What an Association like MTCC can do for a Cancer Center and a non governmental Association from a d

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What an Association like MTCC can do for a Cancer
Center and a non governmental Association from a
developing country ?

• Pr Khaled Rahal
• Pr Hamouda Boussen
• Institut Salah Azaiz. Tunis. Tunisia

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What about Tunisia ?

• Located in Northern Africa, bordering the
  Mediterranean Sea, between Algeria and Libya
• Total Area 163,610 km2 Land 155,360 sq km
  Water 8,250 sq km
• Slightly larger than Georgia
• Total Land boundaries 1,424 km
• Border countries Algeria 965 km, Libya 459 km
• Coastline1,148 km
• Highest point Jebel ech Chambi 1,544 m
• Natural resources petroleum, phosphates, iron
  ore, lead, zinc, salt

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Tunisia demography

• Area in square kilometers 154630 (2004)
• Total population in thousands 10031 (2004)
• Urban population out of total population 65
  (2004)
• Crude birth rate per 1000 population 16.8 (2004)
• Crude death rate per 1000 population 6.0 (2004)
• Population growth rate 1.1 (2004)
• Population below 15 years 26.7 (2004)
• Population 65 years and over 6.8 (2004)
• Dependency ratio 50 (2004)
• Total fertility rate2.0 (2004)
• Life expectancy at birth total population 74.89
  years, male 73.2 years, female 76.71 years
  (2005 est.)
• Total fertility rate 1.75 children

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Tunisia economy

• GDP (purchasing power parity)70.88 billion
  (2004 est.) GDP - real growth rate5.1 (2004
  est.) GDP - per capitapurchasing power parity -
  7,100 (2004 est.) GDP - composition by
  sectoragriculture 13.8 industry 31.8 ,
  services 54.4 (2004 est.) Labor force3.55
  million
• Budgetrevenues 6.799 billion, expenditures
  7.573 billion, including capital expenditures of
  1.6 billion (2004 est.)
• Agriculture-productsolives, olive oil,
  tomatoes, citrus fruit, beef, sugar beets, dates
• Oil - production72,580 bbl/day (2001 est),Oil -
  proved reserves1.7 billion bbl (2004 est.)
  Natural gas - production2.25 billion cu m (2001
  est.)
• Exportstextiles, mechanical goods, phosphates
  and chemicals, agricultural products,
  hydrocarbons. PartnersFrance 33.1, Italy 25.3,
  Germany 9.2, Spain 6.1 (2004)
• Imports11.52 billion f.o.b. (2004 est.) Imports
  - commoditiestextiles, machinery and equipment.
  PartnersFrance 25.1, Italy 19, Germany 8.5,
  Spain 5.3 (2004)
• Currency (code)Tunisian dinar (TND), Exchange
  ratesTunisian dinars per US dollar 1.3707 (2000)

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1200 kms of coasts
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Carrefour of civilisations

• Roman period

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Sites historiques

• Arabo-Byzantine era

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festivals

• International festival of Carthage (july-august)
• International festival of symphonic music of the
  Roman Amphitheatre of El Jem (august)
• Musical october
• Jazz in carthage (april)
• Inernational jazz festival (june)

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MENA ? Thanks and Shukran to

• Samir Khleif, director of the KHCBI
• Sami El Khatib, Research office KHCBI
• Dina and Eman from the research office
• for the organisation and the high level of
  topics andpresentation and we hope to see you in
  Tunisia.

Saadoun Door of Tunis near the ISA
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Breast cancer in Tunisia

• 1st female cancer 25
• 1977 Incidence 8/100 000
• 1994 Incidence 18,5/100 000 F
• Litt Incidence 16 - 100/100 000
• 2004 1500 yearly cases ? incidence of 25 to
  27/100000.

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Breast cancer Nbr of cases per year
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Breast cancer Mean age
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Breast Cancer before 35 years
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Breast cancer Répartition by age
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Institut Salah Azaiz
Pr Najib Mourali, surgical oncologist. First
director

• Unic comprehensive cancer center since 1969
• Unic structure for cancer treatment since 1992
• 200 beds
• Departments of surgical oncology, medical
  oncology, radiotherapy, head and neck surgical
  oncology, nuclear medicine, biostatistics

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Institut Salah Azaiz

• 9 surgical oncologists
• 6 medical oncologists
• 8 radiotherapists
• 5000 new cancers/year
• 600 new breast cancers
• 12000 new consultants/year

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Institut Salah Azaiz

• Department of surgical oncology 72 beds, 5
  operating rooms.
• Department of medical oncology 40 beds, unit of
  pediatric oncology, 5 beds of palliative care
• Department of radiotherapy 2 cobalts, 1 Linac,
  35 beds

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Institut Salah Azaiz

• Department of surgical oncology 72 beds, 5
  operating rooms.
• 7000 surgery procedures, 2000 ambulatory.
• Breast cancer surgery, cervix, ovary, colorectal,
  urology.
• Implantable sites insertions (300/year)

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Institut Salah Azaiz

• Department of Head and Neck surgery, 3 operating
  rooms, 35 beds
• Department of radiology 2 mammographs, 1
  CT-scan 16 slices
• 2 labs of histopathology

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Institut Salah Azaiz

• Specific epidemiological features
• Inflammatory breast cancer 5-7 of BC
• Nasopharyngeal cancer incidence of 3-4/100000
• Cancer in young patients (BC, Digestive, NPC
  chlidrens)

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True inflammatory forms 5-7 of BC in Tunisia
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Inflammatory Breast Cancer Boussen H et al. Semin
Oncol Feb 2008.

