cancer epidemiology and program implementation in low and middle income (lmi) countries: a lesson to...
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Cancer Epidemiology and ProgramImplementation in Low and Middle
Income (LMI) Countries:
A Lesson to Learn
David B. Thomas, MD, DrPH
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Outline of Talk
Cancers of major concern in LMI countries
Setting priorities for cancer control activities inLMI countries
Estimating the magnitude of the cancer problemand identifying high risk groups in LMI
Cancer registration in LMI
The role of epidemiology in the planning andevaluation of cancer control programs in LMIcountries
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Cancers of Major concern in Low and
Middle Income (LMC) Countries
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As a country transitions from a less
developed to a more developed countrycancer will become a more important
problem for 2 reasons:
Rates of most cancers increase with age, so asmore people live longer, more people will
enter the high risk age groups
Rates of many cancers increase as a
population develops a more western life
style
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Age Specific Mortality Rates ofColon Cancer in Japan
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Incidence Rates ofBreast Cancer in 9 Asian
Populations over Time
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In addition to becoming a greater
problem in the future, cancer will
be come a greater problem in
relation to other health problemsas these other health problems
come under control.
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Causes of Death in Thailand, China, South
Korea, and Belgium
(WHO, 2002)
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What are the most common
cancers in LMI countries now, andwhat will be the most common
cancers in the future?
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The 12 Most Common Cancers in the
Developed and Developing Regions of the
World, 2002
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The 12 Most Common Cancers in the
Developed and Developing Regions of the
World, 2002
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The Most Frequent Cancers in LMI
CountriesMales
Now
Lung
Stomach
Liver
Esophagus
In the Future
Lung
Prostate
Colorectal
Bladder
Females
Now
Breast
Cervix
Stomach
Lung
In the Future
Breast
Colorectal
Lung
Corpus uteri
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Outline of Talk
Cancers of major concern in LMI countries
Setting priorities for cancer control activities inLMI countries
Estimating the magnitude of the cancer problemand identifying high risk groups in LMI
Cancer registration in LMI
The role of epidemiology in the planning andevaluation of cancer control programs in LMIcountries
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Setting Priorities for Cancer Control
Activities In planning for cancer control activities,
priorities must be set on the basis of:
The magnitude of the problem (What are the
most important cancer in the population?)
What can be done about the problem?
Primary prevention
Secondary prevention
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Primary Prevention:
Reduce the occurrence of the cancer by
reducing exposure to cancer causing agentsExamples:
Reduce smoking to prevent lung cancer
Reduce exposure to asbestos in the work place
to prevent mesothelioma
Vaccinate against human papilloma viruses to
prevent cervical cancer Vaccinate against hepatitis B virus to prevent
liver cancer
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Secondary Prevention:
Early detection of cancer followed by
attempts at curative treatment
Examples:
Mammographic screening for breast cancer
followed by effective treatment Pap smears for detection of cervical cancer
followed by effective treatment
Note: Before screening can begin, there must
be sufficient resources for diagnosticevaluation in those who screen positive, andtreatment of those found to have the cancer.
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Highest Priority for Cancer Control in
LMI Countries (Underlined)Males
Now
Lung
Stomach
Liver
Esophagus
In the Future
Lung
Prostate
Colorectal
Bladder
Females
Now
Breast
Cervix
Stomach
Lung
In the Future
Breast
Colorectal
Lung
Corpus uteri
Note: This is an example. The actual cancers of highest priority in Indonesia may
differ from these. If possible, priority for cancer control activities should be
established based on local data.
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Outline of Talk
Cancers of major concern in LMI countries
Setting priorities for cancer control activitiesin LMI countries
Methods for assessing the cancer problemlocally
Cancer registration in LMI
The role of epidemiology in the planning andevaluation of cancer control programs in LMIcountries
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Proportional Mortality ratios
Definition: The percentage of all deaths thatare due to various causes
Based on death certificates
Gives information on what the mostimportant causes of death are
Can be misleading due to:
under-reporting of deaths
misclassification of cause of death
the frequency of other causes of death
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Methods for Assessing the Cancer
Problem Locally
Proportional mortality ratios
Proportional incidence ratios
Mortality rates
Incidence rates
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Methods for Assessing the CancerProblem Locally
Proportional mortality ratios
Proportional incidence ratios
Mortality rates
Incidence rates
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What is needed in order to obtain accurate
mortality rates?
Accurate census of the population
Complete ascertainment of all deaths
Accurate information on cause of death
A statistical unit that can analyze the data
Note: Cancer mortality rates will show which cancers are the most
common causes of death. Cancers with the poorest prognosis will
be over-represented, and cancers with better prognosis will be
under-represented by mortality rates.
