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The cancer burden and cancer control in developing countries

The cancer burden and cancer control in developing countries Substantial changes in large parts of the developing world have materialised in the last three decades. These are extremely diverse countries with respect to culture, societal values and political arrangements, but sharing one feature - prevalent poverty and limited resources to protect the health of individuals. The control of emerging chronic diseases in low-resource countries is a formidable challenge. For this reason any intervention should be kept logistically simple and incorporated into a general plan aiming at building gradually the infrastructure that is necessary to bring care to the population at large. The present contribution summarizes some of the priorities in cancer prevention in developing countries and the underlying evidence base, and addresses some of the challenges. Background cost of different interventions. Means to monitor the Many countries in sub-Saharan Africa still struggle with occurrence of cancer in developing countries are still endemic tuberculosis, malaria, AIDS, nutritional defi- very limited, therefore planning relies largely on esti- ciencies and perinatal conditions that cause high rates mates. Based on the comprehensive GLOBOCAN2008 of premature death and permanent disability, a disease [2] dataset, in developing countries as a whole cancers burden at least one order of magnitude greater than of the lung, stomach, breast, liver, colorectum and cervix cancer. But even where substantial economic develop- are the most common sites in this order, each is at least ment has taken place, as in Thailand, Malaysia, China, twice more frequent than the majority of any other can- India or Brazil, it has failed to benefit society at large; certype(Figure 1);theyare amixof malignancies rather, new health threats are on the rise with limited linked to infections and poverty (stomach, liver and cer- control of the long-term burden of prevalent diseases. vix) and westernization of life styles (lung, breast and Moreover, the lack of comprehensive planning of health colorectum). The Figure 1 shows for comparison the systems has led to wider inequalities in access to health ranking in affluent regions where the four top sites are care. lung, breast, colorectum and prostate. In the context of Cancer control encompasses a package of diverse cancer control it is particularly important to remark interventions [1] aiming at reducing morbidity and mor- that in both high- (generally rich) and low-risk (gener- tality from the disease, with wide variations in costs and ally less wealthy) countries, such common sites account for only half of the burden. potential impact. Under serious budgetary constrains and competition with the demands of other diseases, cancer control programmes need to make wise choices Options for prevention to maximise the efficacy of their investments. Smoking of commercial cigarettes used to be uncom- Choices should be driven primarily by the quantifica- mon in developing countries where tobacco smoking is tion of the problem combined with the feasibility and a recent aspect of Westernization of life styles. While interventions to reduce the habit in rich countries is Correspondence: paola.pisani@unito.it now showing positive results, the tobacco industry is University of Turin, Italy pursuing new markets in the developing world [3,4]. Of © 2011 Pisani; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Pisani Environmental Health 2011, 10(Suppl 1):S2 Page 2 of 4 http://www.ehjournal.net/content/10/S1/S2 Less Less dev deve ellop oped ed c co ount untr riie es s M Mo ore d re de evel velo oped ped cou coun nt tri ries es Lu Lu Lun n ng g g Top 6 Top 6 s si ites tes: : Top 4 Top 4 si site tes s: : Bre Bre Brea a ast st st Co Co Colorectum lorectum lorectum 55 55% % o of f al alll 50 50% % o of f a al ll l Stomach Stomach Stomach Pro Pro Pros s stat tat tate e e Li Li Liv v ve e er r r C C Ce e erv rv rvix uteri ix uteri ix uteri Oesoph Oesoph Oesophagu agu agus s s Bl Bl Bla a ad d dd d de e er r r Non-H Non-H Non-Ho o odgkin l dgkin l dgkin ly y ym m mp p ph h ho o oma ma ma Le Le Leu u uk k kaem aem aemi i ia a a Co Co Corp rp rpus us us ute ute uter r riii P P Pa a anc nc ncr r reas eas eas Ki Ki Kidn dn dne e ey y y Br Br Brai ai ain, n n, n n, ne e er r rv v vou ou ous s s s s sy y yst st stem em em Ov Ov Ovar ar ary y y Th Th Thy y yr r roi oi oid d d Me Me Mela la lano no noma of ma of ma of s s sk k kin in in Lar Lar Lary y ynx nx nx Gallbl Gallbl Gallbladd add