Summary

Cancer is absent or low on the health agendas of low- and middle-income countries (LMCs), and minimally represented in global health efforts in those countries. Even as other chronic diseases—cardiovascular disease and mental disorders, in particular—have gained attention in LMCs, cancer is largely left untouched. Cancer is common everywhere and growing as a share of the burden of disease. Eleven million cases of cancer now occur annually worldwide, six million of them in LMCs. Four million deaths from cancer—one million more than deaths from AIDS—have occurred each recent year in LMCs.

Determining health priorities and allocating resources are national decisions. In LMCs, however, these decisions are deeply influenced by priorities of the “global health community”—the public- and private- (for-profit and not-for-profit) sector agencies and organizations that provide advice, assistance at a variety of levels, products and services, and financial support for health and health care. As the burden of cancer and other chronic diseases increases, LMCs and the global community at large should be increasing resources proportionately, yet this has not happened to any noticeable degree.

The National Cancer Institute and the American Cancer Society—two organizations that have recognized the need to raise awareness about and take action against cancer in LMCs—asked the Institute of Medicine to conduct this study and provided the funding for it. The report calls for governments, health professionals, nongovernmental organizations (NGOs), and others in LMCs, with the help of the global health community, to achieve a better understanding of the current and future burden of cancer in LMCs



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Cancer Control Opportunities in Low- and Middle-Income Countries Summary Cancer is absent or low on the health agendas of low- and middle-income countries (LMCs), and minimally represented in global health efforts in those countries. Even as other chronic diseases—cardiovascular disease and mental disorders, in particular—have gained attention in LMCs, cancer is largely left untouched. Cancer is common everywhere and growing as a share of the burden of disease. Eleven million cases of cancer now occur annually worldwide, six million of them in LMCs. Four million deaths from cancer—one million more than deaths from AIDS—have occurred each recent year in LMCs. Determining health priorities and allocating resources are national decisions. In LMCs, however, these decisions are deeply influenced by priorities of the “global health community”—the public- and private- (for-profit and not-for-profit) sector agencies and organizations that provide advice, assistance at a variety of levels, products and services, and financial support for health and health care. As the burden of cancer and other chronic diseases increases, LMCs and the global community at large should be increasing resources proportionately, yet this has not happened to any noticeable degree. The National Cancer Institute and the American Cancer Society—two organizations that have recognized the need to raise awareness about and take action against cancer in LMCs—asked the Institute of Medicine to conduct this study and provided the funding for it. The report calls for governments, health professionals, nongovernmental organizations (NGOs), and others in LMCs, with the help of the global health community, to achieve a better understanding of the current and future burden of cancer in LMCs

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Cancer Control Opportunities in Low- and Middle-Income Countries and to take appropriate and feasible next steps in cancer control. Steps taken now—particularly in prevention—will be rewarded by curbing the growth in cancer rates. Steps taken toward establishing effective cancer diagnosis and treatment (i.e., cancer management), even if modest, can act as a nucleus from which development can grow. “Low- and middle-income countries” include a wide range of nations vastly different in available resources, in rates of economic growth, in political and social conditions, and in the history and current status of health care services and infrastructure. They range from the low-income countries (defined by the World Bank as having a per capita gross national income—GNI—of less than $825 in 2004) where cancer control activity is minimal or nonexistent, to the upper middle-income countries (defined as having a GNI per capita of $3,256–$10,065) where most of the population may have access to at least some cancer services (Figure S-1). This report does not suggest a single prescription for these diverse countries, nor does it envision “comprehensive” cancer control being possible without significant improvements in health care systems. Rather, it recognizes certain global priorities and approaches that are feasible at low resource levels, in the context of national cancer control planning. However, without assistance from the broader global health community—the same span of public- and private-sector agencies and organizations involved in traditional developing country health issues such as infant mortality, child and maternal health, tropical infectious diseases, and HIV/AIDS—it is unlikely that countries will be able to make substantial progress in cancer control. Thus, the recommendations in this report are aimed equally at LMCs and the global health and international development communities. CANCER IN LOW- AND MIDDLE-INCOME COUNTRIES Cancer is common everywhere. However, the mix of cancers that occurs varies around the world, driven largely by environment, geography, and standard of living. Cancer is also regarded differently in different settings: as a preventable and often curable disease in high-income countries; but as a painful death sentence in many LMCs. The rise in cigarette smoking has made lung cancer the most common cancer, and cause of death from cancer in LMCs, just as it is in high-income countries in men and overall. Breast cancer is the most common cancer in women in both LMCs and high-income countries. Among men in LMCs, cancers of the stomach and liver are next most common and among women, cancers of the cervix and stomach. Most cases of stomach and liver cancers, and nearly all cases of cervical cancer are caused by infectious agents: the bacterium Helicobacter pylori, hepatitis B and C viruses, and human papillomaviruses, respectively. In

