen
77.0
29.0
Tunisia
61.9
7.7
Djibouti
57.5
4.7
Jordan
48.0
5.7
Syria
48.0
8.9
Lebanon
46.0
35.0
Kuwait
42.0
4.4
Unhealthy
Lifestyles
Cancers due to infections represent 11% of
the cancer burden in North Africa and 16% of
the cancer burden in west Asia.
 70% of the infection‐related cancers in the
Region are attributable to four infectious
agents: human papilloma virus (HPV) (27%),
Helicobacter pylori (23%), and hepatitis B
and C virus (20%).
 In the Eastern Mediterranean Region obesity is a rapidly growing problem;
already more than 50% of the population is overweight in 12 countries.
King Hussein Cancer Center
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Presentation 100114
Jordan and Kuwait are among the smaller populations in the Eastern
Mediterranean region with impressive indicators related to health and
a growing population that will challenge the current stable situation
Population
Geography
Health
Indicators
Socioecono
mic
Indicators
 Population:
=6,198,677
 Age Structure: 15-64 = 63.7%
 Above 65: 4.5%
 Smokers (m) =48%
 Population (million) = 2.8
 Age Structure: 15-64 = 70.7%
 Age above 65= 3%
 Smokers (m): 40%
Distances: 570 km north to south
 Area 17,818 square kilometer
Urbanization= 78%
 Urbanization= 98%
 Life expectancy @ birth years =71/74
Life expectancy @ birth years=77/79
 Total fertility rate children
born/women = 2.47
Total fertility 2.5
Unemployment rate:
Unemployment rate:
GDP: 4000 USD
13.5%
2.2%
GDP: 48,310 USD
King Hussein Cancer Center
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Presentation 100114
Kuwait is among the smaller populations in the Eastern Mediterranean
region with impressive indicators related to health and a growing
population that will challenge the current situation
Population
 Population (million) = 2.8
 Age Structure: 15-64 = 70.7%
 Age above 65= 3%
 Smokers (m): 40%
 Area 17,818 square kilometer
Geography
 Urbanization= 98%
Health
Indicators
Life expectancy @ birth in
years =77/79
Total fertility 2.5
Socioecono
mic
Indicators
Unemployment rate:
2.2%
GDP: 48,310 USD
King Hussein Cancer Center
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Presentation 100114
Trend of Cancer
1980-2007
4606
4198
4332
Cancer Cases
3302
3380
3591
3430
3362
3354
3478
3142
Population based
2008
2007
2005
2003
Years
2001
1999
1995
1989
1983
Start of Registry
1997
285
Crude Number of Cases
Primary Site
769
550 1126
450
Ten Most Common Cancers Among Males
Jordan 1996-2007
N=14,445/21,332
3678
3412
Hospital based
1396
0
Crude Number of Cases
In Jordan, the National Cancer Registry in 1996 was a major
undertaking to identify the most common cancers (breast & lung) as
well as register cases
Ten Most Common Cancers Among Females
Jordan 1996-2007
N=14,360/21,000
Primary Site
King Hussein Cancer Center
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Presentation 100114
Despite the growing numbers of cancer cases, it is important to note
that Jordan or Kuwait are not worse than other countries in terms of
Cancer incidence…
Age Standardized rate compared with different countries
JNCR 2007
King Hussein Cancer Center
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Presentation 100114
New cancer cases in Jordan are expected to double by 2020 as the
population grows, ages, and lifestyles remain unchanged
Projected Number of Cancer Cases
(by Year) in Jordan
Number of Cases
Population in Million
Population Growth over Time
Year
Year
King Hussein Cancer Center
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Presentation 100114
…and as the Jordanian population ages.
