CANCER CONTROL OPPORTUNITIES IN LOW- AND MIDDLE-INCOME COUNTRIES

Committee on Cancer Control in Low- and Middle-Income Countries

Board on Global Health

Frank A. Sloan and Hellen Gelband, Editors

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
www.nap.edu



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Cancer Control Opportunities in Low- and Middle-Income Countries CANCER CONTROL OPPORTUNITIES IN LOW- AND MIDDLE-INCOME COUNTRIES Committee on Cancer Control in Low- and Middle-Income Countries Board on Global Health Frank A. Sloan and Hellen Gelband, Editors INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Cancer Control Opportunities in Low- and Middle-Income Countries THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. NOI-OD-4-2139 between the National Academy of Sciences and the National Cancer Institute and Grant No. 71685 between the National Academy of Sciences and the American Cancer Society. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Committee on Cancer Control in Low- and Middle-Income Countries. Cancer control opportunities in low- and middle-income countries / Committee on Cancer Control in Low- and Middle-Income Countries, Board on Global Health ; Frank A. Sloan and Hellen Gelband, editors. p. ; cm. Includes bibliographical references. ISBN-13: 978-0-309-10384-8 (pbk.) ISBN-10: 0-309-10384-3 (pbk.) 1. Cancer—Developing countries—Prevention. 2. Cancer—Economic aspects—Developing countries. 3. Cancer—Prevention—International cooperation. I. Sloan, Frank A. II. Gelband, Hellen. III. Title. [DNLM: 1. Neoplasms—prevention & control. 2. Developing Countries. 3. Health Care Rationing. 4. International Cooperation. 5. Neoplasms—economics. QZ 200 I43845 2006] RA645.C3I55 2006 362.196′9940091724—dc22 2006100723 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2007 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Cancer Control Opportunities in Low- and Middle-Income Countries “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Advising the Nation. Improving Health.

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Cancer Control Opportunities in Low- and Middle-Income Countries THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Cancer Control Opportunities in Low- and Middle-Income Countries COMMITTEE ON CANCER CONTROL IN LOW- AND MIDDLE-INCOME COUNTRIES FRANK A. SLOAN (Chair), Center for Health Policy, Law & Management, Duke University, Durham, NC DAVID CLARK, International Observatory on End of Life Care, Institute for Health Research, Lancaster University, Lancaster, England HAILE T. DEBAS, Global Health Sciences, University of California at San Francisco ELMER E. HUERTA, Cancer Preventorium, Washington Cancer Institute at Washington Hospital Center, Washington, DC PRABHAT JHA, University of Toronto Centre for Global Health Research, St. Michael’s Hospital, Toronto, Canada DAVID E. JORANSON, Pain and Policy Studies Group, University of Wisconsin Comprehensive Cancer Center, Madison RANJIT KAUR, Reach to Recovery International and Breast Cancer Welfare Association, Kuala Lumpur, Malaysia KATHLEEN HARDIN MOONEY, University of Utah College of Nursing, Salt Lake City TWALIB A. NGOMA, Ocean Road Cancer Institute, Dar es Salaam, Tanzania D.M. PARKIN, Clinical Trial Service Unit and Epidemiological Studies Unit, Oxford University, England RICHARD PETO, Clinical Trial Service Unit and Epidemiological Studies Unit, Oxford University, England YOUCEF M. RUSTUM, Roswell Park Cancer Institute, Buffalo, NY BHADRASAIN VIKRAM, International Atomic Energy Agency, Vienna, Austria (at IAEA until June 2006) Consultant IAN MAGRATH, International Network for Cancer Treatment and Research, Brussels, Belgium Staff HELLEN GELBAND, Study Director PATRICK KELLEY, Director, Board on Global Health ROGER HERDMAN, Director, National Cancer Policy Forum PENNY SMITH, Research Associate (until October 2005) ALLISON BRANTLEY, Project Assistant (since October 2005)

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Cancer Control Opportunities in Low- and Middle-Income Countries BOARD ON GLOBAL HEALTH MARGARET HAMBURG (Chair), Nuclear Threat Initiative, Washington, DC GEORGE ALLEYNE, Pan American Health Organization, Washington, DC YVES BERGEVIN, United Nations Population Fund, New York DONALD BERWICK (IOM Council liaison), Harvard Medical School, Boston, MA JO IVEY BOUFFORD (IOM Foreign Secretary), New York University, New York DAVID CHALLONER, University of Florida, Gainesville CIRO DE QUADROS, Sabin Vaccine Institute, Washington, DC SUE GOLDIE, Harvard University School of Public Health, Boston, MA RICHARD GUERRANT, University of Virginia School of Medicine, Charlottesville GERALD KEUSCH, Boston University School of Public Health, Boston, MA JEFFREY KOPLAN, Emory University, Atlanta, GA SHEILA LEATHERMAN, University of North Carolina School of Public Health, Chapel Hill MICHAEL MERSON, Duke University Global Health Institute, Durham, NC MARK ROSENBERG, Task Force for Child Survival and Development, Decatur, GA PHILLIP RUSSELL, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD

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Cancer Control Opportunities in Low- and Middle-Income Countries Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Eduardo Cazap, Sociedad Latinoamericana y del Caribe de Oncologia Medica, Buenos Aires, Argentina Susan J. Curry, University of Illinois at Chicago School of Public Health Silvia Franceschi, International Agency for Research on Cancer, Lyon, France Robert A. Hiatt, University of California at San Francisco Comprehensive Cancer Center Edward Katongole-Mbidde, Uganda Virus Research Institute, Entebbe, Uganda Donald Kenkel, Cornell University, Ithaca, NY Gerald T. Keusch, Boston University School of Public Health, Boston, MA Lawrence S. Lewin, Chevy Chase, MD Shahla Masood, University of Florida, Jacksonville M.R. Rajagopal, Pallium India, Thiruvananthapuram, India

