EVIDENCE SHEETS 2013 WORLD CANCER DECLARATION TARGETS
WORLD CANCER DECLARATION TARGET 1
STRENGTHEN HEALTH SYSTEMS FOR EFFECTIVE CANCER CONTROL HEALTH SYSTEMS WILL BE STRENGTHENED TO ENSURE SUSTAINED DELIVERY OF EFFECTIVE AND COMPREHENSIVE, PATIENT-CENTRED CANCER CONTROL PROGRAMMES ACROSS THE LIFE-COURSE
THE FACTS By 2025, low- and middle-income countries (LMICs) will bear the brunt of the estimated 19.3 million new cancer cases per year, with over 70% of the growth in the global cancer burden predicted to occur in developing countries1. National cancer control planning is a vital investment for all countries for delivering an effective and comprehensive cancer control programme that can reduce cancer incidence and mortality, improve the quality of life and wellbeing of cancer patients and their communities as well as mitigate the impact of cancer on national economies.
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National cancer control plans (NCCPs) provide a framework for the systematic and equitable implementation of evidence-guided, cost-effective strategies for cancer prevention and control. An effective NCCP should address the spectrum of the cancer care and control continuum from prevention through to survivorship and palliative care at all health system and societal levels (home, community and specialist care settings), and be integrated with a country’s noncommunicable disease (NCD) control efforts2. Above all, the development of effective NCCPs requires reliable data sourced from population-based cancer registries that are designed to inform governments of the size and nature of the cancer burden in the country, to assess the major cancer risk factors as well as to guide planning, implementation and evaluation of cancer control programmes and policies.
NCCPs also have a vital role in strengthening health systems by addressing key constraints to the delivery of effective, quality cancer services including a skilled health workforce, infrastructure, technologies and medicines, and adequate financing. However, despite the evidence showing the significant economic and social benefits of a health systems approach to the control of cancer and NCDs, figures from 2010 estimate that only 59% of countries have operational cancer plans and only 48% of countries have operational policies, plans or strategies with dedicated funding3.
All governments have approved the WHO Global Action Plan on NCDs 2013-2020 that recommends Member States: 1. establish or strengthen multisectoral national policies for the prevention and control of NCDs5; 2. contribute, on a routine basis, information on trends in NCDs with respect to morbidity, mortality by cause, risk factors and other determinants, disaggregated by age, gender, disability and socioeconomic groups, and; 3. provide information to WHO on progress made in the implementation of national action plans and on effectiveness of national policies and strategies, coordinating country reporting with global analyses. All governments have committed to the development of NCD plans – the time is now for cancer advocates to support this process and ensure that cancer is embedded into comprehensive NCD plans.
HEALTH SYSTEMS STRENGTHENING The World Health Organization defines Health Systems Strengthening (HSS) as (i) the process of identifying and implementing the changes in policy and practice in a country’s health system, so that the country can respond better to its health and health system challenges; and (ii) any array of initiatives and strategies that improves one or more of the functions of the health system and that leads to better health through improvements in access, coverage, quality, or efficiency. As such, strengthening the health system from primary through to tertiary level for cancer prevention and care means more trained health professionals and optimal referral, leading to a greater likelihood of early detection, reduced time to diagnosis, and improved quality of care with the ultimate consequence of preventing cancer deaths.
As of 2010, only 17 African countries had operational policies, strategies or action plans for cancer and only 17% of national programmes against non-communicable diseases were funded4. UICC Advocacy Toolkit 2014 - Evidence Sheets
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MEETING THE CHALLENGE
The recently launched International Cancer Control Partnership (ICCP) Portal (www.iccp-portal.org) is an initiative of the ICCP, a group of organisations whose members were already individually working to support country cancer control planning efforts. Now these organisations are working together to maximise their collective resources to support cancer planners and decision-makers at global, regional and country levels in the development, implementation, monitoring and evaluation of NCCPs. The portal pools together all resources necessary to assist countries to implement global NCD commitments through four key activities: •
Advocacy at global and local levels;
•
Providing a central repository of best practice resources, including a tool for initiating plans and a searchable database of published NCCPs;
•
Addressing data gaps for stepwise development, phased implementation and scale up;
•
Responding to requests for technical assistance from low-income countries.
The ICCP portal supports countries across the entirety of the planning cycle enabling them to tailor plans to the national cancer burden and health systems. Additionally, the International Atomic Energy Agency (IAEA) provides technical support for national cancer planning through the Program of Action for Cancer Therapy (PACT). Through PACT, the IAEA helps Member States to optimise the investments made in cancer control through an imPACT Review, a cancer control assessment tool. imPACT Reviews help countries to swiftly and efficiently respond to the cancer crisis by providing an evaluation of a country’s readiness to implement cancer control programmes, completing an assessment of the national cancer burden and providing recommendations on developing cancer control capacity. The recommendations provided by the IAEA and its partners, through PACT, can then be used to devise or strengthen an NCCP, which will assist Member States in the development and implementation of effective measures that respond to the national cancer control needs.
GLOBAL ADVOCACY MESSAGE NCCPs are a vital investment for all countries in understanding and responding to the cancer burden as part of national efforts to reach the globally adopted goal of a 25% reduction in premature mortality from NCDs by 2025. NCCPs should be based on accurate and reliable data sourced from population-based cancer registries.
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CASE STUDY IAEA/PACT ASSESSES CAMEROON’S CANCER CONTROL CAPACITY AND NEEDS
In common with the majority of African countries, Cameroon faces a growing number of cancer cases, estimated to rise from almost 12,000 in 2008 to almost 20,000 cases by 20256. Breast and cervical cancers account for more than half of cancers among women, while prostate and liver comprise more than a third of cancers for men. In response to the growing need to address Cameroon’s cancer burden, H.E. Minister of Public Health, Mr Andre Mama Fouda, requested the IAEA to conduct an imPACT mission to assess the national cancer control capacity and needs in the country. The mission was conducted from 10 to 14 June 2013. A multi-disciplinary team of experts, nominated by the IAEA, World Health Organization (WHO) and International Agency for Research on Cancer (IARC) undertook the imPACT mission that assessed the different areas of Cameroon’s cancer control measures, including cancer information/registration, prevention, early detection, diagnosis and treatment and palliative care. In its review, the team also determined how the country’s civil society activities contribute to cancer control. The mission team made site visits and met representatives from the Yaoundé General and Central Hospitals, Mbankomo District Hospital, a private clinic in Douala, the Faculty of Medicine and Biomedical Sciences and civil society organisations. During these visits, the mission experts collected data and information from their Cameroonian counterparts involved in the provision of cancer-related services. Cameroon has cancer centres at Yaoundé General Hospital and Douala General Hospital. However, at present only Douala has a functional radiotherapy facility. Constraints in patients’ access to cancer treatment (radiotherapy, chemotherapy and surgical services) present a significant challenge for Cameroon’s cancer control programme.
A comprehensive imPACT Mission Report will be delivered to the Minister of Public Health, including the expert team’s detailed findings and recommendations. The report is designed to assist Cameroon to improve cancer services and reduce the cancer burden in the long term. Acknowledgement: IAEA. The imPACT mission to Cameroon was supported by the Peaceful Uses Initiative and implemented through IAEA Technical Cooperation Project RAF/6/043, Supporting Comprehensive Cancer Control in Africa. For other case studies of successful national cancer control planning, go to: www.iccp-portal.org/case-studies
References: 1. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; 2013. Available from: http://globocan.iarc.fr, accessed on 23/1/2014. 2. WHO. (2011). Global Status Report on noncommunicable diseases 2010. Geneva: World Health Organization. 3. WHO. (2012). Assessing national capacity for the prevention and control of noncommunicable diseases: report of the 2010 global survey. Geneva: World Health Organization. 4. Stefan DC, Elzawawy AM, Khaled HM, et al. (2013). Developing cancer control plans in Africa: examples from five countries. Lancet Oncol, 14, e189-95. 5. WHO. (2013). Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Geneva: World Health Organization. 6. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11[Internet]. Lyon, France: International Agency for Research on Cancer; 2013. Available from: http://globocan.iarc.fr, accessed on 23/1/2014.
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WORLD CANCER DECLARATION TARGET 2
MEASURE CANCER BURDEN AND IMPACT OF CANCER PLANS IN ALL COUNTRIES POPULATION-BASED CANCER REGISTRIES AND SURVEILLANCE SYSTEMS WILL BE ESTABLISHED IN ALL COUNTRIES TO MEASURE THE GLOBAL CANCER BURDEN AND THE IMPACT OF NATIONAL CANCER CONTROL PROGRAMMES
THE FACTS National cancer control plans (NCCPs) in all countries must be based on relevant and accurate incidence data to enable governments to develop effective policies for cancer control. Through the systematic collection of information on all cases of cancer from multiple sources occurring in a defined geographic area, a populationbased cancer registry (PBCR) informs governments of the size and nature of the cancer burden in the country, and the major cancer risk factors. A PBCR is a cost-effective investment to assist countries in setting priorities by identifying cancers with the highest burden, planning for emerging trends, focusing research where it is needed and allocating resources where they will make the greatest difference in cancer mortality and morbidity. It is also an invaluable tool for the evaluation of cancer control programmes and policies aimed at reducing the cancer burden in the community.
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Worldwide, there are more than 700 cancer registries. However, large disparities exist in the distribution of registries between high-income and low- and middleincome countries (LMICs), with a lack of financial resources and expertise meaning that the majority of developing countries do not have PBCRs.
All governments have approved the Global Monitoring Framework on Non-communicable Diseases (NCDs), which includes a commitment to report on cancer incidence and type per 100,000 population as an indicator for the global mortality target of reducing premature NCD deaths by 25% by 20251.
Only 8% of the world’s population is covered by cancer registries, predominantly from high- and middle-income countries. This is despite the fact that 43% of cancer cases and 53% of cancer deaths occur in less developed regions i.e. countries at a low or medium level of the human development index.
GLOBAL STATUS OF CANCER REGISTRATION
High Quality PBCR (national) High Quality PBCR (regional)
Registration activity
PBCR (national or regional)
No data / status unknown
Source: IARC, UICC (2013) Cancer Registries, Why, What and How? UICC Advocacy Toolkit 2014 - Evidence Sheets
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MEETING THE CHALLENGE
KEY COMPONENTS OF A PBCR A PBCR is feasible in all populations, even in lowresource settings, with solutions that can be tailored to the population size and available resources taking into account some key components: Target Population: A PBCR does not need to have national coverage to be effective. Most of the requirements for planning and monitoring can be achieved through registration of a well-described subset (sample) from the national population, such as a specific geographic region, which has access to diagnostic and treatment services. Data Collection: There are multiple sources of data for cancer registries including diagnostic reports, hospital records and vital statistics. Selection of the best method for data collection will depend on local circumstances, in particular whether there are pre-existing patient registries with the relevant information on the cancer patient and their diagnosis; as well as the willingness of institutions to share data. Consequently, the adoption of policies that mandate the communication of cancer cases to the cancer registry will create an enabling environment, and the support of the relevant Ministry as well as key health professionals, are essential to the registry’s success. Mobilisation of Resources: Cancer registration requires dedicated staff including a motivated Registry Director. The number of staff will depend on the registry size and the complexity of data collection (how many hospitals, pre-existing registers, etc). A small registry, covering a population of less than half a million may manage with a single member of staff, larger ones will require more and some specialisation in roles (supervisor, data collectors, secretary). For example, the Kampala registry in Uganda has 3 staff: 1 Director and 2 full time staff managing a population-based cancer registry for a catchment area with a population of two million (about 1,000 new registrations per year). Sustainable structural resources are also essential to support staff, physical facilities and running expenses.