Population Growth (in thousands) by gender and age
Jordan 2005-2050
ASIR by Age Group
per 100,000 Population
Above 50
500
461.4
2005
450
Above 50
Population per 100,000
400
350
300
250
200
2050
150
114.5
100
50
16.9
2.7
5.5
0-14 yrs
15-24 yrs
0
25-44 yrs
45-64 yrs
65 and above
Age Groups
King Hussein Cancer Center
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Presentation 100114
Cancer in Jordan is characterized by late stages diagnosis (similar to
the EMR), highest mortality due to lung cancer and 50% of mortality
under age 64
Frequency
%
0- Insitu
53
1.3
1- Localized
1286
32.7
2- Regional Direct Extension
311
7.9
3- Regional – Lymph Node
326
8.3
4- Regional – (Direct + Lymph
node) Extension
265
6.7
5- Regional - NOS
270
6.9
6- Distant Metastasis
1425
36.2
TOTAL
3936
100.0
900
800
700
600
500
400
300
200
100
0
836
644
263
8
12
37
66
<1
4-Jan
14-May
15-21
25-44
45-64
65 +
Age in years
Cancer Mortality
JNCR 2007
N= 13,298 cases
15
Percent of Deaths
Stage
Cancer Mortality in Jordan by Age
JNCR 2007
Number of deaths
Distribution of Cancer Cases by Stages
Based on SEER Staging
JNCR 2007
10
5
0
Lung
Leukemia
Breast
Colorectal
NHL
Primary Site
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Presentation 100114
At the onset of JBCP, breast cancer used to be detected at late
stages when the survival rate and treatment success are not
promising
Direct Correlation of Survival to Stage
of Detection
Percent of Survival
Stages of Breast Cancer in Jordan
based on KHCC Experience before
JBCP
Stage of disease at Detection
N=550
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ASR of Breast Cancer ( Females)
Data for GCC countries 1998-2005, Oman-2007 ,Egypt 2000-2002 , USA-SEER (white population) 1999-2001
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Median Age at diagnosis of Female Breast cancer in the Arab world
53
49
48
51
47
51
50
45
49
Median Age at diagnosis in Developed Countries
48
46
65 years
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Breast cancer: proportions by age group in Jordan ,
Lebanon , KSA and Kuwait
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Presentation 100114
The region as been trying to address individually and collectively the
burden of cancer but with limited or country specific success
King Hussein Cancer Center
* WHO-EM/NCD/060/E, Towards a strategy for cancer control in Eastern Mediterranean Region, 2009
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Presentation 100114
A regional alliance under the guidance of WHO has been working
since 2007 and has in 2009 set the crucial need for national cancer
control plans as the first step for each country
Establishment
WHO Regional Office, in association with the
Princess Lalla Salma Association against Cancer,
nongovernmental organizations and other relevant
international organizations in the Region, agreed to
establish an alliance against cancer to join forces in
order to generate an appropriate and concerted
effort to prevent and control cancer.
Goals
Conduct publicity and disseminate information
regarding the establishment of the alliance
Create an advocacy plan
Conduct education and increase public awareness
Create a database for cancer in the Region
Establish a network of experts, researchers and
organizations
Promote the development of highly-qualified welltrained human resources in the field of cancer
Mobilize the financial resources needed for the
alliance to perform its functions
Support research in the field of cancer
Conducting monitoring and evaluation
Members
Membres
•Association Lalla Salma de Lutte contre le Cancer
(Maroc)
•The National Higher Committe for Breast Cancer
Control (EAU)
•King Hussein Cancer Center (Jordanie)
•Lebanese Cancer Society (Liban)
•Gulf Federation for Cancer Control (pays du Golfe)
•Egyptian Oncology Forum (Egypte)
•Fakous Cancer Center (Egypte)
•Egyptian Foundation for Cancer Research (Egypte)
•Breast Cancer Foundation (Egypte)
•The National Association for Cancer Awareness
(Oman)
•Zahra Association for Breast Cancer (Arabie
Saoudite)
•Saudi Association for the Fight against Cancer
(Arabie Saoudite)
•Association Tunisienne de lutte contre le cancer
(Tunisie)
•Association des Amis de l’Institut National
d’Oncologie (AMINO) (Maroc)
•Association l’Avenir (Maroc)
