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Developing cancer control plans in Africa: examples from five countries
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Cancer Control in Africa 7 Developing cancer control plans in Africa: examples from five countries Daniela Cristina Stefan, Ahmed M Elzawawy, Hussein M Khaled, Fabien Ntaganda, Anita Asiimwe, Beatrice Wiafe Addai, Seth Wiafe, Isaac F Adewole
The creation and implementation of national cancer control plans is becoming increasingly necessary for countries in Africa, with the number of new cancer cases per year in the continent expected to reach up to 1·5 million by 2020. Examples from South Africa, Egypt, Nigeria, Ghana, and Rwanda describe the state of national cancer control plans and their implementation. Whereas in Rwanda the emphasis is on development of basic facilities needed for cancer care, in those countries with more developed economies, such as South Africa and Nigeria, the political will to fund national cancer control plans is limited, even though the plans exist and are otherwise well conceived. Improved awareness of the increasing burden of cancer and increased advocacy are needed to put pressure on governments to develop, fund, and implement national cancer control plans across the continent.
Introduction Roughly 715 000 new cases of cancer occurred in Africa in 2008 according to GLOBOCAN data,1 and almost 542 000 people died from malignant disease. 5-year prevalence was almost 1·5 million cases, putting substantial demand on already overstretched health-care budgets. Worldwide, cancer incidence could potentially increase to as many as 17 million new cases per year by 2020;2 of these, possibly as many as 1·5 million will occur in Africa. Around the world, many governmental and nongovernmental organisations (NGOs), philanthropic and for-profit outfits, research and higher-education institutions, religious organisations, associations of health-care professionals, parent and patient groups, and many others contribute to the fight against cancer. However, a framework is necessary so that these efforts can be focused and efficiently organised. The establishment of national cancer control plans (also known as national cancer control programmes) by governments can provide the necessary guidance towards control, even where resources are scarce. WHO3 defines national cancer control programmes as “public health programmes designed to reduce cancer incidence and mortality and improve quality of life of cancer patients, through the systematic and equitable implementation of evidence-based strategies for prevention, early detection, diagnosis, treatment, and palliation, making the best use of available resources”. In 2005, the World Health Assembly adopted resolution 58.22,4 which urged member states to intensify action against cancer through the creation of national cancer control programmes, adapted to conditions in each country. From 2006 to 2008, WHO produced a series of six modules that deal with the practicalities of creating and implementing such programmes.5 In view of WHO’s call to action and detailed guidance, many countries in Africa might be expected to have made www.thelancet.com/oncology Vol 14 April 2013
some progress towards the introduction of measures aimed at cancer control. In 2010, WHO did a worldwide assessment of the status of national efforts to fight non-communicable diseases.6,7 Disappointingly, of 46 respondent countries in Africa, only 17 countries (panel) had operational policies, strategies, or action plans for cancer (these terms do not necessarily imply a formal national cancer control plan) in 2010; even more concerning, only 17% of national programmes against non-communicable diseases in Africa were funded. Cancer is a substantial public health problem in Africa; however, few exact data are available—GLOBOCAN data for the continent are mostly estimates. Ideally, accurate data to guide national policies should be provided by national cancer registries. Such data are needed not only to assess the size of the burden of disease, but also to investigate potential risk factors for cancer, to estimate the optimum geographical distribution of resources, to project expenditure, and to measure the effectiveness of policies for prevention and treatment. However, in 2009 the International Association of Cancer Registries reported only 15 national registries in Africa,8 the remaining 60 being hospital or city registries only. Some of these registries are not always functioning—their activities can often be suspended for various lengths of time because of shortages of funds or personnel. Only 12 African countries had reported their data to the International Agency for Research on Cancer (IARC) incidence database9 up to 2002.
Lancet Oncol 2013; 14: e189–95 This is the seventh in a Series of seven papers about cancer control in Africa See Comment page 277 Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa (Prof D C Stefan PhD); Department of Clinical Oncology, Suez Canal University, Suez, Egypt (A M Elzawawy MD); National Cancer Institute, Cairo University, Cairo, Egypt (H M Khaled MD); Rwanda Biomedical Center, King Faisal Teaching Hospital/Rwanda Military Hospital, Kigali, Rwanda (F Ntaganda MMed); Institute of HIV Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda (A Asiimwe MPH); Peace and Love Hospital, Accra, Ghana (B W Addai PhD, S Wiafe MPH); Department of Obstetrics and Gynaecology, College of Medicine, University of Ibadan, Ibadan, Nigeria (Prof I F Adewole FAS); and African Organisation for Research and Training in Cancer, Cape Town, South Africa (I F Adewole) Correspondence to: Prof Daniela Cristina Stefan, PO Box 19063, Department of Paediatrics and Child Health, Tygerberg Hospital and Stellenbosch University, Tygerberg, Cape Town 7505, South Africa [email protected]
Panel: Countries in Africa with operational policies, strategies, or action plans for cancer in 2010 Algeria, Benin, Cameroon, Côte d’Ivoire, Djibouti, Egypt, Gabon, Guinea, Madagascar, Maldives, Mozambique, Niger, Nigeria, South Africa, Tunisia, Zambia, and Zimbabwe Data are from WHO.6,7
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The aim of this Series paper is to explore the obstacles encountered in the establishment and implementation of national cancer control plans Although not all findings will be applicable to every other country in the continent, an attempt was made to select somewhat representative countries—three of the more populous countries in Africa with the largest economies (South Africa, Nigeria, and Egypt) were included, as well as Ghana (a mediumsized country) and Rwanda (a relatively small country).
