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Cancer Control Opportunities in Low- and Middle-Income Countries 8 Cancer Centers in Low- and Middle-Income Countries Cancer centers are the focal points for cancer research and treatment advances in high-income countries. Cancer treatment takes place throughout health care systems, however, where sufficient oncology expertise exists. In the United States, for example, an estimated 80 percent of newly diagnosed cancer patients are treated in local hospitals rather than specialized cancer centers (Hewitt and Simone, 1999). In middle-income countries and some low-income countries, cancer centers have been established for cancer diagnosis and treatment and for palliative care, both in the public and private sectors. In general, most of the oncology expertise in LMCs resides in these centers. Major cancer centers in the United States and other high-income countries take part in other aspects of cancer control, in particular programs in prevention, public education, surveillance, and research. Cancer centers in low- and middle-income countries (LMCs) tend to be less involved in other aspects of cancer control, and therein lies an opportunity. Where resources are limited, cancer centers can play an especially important role in the development of cancer control programs, as catalysts for cancer control nationally, and as points of contact for the global community. This chapter describes LMC cancer centers and their roles, discusses aspects of establishing or expanding the scope of cancer centers with at least some government support and recognition, suggests and emphasizes ways in which international efforts can help LMC centers and thus LMC cancer control, and identifies the functions that these centers might carry out. The recommendation arising from this review is that every country should aim to have at least one publicly supported “cancer center of excellence” as a
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Cancer Control Opportunities in Low- and Middle-Income Countries cancer focus that encourages the broad objectives of cancer control and that provides exemplary patient care, appropriate to the local circumstances. This is not to suggest that a single model applies everywhere or that, as in high-income countries, a goal should not be to expand treatment to the local level, within the health care system more generally. Here, too, the notion of “resource-level appropriateness” applies. A center of excellence in Timbuktu need not look like one in Buenos Aires, Paris, or New York. DEFINITION OF A CANCER CENTER The term “cancer center” has no fixed definition. The United States has a well-developed network of cancer centers with official designation from the National Cancer Institute (NCI), however, and some of the language used to describe them is useful in discussing the goals and functions of cancer centers envisioned in this report for LMCs. The specifics of LMC cancer centers might differ, but the underlying goals are similar. The NCI-designated cancer centers are the centerpiece of the U.S. effort to reduce morbidity and mortality from cancer. This includes not only providing state-of-the-art treatment, but research for the production of new knowledge about the basic nature of cancer, and about new and more effective approaches to prevention, diagnosis, and therapy. NCI describes officially recognized cancer centers as follows: The cancer centers are … the principal deliverers of medical advances to patients and their families and the chief educators of health care professionals and the public. An excellent cancer center is a local, regional, and national resource, having an impact that goes well beyond its own walls into the communities it serves directly and, by the generalizable knowledge it creates, into the world at large…. It is expected, for example, that centers will give greater emphasis to the particular challenges presented by special populations. The disproportionate burden of cancer in minority and other underserved groups is poorly understood and badly in need of attention from the research community…. Cancer centers … are expected to inform the public about their ongoing activities in these areas through public outreach and education (National Cancer Institute, 2006a). Cancer centers are actual, physical places, although they may differ in how they are organized. In the United States and other countries, many cancer centers are single institutions (one building or one campus) that specialize, first and foremost, in the diagnosis and treatment of cancer. In other cases, the cancer center may be a cancer unit within a larger hospital, such as a university medical hospital that treats the full range of health conditions. In still other cases, the cancer “center” is actually a consortium of hospitals or institutions that cooperate in an integrated cancer program.
