cancer in south asia

CANCER CANCER UNDEFEATEDUNDEFEATEDN Engl J Med1997;336:1569-74N Engl J Med1997;336:1569-74

In 1986, we concluded that “some 35 years of intense effort focused largely on improving treatment must be judged a qualified failure.” Now, with 12 more years of data and experience, we see little reason to change that conclusion,..

JOHN C. BAILAR III M.D., PH.D., HEATHER L. G ORNIK M.H.S.

True or FalseTrue or FalseCancer is a major killer Cancer is a major killer disease of “developing disease of “developing countries”?countries”?

Cancer is a “life style” Cancer is a “life style” disease? disease?

New Cancer Cases (Incidence) and Deaths (Mortality) in 2002.

Parkin DM et al: CA Cancer J Clin 2005;55:74–108

Thousands

Parkin DM et al: CA Cancer J Clin 2005;55:74–108

New Cancer Cases (Incidence) and Deaths (Mortality) in 2002.

Thousands

All Cause Mortality

Cancer related mortality 7.6 million

Developing countries

Developed countries

70%

Worldwide Mortality 2005Worldwide Mortality 2005

WHO Cancer Fact sheet number 297

Fight Against CancerFight Against CancerDid you know?Did you know?

–Average years of life lostAverage years of life lostCardiac causesCardiac causes 11 years11 yearsCancerCancer 15 years15 years

IARC Globocan 2002, Figures based on 1998-2002 prevalence

Burden of Cancer

Magnitude of the Problem

New cases in 2020

Future looks GRIM

Number of Cancer CasesNumber of Cancer Cases

CountryCountry MaleMale FemaleFemale TotalTotal <14 yrs<14 yrsIndiaIndia 386,854386,854 426,741426,741 813,595813,595 33%33%PakistanPakistan 61,62461,624 75,09575,095 136,719136,719 42%42%BangladeshBangladesh 39,98439,984 44,09044,090 84,07484,074 35%35%Sri LankaSri Lanka 8,3658,365 9,7779,777 1814218142 26%26%

Nandakumar A et al: UICC Strategies for Cancer Control in South Asia-2006, pp17

ATLAS INDIA 2006

New Cancer Cases in KashmirNew Cancer Cases in Kashmir Population of KashmirPopulation of Kashmir 10 million10 million Cancer incidenceCancer incidence 111/100,000111/100,000

– Urban estimatesUrban estimates Expected new casesExpected new cases 11000/yr11000/yr New cases per dayNew cases per day App 40App 40 However incidence could be much However incidence could be much

higherhigher Expected in 2020Expected in 2020 22000/yr22000/yr

(80/day)(80/day)

0.38

0.82

0.46

0.94

0.6

1.2

00.20.40.60.8

11.21.41.61.8

2005 2010 2020

Cancer in South AsiaCancer in South Asia

Millions

Mortality

UICC 2006

Cancer Related MortalityCancer Related Mortality Higher than Higher than AIDSAIDS, , TBTB, , Malaria Malaria put put

togethertogether Second to cardiovascular diseasesSecond to cardiovascular diseases Years of life lost more than CV Years of life lost more than CV

diseasesdiseases Increasing Increasing definitelydefinitely

Survival related to LiteracySurvival related to LiteracyMumbai-IndiaMumbai-India

Yole BB et al: Asia Pacific J Ca Prev 2004; 5:308

Literacy in South AsiaLiteracy in South Asia

CountryCountry LiteracyLiteracyMaleMale FemaleFemale

BangladeshBangladesh 53.953.9 31.831.8IndiaIndia 68.068.0 44.044.0NepalNepal 65.165.1 42.542.5PakistanPakistan 54.854.8 32.032.0Sri LankaSri Lanka 94.894.8 90.090.0

Socioeconomic Status and Breast Socioeconomic Status and Breast Cancer Outcome in PakistanCancer Outcome in Pakistan

