What an Association like MTCC can do for a Cancer Center and a non governmental Association from a developing country ?

1. What an Association like MTCC can do for a Cancer Center and a non governmental Association from a developing country ? Pr Khaled Rahal Pr Hamouda Boussen Institut Salah Azaiz. Tunis. Tunisia

2. What about Tunisia ? • Located in Northern Africa, bordering the Mediterranean Sea, between Algeria and Libya • Total Area : 163,610 km2 Land: 155,360 sq km Water: 8,250 sq km • Slightly larger than Georgia • Total Land boundaries : 1,424 km • Border countries: Algeria 965 km, Libya 459 km • Coastline:1,148 km • Highest point: Jebel ech Chambi 1,544 m • Natural resources: petroleum, phosphates, iron ore, lead, zinc, salt

3. Tunisia demography • Area in square kilometers 154630 (2004) • Total population in thousands 10031 (2004) • % Urban population out of total population 65 (2004) • Crude birth rate per 1000 population 16.8 (2004) • Crude death rate per 1000 population 6.0 (2004) • % Population growth rate 1.1 (2004) • % Population below 15 years 26.7 (2004) • % Population 65 years and over 6.8 (2004) • % Dependency ratio 50 (2004) • Total fertility rate2.0 (2004) • Life expectancy at birth: total population: 74.89 years, male: 73.2 years, female: 76.71 years (2005 est.) • Total fertility rate: 1.75 children

4. Tunisia economy • GDP (purchasing power parity):$70.88 billion (2004 est.) GDP - real growth rate:5.1% (2004 est.) GDP - per capita:purchasing power parity - $7,100 (2004 est.) GDP - composition by sector:agriculture: 13.8% industry: 31.8% , services: 54.4% (2004 est.) Labor force:3.55 million • Budget:revenues: $6.799 billion, expenditures: $7.573 billion, including capital expenditures of $1.6 billion (2004 est.) • Agriculture-products:olives, olive oil+++, tomatoes, citrus fruit, beef, sugar beets, dates • Oil - production:72,580 bbl/day (2001 est),Oil - proved reserves:1.7 billion bbl (2004 est.) Natural gas - production:2.25 billion cu m (2001 est.) • Exports:textiles, mechanical goods, phosphates and chemicals, agricultural products, hydrocarbons. Partners:France 33.1%, Italy 25.3%, Germany 9.2%, Spain 6.1% (2004) • Imports:$11.52 billion f.o.b. (2004 est.) Imports - commodities:textiles, machinery and equipment. Partners:France 25.1%, Italy 19%, Germany 8.5%, Spain 5.3% (2004) • Currency (code):Tunisian dinar (TND), Exchange rates:Tunisian dinars per US dollar 1.3707 (2000)

5. 1200 kms of coasts

6. Carrefour of civilisations • Roman period

7. Sites historiques • Arabo-Byzantine era

9. festivals • International festival of Carthage (july-august) • International festival of symphonic music of the Roman Amphitheatre of El Jem (august) • Musical october • Jazz in carthage (april) • Inernational jazz festival (june)

10. MENA  Thanks and Shukran to • Samir Khleif, director of the KHCBI • Sami El Khatib, Research office KHCBI • Dina and Eman from the research office • for the organisation and the high level of topics and^presentation and we hope to see you in Tunisia. Saadoun Door of Tunis near the ISA

11. Breast cancer in Tunisia • 1st female cancer : 25 % • 1977 Incidence : 8/100 000 • 1994 Incidence : 18,5/100 000 F • Litt Incidence : 16 - 100/100 000 • 2004 = 1500 yearly cases  incidence of 25 to 27/100000.

12. Breast cancer Nbr of cases per year

13. Breast cancer Mean age

14. Breast Cancer% before 35 years

15. Breast cancerRépartition by age

16. Institut Salah Azaiz • Unic comprehensive cancer center since 1969 • Unic structure for cancer treatment since 1992 • 200 beds • Departments of surgical oncology, medical oncology, radiotherapy, head and neck surgical oncology, nuclear medicine, biostatistics Pr Najib Mourali, surgical oncologist. First director

17. Institut Salah Azaiz • 9 surgical oncologists • 6 medical oncologists • 8 radiotherapists • 5000 new cancers/year • 600 new breast cancers • 12000 new consultants/year

18. Institut Salah Azaiz • Department of surgical oncology ; 72 beds, 5 operating rooms. • Department of medical oncology : 40 beds, unit of pediatric oncology, 5 beds of palliative care • Department of radiotherapy : 2 cobalts, 1 Linac, 35 beds

19. Institut Salah Azaiz • Department of surgical oncology ; 72 beds, 5 operating rooms. • 7000 surgery procedures, 2000 ambulatory. • Breast cancer surgery, cervix, ovary, colorectal, urology. • Implantable sites insertions (300/year)

21. Institut Salah Azaiz • Department of Head and Neck surgery, 3 operating rooms, 35 beds • Department of radiology : 2 mammographs, 1 CT-scan 16 slices • 2 labs of histopathology

22. Institut Salah Azaiz • Specific epidemiological features • Inflammatory breast cancer : 5-7% of BC • Nasopharyngeal cancer : incidence of 3-4/100000 • Cancer in young patients (BC, Digestive, NPC chlidrens++)