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Cancer Control Opportunities in Low- and Middle-Income Countries Except for government-financed medical care, such as Medicare, in the United States the financial federal contribution to officially designated cancer centers is largely NCI support of research and other activities. Patient services and, to some extent, education and outreach, are funded by other means, including patients themselves and their insurers, philanthropic donations, and support from state or local government. CANCER CENTERS IN LMCS By virtue of their sole focus on cancer, cancer centers in LMCs have common ground with cancer centers in the United States and other high-income countries. However, they may differ in emphasis, in structure, and in the specific components of the cancer program they carry out. They may emphasize basic research compared with patient care, outreach, and other functions, for example. In the United States, the patient care components are assumed to be well developed as part of the health care system itself. Thus, research on the full spectrum of cancer control primarily distinguishes NCI-designated cancer centers from the many hospitals and other sites where cancer patients are treated. While some of the more developed middle-income countries may have an existing health care infrastructure that provides adequate cancer diagnosis and treatment, this is not generally the case. Therefore, the development of cancer management (even if limited in scope) will be a primary goal of cancer centers in LMCs. As in high-income countries, cancer centers in LMCs also act as focal points for cancer control nationally and as points of contact internationally. Both of these functions are vital. Being a recognizable international point of contact can bring substantial benefits, discussed later in this chapter. The reasons for being a national focal point may seem obvious. Cancer centers pioneer new treatments, establish the state of the art in treatment and other aspects of cancer control, and act as a reference center for the country. Either formally or informally, leaders in regions where cancer control is poorly developed may also act as reference centers, training centers, or perform other leadership roles. The King Hussein Cancer Center in Amman, Jordan, with the support of the NCI, has begun to fill this role in the Middle East region (NCI, 2006b). Establishment and Core Functions of LMC Cancer Centers The pattern of financing cancer centers in LMCs may be different from that in high-income countries. Ideally, the national government will support at least some functions, and the cancer center will be officially recognized or designated as a national cancer center. In most LMCs, where a large proportion of people do not have health insurance and cancer care is expensive
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Cancer Control Opportunities in Low- and Middle-Income Countries relative to income, the majority may find it impossible to pay for cancer services on their own. Without covering the costs of treatment, and possibly additional expenses incurred by patients and their families (e.g., travel, subsistence of family members accompanying patients), a cancer center may be essentially inaccessible, even for those nearby. A mixture of public (national and international) and private (including philanthropic) funding may be needed to allow access to a wide range of patients. This report recommends that every country aim to establish at least one officially designated or recognized cancer center that incorporates as many of the core functions (listed below) as possible. This could be designated as a “center of excellence.” Where multiple cancer centers exist already, one (or more, if appropriate) could be selected as a center of excellence, with the addition of resources as needed to carry out the core functions. As in the United States and elsewhere, the cancer center may be a single free-standing institution, may be part of a larger complex (university or hospital), or may consist of a consortium of institutions and experts in close collaboration, but identified primarily with the cancer center. This critical mass of expertise and resources is needed to establish the cancer center presence locally and internationally. (“Critical mass” has not yet been defined for low-resource settings, and is a task that should be undertaken by an international collaborative group, possibly as part of the resource-level-appropriate definitions.) It is encouraging that some cancer centers in LMCs have taken on broader roles in cancer control, even without official recognition (see Box 8-1). Cancer institutes such as these, where they exist, may be good candidates to take on national or regional responsibility, with official recognition. We suggest that the core functions that cancer centers in LMCs should strive to offer include: Patient care, including the services of medical oncology, radiotherapy, surgery, supportive services (imaging, pathology), psychosocial services, and palliative care Training in all functions available at the cancer center, as appropriate to the needs and resources of the country (or smaller area, if more than one cancer center of excellence exists in the country) Research, focusing on clinical questions of particular local importance (including research on “resource-level-appropriate” questions) Cancer detection and prevention programs, locally and throughout the country, that are tailored to resource levels Community outreach, including education, prevention programs, and community-based palliative care with pain management using oral morphine
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Cancer Control Opportunities in Low- and Middle-Income Countries BOX 8-1 Some Leading Cancer Centers In LMCS Cancer Institute at Chennai, India The Cancer Institute in Chennai (formerly Madras) carries out a broad agenda of cancer control in South India, where it is the only major cancer center. The Cancer Institute was founded in 1954 by the Women’s Indian Association (WIA, which is the abbreviation by which the Center is known) Cancer Relief Fund by India’s first woman medical graduate. WIA began and remains a voluntary institution with no official acknowledgment of the government (Sharma, 2004). As is the case with cancer centers worldwide, the initial focus was treating patients with cancer, which is still the mainstay. About 100,000 patients are treated each year, regardless of ability to pay. Most patients are poor and pay little or nothing for state-of-the-art care, including surgery, chemotherapy, and radiotherapy for potentially life-prolonging treatment; they also receive palliative care at little or no cost. What distinguishes WIA is its activities beyond patient care. A College of Oncologic Sciences was established in 1984, the first in India to offer specialty training in surgical and medical oncology and medical physics. Graduates of the college are now found in cancer centers all over India. Training in cancer research is now also offered (Sharma, 2004). Early on, WIA adopted cancer prevention and early detection as part of its mission, developed outreach programs for rural areas, developed a population-based cancer registry, and began carrying out a program of basic and applied research on cancer of local importance (cancers of the cervix, breast, and oral cavity and pediatric leukemias). The prevention program consists of a network of initiatives for the public and professionals. Rural training centers train village health nurses and other health workers in cervical cancer screening, breast examinations, and early detection of oral cancer (Shanta, 2000). WIA has been active at a policy level, as well. It was instrumental in exempting cancer drugs from import duty and in launching a national scheme to fund a series of regional cancer centers (Sharma, 2004). WIA has been recognized internationally for its work, which has attracted collaborations and forged strong ties to the global cancer community. It partnered with the World Health Organization (WHO) in 1969 to establish the first international cancer control program in a developing country. Current collaborators and research supporters include the International Network for Cancer Treatment and Research, the World Bank, WHO, and the University of Oxford (Shanta, 2000). Ocean Road Cancer Institute, Dar es Salaam, Tanzania Sub-Saharan Africa has few cancer centers outside of South Africa.