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TECHNICAL SUPPORT The IARC-led multi-agency Global Initiative for Cancer Registry Development (GICR) was launched in 2011 to establish effective mechanisms to expand the coverage and quality of data from PBCRs in less developed countries and to attain a global fund for such activities. The GICR is implemented through “hubs” - IARC regional resource centres capable of providing developmental support towards and for population-based cancer registries. A series of IARC Regional Hubs for Cancer Registration are being rolled out in Africa, Asia and Latin America, with plans for the Caribbean and Pacific Islands (see Case Study). Coordinated by IARC in collaboration with designated local Principal Investigators in each hub, the objective of the hub is to assist in a sustainable expansion of highquality PBCR within defined regions, by providing the necessary mentorship and support; targeted training; guided research capacity; and advocacy tools. Technical support is available at the local level via IARC-coordinated Regional Hubs and through the GICR. For more information about the what, why and how of cancer registries, please visit: www.uicc.org/programmes/gicr/issue
GLOBAL ADVOCACY MESSAGE The establishment of a cancer registry is always possible, even in low-resource settings. A population-based cancer registry does not require national coverage to be effective with coverage of a smaller subset of the population able to provide the basis for national estimates. Taking measures to improve both the quantity as well as the quality of population-based registries, particularly in LMICs, is critical.
CASE STUDY IARC REGIONAL HUB FOR CANCER REGISTRATION: MUMBAI
In October 2012 the first IARC Regional Hub for Cancer Registration became operational based at Tata Memorial Centre in Mumbai (India), covering South, South-East, and East Asia. The hub’s activities have focused on four key areas: training, support, research and networking with significant progress made in the first year. This includes training conducted in three countries (India, Indonesia and Thailand); three-year collaborative research
agreements with cancer registries in Indonesia, Mongolia and Sri Lanka; regional research projects; and outreach to national authorities across the region.
References: 1. WHO. (2013). Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Geneva: World Health Organization.
FIVE MOST FREQUENT FORMS OF CANCER IN 2012 BY HDI
NEW CASES IN 2012 (THOUSANDS)
Female
Male VERY HIGH HDI
HIGH HDI
MEDIUM HDI
LOW HDI
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WORLD CANCER DECLARATION TARGET 3
REDUCE EXPOSURE TO CANCER RISK FACTORS GLOBAL TOBACCO CONSUMPTION, OVERWEIGHT AND OBESITY, UNHEALTHY DIET, ALCOHOL INTAKE, AND LEVELS OF PHYSICAL INACTIVITY, AS WELL AS EXPOSURE TO OTHER KNOWN CANCER RISK FACTORS WILL HAVE FALLEN SIGNIFICANTLY
THE FACTS Healthy Lifestyles Cancer and other high-prevalence non-communicable diseases (NCDs) are linked to common risk factors, namely tobacco use, harmful use of alcohol, an unhealthy diet, and a lack of physical activity making it of critical importance to reduce the level of exposure of individuals and populations to these common modifiable risk factors, and their determinants1. The most common risk factor, tobacco use, is linked to 71% of all lung cancer deaths, and accounts for at least 22% of all cancer deaths2. Alcohol is also a known risk factor for cancer - any level of consumption will increase the risk of cancer3. Alcohol is strongly linked with an increased risk of cancers of the mouth, pharynx, larynx, oesophagus, bowel, liver and breast. Globally, both tobacco and alcohol use start at a young age: Nearly one in five of the world’s adolescents aged 13-15 years use tobacco; and 14% of adolescent girls and 18% of boys
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aged between 13-15 years in low- and middle-income countries (LMICs) are reported to use alcohol3,4. Much of the world is experiencing upward trends in overweight and obesity and of particular concern is the increasing rates of obesity in children and adolescents5. These rising rates of obesity will lead to increased cancer rates unless actions are taken to improve people’s diets and physical activity levels, with overweight and obesity strongly linked to increased risks of bowel, breast, uterine, pancreatic, oesophagus, kidney and gallbladder cancers6. Beyond the four common risk factors, protection from ultraviolet (UV) radiation is also critical for skin cancer prevention. In 2000, excessive exposure to UV radiation caused 60,000 premature deaths (WHO) most of those as a result of recreational exposure.
Occupational & Environmental Exposures The World Health Organization (WHO) estimates that 177,000 cancer deaths each year are related to occupational exposure to selected carcinogens, with one in every three deaths caused by asbestos7,8. Inhalation of asbestos contributes substantially to the burden of lung cancer and causes mesothelioma, cancer of the larynx and the ovaries. Additionally air pollution is a major environmental risk factor for cancer9. The most recent data indicate that in 2010, 223,000 deaths from lung cancer worldwide resulted from air pollution, with the predominant sources being transportation, stationary power generation, industrial and agricultural emissions, and residential heating and cooking. Cost of inaction The economic cost of cancer, estimated to reach US$458 billion in 2030 far outweighs the cost of investing in preventative measures; population-based measures to reduce risk factors (tobacco, unhealthy diet, harmful alcohol use and physical inactivity) for all NCDs including cancer are estimated at just US$2 billion per year for all LMICs10,11.
MEETING THE CHALLENGE
A MULTISECTORAL APPROACH TO PREVENTION Concerted action in all sections of society and at all levels is needed to facilitate the implementation of prevention policies and programmes, including in schools and the workplace. Schools should provide meals to high nutritional standards and facilities for recreation and sport, and include nutrition and physical activity in core curricula14. Workplaces of all sizes can create environments that promote healthy behaviours through provision and access to healthy food options in work facilities;
All governments have approved the Global Monitoring Framework (GMF) on NCDs that recommends the adoption of a set of global targets to significantly reduce exposure to common cancer risk factors12: •
• • • • •
At least 10% relative reduction in the harmful use of alcohol, as appropriate, within the national context A 10% relative reduction in prevalence of insufficient physical activity A 30% relative reduction in mean population intake of salt/sodium A 30% relative reduction in prevalence of current tobacco use in persons aged 15+ years Halt the rise in diabetes and obesity Progress towards this set of targets will be measured by a series of 13 indicators.
Tobacco taxation has been identified as the single most important population-wide measure that governments can take to reduce major risk factors for NCDs17.
providing 100% tobacco smoke-free environments in all indoor workplaces; and work-based health education programmes that create awareness of cancer risk factors. Harnessing the use of Information and Communication Technologies (ICTs) to deliver prevention messages, particularly around healthy behaviours is gaining momentum with the potential to leverage a diverse range of interactive media. For example, mHealth initiatives are being used in developed and developing countries to deliver low-cost, personalised and interactive mHealth interventions to reduce tobacco use (see Case Study).
Unchecked, tobacco-related deaths will increase to more than eight million per year by 2030. More than 80% of those deaths will be in LMICs. UICC Advocacy Toolkit 2014 - Evidence Sheets
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MEETING THE CHALLENGE (CONTINUED)
THE EFFECTIVE USE OF LAW FOR PREVENTION The effective use of law and regulatory measures to reduce the exposure to cancer risks including to tobacco, alcohol and unhealthy foods, as well as environmental exposures, should be integrated within a comprehensive health systems approach to cancer and NCD control. For example, bans on tobacco advertising, promotion and sponsorship are one of the most powerful measures to control tobacco use. As of 2013, 24 countries with 694 million people have introduced complete bans and 100 more countries are close to a complete ban. However, 67 countries currently do not ban any tobacco advertising, promotion and sponsorship activities and greater efforts at the global level are needed to ensure that the WHO Framework Convention on Tobacco Control (FCTC) is implemented in all countries. Regulatory interventions to reduce exposure to unhealthy foods include regulation of consumer information including product labelling and regulation of unhealthy food advertising, promotion and sponsorship, in particular, restriction of marketing of unhealthy food and drinks to children14,16. Additionally, governments should implement and enforce international labour standards for occupational safety and health, particularly those regarding occupational cancer and asbestos (Convention concerning Safety in the Use of Asbestos).
A LIFE-COURSE APPROACH TO PREVENTION Through the adoption of the UN Political Declaration on NCDs in 2011 Member States have recognised the critical importance of reducing the level of exposure to cancer risk factors while at the same time strengthening the capacity of individuals to make healthier choices and promoting a health enabling environment for populations. A life-course approach to prevention is a core principle of the WHO Global Action Plan for NCDs 2013-2020 seeking to address exposure to risk factors at all ages and stages, including during childhood and adolescence when many risk behaviours first start.
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THE ROLE OF THE PRIVATE SECTOR IN PROMOTING HEALTHY LIFESTYLES “NCD action at all levels should engage businesses, as the private sector plays a significant role in the production, distribution and marketing of NCD risk factors, such as unhealthy foods and beverages.” Cary Adams, Chief Executive Officer, UICC (Interview with GBC Health, Why NCDs matter to business) The 2011 UN Political Declaration on NCDs acknowledges the importance of engaging relevant private sector in efforts to prevent and control NCDs, and specifically calls on the private sector to: take measures to implement WHO recommendations on marketing of unhealthy food and beverages to children, promote more food products consistent with a healthy diet, create enabling environments for healthy behaviours in the workplace. Through workplace environments, it is possible to influence the health behaviours of large proportions of the population and to conduct repeated multilevel interventions to influence health behaviours. Data on rates of economically active populations indicate that, globally, approximately 65% of the population aged over 15 years is part of the workforce15. “Companies should establish wellness and education programmes to treat and prevent NCDs among their employees.” Cary Adams, Chief Executive Officer, UICC (Interview with GBC Health, Why NCDs matter to business)
GLOBAL ADVOCACY MESSAGE With the right strategies, more than one in every three cancers can be prevented. Investment in the reduction of a population’s exposure to cancer risk factors is a long-term investment in the health of the population, which will also reduce the overall burden on the health system. Effective cancer prevention at the national level begins with a national cancer control plan (NCCP) that responds to a country’s cancer burden and cancer risk factor prevalence, and is designed to implement evidencebased resource-appropriate policies and programmes that reduce the level of exposure to risk factors for cancer and strengthen the capacity of individuals of all ages to adopt lifestyle choices that promote good health for life.
CASE STUDY BE HE@LTHY, BE MOBILE – A GROUND-BREAKING PARTNERSHIP BETWEEN WHO AND ITU TO USE MHEALTH TO IMPROVE NCD PREVENTION AND TREATMENT
A number of countries are already using mobile technology to deliver health promotion messages on the NCD risk factors; survey the epidemic; persuade users to change unhealthy behaviours; and to help countries implement national laws on NCDs. This new UN initiative will take these successful pilots and scale them up in other countries. WHO will provide the technical assistance and ITU will help implement country projects through government partnership with support from the private sector. The initiative, in its initial four-year period, will scale-up mobile technology in eight priority countries (at least one in each region) for NCD prevention, treatment and policy enforcement. Activities will be two-fold: mHealth operational projects will be implemented within countries, and standard operating procedures developed for running mHealth NCD intervention packages to support more traditional NCD prevention and control work.
Mobile solutions will be primarily sms- or apps-based and will include a range of services including mAwareness, mTraining, mBehavioural change, mSurveillance, mTreatment, mDisease management and mScreening building on existing successful pilots and scaling them to a population level. After identifying priorities for NCDs, a country can then pick solutions from the WHO/ITU mHealth programme’s ‘juke-box’ of possible approaches selected from evidence collected around the world. Costa Rica was the first country to officially enter the mHealth for NCDs programme launched in 2013. The government’s priority was to reduce the number of tobacco-related diseases in the country. They approached the WHO-ITU programme for guidance on approach and intervention models. The programme has been working with them since January 2013 to produce a mobile cessation programme for smokers in Costa Rica wanting to quit. www.itu.int/en/ITU-D/ICT-Applications/Documents/ faqs.pdf
References: 1. WHO. (2011). Global Status Report on noncommunicable diseases 2010. Geneva: World Health Organization. 2. WHO. (2012). Global Report: Mortality attributable to tobacco 2012. Geneva: World Health Organization. 3. WHO. (2011). Global status report on alcohol and health. Geneva: World Health Organization. 4. Warren CW, Jones NR, Eriksen MP, et al. (2006). Patterns of global tobacco use in young people and implications for future chronic disease burden in adults. Lancet , 367, 749-53. 5. Black RE, Victora CG, Walker SP, et al. (2013). Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet, 382, 427-51. 6. World Cancer Research Fund/American Institute for Cancer Research. (2009). Policy and Action for Cancer Prevention: Food, Nutrition, and Physical Activity: A Global Perspective. Washington DC: AICR. 7. WHO. (2011). An overview of the evidence on environmental and occupational determinants of cancer. Geneva: World Health Organization. 8. WHO. (2011). Environmental and Occupational Cancers. Retrieved September 12, 2013 from http://www.who.int/mediacentre/factsheets/fs350/en/ 9. IARC. (2013). IARC Scientific Publication No. 161: Air Pollution and Cancer. (A. C. Kurt Straif, Ed.)