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Cancer Control Opportunities in Low- and Middle-Income Countries Raul C. Ribeiro, St. Jude Children’s Research Hospital, Memphis, TN Roberto Rivera-Luna, Instituto Nacional de Pediatria, Mexico City, Mexico Sylvia C. Robles, The World Bank, Washington, DC Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by David R. Challoner, University of Florida, Gainesville. Appointed by the National Research Council, he was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Cancer Control Opportunities in Low- and Middle-Income Countries Preface In high-income countries, cancer has received considerable public attention because it is one of the major causes of mortality, morbidity, and disease burden. In middle- and particularly in low-income countries, cancer has received less public attention because other diseases, especially infectious diseases, have historically been far more pressing. Although less prominent in relative terms, as this report documents, cancer is a major burden in low- and middle-income countries (LMCs) today. In the future, it is inevitable that cancer will be a more important issue in LMCs. As the competing risk of infectious disease declines, major chronic diseases, including cancer, will move to the forefront as contributors to poor health. Furthermore, to the extent that LMCs adopt the health behaviors of populations in high-income countries, the incidence of chronic diseases such as cancer will increase. If cancer is to be an even greater health problem in the future, given other pressing social priorities, why should LMCs be concerned about it now? First, it is already a greater burden than is widely appreciated. Second, establishing capacity for cancer prevention, diagnosis, and treatment in a country takes time. Third, some cancers can be prevented, and the latency period from the cause to the development of cancer can be several decades. Tobacco use is a case in point. The vast majority of tobacco use is initiated before age 21. Yet most of the deleterious effects of such use occur after age 50. A message of this report is that countries can implement effective policies for reducing tobacco use in their countries, and they can do this rather inexpensively. This report is about “opportunities.” The committee’s concept of op-

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Cancer Control Opportunities in Low- and Middle-Income Countries portunity is broad, ranging from data collection and planning to resource-level-appropriate interventions. We did not use cost-effectiveness or cost-benefit analysis to rank individual projects. There is likely to be important variation in benefits relative to costs between low- and middle-income countries, and within countries in each category. The concept of “resource-level-appropriateness” is central to this report. For the lowest income countries, where most people first present to the health care system with late-stage cancers, cure is usually impossible. Yet much more can be done than at present to promote palliative therapies to improve the quality of life of those who have incurable cancers, particularly near the end of life. At the other end of the spectrum is cancer prevention, which includes educating the public about what they can do to avoid cancer. Some approaches to prevention identified in the report are not costly and are within the ability of lower income countries to finance, sometimes with external assistance. Investments in cancer diagnosis and treatment should vary depending on resources available in the country. A temptation that high-income countries should resist is focusing on exporting the latest, most expensive technologies that may (or may not!) be appropriate for wealthy countries, but for which alternatives exist that may be preferred in low-, and in some cases, middle-income countries. Partnerships are needed between high-income and other countries in developing resource-appropriate strategies. These partnerships may be government to government, but there is great potential for private partnerships, involving, for example, academic health centers in high-income countries and delivery sites in low- or middle-income countries. The report describes such opportunities. We hope it will prove a valuable resource, not only for the report’s sponsors—the National Cancer Institute and the American Cancer Society—for considering how best to use existing knowledge to develop strategies for cancer control that recognize differences among countries in both resources and health care services delivery. Frank A. Sloan J. Alexander McMahon Professor of Health Policy and Management and Professor of Economics Duke University

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Cancer Control Opportunities in Low- and Middle-Income Countries Project Consultants and Commissioned Authors Benjamin O. Anderson, University of Washington and Fred Hutchinson Cancer Research Center, Seattle Michael Barton, University of New South Wales, Australia Vinona Bhatia, University of California at San Francisco Comprehensive Cancer Center Robert W. Carlson, Stanford University, Stanford, CA Mariana De Santis, National University of Cordoba, Argentina Jorge Eisenchlas, Universidad del Salvador, Buenos Aires, Argentina Alexandru E. Eniu, Cancer Institute I. Chiricuta, Cluj-Napoca, Romania Michael Frommer, University of Sydney, Australia Nigel Gray, Victoria, Australia Ednin Hamzah, Hospis Malaysia, Kuala Lumpur, Malaysia Diwani Msemo, Ocean Road Cancer Institute, Dar es Salaam, Tanzania Jesmin Shafiq, University of New South Wales, Australia Leslie Sullivan, Fred Hutchinson Cancer Research Center, Seattle, WA Tatiana Vidaurre Rojas, Instituto Especializado de Enfermedades Neoplásicas, Lima, Peru John Ziegler, University of California at San Francisco Comprehensive Cancer Center

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Cancer Control Opportunities in Low- and Middle-Income Countries Contents     Summary   1 1   Introduction   17 2   Cancer Causes and Risk Factors and the Elements of Cancer Control   27 3   The Cancer Burden in Low- and Middle-Income Countries and How It Is Measured   69 4   Defining Resource-Level-Appropriate Cancer Control   106 5   Preventing Cancers (and Other Diseases) by Reducing Tobacco Use   138 6   Compelling Opportunities in Global Cancer Control   170 7   Palliative Care   225 8   Cancer Centers in Low- and Middle-Income Countries   253 9   Advocacy for Cancer Control   272 10   Expanding the Role of the Global Community in Cancer Control   285     Appendixes     A   Cancer Control in Malaysia and Tanzania   305 B   Acronyms and Abbreviations   322

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