Making a Difference: Strategies for Success

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Making a Difference Strategies for Success

• Aiming for effective cancer control in countries
  with limited resources a collaborative venture

Addressing The Global Cancer Burden
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Why Cancer?

• In 2002, more than half of the 11 million
  estimated patients with cancer were in developing
  countries which have perhaps 5 of global
  resources
• Developing countries still have a lower incidence
  of cancer than affluent nations, but will account
  for an ever increasing fraction of the global
  cancer burden NOW IS THE TIME FOR ACTION
• The WHA has approved a resolution (May 2005)
  recommending that countries develop and implement
  cancer control plans

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The Global Cancer Burden

• Summary statistics less developed versus more
  developed countries

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Crude Incidence Cases
Per 100,000 per annum
Thousands per annum
2002
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Estimates of Population
Millions
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Estimates of All Cancer Cases, Males and Females
Thousands per Annum
Influence of aging and increases in population
size
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Crude Rates by Regions
More affluent regions have higher actual
incidence and mortality rates and higher
mortality incidence ratios
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ASR (World) by region Comparison Effect of Age
Adjustment of rates to a world standard
population creates similar mortality rates in all
regions, but smoothed incidence rates still
higher in richer countries
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Crude Incidence Rate, Females, All Ages, 2002
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Crude Incidence Rate, Males, All Ages, 2002
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Crude Mortality Rate, Males, All Ages, 2002
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The Global Cancer Burden

• Patterns of Cancer

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Inherited Factors
Personal Factors
Metabolism of carcinogens and drugs
Ancestors
Sex
Beliefs
Absorption of carcinogens and drugs
Height and Weight
Strong predisposition to a cancer
Age
Socioeconomic status
Repair of Genetic Damage
Smoking
Immune response to infection
Cancer
Age at menarche and menopause
Pregnancies
Exposure to sunlight or other forms of radiation
Diet
Alcohol Consumption
Exposure to chemical, and biological agents
Sexual Behavior
Chewing or other habits
Occupation
Nutritional status
Lifestyle Factors
Environmental Factors
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Relative Importance of Risk Factors

• Tobacco (approximately 30 in affluent countries)
  
• Diet (approximately 30 in affluent countries) -
  high fat, low fibre diets, alcohol
• Infections (overall 15 up to 40 in developing
  countries)
• Other pollutants, ultraviolet light, asbestos
  and other occupational exposures (especially in
  developing countries)
• Familial/genetic predisposition 4 of cancers.
  Modified by environmental factors, higher in some
  populations (consanguinous)

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Breast Cancer, 2002 Crude Incidence Rate
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Cervical Cancer, 2002 Crude Incidence Rate
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Cancers Associated with Smoking

• Lung
• Upper respiratory sites (e.g., larynx)
• Bladder
• Pancreas
• Oesophagus
• Kidney
• Breast

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Progression of Tobacco Epidemic in Various
Countries
Effective legislative action more easily taken
before or after high smoking rates ACT NOW
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Lung Cancer, Males, 2002Crude Incidence Rate
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Some Regional Cancers

• Nasopharyngeal Carcinoma (salt fish, EBV)
• Adult T cell leukemia lymphoma (HTLV1)
• Gall bladder cancer (diet/genetics/infection)
• Bladder cancer (schistosomiasis)
• Sino-nasal NK/T cell lymphoma (? EBV)
• Burkitts lymphoma (malaria, EBV)
• Childhood adrenocortical carcinoma (genetic)

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Some Cancers Associated with Infection/Infestation

• Cervix, anus, penis, others HPV
• Hepatocellular Carcinoma HBV, HCV
• Stomach, lymphoma H.pylori
• Bladder, bowel, liver Schistosomes, Clonorchis
• Kaposis Sarcoma HHV8
• Lymphomas EBV, HHV8, HTLV1

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East Africa Frequency Males
At least 35 associated with infection
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East Africa Frequency Females
At least 40 associated with infection
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USA Frequency Males
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USA Frequency Females
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Addressing the Global Cancer Burden

• Cancer Control problems faced in developing
  countries

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Cancer Control

• Reduction of the morbidity and mortality
  associated with cancer
• Based on the best available evidence
• Includes
• Primary prevention
• Early detection
• Treatment
• Palliative care

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Approaches to Cancer Control

• Public education and legislation to prevent as
  many cancer as possible
• Public health measures e.g., indoor and outdoor
  pollution or exposure, control of infectious
  diseases associated with cancer
• Early detection education, screening cervix,
  breast, oral, colon and treatment.
• Treatment of invasive cancer
• Palliative care

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Access to Care
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The Problem a Vicious Cycle
Many Patients With Advanced Disease and Many
Potential Patients
High Mortality Rate
Limited Resources
POOR ACCESS
Unmet need for terminal care
LOW CAPACITY
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The Solution Build Capacity
Education Screening
Prevention
Lower Mortality Rate
Fewer Patients with More Limited Disease and
Fewer Potential Patients
Less Limited Resources
Less need and greater capacity for terminal care
GREATER CAPACITY
IMPROVED ACCESS
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INCTR Mission Statement
INCTR is dedicated to helping build capacity for
cancer treatment and research in countries in
which such capacity is presently limited and to
increase the quantity and quality of cancer
research throughout the world.
Catalysis Concerted Effort Communication
Sustainability
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The Goals

• To prevent as many preventable cancers as
  possible
• To cure as many curable cancers as possible
• To improve the quality of life of patients with
  cancer at all stages of their disease