10. Bloom, DE, Cafiero ET, Jane-Llopis E, et al. (2011). The Global Economic Burden of Noncommunicable Diseases. World Economic Forum. Geneva: World Economic Forum. 11. WHO. (2011). Scaling up action against noncommunicable diseases: how much will it cost? Geneva: World Health Organization. 12. WHO. (2013). Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013-2020. Geneva: World Health Organization. 13. Liberman, J. (2013). Making effective use of law in the global governance of NCD prevention. Accessible at: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2342697 14. Hawkes C, Jewell J, Allen, K. (2013). A food policy package for healthy diets and the prevention of obesity and diet-related non-communicable diseases: the NOURISHING framework. Obesity Reviews, 14, 159-168. 15. WHO / World Economic Forum. (2008). Preventing noncommunicable diseases in the workplace through diet and physical activity: WHO/World Economic Forum report of a joint event. Geneva: World Health Organization / World Economic Forum. 16. WHO. (2010). Set of recommendations on the marketing of foods and non-alcoholic beverages to children. Geneva: World Health Organization. 17. Jamison DT, Summers LH, Alleyne G, et al. (2013). Global health 2035: a world converging within a generation. Lancet, Published Online December 3, 2013 http://dx.doi.org/10.1016/.
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WORLD CANCER DECLARATION TARGET 4
UNIVERSAL COVERAGE OF HPV AND HBV VACCINATION THE CANCER CAUSING INFECTIONS HPV AND HBV WILL BE COVERED BY UNIVERSAL VACCINATION PROGRAMMES
THE FACTS Healthy Lifestyles
HPV and Cervical Cancer
Prevention is critical to tackling the cancer burden. For low- and middle-income countries (LMICs), cancer prevention programmes must go beyond addressing behavioural change, with many countries facing a ‘double burden’ of exposures, the most common of which is cancer-causing infections. Chronic infections are estimated to be the cause of around 16% of all cancers globally, with this figure rising to almost 23% in developing countries1,2. Several of the most common cancers in LMICs such as liver and cervical cancers are associated with infections with hepatitis B virus (HBV) and the human papillomavirus (HPV), respectively. This causal link between infection and cancer opens up opportunities for preventing these cancers with safe and effective vaccines now available against both HPV and HBV infection3,4.
There were an estimated 528,000 global cases of cervical cancer and 265,000 global deaths from the disease in 2012, with over 85% of these in LMICs5. In Latin America and Asia, more women die from cervical cancer than from childbirth.
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The currently available HPV vaccines can prevent approximately 70% of cervical cancer cases. These two vaccines have been shown to be at least 90% effective in preventing persistent HPV 16 and 18 infections – the cause of most cervical cancers6,7. As of the end of 2011, 40 countries had introduced HPV vaccine in their national immunisation schedule8. Scientific evidence continues to show that the vaccines have excellent safety profiles, with more than 170 million vaccine doses delivered without any substantive evidence for safety concerns9,10.
HBV and Liver Cancer In 2012, there were 745,000 deaths from liver cancer with almost 85% of cases occurring in developing countries5, with chronic infection with Hepatitis B Virus (HBV) a major cause, accounting for approximately 5055% of cases2. HBV infection acquired in infancy and childhood increases the risk of developing cancer later in life. In highly endemic areas, the most common routes are mother to newborn (perinatal transmission) or infection in early childhood. Where there are high rates of hepatitis B infection, vaccination of newborns has reduced the risk of infection and has also led to a marked reduction in the number of chronic carrier rates11; also see Case Study.
MEETING THE CHALLENGE
REMOVING BARRIERS TO UNIVERSAL ACCESS One of the greatest barriers to universal introduction of HPV immunisation programmes is cost. Progress towards affordable pricing for HPV vaccine is being driven by the GAVI Alliance, with GAVI recently opening a window of support for eligible countries for the introduction of the HPV vaccine at either the national level or as a demonstration project, greatly increasing the capacity of low-income countries to deliver this vaccine13.
A HEALTH SYSTEMS APPROACH TO PREVENTION The HPV vaccine is best introduced as part of a comprehensive strategy to prevent cervical cancer. Pre-cancerous lesions of the cervix caused by persistent HPV infection are detectable prior to progression to invasive cancer, and are treatable. Routine screening and treatment has dramatically reduced cervical cancer
All governments have approved the Global Monitoring Framework on Non-communicable Diseases (NCDs) that calls for the adoption of policies to improve equitable access to prevention programmes including vaccinations against infection-associated cancers12. Progress will be measured by monitoring the following: 1. Availability, as appropriate, if cost-effective and affordable, of vaccines against HPV, according to national programmes and policies. 2. Vaccination coverage against hepatitis B virus monitored by numbers of third doses of Hep-B vaccine (HepB3) administered to infants.
morbidity and mortality in wealthier nations and innovative “screen and treat� approaches for lower income settings have been shown to be effective. Coupling the vaccination of girls with screening and treatment of women will be the most effective strategy to rapidly reduce the cervical cancer burden. Lessons-learned from demonstration projects, particularly PATH-led projects in Vietnam, Peru, Uganda and India, have shown that as a consequence of the target group of young adolescent girls, social mobilisation including the use of social media, and investment in effective IEC (Information, Education, and Communication) is essential for success14,15. Consequently, HPV implementation should also be considered as a platform to improve adolescent health by fostering synergies with other public health interventions such as reproductive health and nutrition, as well as strengthening partnerships across sectors outside of health, including education12,16.
In Sub-Saharan Africa, 1 in 3 cancer cases are attributable to infectious agents, compared to 1 in 35 cases in the United States and Australia. UICC Advocacy Toolkit 2014 - Evidence Sheets
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MEETING THE CHALLENGE (CONTINUED)
GLOBAL ADVOCACY MESSAGE The introduction of safe, effective and affordable vaccines for HBV and HPV as part of national immunisation schedules are specific priorities for countries with high incidence of these cancers and should be implemented as part of national cancer control plans. The World Health Organization (WHO) recommends that vaccination against HBV infection is included in national infant vaccination programmes. The most effective way to reduce the prevalence of chronic HBV infection is by universal infant vaccination with three doses of hepatitis B vaccine, with the first dose delivered within 24 hours of birth4. The WHO recommends HPV immunisation targeted at young adolescent girls aged 9 to 13 years in countries where cervical cancer constitutes a public health priority and where vaccine introduction is feasible, where sustainable financing can be secured and when costeffectiveness is considered. The recommended age range is to target girls before they become sexually active and are exposed to HPV infection. Three doses of the vaccine are required within six months3.
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In September 2013, the GAVI Alliance announced a record-low price for HPV vaccines of US$4.50, representing a two-thirds drop on the lowest current available public price. By 2015, GAVI plans to support vaccination of one million girls in more than 20 countries, with the goal of reaching more than 30 million girls vaccinated in over 40 countries by 2020. Likewise, while WHO has recommended global immunisation against hepatitis B infection since 1992, uptake of the vaccine was slow in poorer countries due to the high price. The GAVI Alliance support of HBV vaccines has been instrumental in accelerating its introduction into national immunisation programmes by addressing affordability. The price of the pentavalent vaccine, a 5-in-1 shot vaccine that combines protection against hepatitis B with diphtheria, tetanus, pertussis and Haemophilus influenzae type b (Hib), has dropped by 30% from US$3.61 per dose in 2007 to US$2.49 per dose in 2011. Today, almost all low-income countries have introduced hepatitis B vaccines into routine immunisation programmes.
CASE STUDY CHINA’S DRAMATIC FALL IN HEPATITIS B INFECTIONS
Just over a decade ago, barely 40% of children in China’s poorest areas were immunised against HBV. Approximately 10% of China’s population were chronic carriers of the disease, which is responsible for hundreds of thousands of deaths every year in China due to liver cancer and cirrhosis.
References
In 2002, GAVI, the Government of China and the China Centre for Disease Control (CDC) started a partnership that lasted until December 2010 to combat the disease.
5. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM,
The collaboration provided first-dose HBV vaccines at birth free of charge to over 25 million newborns in the poorest and most remote provinces of western and central China. However, health authorities faced formidable challenges as immunising babies at birth was difficult as women in remote areas mostly gave birth at home. Raising public awareness of the value of immunisation and encouraging mothers to deliver in hospitals was therefore important. Demonstrating the catalytic impact of GAVI’s support, the Chinese Government decided to introduce the vaccine into its routine immunisation programme in 2005. Since the start of the project, the percentage of newborn children immunised with the first dose at birth has climbed from 64% to over 90% in most areas. Less than 1% of children under five are now chronic carriers of HBV.
1. Wild CP. (2012). The role of cancer research in noncommunicable disease control. J Natl Cancer Instit, 1-8. 2. de Martel C, Ferlay J, & Franceschi S. (2012). Global burden of cancers attributable to infections in 2008; a review and synthetic analysis. Lancet, 13, 607-615. 3. WHO. (2009). WHO position paper on human papillomavirus vaccines. Weekly Epidemiological Record, 84, 117-32. 4. WHO. (2009). WHO position paper on hepatitis B vaccines. Weekly Epidemiological Record, 40, 405-20. Forman D, Bray, F.GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; 2013. Available from: http://globocan.iarc.fr, accessed on 23/01/2014. 6. Ault K. (2007). Effect of prophylactic human papillomavirus L1 virus-like-particle vaccine on risk of cervical intraepithelial neoplasia grade 2, grade 3, and adenocarcinoma in situ: a combine analysis of four randomized clinical trials. Lancet, 369, 1861-8. 7. Paavonen J, Naud P, Salmeron J, et al. (2009). Efficacy of human papillomavirus (HPV)-16/18 AS04-adjusted vaccine against cervical infection and precancer caused by oncogenic HPV types (PATRICIA): final analysis of double-blind, randomised study in young women. Lancet, 374, 301-14. 8. WHO. (2012). Report of the HPV Vaccine Delivery Meeting, Identifying needs for implementation & research. Geneva: Expanded Programme on Immunization (EPI) of the Department of Immunization, Vaccines and Biologicals. 9. Arnheim-Dahlström L, Pasternak B, Svanström H, et al (2013). Autoimmune, neurological, and venous thromboembolic adverse events after immunisation of adolescent girls with quadrivalent human papillomavirus vaccine in Denmark and Sweden: cohort study. BMJ 347:f5906 doi: 10.1136/bmj.f5906 10. GACVS Safety update on HPV Vaccines, Geneva, 13 June 2013. http://www.who.int/ vaccine_safety/committee/topics/hpv/130619HPV_VaccineGACVSstatement.pdf. 11. Chang MH, You SL, Chen CJ, et al (2009). Decreased incidence of hepatocellular carcinoma in hepa¬titis B vaccines: a 20-year follow-up study. J Natl Cancer Inst 101:1348- 55. 12. WHO. (2013). Global action plan for the prevention and control of noncommunicable diseases 2013 -2020. Geneva: World Health Organization. 13. GAVI. (2013). GAVI Factsheet on human papillomavirus. From http://www.gavialliance.org/ support/nvs/human-papillomavirus-vaccine-support/ 14. PATH. (2009). Shaping strategies to introduce HPV vaccines: Formative research results from India, Peru, Uganda, and Vietnam. Seattle: PATH
See more at: www.gavialliance.org/library/news/roi/2010/chinas-dramatic-fall-in-hepatitis-b-infections
15. PATH. (2011). Implementing HPV vaccination programs, Practical experience from PATH. Cervical Cancer Prevention: Practical Experience Series. Seattle: PATH. 16. The Global Fund. (2011). The Global Funds approach to Health Systems Strengthening (HSS). The Global Fund.
