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International Atomic Energy Agency (IAEA)Human Resources Development in Radiation Oncology in the Context of Cancer Control

Programmes in Latin America

International Atomic Energy Agency (IAEA)Human Resources Development in Radiation Oncology in the Context of Cancer Control

Programmes in Latin America

Buenos Aires, 23 a 27 de abril de 2007

Luiz Antonio Santini

National Cancer Institute (INCA)

Brasil

Buenos Aires, 23 a 27 de abril de 2007

Luiz Antonio Santini

National Cancer Institute (INCA)

Brasil

Hospital Complex Hospital Complex

HC IIHC II HC IIIHC III

HC IVHC IVHC I e CEMOHC I e CEMO

AttributionsAttributions

a) Assist the Health Minister in the design of the Na tional Policies for Oncologic care;

b) Conduct national actions of prevention, diagnosi s and treatment of malign neoplasia and its correlated disord ers;

c) Provide medical assistence;

d) Conduct clinical, epidemiological and experimenta l research;

e) Provide formal education, training and developmen t of human resources.

a) Assist the Health Minister in the design of the Na tional Policies for Oncologic care;

b) Conduct national actions of prevention, diagnosi s and treatment of malign neoplasia and its correlated disord ers;

c) Provide medical assistence;

d) Conduct clinical, epidemiological and experimenta l research;

e) Provide formal education, training and developmen t of human resources.

ScreeningScreening

Model of the Natural History of the DiseaseModel of the Natural History of the Disease

STAGES OF ONCOLOGIC CAREOPPORTUNITY EFECTIVENESS

TIME

DiagnósticoTratamentoReabilitação

Sintomase sinais no início

da fase clínica

Sintomas e sinais comdiagnóstico

tardio

Palliative care

Signs and

symptoms

Earlydetection

Research

Genetic predisposition

Information /Communication

Exposure to risk factors

Biological onset

of the disease

ScreeningDiagnosisTreatment

Rehabilitation

Signs and symptoms

on the clinicalphase outset

Signs and symptoms

with latediagnosis

Source: National Cancer Control Programmes. Policie s and managerial guidelines.WHO, 2002. p.59Source: National Cancer Control Programmes. Policie s and managerial guidelines.WHO, 2002. p.59

Location Population screeningBreast YesCervix YesProstate NoIntestines NoSkin NoOral cavity No

Actions for Early DetectionActions for Early Detection

Source: National Cancer Control Programmes. Policies a nd managerial guidelines.WHO, 2002.Source: National Cancer Control Programmes. Policies a nd managerial guidelines.WHO, 2002.

Cancer of the Cervix ScreeningCancer of the Cervix Screening

Incidence in WomenIncidence in Women

Female breast Cervix Colon and rectum

48930

1926013970

Women

Can

cer

Typ

es -

Wom

en

World distribution of incidence coefficientsfor cancer of the cervix in women, 2002

World distribution of incidence coefficientsfor cancer of the cervix in women, 2002

Source: Globocan 2002, IARCSource: Globocan 2002, IARC

Distribution of incidence coefficients for cancerof the cervix in women, 2006

Distribution of incidence coefficients for cancerof the cervix in women, 2006

Source: MS/Instituto Nacional de Câncer - INCASource: MS/Instituto Nacional de Câncer - INCA

Women

Source: National Cancer Control Programmes. Policies a nd managerial guidelines.WHO, 2002. p.60Source: National Cancer Control Programmes. Policies a nd managerial guidelines.WHO, 2002. p.60

Natural History of Cancer of the Cervix

Natural History of Cancer of the Cervix

Cancer of the Cervix Control in Brazil: History

Cancer of the Cervix Control in Brazil: History

PAISM

Pró-Onco

Viva Mulher1st National Campaign

1984 1987 1997/98 1999-2002

Intensification of Viva Mulher -

2nd National Campaign

PCCU –Strategic

GuidelinesViva Mulher

(pilot)

2006

Pacto pela vida

2005

PHASE IPHASE I PHASE IIPHASE II PHASE IIIPHASE III PHASE IVPHASE IV

Phase I - Before 1997Phase I - Before 1997

Proposition of PoliciesReality• Isolated actions • Lack of continuity• Lack of articulation• Non guaranteed treatment • No evaluation

