The National Cancer Institute of Egypt: An Influential Tool in the Management of the Nation’s Oncology Issues

1. The National Cancer Institute of Egypt: An Influential Tool in the Management of the Nation’s Oncology Issues Salah S. Abdel Hadi, M.D. Dean, National Cancer Institute Cairo University, Egypt

2. Outline • Descriptive: • Oncology challenges in developing world (including Egypt) 2. Activities: • NCI’s current impact on oncology challenges. 3. Prospective: • Renovation procedures: Current North & South buildings • Multi centric NCI outlets: New Hospital addition • NCI campus: Three phase novel project .

3. Global Cancer Burden (WHO)

4. New cancer cases on the rise 16 millionin 2020 a 50% increase! 10 millionin 2000 WHO (2003)

5. Background • Estimated new cancer cases each year is expected to rise from 11 million (2002) to 16 million (2020). • 60% (9.6 million) of all these new cases will occur in the less developed world. • These individuals, their families will face the challenge of understanding cancer, and how it affects their lives. • Providing quality & current cancer information to cancer patients, their families, laymen & health care givers is a key function of the National Cancer Institute, Egypt.

6. Introduction Countries with limited resources are defined economically as having an average gross national product/capita of less than USD 350/year. Remarkable advances in treatment of childhood cancer have been “bitter sweet”. High incidence of successful cures in developing countries who hold a minority of the world’s population and a minority of children with cancer. High rate of patient withdrawal from therapy & loss to follow up in studies from developing countries.

7. Introduction The population of developing countries represented 78% of the global total in 1990. Countries with limited resources accounted for 86% of the world’s children in 1990. “Projected to increase to more than 90% by 2030”. The major killers of children in countries with limited resources remain: a) infections, b)malnutrition c)diarrhea/dehydration.

8. Issues Facing Developing World 1. Patient Load. Specialized centers are few and overwhelmed with patients. 2. Treatment Priorities Available agents e.g. chemotherapy and radiation facilities impose choice of management. 3. Impact of existing health problems 4. Hepatitis and nutritional status affect management significantly. 5. Compliance Lack of interest in long term follow up due to economic, cultural and educational reasons.

9. Issues Facing de vIssues Facing Developing World 6. Lack of communication between regional centers in patient follow up & management. 7. Poor registration and follow up facilities. 8. Lack of integrated aproach to: a)appropriate medical surveillance for late effects of treatment. b)counseling services. c) special needs concerning employment, disability, insurance, psychological support.

10. EGYPT: Country Profile Damietta Mansurah Fakous Tanta Alexandria DEMOGRAPHY* Population: 78,887,007 (July 2006 est.) Fertility rate:3.3% % of population under 15: 32.6% Population growth: 2% Rural / Urban population: 58% / 42% Literacy rate: 57.7% HDI: 0,659 (2003) (Rank: 119) Port Said Damanhour Ismaila Minufiyah Cairo Zagazig Al Minya Assiut Sohag Aswan ECONOMY* GDP ppp: $339,2 billion (2005) GDP ppp pc: $4,400(2005 est.) Minimum wage: $33 (public sector - 2001) Unemployment rate: 10% Formal sector: 25% of pop. % of population under poverty line: 3.1% * CIA ; WHO 2005; PNUD HEALTH* Life expectancy:68 72 Malnutrition < 5: 9% Infant mortality: 31.3 ‰ Epidemiological transition: underway

11. Pediatric Oncology Services in Egypt Damietta Mansurah Cancer Institutes: Oncology hospitals – university institutions , provide training program expert care NCI SECI Fakous Tanta Alexandria Port Said Damanhour Ismaila Minufiyah Zagazig Cairo Al Minya Ministry of Health Cancer Centers Comprehensive CC created by the Ministry of Health and Population in 1996 Assiut Sohag University Hospital departments: pediatrics, hematology, radiotherapy, and other adult services Aswan NGO hospitals NGO hospitals located in rural areas with small activity in PO

12. Cancer Profile - Egypt • In Egypt today, the number of new cancer patients per year is estimated to be 100,000. • Accumulated patients represent about three times the number of new cases. • This patient load will expand in the future: • Population continues to grow • Population continues to age, • Prevalence of known etiological factors increase.