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Cancer Control Opportunities in Low- and Middle-Income Countries FIGURE S-1 Low- and middle-income countries by World Bank income category, 2004. SOURCE: Data from World Bank (2005).

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Cancer Control Opportunities in Low- and Middle-Income Countries developing countries, 26 percent of all cancers are attributable directly to infectious agents; in high-income countries, the corresponding figure is only about 8 percent. Cancer stage at the time of detection in LMCs is, on average, substantially further advanced than in wealthy countries. In some countries, as much as 80 percent of cancers may already be incurable when first noted (although this figure is impossible to document). Patients in LMCs also tend to have additional health conditions (co-morbidities) that make their recovery from cancer less likely than patients in high-income countries. Wherever they are, whatever their circumstances, these are real people—adults and children—living with and dying from cancer, with all the pain and misery that it brings. NEXT STEPS IN CANCER CONTROL “Cancer control” describes the totality of activities and interventions intended to reduce the burden of cancer in a population, either by reducing cancer incidence or mortality, or by alleviating the suffering of people with cancer. Prevention, early detection, diagnosis, treatment, psychosocial support, and palliative care are the components of cancer control that can reduce the cancer burden. Surveillance and monitoring are needed to understand the cancer burden and to track progress. All of these require commitments of financial and human resources, including training and education to build the required human resource base, and information for the public to understand what they can do and the services available to them. Cancer control activities are not all conducted within the health care system proper, nor do they always involve only health professionals. Many effective tobacco control interventions (e.g., higher taxes, bans on advertising and promotion) are legal and regulatory in nature. Making morphine available for pain control necessarily involves narcotics control authorities as well as the health care system. Other key interventions are allied to parts of the health care system that otherwise are unrelated to cancer. For example, vaccination against hepatitis B virus to prevent liver cancer is conducted by childhood immunization programs. Where cancer shares risk factors with other chronic diseases—tobacco being by far the most important, but also including diet—control measures will produce benefits for a number of diseases. Within the health care system, some aspects of cancer control can be integrated into primary and higher level health care levels (e.g., vaccinations for HBV and human papillomavirus [HPV]), and others require specialized practitioners and equipment (especially aspects of treatment). From high-income countries, it is obvious that the array of cancer control interventions is huge once basic infrastructure is in place and financing is plentiful. In LMCs, where those conditions do not exist, cancer control must

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Cancer Control Opportunities in Low- and Middle-Income Countries build starting with interventions that are highly effective, cost-effective, and “resource-level appropriate.” Additional steps can always be taken for incremental benefits once a cancer control culture exists and resources for cancer control grow. Cancer Planning Deciding on national cancer control priorities is best accomplished through a formal process of cancer control planning at the national (or, if appropriate, the subnational) level. Emphasizing the importance of this step, the 58th World Health Assembly (WHA) in May 2005 approved a resolution on cancer prevention and control that calls on all 192 WHO Member States to develop national cancer plans and programs. Although they must eventually be embraced by government to be fully effective, national cancer plans may be developed outside of government, such as those spearheaded by NGOs. Regardless of how the effort is led, the process must involve a broad spectrum of stakeholders and interest groups. Steps in cancer control planning have been well described by WHO and additional guidance is available from the International Union Against Cancer (UICC) (with particular emphasis on the role of NGOs in the development of national cancer plans) and other sources. The plan does not have to cover every aspect of cancer control: e.g., an initial focus on tobacco control and palliative care can lead to success in those areas and open the door to adding further goals later. RECOMMENDATION. Cancer control plans should be developed, or updated, in each country every 3 to 5 years through a process that involves all major stakeholders, public and private sectors, as described by WHO, UICC, and others. Cancer control plans should be promoted and supported financially and programmatically through both government action and public advocacy. In both the planning and implementation phases, global partners should provide necessary guidance and financial support. OPPORTUNITIES FOR CANCER CONTROL IN LMCS The following sections identify high-priority opportunities for cancer control in LMCs.