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Methods for Assessing the CancerProblem Locally
Proportional mortality ratios
Proportional incidence ratios
Mortality rates
Incidence rates
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What is needed in order to obtain accurate
cancer incidence rates?
Accurate census of the population
Complete ascertainment of all cancer cases bya population-based cancer registry
Accurate information on type of cancer
A statistical unit that can analyze the data
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Outline of Talk
Cancers of major concern in LMI countries
Setting priorities for cancer control activitiesin LMI countries
Methods for assessing the cancer problemlocally
Cancer registration in LMI
The role of epidemiology in the planning andevaluation of cancer control programs in LMIcountries
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Some Comments on Establishing a
Population Based Cancer Registry-1 With limited resources it is far better to
establish one or more good registries in
carefully selected areas than to attempt toregister all cancers in a large population
such as Indonesia
Selected areas can then serve as resourcesfor conducting epidemiologic studies and
evaluating cancer control programs
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Some comments on Establishing a
Population Based Cancer Registry-2
Criteria for choosing a population for a cancerregistry:
An accurate census, or the facilities and resourcesneeded to obtain accurate census information Large enough population to generate enough cancer
cases to provide stable incidence rates (1-2 million ) Small enough to be able to obtain information on all
of the cancer cases with the available resources. All cancers are treated in a single hospital, or just a
small number of hospitals People should not go out of the area for care
(although people may come into the area for care)
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Some comments on Establishing a
Population Based Cancer-3 The level of cooperation of local offices of
vital statistics, health departments, hospitalsand pathology laboratories in the area mustbe considered
Consider populations of special interest:For example, different ethnic groups of
interest (e.g. in Indonesia, Javanese,Sundanese, Malays, Madurese, Chinese)
For example, populations with unusualexposures of interest (e.g. in areas withexposures to mines or petroleum refineries)
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Some comments on Establishing a
Population Based Cancer-4
Establish a population based registry only if:
There are trained epidemiologist who willutilize the registry to answer relevantquestions
The important questions cannot be answeredby other means (such as hospital-based caseseries, or mortality statistics)
A population-based registry should only be
established if there is a stable source of
funding to ensure that the registry can be
maintained over a long period of time
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Some Comments on Establishing a
Population Based Cancer-5
A population-based registry is best
established in association with a healthdepartment, university, or research
institution so that the data can be
appropriately used for studies of cancer
etiology and cancer care, that provide
answers to questions that need to be
answered to inform decision makers.
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The Role of Epidemiology in The Planning
and Evaluation of Cancer Control Activities
Assess the magnitude of the problem and
identify the most important cancers (already
discussed) Identify high risk groups of people
Assist in designing programs so that they can
be rigorously evaluated
Evaluate success of cancer control programs
Primary prevention programs (prevention of disease)
Secondary prevention programs (reduction in deaths dueto the disease)
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Identification of High Risk Groups of people
People at high risk of disease (for primary prevention)
Identification of groups of people at high risk of getting thedisease (as discussed)
Identification of people at high risk of exposure to knowncarcinogenic agents
E.g. smokers (tobacco smoke), women with sexuallytransmitted diseases (HPV), certain industrial workers(asbestos miners, dye workers)
People at high risk of advanced disease (for secondaryprevention)
Identification of people without access to screeningfacilities
Identification of people who present with advanceddisease
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The Role of Epidemiology in The Planning
and Evaluation of Cancer Control Activities
Assess the magnitude of the problem and
identify the most important cancers (already
discussed)
Identify high risk groups of people
Assist in planning programs so that they can be
rigorously evaluated
Evaluate success of cancer control programs Primary prevention programs (prevention of disease)
Secondary prevention programs (reduction in deaths dueto the disease)
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Measurements of success of Primary and
Secondary Prevention Programs
Primary prevention programs Intermediate endpoint: reduction in exposure to a
carcinogen (e.g. smoking)
Ultimate goal: a reduction in the incidence of the disease
(very long term) Secondary prevention programs
Intermediate endpoints:
Down staging of disease at diagnosis
Increase in survival
Ultimate goal: a reduction in mortality due to thedisease (long term)
Note: a reduction in stage and an increase in survival can occurwithout a reduction in mortality.
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Examples of Planning and Evaluation
of Cancer Control Programs
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Two methods of Implementation and
Evaluation of Secondary PreventionPrograms
Feasibility project to determine whether:
the methods proposed for use in a screening
program are likely to be efficacious, and whether
implementation of the program is likely to be
successful.
