Presentation 100114 Cancer in the Eastern Mediterranean Region

Presentation 100114 Cancer in the Eastern Mediterranean Region Common Challenges and Potentials Mahmoud M. Sarhan, MD, MMM, CPE King Hussein Cancer Center Kuwait City, October 25, 2010 October Breast Cancer Program King Hussein Cancer Center 0

Presentation 091026 It is good to know that cancer is not a new disease but the increased life expectancy and improved diagnosis has made it more evident… Increased Exposure to Carcinogens Carcinogenic Probably Carcinogenic Hepatitis B and C, HPV, Biological gents Helicobacter pylori, HIV, Schistosoma Circadian disruption, household combustion of biomass fuel (primarily wood) Life style Tobacco, areca nut, alcoholic beverages, household combustion of coal Radiation Radon, solar radiation, X-and gamma radiation Complex mixtures Aflatoxins, coal-tar Emissions from high temperature frying Pharmac eutical DES, Estrogen, progesterone, tamoxifen, phenacetin Androgenic steroids, Chloramphenicol Particles and fibers Asbestos, Crystalline silica, wood dust Diesel engine exhaust Metals Arsenic, cadmium, chromium Inorganic lead, Cobalt, tungsten carbide Occupati on Painting, chimney sweeping, coal mining, coke production, Petroleum refining, hairdressing Chemical s benzene, formaldehyde, vinyl chloride Trichloroethylene + Not a Modern Disease + Improved Life Expectancy + Better Clinical Diagnosis Andorra Iceland Hong Kong Japan Switzerland Australia Sweden Israel Macau Canada New Zealand Singapore Norway Spain Cayman Islands Italy Netherlands Malta 80. 6 80. 2 79. 4 79. 0 78. 9 78. 7 78. 6 78. 5 78. 3 78. 2 78. 0 77. 8 77. 7 77. 5 77. 3 King Hussein Cancer Center 1

Presentation 091026 …nevertheless, in the next 10 years, cancer worldwide will be the #1 disease claiming lives and requiring the most investment for prevention, detection, treatment and palliative care Projected global deaths for selected causes (Future Health) Cancer over time Cancer % 36. 3 Ischemic Heart Disease HIV/AIDS Tuberculosis Malaria Other Infectious Diseases Million people Stroke 3% 36. 8% 42. Road Traffic Accidents WHO statistical highlights, 2007 King Hussein Cancer Center 2

Presentation 091026 Cancer will impact the developing / low-middle income countries the most… Deaths in Low Income Countries World Cancer Deaths over Time 5. 3 Total Cancer Deaths in Millions +64% 9. 28 +19% 8. 06 Year Deaths in Low Income Countries (in million) 11. 94 5. 0 year King Hussein Cancer Center 3

Presentation 091026 >5 million from Asia Eastern Western South Central Southeastern King Hussein Cancer Center Source: Globocan 2000 IARC 4

Presentation 100114 It is expected that 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)4 150 100 Eastern Mediterranean Region India Other parts of Asia & Islands Sub-saharan Africa China Latin America & Caribbean Former socialist economy 0 Established Market economy 50 World Increase in death from Cancer (%) 200 projection modelling predicts an increase of between 100% and 180% [Rastogi et al. Projection modelling predicts an increase of between 100% and 180% in EMR [Rastogiet al. 2004]. . Rawaf, S. et al. BMJ 2006; 333: 860 -861 King Hussein Cancer Center 5

