Presentation 091104

King Hussein Cancer Center1

Presented by:Mahmoud M. Sarhan, MD, MMM, CPECEO & Director GeneralKing Hussein Cancer Center

Presented at:International Symposium on Breast Cancer in the Developing World: Meeting the Unforeseen Challenge to Women, Health and Equity

Breast Cancer in the Eastern Mediterranean RegionA Burden with Potential

Boston, MANovember 2-5, 2009

Presentation 091104

King Hussein Cancer Center2

The Eastern Mediterranean region extends from Morocco to Pakistan and has varied income levels, health indicators and geographiesWorld Bank Income group

Country Population (in thousands)

Expenditure on health per capita in US $

High(Total Pop 8,219,000)

Qatar 656 862U.A.E 4,210 661Kuwait 2,645 579Bahrain 708 555

upper Middle(Total Pop 35,472,000)

Lebanon 4,370 573

Saudi Arabia 22,608 366

Oman 2,651 278Libya 5,843 171

World Bank Income group

Country Population (in thousands)

Expenditure on health per capita in US $

lower middle(Total Pop 231,482,000)

Jordan 5,617 177

Palestine 3,827 138Tunisia 9,911 137Iran 66,775 131

Morocco 30,509 72Syria 18,200 59

Egypt 69,323 55

Djibouti 817 47Iraq 26,503 23

Low(Total Pop 238,627,000)

Yemen 21,003 32

Sudan 34,512 21Pakistan 151,816 13

Afghanistan 22,998 11

Somalia 8,298 6

GINI index in many countries varies between 28 and 42

indicating inequality within each country

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King Hussein Cancer Center3

Breast Cancer is the most common cancer in all Eastern Mediterranean countries

Cou

ntry

Rank of Disease

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King Hussein Cancer Center4

BC incidence rate in the region is not higher than the developed world….

Age Standardized Breast CancerIncidence Rate Per 100,000 (2005 in the EMR

New Cases

Cou

ntry

New Cases

Cou

ntry

Crude Breast CancerIncidence Rate Per 100,000 (2005 in the EMR

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King Hussein Cancer Center5

…But it effects women in younger ages than the developed world…

49

53

50

48

47.649.6

46.445

51

Median Age in Developed Countries 65 years

Median age at diagnosis of female breast cancer cases in some Arab countries

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King Hussein Cancer Center6

…and is detected at very late stages…

Country Advanced Stages of Breast Cancer

Sudan 78%

Saudi Arabia 71%

Nile Delta, Egypt 70%

Cairo, Egypt, 66%

Amman, Jordan 69%

Tunis, Tunisia 49% (40%> 5cm)

Iraq 47%

Lahore, Pakistan 46%

Bahrain 33% (70%>2cm)

Stages of Breast Cancer in Jordanbased on KHCC Experience 2005

Stage IV 12.90

Stage III 56.20

Stage II 23.70

Stage I 6.70

Stage 0 0.50

Stage II, 23.70%

Stage 0, 0.50%

Stage III, 56.20%

Stage 1 6.70%

Stage IV, 12.90%

N=550 (~ to 2/3rd of the cases in Jordan)

SOURCE: Towards a strategy for cancer control in the Eastern Mediterranean Region, WHO-EM/NCD/060/E, 2009

State at presentation in breast cancer according to institutional data

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King Hussein Cancer Center7

Cancer will impact the developing / low-middle income countries the most…

0

3.75

7.50

11.25

15.00

2008 2015 2030

9.5

6.9 5.8

2.4 2.4 2.3

High Income Countries Low-Middle Income Countries

+64%

+19%

11.94

9.28

8.06

World Cancer Deaths over Time

Year

Tota

l Can

cer D

eath

s in

Mill

ions

0

2.5

5.0

7.5

10.0

2008 2015 2030

3.5 2.2 1.8

1.8 2.8 3.2

AIDS, Tuberculosis, & Malaria Cancer

5.35.05.0

Deaths in Low Income Countries

yearD

eath

s in

Low

Inco

me

Cou

ntrie

s (in

mill

ion)

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King Hussein Cancer Center8

… and the largest increase in cancer deaths within the next 15 years is likely to be in the Eastern Mediterranean region

Rawaf, S. et al. BMJ 2006;333:860-861

Predicted increase in deaths from cancer over the next 15 years (WHO)4

Wor

ld

Esta

blis

hed

Mar

ket e

cono

my

Form

er s

ocia

list

econ

omy

Latin

Am

eric

a &

C

arib

bean

Chi

na

Sub-

saha

ran

Afr

ica

Oth

er p

arts

of

Asi

a &

Isla

nds

Indi

a

East

ern

Med

iterr

anea

n R

egio

n

Incr

ease

in d

eath

from

Can

cer (

%)

0

50

100

150

200

projection modelling predicts an increase of between 100% and 180%

[Rastogi et al. 2004]..

