Dr Catherine Le Galès-Camus Assistant Director General Noncommunicable Diseases and Mental Health The World Health Organization Speech to the 1 st International Cancer Control Congress Vancouver, Canada Sunday, 23 October, 2005, 18:35-18:55 The Challenge Ahead: Cancer Control in an integrated chronic disease response Good evening, ladies and gentlemen, and thank you to our co-hosts, the Canadian Strategy for Cancer Control and the Public Health Agency of Canada, and for the invitation to speak here this evening amid this beautiful setting of Vancouver. I appreciate the opportunity to address this group on such an important subject. The World Health Organization shares your concern about the growing epidemic of cancer, and the challenges this presents to health systems around the world. We are addressing cancer as a top priority at WHO - the World Health Assembly and the Director General have taken major steps in advancing this issue this year. The WHO Cancer Control Strategy is the central pillar in our response, and will be strengthened by integration with our other approaches and strategies for addressing chronic diseases. But we cannot achieve the goal of controlling cancer alone: it will take dedicated collaboration and resolve from us all here, and beyond, if we are to be successful. As you well know, cancer is the number 2 cause of death worldwide, and according to WHO's latest estimate, over 7 million people will die of cancer this year comprising 13% of all deaths. Without action, cancer-related deaths are projected to increase by almost a fifth over the next 10 years, killing over 9 million people in 2015.
2 This is clearly a global epidemic. Over 70% of cancer deaths are now occurring in low and middle income countries, and it is the poor in these countries who are hardest hit. The economic costs are tremendous and rising. There is not a single country, not a community, and hardly a family, that has not been touched by cancer. These projections are staggering, but even more so when one considers the individual, human impact of these numbers. This is the face of just one of millions affected by cancer. Mariam John is only 13 years old, currently battling for her life against Ewing s sarcoma. Mariam lives in Tanzania, which is a least-developed country with average health expenditures of less than $20 per person per year. The day Mariam was photographed she couldn't have her radiotherapy treatment owing to a power failure at the cancer institute. Miriam's story is one of many compiled for the newly released WHO global report, Preventing chronic diseases: a vital investment, which was produced with the generous support of the Public Health Agency of Canada, for which we thank them. Despite her terrible ordeal and deep fatigue, Mariam remembers how to smile. It is in acknowledgement of Mariam, and the millions like her, that WHO adopted a new resolution on cancer prevention and control at the 58 th World Health Assembly in May of this year. WHO's approach to prevention and control of cancer: Cancer Advisory Group to the Director General: Direction, guidance, expertise Cancer Technical Group: Advice on development and dissemination of the WHO Guide Cancer Control: Knowledge into Action WHO Guide for effective Programmes: Development of practical modular guide to cancer control In order to implement the resolution and develop the WHO Cancer Control Strategy, the Director General of WHO has convened a high-level experts panel. They will give guidance and direction both to the Strategy, and to a new WHO
3 Cancer Control Guide which is in development right now. The Strategy and the Guide are being supported as well by the Technical Advisory Group which will meet this week following the Congress, and which, again, is supported by the Public Health Agency of Canada. The Cancer Control Strategy aims to support Member States to stem rising trends of levels of cancer risk, incidence and mortality. It is intended to improve the quality of life through development of comprehensive and integrated cancer control programmes. The key elements are standard to cancer control: Conducting surveillance of cancer and its risk factors Reducing exposure to cancer risk factors Improving early detection of cancer Improving diagnosis and treatment services for cancer patients Improving the provision of palliative care. For many countries, such as here in Canada and elsewhere, these are elements fundamental to their cancer control efforts, but they are uneven or non-existent in too many parts of the world. We face enormous challenges in ensuring this approach to cancer control is a global movement. The resources and capacity of much of the world to respond and act are just not adequate to the rising incidence and known risk factors. Sridhar Reddy of India didn't get the necessary cancer prevention information or support throughout his life, for example. Sridhar chewed tobacco since he was a teenager and drank alcohol every day for more than 20 years. Sridhar had a first malignant tumor removed from his right cheek last year, at the age of 51, and a second one from his throat earlier this year. At the time he was photographed for the WHO global report, cancer had spread to Sridhar's lungs and liver. Despite the best efforts of renowned oncologists, Sridhar died shortly after he was photographed here, at the age of 52. Without immediate action, lung cancer deaths are expected to rise by almost 40% in India over the next 10 years.