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The Mechanism

• Establishment of long term collaborative
  projects which will have an immediate impact on
  prevention or treatment
• Associate such projects with education and
  training
• Use information collected in the course of such
  projects as a foundation on which to build future
  endeavors

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The Tool Collaboration
Multiple networks organizations, institutions,
experts, supporters
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INCTRs Network
Offices and Branches
Collaborating Units
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Offices and Branches

• USA, UK, France, Brazil, Egypt, Tanzania, India,
  Nepal
• Regional/national coordination of INCTR programs
  and projects
• Access to regional/national resources
• Expansion of local capacity
• Guiding principles INCTR Charter

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Associate Membership

• Corporate Membership (3)
• Partnerships with the corporate world
• Institutional/Organizational Membership (109)
• Provides access to a broad range of expertise
• Participation in INCTR activities
• Individual Associate Membership (75)
• Contributions, financially or in kind
• More important role in the future

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Collaboration with Other Organizations

• ACS Partnership Palliative care, ACSU
• UICC Steering Committee and mentoring of 4
  projects for MyChildMatters (Sanofi-Aventis)
• WHO Technical Committee for Global Cancer
  Control Essential Drugs List (Cytotoxics)
• Institute of Medicine Report on Cancer Control
• IAEA Collaboration in breast cancer and
  potentially, expanded cancer programs
• ESO Meetings (e.g., ESO session in Annual 2007)
• Global Alliance for the Cure of Children with
  Cancer Organizations/institutions for pediatric
  cancer
• AORTIC Discussion phase

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Strategy Groups
International groups identify and implement
disease specific activities in prevention,
treatment, education
Cx Cancer, August 2004
Implementation Meeting, African BL, Tanzania,
August 2004
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INCTR Strategies

• Conduct various projects in specific areas of
  cancer control (cancers in women and children
  highest priority)
• Use centers involved as training sites to improve
  regional and national coverage
• Use multi-institutional clinical trials as a
  complete approach to training, education,
  research and patient care
• Maximize use of IT in training, education,
  monitoring and measuring outcomes

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International NGO or Institution
FUNDING
Visiting Experts
External Training
E-learning?
Government or Local NGO
Local project service provision and training
Education of other primary health care workers
or trainees
Dissemination to other centers
Dissemination to Health Care System
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Population Coverage Example (Wide Application)

• 700 cases of BL in Tanzania
• Identify centers capable of care
• Develop improved diagnostic and referral systems
• Provide training where necessary
• Develop targets for extending care to 80-90 of
  cases

Year 1 Year 2 Year 3
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Value of Cooperative Clinical Trials

• Improved access of patients and professionals to
  the local (few) and international experts
• Carefully designed treatment approach
• Diagnosis and staging must be standardized
• Supportive care must be addressed
• Loss to follow up must be reduced
• May include non-therapeutic components
  (epidemiology, molecular characterization)
• Data must be accurately collected (surveillance)
• Increased communication and hence learning among
  all participants (community of practice)
• Instills good habits of clinical care, and a
  research perspective in junior staff wide
  impact
• Provides a local data base that can be built upon

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Comparison of Treatment Guidelines and Clinical
Trials
Research
Guidelines

• Designed for a specific population in the context
  of available resources
• Usually entails collaboration and mutual learning
• Associated with quality assurance and ethical
  review
• Identifies deficiencies
• Associated with outcome measures
• Generates new information

• Based on available evidence may be from a
  different population and with different resources
  
• Rarely entails collaboration or learning
• No quality control or ethical review
• No identification of deficiencies
• No outcome measures
• No new information

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Obstacles to Conducting Clinical Trials in LR
Settings

• Structural problems in institutions (seniority,
  eminence based medicine)
• Lack of academic mindset health care is a
  service or business no outcome measures
• Lack of professional or financial rewards
• Lack of required infrastructure and funds
• Lack of institutional will to collaborate
• Lack of incentive to perform trials (except
  financial inducement by Big Pharma)
• Inability to ensure good follow-up

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Maximizing IT - 2006

• Telesynergy or internet based lectures and
  discussions
• Provision of presentations, documents and
  training modules on INCTRs portal
• Develop fundable program in data management and
  IT (e.g., India)

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Active Projects (8)

• Reasons for late presentation of retinoblastoma
  15 centers in 11 countries
• Survey of breast cancer management - 4 countries
• Cx Cancer screening (with IARC) 2 countries, 4
  sites
• Treatment of advanced cervical cancer (with Eli
  Lilly) 10 centers in 10 countries
• Treatment and study of ALL in India - 4 centers
• Treatment and study of Burkitts Lymphoma in
  Africa - 4 centers in 3 countries (now expanded
  access)
• Provision of palliative care Nepal (3 centers)
• Expansion of care for leukemia and retinoblastoma
  (Philippines)

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Projects in Planning Phase (6)

• Treatment of locally advanced retinoblastoma
• Treatment of locally advanced breast cancer
• Treatment of Cx cancer
• Extending cervical cancer screening into the
  health care structure India
• Expansion of palliative care program to Tanzania
  and India
• Cancer control in Cameroon

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Relevant Meetings and Expert Visits in Last Year
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Annual Meeting

• Award lectures
• Individual presentations (posters, oral)
• Reports on ongoing INCTR activities
• Keynote lectures
• Educational sessions/workshops on regionally
  important cancers and aspects of cancer control
• Consensus panels on specific topics
• Multidisciplinary conference
• Meet the expert sessions
• Members forum, Strategy groups, committees

Next Annual Meeting Sao Paolo, Brazil, March 2007
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Countries Associated with INCTR