Presentation 100114 The Eastern Mediterranean region extends from Morocco to Pakistan and has varied income levels, health indicators and geographies World Bank Income group Country Population (in thousands) Expenditure on health per capita in US $ Qatar 656 High U. A. E (Total Pop 8, 219, 000) (Total Pop 35, 472, 000) Country Population (in thousands) Expenditure on health per capita in US $ 862 Jordan 5, 617 177 4, 210 661 Palestine 3, 827 138 Kuwait 2, 645 579 9, 911 137 708 555 lower middle Tunisia Bahrain upper Middle Iran 66, 775 131 (Total Pop 231, 482, 000) Morocco 30, 509 72 Syria 18, 200 59 Egypt 69, 323 55 Djibouti 817 47 Iraq 26, 503 23 Yemen 21, 003 32 Low Sudan 34, 512 21 (Total Pop 238, 627, 000) Pakistan 151, 816 13 Afghanistan 22, 998 11 Somalia 8, 298 6 Lebanon 4, 370 573 Saudi Arabia 22, 608 366 Oman 2, 651 278 Libya 5, 843 World Bank Income group 171 GINI index in many countries varies between 28 and 42 indicating inequality within each country King Hussein Cancer Center 6

Presentation 100114 Cancer in the EMRO region is the 4 th leading cause of deaths occurring at a younger age than industrialized countries Remarks → 50% of the cancers in the Region occur before age 55 (10 – 20 years younger than in industrialized countries). → The mortality/incidence ratio is 70% indicating significantly lower survival rates from diagnosed cancer (40% in America, 55% in Europe). projection modelling predicts an increase of between 100% and 180% [Rastogi et al. 2004]. . King Hussein Cancer Center 7

Presentation 100114 Breast Cancer is the most common cancer in most of the Eastern Mediterranean countries preceded sometimes by lung cancer Country Rank of Disease King Hussein Cancer Center 8

Presentation 100114 The 3 leading causes of cancer worldwide are dominantly seen in the region Tobacco Infections 4 Prevalence of tobacco consumption is increasing rapidly and is already above 30% in men in 12 countries of the Region Country Males > 15 years Females > 15 4 Cancers due to infections represent 11% of the cancer burden in North Africa and 16% of the cancer burden in west Asia. Yemen 77. 0 29. 0 4 70% of the infection‐related cancers in the Tunisia 61. 9 7. 7 Djibouti 57. 5 4. 7 Jordan 48. 0 5. 7 Syria 48. 0 8. 9 Lebanon 46. 0 35. 0 Kuwait 42. 0 4. 4 Top Countries Ranking (Males) Prevalence of tobacco smoking a (%) > 40% Unhealthy Lifestyles Region are attributable to four infectious agents: human papilloma virus (HPV) (27%), Helicobacter pylori (23%), and hepatitis B and C virus (20%). 4 In the Eastern Mediterranean Region obesity is a rapidly growing problem; already more than 50% of the population is overweight in 12 countries. King Hussein Cancer Center 9

Presentation 100114 Jordan and Kuwait are among the smaller populations in the Eastern Mediterranean region with impressive indicators related to health and a growing population that will challenge the current stable situation Geography Health Indicators Socioecono mic Indicators 4 Population (million) = 2. 8 4 Age Structure: 15 -64 = 70. 7% 4 Age above 65= 3% 4 Smokers (m): 40% Distances: 570 km north to south Population 4 Population: =6, 198, 677 4 Age Structure: 15 -64 = 63. 7% 4 Above 65: 4. 5% 4 Smokers (m) =48% 4 Area 17, 818 square kilometer Urbanization= 78% 4 Urbanization= 98% 4 Life expectancy @ birth years =71/74 4 Life expectancy @ birth years=77/79 4 Total fertility rate children born/women = 2. 47 4 Total fertility 2. 5 Unemployment rate: 13. 5% Unemployment rate: 2. 2% GDP: 48, 310 USD GDP: 4000 USD King Hussein Cancer Center 10

Presentation 100114 Kuwait is among the smaller populations in the Eastern Mediterranean region with impressive indicators related to health and a growing population that will challenge the current situation Population 4 Population (million) = 2. 8 4 Age Structure: 15 -64 = 70. 7% 4 Age above 65= 3% 4 Smokers (m): 40% 4 Area 17, 818 square kilometer Geography 4 Urbanization= 98% Health Indicators 4 Life expectancy @ birth in years =77/79 4 Total fertility 2. 5 Socioecono mic Indicators Unemployment rate: 2. 2% GDP: 48, 310 USD King Hussein Cancer Center 11