4 We know that primary prevention of cancer is especially important because more than a third of cancer can be prevented by reducing risk factors related to poor diet, lack of physical activity and use of tobacco products. Framework Framework Convention Convention on on Tobacco Tobacco Control Control Global Strategy on Diet, Physical Activity and Health To address these risks and preventive measures, the WHO Cancer Control Strategy will integrate population-based approaches for chronic disease prevention such as the WHO Framework Convention on Tobacco Control, which now has 89 countries as parties to the first-ever global health treaty. The latest party to the treaty is China, which takes number of people globally covered by the Treaty now up to over 4 billion, more than half the world's population. As well there is the Global Strategy on Diet, Physical Activity and Health, which is aimed at addressing issues related to consumption of fats, salts, and the marketing of food to children, in addition to increasing fruit and vegetable consumption, and promoting physical activity. Regulation of environmental and occupational carcinogens are another area of concern. WHO is also working to address the biological causes of cancer through immunization strategies for Hepatitis B virus for example, and we are also now examining the wide public health implications of the harmful use of alcohol. Prevention is the first important step, but for many people with cancer getting a diagnosis, treatment and care are monumental struggles. For too many it requires knowledge, resources and availability that are sorely lacking, nonexistent, over-burdened or out of reach.
5 Maria Saloniki, also from Tanzania, waited three long years to receive an accurate diagnosis. She can hardly remember how many times she went to the local traditional healer, how many doctors in clinics and dispensaries she consulted, how many words she used to describe her pain. Finally, a biopsy revealed breast cancer but unfortunately, by then her cancer was Stage IV, too late for curative treatment. Had the health care system been better equipped to deal with Maria's symptoms and provide diagnosis, treatment and care in a timely manner, Maria's story might have had a very different outcome. In Pakistan, Zahida Bibi s situation is similar to Maria s: she went for several years without receiving a proper diagnosis. Zahida had consulted a doctor once, but was told that everything was normal. After that, Zahida ignored her symptoms for eight long years before seeking medical care again. Both were exposed to risk factors, both had similar challenges getting preventive information and support, early risk assessment and screening, and access to appropriate diagnosis and treatment. Ultimately, however, they received different diagnoses. Doctors finally established the nature of Zahida's problem: diabetes. But too late to save her from losing her foot to the disease. Given the common risk factors, it could have been cancer. Or cardiovascular disease. Although afflicted with different chronic diseases, all the people you have met this evening have suffered the consequences of poorly-functioning health systems
6 and inadequate primary care unable to help them prevent their disease, unable to assess their risks and screen for their disease, and unable to treat the disease at an early stage. This scenario is repeated equally for people at risk for, or suffering from, cardiovascular disease and other chronic diseases. Cancer control will only work when these problems are addressed. In low and middle income countries, and for the impoverished in all countries, chronic diseases present mainly at the primary health care level. In most cases, they also need to be managed in the long-term in these settings. Yet, most primary health care, whether in high, middle or low income settings, is oriented towards acute problems. Too few health care workers are equipped with the knowledge and resources to help prevent, screen or make the correct diagnosis and referral, whether it be cancer, diabetes or CVD. Even less are they equipped for long-term management and care. The solution is to move towards an integrated chronic disease response. This is WHO's recommended approach: it is how we ourselves are now organizing our work, and is crucial to the success of the Cancer Control Strategy. The new report, Preventing Chronic Disease: a vital investment, lays out a unifying framework which is key to effective prevention and control of all chronic diseases, including cancer. The Unifying Framework Integrated prevention and control strategies for all chronic diseases are most effective Comprehensive public health action for entire populations and for individuals A stepwise approach to address the most feasible activities first Intersectoral action is necessary Relevant milestones established Preventing Chronic Disease: a vital investment: http://www.who.int/chp/chronic_disease_report/en/index.html The Framework is based on 5 principles: First, that integrated prevention and control strategies for all chronic diseases are most effective Secondly, comprehensive public health action is needed for both entire populations and for individuals Third, in recognition that many countries won't have the resources to do everything at once, a stepwise approach will address the most feasible activities first Next, that because many of the determinants of chronic disease lie outside the health sector, that intersectoral action is necessary,