Proposition of PoliciesReality• Isolated actions • Lack of continuity• Lack of articulation• Non guaranteed treatment • No evaluation

PHASE II-a.Viva Mulher pilot project (1997 - 1998 )5 municipalities + 1 state

PHASE II-a.Viva Mulher pilot project (1997 - 1998 )5 municipalities + 1 state

• Development of a model for early detection • Standardization of procedures

– Technical procedures for specimen collection and sl ide examination

– Quality and treatment monitoring – Incorporation of new technologies

• Definition of the referral flow• Conduct qualitative research;• Partnership with NGOs, universities, and scientific

societies; • Humanization of health care;• Design of a model for political-managerial articulati on;• Development of a computer system to monitor actions

(SISCOLO).

• Development of a model for early detection • Standardization of procedures

– Technical procedures for specimen collection and sl ide examination

– Quality and treatment monitoring – Incorporation of new technologies

• Definition of the referral flow• Conduct qualitative research;• Partnership with NGOs, universities, and scientific

societies; • Humanization of health care;• Design of a model for political-managerial articulati on;• Development of a computer system to monitor actions

(SISCOLO).

PHASE II-b. National Implementation Phase (Aug/ Sep 1998)

PHASE II-b. National Implementation Phase (Aug/ Sep 1998)

• Implementation of the National Programme for Cancer of the Cervix Control (PNCCCU) on 06/21/98;

• Implementation of actions in all states, with adher ence of 98% of municipalities from August to September 1998.

MAIN ACHIEVEMENTS:– Standardization of screening, diagnosis and treatme nt actions – Extension of actions to all states – Test of the network’s capacity– Doubling of the number of cytology tests – Strengthening of partnerships– Availability of treatment through CAF in the public health care

network – Financing guaranteed

• Implementation of the National Programme for Cancer of the Cervix Control (PNCCCU) on 06/21/98;

• Implementation of actions in all states, with adher ence of 98% of municipalities from August to September 1998.

MAIN ACHIEVEMENTS:– Standardization of screening, diagnosis and treatme nt actions – Extension of actions to all states – Test of the network’s capacity– Doubling of the number of cytology tests – Strengthening of partnerships– Availability of treatment through CAF in the public health care

network – Financing guaranteed

PHASE III. Consolidation Phase (1999-2002)

PHASE III. Consolidation Phase (1999-2002)

OBJECTIVE

Increase access to actions on cancer of the cervix earl y detection for Brazilian women, specially those in the high-risk age group, and guarantee appropriate treatment for the disease and its precursor lesions.

Main strategies: – Consolidation of a geopolitical managerial base, – Articulation of a communication network for women, – Reevaluation of the actual technology availability for diagnosis and

treatment, – Training human resources, and – Designing an evaluation plan

OBJECTIVE

Increase access to actions on cancer of the cervix earl y detection for Brazilian women, specially those in the high-risk age group, and guarantee appropriate treatment for the disease and its precursor lesions.

Main strategies: – Consolidation of a geopolitical managerial base, – Articulation of a communication network for women, – Reevaluation of the actual technology availability for diagnosis and

treatment, – Training human resources, and – Designing an evaluation plan

Phase IV. Populacional Strategy: Cytopathologic screening within primary care

(Strategic guidelines and Pacto pela vida )

Phase IV. Populacional Strategy: Cytopathologic screening within primary care

(Strategic guidelines and Pacto pela vida )

Qualification of diagnosis and treatment:� Quality control of cytopathology testing – specific l egislation for internal and

external control; ME module implemented at SISCOLO

� Terminology based on 2001 Bethesda Consensus (compa rability)-implementation of the new Brazilian version – July 2 006

� Standardized clinical conduct (manual of recommenda tions)

� Technology for clinical treatment implemented: “see and treat” method

Network organization:� Decentralized control actions: municipal sphere

� Activities based on the natural history of the dise ase: from primary prevention to palliative care

� Organization based on the oncologic care network str ucturing

� Expansion of oncologic care based on coverage parame ters

Qualification of diagnosis and treatment:� Quality control of cytopathology testing – specific l egislation for internal and

external control; ME module implemented at SISCOLO

� Terminology based on 2001 Bethesda Consensus (compa rability)-implementation of the new Brazilian version – July 2 006