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Cancer Control Opportunities in Low- and Middle-Income Countries The most prominent is the Ocean Road Cancer Institute (ORCI) in Dar es Salaam, Tanzania, one of the world’s poorest countries. ORCI was established by the government in 1996 and is still the only dedicated cancer center in the country. Cancer is still not a health priority, but the existence and influence of ORCI has begun to change that (Ngoma, 2003). From its origins in the radiotherapy department of Muhimbili University teaching hospital, ORCI offers the full range of cancer management for adults and children—surgery (through Muhimbili hospital), chemotherapy, radiotherapy, palliative care—as well as cervical and breast cancer screening. About 2,000 new patients are seen each year and recently, about 5,000 women have been screened for cervical cancer annually. Services are paid for by the government with no charge to patients. ORCI also acts as the focal point for the Tanzanian National Cancer Control Program. Goals and activities include research, training, prevention programs, improving cancer treatment facilities around the country, and networking nationally and internationally. Recent research collaborations have involved cervical cancer screening using visual inspection, with the International Network for Cancer Treatment and Research (INCTR) and International Agency for Research in Cancer, and treatment of Burkitt’s lymphoma, also with INCTR. ORCI is, in fact, a magnet for international collaboration. INCTR’s only African office operates from ORCI. In early 2006, IAEA announced that ORCI will be the site of the first PACT “Centre of Excellence” (IAEA, 2006). These developments would have been unlikely in Tanzania without the modest nucleus provided by ORCI, and the steady progress it has made during its initial years. Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru The Instituto Nacional de Enfermedades Neoplasicas (National Institute for Neoplastic Illnesses, INEN) was established by the Peruvian government Defining resource-level-appropriate standards of care and providing this information to relevant practitioners and institutions throughout the country (see Chapter 4) Surveillance and monitoring of relevant risk factors and cancer-specific data, consistent with national data collection programs (see Chapter 3) Communications and information technology leadership by early adoption of low-cost advanced technology for a number of purposes, linking inside the country and internationally
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Cancer Control Opportunities in Low- and Middle-Income Countries in 1939 as a center for cancer treatment. It has grown in size and scope over the years and is still the only major cancer institute in the country. INEN is part of the Ministry of Health and has national responsibility for cancer prevention, detection, treatment, and education. The Maes Heller Research Institute has a wide range of programs in basic and clinical research. INEN also functions as a hub for satellite centers that it has organized in other parts of the country (Pinillos, 1990). Early detection and prevention—including antismoking campaigns—have long been high on the INEN agenda. Community support is important to INEN, with several hundred volunteers working regularly at the center. In 1952, INEN was the first Peruvian institution to establish formal postgraduate training programs for medical specialties. Most of the current surgical and medical oncology staff received their training through INEN, as well as additional postgraduate study abroad. INEN is recognized internationally as the focal point for cancer control in Peru, among relatively few such centers in Latin America. The institute is currently the leader in developing a new National Cancer Control Plan and program for Peru, a process that INEN initiated in 2002 (Coalición Multisectorial Peru Contra el Cáncer, 2006). It is collaborating with a large number of Peruvian partners as well as the American Cancer Society, U.S. National Cancer Institute, Pan American Health Organization, and International Union Against Cancer. Support from the American Cancer Society has been made available not only to develop the plan, but to help defray staff costs of the program for the first 2 years of start-up. A major task during the early phase is to secure the future of the program by raising internal funds. This arrangement of support and the centralization of the work in a major cancer center is the first such effort of its kind in Latin America (Personal communication, E. Huerta, Cancer Preventorium, Washington Cancer Center, 2006). International Partnerships and Communication for LMC Cancer Centers One of the observations of this report is that the international health community—cancer centers, the many academic global health programs, and the international development community—have established relatively few activities related to cancer in LMCs. The reasons for this are complex, involving the perceived and real burdens of cancer in comparison with other conditions (especially infectious “tropical diseases” and HIV/AIDS). Another factor appears to be a lack of perceived opportunity for identifying specific projects or types of projects that would further cancer control in
