Cancer Control Strategies in Nigeria

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*Corresponding author: Email: [email protected];

American Journal of TROPICAL MEDICINE &Public Health1(1): 1-10, 2011

SCIENCEDOMAINin ternationalwww.sciencedomain.org

Feasible Cancer Control Strategies for Nigeria:Mini-Review

Kolawole Abimbola Omolara1*

1Department of Obstetrics and Gynaecology, Ahmadu Bello University,

Shika-Zaria, Nigeria.

Received 17th

May 2011Accepted 24

thMay 2011

Online Ready 4th

June 2011

ABSTRACT

Globally the incidence of cancer is rising. In 2007 there were 11 million cancer cases, 7million cancer deaths and 25 million people living with cancer. This is estimated to increaseto 27 million cases, 17 million deaths and 75million people living with cancer in 2050. Morethan 50% of these cases occur in developing countries where cancer is the second mostcommon cause of death. It constitutes 12% of all deaths (after cardiovascular disease);killing more people than HIV/AIDS, Tuberculosis and Malaria combined. Cancers areemerging public health problems in developing countries like Nigeria, where they werepreviously considered rare. However the epidemiological shift and ageing population makecancers a challenge. The number of new cancer cases which was initially estimated to be100,000 per annum increased to about 500,000 in 2010. WHO (2008) estimates thatincidence of cancer in Nigerian men and women by 2020 will be 90.7/100,000 and100.9/100,000; and the deaths rates 72.7/100,000 and 76,000/100,000 respectively. Thecommonest cancers of Nigerian men are cancers of prostate, liver and lymphomas whilecancer of cervix and breasts are commonest in the women. Currently, Nigeria has nonational policy or a comprehensive document on cancer control. There is no organizednational program for cancer prevention. Moreover, control of reproductive cancers is rathermentioned in the National policy on Reproductive Health and Strategic Framework. Theprevention of Human Papilloma Virus (HPV) may occur within the context of the national

program for control of Sexually Transmitted Infections (STI) and HIV.

Keywords: Cancer; Nigeria; Human Papilloma Virus; HIV; control; prevention;

Review Article


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American Journal of TROPICAL MEDICINE & Public Health, 1(1): 1-10, 2011

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1. INTRODUCTION

Cancer, the generic term for carcinoma is the malignant form of uncontrolled growth of cellsand tissues. It is the most dreaded non-communicable disease in developing countries

where it is invariably fatal, due to lack of adequate preventive and curative services. Unlikein developed countries which have policy, strategies and programs for cancer preventionand management (WHO, 2002; Thun, 2010; Nnodu, 2010), consequently although theincidence of cancer is rising globally, the developing countries account for 52% of thisincrease (Parkin, 2003) and for 70% of cancer deaths (UICC, 2006) while only possessing5% of global funds for cancer control and very few human and material resources (Jones,1999). It is the second most common cause of death; constituting 12% of all deaths aftercardiovascular disease. It kills more people than Tuberculosis, HIV/AIDS and Malariacombined (WHO 2006a, 2006b). In 2007, there were 11 million cancer cases, 7 millioncancer deaths and 25 million people living with cancer. This is projected to increase to 27million cases, 17 million deaths and 75million people living with cancer in 2050 (WHO 2005).

The aetiology for many cancers are still unknown, however there are risk factors which are

either modifiable or non-modifiable. The modifiable factors include tobacco use, physicalinactivity, unhealthy diet, obesity, ultraviolet radiation and infectious agents like HumanPapilloma Virus (HPV), Hepatitis Viruses (HBV, HCV) and Helicobacter pylori. The non-modifiable factors include heredity, sex, ethnicity, immunosuppression and ageing (WHO,2002; Nnodu, 2010). Moreover, due to the epidemiological shift, increase in ageingpopulation, high rate of infections and entrenchment of the modifiable risk factors (Thun,2010), cancers will yet pose significant challenge to Nigeria and other developing countrieswhich currently lack cancer control programs directed at reducing cancer incidence andmortality and to improve quality of life (WHO, 2002).There are very few human and materialresources for cancer control in developing countries where cancers occur at younger ages,70% of cancer deaths occur and only 5% of global funds for cancer control is present(Jones, 1999).

Africa carries an increasing cancer burden, 75% of the 650,000 annual cases present late, atyounger ages and about 510,000 deaths occur (Ngoma, 2006). The incidence ranges from70/100,000 to- 100/100,000 people. Infectious agents like Hepatitis B, C, Human PapillomaVirus (HPV), Helicobacter pylori contribute significantly to cancers in developing countries(Mackay 2006). The HIV pandemic is changing the pattern and prevalence of cancerespecially in East Africa where AIDS-related cancers like Kaposi sarcoma, lymphomas, analcancers and cervical cancers are increasing (Parkin, 2003). Kaposi sarcoma (15.5%) is nowthe commonest cancer of men in sub-Saharan Africa and cervical cancer (22.2%) iscommonest in women (Ngoma, 2006).