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WORLD CANCER DECLARATION TARGET 5
REDUCE STIGMA AND DISPEL MYTHS ABOUT CANCER STIGMA ASSOCIATED WITH CANCER WILL BE REDUCED, AND DAMAGING MYTHS AND MISCONCEPTIONS ABOUT THE DISEASE WILL BE DISPELLED
THE FACTS In some cultures and societies cancer can be discussed in the open and is widely talked about in the media. Yet, this is still not the case in many, if not most, settings, where cancer remains a taboo subject and persons with cancer are subject to stigma and discrimination. Negative public perceptions of cancer can make cancer patients feel invisible, stifle informed public discussion and perpetuate a cycle of fear and misinformation that hinders raising awareness about cancer prevention, healthy behaviours and seeking early diagnosis for signs and symptoms. Cancer-related stigma also negatively impacts a patient’s quality of life and is associated with distress including social isolation and depression1,2.
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Understanding and responding to cultural beliefs and practices is essential, particularly in settings where misconceptions about diagnosis and fear of treatment; stigma associated with cancer; and gender and social inequities can lead individuals to seek alternative care such as traditional therapies in place of standard treatment or to avoid care altogether3. The perceptions that cancer is a death sentence is a common myth across many societies and cultures, often resulting in early signs and symptoms being ignored and individuals presenting at an advanced stage of disease when treatment options are limited resulting in high mortality. Cultural issues relating to body image may also hinder women from seeking assistance from health workers.
”What comes to mind when I think of cancer is silence.”
Public education programmes as well as systemic changes supported by policy and legislation are needed in all settings to counter negative stereotypes and discrimination towards cancer patients.
A participant from Ethiopia in an interview on beliefs and practices in breast cancer3
Copyright: © Francois STRUZIK - Image of dignity
Additionally, discrimination in the workplace continues to be a real concern for many cancer patients and their families in all countries with patients often concealing a diagnosis of cancer for fear of loss of employment. In a recent global survey, only about one in ten respondents said that they would tell their employers if they were diagnosed with cancer1. Attitudinal and practical barriers contribute to many cancer survivors facing problems retaining employment or returning to work after treatment. Some employers may discriminate against a person with cancer for fear of lack of performance or their need for extended leave for treatment or rehabilitation. There may also be discomfort around working with someone who has cancer4,5. Many carers are also affected and may face discrimination around the need to take leave from work to care for a family member6.
A participant from Japan in answer to the question “What words come to your mind when you think of cancer?”1
“Due to a lack of knowledge, when they hear the word ‘cancer’ they get scared, some hide it and some use traditional medicine until it becomes too late for treatment.”
All governments have approved the WHO Global Action Plan on Non-communicable Diseases (NCDs) 2013-2020 that supports the adoption of policies to promote public and political awareness, understanding and practice about prevention and control of NCDs7; and promotes affordable, evidence-based, patient/ family-centred self-care with a special focus on populations with low health awareness and/ or literacy. This includes the use of information and communication technologies (ICT), such as the Internet/mobile phone technologies, for the prevention and control of NCDs, including health education, health promotion and communication for all groups.
In a recent study of public attitudes toward cancer and cancer patients in Korea, 72% agreed that cancer patients would not be able to make contributions to society. UICC Advocacy Toolkit 2014 - Evidence Sheets
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MEETING THE CHALLENGE
RAISING AWARENESS ABOUT CANCER Specific efforts are required to improve knowledge of cancer among communities, health professionals and policy makers to dispel common cancer myths, reduce stigma and fear and increase awareness around the options for early detection to improve survival. Communication is critical to breaking the cycle of misinformation. Cancer survivors, especially those with influence in the community or a national celebrity, can give hope to those newly diagnosed with cancer and reduce fear and stigma by sharing their stories. Using multiple media channels to disseminate information and raise population-level awareness of cancer control can also be effective in changing attitudes and improving knowledge1,8. Even in settings where community engagement on cancer is high, among individuals, especially men, the level of knowledge of cancer and the willingness to talk about it with friends and family can be low. An example of a campaign seeking to address this issue is the ‘Get to know cancer’ initiative which aims to help people speak up about their fears about cancer, promote awareness about cancer signs and symptoms and to increase the likelihood of early diagnosis9. The campaign is using innovative strategies to achieve a broad reach – from popup market stalls to partnering with a high profile sports club to reach their global fan base. Other campaigns specifically challenge the taboos and embarrassment surrounding some male cancers (prostate, testicular and colorectal cancers) and create awareness of early signs and symptoms. See www.malecancer.org/abouts for more information.
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COUNTERING DISCRIMINATION IN THE WORKPLACE Countering discrimination in the workplace is an important part of creating a supportive environment for cancer survivors, ensuring a smooth transition back to the workplace for themselves and their carer. For both patients and carers, receiving support in the workplace can be a significant factor from a personal and a practical standpoint. A job can restore normality, routine, stability, social contact and income10. A supportive approach from employers can reduce anxiety and provide the skills and confidence to deal with cancer at work. For employers, making adjustments such as supporting a phased return to work, can be an important factor in getting people back to work successfully10. Policies and legislation that protect cancer patients and their carers from discrimination in the workplace can be applied. For example, in Australia, the Fair Work Act both prohibits employers from taking adverse action against employees for exercising their workplace rights (for example, their leave entitlements); and the dismissal of employees who take temporary absences due to illness, as long as a medical certificate is supplied and the absence is less than three months in one year. Cancer is also is considered to be a disability under antidiscrimination laws meaning that reasonable adjustments must be made so that survivors are not disadvantaged as a result of their cancer5.
MEETING THE CHALLENGE (CONTINUED)
References:
GLOBAL ADVOCACY MESSAGE Talking about cancer challenges negative beliefs, attitudes and behaviours that perpetuate myths about cancer, cause fear and stigma and prevent people from seeking early detection and treatment. Governments, communities, employers and media all have a role to play to challenge perceptions about cancer to create a culture where people are empowered to access quality cancer prevention and care and do not experience discrimination.
The 2014 World Cancer Day campaign “Debunk the myths� aimed to disseminate information and challenge common misconceptions about cancer.
ON FEBRUARY 4TH
1. LIVESTRONG. (2011). Cancer Stigma and Silence Around the World: A LIVESTRONG Report . Austin: LIVESTRONG. http://www.livestrong.org/What-We-Do/Our-Actions/Programs-Partnerships/Anti-StigmaCampaign 2. Cho J, Choi E-K, Kim S, et al. (2013). Association between cancer stigma and depression among cancer survivors: a nationwide survey in Korea. Psycho-Oncology, 22, 2372-78. 3. De Ver Dye T, Bogale S, Hobden C, et al. (2011). A mixed-method assessment of beliefs and practice around breast cancer in Ethiopia: Implications for public health programming and cancer control. Global Public Health, 6, 719-31. 4. Cho J, Smith K, Choi E-K, et al. (2013). Public attitudes toward cancer and cancer patients: a national survey in Korea. Psycho-Oncology, 22, 605-13. 5. McCabe Centre for Law & Cancer, Cancer Council Victoria. (2013). Making the law work better for people affected by cancer. Melbourne: McCabe Centre for Law & Cancer. 6. Girgis A, Lambert S, Johnson C, et al. (2013). Physical, Psychosocial, Relationship, and Economic Burden of Caring for People With Cancer: A Review. J Oncol Practice, 9, 197-202. 7. WHO. (2013). Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Geneva: World Health Organization. 8. Clegg-Lamptey J, Dakubo J, Attobra YN. (2009). Why do breast cancer patients report late or abscond during treatment in Ghana? A pilot study. Ghana Med J 43, 127e31. 9. My Health London: Get To Know Cancer. https://www.myhealth.london.nhs.uk/healthcommunities/get-to-know-cancer. London: NHS. 10. Macmillan Cancer Support. Managing Cancer in the Workplace. Retrieved September 12, 2013 from Macmillan Cancer Support: http://www.macmillan.org.uk/Cancerinformation/ Livingwithandaftercancer/Workandcancer/Supportformanagers/Employersguide/ Managingoverview.aspx
DEBUNK THE MYTHS WORLDCANCERDAY.ORG
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CASE STUDY LIVESTRONG CANCER ANTI-STIGMA INITIATIVE IN SOUTH AFRICA
In April 2010, LIVESTRONG launched a landmark Cancer Anti-Stigma Initiative targeting three areas of South Africa: Mdantsane (Eastern Cape), Khayelitsha (Western Cape) and Soweto (Gauteng). The initiative involved a number of activities including: •
Conducting focus groups and interviews
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Empowering survivors to share their stories
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Holding community events, including concerts, health fairs, fitness contests, and sports tournaments
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Performing a door-to-door campaign with local volunteers to educate the community
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Training community health workers and media figures
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Implementing an SMS-text campaign
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Hosting a nine-week radio call-in show
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Creating TV and radio public service announcements (PSAs) with survivors
Only 18 months later, these efforts produced significant results described here in the infographic. For more information go to: http://blog.livestrong. org/2011/12/12/livestrong-announces-results-ofsuccessful-anti-stigma-initiative-in-south-africa/ and http://vimeo.com/35979042
Created by the LIVESTRONG Foundation and implemented in partnership with John Snow, Inc.
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WORLD CANCER DECLARATION TARGET 6
UNIVERSAL ACCESS TO SCREENING AND EARLY DETECTION FOR CANCER POPULATION-BASED SCREENING AND EARLY DETECTION PROGRAMMES WILL BE UNIVERSALLY IMPLEMENTED, AND LEVELS OF PUBLIC AND PROFESSIONAL AWARENESS ABOUT IMPORTANT CANCER WARNING SIGNS AND SYMPTOMS WILL HAVE IMPROVED.
THE FACTS For many populations, particularly in low-resource settings, the value of early detection and the impact of timely evaluation of symptoms on opportunities for cure and quality of life are poorly understood. It is true that early signs and symptoms are not known for all cancers, but for many cancers, including breast, cervical, colorectal, skin, oral, and some childhood cancers, the benefits of implementing systematic approaches to early detection and care are conclusive. Proven, practical strategies for early detection of these cancers should be implemented in all resource settings and integrated into existing health services.
Awareness is the first step to early detection and improving cancer outcomes. Lack of information and awareness about cancer is a critical obstacle to effective cancer control and care in developing countries, especially for the detection of cancers at earlier and more treatable stages. Equally important is the development of strategies to encourage help-seeking behaviour including awareness and education of ways to recognise the signs and symptoms for some cancers.
A single cervical cancer screening between the ages of 30 and 40 can reduce a woman’s lifetime risk of cervical cancer by 25% to 36%1. UICC Advocacy Toolkit 2014 - Evidence Sheets
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RAISING AWARENESS Comprehensive early detection programmes should include strategies to improve knowledge of cancer among communities, health professionals and policy makers and increase awareness around the options for early detection of some cancers regardless of the resource setting. Understanding and responding to cultural beliefs and practices is essential, particularly in settings where misconceptions about diagnosis and treatment; stigma associated with cancer; and gender and social inequities can lead individuals to seek alternative care in place of standard treatment or to avoid care altogether.
TAILORING EARLY DETECTION & SCREENING Recognition of early warning signs of some cancers is particularly relevant in the context of primary care in lowresource settings – it is cost-effective and in some cases does not require any specialist diagnostic technologies as is the case with inspection for oral cancers and clinical breast examination (CBE) for breast cancer3,4. CBE performed by primary healthcare workers in low- and middle-income (LMICs) has the potential to detect cancers earlier, particularly in areas where the majority of breast cancers are diagnosed at an advanced stage5. For cervical cancer, the screen and treat approach that combines visual inspection with acetic acid (VIA) or HPV DNA testing with cryotherapy for early detection for women 35 to 42 years is currently recommended as part of the WHO package of essential non-communicable (PEN) disease interventions for primary healthcare in low-resource settings6. For childhood cancers, equipping primary healthcare workers with the appropriate knowledge and tools to recognise the warning signs and symptoms of paediatric cancer is essential to reduce the likelihood of misdiagnosis and ensure prompt referral to specialist medical care at an early stage of the disease7.