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Cancer Control Opportunities in Low- and Middle-Income Countries important ways. If the international community is going to become more engaged in the coming years, these issues must be addressed. Once interest is piqued, however, it will be important for international partners to recognize institutions and individuals in LMCs with whom they can establish connections. We see an important function of the cancer center to be an easily identifiable, officially recognized gateway for international collaboration. From the beginning of cancer center establishment (or enhancement of existing centers), the international community should be involved. This does not mean that all outside collaboration should be with a single cancer center. The cancer center is likely to be the first point of contact, however, and could identify other institutions and individuals within the country, for example. This “moth phenomenon” is already apparent, where countries with cancer centers of some prominence attract international attention in preference to countries with no obvious point of contact. Information and communications technologies and applications, including the development of specialized content, continue to proliferate and improve at relatively low cost and can be important sources of international support, as described below. The circumstances of each cancer center, including who its partners are, will determine exactly which ones are adopted—both the technologies and the applications. Connectivity is still a problem in places, but improving globally. Whatever the constraints, high-quality information and communication technology can be available and will be important components at any site. One caveat, however, is that the information actually needed in LMCs may be scarce or may not be accessible easily (e.g., resource-level-appropriate guidelines for most cancers). Health research of direct relevance to LMCs, and to cancer in particular, is rare. Research conducted locally may be published in developing country journals, few of which are indexed by Medline or other major databases, so they may not appear in literature searches (Edejer, 2000). Language is another barrier: Most of the published literature and other material on the Internet is in English. Some of this can be addressed by programs that develop and provide content as well as technology, but this is still limiting. Nonetheless, the field moves quickly and can be made more relevant as time goes on. A few examples of successful tools and programs for developing country health care that could be useful to cancer centers include those described below. SatelLife SatelLife was founded with the purpose of putting technology, in particular space technology, to use for the benefit of people in developing countries. Since the early 1990s, it has accomplished this with both technol-
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Cancer Control Opportunities in Low- and Middle-Income Countries ogy and content for the health care community (SatelLife, 2006). HealthNet “knowledge networks” were created in Eritrea, Ethiopia, Kenya, Uganda, Zimbabwe, and Nepal. The organizations are now locally owned and managed, but supported by SatelLife to provide a variety of services, including free or low-cost email, computer literacy training, health data collection, and information resources. Global information services are accessed in 120 countries. A few years ago, SatelLife began expanding the use of handheld computers (personal digital assistants, or PDAs) to collect and transmit health information in Africa. A collaborative project with the American Red Cross and the Acumen Fund used PDAs to undertake surveys of measles vaccination in Ghana and Kenya. In Ghana, 2,400 parents were surveyed at vaccination centers in 3 days, and in Kenya, the 28 Kenyan Red Cross volunteers surveyed 2,000 parents. The results were ready for analysis immediately. A traditional paper and ink survey would have yielded only 1/10 the number of reports, and would have taken weeks or months to process. The information is of strategic value for planning further immunization campaigns in both countries (American Red Cross, 2002). PDAs are also useful as portable information resources. SatelLife, in collaboration with Skyscape, has provided PDAs with treatment guidelines, essential drug lists, and medical textbooks to doctors and medical students in Uganda (American Red Cross, 2002). World Health Organization: Health InterNetwork Access to Research Initiative Health InterNetwork Access to Research Initiative (HINARI) is a program organized by WHO that provides online access to the full text of 2,900 major biomedical and related journals to local, nonprofit institutions in developing countries. The service is free or low cost, depending on the economic status of the country. Currently, about 1,400 institutions (including cancer centers) in 104 countries (out of 113 eligible) have registered for HINARI. During 2004, users at these institutions downloaded nearly 2 million articles (WHO, 2006). WiRED International Programs WiRED International (for World Internet Resources for Education and Development) is a nonprofit organization that provides medical and health care information, education, and communications resources to communities in low-income areas and postconflict countries (WiRED International, 2006). Projects have been developed in 11 countries in Latin America, Eastern and Central Europe, the Middle East, and Africa. Of particular interest