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King Hussein Cancer Center9

Breast cancer is expected to have the largest share since currently it is the #1 cancer in the Eastern Mediterranean region

1. Breast2. Cervix3. Oral4. Ovary5. Colon

1. Lung2. Bladder3. Stomach4. Oral5. Colon

Males Females

Most Common Cancers

Mortality/Incidence Ratio = 70% for all cancer

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King Hussein Cancer Center10

The Eastern Mediterranean region shares barriers across the spectrum of breast cancer (and cancer) control

Early Detection

Prevention

Diagnosis

Registration and Reporting

Treatment

Rehabilitation and Palliative

Care

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King Hussein Cancer Center11

Barriers to the accessibility of the whole spectrum can be attributed to two types – social limitations and service limitations

Confidential

Cultural Barriers

Stigma & myths pertaining to cancer including religious misunderstandings

Social taboos that extend beyond the female herself leading to fears of being ostracized by husband, family, or society

Socioeconomic barriers

Low level of education (ignorance)

Preference to invest in family/children needs rather than self health

Awareness barriers

Cancer as a taboo subject

No health promotion to break myths of hereditary and contagious disease

Do not seek information and action to understand ailment or prevention

Infrastructure (Physical & Human Resources)

Services across the spectrum are not available, not accessible, and if not, then not useable (screening, referral, diagnosis…etc)

Human resources are scarce and not trained (lack of female technicians, no oncologists …)

Government priorities

Other primary care issues take priority over cancer care

Funding limitations to prevention, screening and purchase of quality care (including costly drugs)

Quality Systems

Absence of proper local academic background and training and training facilities

Incomprehensive academic curricula and lack of Training manuals

No accreditation certification systems or guidelines and protocols

Social Limitations Service Limitations

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King Hussein Cancer Center12

Case in point (1): Service limitations due to lack of human resources

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King Hussein Cancer Center13

Even in Jordan which is considered to have advanced treatment, human resources remain a major challenge

RatioNumber Category

1.5/million population9

Machines

8 Linear 1 Cobalt

2/ machine 18*Radiation Oncologists

* 7 consultants out of 18 are 55 yrs old and above * Total number of residents 15 (9 at KHCC and 6 at

Al-Bashir)

0

37,500,000

75,000,000

112,500,000

150,000,000

2005 2010 2015 2020

To

tal A

nnua

l Vis

its

(in

mill

ions

)

Demand48% Increase

Supply14% Increase

U.S. Oncologist Workforce Shortage

* Demand Factors – Increase in survivorship and aging of U.S. population

* Supply Factors – Limited plans to increase fellowship slots and 50% of U.S. oncologists over age 50

Jordan Current Radiation Oncology Capacity

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King Hussein Cancer Center14

In order to ensure proper health care, major investment in human resources is required

World

Americas

Europe

Western Pacific

Southeast Asia

Eastern Mediterranean

Africa

0 7.5 22.5

Healthcare Workers (Per 1,000 People)

Survival vs. Density of Health Workers

WHO cites a severe shortage of healthcare professionals in developing countries

– Americas: 25 healthcare workers per 1,000 people – Asia: 5 or fewer per 1,000R

emar

ks

Maternal Survival

Child Survival

Infant Survival

Health Care Workers per 1000 population

Prob

abili

ty o

f Sur

viva

l

Density of Health WorkersLow

Low

High

High

Health Workers Save Lives !

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King Hussein Cancer Center15

Intended Regional Aim

Case in point (2): palliative care for many countries is barely existent

Regional Goal

To help alleviate the physical and psychosocial suffering associated with

progressive, incurable illnesses To increase the availability and access

to high-quality hospice and palliative care for patients and families

Regional Objectives

Integrate palliative care and hospice principles into the National Health Strategy by shaping governmental

policies Assure availability and easy access to

opioid analgesics and adjuvant medications

Establish integrated continuums of palliative care, reaching patients in

hospital and community settings

This is 2004 data published in WHO Cancer Control

Strategy 2009. Some dosages have changed ex: Jordan =

2 mg/capita

Worldwide average = 5.8 mg/capita

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King Hussein Cancer Center16

In summary, the Eastern Mediterranean region has a shared breast cancer burden within similar cultural barriers and service and awareness deprivations despite some exceptional cases

Culture Females still dependent on family and males

Shar

ed C

halle

nges

Demo-graphics

More rural than urban societies Level of education not unified Young populations (low life expectancy) Socioeconomic problems preventing

symptomatic patients from seeking medical advice

Cancer and

Cancer Services

New disease (??) Cancer is just another disease No specialization Cancer control not appealing to policy

makers (complex matter)

Inequity in Health Services

Urban societies are more privileged in service

Lack of sufficient Healthcare providers

Female diseases impact women in terms of their ability to wed

Females can not seek health service without male approval/assistance

Lower accessibility to information /awareness Remote unreachable areas Closed communities (tribal) which impacts ability

to report and detect cancer deaths Cancer seen in younger people

Too complex for policy makers to address Non-comprehensive approach Part of overall role of tertiary care centers Funding sidelined for political and military issues

Cancer is not a priority in rural areas (vs. water accessibility, infectious diseases…etc)

Focus on primary health care services

Sample Impacts

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King Hussein Cancer Center17

But this shared burden has a potential of successful interventions through a unified approach to many of the barriers

Cancer Treatment and Palliation King Hussein Cancer Center as a referral, training

and consultation site Jordan University Hospital King Abdullah Hospital Jordan Palliative care system

Human Resource Development Exchange of expertise Training centers Cost sharing for bringing in international trainers Combined curriculum development Unified certification/accreditation system (

replicate Jordan HCAC)

Public Awareness Unified message = decrease in cost of production

and regional outreach

Protocols & GuidelinesBuilding on the Jordan Experience

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King Hussein Cancer Center18

THANKYOU