•Association Coeur de Femmes (Maroc)
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Presentation 100114
Jordan is a model of success that can be presented as a learning
experience and center of excellence
Stages of Cancer Control Development in Jordan
6
5
4
3
2
1
Equity
&
Research
Prevention
Quality &
comprehensive
ness
Local and
International
Expansion
Focus
International Competition
Data
Business as
Usual
Up to
1996
1996
1997
2003
2006
2010
2020
Treatment
1 Treatment through MOH, RMS, PVS
5
Prevention and palliative care initiatives
2 JNCR established
6
Increase in clinical capacity is needed for equity in
patient care, while infrastructural growth is
needed to initiate grade clinical and translational
research
3 Amal Hospital for Cancer Care Established
4 Transforming Al-Amal Hospital to the King
Hussein Cancer Center-1st class cancer care
King Hussein Cancer Center
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Early Detection
& prevention
Presentation 100114
Jordan is implementing two models for the early detection
and prevention of cancer – a bottom up vs. a top down one
Quality and Guidelines
5
Bottom Up
4
3
2
1
Advocacy and
Awareness
Stable
Funding
Capacity
Building
Development of
Services
Legislation –
free early
detection
Breast Cancer
Early Detection
and Screening
National
Target
Top Down
Implementation Plan
1
2
Legislation
Implementation
Alternatives
3
4
Grace Period
5
Smoking Control
Enforcement
Smoke-free
Fines, Taxes, Penalty
King Hussein Cancer Center
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Presentation 100114
Jordan’s health system is dominated by the public sector that
regulates it and provides services as well, followed by the military and
private sector providers
Provider
Basic Role
Ministry
of
Health
(60%)
Law, regulations,
budget, health
expenditure,
insurance
Royal Medical
Service (25%)
+
Description
Cancer Control
 Reactive vs. Proactive
 Limited resources
 Focused on service delivery
 Public health influenced by Int’l
arena
Closed Military
 Independent budget
System with
 Serves 25% of populations
Insurance Scheme  Quality Services
No full plan (under consideration)
Divided activities
Strong registry
Covers all Jordanians
Mediocre quality Rx services
Prevention without outreach
(clinic based)
Rx (not comprehensive)
Private Sector
(XX%)
Regulated by MoH
from Quality
perspective not
pricing
 Business driven
 Varied quality (perceived by
population as a higher quality
sector than government)
Rx focused
Not driven by unified protocols
Very expensive
Varied quality
Universities
(6%)
Free of charge for
enrollees or less
privileged
 Limited budgets
 Acceptable quality
 Innovation limited
No oncology departments
Rx available not comprehensive
Varied quality (KAH vs. JU)
Non-for-Profit
Sector
Free of charge for
enrollees or less
privileged
 Limited budget
 High expertise and focused
expertise
 Dependent on Fundraising
 Only player to date KHCC
 Comprehensive 1st class center
(2 accreditations)
 Outreach, control, diagnosis, Rx
and Palliative care
King Hussein Cancer Center
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Presentation 100114
Despite the varied quality of treatment, Jordan has been
achieving good results comparable to the developed nations
1.0
All Cancers Mortality/Incidence ratios
for selected countries
2002
1.00
0.9
0.8
Mortality/Incidence
0.7
0.6
0.5
Diagnosis &
Treatment
Jordan cancer
Mortality/Incidence ratio
2006
0.90
Male
Female
0.80
0.70
0.60
0.53
0.50
0.44
0.40
0.36
0.4
0.30
0.3
0.20
0.2
0.1
0.0
0.10
0.00
Male
Female
All
King Hussein Cancer Center
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Diagnosis &
Treatment
Presentation 100114
Case in point 1: KHCC’s Department of Pediatrics quality of care
has resulted in survival rates equivalent to those in the USA and
Europe
Survival Distribution Function
Kaplan Meier Survival Function
LEGEND
Survival Function
Product Limit Estimate Curve
Event Free
Survival Function
Censored Observations
Incidence Free Survival
 ALL Pediatric - KHCC 2003 – 2007, (N=200)
 # of events =19
 3 years event free survival =86%
Overall Survival
 ALL Pediatric - KHCC 2003 – 2007, (N=200)
 # Of deaths = 10
 3 Years survival = 94%
Survival Time Month
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Diagnosis &
