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Experiences from Countries of The Mediterranean Rim:

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Turin, 9th 13th September 2008. Palestine Experience in Breast Cancer. Challenges Along the Way ... Histopathology department at BJGH. ... – PowerPoint PPT presentation

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Title: Experiences from Countries of The Mediterranean Rim:


1
Experiences from Countries of The Mediterranean
Rim
  • The 8th IUHPE European Conference on Health
    Promotion and Education
  • Turin, 9th 13th September 2008

2
Palestine Experience in Breast
Cancer Challenges Along the Way
  • Naheel Abu-Khalaf
  • National Cancer Control Project Officer
  • Italian Cooperation-Jerusalem

3
Worldwide Global cancer
  • The global cancer burden will increase in all
    countries (life style changes)
  • - populations increase in size
  • - people live longer
  • - exposure to risk factors (tobacco, fat
    diet etc.)
  • Cancer causes more deaths globally than AIDS,
    malaria and TB combined.

4
The Continuing Crisis
  • WHO estimated 7.6 million people died of cancer
    in 2005 13 (deaths worldwide)
  • Between (2005-2015)
  • 84 million more people will die if urgent
    action is not taken (x 4 flu pandemic of
    1918).

5
Rising burden of cancer in the Middle East (M.
E.) Countries
  • Cancer is not (and never was) simply a problem of
    rich countries
  • gt 50 of all cancer and 70 of all cancer deaths
    occur in low and middle income countries.
  • M.E. countries will bear an ever-increasing share
    of the cancer burden Mortality

6
Breast cancer incidence
  • Worldwide 1,200,000 new cases / year
  • During the last 20 yrs 2 /yr stable increase
  • 1 out of 9 women will get breast cancer during
    life
  • Breast cancer incidence 60-90/100,000in USA , the
    Netherlands, UK, and several European Countries
  • In Asia the incidence is typically 2-4 times
    lower

7
Breast Cancer Incidence among Palestinian Women
  • BC incidence lt other populations. Still, it is
    the most common malignancy among Palestinians.
  • 2nd leading cause of cancer morbidity mortality
    among Palestinian women.
  • In Palestine (1997) 116 cases of BC were recorded
    ( 23of all cancer cases)
  • Average of 222 new BC in 1998-1999
  • Crude incidence rate-ASR 28.8 /100.000 West
    Bank 34.5/100.000 Gaza Strip

8
Young age Advanced stage at presentation of BC
patients in Palestine
  • 64lt 50 years at the time of diagnosis
  • Survival, Age Stage at diagnosis among
    Palestinian
  • Mean age at diagnosis51.5 years
  • 11 of the Palestinian patients were lt age of
    35
  • Survival, Age Stage at diagnosis Jewish
  • Mean age at diagnosis55.9 years
  • 5 of the Jewish patients were lt age of 35

9
Age Distribution In Palestine
  • Age under 5 years 12.1
  • Age under 15 years 38
  • Age over 65 years 3.6
  • In many countries, 15 to 25 of the population is
    above 65 years of age
  • Increasing age of the population ? Increase
    incidence of cancer

Incidence of Cancer In Palestine 2004
10
Increased Incidence young onset of BC
attributed to
  • 1-Genetic predisposition(BRCA1/2 mutat./Ashkenazi
    W)
  • Genotype analysis
  • 2- Environmental Revolution in life style
  • 3- Hormonal risk factors
  • - Increased utilization of hormones
  • - Contraceptives
  • - Fertility treatments

11
Palestinian Population Suggestive Genetic
Predisposition
  • BRCA1/2 mutations in the Arab population
  • Significant Findings Compared with other
    Populations
  • Advanced stage at presentation
  • Younger age at diagnosis
  • Raise the need for
  • (Development of Screening Programs) to
  • 1-Early detection
  • 2-Defining of high risk group

12
Arab Population/Consanguineous Marriages
  • The Palestinian Arab population is genetically
    heterogeneous (Genetic Disorders-not uniform)
  • Nearly 2/3 of the Palestinians live in small
    villages lt10,000 inhabitants. marriages inside
    villages are frequent (small isolated community)

13
Importance of Genetic Studies In Palestine
  • Genetic predisposition may be modified by the
    rapid change in life style and hormonal factors
    in population
  • Aid in population education and compliance with
    early detection screening programs

14
BC-incidence Diagnosis treatment in Bethlehem
District
  • Audit system developed ( multidisciplinary team
    European breast cancer network , sponsored by
    Europe Against cancer program
  • Outcome measures defined by the European Society
    of Mastology (EUSOMA)
  • SQTM software BC statistics computed
  • Comparison between Bethlehem Ragusa
    (south east Sicily) - Ragusa cancer registry

