Would you pay a year's salary for a mammogram? If you earned the average salary in some developing countries, that is what it would cost.
How about a small fraction of that salary to vaccinate your children against a common cancer?
When put this way by Karol Sikora, M.D., former chief of the World Health Organization's cancer program, the message is crystal clear: a country's cancer control strategies must be tailored to economic and epidemiologic realities. Countries must set priorities "rather than just trying to copy what [was] in the Journal of Clinical Oncology last month."
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Priority Ladder
That strategy calls for the creation of national cancer plans by health ministries plans based on WHO priorities but adapted to each country's circumstances. The WHO cancer priority ladder begins with tobacco and infection control, followed by 14 other priorities including treatment of "curable cancers," early detection, pain control, and near the bottom, research. The idea behind the national cancer plans is to apply these priorities to the cancers and risk factors most common in a given country, taking into account available resources.
Sikora, who is also a professor of international cancer medicine at the Imperial College School of Medicine, London, has spent much of the past 2 years promoting this concept around the world.
Listening to him, the message sounds simple: Put resources where they will have the most impact. Focus first on cancers that are curable or preventable with relatively small amounts of money. Above all, prioritize.
"But the politicians don't understand this," says Sikora, who talks about prioritization with missionary zeal. "They take their cancer dollar and say we want a bone marrow transplantation program. But if women are all presenting with stage IV breast cancer, a BMT program will not save lives. It's better to put money into education, so you get earlier presentation."
Last March, one of Sikora's stops was Fort Lauderdale, Fla., where he talked to mostly U.S. oncologists at the annual meeting of the National Comprehensive Cancer Network. His topic was how the NCCN guidelines might be globalized (his proposal will appear in Oncology in November).
But Sikora also told the U.S. oncologists the same thing he has been telling the rest of the world: The global cancer burden is set to double over the next 20 years, and the world needs to do something about it. At the moment there are 10 million new cases of cancer and 6 million deaths. By the year 2020 this will be 20 million new cases and 12 million deaths.
The cancer burden is now greatest in highly developed countries where life spans are longest, Sikora says. "So why is WHO worried about cancer? Why not let the rich pay for their treatment and forget about it?"
Poorer Countries
His answer is that things will be very different in 20 years. About 70% of the 20 million annual new cancer cases by 2020 will be in poorer countries. Cancer will replace infections as the number one killer in all areas but black Africa, according to WHO projections. This means cancer incidence will double, triple, even quadruple in some developing countries, where per capita incomes and cancer resources are not expected to keep pace.
What can be done about this looming problem? WHO projects that cancer control strategies could cut the global incidence by 5 million per year in 20 years and reduce mortality by almost half. Heavy gains in prevention will be needed to reach this goal, including less tobacco use and improved diets.
Treatment too could reduce mortality substantially for some cancers. A prime example is Burkitt's lymphoma, common in parts of Africa. Half of children with this disease are getting no treatment at all, although it is curable with two easily obtained drugs cyclophosphamide and methotrexate at a cost of about $80, he says. Many governments are not making this investment, a problem that Sikora says stems basically from a failure to plan and priortize.
"In many countries, those involved in treating cancer are not really linked with the public health people, and everyone's going off on a tangent."
Preventing hepatitis and other infections could also have a large impact on cancer incidence in some countries. Liver cancer, hepatoma, is the most common cancer in parts of Asia and Africa. It would be almost completely preventable, Sikora says, if affected countries provided systematic hepatitis B and C immunization along with a normal childhood immunization program.
Done in Taiwan
Is this feasible? Sikora points out that it has been done in Taiwan, which instituted a childhood hepatitis immunization program in 1984. Since then, according to early data, the incidence of hepatitis in young children has dropped dramatically. Because hepatitis is an established and major risk factor for liver cancer, the incidence of liver cancer is also expected to decrease.
So far, health ministries in 12 countries have set up pilot cancer programs in conjunction with WHO. Four of them are in eastern Europe, where lung cancer rates are high. Rumania, Lithuania, Estonia, and Ukraine lack the tobacco controls and anti-smoking programs that have evolved in western Europe, according to Sikora. Their plans put a high priority on tobacco control.
In South America, cervical cancer is relatively common, so screening, education, and development of a preventive vaccine are high on the priority lists of the countries with national plans Costa Rica, Uruguay, Argentina, Chile, and Trinidad.
In Tanzania, where a mammography program was once considered, hepatoma and Burkitt's lymphoma are now priorities in the national cancer plan, ahead of breast cancer. Breast cancer is less common here than liver cancer, and its incidence is only a little higher than that of the more easily treated lymphoma.
WHO's goal is to have cancer plans established in at least 60 countries within 5 years. Sikora stresses that each plan will be tailored to the country's economy ("there's no point in trying to set up Rolls Royces if you can't actually afford a motor car") and the epidemiology ("at the moment there are still huge differences in the incidence of cancers around the world").
But the plans will all have one thing in common, as he sees it. "The crux of these programs involves a priority ladder. . . . Where can you put your dollars to get the maximum gain?"
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