13. NCI Egypt Largest comprehensive cancer center operative since late 60s. • Serves 18,000 newly diagnosed cancer patients (800 peds) and 100,000 patients under treatment. • Involved in: • Patient service • Research activities • Post graduate degrees • Training and education • National role

14. Most Common Sites in MalesNCI, Egypt

15. Most Common Sites in FemalesNCI, Egypt

16. Most Common Sites in ChildrenNCI, Egypt

17. Number of new cases NCI 2007(total: 21181) 82% 18%

18. 18,189New Cancer Cases by Age Groups and Gender 47 63 51 55

19. Cancer Profile - Egypt • Egyptian patients with cancer usually present at a relatively advanced stage in their disease, which has a negative impact on treatment results. • Most common cancers encountered: A) Male: urinary bladder (25 %) B)Female: breast (14%) C) Childhood: ALL (25 %) • Activities directed towards avoidance of risk factors, early detection, education and awareness.

20. NCI’s current impact on oncology challenges. Tool 1: Collaboration

21. NCI Egypt, Collaborative Activities • National • Setting up treatment protocols with MOHP • Providing technical support for comprehensive cancer centers nation wide. • Speer heading early detection activities. • International • UICC • INCTR • International Atomic Agency • NCI USA

22. Membership in International Organizations • European organization for research and treatment of cancer (EORTIC). • International Union Against Cancer (UICC) • World Health Organization (WHO) • International Atomic Energy Agency (IAEA) • International Network for Cancer Treatment and Research (INCTR) • Eastern Mediterannean Regional Office/World Health Organization (EMRO)

23. International Available Collaborative Opportunities • A) Jordanian Prospect (KHCC) • Link with Expat. community • Rotation in US during fellowship program • Collaborative efforts • Continutity • Role of senior staff • Role of junior staff • B) French Prospect • Centre Antoine Lacassagne, Nice • Radio therapy • Nutrition • Tumor bank

24. Regional Collaboration“ NCI/KHCC” • Create larger and stronger professional body • Learn from each others skills • Complement each others deficiencies • Create prototype for regional collaboration without intermediaries. • Allow professionals to work in either institution according to developed skills (palliative care/clinical pharmacy)

25. Regional Collaboration“ NCI/KHCC” Ongoing Collaborative activities • Epidemiology • Pain/palliative care • Nursing • Laboratory • Radiation therapy • Pediatric oncology

26. Regional Collaboration“NCI/KAU” Initiation • Visit by University president to NCI. • Visit by Egyptian delegation to KAU. • Saudi academic delegation attending M.D. exams.

27. Regional Collaboration “NCI/KAU” Prospective • Training health care team personnel (doctors, students, pharmacists, lab techs., physicists, nutrition specialists, etc.) • Sharing in supervision and evaluation of MSc. And M.D. dissertations. • Exchange of post grad students/lecturers in various oncology related curriculae.

28. NCI’s current impact on oncology challenges Tool 2: Education • .

29. ACADEMIC PROGRAM AND RESEARCHNCI, Egypt • NCI offers academic degrees in various oncology specialties, including: • Doctoral degrees in surgical oncology, adult and pediatric medical oncology, radiotherapy, pathology, clinical pathology, and cancer biology. • Master's degree in surgical oncology, medical oncology, pediatric oncology and pain control.  • The NCI is the nation's first to receive international research grants to study cancer problems of particular importance to Egypt.

30. III- Degree requirements: • Masters degree with a minimum grade of ''Good''. • Currently, The Masters degree could be either in the general field or the oncology specialty. • After a three year transition period, the Masters degree has to be in the oncology specialty field.

31. Educational Collaborative EffortsNCI, Egypt • Team of US educators visiting NCI Egypt 2007. • Activities: • A) Participation in Cairo University annual post graduate conference • B) Attending a retreat in upper Egypt with NCI counterparts to address oncology educational aspects. • C) Assisting in developing a proposal for creation of a post graduate medical education office at NCI Egypt.