South Africa In April, 2011, South Africa’s Department of Health instituted compulsory cancer registration. 2 years previously, the department had revitalised the National Cancer Registry (which had been established in 1986, but had become almost inactive after 2004 because of insufficient funding and a reduction in incoming reports).10 These two measures represent the growing awareness of the substantial burden of non-communicable diseases in general, and cancers in particular, in South Africa.11 According to a WHO estimate,12 non-communicable diseases caused 28% of the total burden of disease in South Africa in 2004; cancers alone caused about 3% of the total disease burden. Statistics based on 2009 death notifications13 suggest that cancers caused almost 40 000 deaths (6·3% of total deaths) and as such were the third most common cause of death, surpassed only by tuberculosis and by influenza grouped together with pneumonia. Age-standardised incidence of cancer in South Africa was 202 per 100 000 people, according to GLOBOCAN estimates for 2008.1 For the population of 50 million, this incidence is equivalent to 101 000 new cases that year. By comparison, the incidence of tuberculosis in 2011 was 993 per 100 000 people.14 The most common cancers in men were those of the prostate, lung, oesophagus, colorectum, and liver, as well as Kaposi’s sarcoma; in women, cancers of the breast, uterine cervix, oesophagus, colorectum, lung, and uterine corpus were the most common.1 The burden of cancer in South Africa is not a new concern for the health authorities, NGOs, and medical professionals in the country. In 1993, the Cancer Association of South Africa (CANSA) organised a workshop at which the constitution of a national cancer control programme based on WHO recommendations was proposed. Representatives of medical schools, the Medical Research Council, the South African Institute for Medical Research, the outgoing Department of National Health and Population Development, provincial administrations, hospice organisations, and NGOs involved in the effort to control cancer proposed the constitution of a national cancer control programme, based on WHO recommendations and coordinated by a committee supported by the Department of Health. The role of the national cancer control programme was to initiate, coordinate, and monitor all cancer control activities in the country; to combine fundraising efforts; e190
and to militate for improvements in environment and lifestyle as a means to reduce the population risk for cancer. Members of the programme’s steering committee were to be drawn from CANSA and from other NGOs and governmental organisations.15 However, the initiative was not backed by the incoming Department of Health, constituted after the 1994 elections. Other priorities were competing for the healthcare budget and above all the towering challenge of AIDS, with its associated increase in incidence of tuberculosis, demanded a substantial share of health expenditure. Antiretroviral drugs were made available free of charge, both for control of advanced HIV infection and to prevent transmission to the fetus during pregnancy. Several governmental policies did, however, have the potential to reduce the cancer burden. As early as 1993, the Tobacco Products Control Act restricted the advertising of tobacco products and prohibited smoking in public places; later amendments prohibited sponsorships by tobacco manufacturers and introduced further restrictions on vending tobacco products, including raising the minimum age from 16 to 18 years.16,17 A small decrease in the incidence of lung cancer in men suggests that this policy might be having some beneficial effect.18 The Liquor Act does not seem to have been as effective in reducing the consumption of alcohol and no reduction in alcohol-related cancers has been noted.19 Universal screening for cervical cancer was introduced in South Africa in 2000. With only three cervical cytology tests, at ages 30, 40, and 50 years, the programme has the potential to halve the number of new cases of invasive cervical cancer. However, uptake of screening is poor20 and a substantial number of women are lost to follow-up by colposcopy; no statistical assessment yet been reported. The policy is being revised, with one aim being the introduction of a special screening schedule for women with HIV infection, since they can develop cervical cancer at younger ages than women from the general population. A directorate for chronic diseases, disabilities, and geriatrics was established within the Department of Health in 1996. The directorate adopted the CANSA national cancer control programme in 1999 and updated it in 2009. The programme constitutes a comprehensive foundation for effective policies. Cancers of the cervix, prostate, breast, colon, and rectum are set as prominent targets for secondary prevention, and essential prevention modalities are described. Furthermore, the programme also suggests ways to control the prevalent carcinogens in the country—eg, through alcohol control policies. Lastly, clear and comprehensive recommendations are made for the content of future cancer reduction policies. Notwithstanding these developments, the strategic plan21 of the Department of Health for 2011–13 did not mention cancer control on its list of priorities. With few resources, spending had to be prioritised in favour of maintaining the health status of the young, economically and reproductively active segment of the population, www.thelancet.com/oncology Vol 14 April 2013
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which means the targeting of HIV/AIDS, tuberculosis, trauma, and chronic diseases such as cardiovascular diseases and diabetes. HIV infection remains highly prevalent (16·5% of people aged 15–49 years in 2011) and the disease commanded an expenditure of 13 billion rand in 2009.22,23 Only small steps in the right direction have been taken in the past few years. One was the designation of cancer as a notifiable disease. This decision removes the reservations related to patient confidentiality that caused many private medical institutions to abandon reporting of cancers in the past. Together with a functional cancer registry, more accurate measurement of the effect of malignant disease on population health and of the effectiveness of any preventive or curative interventions should now be possible. The establishment of a Ministerial Advisory Committee on the prevention and control of cancer in 2012 is another positive step. The national cancer control programme, however, is still awaiting funding.
Nigeria With a population of 170 123 740, Nigeria is the most populous country in Africa and the seventh most populous in the world.24 Gross national income per head in 2012 was US$2700 (at purchasing power parity).24 According to GLOBOCAN data,1 almost 102 000 new cases of cancer occur annually in the country, and 75 000 deaths per year are caused by malignant disease. 5-year prevalence in the adult population is roughly 223 000. No nationwide, population-based cancer registry exists, but data provided by some smaller population-based and hospital-based registries can be used to estimate the national burden of cancer. These data suggest that the cancer incidence is increasing.25 For example, the Ibadan Cancer Registry recorded 1093 cases in 2001, with a steady increase to 1576 by 2005. Because of a disproportionately high burden of infectious diseases, Nigeria is among those countries that face the challenge of the so-called double burden of communicable and non-communicable diseases. A national cancer control plan was developed in 2008,26 and represents a bold attempt to bring attention to the challenge of cancer in the country and to chart a path to address it. The overall vision is of a collaboration of all stakeholders to reduce the morbidity and mortality from cancer and its socioeconomic effect on the community, and to improve the health and quality of life of people living with cancer. Cancers of the breast, cervix, liver, prostate, colorectum, and skin, as well as leukaemias and retinoblastoma, are identified as priorities in the plan, with clearly articulated goals for the control of each. Although these goals do generally follow the guidelines for cancer control programmes set by WHO, they omit the control of risk factors for cancer. Within the framework of the national cancer control plan, the Federal Ministry of Health established www.thelancet.com/oncology Vol 14 April 2013
a cervical cancer control plan.27 The plan adopted visual inspection with acetic acid and visual inspection with Lugol’s iodine for screening, and human papillomavirus (HPV) vaccination for primary prevention in girls aged 9–15 years. The process by which the goals of the national cancer control plan are to be achieved have not been defined. The implementation unit is referred to as the cancer control desk, which does not have the necessary funding or personnel to function as needed. Defined measures to fight cancer are not mentioned in the country’s strategic health development plan for 2010–15.28 To succeed in the control of malignant disease, Nigeria needs a cancer control department that is fully empowered and adequately funded.
Egypt Egypt is classified as a lower-middle-income country; however, characteristics of high-income, middle-income, and low-income countries coexist. In 2011, the population was 83 million and life expectancy at birth was 73 years.29 Cancer and cardiovascular diseases are the main components of the non-communicable disease burden. Preceded by a registry for the governorate of Gharbia, the National Cancer Registry Program of Egypt was established in 2007.30,31 The country is now covered by a network of population-based registries that contribute data to the national cancer registry. About 68 800 new cancer cases occur per year.1 Most common in men are cancers of the liver (mostly related to hepatitis C virus), bladder (although incidence is decreasing because of improved control of schistosomiasis), non-Hodgkin lymphoma and leukaemia, and cancers of the lung, prostate, brain and nervous tissue, and colorectum. For women, most common are cancers of the breast, liver, non-Hodgkin lymphoma and leukaemia, and cancers of the ovary, uterine body, bladder, colorectum, and uterine cervix.30,31 Egypt has more facilities for cancer treatment than any other country in Africa; however, many elements of cancer control strategy still need to be implemented or improved.32 Cancer management facilities include the Egyptian National Cancer Institute (part of Cairo University); 14 clinical oncology departments in the other public universities; nine cancer centres affiliated to the Ministry of Health; 11 military cancer units that treat both civilian and military patients; oncology clinics at the hospitals run by the Egyptian Health Insurance Organization in most major cities; semi-private, NGO-operated cancer facilities; a charity-run Centre of Excellence of Paediatric Oncology in Cairo; and private-sector clinics and centres. In addition to surgery, most of these facilities have chemotherapy and radiotherapy capabilities (either linear accelerators or cobalt-60 units). Most centres have CT scanners and MRI machines, and the country has five PET-CT scanners. More than 1500 Egyptians have postgraduate qualifications in clinical and medical oncology. e191