2. LITERATURE SURVEY

This is a mini-review of literature and policy documents on cancer control for Nigeria. An

internet search was conducted for publications, policy documents and grey literature usingGoogle and SCOPUS search engines. The database of PUBMED, Cochrane andReproductive Health were searched. Information was retrieved from the websites ofinternational agencies and non-governmental organizations like World Health Organisation(WHO), Federal Ministry of Health (FMOH). Additional information was got from hand-searching some journals.


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3. CANCER SCENARIO IN NIGERIA

Annually, there are about 100,000 new cancer cases in Nigeria, this is estimated to increaseto 500,000 in 2010 (Durosinmi, 2004). WHO (2008) estimates that incidence of cancer in

Nigerian men and women by 2020 will be 90.7/100,000 and 100.9/100,000 (Table 1) and thedeaths rates will be 72.7/100,000 and 76,000/100,000, respectively.

Table 1. Trend of age standardized mortalit y rates (ASMR) for cancer in Nigeria by sex

Year 1960-69 1999 WHO estimate 2020

ASMRMale - 78/100,000

Female -105.1/100,000

Male - 63.9/100,000

Female - 74.5/100,000

Male -72.7/100,000

Female -76/100,000Source: Parkin, 2003;

Cancer currently accounts for 4.4% of all deaths and is likely to increase to 6.8% in 2030(WHO 2008). Out of 89,000 cancer deaths in 2005; 54,000 of these were younger than 70

years. The commonest cancers of Nigerian men are cancers of prostate, liver andlymphomas (Parkin, 2003; Globocan 2008; Awodele et al., 2011). In the women, cancer ofcervix and breasts are commonest (Adebamowo, 2007) with minimal regional variation.

Incidence of cervical cancers compared to other cancers in women of all ages in Nigeria hasbeen shown in figure 2. The Ibadan cancer registry showed a reduction in age standardizedmortality rate from 1960 to 1999 (Tables 1, 2 and 3). This was attributed to introduction ofuser fees and reduction in the coverage area. While cervical cancer is commonest in Zaria,Northern Nigeria (Adewuyi, 2010) as in rest of Africa (Ngoma, 2006), breast cancer hasbecome the commonest cancer of women in Ibadan, Southern Nigeria (Awodele et al., 2011;Parkin, 2003). These common cancers should be the focus of cancer control programs inNigeria.

Fig. 1. Mortality from Cancer in Nigeria


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Table 2. Common cancers in Nigeria by sex

Registry Male Female

Ibadan Registry 1999 Prostate 23.5%Liver 11.6%NHL 10.3%

Breast 35.3%Cervix 24.4%Ovary 4.7%

Zaria Registry 1991/92 Liver 19.9%NHL 15.9%Bladder 9.3%Prostate 7.5%

Cervix 24.8 %Breasts 20.5%NHL 7.9%

Nigeria (overall summary)(Globocan, 2008)

Prostate 18.2%Liver 15.7%Colorectum 7.8%NHL 7.4%Bladder 4.2%

Breast 30.7%Cervix uteri 24.6%Liver 4.6%Colorectum 3.5%NHL 3.3%

NHL is non - Hodgkins lymphoma(Sources Parkin et al 2003, Globocan 2008, Awodele 2011)

Table 3. Summary of cancer statistics for Nigeria

NIGERIA Male Female Both sexes

Population (thousands) 75758 75453 151212Number of new cancer cases(thousands)

40.1 61.7 101.8

Age-standardised rate (W) 95.1 128.4 111.7Risk of getting cancer before age 75(%)

10.4 13.4 11.9

Number of cancer deaths

(thousands)33.2 42.1 75.4

Age-standardised rate (W) 81.3 92.4 86.6Risk of dying from cancer before age75 (%)

8.9 10.3 9.6

5 most frequent cancers Prostate Breast BreastLiver Cervix uteri Cervix uteriNon-Hodgkinlymphoma

Liver Liver

Colorectum Colorectum Prostate

LeukaemiaNon-Hodgkinlymphoma

Non-Hodgkinlymphoma

Methods of estimation (summary)Incidence: Local incidence data: incidence rates were estimated as the weighted average ofthe local rates.Mortality:No data: the number of cancer deaths was estimated from incidence estimates and sitespecific survival estimated by the GDP method.(Source: Globocan 2008)


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Fig. 2. Incidence of cervical cancers compared to other cancers in women of all agesin Nigeria (Source: Globocan, 2008)

3.1 Epidemiology of Common Cancers in Nigeria

Cervical cancer is caused by persistent infection with high risk Human Papilloma Virus(HPV) especially genotypes 16 and 18. The other risk factors include early commencementof intercourse, multiple sex partners, high parity, poverty, smoking and hormonalcontraceptives. Following infection by HPV, invasive cancer develops after 10-15 years

during which pre-cancerous lesions can be identified using screening measures and earlytreatment given to prevent progression to cancer (Sloan, 2007; Parkin, 2003).

