Cancer Control: Past, Present and Future

1. Ian Magrath, INCTR Cancer Control: Past, Present and Future

2. Contents • The Demographic Transition • Global Cancer Situation • Main causes of cancer • The developing crisis • Cardinal Elements of Cancer Control • Engaging a broad range of stakeholders • Increasing efficiency • Economic Considerations

3. Cancer Cause and Society • Cancer results from a combination of genetic and environmental factors • Both vary in different world regions and in different eras • Since the beginning of the industrial revolution the world’s countries have been passing (at different rates) through major social and demographic changes that have greatly influenced the pattern of disease and the size and average age of the population

4. Population Growth Between 1800 and 2000 the world’s population increased 5 fold as living conditions improved and people lived longer 1802; 1 billion 1999; 6 billion 2020; 7.5 billion

5. Demographic Transition • Stage 1: High birth and death rates: pre-industrial • Stage 2: Declining death rate: improved food and water supply, better public health, hygiene • Stage 3: Decline in birth rate (urbanization, etc.) • Stage 4: Low birth and death rates • Stage 5: Contraction (e.g., Europe) 65 15

6. Societal Changes and Disease • Developing countries are in stages 2 and 3, and still have relatively high birth rates such that the world population continues to increase, while people live longer, such than NCDs (cancer) are becoming an increasing problem • Cancer has become more important as a result of tobacco consumption, a more sedentary work and lifestyle (mechanical transportation, office jobs) along with new exposures - tobacco and a variety of chemicals – agricultural, solvents etc., • The increased frequency of NCDs is added to existing communicable diseases increasing the total burden of disease, while resources remain limited • Insufficient resources re: NCDs/cancer lead to late presentation, extensive disease, which is expensive to treat, and a high mortality rate

7. Disease Burden and Resources

8. Incidence and Mortality Rates (ASR) RICHER POORER

9. Most Frequent Cancers - World Males and Females Globocan 2008

10. Most Frequent Cancers - World • Males Females NB. Ratio between incidence and survival

11. Cancer and Development - More Males Females NB. Ratio between incidence and survival

12. Cancer and Development - Less Males Females NB. Ratio between incidence and survival

13. Main Causes of Cancer • Smoking • Overeating • Lack of Exercise • Alcohol • Changes in reproductive behaviour (breast) • But diet largely responsible for post-menopausal • Infectious agents, especially HPV, HBV, These are all controllable either by changes in behavior or vaccination.

14. Fat and Cancer • Large US Study of 90,000 people begun in 1982 • Excess weight accounts for up to 14% of all cancer in men and 20% in women • BMI (height and weight); 18.5-24.9 normal, 25-29.9 overweight; 30 or above obese • Adjustments for smoking and other risk factors • Associations: Breast, uterus, colon, rectum, kidney, esophagus and gall bladder (known) as well as cervix, ovary, multiple myeloma, NHL, pancreas, liver, stomach and prostate (not previously know) Calle, NEJ, June 2010

15. Smoking and Cancer • High risk – 50% who smoke die prematurely • Those who die in middle age lose 20-30 years of life • Smoking stops work (and therefore income for the individual, and tax for the government) • Stopping smoking reduces the risk of cancer – the earlier the better • Preventing smoking is worthwhile but the effect takes many years

16. 1,000 cigarette consumption 1 + Lung cancer deaths per million per year 500 lung cancer 5 lung cancer 0 0 USA: 1900 1920 1940 1960 1980 2000 Delay between cause and effect:cigarettes, then lung cancer deaths USA + 10 Cigarettes per adult per day Cigarettes per adult per day 5 0 1900 1920 1940 1960 1980 2000

17. Smoking All causes 44% 6 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 40% 8 39% 9 41% 12 41% 13 46% 16 46% 19 47% 20 45% 19 41% 16 *risks at period-specificdeath rates for ages 35-69 Poland, 1955-2000 Male death in middle age: changing hazards* www.deathsfromsmoking.net Richard Peto, Judith Watt, Jillian Boreham

18. Smoking 15 18 19 20 20 17 16 14 11 8 6 United Kingdom, 1950-2000 Male death in middle age: changing hazards* 100 All causes UK Males 1950 1955 1960 1965 1970 1975 1980 1985 1990 1985 2000 44% 43% 42% 43% 42% 39% 37% 35% 31% 28% 25% *risks at period-specificdeath rates for ages 35-69 www.deathsfromsmoking.net Richard Peto, Judith Watt, Jillian Boreham

19. 15 10 5 0 45 55 65 75 Age Stopping smoking: avoiding lung cancer Continued smoking: 16% dead from lung cancer Cumulative risk at UK male 1990 ratesBMJ 200Cumulative risk at UK male 1990 ratesBMJ 2000; 321: 323-90; 321: 323-9 15 % Dead from Lung Cancer 10 Stopped age 50: 6% 5 Stopped age 30: 2% 0 Never smoked: <1%