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Cancer Control Opportunities in Low- and Middle-Income Countries to the discussion of cancer centers are Medical Information Centers (MICs) for medical schools and teaching hospitals, and telemedicine centers to link health professionals in different parts of the world. The MICs are computer-based information systems using both local information storage (large fixed disk drives and CD-ROMs) and Internet connectivity to proprietary sites (e.g., WHO’s HINARI database). As comprehensive print libraries are increasingly impractical and computer-based libraries are made more practical and user-friendly, they are beginning to fill the information void in many locations. WiRED has installed MICs in Honduras, Kenya, Kosovo, Iraq, Montenegro, Nicaragua, and Serbia, with installations at multiple sites in most countries. Video conferencing with high-quality cameras has been developed for a variety of activities, including face-to-face meetings in seminars, lectures, and workshops, and for clinical assessment and consultation. An April 2006 video conference between physicians at Baghdad’s Medical City Center and physicians at Children’s Hospital in Washington, DC, was devoted to evaluating the cases of several Iraqi children. During the same month, video conferences were conducted between Rizgari Hospital in Erbil, Iraq and Massachusetts General Hospital and California Pacific Medical Center. Linkages among different hospitals in Iraq are also part of the program. WiRED also has another set of programs dealing with health information for the general public, as well as some specialized uses. A “Video Visit” program was set up in 2000 for Albanian children being treated for cancer in Italy to see and hear their families in Tirana, Albania over live video. St. Jude Children’s Research Hospital International Outreach Program: Cure4Kids Cure4Kids is an Internet-based distance learning program provided free to physicians, nurses, scientists, and health care workers who treat children with catastrophic illnesses (St. Jude Children’s Research Hospital, 2006). The Internet tools include: Online education about catastrophic childhood illnesses Collaborative work spaces for document sharing and online meetings Access to consultation and mentoring by St. Jude faculty Technology and training for better management of patient information More than 8,400 Cure4Kids users in 155 countries were registered as of 2005 (St. Jude Children’s Research Hospital, 2006). Its 200 online seminars
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Cancer Control Opportunities in Low- and Middle-Income Countries about catastrophic childhood illnesses, primarily cancer, are available in seven languages. (See Chapter 6 for more on St. Jude’s programs.) Programme of Action for Cancer Therapy: A Path to Cancer Centers of Excellence The International Atomic Energy Agency (IAEA) has recently taken the lead in efforts to help expand cancer control services in resource-poor countries through a new initiative, the Programme of Action for Cancer Therapy (PACT). Since 1981, IAEA has supported radiotherapy services in its member countries, having spent more than $50 million through the year 2000. Radiotherapy projects were initiated at the request of IAEA Member States under technical cooperation agreements. The projects ranged from setting up a country’s first radiotherapy center to upgrading facilities. All projects included the radiotherapy equipment and, as needed, training in clinical use of the machinery, dosimetry, safety, and maintenance (Levin et al., 2001). As befitted IAEA’s institutional mission, IAEA did not provide for other cancer treatment modalities, nor deal with cancer control more broadly. PACT, although an IAEA initiative, has much broader objectives. It is intended to go beyond radiotherapy by partnering with a range of organizations to establish comprehensive, multidisciplinary cancer control capacity, including training in prevention, early detection, palliative care, and potentially curative treatment in IAEA Member States. PACT was endorsed by the IAEA Board of Governors in June 2004, with a 10-year horizon and the following expectations (IAEA, 2004), assuming partnerships and funding are solidified: At the end of the programme, it is expected that PACT’s engagement with Member States and with other organizations in the public and private sectors will have met the needs of Member States because it will have served to: Strengthen national programmes for cancer control in developing countries. Enable institutions in health sectors to design and support the implementation of policies and projects for the sound application of radiation therapy. Establish radiotherapy centers in each developing country appropriate for its needs, taking into account economic and demographic factors, and in the context of an appropriate national strategy for cancer control. Establish centers of excellence for radiation therapy that will serve as centers of training in all regions served by PACT.
