Cancer in Africa

Professor David Kerr

www.afrox.org ... to enable the delivery of comprehensive cancer care to Africa

Millions of deaths in 2002

0 1 2 3 4 5 6 7 8

Tuberculosis

HIV/AIDS

Malaria

Total TB+HIV+Mal

Cancer

WHO (2003)

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1990 1995 2000 2005 2010 2015 2020

new

can

cer

case

s (m

illio

ns)

year

developingcountries

industrializedcountries

Worldwide annual new cases of cancer

WHO (2003)

10 millionin 2000

16 millionin 2020

a 50% increase!

70% will be in the developing world

1 million / yr in Africa

Important Cancer Types

• Kaposi’s sarcoma

• Cervical cancer

• Hepatocellular carcinoma (HCC)

• Breast cancer

Cervical Cancer

• Related to HPV• Some serotypes more important (16,18)• Serotypes vary between countries• Screening availability and uptake poor in Africa• HPV vaccines would prevent 70-80% Ca ($125)• Costs would be a problem (?large trial)• Radiation availability• Effective Palliation

Gathering the troops

A two-day meeting in London in May 2007.

– Chaired by the Rt. Hon. Alan Milburn

– Over 130 leaders in all aspects of World Health and Cancer Control present and 23 African Health Ministers.

Download the London Declaration on Cancer Care in Africa from www.afrox.org

AfrOx aims to deliver comprehensive cancer care to African countries where it is most

needed …

• Most Africans live in a rural areas with little access to cancer screening, early diagnosis, treatment or palliative care (est. > 250 million people). Differential survival between blacks and whites

• Life-saving radiotherapy is available in only 21 of Africa's 53 countries, or to less than a max 20% the total population

• Over 1/3 of cancer deaths are due to preventable causes such asviral infection, poor nutrition and widespread tobacco use

• In Africa 5% childhood cancers cured compared to 80% in developed world

• In Africa, combination of cancer, poverty, deprivation and ID hinder development of sustainable population and consequently a sustainable future

The economic perspective

• Starting point: Scarce (health care) resources• Objective: Use these to maximise health gain • Method: Compare health interventions

– Assess their net costs– Assess their health benefits– Implement interventions with highest benefits in relation to

cost• This is the cost-effectiveness approach

Gross National Income per

person, 2005

Total health expenditure per person,

2003

Tanzania 730 29 16 2,703Nigeria 1,040 51 13 588Rwanda 1,320 32 14 2,381Uganda 1,500 75 23 1,639Ghana 2,370 98 31 1,086Botswana 10,250 375 238 377

China 6,600 278 101 952UK 32,690 2,389 2,047 83USA 41,950 5,711 2,548 107

Total health expenditure per person,

2003

Govt. health expenditure per person,

2003

Tanzania 730 29 16 2,703Nigeria 1,040 51 13 588Rwanda 1,320 32 14 2,381Uganda 1,500 75 23 1,639Ghana 2,370 98 31 1,086Botswana 10,250 375 238 377

China 6,600 278 101 952UK 32,690 2,389 2,047 83USA 41,950 5,711 2,548 107

Govt. health expenditure per person,

2003

People per nurse, 2002

Tanzania 730 29 16 2,703Nigeria 1,040 51 13 588Rwanda 1,320 32 14 2,381Uganda 1,500 75 23 1,639Ghana 2,370 98 31 1,086Botswana 10,250 375 238 377

China 6,600 278 101 952UK 32,690 2,389 2,047 83USA 41,950 5,711 2,548 107

Govt. health expenditure per person,

2003

People per nurse, 2002

Tanzania 730 29 16 2,703Nigeria 1,040 51 13 588Rwanda 1,320 32 14 2,381Uganda 1,500 75 23 1,639Ghana 2,370 98 31 1,086Botswana 10,250 375 238 377

China 6,600 278 101 952UK 32,690 2,389 2,047 83USA 41,950 5,711 2,548 107

Resource constraints (Int. $s)

Kenya: Country ProfileLocation East Africa

Total population 35, 000, 000

Gross national income per capita (PPP international $):

1,396 US$

Total expenditure on health per capita (Intl $, year):

8.3 US$

Total expenditure on health as % of GDP (WHO stats):

8.1

Life expectancy at birth m/f (2000-2005): 49.9/48.7

ITEMTotal Annual expenditure in Kshs’000

HIV/AIDS 13,649

Reproductive health 12,781

Child Health/MCH 12,333

Malaria control 8,085

Environmental health 5,494

STI control 2,998

TB control 2,394

EPI 2,390

Health Promotion 1,809

Rehabilitation 1,162

Dental health 858

Palliative care** 285

Mental health 136

Ministry of Health Priority List byExpenditure- 2005/2006

What is good value for money?

• Support for breastfeeding mothers $11 per DALY averted• Community newborn care package $9 per DALY averted• Measles vaccination (80% cover) $33 per DALY averted• Treat smear+ tuberculosis $7 per DALY averted• Cataract extraction & lens implant $89 per DALY averted• Insecticide-treated bed nets (ITN) $29 per DALY averted

• 2) What resources are available:– Level of national income– Priority given to health care

• 1) What else could be done with resources

What are the general priorities for AfrOx?