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Cancer Control Opportunities in Low- and Middle-Income Countries Prevention Tobacco Control At a global level, tobacco causes more premature deaths from cancer— and even greater numbers from other causes—than any other single agent. Experience in many high-income countries and a few LMCs has proven that tobacco use and ultimately, its impact, can be reduced substantially through a combination of policy measures. These policy measures include raising prices of tobacco products by increasing taxes on them, banning smoking in public places, banning advertising and promotion of tobacco products, requiring large and dramatic cigarette package warnings, and “counteradvertising” to publicize the adverse health effects of tobacco and the benefits of quitting. The top priority for cancer control is to convince the world’s 1.1 billion smokers (80 percent of whom live in LMCs) to quit: Cessation by today’s smokers will lead to substantial health gains over the next five decades. Preventing children from starting smoking will have full benefits after 2050. The Framework Convention on Tobacco Control (FCTC), the first and only international public health treaty, includes the measures known—largely from high-income countries—to be effective. As provisions of the FCTC are implemented in LMCs, it will be important to reevaluate their effectiveness under a range of economic and societal conditions. RECOMMENDATION. Every country should sign and ratify the Framework Convention on Tobacco Control and implement its provisions, most importantly: Substantial increases in taxation to raise the prices of tobacco products (goal is to have taxes at 80 percent or higher of retail price) Complete advertising and promotion bans on tobacco products Mandating that public spaces be smoke free Large, explicit cigarette packet warnings in local languages (which also helps to reduce smuggling) Support of counteradvertising to publicize the health damage from tobacco and the benefits of stopping tobacco use Liver Cancer and Hepatitis B Vaccination HBV is the cause (often in conjunction with a co-factor) of most cases of liver cancer, taking 500,000 lives each year globally. A safe and highly effective HBV vaccine has been used in most high-income countries and many LMCs since the 1990s, yet vaccination coverage is poor to nonexistent

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Cancer Control Opportunities in Low- and Middle-Income Countries in many countries with the highest rates of liver cancer. In 2001, the latest year for which complete data are available, fewer than 10 percent of babies in Southeast Asia and Africa—among the worst affected areas—were vaccinated against HBV. A three-dose series of HBV vaccines costs less than $2 through UNICEF, a cost that can be subsidized by the Global Alliance for Vaccines and Immunization (GAVI). The countries where children are not immunized are mainly those with inadequate immunization programs for the more traditional vaccines, thus this is not a problem only for HBV vaccination. The future payoffs for HBV vaccination and other scheduled immunizations are enormous; vaccination should remain as high on the cancer control agenda as it is on the child health agenda. Vaccination cannot help the 360 million people worldwide who are currently infected with HBV. However, limiting exposure to the most ubiquitous co-factor—aflatoxin—can substantially lower the risk of liver cancer. Contamination of stored grain by aflatoxin—a chemical produced by certain fungi under humid storage conditions—can be reduced by using low technology techniques such as drying crops in the sun, discarding moldy kernels, and storing crops in natural fiber sacks on wooden pallets. Such efforts may be worthwhile, although they are more complex than vaccination. Furthermore, about one-quarter of liver cancer is caused by hepatitis C virus (HCV) for which there is, as yet, no successful vaccine. RECOMMENDATION. GAVI and other international partners should continue to assist countries to incorporate HBV vaccination into their childhood immunization programs as quickly as possible, with support from the global cancer community. RECOMMENDATION. Countries with a high liver cancer burden and significant aflatoxin contamination of foodstuffs should examine the options for aflatoxin exposure reduction. Development partners should help to implement those measures that are feasible and cost-effective. Cervical Cancer Screening and Human Papillomavirus Vaccines Nearly 300,000 women die from cervical cancer each year, 85 percent of them in LMCs. The cause is persistent infection with one of several strains of the human papillomavirus (HPV). A century ago, cervical cancer was as common in the United States and Europe as it is today in LMCs. Improved living standards, effective treatment for early and somewhat advanced cancers, and screening using the Papanicolaou (Pap) smear are responsible for the steep decline in incidence and mortality in high-income countries.