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Cancer Control Opportunities in Low- and Middle-Income Countries Review the status of radiation protection, safety, and security arrangements at national and local levels, and, as needed, put in place the technical, legal, and regulatory capacities appropriate to take best advantage of radiation therapy. Promote strategic partnerships on cancer therapy between countries and their national research, education, and regulatory systems at the subregional and regional levels; between national and international organizations; and between the public and private sectors. These are ambitious goals. IAEA has a history of collaboration with a variety of other organizations, both governmental and nongovernmental, but the scale intended under PACT is vastly greater than has been the case to date. The success of the program will depend on building robust partnerships that bring funding and technical expertise to the enterprise. PACT’s intended partners include Member States (developed and developing), other United Nations (U.N.) and non-U.N. institutions including those operating at regional and subregional levels, WHO in particular and its regional offices, the International Agency for Research in Cancer (IARC), charitable trusts, foundations, and others in the public and private sectors. IAEA announced in February 2006 (on World Cancer Day) that the first PACT Center of Excellence will be established in Dar es Salaam, Tanzania. Tanzania has one of the few publicly funded cancer centers in sub-Saharan Africa outside of South Africa. This will be the first major IAEA project that goes beyond radiotherapy toward helping the country advance its National Cancer Strategy and Action Plan. IAEA will focus on radiotherapy for treatment and palliation, while other PACT partners will assist with cancer surveillance, prevention, and early detection as well as strengthening civil society and community support for cancer control. Promoting Cancer Center Twinning for LMCs Institutional “twinning” is conceptually simple and appealing as a way to support the establishment and functioning of cancer centers in LMCs by partnering with established cancer centers or units in more developed countries. Twinning represents a long-term commitment of the partners, involving a range of individuals on both sides, with agreement on the expectations of all parties. The relationships should be mutually beneficial and not be seen as a one-way transfer from a high-income to a lower income partner. The concept of resource-level-appropriate care should apply, and equally important, cultural and societal characteristics and norms on both sides must be understood and respected.
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Cancer Control Opportunities in Low- and Middle-Income Countries The best developed examples of twinning in cancer are limited to pediatric cancer centers or units, which are described in detail in Chapter 6. The major program in the United States is St. Jude Children’s Research Hospital International Outreach Program. The program began in 1991 with middle-income-country partners in Latin America. There are now nine countries with one or more centers, and another five countries in other parts of the world. An example originating in Europe is a twinning program begun in 1986 between a pediatric cancer unit in Monza, Italy (the Hemato-Oncology Center of Milan-Bicocca University, Saint Gerardo Hospital) and the Manuel de Jesus Rivera-La Mascota Hospital (referred to as “La Mascota”) in Nicaragua. The program’s success led to greater involvement by Monza, which established the Monza International School for Pediatric HematoOncology (MISPHO), mainly to assist more countries in Latin America through training, workshops, and other collaborative functions. This, in turn, led to the formation of a network of Latin American countries, and additional twinning projects between other Italian pediatric cancer units and units in Bolivia, Cuba, Paraguay, and the Dominican Republic (Masera et al., 2004). Both the St. Jude and Monza programs have resulted in documented improved survival of treated cancer patients. The two most important factors leading to this improvement are use of standard, optimized treatment protocols and a strong emphasis on creating conditions that allow patients to complete, and not abandon, their treatment. World Heart Federation Twin Centres Programme: Twinning for Cardiology An example of twinning outside of cancer is the World Heart Federation’s (WHF’s) “Twin Centres Programme,” the aim of which is “to enhance the quality and capacity of cardiology centres in less advantaged countries or regions” through formal links with leading centers or institutions with high-quality cardiology programs, including prevention, clinical cardiology, research, and training. The program can be used to strengthen existing links and to encourage new ones (World Heart Federation, 2006). The role of the WHF is twofold: to catalyze twinning between institutions and to provide a range of exchange fellowships and traineeships. A central feature of this initiative is the fellowship program, considered an integral part of the development of a twinning arrangement. Fellowships allow young cardiologists and cardiovascular scientists from the lower income country to get training at the partner institution. Awardees must agree to return to their home institution after the training.