32. Educational Collaborative EffortsNCI, Egypt NCI/AUC educational project: 1) Accreditation 2) Development of credit hour system and curriculae review 3) Partnership activities in computer science, IT development, and AV material development. • Joint committee members working in identifying time plan and objectives. • Success of current effort could lead to MOU between both institutions

33. NCI’s current impact on oncology challenges. Tool 3: Research

34. Cancer Research Support • Cairo University approach to financial research support • Prospective research cancer center with financial autonomy and capability planned for NCI, Egypt. • Development of bilateral channels with research centers regionally and internationally. • Introduction of quality control/incentives to centers for policy and procedure development. • Initiation of workshops to standardize scientific rapport. • Initiation of accreditation activities nation wide.

35. Aspects of Research ActivitiesNCI, Egypt • Translational research: • proper characterization of different types of malignancies to define parameters impacting treatment and/or prognosis (biological differences). • Role of infectious/parasitic agents in carciongenesis : • HCV with Hepatocellular carcinoma, • HPV with cancer cervix, • Helicopactor with stomach cancer • Bilharziasis with bladder cancer.

36. Aspects of Research ActivitiesNCI, Egypt • Environmental factors and carcinogenesis: • asbestos and mesothelioma, • intrauterine chemical exposure and infant leukemia. • Genetic/ environmental interaction: • polymorphisms in genes encoding drugs and xenobiotic metabolizing enzymes as risk factor for cancer development, response to therapy and drug toxicity (ALL patients).

37. Obstacles/Barriers to Research 1-Financial constraints: • Defies individual motivation when distributed by allocation. 2-Lack of full time research career path. • Research combined with patient care and private practice. 3- Lack of motivation towards research career pathway • Financial constraints, professional satisfaction, availability of research tools. 4-Variation in research interest/abilities within different centers • Defies ability to initiate multi center studies

38. NCI’s current impact on oncology challenges. Tool 4: Training

39. Educational Collaborative EffortsNCI, Egypt Training Activities: I- National: a) through post graduate degree awarding program b) training site for MOHP Board c) special programs, clinical pharmacy and radiology II. Regional: Iraq, Yemen and Sudan III. International: US and France

40. International Collaboration “ School of Public Health University of Michigan” • NCI gateway to Egyptian Oncology centers (Assiut, Tanta). • Projects by post graduate American students . • Projects focused on: • Epidemiology & pathology of inflammatory breast cancer • Changing epidemiology of bladder cancer • Liver cancer and hepatitis viruses • NCI-Cairo mentors from: Epidemiology, pathology, and medical, surgical, and radiation oncology. • International course offered at NCI. • NCI scientists in Michigan.

41. International Collaboration “ School of Public Health University of Michigan” Learning Experience: • Having the opportunity to work with large patient population and large data sets. • Different laboratory environment (equipment, reagents, and work environment). • Working with incomplete and inconsistent data. • Communication lessons with local mentors and staff during and after the internships.

42. International Collaboration “Gustav Ruse – France” 1. Historical Overview 2. Re-initiated by French partner 3. Combined with Benha University Cancer Center Project (includes local role for NCI in community) 4. Visit of two French students: Accommodation at NCI – Interaction with residents 5. Cultural interaction.

43. NCI Prospective • Renovation procedures: • Current North & South buildings • North Building • State of the art OR and ICU • South Building: • Creation of an out patient independent complex

44. NCI Prospective • Multi centric NCI outlets: New Hospital addition • Advancing into complementary health care outlets. • Hospital planned to impact early detection and community service programs in oncology areas. • Will act as prototype for prospective project in areas of management and HR issues.

45. NCI Prospective • NCI campus: Three phase novel project. • First phase: accommodates 350 beds planned to function within four years. • Fund raising campaigns underway through an NGO with a board of trustees headed by first lady. • Aims at further segregating and highlighting different avenues of services through:> • A) Research institute • B) Palliative care institute • C) Specialized clinical hospital settings • D) Independent academic buildings and activities • E) Separate out patient facility.

46. National Cancer Institute Cairo University 200 years ago 2010