adde e er r r Other phar Other phar Other phary y ynx nx nx Mu Mu Mult lt ltiiip p ple m le m le my y yel el eloma oma oma Na Na Nasoph soph sophar ar ary y yn n nx x x Hodgkin l Hodgkin l Hodgkin ly y ym m mp p ph h ho o oma ma ma Test Test Testis is is 10 10 1000 00 00000 000 000 8 8 80 0 0000 000 0000 0 0 60 60 60000 000 0000 0 0 40 40 400000 0000 0000 2 2 20 0 0000 000 0000 0 0 0 0 0 20 20 20000 000 0000 0 0 40 40 400 0 0000 000 000 60 60 6000 00 0000 00 00 80 80 800 0 0000 000 000 10 10 1000000 00000 00000 Figure 1 Cancer incidence 2008, males and females. Estimated numbers of new cases per year by level of economical development [2]. all possible interventions to reduce the cancer burden, measure the full impact of the intervention; but high comprehensive programmes to prevent tobacco smoking coverage and reduced incidence of chronic hepatitis are the most cost-effective: the impact on future chronic have been achieved [5] promising success also with diseaseburdenisthe largestachievablebypreventing respect to the malignant disease. Sadly, immunization one single factor, against measures that are inexpensive coverage remains low in the regions that would benefit to governments such as banning smoking in public most from this public health measure (Figure 2). places and impose high taxes on the product. Tobacco One of the most celebrated successes of cancer prevention should be a priority for all countries. research is the recognition that virtually all cervix can- Immunization of infants against hepatitis B virus cers are caused by certain types of the Human Papil- (HBV) is probably the second most cost-effective option loma Virus (HPV) with types 16 and 18 accounting for in regions where the infection is still endemic. Lorenzo about 80% of the burden [6]. The finding led to the Tomatis at the International Agency for Research on development and testing of vaccines that are now Cancer saw the potential of such public health measure approved in many countries. The logistics of high cover- in the early eighties when he promoted the establish- age HPV immunization programmes is more complex ment of The Gambia Hepatitis Intervention Study than that of vaccination of infants since they target ado- (GHIS). The main objective of the study was to prove lescents before they become sexually active. Inherent the feasibility of such interventions and quantify the effi- difficulties are amplified in developing countries where cacy of immunization in preventing chronic liver dis- access to preventive medical services is limited in parti- eases and hepatocellular cancer in an African country. cular for girls. Even under the ideal (and unrealistic) hypothesis that all new generations of girls will be Several more years of observation are needed to Pisani Environmental Health 2011, 10(Suppl 1):S2 Page 3 of 4 http://www.ehjournal.net/content/10/S1/S2 and-treat strategy is an effective intervention requiring Immunization coverage limited expenditure. among 1-year-olds (WHO) There is no single strategy to develop cervix cancer control programmes from scratch. With a careful analy- HepB3 WHO Region sis of the size of the problem, feasibility, costs and expected outcomes against the background of existing infrastructure, plans can be gradually built from a mini- African Region 29% mal level —e.g. one life-time HPV-based screening test Region of the Americas 77% with timely treatment accessible to all women from age South-East Asia Region 13% 35 years— andexpandedonthe medium-orlong-term European Region 67% with immunization programmes and repeated screening. The condition for any intervention to be successful and cost-effective is to reach high coverage of the target population; therefore, much attention must be paid to Source: www.who.int/WHOSIS the logistics of how the services are delivered in order [14] to ensure access and high compliance. Figure 2 Immunization coverage among 1-year-olds (WHO). Other preventive interventions that are the object of much research and activities in the West focus on nutri- protected with vaccines, already infected women will tional habits and energy balance, clearly an increasing continue to be threatened by cervix cancer for decades. problem in emerging economies as shown by rising A realistic view must recognise that large strata of rates of diabetes [9] . Tackling obesity and excessive womenindevelopingcountries will continue to be body weight is proving a difficult task in Western coun- exposed to the infection and will develop the disease. tries; it might be even more difficult in populations Prevention of invasive cancer by early detection and where