Socioeconomic Socioeconomic StatusStatus

Stage at Stage at DiagnosisDiagnosis

Treatment OutcomeTreatment Outcome

EarlyEarly LateLate AdequateAdequate 10 yr Surv10 yr SurvLowLow 50%50% 50%50% 44%44% 22%22%HighHigh 75%75% 25%25% 89%89% 73%73%

Aziz Z. Stigma of Breast Cancer in Developing Countries Costs Lives: ESMO Newsletter. January –March, 2003

CountryCountry < 1$/day< 1$/day < 2$/day< 2$/dayIndiaIndia 44.2%44.2% 86.2%86.2%BangladeshBangladesh 29.1%29.1% 77.*%77.*%PakistanPakistan 31.0%31.0% 84.7%84.7%

South Asia IncomeSouth Asia Income

Kurkure AP et al: UICC Strategies for South Asia 2006: 26

Poverty

Lack of Education

•Lack of compliance•Prevention•Early detection•Treatment•Follow up

•Late diagnosis

Breast Cancer Size vs SurvivalBreast Cancer Size vs Survival

0102030405060708090

<2 2 to 5 >5

Cancer Related PainCancer Related Pain

At diagnosis 25%

Advanced disease 75%

During therapy 30%

Goudas LC et al: Cancer Invest 2005;23:519

Morphine requirement - IndiaMorphine requirement - India

Total produced Total produced 142.32 kg/yr142.32 kg/yr ONLY 0.4% of the required amount ONLY 0.4% of the required amount

PRODUCEDPRODUCED

Rajagopal MR et al: J Pain Control 2007;33:615

Palliative Care Problems-Palliative Care Problems-Medical PersonnelMedical Personnel

Lack of awareness Lack of awareness prevents deliveryprevents delivery

Dissemination Dissemination of information of information

OpiophobiaOpiophobia EducationEducationImitation of Imitation of western models of western models of carecare

Develop local Develop local strategies strategies

Seamark D et al: J R Soc Med 2000; 93:292

Palliative Care Problems-PublicPalliative Care Problems-Public

Lack of Lack of awareness awareness creates delays creates delays in seeking in seeking palliative carepalliative care

Public Public educationeducation


Palliative Care Problems-Palliative Care Problems-Social/SystemSocial/System

Silence about cancer Silence about cancer diagnosisdiagnosis

Discuss cancer diagnosis Discuss cancer diagnosis openlyopenly

PovertyPoverty Consider financial Consider financial condition of the patient condition of the patient while prescribingwhile prescribing

Coexistence of multiple Coexistence of multiple systems of medicinesystems of medicine

Work together as Work together as partners not rivals§partners not rivals§

Transport problemsTransport problems Support private sector to Support private sector to create rural centers create rural centers Involve relativesInvolve relatives

Non availability of Non availability of opioidsopioids

Public pressurePublic pressure


is still a cigarette, and still as dangerous!

3 times CO and 5 times Tar compared to a cigarette

a cigarette by any other name …

Betel leaves

Betel nut

Lime

Nicotine Delivery Device

Addicting Nicotine4000 Chemicals60 Carcinogens

Perfect Killing Machine

Hecht SS: Nat Rev Cancer 2003;3:733

Tobacco related cancer (South Asia)Males 50%Females 20% (UICC Data)

Trends in prevalence of smoking at ages 35 59 in men and women in the United Kingdom, 1950 98.

Trends in mortality from lung cancer in men and women in the United Kingdom

BMJ 2000;321;323-329

Trends in prevalence of smoking at ages >60 in men and women in the United Kingdom, 1950 98.

Trends in mortality from lung cancer in men and women in the United Kingdom,

BMJ 2000;321;323-329

Effect of Screening mammography and adjuvant therapy on breast cancer mortality

Berry DA et al: N Engl J Med 2005;353:1784-92.