20. Years of Life Lost (%) (WHO 2004) NCDs affect older people, so less impact WHO Statistics, 2010

21. Age-standardized Mortality Rates (WHO 2004) 70% of cancer deaths in LMI Population in millions, diseases in thousands WHO Statistics, 2010

22. Recent Data • Cancer caused some 13% if all deaths – more than ischaemic heart disease in 2010. • In 2008 there were nearly 12.7 cases and 7.6 million deaths worldwide • 70% of the deaths occurred in developing countries • 85% of childhood cancer is in developing countries, but probably only 10-20% cured, although 70-80% curable • 80% of cervical cancer in developing countries (though much less common in Muslim countries

23. Projected Numbers of New Cases New cancer cases per year (millions) Cases Projection 10 Developing countries 8 6 Industrialized countries 4 2 0 Year 1990 1995 2000 2005 2010 2015 2020 Annals of Oncology: Kanavos: Volume 17; Supplement 8; June 2006

24. % Increase in Cancer in Various Regions between 2005 and 2020 Annals of Oncology Kanavos: Volume 17; Supplement 8; June 2006

25. Controlling Cancer

26. Approaches to Cancer Control • Past: None. • Probably little change in incidence and mortality of cancer since a high fraction of cancers related to infections that could not be controlled. Limited effective treatment • Spontaneous increases occurred due to new exposures (e.g., related to industrial revolution); soot and skin cancer, radium, chemicals, including agricultural, dyes, etc. • Present: Mixed • Many countries have little or no cancer control but pattern changing since more infections are controlled, e.g., schistosomiasis, hepatoma, AIDS, but many countries, as they develop economically are taking on increasingly western lifestyles, and adopting their patterns of cancer

27. Death from Tuberculosis 25% 80% Spontaneous change due to societal evolution: Unanticipated, but once observed creates possibility of prevention – even without knowledge of cause

28. Need for Data and Research • Essential to know what the problem is before it can be actively solved • Cancer registries will identify cancer pattern, but can also track stage and survival and also trends in incidence and mortality • Data must be collected on performance in various sectors of the health system • May need to develop new professions (e.g., cancer public health/health education), task shifting (Drs, nurses) and more collaboration

29. Cancer Control is a Global Problem • Sophisticated data (e.g., genomic profiles) etc. important since it leads to genetic diagnosis and genetic treatment – but costly – therefore most done in high income countries • Expensive technology needs to be simplified and made more accessible for diagnosis, markers, imaging • Civil society needs to create political will to address the issues, e.g., by demonstrating the increasing cancer burden and the economic cost of inaction and engaging with people and communities • Publishing results of what can be achieved, even with limited resources can create incentive for others • International organizations can act as global data bases and think tanks to provide basic, modifiable approaches • More countries in the world should perform research of all kinds so that the needed information is available

30. Possibility of Active Cancer Control • When cause is known, prevention is possible • Stop smoking, eat less, avoid alcohol, exercise more • Children need to grow up with a healthier lifestyle • Changes in present behaviour(e.g., smoking, farming practices) will make a difference (halving smoking, will prevent 25-30 million deaths by 2025) • Vaccination/treatment to reduce chronic infection • Avoidance of known carcinogens (chemicals, sun) • Reversal of behavior patterns (smoking) will take decades; low income countries have the possibility of avoiding mistakes made by the rich

31. Challenges in Cancer Control • Countries with limited resources must select most cost effective interventions (cancer plan is made, with available budget). • Palliative care • Reducing smoking • Cervical/oral cancer screening (if of high enough incidence) • Education of population and doctors about early signs of cancer and what to do • Education and training of cancer professionals (collaboration with other countries often needed) • Develop centers of excellence/reference centers • Creation of professional organizations and cancer societies to help disseminate information

32. Necessary Networking GOVERNMENT: Legislation relevant to control of risk factors and opioid availability Structuring health services Supporting establishment of expert committees PRIMARY CARE PROVIDERS: Public education, early detection Collaboration in care, follow-up and palliation NON-ONCOLOGY SPECIALISTS: Early detection Treatment of early stage disease Rapid referral to oncologists ONCOLOGY SPECIALISTS: Expert diagnosis and treatment Research: clinical and translational Advising government NGOs: INDUSTRY: ACADEMIC ESTABLISHMENTS: Education of health care professionals with basic knowledge of cancer Leadership in epidemiological, public health, clinical and translational research

33. Cancer Control: a Global Effort • Many countries do not have enough well trained health professionals – appropriate persons from more developed countries can help with training, education, hospital organization and health service structure • Vaccines, radiotherapy machines and essential drugs can be made available • Cheap, miniaturized technology will help greatly • Within the country there must be collaboration and concerted effort