over-nutrition coexists with malnutrition. Doc- timely treatment will remain therefore an important tors, health care operators and teachers are in the best component of cancer control policies. position to advise and counsel people; they should be Compared with classical cytology-based screening, the made aware of their responsibility and be trained to HPV technology offers a valid and possibly more cost- monitor, educate and convey targeted messages. effective strategy in secondary prevention of cervix can- The increased risk of breast cancer in emerging economies is seen as the direct expression of econom- cer in low-resource settings, because the sensitivity and ical development; yet, our understanding of the modifi- specificity of available HPV tests in exfoliated cells are able causes of the disease is still very limited leaving much more reproducible than those of cytology which little room for primary prevention beyond avoiding strongly depends on human expertise and skill [7]. In excessive body weight. Improving access to timely treat- fact, to maintain high quality standards of screening by ment of early palpable tumours is likely to result in a cytology in developing countries has proved difficult, greater benefit to the population. Etiological research in costly, and too often ineffective. populations still at low or intermediate risk for the dis- In a large randomised trial in Kerala, India, Sankara- ease offer instead powerful opportunities to test hypoth- nayan and colleagues [8] assessed the efficacy of a single eses based on observations made in the high-risk examination by three screening modalities —HPV test- ing by Hybrid Capture II for 16 high-risk types, cytology Western world. and visual inspection with acetic acid (VIA) — in redu- Finally, an area that is often overlooked among pre- cing mortality from cervix cancer compared with back- ventive actions in low-resource countries is the uncon- ground rates achieved by usual care. The intervention trolled use of carcinogens in industrial processes and was designed to maximise compliance of positive economical activities, often imported from technologi- women with diagnostic follow-up and treatment, given cally advanced economies where regulations impose local living conditions and infrastructure. Colposcopy uses that are safe for workers and the environment, but and biopsy of all suspicious lesions were performed dur- less profitable. Any attempt to estimate the magnitude ing the screening visit; small lesions were treated by of the current and future disease burden due to poten- cryotherapy or loop electrosurgical excision in primary tial carcinogens newly introduced under uncontrolled health units. Eight years after a single screen examina- conditions would be highly controversial as lack of regu- lations implies also lack of monitoring of the amount, tion, mortality from cervix cancer was halved in those usage and disposal of hazardous substances. Nonethe- HPV-tested. Smaller reductions were found in women less, whatever the size of the problem, ethical principles screened by the other two modalities. This project impose the inclusion in any cancer control programme proves that screening for HPV combined with the see- Pisani Environmental Health 2011, 10(Suppl 1):S2 Page 4 of 4 http://www.ehjournal.net/content/10/S1/S2 References of actions to prevent occupational exposure and envir- 1. World Health Organization: Cancer control: knowledge into action. Guide onmental contamination with carcinogens. As a first for Effective Programmes, http://www.who.int/cancer accessed May 2010. step in this direction both rich and poor countries 2. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM: GLOBOCAN 2008, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. should be encouraged to sign up to the Rotterdam Con- 10 [Internet]. Lyon, France: International Agency for Research on Cancer 2010 vention whose objectives are to promote shared respon- [http://globocan.iarc.fr]. sibility in the international trade of hazardous chemicals 3. World Health Organization: Tobacco Atlas (The). Nonserial Publication, WHO, Geneva;Mackay, J., Eriksen, M 2002. and to contribute to their sound use [10]. Bodies sub- 4. Shafey O, Eriksen M, Ross H, Mackay J: The Tobacco Atlas. American Cancer scribing to the Convention commit to disseminate infor- Society. 3rd edition. Atlanta, USA; 2009. mation on the characteristics and hazards of substances 5. Viviani S, Carrieri P, Bah E, Hall AJ, Kirk GD, Mendy M, Montesano R, Plymoth A, Sam O, Van der Sande M, Whittle H, Hainaut P: Gambia traded among parties. Hepatitis Intervention Study. 