15
Cancer Project Main Objectives
  • Developing a Master Plan for National Cancer
    Services
  • and care
  • Developing preventive/ diagnostic/ treatment
    guidelines
  • Palliative care
  • Developing cancer case referral system
  • Developing a criteria for Cancer service
    accreditation
  • Upgrading Cancer Information system
  • Developing Preventive Strategies
  • Developing Early detection Program on main types
    of
  • cancers
  • Developing a Breast Cancer Screening Program
  • Implementing Research Activities
  • Raising the Awareness on Cancer Risk Factors

16
Activities
  • 1 Mapping the Cancer Care Providers.
  • 2 Purchasing of Diagnostic equipment
  • 3 purchasing of Drugs consumables
  • 4 Provision of Furniture computers

17
5-Training Modules
  • Module1Development of a master plan for cancer
    services

  • Module 2 Training on How to develop MIS on
    Cancer
  • Module 3 Training on guidelines for Diagnosis
  • treatment and referrals of
    main Types of
  • Cancers
  • Module 4 Train service providers on the early
  • detection of the main types
    of cancer
  • Trainees
  • West Bank32(18Nurses 4 Resident MDs 8
    Oncologists 2 Cancer Registry)
  • 90 Training Hours18days( 5 hours/day)
  • Gaza 90(Nurses, Resident MDs Oncologists
    ,Specialists Cancer Registry)
  • 104 Training Hours13 days (8 hours/day)

18
6 Training on Clinical Breast Examination CBE
APOF Support
  • CBE Training Class
  • Training Location Holly Family Hospital meeting
    room
  • CBE divided into 4 sessions one day classes
    (18-23)persons for each class
  • Each CBE class was divided into 2 sections
  • 1-Theoretical Part
  • 2-Practical Part
  • Beneficiaries
  • 83 trainees were chosen by MOH
  • (members of PHC staff, GPs, Nurses and MCH
    Staff, NGOs, UNRWA)

19
The projects of APOF in Palestine
  • To develop Onco-Haematology Center at BJGH
  • . To provide Technical diagnostic assistance to
  • Histopathology department at BJGH
  • . To support breast cancer prevention and control
    program MOHIC

20
i
  • Objectives of APOF programs are
  • Local staff training (PHC)
  • Development of guidelines ad protocols and
    procedures of breast cancer management
  • Start up of the Breast Unit in BJGH

21
Establishment of Breast Cancer Screening Program
by APOF
  • APOF Training Steps
  • Step 1 Training for PHC Providers
  • Step 2Training for Radiologist Radio
    Technicians
  • Step3Training for Pathologists
  • -Training on FNA
  • -Training on breast cytology
  • - Histo-pathological evaluation of
    Breast Cancer
  • Step4Training for Surgeons
  • - Updated surgical treatment
    for Breast Cancer
  • - Re-constructive surgery
  • Step 5 Training for Oncologists on Medical
    Therapy
  • Hormonal, Chemotherapy, Target
    radiotherapy

22
…Some considerations Effective Screening Program
  • reach as many people as possible.
  • Every PHC could manage a proper project of health
    information (social cultural environ)
  • public and private health cooperation

23
The survival struggle Fatima Bargouth
24
Diagnostic Challenges
BC Burden on Patients
  • -all family members are affected by the stress of
    the illness
  • - disruption to family life
  • -Feeling of neglect
  • -experience mixed feeling about the illness
  • -its treatment demands
  • -socio-emotional problems

25
Awareness
  • The National Health Education committee in
    Palestine is Committed to continuing education as
    a means of ensuring quality patient care
  • Awareness campaign activities
  • 100 Workshops was held on Awareness on
  • - Breast Cancer symptoms
  • - Breast self examination covering all WB
    districts
  • Two Awareness brochures Posters were produced
  • Breast Self Examination cervical cancer
  • Existent and Previous educational materials and
    brochures were reviewed, Printed distributed to
    many NGOs and Universities.