23. True inflammatory forms 5-7% of BC in Tunisia

24. Inflammatory Breast Cancer Boussen H et al. Semin Oncol Feb 2008. • Inclusion criteria : • Patients classified PEV2 and PEV3*, treated in SAI between January 1976 and December 1981. • Patients classified T4d**, treated in SAI between January 1990 and December 1996. • Exclusion criteria : • The tumors classified PEV 1. • The ulcer tumors (T4skin). * IGR Classification ** UICC Classification of 1988

25. Inflammatory Breast Cancer Boussen H et al. Semin Oncol Feb 2008. • 3 series : • Series A : January 1990 till December 1996 breast cancer classified T4d as per the UICC classification of 1988 (118 cases) • Series B : January 1975 till December 1981 breast cancer classified PEV 2 or PEV 3 as per the IGR classification and reclassified as T4d as per the UICC classification of 1988 given the clinical description reported in the medical folder (175 cases)

26. Inflammatory Breast Cancer Comparative Study • The average clinical tumor size is lower for the patients of series C

27. Inflammatory Breast Cancer Comparative Study • The global survival ratio is better for the patients of the series C (p=0,0001)

28. Inflammatory Breast Cancer

29. Inflammatory Breast Cancer • We propose to consider as inflammatory tumor : every tumor presenting with inflammatory signs, oedema and/or erythema, that spreads to the half of more of the breast.

30. In the years 1970Data of the Institut Salah Azaiz 1968 to 1985 • Mean Clinical tumor size of 58,1 mm • 21,3% of initial metastases • 44% of PEV • % of PEV3 increas with size (10cm) • IDC = 67%, CLI = 2,3% • 7% associated to pregnancy

31. Cancer features at the ISAData of the Institut Salah Azaiz. Boussen et al. (Semin Oncol Feb 2008) • Inflammatory breast cancer 5-7% • Reassesment of the true incidence of IBC (differentiat T4b from T4d) • 600 new breast cancers • Mean clinical tumor size of 40mm • Mean histologic size of 35mm • 10% < 35 years.

32. What news about epidemiological transion of nasopharyngeal carcinomas ? Boussen et al. EMC Oto-rhino-laryngologie [20-590-A-10]. 2007.

33. Clinical presentation of NPC Boussen et la. EMC Oto-rhino-laryngologie [20-590-A-10]. 2007.

34. Cancer features in Tunisia 2004Cancer registries • BC(25%) > Cervix(6%) > Gallbladd > CRC • Lung > H and Neck > Bladder > CRC • % of young patients varying from 5 to 15%(NPC in childrens) • 1 comprehensive center, 2 units of oncology(Med + Radioth) in 2 university hospitals of Sousse and Sfax • Pilot screening-early detection project in one state of Tunis capital(Ariana)

35. Cancer projects in Tunisia • National cancer plan 2007-2010 • Collaboration with French Institut National du Cancer(INCa) • Collaboration with Italy (projects of Gafsa and Jendouba)  mammographs-histopathology units-BC early detection-medical plus paramedics training

36. What MTCC can do for us ?

37. Proposition 1 for MTCC • Good clinical practices in oncology • Evaluation of quality of practice in surgical oncology • Certification of the practice in surgical oncology • Procedures of accreditation • Parameters of evaluation : Nb, rate of success, complications……………… • Treatment guidelines

38. Proposition 2 for MTCC • What Cursus of surgical oncology, medical oncology and radiotherapy ? • What cursus in other mediterranean countries ? • Duration and type • Schedule of evaluation • Theorical program • Practical program

39. Proposition 3 for MTCC • Training for fellows or confirmed specialists (short duration) in surgical oncology, medical oncology and radiotherapy • Constitution of study groups in surgical oncology (IBC, young patients, innovations……….) • Epidemiological survey for inflammatory breast cancer

40. Proposition 4 for MTCC • ATAMCS (Association Tunisienne d’Assistance aux Malades de Cancer du sein) • Created in 2005, board mixing cured patients and oncologists • Psyschosocial plus financial support to patinets affected by BC • Lobbying techniques • Network with breast cancer NG associations • Europa donna

41. Propositions 5 for MTCC • Sustain for screening of colorectal cancer in Tunisia. Previous experiences in Europe and mediterranean countries. • Not done presently in Tunisia • Preliminary cost-study  benefits • Problem of cost-benefit of HPV vaccine in Tunisia • Training in medical epidemiology and biostatistics • Telemedicine with mediterranean centers developping a network

42. Prostate cancer in Tunisia • Predominating cancer in aged male • 5th cancer in man for the cancer of registry of Norhern Tunisia = 139 cases in 1994 • Crude Incidence of 6,4 • Standardised Incidence of 7,7 • 7% of cancers

43. What does MTCC looks like for its developping part ?

44. MTC role in our countries • Counselor for advanced projects • Viability of projects • Auditing the ended projects • Links with international and European associations (scientific, NG…………) • Reliable contact with the official authorities (min health, research………)

45. Thanks to MTCC • Shukran • Ekkharisto • Hvala • Grazie • Gracias • Merci