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Cancer Control Opportunities in Low- and Middle-Income Countries Observations and Lessons Learned Regarding Twinning Arrangements From the pediatric cancer programs, the most important observation is that twinning arrangements have succeeded in treating children with cancer in low-income countries in an appropriate and sustainable way. The programs also serve as demonstrations that such programs can work and that some cancers can be cured. The impacts of twinning programs (and cancer centers more generally) are limited to their resources and reach, of course. As stated by MISPHO leaders: The micro-approach promoted by twinning programs in the context of the “childhood cancer family” is both a symbolic intervention in the direction of globalization with a human face and a concrete contribution towards saving the lives of a minority of the children with cancer … (Masera et al., 2004). Certain characteristics of the institutional relationships in twinning arrangements and of the centers themselves are considered important by those involved. These include (Masera et al., 2004): Long-term commitment Attracting additional (less comprehensive) relationships with other organizations to strengthen the overall effort A reciprocal respect for the autonomy, culture, and local traditions between partners An active but noninvasive role of supervision and scientific advice from the higher income partner A comprehensive disease-oriented approach to program development, including training professionals, assuring the availability of essential drugs and diagnostic tools, and strengthening physical facilities Alliance among health professionals, families, and volunteers to support the center and its patients Development of financial support through a diversified donor pool without excessive reliance on a single source (in particular, not assuming that all financial support will come from the higher income partner); local fundraising, at whatever level possible, is important Assured salary support for at least a core of center personnel Attention to quality of care, with standards and monitoring, from the inception Promotion of collaborative research projects of local relevance, with LMC scientists in the lead
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Cancer Control Opportunities in Low- and Middle-Income Countries Cancer Centers and Other Chronic Diseases One potential drawback of promoting cancer centers to lead in the full range of cancer control activities is the isolation of cancer from other noncommunicable diseases. This concern is timely given WHO’s recent reorganization and major report on chronic disease prevention, which emphasizes the commonalities among the major noncommunicable diseases, including cancer. WHO recommends that every country develop a chronic disease policy “that sets out the vision for prevention and control of the major chronic diseases and provides the basis for action in the next 5–10 years” (Epping-Jordan et al., 2005). The 2005 World Health Assembly Resolution on Cancer Prevention and Control calls for universal national cancer control plans and programs (World Health Assembly, 2005). This suggests a need for coordination, while recognizing that cancer control has unique requirements apart from those of other chronic diseases. The WHO chronic disease emphasis is focused largely on prevention and not the other aspects of control. The most significant shared risk factor, by far, is tobacco. Tobacco control continues to gain momentum internationally as an independent issue with its own initiatives, stimulated by the Framework Convention on Tobacco Control. The cancer control community (in particular, the International Union Against Cancer, also known as UICC) has been a strong force for tobacco control and this will undoubtedly continue, unaffected by cancer centers taking the lead in cancer control. To a lesser extent (but still important), the promotion of healthy diets and weight control are beneficial for cancer as well as other chronic diseases. Palliative care is the aspect of cancer patient care that is of greatest relevance for the range of chronic diseases. Historically, palliative care developed in high-income countries specifically for cancer patients and even now, that is the main focus. Rather than the other major noncommunicable diseases, people with AIDS are benefiting from palliative care structures (mainly hospice programs) put in place for cancer. Developing palliative care more broadly—at least initially, concentrating on end-of-life care—is a challenge for all countries (WHO, 2005). Although cancer centers with cancer control responsibilities should organize palliative care, the care itself should be delivered to a large extent as home care, in the community through local health workers. So, although it is unlikely that many non-cancer patients will receive palliative care at cancer centers, all patients should benefit from programs in the community, organized through the health care system and serving all people in need, regardless of diagnosis.
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Cancer Control Opportunities in Low- and Middle-Income Countries DISCUSSION Cancer centers are recognized around the world first and foremost as institutions specializing in cancer diagnosis and treatment. The concentration of clinical expertise and the large number of patients with cancers of all types and stages make cancer centers an obvious place for cancer research to flourish, as well. This is, in fact, the natural evolution that has taken place in high-income countries and some LMCs. A natural extension of cancer center functions is in prevention programs, which require outreach to the community to educate the public about the value and availability of screening and to inform them about other prevention approaches. In LMCs, where resources are scarce, the cancer center may take on even greater importance than is the case in high-income countries. Many low-income countries, mainly in Africa, have no recognized cancer centers (Personal communication, T. Ngoma, Ocean Road Cancer Institute, Dar es Salaam, Tanzania, March 2006). Most, if not all, middle-income countries do have cancer centers, although most appear to be limited to cancer diagnosis and treatment; if they offer screening, it is for people referred to or requesting the service (i.e., opportunistic screening) and not part of an organized screening program for the broader population. This is the norm in Latin America, at least (Eisenchlas, 2006). Where recognized public-sector cancer centers do not exist or are very few (which is the case in at least a number of low-income countries), it is likely that there are also very few physicians and other health care personnel trained in oncology in the country. To create the conditions under which a multidisciplinary team can assemble to provide appropriate care in the public sector (as well as take on the other challenges discussed in this chapter), the idea of the cancer center is most appealing. The critical mass of cancer professionals includes physicians, nurses, social workers, and the variety of necessary technicians for patient care