� Standardized clinical conduct (manual of recommenda tions)

� Technology for clinical treatment implemented: “see and treat” method

Network organization:� Decentralized control actions: municipal sphere

� Activities based on the natural history of the dise ase: from primary prevention to palliative care

� Organization based on the oncologic care network str ucturing

� Expansion of oncologic care based on coverage parame ters

Cancer of the Cervix Control in Numbers

Cancer of the Cervix Control in Numbers

• Pilot Project (5 municipalities + 1 state; 1997/98)– 124.440 Women

• Intensification Phase of the Programme (Brazil; August/September 1998)– 3.177.740 women

• Consolidation Phase of the Programme – ROUTINE -(Brazil; since 1999)– Until 1998 - 6 million cytology tests per year– 1999 to 2002 – 8 million cytology tests per year – After 2002 – 11 million cytology per year

• Pilot Project (5 municipalities + 1 state; 1997/98)– 124.440 Women

• Intensification Phase of the Programme (Brazil; August/September 1998)– 3.177.740 women

• Consolidation Phase of the Programme – ROUTINE -(Brazil; since 1999)– Until 1998 - 6 million cytology tests per year– 1999 to 2002 – 8 million cytology tests per year – After 2002 – 11 million cytology per year

Number of cervical cytopathologic Tests Brazil, 1995 to 2006

Number of cervical cytopathologic Tests Brazil, 1995 to 2006

0

2.000.000

4.000.000

6.000.000

8.000.000

10.000.000

12.000.000

14.000.000

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

1998 and 2002 campaign

Routine

0

2.000.000

4.000.000

6.000.000

8.000.000

10.000.000

12.000.000

14.000.000

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Year

Num

ber

of T

ests

North Northeast Southeast South Central Total for Brasil

Number of Cervical Cytopatologic Tests per Year in Brazil and Brazilian Regions,

from 1995 to 2006 *

Number of Cervical Cytopatologic Tests per Year in Brazil and Brazilian Regions,

from 1995 to 2006 *

•Projection for 2006 (data for 11 months)

Source: Datasus (www.datasus.gov.br , access on 02/02/2007)

•Projection for 2006 (data for 11 months)


0,00

10,00

20,00

30,00

40,00

50,00

60,00

70,00

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

Year

Am

ount

(R$)

Expenditure for Cervical CytopathologicTests. Brazil, 1995 to 2006 *

Expenditure for Cervical CytopathologicTests. Brazil, 1995 to 2006 *

* Until November 2006; Expenditure in millions (Reais)


* Until November 2006; Expenditure in millions (Reais)


4,9%

31,2%

40,8%

16,4%

6,6%

North Northeast Southeast South Central

Proportion of Expenditure for Cytopathologic Tests per Region.

Brazil, 1995 to 2006

Proportion of Expenditure for Cytopathologic Tests per Region.

Brazil, 1995 to 2006

Source: Datasus (www.datasus.gov.br , access on 02/02/2007)Source: Datasus (www.datasus.gov.br , access on 02/02/2007)

Sources: Dados dos Registros de Câncer Base Populac ionalMP/Fundação Instituto Brasileiro de Geografia e Est atística – IBGEMS/INCA/Conprev/Divisão de Informação


Specific Rates for Cancer of the Cervix Incidence, Salvador, 1998 - 2002

Specific Rates for Cancer of the Cervix Incidence, Salvador, 1998 - 2002

0,0

10,0

20,0

30,0

40,0

50,0

60,0

70,0

80,0

Age group

Spe

cific

rat

e

C53 - Cervix malign neoplasia D06 - Cervix carcinoma “in situ”

0-4

5-9

10-1

415

-19

20-2

425

-29

30-3

435

-39

40-4

445

-49

50-5

455

-59

60-6

465

-69

70-7

475

-79

80-8

4 85,

*Adjusted by População Padrão Mundial, modified by Doll et al.(1966)Source: Registro de Câncer de Base Populacional de Salvador*Adjusted by População Padrão Mundial, modified by Doll et al.(1966)Source: Registro de Câncer de Base Populacional de Salvador

Incidence* of Cancer of the Cervix, Salvador, 1997-2001

Incidence* of Cancer of the Cervix, Salvador, 1997-2001

(1) População Padrão Mundial, modificada por Doll et al.(1966)

(2) População de Salvador, 1997-2001 - IBGE

Fontes: Fundação Instituto Brasileiro de Geografia e Estatística - IBGE

Divisão de Informção - CONPREV/INCA/MS

Registro de Câncer de Base Populacional de Salvador

Taxas de Incidência por

câncer do Colo do Úter o,

Útero, SOE e Carcinoma "in si tu",

ajustadas por idade

pela população mundial,

por 100.000 mulheres,

Salvador, entre 1997 e

2001.