Presentation 100114 Crude Number of Cases In Jordan, the National Cancer Registry in 1996 was a major undertaking to identify the most common cancers (breast & lung) as well as register cases Cancer Cases Trend of Cancer 1980 -2007 Ten Most Common Cancers Among Males Jordan 1996 -2007 N=14, 445/21, 332 Years 2008 Population based Start of Registry Hospital based Crude Number of Cases Primary Site Ten Most Common Cancers Among Females Jordan 1996 -2007 N=14, 360/21, 000 Primary Site King Hussein Cancer Center 12

Presentation 100114 Despite the growing numbers of cancer cases, it is important to note that Jordan or Kuwait are not worse than other countries in terms of Cancer incidence… Age Standardized rate compared with different countries JNCR 2007 King Hussein Cancer Center 13

Presentation 100114 New cancer cases in Jordan are expected to double by 2020 as the population grows, ages, and lifestyles remain unchanged Projected Number of Cancer Cases (by Year) in Jordan Number of Cases Population in Million Population Growth over Time Year King Hussein Cancer Center 14

Presentation 100114 …and as the Jordanian population ages. Population Growth (in thousands) by gender and age Jordan 2005 -2050 ASIR by Age Group per 100, 000 Population 2050 Above 50 Population per 100, 000 2005 Above 50 Age Groups King Hussein Cancer Center 15

Presentation 100114 Cancer in Jordan is characterized by late stages diagnosis (similar to the EMR), highest mortality due to lung cancer and 50% of mortality under age 64 Stage Frequency % 0 - Insitu 53 1. 3 1 - Localized 1286 32. 7 2 - Regional Direct Extension 311 7. 9 3 - Regional – Lymph Node 326 Cancer Mortality in Jordan by Age JNCR 2007 Number of deaths Distribution of Cancer Cases by Stages Based on SEER Staging JNCR 2007 8. 3 265 6. 7 5 - Regional - NOS 270 6. 9 6 - Distant Metastasis 1425 36. 2 TOTAL 3936 Cancer Mortality JNCR 2007 N= 13, 298 cases 100. 0 Percent of Deaths 4 - Regional – (Direct + Lymph node) Extension Age in years Primary Site King Hussein Cancer Center 16

Presentation 100114 At the onset of JBCP, breast cancer used to be detected at late stages when the survival rate and treatment success are not promising Direct Correlation of Survival to Stage of Detection Percent of Survival Stages of Breast Cancer in Jordan based on KHCC Experience before JBCP Stage of disease at Detection N=550 King Hussein Cancer Center 17

Presentation 100114 ASR of Breast Cancer ( Females) ASR of Data for GCC countries 1998 -2005, Oman-2007 , Egypt 2000 -2002 , USA-SEER (white population) 1999 -2001 King Hussein Cancer Center 18

Presentation 100114 Median Age at diagnosis of Female Breast cancer in the Arab world 53 51 49 48 47 51 50 45 49 48 46 Median Age at diagnosis in Developed Countries 65 years King Hussein Cancer Center 19

Presentation 100114 Breast cancer: proportions by age group in Jordan , Lebanon , KSA and Kuwait King Hussein Cancer Center 20

Presentation 100114 The region as been trying to address individually and collectively the burden of cancer but with limited or country specific success King Hussein Cancer Center * WHO-EM/NCD/060/E, Towards a strategy for cancer control in Eastern Mediterranean Region, 2009 21

