Cancer Epidemiology and Program

Implementation in Low and Middle

Income (LMI) Countries:

A Lesson to Learn

David B. Thomas, MD, DrPH

 Outline of Talk
• Cancers of major concern in LMI countries
• Setting priorities for cancer control activities in
LMI countries
• Estimating the magnitude of the cancer problem
and identifying high risk groups in LMI
• Cancer registration in LMI
• The role of epidemiology in the planning and
evaluation of cancer control programs in LMI
countries
Cancers of Major concern in Low and
Middle Income (LMC) Countries
As a country transitions from a less
developed to a more developed country
cancer will become a more important
problem for 2 reasons:
• Rates of most cancers increase with age, so as
more people live longer, more people will
enter the high risk age groups
• Rates of many cancers increase as a
population develops a more “western” life
style
Age Specific Mortality Rates of Colon Cancer in Japan
Incidence Rates of Breast Cancer in 9 Asian
Populations over Time
In addition to becoming a greater
problem in the future, cancer will
be come a greater problem in
relation to other health problems
as these other health problems
come under control.
 Causes of Death in Thailand, China, South
Korea, and Belgium
(WHO, 2002)
•
What are the most common
cancers in LMI countries now, and
what will be the most common
cancers in the future?
 The 12 Most Common Cancers in the
Developed and Developing Regions of the
World, 2002
 The 12 Most Common Cancers in the
Developed and Developing Regions of the
World, 2002
 The Most Frequent Cancers in LMI
Countries
Males Females
• Now • Now
– Lung – Breast
– Stomach – Cervix
– Liver – Stomach
– Esophagus – Lung
• In the Future • In the Future
– Lung – Breast
– Prostate – Colorectal
– Colorectal – Lung
– Bladder – Corpus uteri
 Outline of Talk
• Cancers of major concern in LMI countries
• Setting priorities for cancer control activities in
LMI countries
• Estimating the magnitude of the cancer problem
and identifying high risk groups in LMI
• Cancer registration in LMI
• The role of epidemiology in the planning and
evaluation of cancer control programs in LMI
countries
 Setting Priorities for Cancer Control
Activities
• In planning for cancer control activities,
priorities must be set on the basis of:
– The magnitude of the problem (What are the
most important cancer in the population?)
– What can be done about the problem?
• Primary prevention
• Secondary prevention
Primary Prevention:
Reduce the occurrence of the cancer by
reducing exposure to cancer causing agents
Examples:
• Reduce smoking to prevent lung cancer
• Reduce exposure to asbestos in the work place
to prevent mesothelioma
• Vaccinate against human papilloma viruses to
prevent cervical cancer
• Vaccinate against hepatitis B virus to prevent
liver cancer
Secondary Prevention:
Early detection of cancer followed by
attempts at curative treatment
Examples:
• Mammographic screening for breast cancer
followed by effective treatment
• Pap smears for detection of cervical cancer
followed by effective treatment
• Note: Before screening can begin, there must
be sufficient resources for diagnostic
evaluation in those who screen positive, and
treatment of those found to have the cancer.
 Highest Priority for Cancer Control in
LMI Countries (Underlined)
Males Females
• Now • Now
– Lung – Breast
– Stomach – Cervix
– Liver – Stomach
– Esophagus – Lung
• In the Future • In the Future
– Lung – Breast
– Prostate – Colorectal
– Colorectal – Lung
– Bladder – Corpus uteri
Note: This is an example. The actual cancers of highest priority in Indonesia may
differ from these. If possible, priority for cancer control activities should be
established based on local data.
 Outline of Talk
• Cancers of major concern in LMI countries
• Setting priorities for cancer control activities
in LMI countries
• Methods for assessing the cancer problem
locally
• Cancer registration in LMI
• The role of epidemiology in the planning and
evaluation of cancer control programs in LMI
countries
 Methods for Assessing the Cancer
Problem Locally

• Proportional mortality ratios

• Proportional incidence ratios
• Mortality rates
• Incidence rates
 Proportional Mortality ratios
• Definition: The percentage of all deaths that
are due to various causes
• Based on death certificates
• Gives information on what the most
important causes of death are
• Can be misleading due to:
– under-reporting of deaths
– misclassification of cause of death
– the frequency of other causes of death
 Methods for Assessing the Cancer
Problem Locally