• Partnership with IARC world leaders in the field

• Build on hospital based registries

• Training fellowships supported by WHO

Cancer Intelligence Units

• Partnership with Gates Foundation

• Consider health economic and legal matters

Tobacco Control

• Major development on HPV vaccine • Current cost $125 per jab

• Will be reviewed by GAVI Summer, 2008

• Coalition of Pharma, Gates, World Bank, WHO, AfrOx and African Health Ministries

Cancer Prevention

• Focus on curable childhood cancer

• Partner with International Society of Paeditric Oncology

• Training fellowships

• Simplify treatment regime

Cancer Treatment

Nephroblastoma in Nigeria n = 42, 5 year survival 38% late presentation: late referral, ignorance, recourse to orthodox medicine after traditional practitioners and prayer houses have failed. Resource deficiency: 5 patients could not afford chemotherapeutic drugs, operation was delayed on 7 children because, they could not afford blood and antibiotics. Poverty was largely responsible for default from treatment. Poor compliance to treatment regimen: 17 children could not comply. Chemotherapeutic drugs were given only when available. Lack of collaboration amongst clinical community.

The cost-effectiveness planeNew treatment more

effective but more costly

New treatment more effective

New treatment more costly

Not costly & very effective

Costly & not very effective

Maximum acceptable cost-effectiveness ratio?

Is it ethically justifiable to develop lowcost, moderately effective cancer treatments?

• Modulated-dose oral chemo regimes for BC?

• Tamoxifen for breast lumps clinically described as cancer?

• Introduction of opiates despite cultural and religious barriers

• Training fellowships in partnership with Global Palliative Care fund

Palliative Care

The combination of Ghana’s historic ties with Britain, its record of good governance and the commitment of local policy-makers and clinicians to control cancer make Ghana an excellent starting point for AfrOx to develop its work in Sub-Saharan Africa.

Ghana has a population of 23 million which is served by only two oncology centres, one in the capital Accra and one in Kumasi. There are only 4 oncologists in the country and no specialist cancer nurses.

Our 5 year programme covers the spectrum of cancer control:

Policy support for national cancer plan. Raising public awareness of cancer. Cancer prevention through screening and vaccination. The early diagnosis and treatment of children's cancer. Improvement in palliative care. Training and education of healthcare staff.

Our programmes in Ghana will serve as a template that could be adapted for other African countries.

Afrox in Ghana

Major Achievements (1)

Public Policy Projects: African Cancer Reform Convention, London, 2007 (Sierra Leone, Rwanda, Uganda, Nigeria, Burkina Faso, Cote D’Ivoire, Gambia, Egypt, Yemen, Ghana ,Tanzania, India, Cameroon, Morocco, Mozambique, Libya, Benin, Malawi, Botswana, South Africa, Congo, Kenya, Zimbabwe, Mauritius, Zambia, Lesotho and Tunisia). Towards the Prevention of Cervical Cancer in Africa Conference, Oxford 2009.

Early Diagnosis and Prevention Projects: Cancer Awareness in Ghana: AfrOx supported the Cancer Society of Ghana (CSG) with a capacity building grant in 2008.  Developing a Cancer Code for Africa (collaboration with ESMO and WHO).

Major Achievements (2)Cure the Curable Projects:

Improving Paediatric Oncology Services in Ghana: AfrOx is funding a 5-year twinning programme between the Paediatric Cancer Unit at the Korle Bu Teaching Hospital, Accra, Ghana and the Royal Hospital for Sick Children, Edinburgh.

Palliative Care Projects:

Palliative Care Training: Two workshops held in January and October 2009, attended by over 100 doctors, nurses, pharmacists and other health-workers, resulted in significant improvement in end of life care in Ghana’s teaching hospitals. 

Training and Education: Public lectures, Radio and TV appearances raising cancer awareness in Accra and Kumasi; Milburn, Arbuthnott, Kerr and Roddan 2007- 2009. Clinician training and education workshops in Ghana, May 2009 (Sharma and Kerr): Workshop on Health Economics of Cancer Control, Africa Cancer Conference, 2009 (Kerr). E-Cancer Filming Project, Africa Cancer Conference, 2009 (Kerr). Practical workshop on bone marrow aspirates for children, SIOP conference, Ghana 2010 (Eden and Sharma).

AfrOx Projects

• Childhood cancer Twinning project• HPV vaccination pilot programme• AfrOx/ AORTIC wider twinning with NHS• AfrOx/ESMO Cancer code and poster campaign

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Extend the ESMO Community

Extend ESMO’s place in the world by working to improve cancer services in developing countries

• ESMO Developing Countries Task Force

• ESMO Cancer Prevention Working Group

• ESMO Guidelines Working Group

• ESMO Palliative Care Working Group

• ESMO National Representatives

• ESMO Educational Committee, etc.

The time for taking concerted action against cancer in African and the rest of the developing world has come

No one government, organisation or charity can tackle the looming cancer epidemic on its own

If the international community acts now, we have the chance to make an extraordinary difference by preventing a major tragedy unfolding and saving countless lives

Only by combining our resources and skills, will we be able to make an impact!

We hope that you will work together with us to achieve the goal of improving cancer care in Africa.

The Way Forward