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Kuwait City, October 25, 2010 October Breast Cancer Program

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.

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Kuwait City, October 25, 2010 October Breast Cancer Program

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  1. 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

  2. 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… Carcinogenic Probably Carcinogenic Biolog-ical gents Hepatitis B and C, HPV, Helicobacter pylori, HIV, Schistosoma Life style Tobacco, areca nut, alcoholic beverages, household combustion of coal Circadian disruption, household combustion of biomass fuel (primarily wood) Radiation Radon, solar radiation, X-and gamma radiation Complex mixtures Aflatoxins, coal-tar Emissions from high temperature frying Pharmaceutical 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 Occupation Painting, chimney sweeping, coal mining, coke production, Petroleum refining, hairdressing Chemicals benzene, formaldehyde, vinyl chloride Trichloroethylene IncreasedExposure toCarcinogens + Andorra 80.6 Not a Modern Disease Iceland 80.2 Hong Kong 79.4 Japan 79.0 Switzerland 79.0 + Australia 78.9 Sweden 78.7 Israel 78.6 Improved Life Expectancy Macau 78.5 Canada 78.3 New Zealand 78.2 Singapore 78.0 + Norway 77.8 Spain 77.7 Cayman Islands 77.5 Italy 77.5 Better Clinical Diagnosis Netherlands 77.5 Malta 77.3

  3. …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 42.8% 36.3% 36.3% Projected global deaths for selected causes (Future Health) Cancer over time Cancer Ischemic Heart Disease Stroke HIV/AIDS Million people Tuberculosis OtherInfectiousDiseases Malaria RoadTrafficAccidents WHO statistical highlights, 2007

  4. Cancer will impact the developing / low-middle income countries the most… Deaths in Low Income Countries World Cancer Deaths over Time 5.3 11.94 5.0 5.0 +64% 9.28 +19% 8.06 Deaths in Low Income Countries (in million) Total Cancer Deaths in Millions year Year

  5. >5 million from Asia Eastern Western South Central Southeastern Source: Globocan 2000 IARC

  6. 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)4 200 150 100 Increase in death from Cancer (%) 50 0 World Established Market economy Former socialist economy Latin America & Caribbean Other parts of Asia & Islands China Sub-saharan Africa India Eastern Mediterranean Region projection modelling predicts an increase of between 100% and 180% [Rastogi et al. 2004].. Projection modelling predicts an increase of between 100% and 180% in EMR [Rastogiet al. 2004].. Rawaf, S. et al. BMJ 2006;333:860-861

  7. The Eastern Mediterranean region extends from Morocco to Pakistan and has varied income levels, health indicators and geographies GINI index in many countries varies between 28 and 42 indicating inequality within each country

  8. 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]..

  9. Breast Cancer is the most common cancer in most of the Eastern Mediterranean countries preceded sometimes by lung cancer Rank of Disease Country

  10. 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 • 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%). Unhealthy Lifestyles • In the Eastern Mediterranean Region obesity is a rapidly growing problem; already more than 50% of the population is overweight in 12 countries.

  11. 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 • 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% Geography Distances: 570 km north to south Urbanization= 78% • Area 17,818 square kilometer • Urbanization= 98% Health Indicators • Life expectancy @ birth years =71/74 • Total fertility rate children born/women = 2.47 • Life expectancy @ birth years=77/79 • Total fertility 2.5 Socioeconomic Indicators Unemployment rate: 13.5% GDP: 4000 USD Unemployment rate: 2.2% GDP: 48,310 USD

  12. 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 (million) = 2.8 • Age Structure: 15-64 = 70.7% • Age above 65= 3% • Smokers (m): 40% Population Geography • Area 17,818 square kilometer • Urbanization= 98% Health Indicators • Life expectancy @ birth in years =77/79 • Total fertility 2.5 Socioeconomic Indicators Unemployment rate: 2.2% GDP: 48,310 USD

  13. 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 Males Jordan 1996-2007 N=14,445/21,332 Trend of Cancer1980-2007 Crude Number of Cases Primary Site Cancer Cases Ten Most Common Cancers Among Females Jordan 1996-2007 N=14,360/21,000 Hospital based Population based Crude Number of Cases Start of Registry Years 2008 Primary Site

  14. 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

  15. New cancer cases in Jordan are expected to double by 2020 as the population grows, ages, and lifestyles remain unchanged Population Growth over Time Projected Number of Cancer Cases (by Year) in Jordan Population in Million Number of Cases Year Year

  16. …and as the Jordanian population ages. Population Growth (in thousands) by gender and ageJordan 2005-2050 ASIR by Age Group per 100,000 Population Above 50 2005 Population per 100,000 Above 50 2050 Age Groups

  17. 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 Distribution of Cancer Cases by StagesBased on SEER StagingJNCR 2007 Cancer Mortality in Jordan by AgeJNCR 2007 Number of deaths Age in years Cancer Mortality JNCR 2007N= 13,298 cases Y’Axis’Label Percent of Deaths Primary Site

  18. At the onset of JBCP, breast cancer used to be detected at late stages when the survival rate and treatment success are not promising Stages of Breast Cancer in Jordanbased on KHCC Experience before JBCP Direct Correlation of Survival to Stage of Detection Percent of Survival Stage of disease at Detection N=550