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According to the WHO survey,7 Egypt had an operational policy, strategy, or action plan for cancer in 2010. However, no structured national cancer control programme as recommended by WHO3 is in place. Practical measures are needed for the optimum allocation of available resources to reduce the numbers of cancer cases and deaths and to improve quality of life for patients with cancer, through adoption of WHO recommendations.3 As an example of poorly coordinated policies, an expensive and ineffective government project to implement mammographic screening across Egypt with new mobile units was launched 4 years ago without consideration of the existing allocation of resources or the practicalities involved.33 As a result, after 20 000 mammograms, only about 90 breast cancers had been discovered. By contrast, a programme in the rural region of Fakous and the urban region of Port Said to use local resources to increase awareness of breast cancer and its treatment by organising home visits from primary care workers and meetings with local women resulted in a substantial reduction in cases of advanced breast cancer. About 20% of breast cancer cases in Port Said were amenable to conservative breast cancer surgery in 2008, and the number of stage III and IV cases had halved by 2004–08 compared with 1992–2003.34 Conversely, early detection programmes without access to treatments would be fruitless and frustrating for both patients and health professionals. In addition to a coordinated national cancer control plan based on WHO guidelines, a few other recommendations could enhance the effectiveness of cancer care in Egypt. First, effective cancer prevention programmes customised to the community should be fostered, particularly for tobacco control, prevention of hepatitis C infection, and breast cancer awareness. Second, affordability of curative and palliative care could be improved via the approaches described in the win-win scientific initiative (ie, through evidence-based optimisation of diagnostic and therapeutic protocols, without compromisation of patient outcomes).35 Third, the notions of value and effectiveness in cancer care should be adopted. Fourth, the health-care workforce should be efficiently coordinated by an accountable leadership. Fifth, efforts should be made to ensure the continuity and progress of the national cancer registry and to support the exchange of information internationally, both within Africa and beyond. Sixth, training and workforce capacity building are needed to improve research into cost-effective cancer-control interventions and clinical trials. Finally, cooperation and partnerships with regional, African, and global organisations should be enhanced, with special emphasis on partnerships with organisation such as the African Organisation for Research and Training in Cancer. e192
Ghana Ghana has a population of 24 million people, and the median life expectancy is 59 years.36 According to one estimate,30 the country has an average of one nurse for every 1500 and one doctor for every 20 000 people.37 No systematic national cancer programme is in place and the development of a national cancer registry is at a rudimentary stage.38 As a result, accurate estimation of the national cancer burden is difficult. Moreover, without accurate information about the regional distribution of cancers in the country, no realistic basis exists upon which to match the provision of cancer care with demand to ensure efficient resource use and equitable access. According to GLOBOCAN,1 roughly 16 000 cases of cancer occur annually in Ghana, with the five most common being cancers of the liver, breast, cervix, prostate, and stomach.38 Cancer is the fourth most common cause of death in the country.39 Five oncology centres now operate in Ghana: the Korle Bu Teaching Hospital and the Peace and Love Hospital in Accra; the Komfo Anokye Teaching Hospital and the Peace and Love Hospital in Kumasi; and the Sweden Ghana Medical Centre in Tema. Radiation oncologists are scarce, and are concentrated at Korle Bu and Komfo Anokye teaching hospitals. Once its radiotherapy unit is installed, the Peace and Love Hospital in Kumasi will become the only fully fledged breast cancer treatment centre in the country.40 Currently, the Sweden Ghana Medical Centre provides only radiotherapy and chemotherapy, since it has not started to offer surgery. No specialised oncology nursing school exists in the country, so general nurses who have received some minimum training in oncology staff the cancer centres. Cancer care in Ghana has improved substantially in the past 10 years. Solid tumours used to be managed entirely with surgery followed by some form of chemotherapy, or by chemotherapy alone.41 Patients with metastatic disease received no palliative care. However, since radiotherapy was introduced to Korle Bu Teaching Hospital in 1997 and to Komfo Anokye Teaching Hospital in 2004, multidisciplinary approaches with some adjuvant treatments and palliative care strategies have enhanced cancer management in the country. Despite these advances, however, most patients with cancer still present at late stages,42 because of personal factors and deficiencies in the general health-care system. As well as advances in cancer management in Ghana,41 patient awareness has improved, with the support of the media, physicians, and NGOs, such that patients are more aware of the curative and palliative treatments available and the need for early diagnosis and treatment. As a result, the number of people who turn up for medical consultation with early symptoms of cancer is increasing, patients are living longer, and cancer survivor groups such as the Peace and Love Survivors Association are being inaugurated with hundreds of members.43 www.thelancet.com/oncology Vol 14 April 2013
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Ghana faces several challenges to cancer management, including a scarcity of trained professionals and the prohibitive costs of investigations and treatments.41 Although a systemic shortage of drugs affects the country, oncology treatment centres are working with insurance and pharmaceutical companies to make basic cancer drugs available through the national health insurance system.41 The government, through the Ministry of Health and the Ghana Health Service, is committed to improve cancer care through collaboration with international organisations such as the International Atomic Energy Agency’s programme of action for cancer therapy and the Africa Oxford Cancer Foundation for the development of a comprehensive national cancer control plan. The plan is expected to cover a wide range of strategies and related policies, including raising public awareness of cancer; cancer prevention through screening and vaccination; early diagnosis and treatment of cancer in children; improvement of palliative care; and training and education of health-care staff.44 In view of the paucity of qualified workers and technological resources, integrated, evidence-based, and cost-effective interventions throughout the cancer management process would be the most effective way to confront the rising cancer burden in Ghana.
Rwanda Rwanda has a population of more than 11 million people and a median life expectancy of 58 years. Health expenditure was 9% of gross domestic product in 2009, and there are roughly two physicians for every 100 000 people.45 According to GLOBOCAN data,1 6600 new cases of cancer occur annually; the five most common are cervical cancer, liver cancer, Kaposi’s sarcoma, and cancers of the stomach and breast. About 5300 people die from cancer each year. Rwanda does not have a formal national cancer control plan as defined by the WHO guidelines. However, several initiatives have been launched by the Ministry of Health, in collaboration with various international donors and medical institutions, which focus on prevention, diagnosis, treatment, and palliation. Plans exist to formalise these initiatives into a national cancer programme. Four pilot hospitals—King Faisal Hospital and Rwanda Military Hospital (both in Kigali), University Hospital Centre of Kigali (Centre Hospitalier Universitaire de Kigali, Kigali), and Butaro Hospital in Burera District—have been selected to handle cancer care; other hospitals will be made operational for cancer management in the future. The Rwandan Ministry of Health has both in-country and international partners in cancer management, and additional collaborators would be welcomed. Partners currently working at sketching out a national cancer programme are the Ministry of Health, Rwanda Biomedical Centre (Kigali), Partners in Health (Boston, MA, USA), and Rwanda 4cure (affiliated with Memorial www.thelancet.com/oncology Vol 14 April 2013
Sloan-Kettering Cancer Center [New York, NY, USA]), and Stellenbosch University (Cape Town, South Africa). Cancer prevention and control activities cover HPV vaccination, anti-tobacco campaigns, and population information campaigns about healthy lifestyles, and soon will include early detection by use of a pilot mobile clinic in the Kigali area. Treatment of patients with cancer is based on the national cancer protocol, which was created and adopted in 2012 at the Annual International Conference on Child Health in Kigali, with the collaboration of members of Partners in Health, WHO Regional Office for Africa, Stellenbosch University, Strasbourg University, and the University of Dakar. Seven cancers in adults have been prioritised: prostate cancer, breast cancer, lymphoma, chronic myeloid leukaemia, colorectal cancer, gastric cancer, and multiple myeloma. In paediatric oncology, acute lymphoblastic leukaemia, Burkitt’s lymphoma, nephroblastoma, non-Hodgkin lymphoma, and Hodgkin’s lymphoma have been prioritised. These priorities were defined on the basis of the prevalence of each cancer in Rwanda and the availability of treatments. Although no exact data for the incidence and prevalence of cancers in Rwanda exist, an initiative was launched by the Ministry of Health in 2010 to institute a national cancer registry.46 Two hospitals are currently providing effective cancer treatment—Butaro Hospital in Burera District and King Faisal Hospital in Kigali. The other two hospitals listed among the pilots will be operational for cancer management in the near future. One centre (Kibagabaga Hospital in Gasabo District of Kigali) has been designated as a palliation centre, and is operating effectively. Diagnostic capacity in Rwanda is poor; histology departments offer basic immunostaining and assessment of markers for breast cancer. Haematology capacity is limited to morphology and to the few stains that are usually available. MRI is only available at King Faisal Hospital. Several training activities have been implemented in specific centres to advance cancer management, chemotherapy, and infection control for patients with cancer. Financing of cancer management in Rwanda remains a tough question to address—cancer care requires substantial and sustained investment of resources. Development of the necessary skills is also a major challenge, but one that can be addressed progressively, in partnership with international cancer institutions.
