SARHAN - breast cancer in the eastern meditteranean...
Transcript of SARHAN - breast cancer in the eastern meditteranean...
Presentation 091104
King Hussein Cancer Center1
Presented by:Mahmoud M. Sarhan, MD, MMM, CPECEO & Director GeneralKing Hussein Cancer Center
Presented at:International Symposium on Breast Cancer in the Developing World: Meeting the Unforeseen Challenge to Women, Health and Equity
Breast Cancer in the Eastern Mediterranean RegionA Burden with Potential
Boston, MANovember 2-5, 2009
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King Hussein Cancer Center2
The Eastern Mediterranean region extends from Morocco to Pakistan and has varied income levels, health indicators and geographiesWorld Bank Income group
Country Population (in thousands)
Expenditure on health per capita in US $
High(Total Pop 8,219,000)
Qatar 656 862U.A.E 4,210 661Kuwait 2,645 579Bahrain 708 555
upper Middle(Total Pop 35,472,000)
Lebanon 4,370 573
Saudi Arabia 22,608 366
Oman 2,651 278Libya 5,843 171
World Bank Income group
Country Population (in thousands)
Expenditure on health per capita in US $
lower middle(Total Pop 231,482,000)
Jordan 5,617 177
Palestine 3,827 138Tunisia 9,911 137Iran 66,775 131
Morocco 30,509 72Syria 18,200 59
Egypt 69,323 55
Djibouti 817 47Iraq 26,503 23
Low(Total Pop 238,627,000)
Yemen 21,003 32
Sudan 34,512 21Pakistan 151,816 13
Afghanistan 22,998 11
Somalia 8,298 6
GINI index in many countries varies between 28 and 42
indicating inequality within each country
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King Hussein Cancer Center3
Breast Cancer is the most common cancer in all Eastern Mediterranean countries
Cou
ntry
Rank of Disease
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BC incidence rate in the region is not higher than the developed world….
Age Standardized Breast CancerIncidence Rate Per 100,000 (2005 in the EMR
New Cases
Cou
ntry
New Cases
Cou
ntry
Crude Breast CancerIncidence Rate Per 100,000 (2005 in the EMR
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…But it effects women in younger ages than the developed world…
49
53
50
48
47.649.6
46.445
51
Median Age in Developed Countries 65 years
Median age at diagnosis of female breast cancer cases in some Arab countries
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…and is detected at very late stages…
Country Advanced Stages of Breast Cancer
Sudan 78%
Saudi Arabia 71%
Nile Delta, Egypt 70%
Cairo, Egypt, 66%
Amman, Jordan 69%
Tunis, Tunisia 49% (40%> 5cm)
Iraq 47%
Lahore, Pakistan 46%
Bahrain 33% (70%>2cm)
Stages of Breast Cancer in Jordanbased on KHCC Experience 2005
Stage IV 12.90
Stage III 56.20
Stage II 23.70
Stage I 6.70
Stage 0 0.50
Stage II, 23.70%
Stage 0, 0.50%
Stage III, 56.20%
Stage 1 6.70%
Stage IV, 12.90%
N=550 (~ to 2/3rd of the cases in Jordan)
SOURCE: Towards a strategy for cancer control in the Eastern Mediterranean Region, WHO-EM/NCD/060/E, 2009
State at presentation in breast cancer according to institutional data
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King Hussein Cancer Center7
Cancer will impact the developing / low-middle income countries the most…
0
3.75
7.50
11.25
15.00
2008 2015 2030
9.5
6.9 5.8
2.4 2.4 2.3
High Income Countries Low-Middle Income Countries
+64%
+19%
11.94
9.28
8.06
World Cancer Deaths over Time
Year
Tota
l Can
cer D
eath
s in
Mill
ions
0
2.5
5.0
7.5
10.0
2008 2015 2030
3.5 2.2 1.8
1.8 2.8 3.2
AIDS, Tuberculosis, & Malaria Cancer
5.35.05.0
Deaths in Low Income Countries
yearD
eath
s in
Low
Inco
me
Cou
ntrie
s (in
mill
ion)
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King Hussein Cancer Center8
… and the largest increase in cancer deaths within the next 15 years is likely to be in the Eastern Mediterranean region
Rawaf, S. et al. BMJ 2006;333:860-861
Predicted increase in deaths from cancer over the next 15 years (WHO)4
Wor
ld
Esta
blis
hed
Mar
ket e
cono
my
Form
er s
ocia
list
econ
omy
Latin
Am
eric
a &
C
arib
bean
Chi
na
Sub-
saha
ran
Afr
ica
Oth
er p
arts
of
Asi
a &
Isla
nds
Indi
a
East
ern
Med
iterr
anea
n R
egio
n
Incr
ease
in d
eath
from
Can
cer (
%)
0
50
100
150
200
projection modelling predicts an increase of between 100% and 180%
[Rastogi et al. 2004]..