Presentation 100114 A regional alliance under the guidance of WHO has been working since 2007 and has in 2009 set the crucial need for national cancer control plans as the first step for each country Establishment WHO Regional Office, in association with the Princess Lalla Salma Association against Cancer, nongovernmental organizations and other relevant international organizations in the Region, agreed to establish an alliance against cancer to join forces in order to generate an appropriate and concerted effort to prevent and control cancer. Goals Conduct publicity and disseminate information regarding the establishment of the alliance Create an advocacy plan Conduct education and increase public awareness Create a database for cancer in the Region Establish a network of experts, researchers and organizations Promote the development of highly-qualified welltrained human resources in the field of cancer Mobilize the financial resources needed for the alliance to perform its functions Support research in the field of cancer Conducting monitoring and evaluation Members Membres • Association Lalla Salma de Lutte contre le Cancer (Maroc) • The National Higher Committe for Breast Cancer Control (EAU) • King Hussein Cancer Center (Jordanie) • Lebanese Cancer Society (Liban) • Gulf Federation for Cancer Control (pays du Golfe) • Egyptian Oncology Forum (Egypte) • Fakous Cancer Center (Egypte) • Egyptian Foundation for Cancer Research (Egypte) • Breast Cancer Foundation (Egypte) • The National Association for Cancer Awareness (Oman) • Zahra Association for Breast Cancer (Arabie Saoudite) • Saudi Association for the Fight against Cancer (Arabie Saoudite) • Association Tunisienne de lutte contre le cancer (Tunisie) • Association des Amis de l’Institut National d’Oncologie (AMINO) (Maroc) • Association l’Avenir (Maroc) • Association Coeur de Femmes (Maroc) King Hussein Cancer Center 22

Presentation 100114 Jordan is a model of success that can be presented as a learning experience and center of excellence Stages of Cancer Control Development in Jordan 6 5 sing ea Incr din Rea 2 1 4 ess 3 Focus Quality & comprehensive ness Prevention International Competition Data Equity & Research Local and International Expansion Business as Usual Up to 1996 1997 2003 5 2 JNCR established 6 4 Transforming Al-Amal Hospital to the King Hussein Cancer Center-1 st class cancer care 2010 2020 Treatment 1 Treatment through MOH, RMS, PVS 3 Amal Hospital for Cancer Care Established 2006 Prevention and palliative care initiatives Increase in clinical capacity is needed for equity in patient care, while infrastructural growth is needed to initiate grade clinical and translational research King Hussein Cancer Center 23

Early Detection & prevention Presentation 100114 Jordan is implementing two models for the early detection and prevention of cancer – a bottom up vs. a top down one Quality and Guidelines 5 Bottom Up 4 3 2 1 Advocacy and Awareness Stable Funding Capacity Building Development of Services Legislation – free early detection Breast Cancer Early Detection and Screening National Target Top Down Implementation Plan 1 2 Legislation Implementation Alternatives 3 4 Grace Period 5 Smoking Control Enforcement Smoke-free Fines, Taxes, Penalty King Hussein Cancer Center 24

Presentation 100114 Jordan’s health system is dominated by the public sector that regulates it and provides services as well, followed by the military and private sector providers Provider Basic Role Ministry of Health (60%) Law, regulations, budget, health expenditure, insurance Royal Medical Service (25%) Private Sector (XX%) + Universities (6%) Non-for-Profit Sector Description 4 Reactive vs. Proactive 4 Limited resources 4 Focused on service delivery 4 Public health influenced by Int’l arena Cancer Control 4 No full plan (under consideration) 4 Divided activities 4 Strong registry 4 Covers all Jordanians 4 Mediocre quality Rx services 4 Independent budget Closed Military 4 Serves 25% of populations System with Insurance Scheme 4 Quality Services 4 Prevention without outreach (clinic based) 4 Rx (not comprehensive) Regulated by Mo. H 4 Business driven from Quality 4 Varied quality (perceived by perspective not population as a higher quality pricing sector than government) 4 Rx focused 4 Not driven by unified protocols 4 Very expensive 4 Varied quality Free of charge for 4 Limited budgets enrollees or less 4 Acceptable quality privileged 4 Innovation limited 4 No oncology departments 4 Rx available not comprehensive 4 Varied quality (KAH vs. JU) 4 Limited budget Free of charge for 4 High expertise and focused enrollees or less expertise privileged 4 Dependent on Fundraising 4 Only player to date KHCC 4 Comprehensive 1 st class center (2 accreditations) 4 Outreach, control, diagnosis, Rx and Palliative care King Hussein Cancer Center 25