For more on the International Atomic Energy Agency’s programme of action for cancer therapy see http://cancer. iaea.org/index.asp For more on the Africa Oxford Cancer Foundation see http://www.afrox.org/
Discussion Several commonalities can be identified from these five country examples. For example, an increasing awareness that national cancer registries are essential to understand the epidemiology of cancer, to create effective policies, and to trace progress in prevention and treatment is apparent. Thus, steps are being taken to create such registries or to support and extend the activity of existing ones. e193
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Another common thread is the scarcity of resources available for the fight against cancer. This problem is especially evident in countries with relatively small, agriculture-based economies. For example, Rwanda receives some international aid money and its cancer care infrastructure relies to a large extent on external funds and foreign personnel.45 Under these circumstances, the priority is to establish basic curative and palliative facilities on a sustainable basis. Although less of a problem for wealthier countries such as South Africa and Egypt, the development and retention of skills is a crucial issue for poorer countries such as Rwanda and Ghana. Such countries rely on international collaboration for the training of doctors and nurses in oncology care. In countries with relatively large economies, such as South Africa and Nigeria, well conceived national cancer control plans might exist, but are not adequately funded. In such cases the scarcity of resources is relative—health budgets are mostly spent on containing infectious diseases, among which malaria, tuberculosis, and HIV are most prevalent. The young and economically active segment of the population can be substantially affected by these diseases, and national prosperity depends on the good health of this population group. In addition, cancer treatment is resource-intensive and costly, and because most patients present late, their survival is short. People affected by cancer rarely develop political influence (eg, as politically active survivor groups) because most patients do not live long enough. Moreover, the effect of risk factors for cancer (eg, tobacco smoking) is not immediately apparent, but rather takes decades, and does not manifest itself in all exposed individuals. A very clear awareness of risk factors for cancer is necessary in the population so that pressure can be exerted on political leaders to institute policies for cancer prevention. The case of Egypt shows the need for concerted and rational use of resources, which could have been facilitated by a national cancer control plan; one mammography programme proved to be expensive and ineffective,
Search strategy and selection criteria We searched PubMed and Google Scholar using the terms “(national) cancer plan/programme”, “cancer policy”, and “Africa” for articles published in English or French between Jan 1, 2002 and Dec 31, 2012. Additional data were obtained from the websites of WHO, the International Agency for Research on Cancer, the International Association of Cancer Registries, and the departments of health of South Africa, Nigeria, and Egypt. For each country, reports were semi-structured; although they centred on the presence or absence of a national cancer control plan and included a presentation of the general status of the cancer burden and cancer care facilities, the authors of each section freely described the situation of cancer control planning in their countries.
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whereas another programme, based on increasing public awareness of breast cancer and clinical examination by primary health-care workers, resulted in early diagnosis and treatment of breast cancers.33,34 Some African countries at this stage need the most basic facilities to treat patients with cancer, an endeavour for which they require international support. In higherincome countries, the emphasis should be on improving awareness of the increasing burden of cancer and increasing advocacy activities to put pressure on governments to implement and fund cancer control policies. Contributors DCS wrote the introduction, discussion, and the section about South Africa and edited and revised the paper. AME and HMK wrote the section about Egypt; BWA and SW wrote the section about Ghana; FN and AA wrote the section about Rwanda; and IFA wrote the section about Nigeria. Conflicts of interest DCS sits on the Ministerial Advisory Committee on the Prevention and Control of Cancer in South Africa. IFA chaired the panel that developed Nigeria’s cervical cancer control plan. He also received honoraria from GlaxoSmithKline for participation in various speaker forums, and for serving on the independent data safety monitoring committee for a multinational study. The other authors declare that they have no conflicts of interest. References 1 Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. GLOBOCAN 2008—cancer incidence and mortality worldwide: IARC CancerBase No 10. Lyon: International Agency for Research on Cancer, 2010. 2 Bray F, Møller B. Predicting the future burden of cancer. Nat Rev Cancer 2005; 6: 63–74. 3 WHO. National cancer control programmes: policies and managerial guidelines, 2nd edn. Geneva: World Health Organization, 2002. 4 WHO. World Health Assembly Resolution WHA58.22 (May 2005). http://www.who.int/ipcs/publications/wha/cancer_resolution.pdf (accessed Jan 11, 2013). 5 WHO. Cancer control: knowledge into action. http://who.int/ cancer/modules/en/index.html (accessed Jan 11, 2013). 6 WHO. Global status report on non-communicable diseases 2010. Geneva: World Health Organization, 2011. http://who.int/nmh/ publications/ncd_report2010/en/index.html (accessed Jan 12, 2013). 7 WHO. Global Health Observatory data repository: NCD country capacity survey 2010. http://apps.who.int/gho/data/ (accessed Jan 13, 2013). 8 International Association of Cancer Registries. IACR members— Africa—October 2009. www.iacr.com.fr/Africact_oct09.pdf (accessed Jan 13, 2013). 9 IARC. Cancer incidence in five continents—cancer registry list. ci5. iarc.fr/CI5I-IX/Ci5i-ix.htm (accessed Jan 13, 2013). 10 National Cancer Registry of South Africa (NCR-SA) http://afcrn.org/ membership/membership-list/87-ncr-sa (accessed Feb 26, 2013). 11 Mayosi BM, Flisher AJ, Lalloo UG, Sitas F, Tollman SM, Bradshaw D. The burden of non-communicable diseases in South Africa. Lancet 2009; 374: 934–47. 12 WHO. The global burden of disease: 2004 update. Geneva: World Health Organization, 2008. 13 Statistics South Africa. Mortality and causes of death in South Africa, 2009: findings from death notification. Statistical Release P0309.3. Pretoria: Statistics South Africa, 2011. 14 WHO. Tuberculosis profile: South Africa. https://extranet.who.int/ sree/Reports?op=Replet&name=%2FWHO_HQ_Reports%2FG2%2 FPROD%2FEXT%2FTBCountryProfile&ISO2=ZA&LAN=EN&outty pe=html (accessed Dec 21, 2012). 15 Ncayiyana DJ. A cancer control programme for South Africa. S Afr Med J 1994; 84: 315. 16 Tobacco Products Control Act, 1993. http://www.acts.co.za/tobacco/ index.htm (accessed March 10, 2013).