20 years into the Gambia Hepatitis Intervention Study: assessment of initial hypotheses and prospects for Cancer care evaluation of protective effectiveness against liver cancer. Cancer Epidemiol Biomarkers Prev 2008, 17:3216-23. In rich countries the combination of early detection and 6. Walboomers JM, Jacobs MV, Manos MM, Bosch FX, Kummer JA, Shah KV, new treatments that can improve disease outcomes have Snijders PJ, Peto J, Meijer CJ, Muñoz N: Human papillomavirus is a contributed to a modest but constant decline in cancer necessary cause of invasive cervical cancer worldwide. J Pathol 1999, 189:12-9. mortality rates that started in the 1980s [11]. The main 7. Cuzick J, Arbyn M, Sankaranarayanan R, Tsu V, Ronco G, Mayrand MH, determinant of such success is not the availability of Dillner J, Meijer CJ: Overview of human papillomavirus-based and other more effective curative drugs but widespread access to novel options for cervical cancer screening in developed and developing countries. Vaccine 2008, 26(Suppl 10):K29-41. health care through comprehensive health systems. In 8. Sankaranarayanan R, Nene BM, Shastri SS, Jayant K, Muwonge R, developing countries, poor infrastructure to intervene Budukh AM, Hingmire S, Malvi SG, Thorat R, Kothari A, Chinoy R, Kelkar R, timely and to deliver even basic care may jeopardize Kane S, Desai S, Keskar VR, Rajeshwarkar R, Panse N, Dinshaw KA: HPV screening for cervical cancer in rural India. N Engl J Med 2009, well-meaning projects directed to specific diseases or 360:1385-94. conditions. Actions directed to specific outcomes, e.g. 9. Chan JC, Malik V, Jia W, Kadowaki T, Yajnik CS, Yoon KH, Hu FB: Diabetes in making treatment for some childhood malignancies and Asia: epidemiology, risk factors, and pathophysiology. JAMA 2009, 301(20):2129-40. early breast cancer available to all cases, should be 10. Harjula H: Hazardous waste: recognition of the problem and response. selected and included in a cancer control plans only if Ann N Y Acad Sci 2006, 1076:462-77. they have high potential impact (high rate of success) at 11. Abegunde DO, Mathers CD, Adam T, Ortegon M, Strong K: The burden and costs of chronic diseases in low-income and middle-income affordable costs. Having this principles in mind, the countries. Lancet 2007, 370(9603):1929-38. development of means to provide pain relief and pallia- 12. Stjernswärd J: WHO cancer pain relief programme. Cancer Surv 1988, tive care to cancer cases and other terminally ill patients 7:195-208. 13. Stjernswärd J, Foley KM, Ferris FD: Integrating palliative care into national is a much cost-effective option (in developing countries policies. J Pain Symptom Manage 2007, 33(5):514-20. two cases in three die from the disease): to reduce the 14. World Health Organization: Global Health Risks: Mortality and burden of suffering is a benefit that all human beings value, it does disease attributable to selected major risks. WHO, Geneva; 2009. not require sophisticated technology, and it is for all doi:10.1186/1476-069X-10-S1-S2 cases. Back in the 1980s, having recognised that lack of Cite this article as: Pisani: The cancer burden and cancer control in developing countries. Environmental Health 2011 10(Suppl 1):S2. access to palliative care in poor countries was a major public health problem, the WHO established the Cancer Pain Programme [12]. Twenty years later, palliative care still struggles to gain priority with policy-makers. Only recently palliative care and pain relief programmes have been considered a necessary component of the mini- mum core services that health systems ought to offer to citizens [13] . Submit your next manuscript to BioMed Central and take full advantage of: Acknowledgements This article has been published as part of Environmental Health Volume 10 • Convenient online submission Supplement 1, 2011: Proceedings of the First Lorenzo Tomatis Conference on Environment and Cancer. The full contents of the supplement are • Thorough peer review available online at http://www.ehjournal.net/supplements/10/S1. • No space constraints or color figure charges • Immediate publication on acceptance Competing interests The author declare no competing financial or non-financial interests. • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Published: 5 April 2011 Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Environmental Health Springer Journals

The cancer burden and cancer control in developing countries

Environmental Health , Volume 10 (1) – Apr 5, 2011

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Springer Journals
Copyright
Copyright © 2011 by Pisani; licensee BioMed Central Ltd.