Data based on multiple models

Age adjusted breast cancer mortality rates: 2003 vs 198924% lessSmith RA. NEJM 2007; 356:1362

Persistent Non-Hodgkin’s Lymphoma

Juweid ME and Cheson BD. N Engl J Med 2006;354:496-507

Early Detection of Persistent Hodgkin’s Disease


Early Detection of Recurrent Cervical Carcinoma


Lymph nodes of Pts from Dutch Trial ASCO Presentation

Cell surface

HER2 protein (HER2 receptor)

Other EGFR/HER family receptor

Cell nucleus

Activated HER2-HER2 dimers

Growth signal

Cell nucleus

Tumor cell growth

Herceptin monoclonal antibody

Krause DS et al: N Engl J Med 2005; 353:172

Tyrosine kinase as a targetTyrosine kinase as a target

Kinase domain


Tyrosine kinase as a targetTyrosine kinase as a target

Binds CD20, which is present on normal and Binds CD20, which is present on normal and malignant pre-B and mature B cells; malignant pre-B and mature B cells; >90% of B-cell NHL express CD20 >90% of B-cell NHL express CD20 May induce antibody-dependent cell-mediated May induce antibody-dependent cell-mediated cytotoxicity (ADCC) and complement-dependent cytotoxicity (ADCC) and complement-dependent cytotoxicity, based on in vitro data cytotoxicity, based on in vitro data Also triggers apoptosis (programmed cell death) Also triggers apoptosis (programmed cell death) in vitro in vitro No apparent dependence on cell cycle for No apparent dependence on cell cycle for activityactivity

Rituximab

Rosenberg SA NEJM 2004; 350:1461

Lymphocytes: Sufficient number of recognizing tumor cells

Reach the tumor

Must be able to destroy the tumor cells

National Cancer Institute USA National Cancer Institute USA BudgetBudget

Ramsey SD: J Clin Oncol 2007;25:175

USA Health Care EconomyUSA Health Care Economy 2006 budget 2.1 trillion dollars2006 budget 2.1 trillion dollars 7000 US$ per person7000 US$ per person NCI budget 4.87 billion dollarsNCI budget 4.87 billion dollars 260 non profit organizations working 260 non profit organizations working

for cancer in USAfor cancer in USA– More than heart disease, stroke, AIDS, More than heart disease, stroke, AIDS,

Alzheimer's disease togetherAlzheimer's disease together

Ramsey SD: J Clin Oncol 2007;25:175

Metastatic Colorectal Cancer Cost Metastatic Colorectal Cancer Cost Effectiveness Effectiveness

Wong Y et al: J Clin Oncol2006;24:149

Health Expenses vs GDPHealth Expenses vs GDP

Meropol NJ et l: J Clin Oncol 2007; 25:180

14 (3

)14

(3)

15 (10)15 (10)

14 (4)14 (4)

180 (147)180 (147)

14 (4)14 (4)

43 (19)43 (19)

31 (5)31 (5)

Per capita expenditure on health South Asia-US$Total (Public)

whostat2007_6healthsystems_nhahttp://www3.who.int/whosis/countryAccessed September 2007

http://www3.who.int/whosis/country

Radiotherapy Facilities in India Radiotherapy Facilities in India

05

1015202530354045

TN Mah Kar UP Ker WB MP Guj Har Ass Ori Pun Bih J&K

Cobalt LineacUICC 2006

70% of world’s cancer in developing countries: and these have just 5% of the resources to fight it.

Dinshaw KA: Fifty yrs of Cancer Control.. NCCP: MOHFW:2002:6

Radiotherapy facilitiesRadiotherapy facilities

Developed Developing

Stewart BW et al: World Cancer Report IARC: 2003

Population

Radiotherapy facilities

Needed for 50-60% of pts during the course of illness

2020

Data NR etal: Lancet Oncology 2004;5:696

Oncologist’s PerspectiveOncologist’s Perspective

Patients should have access to Patients should have access to effective therapy regardless of costeffective therapy regardless of cost

Or….continue care till a thresholdOr….continue care till a threshold– 300,000 US$ per quality adjusted life 300,000 US$ per quality adjusted life

year gained year gained

Nadler E et al: Oncologist 2006; 11:90

“Every man has his price”

Bernard Williams: A critique of utilitarianism

cancer in south asia

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