Treatment
Presentation 100114
Case in point 2: KHCC’s Stem Cell Transplantation Program
has resulted in survival rates equivalent to those in the USA and
Europe
Survival Probability
Product-Limit Survival Function Estimate
Survival Time Month
King Hussein Cancer Center
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Palliative Care
Presentation 100114
As for palliative care, Jordan has established a national committee to
improve provision of services as recommended internationally
Goal
 To help alleviate the physical and psychosocial suffering
associated with progressive, incurable illnesses throughout
Jordan and the region
 To increase the availability and access to high-quality hospice
and palliative care for patients and families throughout Jordan
OBJECTIVE
 Integrate palliative care and hospice
principles into the National Health
Strategy by shaping governmental
policies
 Assure availability and easy access to
opioid analgesics and adjuvant
medications throughout the Kingdom
 Establish integrated continuums of
palliative care programs, reaching
patients in hospital and community
settings
 Promote Jordan as a model and
reference for palliative care practice
and education in the region
Lead King Hussein Cancer Center
Support Ministry of Health
Top-Down
Activities
Advocacy – change in opiod prescription regulation
Ten-day policy
Authority with MOH Minister rather than by law
Bottom-up
Activities
 Education – integrate into universities (nursing and
medical schools) as a part of the curriculum
 Training - Establishment of training programs –
KHCC (doctors, nurses, policy makers..etc)
 Pharmaceuticals – to develop immediate release
morphine tablets
Emerging
Approach
“Decent
Care”
Globalization is putting the social cohesion of many countries under
stress, and health systems, as key constituents of the architecture
of contemporary societies, are clearly not performing as well as
they could and as they should … People are increasingly impatient
with the inability of health services to deliver levels of national
coverage that meet stated demands and changing needs, and with
their failure to provide services in way that correspond to their
expectations. Few would disagree that health systems need to
respond better – faster – to the challenges of a changing world.
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Presentation 100114
With the current and growing cancer burden the region remains
extensively challenged
Lack of government national support
Social Limitations
 Cultural Barriers
 Other primary care issues take priority over cancer
care
 Funding limitations to prevention, screening and
purchase of quality care (including costly drugs)
 Stigma & myths pertaining to cancer including
religious misunderstandings
 Social taboos that extend beyond the female
herself leading to fears of being ostracized by
husband, family, or society
 Socioeconomic barriers
 Low level of education (ignorance)
Monetary Limitations
 Lack of Specific Funds Targeted towards Cancer
 Preference to invest in family/children needs
rather than self health
 Awareness barriers
 High Cost of Drugs and overall treatment

Cancer as a taboo subject
 (GDP per capita for most countries in the region is
below $ 6000)

No health promotion to break myths of hereditary
and contagious disease
 (Average cost of treatment is approximately $25,000
without complications)

Do not seek information and action to understand
ailment or prevention
 Major International Funds have not been allocated
towards Cancer Control in the region
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Presentation 100114
Service limitations
Healthcare
Workers (Per
1,000population
People)
Health
Care Workers
per 1000
Service Limitations
World
Americas
 Multidisciplinary approach to treatment is
not systematically implemented in some
treatment centres
Europe
Western Pacific
 An increasing number of cancers are being
treated with combined modality therapy. A
major issue in this regard is the cost and
availability of cytotoxic drugs.
Southeast Asia
Eastern Mediterranean
 There are relatively few trained radiation,
medical or pediatric oncologists in many
countries of the Region, and very few
oncology nurses and social workers.