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Cancer Control Opportunities in Low- and Middle-Income Countries Two developing strategies could transform cervical cancer control in LMCs: (1) vaccines to prevent HPV infection, and (2) screening methods that are more compatible with LMC resources and infrastructure than are Pap smear programs. A vaccine against the two most common carcinogenic strains of HPV entered the market in 2006 and another is expected soon. The initial market is in affluent countries; however, if adopted, the greatest impact of these vaccines will be in LMCs with highest cervical cancer rates. They could prevent of hundreds of thousands of deaths every year, starting several decades after establishment of a vaccination program. Governments and the international health community should take concrete steps now to develop HPV immunization policies and the means to pay for what is currently an expensive vaccine. Operational issues (e.g., developing immunization schedules, including the optimal age for immunization; deciding whether to immunize only girls or both girls and boys) also must be addressed. For pre-vaccination generations of women, the vaccines cannot help. However, two new approaches to screening and treatment of precancerous lesions are available. Techniques for testing and treatment of precancerous lesions in a single visit, using “direct visualization” (either visualization with coloration with acetic acid [VIA] or with Lugol’s iodine [VILI]) have been piloted in trials in LMCs, with positive results. The treatment (for women without advanced disease) is by cryotherapy—freezing of abnormal tissue. Ongoing demonstration projects will provide a firmer information base on which to decide about the suitability and effectiveness of these techniques for broader use. The second technique involves testing for chronic HPV infection. HPV testing currently requires two visits if treatment is needed, but quick-reading tests are being developed that could eliminate the need for a second visit. While these screening methods may be feasible in some settings (mainly middle-income countries), they can only be successful where a reasonable healthcare infrastructure exists and care for detected cancers can be accessed, a requirement that, unfortunately, still excludes many countries. Where they are feasible, the value of such programs can be great: Even one or two appropriately timed screenings in a lifetime could reduce the incidence of invasive cervical cancer by as much as 40 percent. RECOMMENDATION. Countries should actively plan for the introduction of HPV vaccination as more information becomes available about the vaccines and as they become affordable. The international community should support a global dialogue on HPV vaccine policy and pricing. RECOMMENDATION. Countries and global partners should follow the evolving information on newer screening approaches and determine the feasibility of adoption, given local resources and infrastructure.

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Cancer Control Opportunities in Low- and Middle-Income Countries Cancer Management: Diagnosis, Treatment, and Psychosocial Support In low-income countries, most people with cancer have no access to potentially curative treatment. In middle-income countries, existing services and resources are variable but generally limited. Where few or no services exist, the emphasis should be on establishing a core of expertise and limited cancer management that can be expanded as resources permit. Where some services are available but resources are stretched or inadequate, the emphases should be as follows: (1) ensuring that the most appropriate and most cost-effective measures are provided in well-equipped medical institutions and futile attempts at cure are avoided, and (2) ensuring that the stage is set for services to expand. Along with clinical medical services, people with cancer and those around them benefit from psychosocial support to deal with the physical, psychological, and social impacts of the disease and improve quality of life. Psychosocial support can commence at diagnosis and continue through treatment and recovery or death. In LMCs, psychosocial support can be offered by a wide range of health care workers and lay people. Resource-Level-Appropriate Treatment for Curable Cancers The concept of “resource-level appropriateness” recognizes that effective interventions for the most curable cancers have progressed in high-income countries through more than one generation. The most appropriate choice for an LMC may not be the current choice in New York or Paris. For example, breast-conserving surgery for early-stage breast cancer requires treatment with radiotherapy. If radiotherapy is not available, women’s lives can still be saved with more extensive surgery. Comprehensive information on the range of choices is rarely available, however. The major exception is the result of a recent, highly innovative effort, the Breast Health Global Initiative (BHGI). The BHGI is an international collaboration initiated by an American breast surgeon who eventually attracted a wide range of partners from both high-income and lower income countries. Financial support initially came from a foundation devoted to breast cancer with later support from the National Cancer Institute (NCI) and others. BHGI has produced a comprehensive set of resource-specific, stage-specific evidence-based guidelines, which will be updated biannually, for all aspects of breast cancer management. The BHGI process involved “summit” meetings with expert researchers, practitioners, and patients from all over the world. A next phase that is under way involves helping centers in LMCs adopt, adapt, and implement the guidelines, and developing procedures for implementation so that the guidelines can be disseminated widely.