0

2

4

6

8

10

12

14

16

18

20

Anos

Colo do Útero Útero, SOEColo do Útero e Útero, SOE Carcinoma "in situ" do Colo do Útero

0,0

5,0

10,0

15,0

20,0

25,0

30,0

35,0

40,0

45,0

50,0

55,0

1997

1998

1999

2000

2001

Years

Rat

e/10

0000

Invasive carcinoma of the cervix Carcinoma “in situ” of the cervix



Specific Rates for Cancer of the Cervix Incidence, Porto Alegre, 1997- 2001.

Specific Rates for Cancer of the Cervix Incidence, Porto Alegre, 1997- 2001.

Age group

0,0

10,0

20,0

30,0

40,0

50,0

60,0

70,0

Spe

cific

rate

C53 - Cervix malign neoplasia D06 - Cervix carcinoma “in situ

0-4

5-9

10-1

415

-19

20-2

425

-29

30-3

435

-39

40-4

445

-49

50-5

455

-59

60-6

465

-69

70-7

475

-79

80-8

4 85,

Sources: Dados dos Registros de Câncer Base Populacio nalMP/Fundação Instituto Brasileiro de Geografia e Estatís tica – IBGEMS/INCA/Conprev/Divisão de Informação

Sources: Dados dos Registros de Câncer Base Populacio nalMP/Fundação Instituto Brasileiro de Geografia e Estatís tica – IBGEMS/INCA/Conprev/Divisão de Informação

*População Padrão Mundial*População Padrão Mundial

Specific Rates for Cancer of the Cervix Incidence, Age Adjusted*.Porto Alegre,1997- 2001.

Specific Rates for Cancer of the Cervix Incidence, Age Adjusted*.Porto Alegre,1997- 2001.

1997 1998 1999 2000 2001

C53 - Cervix malign neoplasia D06 - Cervix carcinoma “in situ

0,0

Spe

cific

rate

10,0

20,0

30,0

Current NecessitiesCurrent Necessities

• Increase quality of cytopathology test

• Increase quality of specimen collection

• Guarantee patient follow-up

• Increase quality of cytopathology test

• Increase quality of specimen collection

• Guarantee patient follow-up

Main ChallengesMain Challenges

• Organization of Services

• System of Information

• Permanent Education

• Process and Results’ Evaluation

• Organization of Services

• System of Information

• Permanent Education

• Process and Results’ Evaluation

Cancer in Numbers WorldwideCancer in Numbers Worldwide

Source: 2005 UICC ReportSource: 2005 UICC Report

2006

11 million new cases

7 million deaths

2020

16 million new cases

12 million deaths

60% OF NEW CASES IN LESS DEVELOPED COUNTRIES

60% OF NEW CASES IN LESS DEVELOPED COUNTRIES

New Cancer Cases per YearNew Cancer Cases per Year

WHO (2003)WHO (2003)

3

4

5

6

7

8

9

10

1990 1995 2000 2005 2010 2015 2020

new

can

cer

case

s (m

illio

ns)

year

developingcountries

industrializedcountries

10 million in 2000

16 million in 2020

50% more

16 million in 2020

50% more

Brazilian Plan of Action Cancer of the Cervix Control 2005 – 2007

Brazilian Plan of Action Cancer of the Cervix Control 2005 – 2007

Strategic Guidelines• Increase coverage for target population • Guarantee quality of tests• Develop human resources • Strengthen systems of information • Conduct research • Mobilize society

Strategic Guidelines• Increase coverage for target population • Guarantee quality of tests• Develop human resources • Strengthen systems of information • Conduct research • Mobilize society

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