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For breast, colorectal and cervical cancers, there is robust evidence to support the implementation of populationbased screening programmes that are tailored to the countries’ resources and burden of disease2, 8-10. Critical issues for all screening programmes include selecting the test that is most appropriate for the context in order to achieve high screening coverage, high quality testing and reliable follow up. Ultimately, the success of early detection programmes can be measured by a reduction in the stage of the cancer at diagnosis with earlier diagnosis associated with a reduction in the risk of dying from cancer.
TRAINING OF HEALTH PERSONNEL Whilst specialty cancer care is essential, this can be complemented by a skilled workforce at the primary care level to facilitate greater access to early detection programmes. Investment in continuing professional development to equip healthcare workers with the appropriate tools and knowledge to recognise the early signs and symptoms of some cancers, as well as to perform appropriate early detection measures, is essential. In addition to conventional teaching methods, the utilisation of Information and Communication Technologies can address training and personnel gaps through multi-media tools in a cost-effective manner11.
With few exceptions, early stage cancers are less lethal and more treatable than late stage cancers.
MEETING THE CHALLENGE (CONTINUED)
All governments have approved the WHO Global Action Plan on Non-communicable Diseases (NCDs) that endorses a set of policy actions and indicators as part of a national systems response to NCDs including2: ---
Cervical and breast together account for over 785,000 deaths each year with the large majority of deaths occurring in low- and middleincome countries12.
GLOBAL ADVOCACY MESSAGE The cancer burden in all countries can be significantly reduced by ensuring the availability of, and access to, affordable early detection programmes for which there is evidence of efficacy in the population in question, including screening for breast, cervical, colorectal, skin and oral cancers. Awareness is the first step to early detection and improving cancer outcomes. Specific efforts are needed to raise awareness in the community and among healthcare workers that cancer outcomes can be improved through early detection regardless of the technique or the resource setting. The approach and scope of an early detection programme should be tailored to resources as well as cultural beliefs and practices, with the flexibility for governments to initiate and expand services as resource levels increase. Appropriate training of health personnel is critical in all settings but particularly in low-income countries where education of frontline health staff is a key component of a successful early detection strategy.
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Prevention of cervical cancer screening through VIA or Pap smear Population-based cervical cancer screening linked with timely treatment Population-based breast cancer and mammography screening (50 – 70 years) linked with timely treatment Population-based colorectal cancer screening including through faecal occult blood testing, as appropriate at age >50 linked with timely treatment Oral cancer screening in high-risk groups (e.g. tobacco users, betel-nut chewers) linked with timely treatment.
References: 1. Goldie SJ, Gaffikin L, Goldhaber-Fiebert JD, et al. (2005). Cost-effectiveness of cervicalcancer screening in five developing countries. N Engl J Med 353, 2158-68. 2. WHO. (2013). Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Geneva: World Health Organization. 3. Petersen PE (2009). Oral cancer prevention and control – The approach of the World Health Organization. Oral Oncology 45, 454-460. 4. Yip CH, Smith RA, Anderson BO, et al. (2008). Guideline Implementation for Breast Healthcare in Low- and Middle-Income Countries Early Detection Resource Allocation. Cancer 113, 2244-56. 5. El Saghir NS, Adebamowo CA, Anderson BO, et al. (2011). Breast cancer management in low-resource countries: consensus statement from the Breast Health Global Initiative. The Breast 20, S3-S11. 6. WHO. (2010). Package of essential noncommunicable (PEN) disease interventions for primary health care in low-resource settings. Geneva: WHO. 7. Workman GM, Ribeiro RC, Rai SN. et al. (2007). Pediatric cancer knowledge: assessment of knowledge of warning signs and symptoms for pediatric cancer among Brazilian community health workers. J Cancer Educ 22, 181-5. 8. Franceschi S, Denny L, Irwin KL, et al. (2011). Eurogin 2010 roadmap on cervical cancer prevention. International Journal of Cancer. 128, 2765-74. 9. Anderson BO, Yip C-H, Smith RA, et al. (2008). Guideline implementation for breast healthcare in low-income and middle-income countries, Overview of the Breast Health Global Initiative Global Summit 2007. Cancer, 113, 2221-43 10. Winawer SJ, Krabshuis J, Lambert R, et al. (2011). World Gastroenterology Organization Guidelines Committee. Cascade colorectal cancer screening guidelines: a global conceptual model. J Clin Gastroenterol 45, 297-300. 11. iheed Institute. (2012). Preparing the next generation of community health workers: The power of technology for training. iheed Institute, the Barr Foundation, the mHealth Alliance, and the MDG Health Alliance. Cork, Ireland: Dalberg Global Development Advisors. 12. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; 2013. Available from: http://globocan.iarc.fr, accessed on 23/01/2014. 13. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; 2013. Available from: http://globocan.iarc.fr, accessed on 23/01/2014.
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CASE STUDY COMMUNITY-BASED PROGRAMME FOR BREAST HEALTH, PERU
Background: According to 2012 Globocan data, Peru had an estimated 3,952 new cases of breast cancer and 1,208 deaths in 2012, with an age-standardied annual incidence rate of 28/100,000 women13. While current incidence is lower than in many countries of the global north, mortality rates are nearly as high, suggesting a much higher case-fatality rate in low- and middle-income countries such as Peru. Project Description: Since 2011, PATH has provided technical assistance to regional and national partners to introduce a model of care to improve access to and the quality of breast cancer screening, diagnosis, and referral for treatment at lower levels of the health system. Phase 1 of this effort, which concluded in June 2013, was implemented in Pacasmayo Province in the region of La Libertad in Peru. This model was made up of three key components: breast health promotion by established community health promoters, clinical breast exam (CBE) offered by professional midwives and general doctors that targeted women aged 40 to 64 for screening (and women of any age presenting with symptoms or concerns), and tissue sampling by fine needle aspiration (FNA) taken by hospital-based physicians at the district level. Cytological samples from the FNA procedure were interpreted at the regional cancer centre in Trujillo. If necessary, patients were subsequently referred to the same centre for final diagnosis and treatment. In addition, a “patient navigation” training programme to support women after diagnosis is currently being introduced.
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Partners: PATH has been collaborating with the Peru National Cancer Institute (INEN), the Regional Cancer Institute in Trujillo (IREN-Norte), and the Ministry of Health (MINSA), particularly at the regional health administration level (GERESA) in La Libertad. In addition to providing technical leadership and support, INEN has committed its own resources to key inputs, such as training, for the pilot project, while GERESA and IREN-Norte have committed staff time, materials, and other critical inputs. Results: Prior to this pilot, CBE was nominally available in this health network, but detection rates were low due to inadequate and inconsistent clinical training. Over the course of Phase 1, 52 midwives and general doctors were trained in CBE, 48 community promoters were trained in breast health, and three doctors at the district hospital were trained in FNA sampling and slide preparation. Curricula, educational materials, and job aids, informed by qualitative research with women and medical providers, were also produced and disseminated throughout the province. As of December 2012, more than 7,400 women had undergone CBE. From June 2011 to June 2013, 105 women underwent FNA biopsy, and eight women with cancer were identified, all of whom have received treatment. This work was generously supported by the Norwegian Cancer Society/The Norwegian Breast Cancer Society and Susan G. Komen for the Cure®. For more information: http://www.path.org/
WORLD CANCER DECLARATION TARGET 7
IMPROVE ACCESS TO SERVICES ACROSS THE CANCER CARE CONTINUUM ACCESS TO ACCURATE CANCER DIAGNOSIS, QUALITY MULTIMODAL TREATMENT, REHABILITATION, SUPPORTIVE AND PALLIATIVE CARE SERVICES, INCLUDING THE AVAILABILITY OF AFFORDABLE ESSENTIAL MEDICINES AND TECHNOLOGIES, WILL HAVE IMPROVED
THE FACTS Cancer is a complex disease with the appropriate treatment and care of most cancers requiring a multi-faceted approach that spans the entire cancer continuum, from prevention to supportive care and palliation (Figure 1). Patients in low-resource settings whose cancer may be curable in high-income countries, often suffer and die unnecessarily due to a lack of awareness, resources and access to affordable, effective and quality cancer services that enable early diagnosis and appropriate treatment and care1. A multidisciplinary approach to cancer is feasible in all settings when based on existing health resources and infrastructure; the national cancer burden; countryspecific cancer risks; political and social conditions; and cultural beliefs and practices, as part of a national cancer control plan (NCCP) to deliver locally appropriate, effective solutions that provide sustainable quality cancer services.
All governments have approved the WHO Global Action Plan on Non-communicable Diseases (NCDs) 2013-2020 that promotes universal health coverage as an overarching principle for the prevention and control of NCDs recognising that all people should have access, without discrimination, to nationally determined sets of the needed promotive, preventive, curative and rehabilitative and palliative basic health services and essential, safe, affordable, effective and quality medicines and diagnostics2. At the same time, it must be ensured that the use of these services does not expose the users to financial hardship, with a special emphasis on the poor and populations living in vulnerable situations.
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FIGURE 1: THE CORE ELEMENTS OF A COMPREHENSIVE CANCER CONTROL AND CARE CONTINUUM
A rights-based approach to cancer care The right to health was enshrined in the Constitution of the World Health Organization (WHO) in 1946, and included in the Universal Declaration of Human Rights two years later. Every country has now signed up to at least one treaty that acknowledges the right to health, yet in many countries inequality is deepening – the double disease burden of exposures in many low- and middle-income countries (LMICs), ineffectual health systems and lack of social protection are widening gaps in access to cancer services and financial risk. Applying a human rights-based approach to cancer care acknowledges that access to services is a matter of social justice and can assist in identifying and addressing the inequalities and discriminatory practices that affect a person’s access to affordable, quality and timely clinical and supportive care services across the cancer care continuum.
Universal health coverage (UHC) is defined by WHO as ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.
There is a ~90% survival rate for childhood cancer in some high-income countries compared to ~10% in some low- and middle-income countries due to lack of access to effective treatment. 28
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MEETING THE CHALLENGE
NCCPs should consider the full spectrum of multidisciplinary cancer services and infrastructure across the continuum of care, acknowledging that high quality cancer care is not possible without investment in each of the critical components of a multidisciplinary approach. This must include specific efforts to provide supportive care including psychosocial support. Of equal importance is to address affordability of care to protect individuals and families from financial hardship as a consequence of out-of-pocket expenses. The provision of UHC and other social protection measures can play an important role in closing the unacceptable gaps in access to cancer services that occur in most LMICs. Through the integration of UHC in the post-2015 framework, the international community has the opportunity to provide a country-driven strategy for ensuring that all people obtain the health services they need, without suffering financial hardship3,4. The capacity for low-income countries to move towards UHC has been demonstrated in at least nine low-income and lower-middle-income countries in Africa and Asia. Each of these countries has implemented varied national health insurance models, with some countries (India, Kenya, the Philippines) that originally covered only inpatient services now moving to expanding benefits to cover both primary and preventive services5. Many more countries are now undergoing reforms towards UHC including South Africa, Vietnam, Ghana and Rwanda.
UHC can be an enabler for strong health systems that are able to respond to all major challenges to health including cancer and other NCDs, as well as communicable diseases and injuries, many of which share common underlying determinants and are inter-related. At the same time, governments should address other key barriers to access to quality cancer care, including investment in infrastructure and a skilled and supported cancer workforce; addressing social and cultural beliefs and practices that hinder access to care including stigma; and countering barriers to quality services across the cancer care continuum including access to affordable, effective and quality cancer medicines and technologies.
GLOBAL ADVOCACY MESSAGE Effective, quality cancer care is achievable in all settings using locally appropriate solutions that provide sustainable and equitable services that span the spectrum of the cancer care continuum. Social protection measures, including universal health coverage, are essential to address the financial impacts of cancer and other NCDs on people and families to ensure they do not fall into poverty due to disability and out-of-pocket expenses. All people have the right to access proven effective cancer treatment and services on equal terms regardless of geography and without suffering economic hardship as a consequence.