Breast Cancer is commoner in women of age 50years and older. The two primary riskfactors for breast cancer are increasing age and female gender. Other risk factors includeearly menarche, obesity, lower levels of physical activity, nulliparity, smoking, alcohol, use ofhormone replacement therapy. It often presents as breast lump or bloody nipple discharge(Adebamowo, 2007; Barton, 1999). Thus screening can be done through periodic breastexamination and mammography of women above 40 years if available.

Liver cancer is common in men of age 40 years and older (DCPP, 2007). The risk factorsincludes infection with Hepatitis B or C viruses (transmitted through infected blood, unsterileneedles and unsafe sex), alcohol use and food contamination by Aflatoxin a fungus (Sitas,

2006). Since early diagnosis and treatment of the cancer is difficult, it is better prevented.

Prostate cancer is commoner in men from 50 years old. Ageing, family history, highconsumption of fat and red meats as well as use of sex hormones are associated risk factors(Sitas, 2006). Screening is either done through done through prostate-specific antigen (PSA)levels, trans-rectal ultrasound scan and Digital Rectal Examination (DRE). Lung cancer is


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not so common in Nigeria probably because of low smoking prevalence which may howeverincrease due to increasing advertisement and promotion by the tobacco companies.

3.2 Cancer Control in Nigeria

The aim of cancer control program is to reduce the burden and risk factors for cancer andimprove the quality of life. This is achieved by prevention, early detection/diagnosis andtreatment as well as palliative care and psychosocial support. The program should beevidenced based, equitable, sustainable, integrated into existing ones and gradually scaledup (WHO, 2002). There is currently no National policy on cancer control in Nigeria; however,control of reproductive cancers is included in the National policy on reproductive health andstrategic framework (FMOH, 2004; WHO, 2006b). It is also related to the policies on foodand nutrition and health promotion (FGN, 2003). Currently, Nigeria has less than 100oncologists about 100 pathologists and four radiotherapy centres, thus cancer control shouldfocus on prevalent cancer pattern and cost-effectiveness (Durosinmi, 2004).

4. PREVENTION STRATEGIES

Generally 43% of all cancers are preventable using primary, secondary or tertiary measures(WHO, 2002). Primary measures aim at reducing or eliminating exposure to risk factors orcarcinogens. Secondary ones aim at early detection of cancer or screening for pre-cancerstages, while tertiary measures are treatment or palliative care given to diagnosed cancercases to avoid complications and improve quality of life (DCPP, 2007). One- third of cancersare preventable by controlling tobacco and alcohol use, improving diet and by immunizingagainst Hepatitis B virus. Another third are amenable to early detection and treatment whilethe remaining third which are advanced will benefit from palliative treatment (WHO, 2002).Since Nigeria is a Low-resource country, health promotion should be done for generalcancer prevention and cost-effective measures can be applied initially to at least two or threeof the common preventable cancers as a pilot and later scaled up (WHO, 2002; Jones,1999).

4.1 Primary Prevention

Health promotion should include increasing level of physical activity of Nigerians andpreventing obesity. This involves promoting cycling, walking, physical fitness in schools andcommunity (DCPP, 2007). This can be done through housing and environmental policies.Car and fuel taxes can discourage driving. Also health promotion to promote safe sex,reduce early onset of sex and number of partners will contribute to decreasing cancer ofcervix.

4.1.1 Dietary control

Poor diet is associated with 20% of cancers. Health promotion should include increase

consumption of fruits and vegetables, while reducing salt, food additives, fat and red meatconsumption which may be risk factors for prostate, stomach and breast cancers (Jones,1999).


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4.1.2 Tobacco and alcoho l control

Tobacco use is underlying risk factor for 30% of cancers. Alcohol consumption seems toaggravate this effect on cancers of stomach, mouth and mouth. Alcohol can be regulated by

legislation on age and high taxes (WHO, 2002). Tobacco policy should include legislation toincrease tax on tobacco, reduce marketing, banning tobacco adverts, anti-smokingcampaigns, graphic warnings on cigarette packets, reducing young peoples access totobacco, restrict smoking in workplace and, public places. Nigeria should implementmeasures included in WHO Framework Convention on Tobacco Control (FCTC).