Presentation 100114 Despite the varied quality of treatment, Jordan has been achieving good results comparable to the developed nations All Cancers Mortality/Incidence ratios for selected countries 2002 Diagnosis & Treatment Jordan cancer Mortality/Incidence ratio 2006 King Hussein Cancer Center 26

Diagnosis & Treatment Presentation 100114 Case in point 1: KHCC’s Department of Pediatrics quality of care has resulted in survival rates equivalent to those in the USA and Europe Survival Distribution Function Kaplan Meier Survival Function LEGEND Survival Function Product Limit Estimate Curve Event Free Survival Function Censored Observations Incidence Free Survival 4 ALL Pediatric - KHCC 2003 – 2007, (N=200) 4 # of events =19 4 3 years event free survival =86% Overall Survival 4 ALL Pediatric - KHCC 2003 – 2007, (N=200) 4 # Of deaths = 10 4 3 Years survival = 94% Survival Time Month King Hussein Cancer Center 27

Diagnosis & Treatment Presentation 100114 Case in point 2: KHCC’s Stem Cell Transplantation Program has resulted in survival rates equivalent to those in the USA and Europe Survival Probability Product-Limit Survival Function Estimate Survival Time Month King Hussein Cancer Center 28

Palliative Care Presentation 100114 As for palliative care, Jordan has established a national committee to improve provision of services as recommended internationally Goal 4 To help alleviate the physical and psychosocial suffering associated with progressive, incurable illnesses throughout Jordan and the region 4 To increase the availability and access to high-quality hospice and palliative care for patients and families throughout Jordan OBJECTIVE 4 Integrate palliative care and hospice principles into the National Health Strategy by shaping governmental policies 4 Assure availability and easy access to opioid analgesics and adjuvant medications throughout the Kingdom 4 Establish integrated continuums of palliative care programs, reaching patients in hospital and community settings 4 Promote Jordan as a model and reference for palliative care practice and education in the region Lead King Hussein Cancer Center Support Ministry of Health Top-Down Activities 4 Advocacy – change in opiod prescription regulation 4 Ten-day policy 4 Authority with MOH Minister rather than by law Bottom-up Activities 4 Education – integrate into universities (nursing and medical schools) as a part of the curriculum 4 Training - Establishment of training programs – KHCC (doctors, nurses, policy makers. . etc) 4 Pharmaceuticals – to develop immediate release morphine tablets Emerging Approach “Decent Care” Globalization is putting the social cohesion of many countries under stress, and health systems, as key constituents of the architecture of contemporary societies, are clearly not performing as well as they could and as they should … People are increasingly impatient with the inability of health services to deliver levels of national coverage that meet stated demands and changing needs, and with their failure to provide services in way that correspond to their expectations. Few would disagree that health systems need to respond better – faster – to the challenges of a changing world. King Hussein Cancer Center 29

Presentation 100114 With the current and growing cancer burden the region remains extensively challenged Lack of government national support Social Limitations 4 Cultural Barriers 4 Other primary care issues take priority over cancer care 4 Funding limitations to prevention, screening and purchase of quality care (including costly drugs) § 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 4 Socioeconomic barriers § Low level of education (ignorance) Monetary Limitations 4 Lack of Specific Funds Targeted towards Cancer § Preference to invest in family/children needs rather than self health 4 Awareness barriers 4 High Cost of Drugs and overall treatment § Cancer as a taboo subject 4 (GDP per capita for most countries in the region is below $ 6000) § No health promotion to break myths of hereditary and contagious disease 4 (Average cost of treatment is approximately $25, 000 without complications) § Do not seek information and action to understand ailment or prevention 4 Major International Funds have not been allocated towards Cancer Control in the region King Hussein Cancer Center 30