• Inclusion criteria
• Patients classified PEV2 and PEV3, treated in
  SAI between January 1976 and December 1981.
• Patients classified T4d, treated in SAI between
  January 1990 and December 1996.
• Exclusion criteria
• The tumors classified PEV 1.
• The ulcer tumors (T4skin).

IGR Classification UICC Classification of
1988
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Inflammatory Breast Cancer Boussen H et al. Semin
Oncol Feb 2008.

• 3 series
• Series A January 1990 till December 1996 breast
  cancer classified T4d as per the UICC
  classification of 1988 (118 cases)
• Series B January 1975 till December 1981 breast
  cancer classified PEV 2 or PEV 3 as per the IGR
  classification and reclassified as T4d as per the
  UICC classification of 1988 given the clinical
  description reported in the medical folder (175
  cases)

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Inflammatory Breast Cancer Comparative Study

• The average clinical tumor size is lower for the
  patients of series C

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Inflammatory Breast Cancer Comparative Study

• The global survival ratio is better for the
  patients of the series C (p0,0001)

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Inflammatory Breast Cancer
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Inflammatory Breast Cancer

• We propose to consider as inflammatory tumor
• every tumor presenting with inflammatory signs,
  oedema and/or erythema, that spreads to the half
  of more of the breast.

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In the years 1970 Data of the Institut Salah
Azaiz 1968 to 1985

• Mean Clinical tumor size of 58,1 mm
• 21,3 of initial metastases
• 44 of PEV
• of PEV3 increas with size (10cm)
• IDC 67, CLI 2,3
• 7 associated to pregnancy

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Cancer features at the ISA Data of the Institut
Salah Azaiz. Boussen et al. (Semin Oncol Feb 2008)

• Inflammatory breast cancer 5-7
• Reassesment of the true incidence of IBC
  (differentiat T4b from T4d)
• 600 new breast cancers
• Mean clinical tumor size of 40mm
• Mean histologic size of 35mm
• 10 lt 35 years.

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What news about epidemiological transion of
nasopharyngeal carcinomas ?
Boussen et al. EMC Oto-rhino-laryngologie
20-590-A-10. 2007.
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Clinical presentation of NPC

Boussen et la. EMC Oto-rhino-laryngologie
20-590-A-10. 2007.
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Cancer features in Tunisia 2004Cancer registries

• BC(25) gt Cervix(6) gt Gallbladd gt CRC
• Lung gt H and Neck gt Bladder gt CRC
• of young patients varying from 5 to 15(NPC in
  childrens)
• 1 comprehensive center, 2 units of oncology(Med
  Radioth) in 2 university hospitals of Sousse and
  Sfax
• Pilot screening-early detection project in one
  state of Tunis capital(Ariana)

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Cancer projects in Tunisia

• National cancer plan 2007-2010
• Collaboration with French Institut National du
  Cancer(INCa)
• Collaboration with Italy (projects of Gafsa and
  Jendouba) ? mammographs-histopathology units-BC
  early detection-medical plus paramedics training

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What MTCC can do for us ?
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Proposition 1 for MTCC

• Good clinical practices in oncology
• Evaluation of quality of practice in surgical
  oncology
• Certification of the practice in surgical
  oncology
• Procedures of accreditation
• Parameters of evaluation Nb, rate of success,
  complications
• Treatment guidelines

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Proposition 2 for MTCC

• What Cursus of surgical oncology, medical
  oncology and radiotherapy ?
• What cursus in other mediterranean countries ?
• Duration and type
• Schedule of evaluation
• Theorical program
• Practical program

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Proposition 3 for MTCC

• Training for fellows or confirmed specialists
  (short duration) in surgical oncology, medical
  oncology and radiotherapy
• Constitution of study groups in surgical oncology
  (IBC, young patients, innovations.)
• Epidemiological survey for inflammatory breast
  cancer

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Proposition 4 for MTCC

• ATAMCS (Association Tunisienne dAssistance aux
  Malades de Cancer du sein)
• Created in 2005, board mixing cured patients and
  oncologists
• Psyschosocial plus financial support to patinets
  affected by BC
• Lobbying techniques
• Network with breast cancer NG associations
• Europa donna

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Propositions 5 for MTCC

• Sustain for screening of colorectal cancer in
  Tunisia. Previous experiences in Europe and
  mediterranean countries.
• Not done presently in Tunisia
• Preliminary cost-study ? benefits
• Problem of cost-benefit of HPV vaccine in Tunisia
• Training in medical epidemiology and
  biostatistics
• Telemedicine with mediterranean centers
  developping a network

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Prostate cancer in Tunisia

• Predominating cancer in aged male
• 5th cancer in man for the cancer of registry of
  Norhern Tunisia 139 cases in 1994
• Crude Incidence of 6,4
• Standardised Incidence of 7,7
• 7 of cancers

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What does MTCC looks like for its developping
part ?
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MTC role in our countries

• Counselor for advanced projects
• Viability of projects
• Auditing the ended projects
• Links with international and European
  associations (scientific, NG)
• Reliable contact with the official authorities
  (min health, research)

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Thanks to MTCC

• Shukran
• Ekkharisto
• Hvala
• Grazie
• Gracias
• Merci