34. Challenges in Cancer Control • Unless there are adequate facilities for treatment, early detection is pointless • Even existing cancer centers/hospitals are often poorly run, with limited communication among staff (no tumor boards, death conferences, continuing education systems, incentives for good work) • Insurance systems of some kind must be introduced (initially “catastrophic”) to give access to the poor • Economize as much as possible (“polyvalent screening, find ways of introducing healthy lifestyles, cooperation among government departments and the media (finance, health, sport, food, alcohol, drugs, media (embedded messages ) • Create legislation to ensure health care available for all

35. The Global Economic Cost of Cancer • The total global economic impact from premature death and disability from cancer for 2008 was $895 billion (15% of the worlds GDP and 20% more than heart disease) = 83 million years of healthy life lost • Cancers of the lung, bronchus and trachea account for nearly $188, colorectal $99 and breast $88 billion dollars in economic loss. • Among low income countries, cervical cancer accounts for 10% of the economic lost, second only to mouth and throat cancers • The loss from cancer is the largest drain on the global economy and exceeds that of infectious diseases (American Cancer Society)

36. Health Expenditure 1 21 < $50 2 25 >$2000 Data from WHO World Health Statistics 2007 193 countries, 2004, International dollars

37. Fraction of People with Insurance 1 43 countries >99% 2 59 countries <1% Data from WHO World Health Statistics 2007 193 countries, 2004

38. Future of Cancer Control • Individuals must take more responsibility for their health: • But must be provided with necessary information • Can use mobile phones for records, reminders etc. • Health services must be organized at regional or national levels to ensure efficiency and maximal use of resources; national access to patient records (web) • More cooperation at primary, secondary and tertiary levels • Advantage taken of technology • On-line training and education • Cheap diagnostic devices available at point of service (e.g., malaria, bacterial diseases, eventually cancer - serum) • Multisectorial approach on part of government

39. Photonics-based Telemedicine • Based on cell-phone technology (4 billion now throughout the world) • Most phones already have advanced digital imaging and sensing platforms that can be used for various types of health monitoring and diagnostics • e.g., UCLA has developed a lens free, on-chip cytometry and microscopy platform that utilizes compact components to enable digital recognition and 3D microscopic imaging of cells with sub-cellular resolution over a large field of view, and with vastly improved light detection properties, without the need for any lenses, bulky optical components or coherent sources such as lasers. [AydoganOzcan]

40. INCTR Mission Statement INCTR is dedicated to helping build capacity for cancer treatment and research in countries in which such capacity is presently limited ……and to increase the quantity and quality of cancer research throughout the world. Catalysis Concerted Effort Communication Sustainability

41. Offices and Branches

42. INCTR’s Network Offices and Branches Collaborating Units

43. PROGRAMS AND BRANCHES Foundational Clinical Studies Pediatric Cancer Adult Oncology (coming) Pathology Palliative Care Nursing Oncology/ Psychosocial Cancer Registration Programs Tanzania Cameroon India Brazil Nepal Branches Belgium Egypt USA France UK Canada

44. Strategies for Improving Cancer Control Strategies for Improving Cancer Control Long term research projects leading to and improved care and outcome. Creating Centers of Excellence for service provision, and training networks. Connecting with the Primary Health Care System and the public to improve knowledge, ensure early diagnosis and promote healthy living styles Evaluating evidence-based progress. Foundational program: Encouraging an evidence-based approach and emphasizing training and education.

45. Building Focal Points Training Care Research Regional coordination essential Early Detection Community Treatment Cancer Unit/Center Palliative Care Community Creation of Evidence/Clinical Studies Education and Training of Health Professionals

46. Past and Future Strategies - 1 • Challenge: • Obstacles to access to effective care (late presentation, poor pathology) • Solution: • Identify problems with colleagues in developing countries through site visits and focused workshops , surveys or actual studies • Propose, implement and evaluate solutions solution through upgrading services , training and educating staff, sometimes long term postings • Challenge: • Limited human resources • Solution: • Create large faculty of health professionals and a coordinated partnership network to provide continuing education to the cancer health work force and to expand it. • Us IT to complement classical training approaches • Address division of labor: e.g. involve non-specialists in early detection and palliative care; upgrade nurses, improve links between primary and tertiary care and ensure constant flow of information

47. Past and Future Strategies - 2 • Choose solutions based on local problems and resources, and ideally, local evidence • Create centers of excellence/competence that provide patient services, professional training and create evidence to improve outcomes • Develop national and international networks to share relevant knowledge and expand access to interventions • Create a truly global approach to cancer control by working with relevant partners and ensure maximal efficiency of effort

48. SOME INCTR PARTNERS • National Cancer Institute (USA) • National Cancer Institute (France) • World Health Organization (Official Capacity) • Programme of Action for Cancer Therapy (IAEA-PACT) • European School of Oncology (ESO) • Union for International Cancer Control (UICC) • Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries (GTF.CCC)

49. Some INCTR Projects

50. CANCER CAN BE PREVENTED AND CURED Thank You E-mail: info@inctr.be http://www.inctr.org