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Breast cancer is expected to have the largest share since currently it is the #1 cancer in the Eastern Mediterranean region
1. Breast2. Cervix3. Oral4. Ovary5. Colon
1. Lung2. Bladder3. Stomach4. Oral5. Colon
Males Females
Most Common Cancers
Mortality/Incidence Ratio = 70% for all cancer
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King Hussein Cancer Center10
The Eastern Mediterranean region shares barriers across the spectrum of breast cancer (and cancer) control
Early Detection
Prevention
Diagnosis
Registration and Reporting
Treatment
Rehabilitation and Palliative
Care
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Barriers to the accessibility of the whole spectrum can be attributed to two types – social limitations and service limitations
Confidential
Cultural Barriers
Stigma & myths pertaining to cancer including religious misunderstandings
Social taboos that extend beyond the female herself leading to fears of being ostracized by husband, family, or society
Socioeconomic barriers
Low level of education (ignorance)
Preference to invest in family/children needs rather than self health
Awareness barriers
Cancer as a taboo subject
No health promotion to break myths of hereditary and contagious disease
Do not seek information and action to understand ailment or prevention
Infrastructure (Physical & Human Resources)
Services across the spectrum are not available, not accessible, and if not, then not useable (screening, referral, diagnosis…etc)
Human resources are scarce and not trained (lack of female technicians, no oncologists …)
Government priorities
Other primary care issues take priority over cancer care
Funding limitations to prevention, screening and purchase of quality care (including costly drugs)
Quality Systems
Absence of proper local academic background and training and training facilities
Incomprehensive academic curricula and lack of Training manuals
No accreditation certification systems or guidelines and protocols
Social Limitations Service Limitations
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King Hussein Cancer Center12
Case in point (1): Service limitations due to lack of human resources
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King Hussein Cancer Center13
Even in Jordan which is considered to have advanced treatment, human resources remain a major challenge
RatioNumber Category
1.5/million population9
Machines
8 Linear 1 Cobalt
2/ machine 18*Radiation Oncologists
* 7 consultants out of 18 are 55 yrs old and above * Total number of residents 15 (9 at KHCC and 6 at
Al-Bashir)
0
37,500,000
75,000,000
112,500,000
150,000,000
2005 2010 2015 2020
To
tal A
nnua
l Vis
its
(in
mill
ions
)
Demand48% Increase
Supply14% Increase
U.S. Oncologist Workforce Shortage
* Demand Factors – Increase in survivorship and aging of U.S. population
* Supply Factors – Limited plans to increase fellowship slots and 50% of U.S. oncologists over age 50
Jordan Current Radiation Oncology Capacity
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In order to ensure proper health care, major investment in human resources is required
World
Americas
Europe
Western Pacific
Southeast Asia
Eastern Mediterranean
Africa
0 7.5 22.5
Healthcare Workers (Per 1,000 People)
Survival vs. Density of Health Workers
WHO cites a severe shortage of healthcare professionals in developing countries
– Americas: 25 healthcare workers per 1,000 people – Asia: 5 or fewer per 1,000R
emar
ks
Maternal Survival
Child Survival
Infant Survival
Health Care Workers per 1000 population
Prob
abili
ty o
f Sur
viva
l
Density of Health WorkersLow
Low
High
High
Health Workers Save Lives !
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Intended Regional Aim
Case in point (2): palliative care for many countries is barely existent
Regional Goal
To help alleviate the physical and psychosocial suffering associated with
progressive, incurable illnesses To increase the availability and access
to high-quality hospice and palliative care for patients and families
Regional Objectives
Integrate palliative care and hospice principles into the National Health Strategy by shaping governmental
policies Assure availability and easy access to
opioid analgesics and adjuvant medications
Establish integrated continuums of palliative care, reaching patients in
hospital and community settings
This is 2004 data published in WHO Cancer Control
Strategy 2009. Some dosages have changed ex: Jordan =
2 mg/capita
Worldwide average = 5.8 mg/capita
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King Hussein Cancer Center16
In summary, the Eastern Mediterranean region has a shared breast cancer burden within similar cultural barriers and service and awareness deprivations despite some exceptional cases
Culture Females still dependent on family and males
Shar
ed C
halle
nges
Demo-graphics
More rural than urban societies Level of education not unified Young populations (low life expectancy) Socioeconomic problems preventing
symptomatic patients from seeking medical advice
Cancer and
Cancer Services
New disease (??) Cancer is just another disease No specialization Cancer control not appealing to policy
makers (complex matter)
Inequity in Health Services
Urban societies are more privileged in service
Lack of sufficient Healthcare providers
Female diseases impact women in terms of their ability to wed
Females can not seek health service without male approval/assistance
Lower accessibility to information /awareness Remote unreachable areas Closed communities (tribal) which impacts ability
to report and detect cancer deaths Cancer seen in younger people
Too complex for policy makers to address Non-comprehensive approach Part of overall role of tertiary care centers Funding sidelined for political and military issues
Cancer is not a priority in rural areas (vs. water accessibility, infectious diseases…etc)
Focus on primary health care services
Sample Impacts
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But this shared burden has a potential of successful interventions through a unified approach to many of the barriers
Cancer Treatment and Palliation King Hussein Cancer Center as a referral, training
and consultation site Jordan University Hospital King Abdullah Hospital Jordan Palliative care system
Human Resource Development Exchange of expertise Training centers Cost sharing for bringing in international trainers Combined curriculum development Unified certification/accreditation system (
replicate Jordan HCAC)
Public Awareness Unified message = decrease in cost of production
and regional outreach
Protocols & GuidelinesBuilding on the Jordan Experience
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