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Harford JB. Breast-cancer early detection in low-income and middle-income countries: do what you can versus one size fits all. Lancet Oncol 2011; 12: 306–12. Omar S, Elzawawy A, Omar A. Down staging of the breast cancer in a low resource setting, rural (Fakous Cancer Centre) and urban (Port Said)—Egypt. Global Summit on International Breast Health; Chicago IL, USA; June 9–11, 2010. http://portal.bhgi.org/ GlobalPortfolio/globalsummit/Documents/Presentations/OMAR. pdf (accessed Feb 18, 2013). Elzawawy A. Science and affordability of cancer drugs and radiotherapy in the world—win–win scenarios. In: Mohan R, ed. Advances in cancer management. InTech, 2012: 255–78. http://cdn. intechopen.com/pdfs/26808/InTech-Science_and_affordability_of_ cancer_drugs_and_radiotherapy_in_the_world_win_win_scenarios. pdf (accessed Feb 12, 2013). Central Intelligence Agency. World Factbook: Ghana. https://www. cia.gov/library/publications/the-world-factbook/geos/gh.html (accessed March 1, 2013). Abdullahi AA. Trends and challenges of traditional medicine in Africa. Afr J Tradit Complement Altern Med 2011; 8 (suppl 5): 115–23. Wiredu EK, Armah HB. Cancer mortality patterns in Ghana: a 10-year review of autopsies and hospital mortality. BMC Public Health 2006; 6: 159. Abbey EE. Cancer cases alarming. Ghanamma.com, Nov 7, 2012. http://www.ghanamma.com/archive/2012/11/cancer-cases-alarming (accessed Feb 5, 2013). Anderson BO, Cazap E, El Saghir NS, et al. Optimisation of breast cancer management in low-resource and middle-resource countries: executive summary of the Breast Health Global Initiative consensus, 2010. Lancet Oncol 2011; 12: 387–98. Vanderpuye V. The current state of cancer care in Ghana: geography should not hinder patient care. ASCO Daily News. http:// chicago2012.asco.org/ASCODailyNews/PalliativeinGhana.aspx (accessed Feb 5, 2013). Clegg-Lamptey J, Dakubo J, Attobra YN. Why do breast cancer patients report late or abscond during treatment in Ghana? A pilot study. Ghana Med J 2009; 43: 127–31. Ghana News Agency. Breast cancer survivors advocate sustained education on disease. Ghana News Agency, Jan 27, 2013. http:// ghananewsagency.org/health/breast-cancer-survivors-advocatesustained-education-on-disease-55566 (accessed Feb 5, 2013). AfrOx. Where we work. http://www.afrox.org/19/where-we-work (accessed Feb 4, 2013). Central Intelligence Agency. World Factbook: Rwanda. https://www. cia.gov/library/publications/the-world-factbook/geos/rw.html (accessed Feb 22, 2013). African Cancer Registry Network. Rwanda Cancer Registry. http://afcrn.org/membership/members/80-rwanda-cancer-registry (accessed March 10, 2013).
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Cancer Control in Africa 7 Developing cancer control plans in Africa: examples from five countries Daniela Cristina Stefan, Ahmed M Elzawawy, Hussein M Khaled, Fabien Ntaganda, Anita Asiimwe, Beatrice Wiafe Addai, Seth Wiafe, Isaac F Adewole
The creation and implementation of national cancer control plans is becoming increasingly necessary for countries in Africa, with the number of new cancer cases per year in the continent expected to reach up to 1·5 million by 2020. Examples from South Africa, Egypt, Nigeria, Ghana, and Rwanda describe the state of national cancer control plans and their implementation. Whereas in Rwanda the emphasis is on development of basic facilities needed for cancer care, in those countries with more developed economies, such as South Africa and Nigeria, the political will to fund national cancer control plans is limited, even though the plans exist and are otherwise well conceived. Improved awareness of the increasing burden of cancer and increased advocacy are needed to put pressure on governments to develop, fund, and implement national cancer control plans across the continent.
Introduction Roughly 715 000 new cases of cancer occurred in Africa in 2008 according to GLOBOCAN data,1 and almost 542 000 people died from malignant disease. 5-year prevalence was almost 1·5 million cases, putting substantial demand on already overstretched health-care budgets. Worldwide, cancer incidence could potentially increase to as many as 17 million new cases per year by 2020;2 of these, possibly as many as 1·5 million will occur in Africa. Around the world, many governmental and nongovernmental organisations (NGOs), philanthropic and for-profit outfits, research and higher-education institutions, religious organisations, associations of health-care professionals, parent and patient groups, and many others contribute to the fight against cancer. However, a framework is necessary so that these efforts can be focused and efficiently organised. The establishment of national cancer control plans (also known as national cancer control programmes) by governments can provide the necessary guidance towards control, even where resources are scarce. WHO3 defines national cancer control programmes as “public health programmes designed to reduce cancer incidence and mortality and improve quality of life of cancer patients, through the systematic and equitable implementation of evidence-based strategies for prevention, early detection, diagnosis, treatment, and palliation, making the best use of available resources”. In 2005, the World Health Assembly adopted resolution 58.22,4 which urged member states to intensify action against cancer through the creation of national cancer control programmes, adapted to conditions in each country. From 2006 to 2008, WHO produced a series of six modules that deal with the practicalities of creating and implementing such programmes.5 In view of WHO’s call to action and detailed guidance, many countries in Africa might be expected to have made www.thelancet.com/oncology Vol 14 April 2013
some progress towards the introduction of measures aimed at cancer control. In 2010, WHO did a worldwide assessment of the status of national efforts to fight non-communicable diseases.6,7 Disappointingly, of 46 respondent countries in Africa, only 17 countries (panel) had operational policies, strategies, or action plans for cancer (these terms do not necessarily imply a formal national cancer control plan) in 2010; even more concerning, only 17% of national programmes against non-communicable diseases in Africa were funded. Cancer is a substantial public health problem in Africa; however, few exact data are available—GLOBOCAN data for the continent are mostly estimates. Ideally, accurate data to guide national policies should be provided by national cancer registries. Such data are needed not only to assess the size of the burden of disease, but also to investigate potential risk factors for cancer, to estimate the optimum geographical distribution of resources, to project expenditure, and to measure the effectiveness of policies for prevention and treatment. However, in 2009 the International Association of Cancer Registries reported only 15 national registries in Africa,8 the remaining 60 being hospital or city registries only. Some of these registries are not always functioning—their activities can often be suspended for various lengths of time because of shortages of funds or personnel. Only 12 African countries had reported their data to the International Agency for Research on Cancer (IARC) incidence database9 up to 2002.
Lancet Oncol 2013; 14: e189–95 This is the seventh in a Series of seven papers about cancer control in Africa See Comment page 277 Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa (Prof D C Stefan PhD); Department of Clinical Oncology, Suez Canal University, Suez, Egypt (A M Elzawawy MD); National Cancer Institute, Cairo University, Cairo, Egypt (H M Khaled MD); Rwanda Biomedical Center, King Faisal Teaching Hospital/Rwanda Military Hospital, Kigali, Rwanda (F Ntaganda MMed); Institute of HIV Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda (A Asiimwe MPH); Peace and Love Hospital, Accra, Ghana (B W Addai PhD, S Wiafe MPH); Department of Obstetrics and Gynaecology, College of Medicine, University of Ibadan, Ibadan, Nigeria (Prof I F Adewole FAS); and African Organisation for Research and Training in Cancer, Cape Town, South Africa (I F Adewole) Correspondence to: Prof Daniela Cristina Stefan, PO Box 19063, Department of Paediatrics and Child Health, Tygerberg Hospital and Stellenbosch University, Tygerberg, Cape Town 7505, South Africa [email protected]
Panel: Countries in Africa with operational policies, strategies, or action plans for cancer in 2010 Algeria, Benin, Cameroon, Côte d’Ivoire, Djibouti, Egypt, Gabon, Guinea, Madagascar, Maldives, Mozambique, Niger, Nigeria, South Africa, Tunisia, Zambia, and Zimbabwe Data are from WHO.6,7
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The aim of this Series paper is to explore the obstacles encountered in the establishment and implementation of national cancer control plans Although not all findings will be applicable to every other country in the continent, an attempt was made to select somewhat representative countries—three of the more populous countries in Africa with the largest economies (South Africa, Nigeria, and Egypt) were included, as well as Ghana (a mediumsized country) and Rwanda (a relatively small country).