Subject
Environment; Environmental Health; Occupational Medicine/Industrial Medicine; Public Health
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1476-069X
DOI
10.1186/1476-069X-10-S1-S2
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21489212
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Abstract

Substantial changes in large parts of the developing world have materialised in the last three decades. These are extremely diverse countries with respect to culture, societal values and political arrangements, but sharing one feature - prevalent poverty and limited resources to protect the health of individuals. The control of emerging chronic diseases in low-resource countries is a formidable challenge. For this reason any intervention should be kept logistically simple and incorporated into a general plan aiming at building gradually the infrastructure that is necessary to bring care to the population at large. The present contribution summarizes some of the priorities in cancer prevention in developing countries and the underlying evidence base, and addresses some of the challenges. Background cost of different interventions. Means to monitor the Many countries in sub-Saharan Africa still struggle with occurrence of cancer in developing countries are still endemic tuberculosis, malaria, AIDS, nutritional defi- very limited, therefore planning relies largely on esti- ciencies and perinatal conditions that cause high rates mates. Based on the comprehensive GLOBOCAN2008 of premature death and permanent disability, a disease [2] dataset, in developing countries as a whole cancers burden at least one order of magnitude greater than of the lung, stomach, breast, liver, colorectum and cervix cancer. But even where substantial economic develop- are the most common sites in this order, each is at least ment has taken place, as in Thailand, Malaysia, China, twice more frequent than the majority of any other can- India or Brazil, it has failed to benefit society at large; certype(Figure 1);theyare amixof malignancies rather, new health threats are on the rise with limited linked to infections and poverty (stomach, liver and cer- control of the long-term burden of prevalent diseases. vix) and westernization of life styles (lung, breast and Moreover, the lack of comprehensive planning of health colorectum). The Figure 1 shows for comparison the systems has led to wider inequalities in access to health ranking in affluent regions where the four top sites are care. lung, breast, colorectum and prostate. In the context of Cancer control encompasses a package of diverse cancer control it is particularly important to remark interventions [1] aiming at reducing morbidity and mor- that in both high- (generally rich) and low-risk (gener- tality from the disease, with wide variations in costs and ally less wealthy) countries, such common sites account for only half of the burden. potential impact. Under serious budgetary constrains and competition with the demands of other diseases, cancer control programmes need to make wise choices Options for prevention to maximise the efficacy of their investments. Smoking of commercial cigarettes used to be uncom- Choices should be driven primarily by the quantifica- mon in developing countries where tobacco smoking is tion of the problem combined with the feasibility and a recent aspect of Westernization of life styles. While interventions to reduce the habit in rich countries is Correspondence: paola.pisani@unito.it now showing positive results, the tobacco industry is University of Turin, Italy pursuing new markets in the developing world [3,4]. Of © 2011 Pisani; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Pisani Environmental Health 2011, 10(Suppl 1):S2 Page 2 of 4 http://www.ehjournal.net/content/10/S1/S2 Less Less dev deve ellop oped ed c co ount untr riie es s M Mo ore d re de evel velo oped ped cou coun nt tri ries es Lu Lu Lun n ng g g Top 6 Top 6 s si ites tes: : Top 4 Top 4 si site tes s: : Bre Bre Brea a ast st st Co Co Colorectum lorectum lorectum 55 55% % o of f al alll 50 50% % o of f a al ll l Stomach Stomach Stomach Pro Pro Pros s stat tat tate e e Li Li Liv v ve e er r r C C Ce e erv rv rvix uteri ix uteri ix uteri Oesoph Oesoph Oesophagu agu agus s s Bl Bl Bla a ad d dd d de e er r r Non-H Non-H Non-Ho o odgkin l dgkin l dgkin ly y ym m mp p ph h ho o oma ma ma Le Le Leu u uk k kaem aem aemi i ia a a Co Co Corp rp rpus us us ute ute uter r riii P P Pa a anc nc ncr r reas eas eas Ki Ki Kidn dn dne e ey y y Br Br Brai ai ain, n n, n n, ne e er r rv v vou ou ous s s s s sy y yst st stem em em Ov Ov Ovar ar ary y y Th Th Thy y yr r roi oi oid d d Me Me Mela la lano no noma of ma of ma of s s sk k kin in in Lar Lar Lary y ynx nx nx Gallbl Gallbl Gallbladd add adde e er r r Other phar Other phar Other