Presentation 100114 Service limitations Health Care Workers per 1000 population Service Limitations 4 Multidisciplinary approach to treatment is not systematically implemented in some treatment centres 4 An increasing number of cancers are being treated with combined modality therapy. A major issue in this regard is the cost and availability of cytotoxic drugs. Remarks 4 There are relatively few trained radiation, medical or pediatric oncologists in many countries of the Region, and very few oncology nurses and social workers. 4 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 4 The roles of nursing staff and paramedical could be expanded to reduce the load on specialists King Hussein Cancer Center 31

Presentation 100114 Palliative care for many countries is barely existent Sources: International Narcotics Control Board; United Nations population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2009 King Hussein Cancer Center 32

Presentation 100114 In Jordan as well, despite the strides to cancer care, some challenges remain to contest the ability to focus on quality and equity Human Resources Accessibility to Care 4 Lack of health specialized primary care and support care providers: Especially in support services and early 4 Increased prices of drugs: Due to the increased prices detection, health professionals in Jordan do not receive consistent and focused training for cancer related issues nor have specific academic lines that they can pursue for that purpose 4 Brain drain : Skilled and educated health providers are solicited by neighboring countries especially those who can offer more competitive packages – this will increase of drugs that make a difference in cancer treatment, many patients are deprived of life saving interventions and the burden on the government is increasing 4 No primary care focus on Cancer: The focus on maternal & child health, infectious diseases, and cardiovascular diseases remains the core work of the primary health care centers leading to decreased ability to identify cancer early among other drawbacks 4 No enforcement of Palliative Care: Despite the national consensus on palliative care criteria, there is no enforcement of the agreed approach Quality of Services Public Awareness 4 Lack of treatment protocols: No unified protocols are 4 Misinformed public: Due to technological advances in applied in diagnosis and treatment of cancer but purely based on provider’s academic and on-the-job training 4 Lack of standard operating procedures: The comprehensive approach to cancer care is not applied in all health care venues except at KHCC 4 Limited Advanced Experience: The approach and communication public put pressure on health sector to go for drugs and procedural interventions that are trial based which undermines the sector’s ability to perform and to be trusted 4 Lack of awareness of risk factors: Except for breast cancer, there is no / minimal work or focused work on the importance of healthy lifestyles accessibility to tap into advanced resources is non existent King Hussein Cancer Center 33

Presentation 100114 In Jordan, Cancer control is on the right track … Remarks 4 Only population-based data can identify the overall national problem (although institutional data useful) 4 Only planning at a population level can ensure improved access for all 4 Only population-based data can identify resources required to control cancer at a national level 4 Only nation-wide collaboration can assess and make maximal use of all available national resources 4 Only population-based data can give a clear idea of the overall effect of interventions King Hussein Cancer Center 34

Presentation 100114 Efforts need to become more streamlined and unified to ensure continued success across all sectors 4 PRIMARY CARE PROVIDERS – Public education, early detection 4 GOVERMENT – Legislation relevant to control of risk factors and opioid availability – Collaboration in care, follow-up and palliation – Structuring health services 4 NGOs: – Supporting establishment of expert committees – Orchestrating goals – Education & outreach – advocacy: 4 NON-ONCOLOGY SPECIALISTS – Early detection – Treatment of early stage disease 4 ONCOLOGY SPECIALISTS: – Rapid referral to oncologists 4 INDUSTRY: – Access to new innovative products and services – Expert diagnosis and treatment – Research: clinical and translational – Advising government – Research – Sponsorship – Monitoring outputs, outcomes and impact 4 ACADEMIC ESTABLISHMENTS – Education of health care professionals with basic knowledge of cancer – Leadership in care, epidemiological, public health, clinical and translational research Food for thought: Need for Higher council for Cancer Control ? ? ? King Hussein Cancer Center 35

Presentation 100114 4 Thank You King Hussein Cancer Center 36