Implementation of National Cancer Control Programs A'Murat TUNCER MD Director, Cancer Control Depart

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Implementation of National Cancer Control
Programs A.Murat TUNCER MD Director,
Cancer Control Department, MoH
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Burden of the Diseases

• Dramatic shift in the distribution of deaths
• from younger to older ages
• from Group I diseases (communicable, maternal,
  perinatal and nutritional) to non-communicable
  disease (Group II)
• The proportion of deaths due to non-communicable
  disease is projected to rise from 59 in 2002 to
  66 in 2030

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Cancer Risk Factors

• Smoking
• Number of the smokers
• 2010 1.4 billion
• 2020 1.6 billion
• 2030 1.8 billion
• Ageing
• Number of people aged 60 years and above
• 2010 0.8 billion (11.2 )
• 2020 1 billion (13.6 )
• 2030 1.4 billion (16.7 )
• Obesity
• Percentage of obese people in Europe
• 2010 15-28
• 2020 19-35
• 2030 23-43

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Cancer Burden in Europe(Ferlay et al. 2007)

• EU25 2.3 million new cases, 1 million deaths
• Continent3.2 million new cases, 1,7 million
  deaths (55 men)
• Lungprostatebreastcolorectalgt50 incidence,
  gt45 mortality
• Male Lung, prostate, colon-rectum, stomach,
  bladder
• Female Breast, colon-rectum, lung, stomach,
  ovary

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Geographical Variations

• Two-fold range in age-adjusted incidence and
  mortality in man and 1.5-fold in women
• Highest overall cancer incidence rates in men
  Hungary
• Highest overall cancer incidence rates in women
  Denmark and Iceland

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Pharmacetical expenditure ( of total exp)
Health Expenditure (USD/pp)
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Physician per 1.000 p
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Tobacco consumption( of adults)
Obesity (BMIgt30 of adults)
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Chemotherapy for advanced cancer
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40
55
95
AML Breast Ovary Small-cell lung Sarcoma Myeloma
Non-small cell lung Colon Stomach Prostate Pancrea
s Glioma
Hodgkin ALL Testis Choriocarcinoma Childhood
Burkitt
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International policies and instruments for
primary prevention and health promotion

• General
• Europe Code against Cancer (2003 being updated)
• Alcohol
• WHO Resolution on framework for alcohol policy
• EU Alcohol strategy
• European Alcohol and Health Forum
• Nutrition
• WHO food and nutrition action plan
• Global Strategy on Diet and Physical Activity
• EU White Paper on Strategy for Europe on
  nutrition overweight and Obesity
• EU Platform for action on Diet, Physical Activity
  and Health

• Tobacco
• EU Directives on advertising and product
  regulation
• Green Paper on Smoke-free environment
• WHO Framework Convention on Tobacco Control
• HELP campaign
• Environment
• European Environment and Health Strategy
• European Environment and Health Action plan
  2004-2010
• Health and safety at work strategy
• Other policies and instruments
• Free movement and pricing of unhealthy products,
  consumer protection, environmental policy, etc.

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The European Code Against Cancer

• Stricktly apply the legislation designed to
  prevent any exposure to carcinogenic substances
• Women over 25 should participate in cervical
  screening
• Women over 50 should participate in breast
  screening
• Men and women over 50 should participate in colon
  screening
• Participate in vaccination programmes against
  hepatitis B

• Do not smoke
• Avoid obesity
• Moderate physical exercise every day
• Increase daily intake and variety of fruit and
  vegatables
• If you drink alcohol do so in moderation
• Avoid excessive sun exposure

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Cancer Screening Issues

• Earlier detection higher survival chances.
• Screening opportunistic, selective, organised,
  population based,national , regional, pilot
  studies
• (Variety of approaches throughout the EU, not
  all of them are equally effective!)

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Cervical cancer screeening in Europe

• National-population based
• UK
• Norvey,Finland,Sweden,Denmark,Netherland
• Hungary
• Slovenia,Latvia
• Regional Screening
• Spain,Portugal,Italy,Romania,Austria,Czhec
  Republic,Belgium
• Pilot Programs
• France,Greece,Ireland,Estonia
• No National Population Based Program
• Germany

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Cervical cancer screening in Europe

• Slovenia 30 coverage
• Scandinavian countries 100
• Not younger than 20, not older than 35
• Stop at 60-70
• Intervals and policies are different

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Screening for breast cancer

• 50-69 years, two-year interval
• Northern European countries participation 80,
  recall rates 1-8
• Consistent mortality reduction 20-35
• Sweden 15-20 years 12-18
• Edinburgh,Scotland 14 years 21

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Screening for colorectal cancer