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Cancer Control Opportunities in Low- and Middle-Income Countries The BHGI model could be applied to other cancers for which highly effective treatments are available. The common cancers that fit this description are cancers of the breast, cervix, head and neck, and colon and rectum. A large proportion of cancers affecting children and young adults are also highly curable, in particular, leukemias and lymphomas, retinoblastoma, and testicular cancer. A hurdle in organizing such efforts will be financial support. The BHGI was able to begin and build because of early support from the Susan J. Komen Foundation, the most visible breast cancer advocacy group in the United States. Advocacy does exist for all the cancers in the list above, but they are not as powerful as the forces that have massed against breast cancer. The BHGI example, however, has laid groundwork that should make it easier for public sector sources, professional societies, advocacy organizations, and others to support efforts for other cancers. RECOMMENDATION. Resource-level-appropriate guidelines should be developed for the overall management of major cancers for which treatment can make a substantial difference in a meaningful proportion of patients, and for selected pediatric cancers. The BHGI model could be used or others developed. The priority adult cancers for which resource-level-specific guidelines are needed are cervical cancer, colon cancer, and head and neck cancers. Pediatric priority cancers are leukemias and lymphomas. Motivated professionals from high-income countries and LMCs should work together to spearhead these efforts, with financial support from a variety of institutions. Cancer “Centers of Excellence” Providing guidelines for cancer diagnosis and treatment is of no benefit without a medical institution and professionals who can apply them. Countries should consider supporting at least one well-functioning government-supported cancer center where patients can go for diagnosis, treatment, palliation, and vital psychosocial services. The center should also undertake locally relevant research. Even if capacity is limited, such centers can act as focal points for national cancer control and as points of contact for the international cancer control and clinical oncology communities. In the poorest countries, and in small countries that wish to develop this capacity, the center may be a unit in a hospital, focusing only on selected aspects of treatment or on specific types of cancer. In countries that already have one or more cancer centers, it may only require enhancing the functions of one or more center. Financing to initiate and operate cancer centers in LMCs can come from a variety of public and private sources, including taxes on tobacco products.

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Cancer Control Opportunities in Low- and Middle-Income Countries Some international support is available for establishing or upgrading cancer centers. A new organizational unit of the International Atomic Energy Agency (IAEA), building on a 25-year history of support for radiotherapy, is the Programme of Action for Cancer Therapy (PACT), which is intended to attract additional funding and collaboration from United Nations Member States and other donors. PACT is likely to be a major source of new and upgraded cancer centers for at least the next decade. Radiotherapy remains a centerpiece, but PACT intends to develop and maintain equivalent capability in medical and surgical oncology. Institutional “twinning” is an approach that should see expanded use in improving and expanding cancer control in LMCs. Twinning involves long-term pairings of established cancer centers with new or existing centers in LMCs. Hallmarks of successful twinning programs are regular exchanges of information and often personnel, attention to funding (although not necessarily money flowing from the high-income partner), training, and technical issues. The oncology community is well organized in affluent countries and has the capacity to help to organize twinning programs. A special opportunity and responsibility is the treatment of children and young people with specific highly curable types of cancer. The total numbers are small compared with cancers in adults—approximately 160,000 children and young adults get cancer every year, worldwide. Currently, 80 percent of U.S. children under age 15 with cancer are cured, but 80 percent of the world’s children who develop cancer live in countries where most die because of late diagnosis and lack of treatment. RECOMMENDATION. Countries should consider establishing a government-supported cancer “center of excellence” that provides resource-level-appropriate services to the public and acts as a reference point for national cancer control. This could be a new center or designation of an existing one. RECOMMENDATION. International partners should assist in developing and improving cancer centers in LMCs through twinning arrangements and other means. The recently formed PACT, established by the IAEA, could—in collaboration with a range of partners—take on this role. Financial contributions from national governments (research funding institutions and bilateral aid agencies) could be channeled into this effort as a means of progressively increasing the global donor community’s investments in cancer control in LMCs in ways likely to have the biggest impact. RECOMMENDATION. Countries should aim to provide access to treatment and psychosocial services for children and young adults