26
Establishment of BC unit in BJGH
  • No proven way to prevent BC
  • Mammography CBE offer best chance of saving
    lives
  • Regular Mammography (W 56-69 Yrs) can reduce
    deaths from BC by 1/3 or more

27
Clinical Breast Examination
  • CBE class was implemented with the support of
    APOF
  • Plastic model was used to train PHC providers in
    area around BJGH

28
Capacity building Cancer program in Palestine
  • Training of the cancer services providers
    Hospitals ( pilot area-BJGH)
  • On cancer services accreditation
  • On cancer information system
  • On early detection of all types of cancers
  • On breast cancer screening

29
Diagnostic Challenges
Challenges
  • Communications Barriers
  • Informed decisions
  • Code status
  • Legal dimension
  • Patient Rights
  • Second opinion
  • All the available options

30
Diagnostic Challenges
Technical Challenges
  • Political dimension
  • Patient staff movement
  • Procedure for permits
  • Licensing of radiation therapy facilities
    radioisotopes
  • Financial
  • unemployment
  • No social security
  • no medical insurance
  • Referral System
  • Logistics
  • Different procedures at different institutions

31
Diagnostic Challenges
Diagnostic Challenges
  • Histo-pathology
  • Regular pathology margin, special stains
  • Additional tests ER, PR, Her 2
  • FlSH for verification of Her 2 status
  • Flow cytometry cytogenetics
  • Radiology
  • Nuclear Imaging
  • PET CT

32
Diagnostic Challenges
Therapeutic Challenges
  • Surgical Issues
  • Orientation of margins
  • Number of resected lymph node
  • Sentinel lymph node biopsy
  • Other Issues
  • Inadequate staging
  • radioactive isotopes

33
Diagnostic Challenges
Financial Challenges
  • More effective new drugs for more diseases in
    more patients who will live longer and spend more
    time on prolonged therapy
  • Probable emergence of effective preventative
    therapy for high-risk well populations
  • Continuous pressure from public and health care
    professionals for access to new agents

34
Diagnostic Challenges
Financial Challenges
  • Increasing requirements for education,
    recruitment, retention and funding of a broad
    range of health care professionals involved in
    the delivery of care
  • Health care systems must plan, prioritize and
    evaluate new and existing programs across all
    areas of health care in order to ensure optimal
    distribution of resources.
  • Problems are 'systemic' throughout Palestine and
    the Middle Eastern Countries

35
Diagnostic Challenges
Palliative Care
  • No pain specialists or clinics
  • No hospice program
  • Morphine other opioids are not easily
    accessible or financially affordable
  • For the West Bank patients, very limited options
    of pain medications are available

36
Multidisciplinary Approach
  • Its evolving, but for the most part the patient
    care is fragmented
  • Tumour Board meetings are becoming a regular
    thing at some centrers
  • Working groups, much talked about, but therere
    technical factors
  • Hopefully, inter-institutional meetings would
    become regular

37
Ethical Issues In Palestine Leaving from the past
looking to the future
  • -One of the most highly educated group
  • -Ethical concerns in participation and
    empowerment
  • - The beliefs moral traditions

38
Diagnostic Challenges
The Road Ahead
  • -Education is the key to a better future
  • -The need to evaluate the success and failure in
    Health Promotion in different cultures
  • - Respectful of individual differences and
  • Traditional values

39
Health Development
  • needs to be build from bottom to top
  • we will end up with social Darwinism The
    one who survive
    (The richest , the most powerful....)

40
Research
  • The need of well designed studies in understudied
    population
  • Basic research
  • Research survey on topics relatedto Occupational
    cancers
  • Statistical analysis of Cancer registry data
    analyses

41
US-Middle East Partnership for BC Awareness
Research-MEPI
  • Introduction of comprehensive baseline
    assessments of breast cancer awareness and
    services in Egypt OPT
  • Noted significant achievements in Jordan Saudi
    Arabia
  • Expand its reach , based on results of this newly
    research tool partnership

42
Published in BMC Cancer-2007
  • A novel BRCA-1 mutation in Arab kindred from east
    Jerusalem with breast and ovarian cancer BMC
    Cancer 2007
  •  The electronic version of this article can be
    found online at http//www.biomedcentral.com/1471
    -2407/7/14

43
There is nothing like a dream to create future
Victor Hugo
Thank You
44
The end ( or rather the beginning)
45
HEBRON
46
The program of local staff training for breast
cancer screening project
47
Allocate Resources Based on NEED
  • Need Disease epidemiology
  • This appears to be a reasonable approach to
    managing resources.
  • However, NEED is a difficult term because the
    major stakeholders have different definitions.
  • NEED may also neglect health promotion and
    preventive medicine.

48
Strategies on breast cancer control policy
  • 1-Develop actions in the field of breast cancer
    training awareness and research
  • 2- Prevent deaths from breast cancer there is a
    need of
  • -early detection programs
  • -evaluate some indicators on diagnosis and
    treatment
  • - Set a baseline for a mammography breast cancer
    screening
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