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through a set of very cost-eff ective interventions, as suggested by the global and regional action plans for non-communicable diseases. In collaboration with the Government of China, a focused approach has been initiated in the provinces of Chongqing, Guanxi, and Shanxi to strengthen the prevention and control of non-communicable diseases (including cancer control) under the Western Area Health Initiative. Tobacco control is a priority for WHO and China is working towards control of tobacco products through legislation and regulation. The WHO Regional Offi ce for the Western Pacifi c is working with the National Patriotic Health Campaign Committee in China to expand and scale up healthy cities as a platform for many interventions, including reduction of environmental pollution. The WHO Regional Offi ce for the Western Pacifi c has developed programmes for leadership in cancer control (eg, CanLEAD), and off ers country-specifi c support for registration, screening, and palliative care for cancer.7

A set of very cost-eff ective interventions are provided in the Global Action Plan to reduce tobacco and harmful alcohol use, improve unhealthy diets, and increase physical activity. These measures are mostly regulatory, legal, and fi scal interventions, and will aff ect rates of non-communicable diseases (including cancer) in large populations. China can further strengthen the comprehensive approach to risk-factor reduction through these interventions and expand early detection and management of cancer. Widespread coverage of vaccines

for hepatitis B and human papillomavirus can help to further reduce infection-related cancers. A nationally representative cancer registry with improved quality and coverage will help to identify priorities and to track the progress of cancer control in China.

Cherian Varghese, *Hai-Rim Shin Noncommunicable Disease and Health Promotion Team, WHO Regional Offi ce for the Western Pacifi c, Manila, Philippinesshinh@wpro.who.int

We declare that we have no competing interests. We are staff members of WHO. We are responsible for the views expressed in this Comment, and they do not necessarily represent the decisions, policy, or views of WHO.

© 2014 World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved.

1 Goss PE, Strasser-Weippl K, Lee-Bychkovsky BL, et al. Challenges to eff ective cancer control in China, India, and Russia. Lancet Oncol 2014; 15: 489–538.

2 UN General Assembly. Political declaration of the high-level meeting of the General Assembly on the prevention and control of non-communicable diseases (A/RES/66/2). January, 2012. http://www.who.int/nmh/events/un_ncd_summit2011/political_declaration_en.pdf?ua=1 (accessed Feb 18, 2014).

3 WHO. Western Pacifi c regional action plan for the prevention and control of noncommunicable diseases (2014–2020). 2013. http://www.wpro.who.int/noncommunicable_diseases/about/WP_RAPNCD_2014-2020.pdf (accessed Feb 18, 2014).

4 International Agency for Research on Cancer. GLOBOCAN 2012: estimated cancer incidence, mortality and prevalence worldwide in 2012. http://globocan.iarc.fr/Pages/fact_sheets_population.aspx (accessed Feb 18, 2014).

5 Liang H, Wang JB, Xiao HJ, et al. Estimation of cancer incidence and mortality attributable to alcohol drinking in China. BMC Public Health 2010; 10: 730.

6 WHO. Meeting report workshop on leadership and capacity-building for cancer control. 2013. http://www.wpro.who.int/noncommunicable_diseases/documents/workshop_CanLEAD/en/index.html (accessed Feb 18, 2014).

7 Wang JB, Jiang Y, Liang H, et al. Attributable causes of cancer in China. Ann Oncol 2012; 23: 2983–89.

A health-system response to cancer in IndiaDo

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Non-communicable diseases have not been perceived solely as diseases of rich countries for some time. However, India’s high rate of diabetes came as a surprise to many in 2011, when The Lancet NCD Action Group and the NCD Alliance1 revised world fi gures. Although information about cancer in India is incomplete, as the Commission by Paul Goss and colleagues,2 published in The Lancet Oncology, shows—after being in operation for 30 years, population-based registries cover only 7% of patients with cancer—cancer is now emerging as an important health problem, and already causes 6% of all adult deaths in India every year. Data from GLOBOCAN 2012 predict overall mortality for both sexes from

cancer in India—682 830 deaths in 2012—to rise to 844 578 in 2020, and nearly 1 million (959 868) by 2025. This projection implies a 4% rise in mortality in 2020 compared with 2012, and a 40% increase in 2025 compared with 2012.