South Africa In April, 2011, South Africa’s Department of Health instituted compulsory cancer registration. 2 years previously, the department had revitalised the National Cancer Registry (which had been established in 1986, but had become almost inactive after 2004 because of insufficient funding and a reduction in incoming reports).10 These two measures represent the growing awareness of the substantial burden of non-communicable diseases in general, and cancers in particular, in South Africa.11 According to a WHO estimate,12 non-communicable diseases caused 28% of the total burden of disease in South Africa in 2004; cancers alone caused about 3% of the total disease burden. Statistics based on 2009 death notifications13 suggest that cancers caused almost 40 000 deaths (6·3% of total deaths) and as such were the third most common cause of death, surpassed only by tuberculosis and by influenza grouped together with pneumonia. Age-standardised incidence of cancer in South Africa was 202 per 100 000 people, according to GLOBOCAN estimates for 2008.1 For the population of 50 million, this incidence is equivalent to 101 000 new cases that year. By comparison, the incidence of tuberculosis in 2011 was 993 per 100 000 people.14 The most common cancers in men were those of the prostate, lung, oesophagus, colorectum, and liver, as well as Kaposi’s sarcoma; in women, cancers of the breast, uterine cervix, oesophagus, colorectum, lung, and uterine corpus were the most common.1 The burden of cancer in South Africa is not a new concern for the health authorities, NGOs, and medical professionals in the country. In 1993, the Cancer Association of South Africa (CANSA) organised a workshop at which the constitution of a national cancer control programme based on WHO recommendations was proposed. Representatives of medical schools, the Medical Research Council, the South African Institute for Medical Research, the outgoing Department of National Health and Population Development, provincial administrations, hospice organisations, and NGOs involved in the effort to control cancer proposed the constitution of a national cancer control programme, based on WHO recommendations and coordinated by a committee supported by the Department of Health. The role of the national cancer control programme was to initiate, coordinate, and monitor all cancer control activities in the country; to combine fundraising efforts; e190
and to militate for improvements in environment and lifestyle as a means to reduce the population risk for cancer. Members of the programme’s steering committee were to be drawn from CANSA and from other NGOs and governmental organisations.15 However, the initiative was not backed by the incoming Department of Health, constituted after the 1994 elections. Other priorities were competing for the healthcare budget and above all the towering challenge of AIDS, with its associated increase in incidence of tuberculosis, demanded a substantial share of health expenditure. Antiretroviral drugs were made available free of charge, both for control of advanced HIV infection and to prevent transmission to the fetus during pregnancy. Several governmental policies did, however, have the potential to reduce the cancer burden. As early as 1993, the Tobacco Products Control Act restricted the advertising of tobacco products and prohibited smoking in public places; later amendments prohibited sponsorships by tobacco manufacturers and introduced further restrictions on vending tobacco products, including raising the minimum age from 16 to 18 years.16,17 A small decrease in the incidence of lung cancer in men suggests that this policy might be having some beneficial effect.18 The Liquor Act does not seem to have been as effective in reducing the consumption of alcohol and no reduction in alcohol-related cancers has been noted.19 Universal screening for cervical cancer was introduced in South Africa in 2000. With only three cervical cytology tests, at ages 30, 40, and 50 years, the programme has the potential to halve the number of new cases of invasive cervical cancer. However, uptake of screening is poor20 and a substantial number of women are lost to follow-up by colposcopy; no statistical assessment yet been reported. The policy is being revised, with one aim being the introduction of a special screening schedule for women with HIV infection, since they can develop cervical cancer at younger ages than women from the general population. A directorate for chronic diseases, disabilities, and geriatrics was established within the Department of Health in 1996. The directorate adopted the CANSA national cancer control programme in 1999 and updated it in 2009. The programme constitutes a comprehensive foundation for effective policies. Cancers of the cervix, prostate, breast, colon, and rectum are set as prominent targets for secondary prevention, and essential prevention modalities are described. Furthermore, the programme also suggests ways to control the prevalent carcinogens in the country—eg, through alcohol control policies. Lastly, clear and comprehensive recommendations are made for the content of future cancer reduction policies. Notwithstanding these developments, the strategic plan21 of the Department of Health for 2011–13 did not mention cancer control on its list of priorities. With few resources, spending had to be prioritised in favour of maintaining the health status of the young, economically and reproductively active segment of the population, www.thelancet.com/oncology Vol 14 April 2013
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which means the targeting of HIV/AIDS, tuberculosis, trauma, and chronic diseases such as cardiovascular diseases and diabetes. HIV infection remains highly prevalent (16·5% of people aged 15–49 years in 2011) and the disease commanded an expenditure of 13 billion rand in 2009.22,23 Only small steps in the right direction have been taken in the past few years. One was the designation of cancer as a notifiable disease. This decision removes the reservations related to patient confidentiality that caused many private medical institutions to abandon reporting of cancers in the past. Together with a functional cancer registry, more accurate measurement of the effect of malignant disease on population health and of the effectiveness of any preventive or curative interventions should now be possible. The establishment of a Ministerial Advisory Committee on the prevention and control of cancer in 2012 is another positive step. The national cancer control programme, however, is still awaiting funding.
Nigeria With a population of 170 123 740, Nigeria is the most populous country in Africa and the seventh most populous in the world.24 Gross national income per head in 2012 was US$2700 (at purchasing power parity).24 According to GLOBOCAN data,1 almost 102 000 new cases of cancer occur annually in the country, and 75 000 deaths per year are caused by malignant disease. 5-year prevalence in the adult population is roughly 223 000. No nationwide, population-based cancer registry exists, but data provided by some smaller population-based and hospital-based registries can be used to estimate the national burden of cancer. These data suggest that the cancer incidence is increasing.25 For example, the Ibadan Cancer Registry recorded 1093 cases in 2001, with a steady increase to 1576 by 2005. Because of a disproportionately high burden of infectious diseases, Nigeria is among those countries that face the challenge of the so-called double burden of communicable and non-communicable diseases. A national cancer control plan was developed in 2008,26 and represents a bold attempt to bring attention to the challenge of cancer in the country and to chart a path to address it. The overall vision is of a collaboration of all stakeholders to reduce the morbidity and mortality from cancer and its socioeconomic effect on the community, and to improve the health and quality of life of people living with cancer. Cancers of the breast, cervix, liver, prostate, colorectum, and skin, as well as leukaemias and retinoblastoma, are identified as priorities in the plan, with clearly articulated goals for the control of each. Although these goals do generally follow the guidelines for cancer control programmes set by WHO, they omit the control of risk factors for cancer. Within the framework of the national cancer control plan, the Federal Ministry of Health established www.thelancet.com/oncology Vol 14 April 2013
a cervical cancer control plan.27 The plan adopted visual inspection with acetic acid and visual inspection with Lugol’s iodine for screening, and human papillomavirus (HPV) vaccination for primary prevention in girls aged 9–15 years. The process by which the goals of the national cancer control plan are to be achieved have not been defined. The implementation unit is referred to as the cancer control desk, which does not have the necessary funding or personnel to function as needed. Defined measures to fight cancer are not mentioned in the country’s strategic health development plan for 2010–15.28 To succeed in the control of malignant disease, Nigeria needs a cancer control department that is fully empowered and adequately funded.