• Proportional mortality ratios

• Proportional incidence ratios
• Mortality rates
• Incidence rates
 Proportional Incidence Ratios
• Definition: The proportion of all cancers in a series
that are of a particular type
• Based on a series of cases that are collected from
hospital records or a hospital-based cancer registry
• Gives information on what the most important
cancers are
• Can be misleading due to:
– Patterns of cancer care. Some types of cancer may be
more likely to be treated in the hospital than others
– Misdiagnosis
– Frequency of other cancers
 Methods for Assessing the Cancer
Problem Locally

• Proportional mortality ratios

• Proportional incidence ratios
• Mortality rates
• Incidence rates
 What is needed in order to obtain accurate
mortality rates?

• Accurate census of the population

• Complete ascertainment of all deaths
• Accurate information on cause of death
• A statistical unit that can analyze the data
Note: Cancer mortality rates will show which cancers are the most
common causes of death. Cancers with the poorest prognosis will
be over-represented, and cancers with better prognosis will be
under-represented by mortality rates.
 Methods for Assessing the Cancer
Problem Locally

• Proportional mortality ratios

• Proportional incidence ratios
• Mortality rates
• Incidence rates
What is needed in order to obtain accurate
cancer incidence rates?

• Accurate census of the population

• Complete ascertainment of all cancer cases by
a population-based cancer registry
• Accurate information on type of cancer
• A statistical unit that can analyze the data
 Outline of Talk
• Cancers of major concern in LMI countries
• Setting priorities for cancer control activities
in LMI countries
• Methods for assessing the cancer problem
locally
• Cancer registration in LMI
• The role of epidemiology in the planning and
evaluation of cancer control programs in LMI
countries
 Some Comments on Establishing a
Population Based Cancer Registry-1
• With limited resources it is far better to
establish one or more good registries in
carefully selected areas than to attempt to
register all cancers in a large population
such as Indonesia
• Selected areas can then serve as resources
for conducting epidemiologic studies and
evaluating cancer control programs
 Some comments on Establishing a
Population Based Cancer Registry-2

• Criteria for choosing a population for a cancer

registry:
– An accurate census, or the facilities and resources
needed to obtain accurate census information
– Large enough population to generate enough cancer
cases to provide stable incidence rates (1-2 million )
– Small enough to be able to obtain information on all
of the cancer cases with the available resources.
– All cancers are treated in a single hospital, or just a
small number of hospitals
– People should not go out of the area for care
(although people may come into the area for care)
 Some comments on Establishing a
Population Based Cancer-3
• The level of cooperation of local offices of
vital statistics, health departments, hospitals
and pathology laboratories in the area must
be considered
• Consider populations of special interest:
– For example, different ethnic groups of
interest (e.g. in Indonesia, Javanese,
Sundanese, Malays, Madurese, Chinese)
– For example, populations with unusual
exposures of interest (e.g. in areas with
exposures to mines or petroleum refineries)
 Some comments on Establishing a
Population Based Cancer-4
• Establish a population based registry only if:
– There are trained epidemiologist who will
utilize the registry to answer relevant
questions
– The important questions cannot be answered
by other means (such as hospital-based case
series, or mortality statistics)
• A population-based registry should only be
established if there is a stable source of
funding to ensure that the registry can be
maintained over a long period of time
Some Comments on Establishing a
Population Based Cancer-5

• A population-based registry is best

established in association with a health
department, university, or research
institution so that the data can be
appropriately used for studies of cancer
etiology and cancer care, that provide
answers to questions that need to be
answered to inform decision makers.
 Outline of Talk
• Cancers of major concern in LMI countries
• Setting priorities for cancer control activities
in LMI countries
• Methods for assessing the cancer problem
locally
• Cancer registration in LMI
• The role of epidemiology in the planning and
evaluation of cancer control programs in LMI
countries
 The Role of Epidemiology in The Planning
and Evaluation of Cancer Control Activities
• Assess the magnitude of the problem and
identify the most important cancers (already
discussed)
• Identify high risk groups of people
• Assist in designing programs so that they can
be rigorously evaluated
• Evaluate success of cancer control programs
– Primary prevention programs (prevention of disease)
– Secondary prevention programs (reduction in deaths due
to the disease)
 Identification of High Risk Groups of people