The severe eff ects of cancer on individuals and families are both emotional and economic. In India, almost half of families of patients with cancer experienced catastrophic spending, and a quarter of such families were impoverished as a result of the disease in 2010.3 Cancer already has a major eff ect on health systems and related costs, which will increase even further in the future. Cancer will undoubtedly be a major challenge for

See The Lancet Oncology Commission page 489

For GLOBOCAN 2012 see http://globocan.iarc.fr/Default.aspx

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public health, economics, and society in the years and decades to come.

40% of all cancers in India are attributable to tobacco use; cancer of the oral cavity is a major cause of mortality for both men and women. Cancers associated with reproductive health are important health problems for women in the context of complex social attitudes about gender relationships in India. Health-service eff ectiveness is low; cancer incidence is lower than in western countries, but mortality is higher. Although the incidence of cancer in rural areas is half that of urban areas, age-standardised mortality for cancer is similar in rural and urban areas in India, suggesting low service use.

Accordingly, the authors of the Commission rightly point out that the main issues to consider are aff ordability of care, provision of adequate health personnel and infrastructure, and overcoming of sociocultural barriers to cancer control. India needs money, staff , and technological resources, in addition to cultural eff orts, to fi ght cancer. Furthermore, the National Cancer Control Programme started in 1975 and subsequent programmes (eg, the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke and the Health Minister’s Cancer Patient Fund) need further strengthening, despite the progress they have achieved.

The WHO India Country Offi ce, in agreement with the Government of India, has called for eff orts against chronic and non-communicable diseases to be addressed not simply with vertical arrangements (ie, single-disease single-benefi ciary programmes for specifi c groups), but rather with a health-systems approach towards universal health coverage.4

First, assessment of health-systems performance needs to be put in place at an institutional level to provide improved understanding of cancer in terms of incidence; mortality and survival; access to and quality of preventive, diagnostic, and treatment services; protection against adverse fi nancial consequences of treatment; and response to the population’s expectations.

Second, funding is needed for a robust package of services of suffi cient quality for all people in India. The country has increased the share of gross domestic product spent on health in recent years,5 but the available resources are insuffi cient; government expense per patient with cancer in India is US$641, compared

with $2202 in China, $3784 in Russia, and $86 758 in the USA.

Achievement of universal health coverage also needs improvements in prevention, early detection, eff ective treatments, integrated care, and research.6 A concerted response for cancer is needed from the Union-sponsored National Rural Health Mission, the National Urban Health Mission, and the Rashtriya Swasthya Bima Yojana (an insurance scheme for the costs of hospital admission launched in 2008 to protect households below the poverty line), as well as other schemes at the state and municipal level.

Primary prevention means promotion of healthy lifestyles, reduced tobacco use, investment to change social attitudes and personal habits, improvement of cancer registries, and mass screening for some cancers. Secondary prevention of cancer needs involvement of the public and private sectors through as many facilities (ie, primary care centres and secondary and tertiary care hospitals) and professionals (eg, doctors, nurses, and specialists) as possible. Integrated systems for quality assurance follow-up and assessment, identifi cation of eff ective (but cheap) treatment protocols and services, and production of aff ordable medicines should help to keep costs within the available resources. Improvement of access to pain treatment and the development of palliative care are also indispensable.

Improvement of cancer control is a complex and long-term process, needing patience and sustained eff orts. The recent success with polio eradication in India7 is a reminder that even the most ambitious goals can be accomplished with wide support. Increased awareness for cancer-related issues among decision makers and key stakeholders is, and will remain, essential. Beyond eff orts for advocacy and lobbying, all opportunities need to be seized to improve primary and secondary prevention and access to aff ordable treatments. However, all these eff orts cannot produce results without improvements to the eff ectiveness and equity of health services—the objective should be that those resources and services are off ered to all. Although specifi c control programmes and plans are necessary, a health-system response to cancer is what is needed the most.

Nata MenabdeWHO Country Offi ce for India, New Delhi 110 011, Indiamenabden@who.int

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I declare that I have no competing interests. I am a staff member of WHO. I alone am responsible for the views expressed in this Comment, and they do not necessarily represent the decisions, policy, or views of WHO.

© 2014 World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved.