Egypt Egypt is classified as a lower-middle-income country; however, characteristics of high-income, middle-income, and low-income countries coexist. In 2011, the population was 83 million and life expectancy at birth was 73 years.29 Cancer and cardiovascular diseases are the main components of the non-communicable disease burden. Preceded by a registry for the governorate of Gharbia, the National Cancer Registry Program of Egypt was established in 2007.30,31 The country is now covered by a network of population-based registries that contribute data to the national cancer registry. About 68 800 new cancer cases occur per year.1 Most common in men are cancers of the liver (mostly related to hepatitis C virus), bladder (although incidence is decreasing because of improved control of schistosomiasis), non-Hodgkin lymphoma and leukaemia, and cancers of the lung, prostate, brain and nervous tissue, and colorectum. For women, most common are cancers of the breast, liver, non-Hodgkin lymphoma and leukaemia, and cancers of the ovary, uterine body, bladder, colorectum, and uterine cervix.30,31 Egypt has more facilities for cancer treatment than any other country in Africa; however, many elements of cancer control strategy still need to be implemented or improved.32 Cancer management facilities include the Egyptian National Cancer Institute (part of Cairo University); 14 clinical oncology departments in the other public universities; nine cancer centres affiliated to the Ministry of Health; 11 military cancer units that treat both civilian and military patients; oncology clinics at the hospitals run by the Egyptian Health Insurance Organization in most major cities; semi-private, NGO-operated cancer facilities; a charity-run Centre of Excellence of Paediatric Oncology in Cairo; and private-sector clinics and centres. In addition to surgery, most of these facilities have chemotherapy and radiotherapy capabilities (either linear accelerators or cobalt-60 units). Most centres have CT scanners and MRI machines, and the country has five PET-CT scanners. More than 1500 Egyptians have postgraduate qualifications in clinical and medical oncology. e191
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According to the WHO survey,7 Egypt had an operational policy, strategy, or action plan for cancer in 2010. However, no structured national cancer control programme as recommended by WHO3 is in place. Practical measures are needed for the optimum allocation of available resources to reduce the numbers of cancer cases and deaths and to improve quality of life for patients with cancer, through adoption of WHO recommendations.3 As an example of poorly coordinated policies, an expensive and ineffective government project to implement mammographic screening across Egypt with new mobile units was launched 4 years ago without consideration of the existing allocation of resources or the practicalities involved.33 As a result, after 20 000 mammograms, only about 90 breast cancers had been discovered. By contrast, a programme in the rural region of Fakous and the urban region of Port Said to use local resources to increase awareness of breast cancer and its treatment by organising home visits from primary care workers and meetings with local women resulted in a substantial reduction in cases of advanced breast cancer. About 20% of breast cancer cases in Port Said were amenable to conservative breast cancer surgery in 2008, and the number of stage III and IV cases had halved by 2004–08 compared with 1992–2003.34 Conversely, early detection programmes without access to treatments would be fruitless and frustrating for both patients and health professionals. In addition to a coordinated national cancer control plan based on WHO guidelines, a few other recommendations could enhance the effectiveness of cancer care in Egypt. First, effective cancer prevention programmes customised to the community should be fostered, particularly for tobacco control, prevention of hepatitis C infection, and breast cancer awareness. Second, affordability of curative and palliative care could be improved via the approaches described in the win-win scientific initiative (ie, through evidence-based optimisation of diagnostic and therapeutic protocols, without compromisation of patient outcomes).35 Third, the notions of value and effectiveness in cancer care should be adopted. Fourth, the health-care workforce should be efficiently coordinated by an accountable leadership. Fifth, efforts should be made to ensure the continuity and progress of the national cancer registry and to support the exchange of information internationally, both within Africa and beyond. Sixth, training and workforce capacity building are needed to improve research into cost-effective cancer-control interventions and clinical trials. Finally, cooperation and partnerships with regional, African, and global organisations should be enhanced, with special emphasis on partnerships with organisation such as the African Organisation for Research and Training in Cancer. e192
Ghana Ghana has a population of 24 million people, and the median life expectancy is 59 years.36 According to one estimate,30 the country has an average of one nurse for every 1500 and one doctor for every 20 000 people.37 No systematic national cancer programme is in place and the development of a national cancer registry is at a rudimentary stage.38 As a result, accurate estimation of the national cancer burden is difficult. Moreover, without accurate information about the regional distribution of cancers in the country, no realistic basis exists upon which to match the provision of cancer care with demand to ensure efficient resource use and equitable access. According to GLOBOCAN,1 roughly 16 000 cases of cancer occur annually in Ghana, with the five most common being cancers of the liver, breast, cervix, prostate, and stomach.38 Cancer is the fourth most common cause of death in the country.39 Five oncology centres now operate in Ghana: the Korle Bu Teaching Hospital and the Peace and Love Hospital in Accra; the Komfo Anokye Teaching Hospital and the Peace and Love Hospital in Kumasi; and the Sweden Ghana Medical Centre in Tema. Radiation oncologists are scarce, and are concentrated at Korle Bu and Komfo Anokye teaching hospitals. Once its radiotherapy unit is installed, the Peace and Love Hospital in Kumasi will become the only fully fledged breast cancer treatment centre in the country.40 Currently, the Sweden Ghana Medical Centre provides only radiotherapy and chemotherapy, since it has not started to offer surgery. No specialised oncology nursing school exists in the country, so general nurses who have received some minimum training in oncology staff the cancer centres. Cancer care in Ghana has improved substantially in the past 10 years. Solid tumours used to be managed entirely with surgery followed by some form of chemotherapy, or by chemotherapy alone.41 Patients with metastatic disease received no palliative care. However, since radiotherapy was introduced to Korle Bu Teaching Hospital in 1997 and to Komfo Anokye Teaching Hospital in 2004, multidisciplinary approaches with some adjuvant treatments and palliative care strategies have enhanced cancer management in the country. Despite these advances, however, most patients with cancer still present at late stages,42 because of personal factors and deficiencies in the general health-care system. As well as advances in cancer management in Ghana,41 patient awareness has improved, with the support of the media, physicians, and NGOs, such that patients are more aware of the curative and palliative treatments available and the need for early diagnosis and treatment. As a result, the number of people who turn up for medical consultation with early symptoms of cancer is increasing, patients are living longer, and cancer survivor groups such as the Peace and Love Survivors Association are being inaugurated with hundreds of members.43 www.thelancet.com/oncology Vol 14 April 2013
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Ghana faces several challenges to cancer management, including a scarcity of trained professionals and the prohibitive costs of investigations and treatments.41 Although a systemic shortage of drugs affects the country, oncology treatment centres are working with insurance and pharmaceutical companies to make basic cancer drugs available through the national health insurance system.41 The government, through the Ministry of Health and the Ghana Health Service, is committed to improve cancer care through collaboration with international organisations such as the International Atomic Energy Agency’s programme of action for cancer therapy and the Africa Oxford Cancer Foundation for the development of a comprehensive national cancer control plan. The plan is expected to cover a wide range of strategies and related policies, including raising public awareness of cancer; cancer prevention through screening and vaccination; early diagnosis and treatment of cancer in children; improvement of palliative care; and training and education of health-care staff.44 In view of the paucity of qualified workers and technological resources, integrated, evidence-based, and cost-effective interventions throughout the cancer management process would be the most effective way to confront the rising cancer burden in Ghana.
Rwanda Rwanda has a population of more than 11 million people and a median life expectancy of 58 years. Health expenditure was 9% of gross domestic product in 2009, and there are roughly two physicians for every 100 000 people.45 According to GLOBOCAN data,1 6600 new cases of cancer occur annually; the five most common are cervical cancer, liver cancer, Kaposi’s sarcoma, and cancers of the stomach and breast. About 5300 people die from cancer each year. Rwanda does not have a formal national cancer control plan as defined by the WHO guidelines. However, several initiatives have been launched by the Ministry of Health, in collaboration with various international donors and medical institutions, which focus on prevention, diagnosis, treatment, and palliation. Plans exist to formalise these initiatives into a national cancer programme. Four pilot hospitals—King Faisal Hospital and Rwanda Military Hospital (both in Kigali), University Hospital Centre of Kigali (Centre Hospitalier Universitaire de Kigali, Kigali), and Butaro Hospital in Burera District—have been selected to handle cancer care; other hospitals will be made operational for cancer management in the future. The Rwandan Ministry of Health has both in-country and international partners in cancer management, and additional collaborators would be welcomed. Partners currently working at sketching out a national cancer programme are the Ministry of Health, Rwanda Biomedical Centre (Kigali), Partners in Health (Boston, MA, USA), and Rwanda 4cure (affiliated with Memorial www.thelancet.com/oncology Vol 14 April 2013
Sloan-Kettering Cancer Center [New York, NY, USA]), and Stellenbosch University (Cape Town, South Africa). Cancer prevention and control activities cover HPV vaccination, anti-tobacco campaigns, and population information campaigns about healthy lifestyles, and soon will include early detection by use of a pilot mobile clinic in the Kigali area. Treatment of patients with cancer is based on the national cancer protocol, which was created and adopted in 2012 at the Annual International Conference on Child Health in Kigali, with the collaboration of members of Partners in Health, WHO Regional Office for Africa, Stellenbosch University, Strasbourg University, and the University of Dakar. Seven cancers in adults have been prioritised: prostate cancer, breast cancer, lymphoma, chronic myeloid leukaemia, colorectal cancer, gastric cancer, and multiple myeloma. In paediatric oncology, acute lymphoblastic leukaemia, Burkitt’s lymphoma, nephroblastoma, non-Hodgkin lymphoma, and Hodgkin’s lymphoma have been prioritised. These priorities were defined on the basis of the prevalence of each cancer in Rwanda and the availability of treatments. Although no exact data for the incidence and prevalence of cancers in Rwanda exist, an initiative was launched by the Ministry of Health in 2010 to institute a national cancer registry.46 Two hospitals are currently providing effective cancer treatment—Butaro Hospital in Burera District and King Faisal Hospital in Kigali. The other two hospitals listed among the pilots will be operational for cancer management in the near future. One centre (Kibagabaga Hospital in Gasabo District of Kigali) has been designated as a palliation centre, and is operating effectively. Diagnostic capacity in Rwanda is poor; histology departments offer basic immunostaining and assessment of markers for breast cancer. Haematology capacity is limited to morphology and to the few stains that are usually available. MRI is only available at King Faisal Hospital. Several training activities have been implemented in specific centres to advance cancer management, chemotherapy, and infection control for patients with cancer. Financing of cancer management in Rwanda remains a tough question to address—cancer care requires substantial and sustained investment of resources. Development of the necessary skills is also a major challenge, but one that can be addressed progressively, in partnership with international cancer institutions.