4.1.3 Vaccination

Improving coverage of Hepatitis B vaccination especially as part of childhood immunizationwill contribute to reduction of liver cancer. Other measures include safe injection and bloodtransfusion practices as well as promotion of universal health precautions (DCPP, 2007).Proper storage of grains will prevent aflatoxin mould another cofactor for liver cancer. TheHPV vaccine will hopefully be accessible to Nigerians within ten years if the price can be

subsidized by international organizations such as (Global Alliance for Vaccines andImmunisations) GAVI. This can cause 70% reduction in cervical cancer (WHO, 2002). TheMOH should prepare to integrate this into existing cervical cancer prevention measures.Research on prevalent local HPV genotypes is needed and pilot prevention programs can beinitiated.

4.2 Secondary Prevention

Screening programs in Nigeria should start with cervical, breast and prostate cancers, sincescreening for liver cancer without effective treatment measures will not reduce mortality(DCPP 2007). The cervical cancer screening should be coordinated and emphasis should beshifted to using cheaper alternatives like Visual Inspection with Acetic acid (VIA) or VisualInspection with Lugols Iodine (VILI) for screening at community levels at high coverage.

Cytology may continue in teaching hospitals. Nigeria is believed to have capacity to annuallyscreen the estimated 8000 women of reproductive age and to manage lesions found(Adewole, 2005). According to Katz (2006) and WHO (2008) a National program cancommence with once in a lifetime screen especially of 35-40 year old women which canreduce cervical cancer by 25-35%. Later ten-yearly or thrice-in a lifetime screening ofwomen between 15-64 years old can start. HPV DNA testing is another cost-effectivemeasure but not feasible in Nigeria for now due to cost and non-availability.

Although, mammography for all Nigerian women over 40 years is currently not feasible, fewhospitals with the machine can start pilot studies and opportunistic screening. However,Periodic Breast Examination (PBE) should be promoted for all women especially above 25years. Clinical Breast Examination (CSE) with 54% sensitivity and 94% specificity is effectivefor early diagnosis (Barton, 1999). Screening for prostate cancer in men over 50 years old

using Prostatic Surface Antigen (PSA) and trans-rectal ultrasound can commence as pilotprogram, while Digital Rectal examination (DRE) continues as opportunistic screening(WHO, 2002).


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4.3 Tertiary Prevention

4.3.1 Early treatment

Cancers of cervix, breast and prostate are potentially curable if detected early andadequately treated (WHO 2002). Currently they are managed in Nigerian tertiary hospitalsusually with no national treatment protocols and expertise is restricted by low volume ofcases. There is need for specialized cancer centres in the six geopolitical zones. These willbe referral centres providing specialized care, training and conducting research. They shouldbe equipped to provide investigations, radiotherapy, chemotherapy and radical surgery.They should collaborate with other cancer centres in developed countries (Adebamowo,2007).

4.3.2 Palliation

The quality of life of cancer patients with terminal disease or when treatment is unavailablecan be improved by providing analgesics using a step ladder approach from simple drugs

like aspirin to opiates (WHO, 2002; Sloan, 2007). Analgesics are given orally and timed notwaiting for patient to demand it. Nigeria will need to relax some drug regulation laws in orderto increase access to these drugs. Palliative care requires collaboration with counsellors andreligious leaders. It can be provided at hospices or at home so that pressure on healthsystem can be reduced.

5. CONCLUSION

Cancer incidence and mortality are emerging public health problems in developing countrieslike Nigeria. This is due mostly to increasing ageing population, high prevalence of cancersassociated or caused by infections including HIV and entrenchment of the modifiable riskfactors in the populace. In view of the paucity of human and material resources, the Nigeriangovernment will need to urgently work on cancer control policy, strategies and programs

especially for common cancers of breast, cervix, prostate, liver and prostate. Cancerprevention should commence at community level with cost-effective measures directedinitially at two or three of the common preventable cancers chosen for pilot programs.Subsequently as resources improve, this can be scaled up. There should be concerted effortto introduce the HPV vaccine, whilst improving coverage for Hepatitis vaccinations. Also, theactivities of various hospitals, NGOs, government and researchers should be coordinated bya central (national) body. There should be improvement in on-going surveillance for cancersand their risk factors through community surveys and regional cancer registries. Finally,there is need to build capacity of personnel and facilities involved in cancer care, these willcontribute to reducing the burden of cancer in Nigeria.

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Adewole, I.F., Benedet, J.L., Crain, B.T., Follen, M. (2005).Evolving a Strategic Approach toCervical Cancer Control in Africa. Gynecologic Oncology, S209-212.


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Accessed on 10/6/2008.________________________________________________________________________ 2011 Kolawole; This is an Open Access article distributed under the terms of the Creative Commons AttributionLicense (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproductionin any medium, provided the original work is properly cited.

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Cancer Control Strategies in Nigeria