  19. ASR of Breast Cancer ( Females) Data for GCC countries 1998-2005, Oman-2007 ,Egypt 2000-2002 , USA-SEER (white population) 1999-2001

  20. Median Age at diagnosis of Female Breast cancer in the Arab world 53 49 48 51 47 51 50 45 49 48 46 Median Age at diagnosis in Developed Countries 65 years

  21. Breast cancer: proportions by age group in Jordan , Lebanon , KSA and Kuwait

  22. The region as been trying to address individually and collectively the burden of cancer but with limited or country specific success * WHO-EM/NCD/060/E, Towards a strategy for cancer control in Eastern Mediterranean Region, 2009

  23. 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. • 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) Members 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 well-trained 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

  24. Treatment through MOH, RMS, PVS JNCR established Amal Hospital for Cancer Care Established • Transforming Al-Amal Hospital to the King Hussein Cancer Center-1st class cancer care Prevention and palliative care initiatives Increase in clinical capacity is needed for equity in patient care, while infrastructural growth is needed to initiate grade clinical and translational research 1 5 3 4 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 Equity & Research 5 Prevention 4 Quality & comprehensiveness IncreasingReadiness 3 Focus Local and International Expansion 2 Data 1 International Competition Business as Usual Up to 1996 1996 1997 2003 2006 2010 2020 Treatment 2 6

  25. Early Detection& prevention 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 Legislation – free early detection 4 StableFunding 3 Capacity Building 2 Development of Services Breast Cancer Early Detection and Screening 1 Bottom Up Advocacy and Awareness NationalTarget Implementation Plan Fines, Taxes, Penalty 1 Legislation 2 Implementation Alternatives 3 Top Down Grace Period 4 Enforcement 5 Smoke-free Smoking Control

  26. 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 Description Cancer Control Ministry of Health(60%) Law, regulations, budget, health expenditure, insurance • Reactive vs. Proactive • Limited resources • Focused on service delivery • Public health influenced by Int’l arena • No full plan (under consideration) • Divided activities • Strong registry • Covers all Jordanians • Mediocre quality Rx services Royal Medical Service (25%) Closed Military System with Insurance Scheme • Independent budget • Serves 25% of populations • Quality 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

  27. Despite the varied quality of treatment, Jordan has been achieving good results comparable to the developed nations Diagnosis & Treatment All Cancers Mortality/Incidence ratios for selected countries 2002 Jordan cancer Mortality/Incidence ratio2006

  28. Diagnosis & Treatment 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 Kaplan Meier Survival Function LEGEND Survival Function Product Limit Estimate Curve Event FreeSurvival Function Censored Observations Survival Distribution Function 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

  29. Diagnosis & Treatment Case in point 2: KHCC’s Stem Cell Transplantation Program has resulted in survival rates equivalent to those in the USA and Europe Product-Limit Survival Function Estimate Survival Probability Survival Time Month

  30. Palliative Care 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 Lead King Hussein Cancer Center Support Ministry of Health As for palliative care, Jordan has established a national committee to improve provision of services as recommended internationally OBJECTIVE Top-Down Activities • Advocacy – change in opiod prescription regulation • Ten-day policy • Authority with MOH Minister rather than by law • 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 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.

  31. With the current and growing cancer burden the region remains extensively challenged Lack of government national support Social Limitations • Other primary care issues take priority over cancer care • Funding limitations to prevention, screening and purchase of quality care (including costly drugs) • Cultural Barriers • 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) • Preference to invest in family/children needs rather than self health • Awareness barriers • Cancer as a taboo subject • No health promotion to break myths of hereditary and contagious disease • Do not seek information and action to understand ailment or prevention Monetary Limitations • Lack of Specific Funds Targeted towards Cancer • High Cost of Drugs and overall treatment • (GDP per capita for most countries in the region is below $ 6000) • (Average cost of treatment is approximately $25,000 without complications) • Major International Funds have not been allocated towards Cancer Control in the region

  32. Service limitations Service Limitations Health Care Workers per 1000 population • Multidisciplinary approach to treatment is not systematically implemented in some treatment centres • 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. • There are relatively few trained radiation, medical or pediatric oncologists in many countries of the Region, and very few oncology nurses and social workers. • The roles of nursing staff and paramedical could be expanded to reduce the load on specialists • 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 Remarks

  33. Palliative care for many countries is barely existent Sources: International Narcotics Control Board; United Nations population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2009

  34. Accessibility to Care • Increased prices of drugs: Due to the increased 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 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 • Lack of health specialized primary care and support care providers: Especially in support services and early 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 Quality of Services • Lack of treatment protocols: No unified protocols are 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 accessibility to tap into advanced resources is non existent Public Awareness • Misinformed public: Due to technological advances in 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

  35. 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

  36. Efforts need to become more streamlined and unified to ensure continued success across all sectors • GOVERMENT • Legislation relevant to control of risk factors and opioid availability • Structuring health services • Supporting establishment of expert committees • Orchestrating goals • Monitoring outputs, outcomes and impact • 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: • Education & outreach • advocacy: • INDUSTRY: • Access to new innovative products and services • Research • Sponsorship • 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 ???

  37. Thank You

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