and training new personnel, at a minimum. This critical mass is needed to attract and retain excellent staff and to take advantage of economies of scale and of scope. Going a step farther, cancer centers in LMCs—where cancer expertise and resources are concentrated—are the logical centers of gravity for national cancer control programs involving both clinical services to patients as well as public awareness, prevention, surveillance, research, and other functions in the cancer plan and program. It will be necessary for each country to first take stock of their existing capacities, including the human and material resources needed for cancer control and then decide how to move forward. This is the approach currently being developed in Peru, for example (see Box 8-1). It is recognized that creating cancer centers of excellence either from scratch or by augmenting existing cancer centers might also have negative consequences. By definition, they will concentrate already scarce resources
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Cancer Control Opportunities in Low- and Middle-Income Countries for cancer, and in most cases, require additional funding, which might be diverted from other health priorities. Access inevitably will be limited, at least geographically, benefiting some more than others. Thus health care equity will not be served, although the intent is that the cancer center will develop outreach programs and become a reference center for other cancer centers. However, these developments may take years or decades to achieve, depending on resource availability and on the management and accomplishments of the keystone center. There is always a danger that the cancer center will be seen as a political prize to be awarded other than on the basis of merit—both the choice of which site will become a center of excellence and the choice of high-level administrators. On balance, we believe the positives outweigh the negatives, but this cannot be guaranteed everywhere. SUMMARY AND RECOMMENDATIONS The goal of creating and supporting centers of excellence for cancer control in many countries over the next decade is ambitious but achievable. The scope of the task is not easily definable, however, because there is no inventory of cancer centers and their current capabilities. In Latin America, where every country has cancer centers—some have many—almost all are centers for diagnosis and treatment only, with no broader cancer control functions (Eisenchlas, 2006). Countries should not have to undertake these efforts on their own. The number of international programs—including PACT, described earlier— demonstrates that there is support from the global community to expand cancer centers. The amount and nature of this support over the coming decade is not predictable at present; it will depend, among other things, on the success of PACT in attracting partner organizations. To some extent, it will also depend on the demand by LMCs, which must demonstrate commitment to these projects. No other global effort comparable to PACT exists, although arrangements among individual countries are always possible. In addition to support for the creation or expansion of public cancer centers through PACT or other sources, global partners—one or more—can greatly enhance the development of cancer control capabilities. In cancer, twinning relationships have been largely unexplored outside of pediatric cancer units, but these serve as useful examples. One way of promoting twinning would be for a convener or organizer to establish one or more models (e.g., for different levels of involvement) for institutions to follow, and to facilitate matching institutions. Fellowships, such as those offered by WHF, could also be useful incentives for new twinning programs. Various organizations could play this role, including the U.S. National Cancer Institute (and other high-income-country research and funding organizations).
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Cancer Control Opportunities in Low- and Middle-Income Countries RECOMMENDATION 8-1. 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 8-2. 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. REFERENCES American Red Cross. 2002. SATELLIFE Wins Swedish Health Award for IT Program in Africa. [Online]. Available: http://www.redcross.org/news/in/measles/021022satelife.html [accessed May 3, 2006]. Coalicion Multisectorial Peru Contra el Cancer. 2006. Documento De Consenso. Lima, Peru: Ministerio de Salud. Edejer TT. 2000. Disseminating health information in developing countries: The role of the Internet. BMJ 321(7264):797–800. Eisenchlas J. 2006. Cancer Prevention and Management in Latin America. Commissioned by the Institute of Medicine. Unpublished. Epping-Jordan JE, Galea G, Tukuitonga C, Beaglehole R. 2005. Preventing chronic diseases: Taking stepwise action. Lancet 366(9497):1667–1771. IAEA (International Atomic Energy Agency). 2004. Programme of Action for Cancer Therapy: Report by the Director General to the Board of Governors. Vienna, Austria: IAEA. IAEA. 2006, February. IAEA Responds to Cancer Crisis in Tanzania. [Online]. Available: http://www.iaea.org/NewsCenter/PressReleases/2006/prn200603.html [accessed May 8, 2006]. Levin V, Meghzifene A, Izewska J, Tatsuzaki H. 2001. Improving cancer care: Increased need for radiotherapy in developing countries. IAEA Bulletin 43(2):25–32. Masera G, Baez F, Biondi A, Cavalli F, Chiesa R, Conter V, Fossati-Bellani F, Marinoni M, Sala A, Valsecchi MG, Tognini G. 2004. Bridging the childhood cancer mortality gap between economically developed and low-income countries: Lessons from the MISPHO experience. In: Tannenberger S, Cavalli F, Pannuti F, eds. Cancer in Developing Countries: The Great Challenge for Oncology in the 21st Century. Munich, Germany: W. Zuckschwerdt Verlag GmbH. Pp. 42–60. National Cancer Institute. 2006a. Cancer Centers: Policies and Guidelines Relating to the Cancer-Center Support Grant; Part I: Description of the Program and Its Policies. [Online]. Available: http://www3.cancer.gov/cancercenters/ccsg_comp_pt1_5.html#5essential [accessed April 28, 2006]. National Cancer Institute. 2006b. NCI International Portfolio: Addressing the Global Challenge of Cancer. Bethesda, MD: National Institutes of Health.
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