Oral Cancer: Rationale for inclusion in SEA Regional NCD Strategy Expert Consultation 11.-13.6.2013 Bangkok Dr Habib Benzian Founder The Health Bureau Ltd UK Director Fit for School International UK Senior Advisor Fit for School Inc. Philippines Regional Office for South-East Asia
This presentation 1. Oral Cancer in SEAR 2. Coherence with major strategies 3. Available Public Health Strategies 4. Achievability 5. Data availability & baselines 6. Possible target and indicators Key references listed in supporting background document
Oral Cancer - ICD10 Definitions ICD10 Code Cancer localisation C00 Lip C01-02 Tongue C03-06 Mouth C07-08 Salivary glands Oral Cancer GLOBOCAN C09-14 Pharynx
Oral Cancer
Estimated cumulative mortality (percent) Cancer of lip/oral cacity, both sexes (0-74) Schools are key determinants of health
Estimated age-standardised incidence for lip/oral cavity cancer, males
WHO Region AFRO AMRO/PAHO SEARO EMRO WPRO EURO Most common cancer Male Female 1. Kaposi 2. Liver 1. Cervix 2. Breast 3. Prostate 4. Esoph. 3. Liver 4. Kaposi 1. Prostate 2. Lung 1. Breast 2. Lung 3. Colon 4. Stomach 3. Stomach 4. Cervix 1. Lung 2. Oral 1. Cervix 2. Breast 3. Pharynx 4. Esoph. 3. Oral 4. Ovary 1. Lung 2. Bladder 1. Breast 2. Cervix 3. Stomach 4. Oral 3. Oral 4. Ovary 1. Stomach 2. Lung 1. Breast 2. Stomach 3. Colon 4. Bladder 3. Lung 4. Colon 1. Kaposi 2. Prostate 1. Breast 2. Colon 3. Colon 4. Bladder 3. Lung 4. Uterus Adapted from : Are C, Rajaram S, Are M, Raj H, Anderson BO, Chaluvarya Swamy R, Vijayakumar M, Song T, Pandey M, Edney JA, Cazap EL. A review of global cancer burden: trends, challenges, strategies, and a role for surgeons. J Surg Oncol. 2013;107(2):221-226.
Highest incidence: Maldives (male), Bangladesh (female), High incidence: Male - Maldives, Bangladesh, India, Nepal Female - Bangladesh, India, Maldives Moderate incidence: Male - Bhutan, Thailand Female - Sri Lanka, Thailand Low incidence: Male - Korea, Indonesia, Timor, Myanmar Female - Korea, Indonesia, Bhutan, Myanmar, Timor
Ranking of SEAR countries (overall incidence ASR) 1. Maldives (16.5) 2. Sri Lanka (10.3) 3. Bangladesh (9.7) 4. India (7.5) 5. Nepal (6.7) 6. Thailand (5.9) 7. Bhutan (5.7) 8. Myanmar (4.5) 9. Timor Leste (2.6) 10. Indonesia (2.4) 11. DP Korea (0.9) (GLOBOCAN 2008)
Estimated DALY for lip/oral cavity cancer
Coherence with major strategies Global NCD Action Plan 2013 2 Political Declaration on NCDs 2011 WHO Oral Health Action Plan 2007 WHA Resolution on Cancer Prevention and Control 2005 All policies mention oral cancer explicitly or implicitly, often in the context of screening for prevention (similar to cervical cancer)
Available Public Health Strategies 3 1. Primary Prevention Reducing exposure to risk factors 2. Secondary Prevention Screening for malignant and premalignant lesions 3. Tertiary Prevention Clinical care and rehabilitation
Primary prevention of oral cancer Key risk factors: Tobacco, alcohol, HPV infection, consumption of carcinogens (areca nut, betel, etc), nutritional deficiencies, oral/dental neglect, other factors Common risk factor concept Shared broader determinants Similar socio-economic gradients and inequalities
Highly endemic risk factors in SEAR
Secondary prevention of oral cancer Visual screening Simple visual examination, no adjunctive tests, minimal training required, quick & simple Can be performed by non-dental professionals Good evidence for screening of high-risk populations Clear referral process and subsequent treatment must be ensured - otherwise screening is not appropriate Importance of self-examination and awareness
Tertiary prevention of oral cancer Surgery, radiotherapy, chemotherapy Usually complex interventions, survival rate depends on tumor stage and facility/surgeon competence Persistently low survival rates and highest impacts on quality of life High costs of care, lack of trained surgeons and specialised facilities make it difficult for low- and middle-income countries to offer appropriate services
"Treatment will never represent the route to reduced incidence." Gupta B, Ariyawardana A, Johnson NW. Oral cancer in India continues in epidemic proportions: evidence base and policy initiatives. International Dental Journal 2013;63(1):12-25.
Achievabilitiy at country level Primary prevention 4 Good evidence for risk factor reduction Secondary prevention Examples of successful screening programmes in a number of SEA countries Tertiary prevention/care Weak, patchy, complex & expensive
Reduction of common risk factors and visual screening of populations at risk should be the public health priorities to address oral cancer
Data availability & baselines Functioning cancer registration is vital 5 (no difference to other cancers) Oral cancer must be integrated in such systems, if possible with staging info Capacity in the region varies from good to non-existent Minimum baselines available from GLOBOCAN 2008 or better based on newer national data
Conclusion: Oral Cancer... 1. Is a significant public health problem 2. Is in line with major strategies 3. Public health strategies are available 4. They are potentially achievable 5. Data & baselines are available
Decisions required: 1. Include oral cancer as a voluntary indicator? 2. If yes - upgrade to target(s)? Which targets? 3. If no - how to address and recognise the issue otherwise?
Additional voluntary target 6 25% reduction of premature mortality from oral cancer (lip/oral cavity) by 2025 In line with wording and approach of the Global NCD Action Plan - value to be discussed Positive: Reflects risk reduction and health system performance (tracer), contributes to overall reduction of cancer/ncd mortality, relevant for male and female Negative: Rather ambitious
Options for indicators related to oral cancer* Option 1 35% relative reduction of age-standardised overall oral cancer incidence Option 2 At least 50% of individuals at risk for oral cancer screened once in 2 years Option 3 50% of health care providers competent for visual screening and rapid referral Option 4 30% increase of early detection of oral cancer * Indicator options adapted from WHO/FDI/IADR Global Goals for Oral Health by 2020
Dr Margaret Chan Director General of the WHO "Oral diseases are a neglected area of international health. We have the tools and best practices to address them but we need to ensure that they are applied and implemented." January 2007 Resolution WHA60/R17
Thank you