• People at high risk of disease (for primary prevention)

– Identification of groups of people at high risk of getting the
disease (as discussed)
– Identification of people at high risk of exposure to known
carcinogenic agents
• E.g. smokers (tobacco smoke), women with sexually
transmitted diseases (HPV), certain industrial workers
(asbestos miners, dye workers)
• People at high risk of advanced disease (for secondary
prevention)
– Identification of people without access to screening
facilities
– Identification of people who present with advanced
disease
 The Role of Epidemiology in The Planning
and Evaluation of Cancer Control Activities
• Assess the magnitude of the problem and
identify the most important cancers (already
discussed)
• Identify high risk groups of people
• Assist in planning programs so that they can be
rigorously evaluated
• Evaluate success of cancer control programs
– Primary prevention programs (prevention of disease)
– Secondary prevention programs (reduction in deaths due
to the disease)
 Measurements of success of Primary and
Secondary Prevention Programs
• Primary prevention programs
– Intermediate endpoint: reduction in exposure to a
carcinogen (e.g. smoking)
– Ultimate goal: a reduction in the incidence of the disease
(very long term)
• Secondary prevention programs
– Intermediate endpoints:
• Down staging of disease at diagnosis
• Increase in survival
– Ultimate goal: a reduction in mortality due to the
disease (long term)
Note: a reduction in stage and an increase in survival can occur
without a reduction in mortality.
Examples of Planning and Evaluation
of Cancer Control Programs
 Breast Health Global Initiative 2008:
Implementation of programs in
accordance with BHGI guidelines
• Meeting in Budapest, Hungary, to develop
strategies
• Attempts to obtain funding (e.g. Komen
Foundation
• Helped fund the development and evaluation
of screening projects :
– E.g. Jakarta, Indonesia
– E.g. Bogota, Colombia
 Two methods of Implementation and
Evaluation of Secondary Prevention
Programs
• Feasibility project to determine whether:
– the methods proposed for use in a screening
program are likely to be efficacious, and whether
– implementation of the program is likely to be
successful.
• Phased implementation of a screening program
to determine if the program is efficacious
 Feasibility Project
• Definition: A project conducted in a limited
portion of a population to determine whether
a proposed screening method is likely to be
efficacious, and whether the program that will
be based on the method can be successfully
implemented
• The project may be evaluated by:
– Comparing the screening method with a standard
method of screening to determine whether the
method is likely to be efficacious (Step 1)
– Determining the proportion of the target population
that can be screened. This will indicate whether the
program is feasible (Step 2)
An Example of a Feasibility Project:
Early Breast Cancer Detection Through
Clinical Breast Examination Training for
Midwives in Rural Jakarta, Indonesia
[Dr. Kardinah and colleagues]
• Purpose: To determine whether training
midwives to perform CBE, and to teach
women BSE, can result in breast cancers
being diagnosed at an earlier stage
• Location: Sub-District of Koja in Jakarta
– Population: 284,000 women eligible for screening
– 6 primary health clinics
Early Breast Cancer Detection Through
Clinical Breast Examination Training for
Midwives in Rural Jakarta (Cont.)
• Step 1-Methods:
– Volunteers recruit women to come to clinics for
screening
– Midwives perform CBE and teach BSE
– Women are then independently screened by
mammography
– Women with a positive screening by any method are
clinically evaluated and receive further diagnostic
procedures if indicated
– Women who are found to have breast cancer are
treated
Early Breast Cancer Detection Through
Clinical Breast Examination Training
for Midwives in Rural Jakarta (Cont.)
• Step 1-Evaluation:
– Comparison of CBE to mammography:
• Detection rates of breast cancer by CBE and by
mammography alone, and by both methods
• False positive rates by each method alone, and by both
methods combined
• Size and stage of tumors detected by each method
alone and by both methods
– These results will indicate whether the screening
method used in the program (CBE) is likely to be
efficacious if successfully implemented.
Early Breast Cancer Detection Through
Clinical Breast Examination Training for
Midwives in Rural Jakarta (Cont.)
• Step 2-Methods:
– If the results in step 1 are encouraging, they may
then attempt to recruit all of the women in the
target population
• Step 2-Evaluation:
– Determine the % of women in the target
population that are screened
– If the percentage is high, then it can be concluded
that a larger program using the same methods
could also be successfully implemented
• Note: The next logical step would then be to
initiate phased implementation