For more on the International Atomic Energy Agency’s programme of action for cancer therapy see http://cancer. iaea.org/index.asp For more on the Africa Oxford Cancer Foundation see http://www.afrox.org/
Discussion Several commonalities can be identified from these five country examples. For example, an increasing awareness that national cancer registries are essential to understand the epidemiology of cancer, to create effective policies, and to trace progress in prevention and treatment is apparent. Thus, steps are being taken to create such registries or to support and extend the activity of existing ones. e193
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Another common thread is the scarcity of resources available for the fight against cancer. This problem is especially evident in countries with relatively small, agriculture-based economies. For example, Rwanda receives some international aid money and its cancer care infrastructure relies to a large extent on external funds and foreign personnel.45 Under these circumstances, the priority is to establish basic curative and palliative facilities on a sustainable basis. Although less of a problem for wealthier countries such as South Africa and Egypt, the development and retention of skills is a crucial issue for poorer countries such as Rwanda and Ghana. Such countries rely on international collaboration for the training of doctors and nurses in oncology care. In countries with relatively large economies, such as South Africa and Nigeria, well conceived national cancer control plans might exist, but are not adequately funded. In such cases the scarcity of resources is relative—health budgets are mostly spent on containing infectious diseases, among which malaria, tuberculosis, and HIV are most prevalent. The young and economically active segment of the population can be substantially affected by these diseases, and national prosperity depends on the good health of this population group. In addition, cancer treatment is resource-intensive and costly, and because most patients present late, their survival is short. People affected by cancer rarely develop political influence (eg, as politically active survivor groups) because most patients do not live long enough. Moreover, the effect of risk factors for cancer (eg, tobacco smoking) is not immediately apparent, but rather takes decades, and does not manifest itself in all exposed individuals. A very clear awareness of risk factors for cancer is necessary in the population so that pressure can be exerted on political leaders to institute policies for cancer prevention. The case of Egypt shows the need for concerted and rational use of resources, which could have been facilitated by a national cancer control plan; one mammography programme proved to be expensive and ineffective,
Search strategy and selection criteria We searched PubMed and Google Scholar using the terms “(national) cancer plan/programme”, “cancer policy”, and “Africa” for articles published in English or French between Jan 1, 2002 and Dec 31, 2012. Additional data were obtained from the websites of WHO, the International Agency for Research on Cancer, the International Association of Cancer Registries, and the departments of health of South Africa, Nigeria, and Egypt. For each country, reports were semi-structured; although they centred on the presence or absence of a national cancer control plan and included a presentation of the general status of the cancer burden and cancer care facilities, the authors of each section freely described the situation of cancer control planning in their countries.
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whereas another programme, based on increasing public awareness of breast cancer and clinical examination by primary health-care workers, resulted in early diagnosis and treatment of breast cancers.33,34 Some African countries at this stage need the most basic facilities to treat patients with cancer, an endeavour for which they require international support. In higherincome countries, the emphasis should be on improving awareness of the increasing burden of cancer and increasing advocacy activities to put pressure on governments to implement and fund cancer control policies. Contributors DCS wrote the introduction, discussion, and the section about South Africa and edited and revised the paper. AME and HMK wrote the section about Egypt; BWA and SW wrote the section about Ghana; FN and AA wrote the section about Rwanda; and IFA wrote the section about Nigeria. Conflicts of interest DCS sits on the Ministerial Advisory Committee on the Prevention and Control of Cancer in South Africa. IFA chaired the panel that developed Nigeria’s cervical cancer control plan. He also received honoraria from GlaxoSmithKline for participation in various speaker forums, and for serving on the independent data safety monitoring committee for a multinational study. The other authors declare that they have no conflicts of interest. References 1 Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. GLOBOCAN 2008—cancer incidence and mortality worldwide: IARC CancerBase No 10. Lyon: International Agency for Research on Cancer, 2010. 2 Bray F, Møller B. Predicting the future burden of cancer. Nat Rev Cancer 2005; 6: 63–74. 3 WHO. National cancer control programmes: policies and managerial guidelines, 2nd edn. Geneva: World Health Organization, 2002. 4 WHO. World Health Assembly Resolution WHA58.22 (May 2005). http://www.who.int/ipcs/publications/wha/cancer_resolution.pdf (accessed Jan 11, 2013). 5 WHO. Cancer control: knowledge into action. http://who.int/ cancer/modules/en/index.html (accessed Jan 11, 2013). 6 WHO. Global status report on non-communicable diseases 2010. Geneva: World Health Organization, 2011. http://who.int/nmh/ publications/ncd_report2010/en/index.html (accessed Jan 12, 2013). 7 WHO. Global Health Observatory data repository: NCD country capacity survey 2010. http://apps.who.int/gho/data/ (accessed Jan 13, 2013). 8 International Association of Cancer Registries. IACR members— Africa—October 2009. www.iacr.com.fr/Africact_oct09.pdf (accessed Jan 13, 2013). 9 IARC. Cancer incidence in five continents—cancer registry list. ci5. iarc.fr/CI5I-IX/Ci5i-ix.htm (accessed Jan 13, 2013). 10 National Cancer Registry of South Africa (NCR-SA) http://afcrn.org/ membership/membership-list/87-ncr-sa (accessed Feb 26, 2013). 11 Mayosi BM, Flisher AJ, Lalloo UG, Sitas F, Tollman SM, Bradshaw D. The burden of non-communicable diseases in South Africa. Lancet 2009; 374: 934–47. 12 WHO. The global burden of disease: 2004 update. Geneva: World Health Organization, 2008. 13 Statistics South Africa. Mortality and causes of death in South Africa, 2009: findings from death notification. Statistical Release P0309.3. Pretoria: Statistics South Africa, 2011. 14 WHO. Tuberculosis profile: South Africa. https://extranet.who.int/ sree/Reports?op=Replet&name=%2FWHO_HQ_Reports%2FG2%2 FPROD%2FEXT%2FTBCountryProfile&ISO2=ZA&LAN=EN&outty pe=html (accessed Dec 21, 2012). 15 Ncayiyana DJ. A cancer control programme for South Africa. S Afr Med J 1994; 84: 315. 16 Tobacco Products Control Act, 1993. http://www.acts.co.za/tobacco/ index.htm (accessed March 10, 2013).
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