Breast Cancer in the Eastern Mediterranean Region A Burden with Potential Presented by: Mahmoud M. Sarhan, MD, MMM, CPE CEO & Director General Presented at: International Symposium on Breast Cancer in the Developing World: Meeting the Unforeseen Challenge to Women, Health and Equity Boston, MA November 2-5, 2009 1
The Eastern Mediterranean region extends from Morocco to Pakistan and has varied income levels, health indicators and geographies World Bank High (Total Pop 8,219,000) Country Population Expenditure Qatar (in 656 on 862health per U.A.E 4,210 661 Kuwait 2,645 579 Bahrain 708 555 Lebanon 4,370 573 World Bank Income group Country Population (in thousands) Jordan 5,617 177 Palestine 3,827 138 Tunisia 9,911 137 Expenditure on health per capita in US upper Middle (Total Pop 35,472,000) Saudi Arabia 22,608 366 lower middle (Total Pop 231,482,000) Iran 66,775 131 Morocco 30,509 72 Syria 18,200 59 Egypt 69,323 55 Djibouti 817 47 Iraq 26,503 23 Oman 2,651 278 Libya 5,843 171 Yemen 21,003 32 GINI index in many countries varies between 28 and 42 indicating inequality within each country Low (Total Pop 238,627,000) Sudan 34,512 21 Pakistan 151,816 13 Afghanistan 22,998 11 Somalia 8,298 6 2
Breast Cancer is the most common cancer in all Eastern Mediterranean countries Rank of Disease Country 3
BC incidence rate in the region is not higher than the developed world. Age Standardized Breast Cancer Incidence Rate Per 100,000 (2005 in the EMR Crude Breast Cancer Incidence Rate Per 100,000 (2005 in the EMR Country Country New Cases New Cases 4
But it effects women in younger ages than the developed world Median age at diagnosis of female breast cancer cases in some Arab countries 53 49.6 51 47.6 50 45 49 48 46.4 Median Age in Developed Countries 65 years 5
and is detected at very late stages Stages of Breast Cancer in Jordan based on KHCC Experience 2005 Stage 0, 0.50% Stage IV, Stage Stage IV Stage 0 I 12.90% 12.90 0.506.70 Stage III, 56.20% Stage III 56.20 Stage 1 6.70% Stage II, 23.70% Stage II 23.70 State at presentation in breast cancer according to institutional data Country Advanced Stages of Breast Cancer Sudan 78% Saudi Arabia 71% Nile Delta, Egypt 70% Cairo, Egypt, 66% Amman, Jordan 69% Tunis, Tunisia Iraq 47% Lahore, Pakistan 46% Bahrain 49% (40%> 5cm) 33% (70%>2cm) N=550 (~ to 2/3 rd of the cases in Jordan) SOURCE: Towards a strategy for cancer control in the Eastern Mediterranean Region, WHO-EM/NCD/060/E, 2009 6
Cancer will impact the developing / low-middle income countries the most World Cancer Deaths over Time Deaths in Low Income Countries Total Cancer Deaths in Millions 15.00 11.25 7.50 3.75 8.06 5.8 9.28 6.9 +19% 11.94 9.5 +64% Deaths in Low Income Countries (in million) 10.0 7.5 5.0 2.5 5.0 1.8 5.0 2.2 5.3 3.5 0 2.3 2.4 2.4 Year 2008 2015 2030 Low-Middle Income Countries High Income Countries 0 3.2 2.8 1.8 year 2008 2015 2030 AIDS, Tuberculosis, & Malaria Cancer 7
and the largest increase in cancer deaths within the next 15 years is likely to be in the Eastern Mediterranean region Predicted increase in deaths from cancer over the next 15 years (WHO)4 Increase in death from Cancer (%) 200 150 100 50 0 World Established Market economy Former socialist economy Latin America & Caribbean China Sub-saharan Africa Other parts of Asia & Islands India Eastern Mediterranean Region Rawaf, S. et al. BMJ 2006;333:860-861 projection modelling predicts an increase of between 100% and 180% [Rastogi et al. 2004].. 8
Breast cancer is expected to have the largest share since currently it is the #1 cancer in the Eastern Mediterranean region Most Common Cancers Males 1. Lung 2. Bladder 3. Stomach 4. Oral 5. Colon Females 1. Breast 2. Cervix 3. Oral 4. Ovary 5. Colon Mortality/Incidence Ratio = 70% for all cancer 9
The Eastern Mediterranean region shares barriers across the spectrum of breast cancer (and cancer) control Prevention Rehabilitation and Palliative Care Early Detection Treatment Diagnosis Registration and Reporting 10
Barriers to the accessibility of the whole spectrum can be attributed to two types social limitations and service limitations Social Limitations Service Limitations 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 Confid 11
Case in point (1): Service limitations due to lack of human resources 12
Even in Jordan which is considered to have advanced treatment, human resources remain a major challenge Jordan Current Radiation Oncology Capacity U.S. Oncologist Workforce Shortage Category Machines 8 Linear 1 Cobalt Radiation Oncologists Number 9 18* Ratio 1.5/million population 2/ machine Total Annual Visits (in millions) 150,000,000 112,500,000 75,000,000 37,500,000 Demand 48% Increase Supply 0 14% Increase 2005 2010 2015 2020 * 7 consultants out of 18 are 55 yrs old and above * Total number of residents 15 (9 at KHCC and 6 at Al-Bashir) * 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 13
In order to ensure proper health care, major investment in human resources is required Health Care Workers per 1000 population Survival vs. Density of Health Workers Healthcare Workers (Per 1,000 People) High World Americas Europe Western Pacific Southeast Asia Eastern Mediterranean Africa Probability of Survival Maternal Survival Child Survival Infant Survival 0 7.5 22.5 Low Low Density of Health Workers High Remarks WHO cites a severe shortage of healthcare professionals in developing countries Americas: 25 healthcare workers per 1,000 people Asia: 5 or fewer per 1,000 Health Workers Save Lives! 14
Case in point (2): palliative care for many countries is barely existent Intended Regional Aim Regional Goal This is 2004 data published in WHO Cancer Control Strategy 2009. Some dosages have changed ex: Jordan = 2 mg/capita 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 Worldwide average = 5.8 mg/capita 15
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 Sample Impacts Shared Challenges Culture Demographics Inequity in Health Services Females still dependent on family and males More rural than urban societies Level of education not unified Young populations (low life expectancy) Socioeconomic problems preventing symptomatic patients from seeking medical advice 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 Cancer is not a priority in rural areas (vs. water accessibility, infectious diseases etc) Focus on primary health care services Cancer and Cancer Services New disease (??) Cancer is just another disease No specialization Cancer control not appealing to policy makers (complex matter) 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 16
Presentation 091104 But this shared burden has a potential of successful interventions through a unified approach to many of the barriers Building on the Jordan Experience Protocols & Guidelines Cancer Treatment and Palliation as a referral, training and consultation site Jordan University Hospital King Abdullah Hospital Jordan Palliative care system Human Resource Development Public Awareness Exchange of expertise Unified message = decrease in cost of production and regional outreach Training centers Cost sharing for bringing in international trainers Combined curriculum development Unified certification/accreditation system ( replicate Jordan HCAC) 17
THANK YOU 18