 Two methods of Implementation and
Evaluation of Secondary Prevention
Programs
• Feasibility project to determine whether:
– the methods proposed for use in a screening
program are likely to be efficacious, and whether
– implementation of the program is likely to be
successful.
• Phased implementation of a screening program
to determine if the program is efficacious
 Phased Implementation
• Definition: The planned introduction of a program in some
segments of a population before others so that the efficacy
of the program can be evaluated
• New methods of screening for early breast cancer are
necessarily introduced into low and middle income countries
gradually, so for a period of time some women will be
screened and some will not.
• One can take advantage of this situation and introduce
screening in a rational manner so that those initially screened
and those not initially screened can be compared and the
efficacy of the screening program can be evaluated.
• Well defined endpoints (e.g. tumor size and stage) are
compared in the segments of the population with and
without the new program
• If there is a favorable difference in the screened segments of
the population, then the program can be implemented in the
rest of the population
 An Example of Phased Implementation:
Breast Cancer Screening by Opportunistic
Mammography plus CBE in Colombia-1
[Dr. Raul Murillo and colleagues]
• Primary health care centers in Bogota were randomized to
either opportunistic screening centers or control centers
• Women eligible for care in the centers that were
randomized to screening are offered mammography and CBE
when they come to the health center for their medical care.
Those who accept are screened.
• Women eligible for care in the control centers are not
offered screening, but they are offered educational material
on breast cancer when they come to the health center for
their medical care. Those who receive the informational
material are “pseudo-screened”.
An Example of Phased Implementation:
Breast Cancer Screening by Opportunistic
Mammography plus CBE in Colombia-2
[Dr. Raul Murillo and colleagues]
• A system has been developed to identify all
breast cancers that occur in women in both
groups
• Special training is given to medical personnel so
breast cancers that develop in women in both
groups are diagnosed, staged, and treated in
the same manner, and according to BHGI
guidelines
An Example of Phased Implementation:
Breast Cancer Screening by Opportunistic
Mammography plus CBE in Colombia-3
[Dr. Raul Murillo and colleagues]
 An Example of Phased Implementation: Breast
Cancer Screening by Opportunistic
Mammography plus CBE in Colombia-4
[Dr. Raul Murillo and colleagues]
• Breast cancers detected by screening will be compared
to the cancers that occur in the pseudo-screened group
on TNM staging to determine the efficacy of the
screening method in down-staging at diagnosis.
• The percentage of women in the intervention arm who
are screened will be calculated to estimate the
coverage of the target population
• All of the cancers in the intervention and control arms
of the study will be compared on TNM staging to
determine the impact of the program on the total
breast cancers in the population of women targeted for
screening
 Phased Implementation (cont.)
• Note that phased implementation requires
no more resources for screening than does
opportunistic screening
• It does require additional resources for
evaluation:
– Selection of the segments of the population for
implementation
– Data collection in both the segments of the
population with the new screening program and
in the segments in which the program has not
been introduced
– Data processing and analysis
• The BHGI is assisting in the evaluation efforts
 Summary and Final Comments-1
• As LMI countries develop economically, cancer will become
a more important public health problem
• Population based cancer registration can be useful in
assessing the cancer problem, but other less expensive
methods also exist that should be considered before
establishing a registry.
• If population based registries are established, it is
preferable to do so in limited and carefully selected
populations than to attempt to establish a nation wide
registry.
• Prioritize the development of cancer control activities on
the basis of the importance of the cancer, the known
effectiveness of the means that exist for primary or
secondary prevention, and the resources available to utilize
these means.
 Summary and Final Comments-2

• Cancer control activities should be initiated in such a

manner that they can be rigorously evaluated
• Epidemiologists can play an important role in setting
priorities for cancer control activities, in planning
these activities, and in the evaluation of their
effectiveness
• The training of cancer epidemiologists is therefore an
important early step in developing cancer control
activities
END