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CASE STUDY BRINGING CANCER CARE INTO LAW IN KENYA: THE CANCER PREVENTION AND CONTROL ACT 2012
The journey towards having a dedicated cancer bill started in 2009 as an idea by members and volunteers of the Kenya Cancer Association. The key breakthrough for this proposal was when expert drafters, supported by UICC, assisted in creating the initial legal framework for the Act consolidating ideas borrowed from countries in the region and worldwide who had successfully developed a cancer institute dedicated to education, training, management, research and related aspects of holistic cancer care.
To help ensure that the bill would be prioritised, the Kenya Cancer Association wrote to the Parliamentary Committee on Health, seeking an intervention and a possible way to fast track the bill through Parliament. In 2011 after various meetings and stakeholder review sessions, the Parliamentary Committee on Health brought the final draft onto the floor of the house for the first reading in early 2012. Through enormous support from members of parliament and the Ministry of Health, the bill was finally passed by parliament in 2012. The Cancer Prevention and Control Act 2012 was signed into law by His Excellency the President of Kenya in July 2012. Acknowledgements: Kenya Cancer Association
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Š Moonshine Agency Pty Ltd 2012
The first stakeholders meeting brought together cancer specialists, experts from the division of NCDs, legal experts, cancer survivors, palliative care and medical research experts. With meeting support provided by a private sector alliance in Kenya, efforts to consolidate and review the draft were begun. The zero draft was ready by the end of 2009 (it was then known as the Cancer Control Act 2009). However, it was only on World Cancer Day, 4th February 2010 that the draft was delivered to the Minister of Medical Services in Nairobi.
References: 1. Knaul FM, Frenk J & Shulman L. (2011). Closing the Cancer Divide: A Blueprint to Expand Access in Low and Middle Income Countries. Harvard Global Equity Initiative. Boston: Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries. 2. WHO. (2013). Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Geneva: World Health Organization. 3. Vega J. (2013). Universal health coverage: the post-2015 development agenda. Lancet, 381, 179-80. 4. Rockefeller Foundation, Save the Children, UNICEF, WHO. (2013). Universal Health Coverage: A commitment to close the gap. London: Save the Children. 5. Lagomarsino G, et al. (2012). Moving towards universal health coverage: health insurance reforms in nine developing countries in Africa and Asia. Lancet, 380, 933-43.
WORLD CANCER DECLARATION TARGET 7
IMPROVE ACCESS TO ESSENTIAL CANCER MEDICINES AND RADIOTHERAPY ACCESS TO ACCURATE CANCER DIAGNOSIS, QUALITY MULTIMODAL TREATMENT, REHABILITATION, SUPPORTIVE AND PALLIATIVE CARE SERVICES, INCLUDING THE AVAILABILITY OF AFFORDABLE ESSENTIAL MEDICINES AND TECHNOLOGIES, WILL HAVE IMPROVED
THE FACTS The administration of essential cancer medicines and radiotherapy are effective and critical components of highquality multimodal cancer treatment. However, access falls dramatically short of demand, most notably in low- and middle-income countries (LMICs) resulting in unnecessary suffering and deaths from cancers that are treatable in high-resource settings1,2. Data reported from 36 LMICs showed that the mean availability of NCD generic medicines was 36% in the public sector and 55% in the private sector (but at a much higher price)3. A particular issue is the insufficient access to opioid analgesics for pain relief and palliative care with high-income countries consuming 93% of the world’s morphine supply while 65% of deaths from cancer occur in LMICs4. Affordability of cancer medicines must also be addressed. Household surveys have shown that 41–56% of households in LMICs spend all of their health-related expenditure on medicines; and that poor households in these countries spend up to 9.5% of their household expenditure on medicines. The cost of cancer medicines
does not have to be prohibitively expensive - most of the off-patent generic cancer medicines required for LMICs are available for less than $US100 per course of treatment, and nearly all for under $US10005. Radiotherapy is recognised as an essential tool in the cure and palliation of cancer, and is recommended in 52% of new cancer patients. In LMICs, the need for RT may in fact be higher due to a more advanced stage of disease at presentation6. The International Atomic Energy Agency (IAEA) estimates that there is currently a deficiency of at least 5,000 radiotherapy machines in LMICs. This shortage means that up to 70% of cancer patients in LMICs who may benefit from radiation medicine do not receive this essential curative or pain relieving treatment. Furthermore, radiotherapy is often perceived as a complex and expensive solution. However, a lack of investment in this critical treatment modality will exacerbate the burden of cancer and reinforce the disparities in access to cancer care.
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All governments have approved the Global Monitoring Framework for Non-communicable Diseases (NCDs) that recommends adoption of the global target of an 80% availability of the affordable basic technologies and essential medicines, including generics, required to treat major NCDs in both public and private facilities7. Progress will be measured by monitoring the availability and affordability of quality, safe and efficacious essential NCD medicines, including generics, and basic technologies in both public and private facilities.
CIAN Agency © François Struzik -‐ simply human
However, the list of basic technologies does not include radiotherapy and no alternate targets or indicators have been adopted with the draft framework to monitor availability and access to radiotherapy as part of comprehensive national cancer control plans.
The WHO Model List of Essential Medicines for adults (EML) and children (EMLc) presents a set of medicines that are considered to be costeffective and of critical public health importance in all countries. In this context, “Essential medicines” are defined as those that “satisfy the priority healthcare needs of the population; they should therefore be available at all times in adequate amounts and in appropriate dosage forms, at a price the community can afford.” In informing national pharmaceutical policies, the WHO Model List serves as a key lever to improve access to essential medicines including cancer medicines worldwide. A review being undertaken by the expert committee is considering a new structure for the section on cytotoxics and adjuvant medicines to ensure that the WHO EML best reflects the cancer medicines that are most essential for patients worldwide.
29 of 52 African nations have no radiotherapy facilities at all, and these 29 countries comprise an estimated 198 million people. 32
UICC Advocacy Toolkit 2014 - Evidence Sheets
MEETING THE CHALLENGE
Improved access to effective affordable multimodal treatment for cancer should be a genuine priority for the post-2015 development agenda supported by action, resources, and systematic monitoring with specific actions taken to meet the global target of an 80% availability of the affordable and essential medicines and basic technologies, including radiotherapy. The safe and effective delivery of cancer medicines and radiotherapy, as part of a team-based approach to cancer care, is achievable in both high- and low-income settings if implemented as part of a national cancer control plan and according to evidence-based clinical guidelines that are appropriate for the level of resources. Investments in the necessary infrastructure and a skilled and supported health workforce should be priorities. These should include the development of laboratory, pathology, and clinical services for cancer diagnosis, staging, and monitoring of effectiveness and safety of chemotherapy; additional radiotherapy equipment to address overall capacity constraints and to replace out-dated, less effective, machines; and education and training of healthcare professionals to ensure the safe and proper administration of chemotherapy and other systemic therapies, and to maximise the application and impact of radiotherapy. The majority of critical anti-cancer drugs are off patent and included on the WHO Model List of Essential Medicines. National cancer planning processes should identify a list of essential cancer medicines for training, supply, and reimbursement in conjunction with the development of evidence-based national clinical guidelines. The evaluation of newer, more costly, cancer drugs should be done on an individual basis within the national cancer control planning process to make the best possible use of resources. As the available resources increase so should the number and variety of cancer medicines available for cancer treatment with governments using the full flexibilities of international trade agreements to provide access to on-patent medicines where appropriate8.
Ensuring access to quality cancer medicines requires national authorities to also consider mechanisms to increase efficiency in procurement, supply, and use to promote access to medicines within the existing health budget8; Key recommendations include: the promotion of the use of generic NCD medicines through legislation, quality assurance, advocacy, and financial incentives; the creation of a dedicated national body that is responsible for the promotion of safe and efficient use of medicines; and the review of laws and practices and removal of unnecessary constraints on use of opioid analgesics. Greater awareness is needed amongst policy makers, health professionals, patients and caregivers of the increasing benefits of using modern radiotherapy: more than half of all cancer patients benefit from a therapy that is targeted more accurately than ever before, treatment times are shorter due to advances in technology, cure rates are increased, and side effects are reduced. Radiotherapy has been shown to be a cost-effective approach to cancer treatment in high-income countries, and evidence to further support cost-effectiveness is also emerging from developing countries. For example, the Breast Health Global Initiative (BGHI) produced regional estimates on the cost-effectiveness of treatment for breast cancer in Africa, Asia, and North America, and concluded that radiotherapy is generally cost-effective9. The emergence of new initiatives and partnerships such as the Global Task Force on Radiotherapy for Cancer Control (GTFRCC) and the Advisory Group on Increasing Access to Radiotherapy Technologies in developing countries (AGaRT), are bringing together experts from a diverse range of disciplines to drive coordinated action, through a strategic and systematic approach to increase the ability to provide radiotherapy affordably and safely in LMICs.
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MEETING THE CHALLENGE
A COORDINATED GLOBAL RESPONSE TO ADDRESSING ACCESS TO RADIOTHERAPY A Global Task Force on Radiotherapy for Cancer Control (GTFRCC) has been convened by UICC to provide a clear global assessment of the cancer treatment shortfall of radiotherapy to raise awareness, facilitate planning, attract investment, and improve global access to this essential treatment modality. By bringing cancer leaders together with radiotherapy professionals, industry partners, cancer control organisations, patient groups, economists, and enablers of healthcare change, the GTFRCC seeks to clarify the challenge, identify opportunities, and quantify the investment needed to provide equity in global access to radiotherapy. For more information, please visit www.uicc.org/advocacy.
GLOBAL ADVOCACY MESSAGE The post-2015 development agenda should recognise and implement measures to ensure that all people have sustainable access, without discrimination, to essential safe, affordable, effective and quality-assured cancer medicines and technologies, including radiotherapy. All countries should ensure access to cancer drugs on the WHO Model List of Essential Medicines that are low-cost and effective. Access and affordability of essential cancer medicines can be facilitated through the adoption of policies that support the use of generic medicines. Access to new, patented, and expensive NCD medicines should be considered on an individual basis based on priorities identified within national cancer control planning with the number and variety of cancer medicines increasing with the level of available resources.
Š CIAN Agency Š Majority World - 02
Radiotherapy is a critical component of high-quality cancer care. It can cure cancers alone, or in combination with surgery or chemotherapy.