• 50-74 age group
• two specimens on three consecutive days(FOB)
• one and two-year screening intervals
• meta-analysis(Towler et al,1998) 6-18reduction
  in mortality
• Nottingham trial
• there was no reduction in incidence
• significant reduction (19) in mortality
• Danish study
• 14 mortality reduction
• Finland 1/3 population covered in 2007
• France, Italy, Netherlands, Poland, UK Regional
  initiatives implementation

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BULDING BLOCKS of CANCERS FUTURE
Society willingness to pay Expectations Economy S
elfishness Spirutialism Family integrity Ethics Po
litical ideology
TECHNOLOGY Biomarker Prevention Screening Diagnosi
s Surgery Radiotherapy Drugs Supprtive care
THE CANCER FUTURE
FINANCE Self-pay Co-payment Optional
insurance Mandatory insurance State
insurance HMO NHS Charity
DELIVERY Hospital-hotel Specialist-primary
Care Professionals role Public vs
private Globalization
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Organisation

• Health Authority Ministry of Health(MoH)
• Drug and pharmacy Prices and certifications
• Treatment services Hospitals
• Cancer Control Department Cancer Control Program
• Public Health Nutritional habits and control of
  the market, tobacco control and
  quitting/cessation programs,healthy life
  style,physical activity
• Collaboration
• Education Ministry of Education (Higher
  Education Council -Universities), NGOs
• Research projects (some) State Planning
  Department (DPT) and Turkish Scientific and
  Technical Council (TUBITAK)
• Finance Ministry of Finance, Department of
  Tresury

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Responsability
Admission flow
Money
Screening
State Hospitals
Primary Health Care
General Health Insurance System
MoH
Patient
Ministry of Finance
DPT
Private Hospitals
University Hospitals
Research
Ministry of Education (High Education Council)
TUBITAK
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Cancer Mortality Turkey (ASR/World per 100,000
Source Globocan 2002)
Lung cancer in Turkey is an even higher
percentage (40) of male cancer deaths Stomach
cancer is unusually high in Turkey accounting for
9.5 of male cancer deaths
Stomach cancer is unusually high in Turkey
accounting for 9 of female cancer deaths Cervix
cancer gt4 of female cancer deaths in Turkey
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Human Resources(for 150.000 new
cases/yearDoctors per 1.000 pop 1.2)

• Medical Oncologist 175
• Pediatric Oncologist 97
• Radiation Oncologist 306
• Pathologist 800
• Radiation Physicist 88
• Oncology Nurse 525
• Physcolog 50
• Social Workers 23

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International papers related with cancer
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VISION OF CANCER CONTROL PROGRAM
SHORT TERM 2008-2010
MID TERM 2010-15
LONG TERM 2030
Organisation for treatment and palliative care
17 Comprehensive center 54 Cancer center
14 Treatment center Human resources New
specialities Dosimetrist
Cytotechnologist Radiology,Pathology
Education and sub.sp. Screen 70 of the target
population
National Cancer Institute Cancer early
diagnosis, screening and education centers for
each city (81) National standart protocols for
breast, cervical and colorectal cancer
screening Active, population based 11 registries
covering 35 Tobacco control
Decrease 15 incidence rate in tobacco related
cancers , 10 in total. Decrease the advanced
stage in screened cancers Decrease cancer
mortality
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CSED and ECs (KETEM)
Awareness
Diagnosis and treatment standarts
Screening Breast, cervix and colon-rectum
Advanced stage
Mortality
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Proje
Diyarbakir
Cancer Screening and Education Centers Project
Kanser Tarama ve Egitim Merkezleri Projesi
/
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Proje
Istanbul
Cancer Screening and Education Centers Project
Kanser Tarama ve Egitim Merkezleri Projesi
/
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Proje
Antalya
Cancer Screening and Education Centers Project
Kanser Tarama ve Egitim Merkezleri Projesi
/
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Strategic Approach

• Budget and investment
• human resources, capacity building, substructur
• Priorities of the problems
• Differences and similarities
• National cancer research strategy
• Original and cost-benefit studies
• Implement policies, strategies and plans
• Collaboration/cooperation/
• organisation
• Govermental responsibility

• Reduce inequity
• Improve cancer services
• Resources
• Clinical guidelines
• Systematic training
• Accreditation
• Monitoring
• Increase prevention and early diagnosis
• Education
• Reduce avoidable premature deaths
• (150.000 12 EU)

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WHO GLOBAL ACTION PLAN SEVEN COMPONENTS

• 1.Advocate for cancer prevention, cure and care
• 2.Promote WHO strategies impacting on cancer
• 3.Promote National Cancer Control Programmes
  (NCCP) in countries based on the four goals and
  multiple strategies approach
• 4.Support NCCP development and implamentation in
  High Burden Low and Middle Income Countries
  (LMCs)
• 5.Monitor implementation and impact of national
  and global interventionsthe WHO Cancer
  Surveillance Project.
• 6.Develop WHO Technical Advisory Committee on
  Cancer
• 7.Develop concultation process to identify
  research priorities to support Action Plan.