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Cancer Control Opportunities in Low- and Middle-Income Countries with highly curable cancers in pediatric cancer units in cancer centers or children’s hospitals. Palliative Care Late diagnosis of most cancers in LMCs and a lack of treatment options even when diagnosis is early means large numbers of patients who can benefit from palliative care. The cornerstone of palliative care is pain control with oral morphine or other strong opioid analgesics. These medications are largely unavailable in LMCs (and in many high-income countries); in addition to medication, palliative care involves a range of other services to relieve and manage symptoms and to provide psychosocial support to patients and families in the communities where they live. The two major obstacles to palliative care in LMCs are (1) legal, societal, and educational barriers to opioid availability; and (2) lack of programs to deliver palliative care at the community level. Progress in the past 10 years has demonstrated that barriers to opioid availability can be overcome and that palliative care can be delivered effectively and inexpensively, even in LMCs. A major barrier to making morphine available to cancer patients in severe pain is the irrational fear of opioids that continues to exist among policy makers, regulators, law enforcement, health professionals, and the public. WHO and the International Narcotics Control Board (INCB) play key roles in educating relevant parties and encouraging governments to examine their national policies for unduly strict drug regulations. International collaborations and the provision of funding are vital to continued progress. Because people dying from AIDS require much the same palliative care as do cancer patients, building or adapting organizations to serve both types of patient presents a new set of opportunities. RECOMMENDATION. Governments should collaborate with national organizations and leaders to identify and remove barriers to ensure that opioid pain medications, as well as other essential palliative care medications, are available under appropriate control. The INCB and WHO should provide enhanced guidance and support, and assist governments with this task. RECOMMENDATION. Palliative care, not limited to pain control, should be provided in the community to the extent possible. This may require developing new models, including training of personnel and innovations in types of personnel who can deliver both psychosocial services and symptom relief interventions.

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Cancer Control Opportunities in Low- and Middle-Income Countries Surveillance and Monitoring Few LMCs have accurate, recent data about their cancer burden or major risk factors for cancer, consistent with generally poor vital and health statistics. Estimates of cancer incidence and mortality by cancer type, age, and gender have been produced for every country by the International Agency for Research on Cancer (IARC). These estimates are useful for setting initial priorities, but cannot be used to track progress or to define priorities. Major improvements in vital and health statistics are long term goals, but over the short term, modest improvements can be made. In particular, it is relatively inexpensive to gather information on the major risk factors for cancer and other noncommunicable diseases in periodic cross-sectional surveys. WHO has developed standardized survey instruments in “STEPS,” a Stepwise Approach to Chronic Disease Risk Factor Surveillance. Questionnaire-based data gathering about tobacco use, alcohol consumption, diet, and physical activity constitute the first “step.” Steps 2 and 3 add physical and physiological measurements of risk factors for the other major chronic diseases: weight and blood pressure measurements; and blood glucose and cholesterol, respectively. STEPS has the advantage of producing comparable information across countries as well as over time. More ambitious is measuring causes of death in a population. In low-income countries in particular, this is difficult because many people die without medical care, or at least without a diagnosis. Systems based on “verbal autopsies” can be developed in place of medical certification, as has been demonstrated in India’s “Million Death Study,” in areas that constitute a nationally representative sample of deaths. Longitudinal studies of chronic disease risk factors and causes of death involving in total several million people have been initiated as collaborations between researchers in LMCs and high-income countries. Results have already been produced in a few LMCs such as China, India, and Mexico. In these studies, adults are interviewed briefly about major risk factors (e.g., smoking, diet) and have basic physical measurements taken (and blood, in some cases). Households are revisited periodically to record household members’ vital status, and the participants are resurveyed every 3 to 5 years. When cohort members die, the cause of death is ascertained. Such studies are complex, requiring extensive planning and the sustained commitment of human and financial resources. Studies now under way cost on average $1 per person per year to maintain. Finally, cancer registries that record cancer cases and outcomes over time—in specific hospitals, or more usefully, in defined geographic areas—are important for understanding local cancer patterns of those who come to medical attention. Registries require sustained commitments and trained personnel, which are most feasible in urban areas where diagnosis and treatment are available.