Phased implementation of a screening programto determine if the program is efficacious
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An Example of a Feasibility Project:
Early Breast Cancer Detection Through
Clinical Breast Examination Training for
Midwives in Rural Jakarta, Indonesia
[Dr. Kardinah and colleagues]
Purpose: To determine whether training
midwives to perform CBE, and to teach
women BSE, can result in breast cancers
being diagnosed at an earlier stage Location: Sub-District of Koja in Jakarta
Population: 284,000 women eligible for screening
6 primary health clinics
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Early Breast Cancer Detection Through
Clinical Breast Examination Training for
Midwives in Rural Jakarta (Cont.)
Step 1-Methods:
Volunteers recruit women to come to clinics for
screening Midwives perform CBE and teach BSE
Women are then independently screened bymammography
Women with a positive screening by any method areclinically evaluated and receive further diagnosticprocedures if indicated
Women who are found to have breast cancer aretreated
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Early Breast Cancer Detection Through
Clinical Breast Examination Training
for Midwives in Rural Jakarta (Cont.)
Step 1-Evaluation:
Comparison of CBE to mammography:
Detection rates of breast cancer by CBE and by
mammography alone, and by both methods
False positive rates by each method alone, and by both
methods combined
Size and stage of tumors detected by each methodalone and by both methods
These results will indicate whether the screening
method used in the program (CBE) is likely to be
efficacious if successfully implemented.
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Early Breast Cancer Detection Through
Clinical Breast Examination Training for
Midwives in Rural Jakarta (Cont.) Step 2-Methods:
If the results in step 1 are encouraging, they may
then attempt to recruit all of the women in thetarget population
Step 2-Evaluation:
Determine the % of women in the targetpopulation that are screened
If the percentage is high, then it can be concludedthat a larger program using the same methodscould also be successfully implemented
Note: The next logical step would then be to
initiate phased implementation
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Two methods of Implementation and
Evaluation of Secondary Prevention
Programs
Feasibility project to determine whether:
the methods proposed for use in a screening
program are likely to be efficacious, and whether
implementation of the program is likely to be
successful.
Phased implementation of a screening programto determine if the program is efficacious
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An Example of Phased Implementation:
Breast Cancer Screening by Opportunistic
Mammography plus CBE in Colombia-1[Dr. Raul Murillo and colleagues]
Primary health care centers in Bogota were randomized to
either opportunistic screening centers or control centers
Women eligible for care in the centers that were
randomized to screening are offered mammography and CBE
when they come to the health center for their medical care.
Those who accept are screened.
Women eligible for care in the control centers are notoffered screening, but they are offered educational material
on breast cancer when they come to the health center for
their medical care. Those who receive the informational
material are pseudo-screened.
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An Example of Phased Implementation:
Breast Cancer Screening by OpportunisticMammography plus CBE in Colombia-2
[Dr. Raul Murillo and colleagues]
A system has been developed to identify allbreast cancers that occur in women in both
groups
Special training is given to medical personnel so
breast cancers that develop in women in bothgroups are diagnosed, staged, and treated in
the same manner, and according to BHGI
guidelines
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An Example of Phased Implementation:
Breast Cancer Screening by Opportunistic
Mammography plus CBE in Colombia-3[Dr. Raul Murillo and colleagues]
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An Example of Phased Implementation: Breast
Cancer Screening by Opportunistic
Mammography plus CBE in Colombia-4[Dr. Raul Murillo and colleagues]
Breast cancers detected by screening will be comparedto the cancers that occur in the pseudo-screened group
on TNM staging to determine the efficacy of thescreening method in down-staging at diagnosis.
The percentage of women in the intervention arm whoare screened will be calculated to estimate the
coverage of the target population All of the cancers in the intervention and control arms
of the study will be compared on TNM staging todetermine the impact of the program on the totalbreast cancers in the population of women targeted for
screenin
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Phased Implementation (cont.)
Note that phased implementation requiresno more resources for screening than doesopportunistic screening
It does require additional resources for
evaluation: Selection of the segments of the population for
implementation
Data collection in both the segments of the
population with the new screening program andin the segments in which the program has notbeen introduced
Data processing and analysis
The BHGI is assisting in the evaluation efforts
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Summary and Final Comments-1
As LMI countries develop economically, cancer will become
a more important public health problem
Population based cancer registration can be useful in
assessing the cancer problem, but other less expensive
methods also exist that should be considered before
establishing a registry. If population based registries are established, it is
preferable to do so in limited and carefully selected
populations than to attempt to establish a nation wide
registry.
Prioritize the development of cancer control activities on
the basis of the importance of the cancer, the known
effectiveness of the means that exist for primary or
secondary prevention, and the resources available to utilize
these means.
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Summary and Final Comments-2
Cancer control activities should be initiated in such a
manner that they can be rigorously evaluated
Epidemiologists can play an important role in settingpriorities for cancer control activities, in planning
these activities, and in the evaluation of their
effectiveness
The training of cancer epidemiologists is therefore animportant early step in developing cancer control
activities
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END