7 Finally, that relevant milestones should be should be established at each step. I encourage you to read the chronic disease report for the most up-to-date global survey of chronic diseases, including cancer, as well as many practical solutions, best practices and a more detailed expose of the unified framework. Integrated Chronic Disease Response Population-based prevention Strengthened primary health care Integration with specialist care The integrated chronic disease response is, in essence, a support system to disease-specific strategies such as Cancer Control, focusing on three key elements: Implementing population-based prevention, strengthening primary health care to address chronic diseases, and integrating with specialist treatment and care. In order for this approach to work however, it is crucial that primary health care be strengthened. This is especially important in order to support patients with comorbidities, who might be seeing several specialists for distinct medical problems. While clinical treatment is - and will always be - dependent upon the unique features of a specific disease, the general components of good health care for chronic diseases have common features which make them effective across all chronic health problems. These components include: a well defined care plan, patient self-management, scheduled follow-up appointments, monitoring of outcome and adherence, and step-by-step treatment protocols. When viewed this way, seemingly disparate conditions such as heart disease, diabetes and cancer seem far more alike than different. PRIMARY HEALTH CARE SPECIALIST CARE Preventive education and support Risk Assessment Early detection Referral Diagnosis Follow-up care Back referrals Treatment plan Palliative care
8 There can be no doubt as to the crucial value in this scenario of specific cancer expertise, knowledge, treatment and approaches to reducing and treating cancer. Certainly speciality care is - and will always remain - an essential element of the response to cancer and other chronic diseases. This integrated framework is designed to support and enhance, rather than replace or degrade. There must be appropriate referral and back-referral mechanisms in place to ensure seamless care across settings and time. In addition to direct care provision, specialists also have an essential function to play in developing diagnosis and treatment protocols, educating primary health care workers on proper diagnosis and referral, and providing consultations to primary health care workers on difficult cases. The goal of the integrated approach should be improved health, less waste and inefficiency and a less frustrating experience for both professionals and patients alike. Ultimately, it is the patients such as those we have met this evening for whom all these approaches, frameworks and strategies are intended. The Cancer Control Strategy and the integrated chronic disease framework are intended to work hand-in-hand towards that goal. What would a well-functioning health system, that emphasizes integration, prevention, and strengthened primary health care, and preserves speciality care, have meant for people like Sridhar, Maria and Zahida? Sridhar might have had his cancer prevented and might never have needed costly treatment, which has now left his wife not only a grieving widow, but also deeply in debt. Maria s breast cancer might have been caught in time to be successfully treated. Zahida would have been accurately diagnosed the first time she sought medical help. She might not have lost her foot to diabetes complications.
9 And Mariam. Mariam might not have to endure the unending pain, the suffering of day-long journeys by bus from her home to the cancer hospital, the power failures that routinely disrupt her treatment. Perhaps most importantly, with a well-functioning health system, one that emphasized integration, prevention, and strengthened primary health care, sideby-side with high-quality speciality care, Mariam might have a realistic chance to fulfil her dream: to grow up and become a health minister. In Mariam s words: a health minister can help others and wants everyone to be healthy," she says. "I have good grades, I know I can make it." For those here who come from countries with well-developed and established cancer control strategies, I ask you to consider how you can contribute to making it a truly global movement: how to help others develop their approaches, strengthen their healthcare systems and build capacity for addressing the needs of the millions of people who are, or may soon, suffer from the global epidemic of cancer. Because it is clear: the challenge is great, but the need is greater for collaborative effort to raise the profile of cancer on the global and national agendas, to raise the funds necessary to support the effort, and ultimately to implement the necessary changes. WHO has made Cancer Control a top priority, and is eager to work with you to achieve it. Finally, I urge you to keep the images and stories of Sridhar, Maria and Zahida, and this haunting face of young Mariam, in your mind's eye this week as you work towards consensus and vision on Cancer Control, and towards endorsing the concept of an integrated chronic disease approach. I thank you all for listening, I thank the Public Health Agency of Canada and the Canadian Cancer Control Strategy for the kind invitation and this opportunity to speak here today, and I count on your support for global efforts to come. -30-