1 Beaglehole R, Bonita R, Horton R, et al, for The Lancet NCD Action Group and the NCD Alliance. Priority actions for the non-communicable disease crisis. Lancet 2011; 377: 1438–47.

2 Goss PE, Strasser-Weippl K, Lee-Bychkovsky BL, et al. Challenges to eff ective cancer control in China, India, and Russia. Lancet Oncol 2014; 15: 489–538.

3 Mahal A, Karan A, Engelgau M. The economic implications of non-communicable disease for India. Washington, DC: World Bank, 2010.

See The Lancet Oncology Commission page 489

For the WHO Framework Convention on Tobacco Control see http://www.who.int/fctc/signatories_parties/en/index.html

Cancer in Russia: refl ections from WHO in EuropeThe Commission about cancer in China, India, and Russia by Paul Goss and colleagues,1 published in The Lancet Oncology, provides a valuable and thought-provoking assessment of eff orts to confront the burden of cancer in the Russian Federation. We welcome this work, because it points out many avenues to reach the targets of the WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases,2 and the European Health Policy, Health 2020.3 We focus on two key areas: tobacco control and trends in breast and cervical cancer.

Russia became party to the WHO Framework Convention on Tobacco Control in May, 2008. Since then, the tobacco industry has aggressively opposed strong laws for tobacco control at every opportunity. However, the well-coordinated actions of advocates for tobacco control in Russia have prevailed, providing a good case study of the potential for science and advocacy in public health.

WHO and the Russian Government have collaborated on two studies. The fi rst was the 2009 Global Adult Tobacco Survey (GATS).4 The survey investigators estimated that 39·1% of Russian adults smoked tobacco, the highest among the 21 countries that took part in the survey. Overall, the fi ndings suggested a positive environment for tobacco control in Russia, with most adults believing that smoking should be prohibited in public places and favouring prohibition of all tobacco advertisements. Nevertheless, the survey fi ndings also showed that the policies for tobacco control at the time permitted high exposure to secondhand smoke, and that the health warnings on cigarette packs were not eff ective. In the second study, the long-term eff ects of tobacco control in the country were estimated by application

of SimSmoke, a simulation model of tobacco control.5 The model estimated that a strong set of policies for tobacco control in Russia could reduce smoking preva-lence by as much as 30% by 2020, potentially averting 3·7 million premature deaths in 2015–55.

These fi ndings created an opportunity for policy makers and the tobacco control community in Russia to develop and implement strong policy measures. In August, 2011, the Ministry of Health and Social Development started to draft legislation for tobacco control with technical support from WHO experts. Within 2 years the Federal Tobacco Act was signed, and came into force on June 1, 2013. The new law includes, as key measures, a ban on smoking in public places, increased excise duty and fi xed retail price for tobacco products, public information campaigns, and a ban for advertising and sponsorship of tobacco products.

Offi cials at the Russian Ministry of Health expect that, with the political will to overcome resistance from the tobacco industry, the measures enacted under the new law will increase life expectancy from 70 years in 2011 to 74 years in 2018. The number of people protected by measures for tobacco control in Russia will certainly increase at an accelerated pace in the coming years, achieving (or possibly exceeding) the global voluntary target of a 30% relative reduction in tobacco use by 2025.

The recommendations of the Commission for breast and cervical cancer are particularly relevant, not just for Russia, but for a range of countries in the Commonwealth of Independent States, which share many characteristics of the burden of disease. The WHO-Europe Health For All database provides comparative indices of mortality from

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4 WHO Country Offi ce for India, Ministry of Health and Family Welfare, Government of India. WHO country cooperation strategy: India 2012–2017. 2012. http://www.who.int/countryfocus/cooperation_strategy/ccs_ind_en.pdf (accessed Feb 3, 2014).

5 La Forgia G, Nagpal S. Government-sponsored health insurance in India: are you covered? Washington, DC: World Bank, 2012.

6 Planning Commission of India. Health Chapter 12th Plan. Delhi: Planning Commission of India, 2012.

7 Bhalla N. Global polio fi ght reaches milestone as India frees itself of the virus—WHO. Jan 13, 2014. http://www.trust.org/item/20140113080329-0mx7n/ (accessed Feb 27, 2014).

For the European Health For All database see http://data.euro.who.int/hfadb