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CASE STUDY DELIVERING RADIOTHERAPY AS PART OF COMPREHENSIVE CANCER CONTROL
In 2004, IAEA launched a Programme of Action for Cancer Therapy (PACT) whose mission is to contribute to the improvement of cancer survival in developing countries by integrating radiotherapy investments into public health systems. PACT works to maximise the impact and effectiveness of radiotherapy by integrating it into comprehensive cancer strategies within the framework of a national cancer control plan to ensure that all relevant cancer services are delivered via timely, planned and balanced investments across the health system. Working with the WHO and other leading international and national organisations in cancer prevention and control including UICC, PACT core activities include developing and initiating sustainable, integrated cancer control programmes in PACT Model Demonstration Site (PMDS) countries. To date, eight IAEA Member States are participating as PMDS, namely Albania, Ghana, Mongolia, Nicaragua, Sri Lanka, The United Republic of Tanzania, Vietnam and Yemen. Since its launch, over US$18 million has been mobilised through PACT for the eight PMDSs. This funding has been used for advocacy, cancer control capacity building (training of cancer control health professionals and sponsorship of participation in international events), the provision of radiotherapy units and the implementation of expert missions. For example, in Yemen, as the number of cancer cases continues to grow, capacities to treat patients remain underdeveloped and limited. The country’s only cancer therapy centre, located in Sana’a, relies on two radiotherapy machines, too few to cater for the population of over 24 million. To increase the availability and accessibility of cancer care in the country, the government of Yemen is now planning the construction of the first oncology centre in the seaport city of
Aden, with the help of PACT and the IAEA’s technical cooperation programme. At a consultative meeting to discuss this important undertaking in 2013, the meeting delegates from Yemen, together with an IAEA team, completed the proposed design for the new oncology centre and finalised a bankable document that sets out the purpose of the programme and its requirements needed for resource mobilisation. For more information on PACT go to http://cancer.iaea.org/
References: 1. Di Cesare M, Khang Y-H, Asaria P, et al, on behalf of The Lancet NCD Action Group. (2013). Inequalities in non-communicable diseases and effective responses. Lancet, 381, 585-97. 2. Hanna TP, Kangolle AC. (2010). Cancer control in developing countries: using health data and health services research to measure and improve access, quality and efficiency. BMC Int Health Hum Rights 10, 24. 3. Cameron A, Ewen M, Ross-Degnan D, et al. (2009). Medicine prices, availability, and affordability in 36 developing and middle-income countries: a secondary analysis. Lancet 373, 240–49. 4. Global Alliance to Pain Relief Initiative (GAPRI). Access to Essential Pain Medicines Brief (2010). Available from: http://www.gapri.org/understandproblem. 5. Knaul FM, Frenk J, Shulman L. (2011). Closing the Cancer Divide: A Blueprint to Expand Access in Low and Middle Income Countries. Harvard Global Equity Initiative. Boston: Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries. 6. Delaney G, Jacob S, Featherstone C, Barton M. (2005). The role of radiotherapy in cancer treatment: estimating optimal utilization from a review of evidence-based clinical guidelines. Cancer 104, 1129-37. 7. WHO. (2013). Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Geneva: World Health Organization. 8. Hogerzeil HV, Liberman J, Wirtz VJ, et al. (2013). Promotion of access to essential medicines for non-communicable diseases: practical implications of the UN political declaration. Lancet , 381, 680-9.
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WORLD CANCER DECLARATION TARGET 8
UNIVERSAL AVAILABILITY OF PAIN CONTROL AND DISTRESS MANAGEMENT EFFECTIVE PAIN CONTROL AND DISTRESS MANAGEMENT SERVICES WILL BE UNIVERSALLY AVAILABLE
THE FACTS Among patients with terminal cancer, 80% are estimated to experience moderate to severe pain due to inequitable access to medicines1,2. Even though the World Health Organization (WHO) considers morphine an essential medicine, there are unacceptable disparities in worldwide use of opioids for the treatment of pain, with high-income countries consuming 93% of the world’s morphine supply while 70% of deaths from cancer occur in low- and middle-income countries3. Cost, safety and efficacy are not the major drivers impairing access. Morphine is safe, effective, inexpensive, and easy to administer in resource-constrained settings. The major barriers to the adequate use of opioids are predominantly related to policy and legislative restrictions. Limitations on availability; out-dated policies that discourage access; unnecessary administrative obstacles and costs; and inadequate clinician education and empowerment; all contribute to many people living and
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dying in untreated pain4. For example, a recent survey conducted in 79 countries and 25 Indian states, showed that most countries had four or more policy-related barriers that severely limited patient access to pain relief. Across all regions, limitations were found on the types of hospitals or wards where opioids can be administered, the dose and length of time allowed by a single prescription and which clinician can prescribe opioids4,5. Up to 58% of patients in palliative care experience significant levels of emotional distress, that impacts their quality of life and alleviation of physical symptoms including pain, as well as physical and social functioning6. Likewise, cancer pain can is often linked to high levels of psychological distress, including higher levels of depression, anxiety, and fear7.
MEETING THE CHALLENGE
REMOVING BARRIERS TO PAIN RELIEF UICC, through its Global Access to Pain Relief Initiative (GAPRI) is developing a partnership with the United Nations Office on Drugs and Crime (UNODC) and WHO to enhance access to internationally controlled drugs for pain relief. Specific efforts are focused on regulatory revision and reform; data collection; awareness-raising and public education; procurement and distribution; community-based healthcare provision; and standards of care in healthcare facilities. Another priority is to implement the Commission of Narcotic Drugs Resolutions 53/4 and 54/6 which support action to enhance availability of controlled medications while preventing their diversion and abuse; and the recommendations contained in the International Narcotics Control Board’s (INCB) Report in 2010 which includes recommendations relating to data collection, laws and policies, and public awareness. It is clear that no single approach will work across regions. However, there are countries in each region—including Uganda, Vietnam, Nepal, Jamaica— where recent government leadership, civil society engagement and education and mobilisation of clinicians have resulted in important and replicable policy change and increased access to pain medications.
EDUCATION OF HEALTH WORKERS Inadequate clinician education and recurring misconceptions are persistent barriers to increased opioid use throughout the developing world4. Clinicians must be educated, informed and legally empowered to prescribe as they see fit based on individual patients needs. There is broad consensus among the international community that inadequate education of healthcare providers is one of the most pervasive and urgent obstacles to address. A recent Human Rights Watch survey on palliative care
All governments have approved the WHO Global Action Plan on Non-communicable Diseases (NCDs) 2013-2020 that promotes the development and implementation of a national palliative care policy using costeffective treatment modalities, including opioids analgesics for pain relief and training health workers, with progress to be measured by the indicator: “Access to palliative care assessed by morphine-equivalent consumption of strong opioid analgesics (excluding methadone) per death from cancer”8.
barriers in 40 countries found that most countries had inadequate medical education in palliative care and pain management and four of the countries surveyed had no relevant curriculum in these areas at all9. Likewise, health workers should receive education and training to equip them with the necessary knowledge and skills in the screening and management of distress to improve symptom management and psychosocial wellness10.
PALLIATIVE CARE AS PART OF A HEALTH SYSTEMS RESPONSE Recent commitments by governments to integrate palliative care within a health systems approach to NCDs provide a critical advocacy platform to push for universal access to specialised palliative care services including psychosocial care for the management of distress. In a key development, the Executive Board of the WHO discussed palliative care needs and barriers at its meeting in January 2014, and approved a palliative care resolution that will be tabled for adoption by governments at the 67th World Health Assembly in May 2014. It is essential that civil society take advantage of this growing momentum to ensure that governments are held accountable for existing commitments on palliative care, and continue to advocate for the adoption of a comprehensive resolution in May 2014 that recognises palliative care and access to pain relief as a human right.
Worldwide, approximately 2.7 million people died from cancer or HIV in untreated pain in 2011. UICC Advocacy Toolkit 2014 - Evidence Sheets
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GLOBAL ADVOCACY MESSAGE A small number of medications, none of which are limited by patent, can control pain for almost 90% of all people with cancer pain12 including children13. The use of these to reduce pain, as well as specific efforts to manage patient distress are integral to specialised palliative care services. Countries must invest in the policies and procedures that enable access, effective and safe prescribing, dispensing and administering of key medications, especially opioids; as well as education of healthcare providers to equip them with the skills and knowledge required to deliver quality palliative care.
In June 2009, the International Psycho-Oncology Society (IPOS) first made the recommendation to revise cancer care standards and clinical practice guidelines by ranking distress as the sixth vital sign in cancer care. The IPOS recommendation was officially endorsed by UICC at the World Cancer Congress in August 201011.
Š Life Before Death stills
Psychosocial care must be integrated into routine cancer treatment.
Distress is a multifactorial unpleasant emotional experience of psychological (cognitive, behavioural, emotional), social, and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms and its treatment. Distress extends along a continuum, ranging from common normal feelings of vulnerability, sadness, and fears to problems that can become disabling, such as depression, anxiety, panic, social isolation, and existential and spiritual crisis.
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CASE STUDY HOSPICE AFRICA UGANDA: BRINGING EDUCATION AND TRAINING IN PALLIATIVE CARE TO AFRICA
Hospice Africa Uganda (HAU) was established in 1993 to care for cancer and HIV/AIDS patients by bringing modern methods of pain and symptom control, counselling and spiritual support to patients and their families, mainly in their own homes and hospitals. Twenty years on, HAU has cared for 21,818 patients. In 2012-2013, 61% of new patients on the palliative care programme presented with cancer - with cervical cancer the most common malignancy seen at HAU, and the leading one for women. Over 8% of patients seen at HAU were children in 20122013, with 178 out of 299 children presenting with cancer. The high quality education and training of healthcare workers in palliative care is integral to the work of HAU including oversight of the Institute of Hospice and Palliative Care in Africa (IHPCA). IHPCA conducts several training courses and supports an e-learning platform to improve the effectiveness of the Institute’s distance learning programmes allowing trainees to send and receive feedback from lectures and assignments in a more systematic and timely way. HAU team members also have the opportunity to participate in a range of opportunities for professional development. Additionally, HAU supports international programmes that support education and training in palliative care in many African countries including the recent establishment of a Palliative Care Initiators Course for Francophone Africa that provides an introduction to palliative care as well as pain and symptom assessment and management; psychosocial cultural and spiritual issues and end of life care as well as ‘Training of Trainers’. The training aims to build specialist palliative care competencies within specified HIV/AIDS organiations as well as care for cancer patients. For more information, go to http://hospiceafrica.or.ug/index.php/ academic.html.
References: 1. Daut R, Cleeland C. (1982). The prevalence and severity of pain in cancer. Cancer, 50, 1913-8. 2. Foley KM, Wagner JL, Joranson DE, Gelband H. (2006). Pain Control for People with Cancer and AIDS. Disease Control Priorities in Developing Countries. 2nd ed. New York: Oxford University Press, p. 981–94. 3. Global Alliance to Pain Relief Initiative (GAPRI). Access to Essential Pain Medicines Brief (2010). Available from: http://www.gapri.org/understand-problem 4. Global Opioid Policy Initiative. (2013). Global Access to Pain Relief: Evidence for Action. Available from: http://www.uicc.org/programmes/gapri. 5. Cherny NI, Cleary J, Scholten W, Radbruch L, Torode, J. (2013). The Global Opioid Policy Initiative (GOPI) project to evaluate the availability and accessibility of opioids for the management of cancer pain in Africa, Asia, Latin America and the Caribbean, and Middle East: introduction and methodology. Ann Oncol 24 (Suppl 11), xi7–xi13. 6. Potash M, Breitbart W. (2002). Affective disor¬ders in advanced cancer. Hematol Oncol Clin North Am 16, 671–700. 7. Zaza C, Baine N. Cancer pain and psychosocial factors: a critical review of the literature. (2002). J Pain Symptom Manage 24, 526–42. 8. WHO. (2013). Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Geneva: World Health Organization. 9. Human Rights Watch. Global State of Pain Treatment: Access to Palliative Care as a Human Right. May 2011. Available from: http://www.hrw.org/sites/default/files/reports/hhr0511W.pdf 10. National Comprehensive Cancer Network. NCCN Guidelines, 2013, Distress Management http://www.nccn.org/professionals/physician_gls/pdf/distress.pdf 11. Bultz, B.D. and Johansen, C. (2011). Screening for Distress, the 6th Vital Sign: where are we, and where are we going? Psycho-Oncology, 20, 569-71. 12. Zech DF, Grond S, Lynch J, et al. (1995). Validation of World Health Organization Guidelines for cancer pain relief: a 10-year prospective study. Pain 63, 65-76. 13. 1Zernikow B, Smale H, Michel E, et al. (2006). Paediatric cancer pain management using the WHO analgesic ladder--results of a prospective analysis from 2265 treatment days during a quality improvement study. Eur J Pain, 10, 587-95.
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WORLD CANCER DECLARATION TARGET 9
IMPROVE EDUCATION AND TRAINING OF HEALTHCARE PROFESSIONALS INNOVATIVE EDUCATION AND TRAINING OPPORTUNITIES FOR HEALTHCARE PROFESSIONALS IN ALL DISCIPLINES OF CANCER CONTROL WILL HAVE IMPROVED SIGNIFICANTLY, PARTICULARLY IN LOW- AND MIDDLE-INCOME COUNTRIES
THE FACTS A critical shortage of skilled healthcare professionals exists in many countries and represents one of the greatest challenges for achieving universal and equitable access to quality cancer services today. While progress is being made towards the basic threshold of 23 skilled health professionals per 10,000 people, there are still 83 countries that fall below this threshold1. The pool of skilled workers is also unevenly distributed, with high concentrations in urban areas and many working in the private sector rather than in public healthcare. The current rates of training of new health professionals are also falling well below current and projected demand. Whilst the largest shortages in numerical terms are expected to be in parts of Asia, it is in sub-Saharan Africa where the shortages will be especially acute. For example, in the 47 countries of sub-Saharan Africa, just 168 medical schools exist2. Of those countries, 11 have no medical schools, and 24 countries have only one medical school1.