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Cancer Control Opportunities in Low- and Middle-Income Countries RECOMMENDATION. The following should be considered: Risk factor surveillance for chronic diseases should be initiated in many countries using standardized questionnaires (e.g., STEPS). Collection of cause-specific mortality data should be a long-term goal in every country. Where vital statistics systems are weak or nonexistent, initial data collection may be in sentinel sites rather than nationwide. Improved mortality reporting at a level appropriate to the country should be supported as a part of cancer control activities. Longitudinal studies of chronic disease risk factors and mortality should be initiated in a few additional middle-income countries. Cancer registries should be developed in conjunction with cancer control activities, mainly in urban areas where diagnostic and treatment services exist. Where new or existing cancer centers are developed into centers of excellence, registries in the catchment area should be a part of the development. The Global Community Cancer control will not advance in LMCs without support from the global health and development community for the invariably small constituencies within these countries. Multilateral and bilateral aid agencies, foundations and other philanthropies, professional organizations and the academic community all have roles to play in developing the global cancer control agenda, working with countries to prioritize and plan next steps, and providing resources to carry out plans. With a few exceptions (e.g., tobacco control and to a lesser extent, palliative care), cancer control has had little support while the infectious and nutritional diseases have dominated the efforts of the global health community. Thus far, it has been cancer-specific organizations or units that have promoted cancer control in LMCs. WHO’s small cancer program has continued to provide guidance and other parts of WHO headquarters have taken up specific cancers or types of exposures. IARC has played the leading role in defining the causes of cancer and in surveillance, largely to the benefit of high-income countries, with spillover benefits to LMCs, as well as some efforts, particularly in recent years, more directed to LMC problems (e.g., an emphasis on cervical cancer in LMCs). In the private non-profit sector, the International Union Against Cancer, largely devoted to cancer control

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Cancer Control Opportunities in Low- and Middle-Income Countries and advocacy in resource-rich countries, has become more active in LMCs in recent years. The broader global health community has, by and large, not followed. Another major untapped resource is the burgeoning interest in global health at universities in the United States and other countries. The recent formation of many global health programs should be seen as an opportunity to expand the topic areas in which these units work. For this to happen, faculty and administrators must become aware of new types of projects, in cancer and other areas, that are possible, in addition to the traditional emphases on infectious and nutritional diseases. Cancer centers in the United States and other wealthy countries also may not be aware of opportunities for twinning and other collaborations with centers in LMCs. RECOMMENDATION. International Organizations WHO should maintain a strong capacity for cancer control analysis and guidance to assist the many countries that rely on them for health-related information and policy advice. Capacity is needed both at WHO headquarters and in the regional offices. RECOMMENDATION. Development Assistance The bilateral aid agencies, including the U.S. Agency for International Development, should consider adding aspects of cancer control to their discussion agendas with LMCs, and adding funding for specific projects that fit into national cancer control plans and programs. RECOMMENDATION. Advocacy Established cancer advocacy organizations, mainly in high-income countries, should actively support and assist the growth of cancer advocacy in LMCs. Specific activities would include setting up advocacy networks within countries, within regions and internationally; identifying successful approaches to cancer advocacy and replicating or adapting them for use in other settings; and providing hands-on training and technical assistance. RECOMMENDATION. National Institutions The U.S. National Cancer Institute and other established cancer research and funding organizations both in the United States (e.g., the Centers for Disease Control and Prevention) and in other countries should help to establish and facilitate relationships between U.S. cancer centers and centers in LMCs and encourage U.S. researchers, through grant programs, to undertake collaborative research of relevance to LMCs.

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Cancer Control Opportunities in Low- and Middle-Income Countries RECOMMENDATION. The Academic Community Universities with active global health programs should consider opportunities in cancer control, as well as the more traditional areas of focus. If a university consortium is developed, one function should be to encourage and facilitate a broader agenda of topics, cancer control among them.