Africa
Remarks
0
5
10
15
20
25
30
 WHO cites a severe shortage of healthcare professionals
in developing countries
– Americas: 25 healthcare workers per 1,000 people
– Asia: 5 or fewer per 1,000
 The roles of nursing staff and paramedical
could be expanded to reduce the load on
specialists
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Presentation 100114
Palliative care for many countries is barely existent
2.5
EMRO mean , 0.612mg
Global mean= 5.9823mg
2
Morphine Consumption
(mg/capita)
1.5
1
0.5
0
Sources: International Narcotics Control Board; United Nations population data
By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2009
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Presentation 100114
In Jordan as well, despite the strides to cancer care, some challenges
remain to contest the ability to focus on quality and equity
Human Resources
Accessibility to Care
 Lack of health specialized primary care and support
care providers: Especially in support services and early
 Increased prices of drugs: Due to the increased
detection, health professionals in Jordan do not receive
consistent and focused training for cancer related issues nor
have specific academic lines that they can pursue for that
purpose
 Brain drain : Skilled and educated health providers are
solicited by neighboring countries especially those who can
offer more competitive packages – this will increase
prices of drugs that make a difference in cancer treatment,
many patients are deprived of life saving interventions and
the burden on the government is increasing
 No primary care focus on Cancer: The focus on
maternal & child health, infectious diseases, and
cardiovascular diseases remains the core work of the
primary health care centers leading to decreased ability to
identify cancer early among other drawbacks
 No enforcement of Palliative Care: Despite the
national consensus on palliative care criteria, there is no
enforcement of the agreed approach
Quality of Services
Public Awareness
 Lack of treatment protocols: No unified protocols are
 Misinformed public: Due to technological advances in
applied in diagnosis and treatment of cancer but purely
based on provider’s academic and on-the-job training
 Lack of standard operating procedures: The
comprehensive approach to cancer care is not
applied in all health care venues except at KHCC
 Limited Advanced Experience: The approach and
communication public put pressure on health sector to go for
drugs and procedural interventions that are trial based which
undermines the sector’s ability to perform and to be trusted
 Lack of awareness of risk factors: Except for breast
cancer, there is no / minimal work or focused work on the
importance of healthy lifestyles
accessibility to tap into advanced resources is non existent
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Presentation 100114
In Jordan, Cancer control is on the right track …
Remarks
 Only population-based data
can identify the overall national
problem (although institutional
data useful)
 Only planning at a population
level can ensure improved
access for all
 Only population-based data
can identify resources required
to control cancer at a national
level
 Only nation-wide collaboration
can assess and make maximal
use of all available national
resources
 Only population-based data
can give a clear idea of the
overall effect of interventions
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Presentation 100114
Efforts need to become more streamlined and unified to ensure
continued success across all sectors
 PRIMARY CARE
PROVIDERS
– Public education,
early detection
 GOVERMENT
– Legislation
relevant to control
of risk factors and
opioid availability
– Collaboration in
care, follow-up and
palliation
– Structuring health
services
 NGOs:
– Supporting
establishment of
expert committees
– Orchestrating
goals
– Education &
outreach
– advocacy:
 NON-ONCOLOGY
SPECIALISTS
– Early detection
– Treatment of early
stage disease
 ONCOLOGY
SPECIALISTS:
– Rapid referral to
oncologists
– Expert diagnosis
and treatment
– Research: clinical
and translational
 INDUSTRY:
– Access to new
innovative products
and services
– Advising
government
– Research
– Sponsorship
– Monitoring
outputs, outcomes
and impact
 ACADEMIC ESTABLISHMENTS
– Education of health care professionals with basic knowledge of cancer
– Leadership in care, epidemiological, public health, clinical and
translational research
Food for thought: Need for Higher council for Cancer Control ???
King Hussein Cancer Center
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Presentation 100114
Thank You
King Hussein Cancer Center
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