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and treatment; care provided by inadequately trained professionals; fragmentation of services; worsening UICC’s Global Education and Trainingand Initiative of disparities in cancer outcomes (C-Change, (GETI) provides leadership in healthcare 2012). workforce solutions, based on evidence, sharing of best practice and targeted training. GETI aims to: encourage more healthcare students to enter the field of oncology by improving access to training opportunities; reduce the negative impact of emigration in the oncology field; and improve the knowledge of those already working in the field and inspire more leaders to emerge in cancer control and research.
In the absence of a systematic mapping of the global cancer workforce, the current number of cancer healthcare professionals worldwide is unknown. However, individual reports at the country level demonstrate the growing shortages of skilled doctors, nurses, allied health professionals and pharmacists trained in oncology, as well as the challenges the existing cancer workforce face in providing quality, compassionate care in the context of the increasing numbers of newly diagnosed patients and survivors3,4. In the United States, a workforce study by the American Society of Clinical Oncology (ASCO) projects a significant shortage of medical and gynaecologic oncologists by 2020. The study reported that an aging and growing population, increasing numbers of cancer survivors, and slower growth in the supply of oncologists, is predicted to result in a shortage of 2,550 to 4,080 oncologists by 2020. A separate study showed that currently the United States has approximately 4,400 hospice and palliative medicine physicians, but 6,000 to 18,000 are needed to meet the gap between supply and demand5. Globally, a failure to take action to address shortages in cancer healthcare professionals will have a lasting impact on the accessibility and quality of care, with delays in diagnosis and treatment; care provided by inadequately trained professionals; fragmentation of services; and worsening of disparities in cancer outcomes6.
All governments have approved the WHO Global Action Plan on Non-communicable Diseases (NCDs) 2013-2020 that calls for the identification of competencies required and investment in improving the knowledge, skills and motivation of the current health workforce to address NCDs and planning to address projected health workforce needs for the future6. Additionally, it recommends that Member States adopt policies that: •
Incorporate the prevention and control of NCDs in the training of all health personnel including community health workers, social workers, professional and non-professional (technical, vocational) staff, with an emphasis on primary healthcare.
•
Develop career tracks for health workers through strengthening postgraduate training, with a special focus on NCDs, in various professional disciplines (for example, medicine, allied health sciences, nursing, pharmacy, public health administration, nutrition, health economics, social work and medical education) and enhancing career advancement for non-professional staff.
COUNTRIES WITH A CRITICAL SHORTAGE OF HEALTH SERVICE PROVIDERS
The world today is short of 7.2 million healthcare workers – without specific efforts to address this shortage, this figure will reach 12.9 million by 20351. UICC Advocacy Toolkit 2014 - Evidence Sheets
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MEETING THE CHALLENGE
There is broad consensus among the international community that inadequate education of healthcare providers is one of the most pervasive and urgent obstacles to address. Innovative models of education and training and deployment of cancer health professionals are required to equip the cancer workforce with the right skills, knowledge and competencies to meet the needs of individuals and communities. Continuing professional development (CPD) is a systematic and ongoing process of education, inservice training, learning, and support activities that build on initial education and training to ensure continuing competence, extend knowledge and skills to new responsibilities or changing roles, and increase personal and professional effectiveness. Investment in continuing professional development (CPD) to equip healthcare workers with the appropriate tools and knowledge to deliver best practice services across the cancer care continuum is vital. This includes building expertise and capacity amongst health professionals to recognise the early signs and symptoms of some cancers, as well as appropriate early detection measures; ensuring the safe and proper administration of chemotherapy and other cancer treatment modalities including radiotherapy and surgery; and delivering palliative care and pain and distress management, to reduce the morbidity and mortality of cancer in all populations. Beyond conventional teaching methods, the potential exists to increase the utilisation of Information and Communication Technologies (ICTs) to address the gaps in the training of healthcare workers to equip them with the skills and knowledge to engage in early detection programmes. At the primary level, initiatives that integrate multimedia approaches (e.g. video, animation, audio) can enhance organisational learning and skill development of health workers7. For community health workers, combining face-to-face, paper based learning with multimedia content in the classroom and remotely, can deliver content that is understandable and easily remembered7. At the organisational level, using digital content can create opportunities for collaboration and sharing of content with other institutions and assist with standardisation of treatment protocols and clinical guidelines.
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For more specialised training, online distance education programmes can facilitate mentoring, networking and collaboration. For example, the St Jude Cure4Kids international medical education website and online collaboration centre provides high quality content for continuing education and web communication tools to support collaborations among paediatric oncologists and health professionals in 187 countries (www.cure4kids. org/ums/home/). While the educational format used should be the most effective and efficient method for meeting the learning objectives, the ability to build on programmes already in existence is an important consideration. For example, the VUCCnet Africa project is an e-learning programme designed to train healthcare workers in cancer care and treatment to address healthcare workforce shortages in Africa8. VUCCnet builds on existing materials, African training networks and African infrastructure to ensure that cancer education and training programmes are embedded into established education and training institutions. For more information on this, please visit: www.iaea.org/newscenter/ multimedia/podcasts/vuccnet_091113.mp3. Improving the value of the cancer workforce through the optimisation of the role and organisation of cancer professionals is essential to realise the full value of the workforce4. This includes support of cancer healthcare professionals to leverage their time, talent and distribution4. The concept of optimal tasking for cancer care has been proposed whereby tasks are both shared among health workers with differing levels of training combined with the shifting of some tasks from specialist healthcare providers to other groups of health workers such as mid-level and lay health providers9. This has proven an effective way to engage expert patients, community health workers, clinical health assistants, nurses and physicians working in primary care level facilities to provide more and better access to cancer control and care services at each stage of the cancer control and care continuum. Using breast cancer as an example, to support early detection, health workers at the primary care level, including nurses, should be trained to identify risk factors related to family history, teach women about breast health and assist them in recognising warning signs, and help women seek a diagnosis.
MEETING THE CHALLENGE (CONTINUED)
“One of the challenges for achieving universal health coverage is ensuring that everyone - especially people in vulnerable communities and remote areas - has access to well-trained, culturally-sensitive and competent health staff. The best strategy for achieving this is by strengthening multidisciplinary teams at the primary health care level.” Dr. Carissa Etienne, WHO Regional Director for the Americas.
BUILDING WORKFORCE CAPACITY FOR UNIVERSAL HEALTH COVERAGE The Recife Political Declaration on Human Resources for Health (HRH) adopted in November 2013 stresses the importance of investing in HRH for attaining universal healthcare and presents a call to action for workforce development at all levels, in particular at the country level. Leaders committed to support a shared vision among all stakeholders and strengthen health systems and HRH, including through: adopting a system approach towards a sustainable health workforce; enhancing HRH information systems; transformative education systems and continuous education opportunities; strengthened HRH governance; and improved health workforce distribution and retention. For the full declaration, go to: www.who.int/workforcealliance/forum/2013/ recife_declaration_13nov.pdf
GLOBAL ADVOCACY MESSAGE
Reference:
Major reductions in premature deaths from cancer, and improvements in quality of life and cancer survival rates cannot be achieved without a skilled and supported cancer workforce with formalised expertise in all disciplines of cancer control and at all levels of health service.
1. Global Health Workforce Alliance. (2013). A universal truth: no health without a workforce. Geneva: World Health Organization. 2. Mullan F, Frehywot S, Omaswa F. (2011). Medical schools in sub-Saharan Africa. Lancet, 377, 1113-21. 3. Canadian Partnership Against Cancer. (2010). The Cancer Workforce Scoping Study: A Report from the Front Lines of Canada’s Cancer Control Workforce. 4. C-Change. (2012). A National Strategy to Strengthen the Cancer Workforce: Position Statement and Call to Action. Retrieved November 24, 2013, from C-Change Collaboratoring to Conquer Cancer: http://c-changetogether.org/Websites/cchange/ images/Workforce/WORKFORKCE_POSITION_STATEMENT-_with_endorsements-_ February_28_2013.pdf 5. Lupu D, American Academy of Hospice and Palliative Medicine Workforce Task Force. (2010). Estimate of current hospice and palliative medicine physician workforce shortage. J Pain Symptom Manage 40, 899-911. 6. WHO. (2013). Global action plan for the prevention and control of noncommunicable diseases 2013 -2020. Geneva: WHO. 7. iheed Institute. (2012). Preparing the next generation of community health workers: The power of technology for training. iheed Institute, the Barr Foundation, the mHealth Alliance, and the MDG Health Alliance. Cork, Ireland: Dalberg Global Development Advisors. 8. IAEA. VUCCnet: Virtual University for Cancer Control, Africa Pilot, International Atomic Energy Agency, Vienna. Available at: http://cancer.iaea.org/documents/ VUCCnetBrochure.pdf 9. Knaul FM, Frenk J, Shulman L. (2011). Closing the Cancer Divide: A Blueprint to Expand Access in Low and Middle Income Countries. Harvard Global Equity Initiative. Boston: Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries.
Developing innovative education and training programmes for cancer healthcare professionals that build on existing materials, training networks and infrastructure is the best approach. Sustained and accelerated progress towards universal health coverage must be linked with specific efforts to strengthen the health workforce. Greater attention is needed to systematically monitor shifts in the character and size of the cancer workforce, to inform new and existing programs, and to advocate for policy changes to address workforce shortages.
UICC Advocacy Toolkit 2014 - Evidence Sheets
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CASE STUDY HUE CENTRAL HOSPITAL: TRAINING OF NURSES IN CHILDHOOD CANCER
CONTINUOUS MEDICAL EDUCATION In Vietnam there is no local specialised paediatric oncology nursing curriculum to help prepare nurses to provide safe and high quality paediatric oncology care. Having a well-structured nursing education curricula in paediatric oncology that can be adapted at regional/local level is crucial to improve the quality of care for children with cancer. The paediatric oncology nursing training project took place in Hue Central Hospital which is a leading referral hospital in the central region of Vietnam. The overall objective of the project supported by UICC is to strengthen the paediatric oncology unit at Hue Central Hospital, Paediatric Center by improving the skills and knowledge of nurses in paediatric oncology care. The training covered nursing care issues (such as principles and guidelines of care, treatment of childhood cancer, infection control), distribution of work (such as symptom control and management), and process control (such as administration of medication, assisting in procedures, patient and family education). It adopted a ‘train the trainer’ approach whereby nurses were selected to undergo training and subsequently develop and implement a training plan for their colleagues.
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UICC Advocacy Toolkit 2014 - Evidence Sheets
In the first phase of the project, a needs assessment was undertaken. Two nurses from the Hue Central Hospital paediatric oncology unit (a nurse leader and a clinical nurse) were identified to go through a onemonth paediatric oncology training in Singapore in March 2013 at the National University Hospital and at KK Hospital. There, they were taught the basics of hygiene, treatment and paediatric oncology, based on a curriculum developed specially with the help of St Jude Children’s Research Hospital, Memphis, designed for relevance to local reality and requirements. With the help of regional paediatric oncology experts, the trained nurses developed a training plan to teach other nursing colleagues at Hue the key elements that they acquired during their stay. This ‘train the trainer’ model has been very effective in enabling nurses to become nurse educators to apply a well-structured nursing education locally. Improvements in practice such as infection control, sanitation, patient safety, and close communication with patients/parents have been noted. The trained nurses have also developed a stronger working relationship with the doctors working in paediatric oncology, and are starting to take on some tasks that were reserved for doctors in the past, such as measuring medication.