phary y ynx nx nx Mu Mu Mult lt ltiiip p ple m le m le my y yel el eloma oma oma Na Na Nasoph soph sophar ar ary y yn n nx x x Hodgkin l Hodgkin l Hodgkin ly y ym m mp p ph h ho o oma ma ma Test Test Testis is is 10 10 1000 00 00000 000 000 8 8 80 0 0000 000 0000 0 0 60 60 60000 000 0000 0 0 40 40 400000 0000 0000 2 2 20 0 0000 000 0000 0 0 0 0 0 20 20 20000 000 0000 0 0 40 40 400 0 0000 000 000 60 60 6000 00 0000 00 00 80 80 800 0 0000 000 000 10 10 1000000 00000 00000 Figure 1 Cancer incidence 2008, males and females. Estimated numbers of new cases per year by level of economical development [2]. all possible interventions to reduce the cancer burden, measure the full impact of the intervention; but high comprehensive programmes to prevent tobacco smoking coverage and reduced incidence of chronic hepatitis are the most cost-effective: the impact on future chronic have been achieved [5] promising success also with diseaseburdenisthe largestachievablebypreventing respect to the malignant disease. Sadly, immunization one single factor, against measures that are inexpensive coverage remains low in the regions that would benefit to governments such as banning smoking in public most from this public health measure (Figure 2). places and impose high taxes on the product. Tobacco One of the most celebrated successes of cancer prevention should be a priority for all countries. research is the recognition that virtually all cervix can- Immunization of infants against hepatitis B virus cers are caused by certain types of the Human Papil- (HBV) is probably the second most cost-effective option loma Virus (HPV) with types 16 and 18 accounting for in regions where the infection is still endemic. Lorenzo about 80% of the burden [6]. The finding led to the Tomatis at the International Agency for Research on development and testing of vaccines that are now Cancer saw the potential of such public health measure approved in many countries. The logistics of high cover- in the early eighties when he promoted the establish- age HPV immunization programmes is more complex ment of The Gambia Hepatitis Intervention Study than that of vaccination of infants since they target ado- (GHIS). The main objective of the study was to prove lescents before they become sexually active. Inherent the feasibility of such interventions and quantify the effi- difficulties are amplified in developing countries where cacy of immunization in preventing chronic liver dis- access to preventive medical services is limited in parti- eases and hepatocellular cancer in an African country. cular for girls. Even under the ideal (and unrealistic) hypothesis that all new generations of girls will be Several more years of observation are needed to Pisani Environmental Health 2011, 10(Suppl 1):S2 Page 3 of 4 http://www.ehjournal.net/content/10/S1/S2 and-treat strategy is an effective intervention requiring Immunization coverage limited expenditure. among 1-year-olds (WHO) There is no single strategy to develop cervix cancer control programmes from scratch. With a careful analy- HepB3 WHO Region sis of the size of the problem, feasibility, costs and expected outcomes against the background of existing infrastructure, plans can be gradually built from a mini- African Region 29% mal level —e.g. one life-time HPV-based screening test Region of the Americas 77% with timely treatment accessible to all women from age South-East Asia Region 13% 35 years— andexpandedonthe medium-orlong-term European Region 67% with immunization programmes and repeated screening. The condition for any intervention to be successful and cost-effective is to reach high coverage of the target population; therefore, much attention must be paid to Source: www.who.int/WHOSIS the logistics of how the services are delivered in order [14] to ensure access and high compliance. Figure 2 Immunization coverage among 1-year-olds (WHO). Other preventive interventions that are the object of much research and activities in the West focus on nutri- protected with vaccines, already infected women will tional habits and energy balance, clearly an increasing continue to be threatened by cervix cancer for decades. problem in emerging economies as shown by rising A realistic view must recognise that large strata of rates of diabetes [9] . Tackling obesity and excessive womenindevelopingcountries will continue to be body weight is proving a difficult task in Western coun- exposed to the infection and will develop the disease. tries; it might be even more difficult in populations Prevention of invasive cancer by early detection and where over-nutrition coexists with malnutrition. Doc- timely treatment will remain therefore an important tors, health care operators and teachers are in the best component of cancer control policies. position to advise and counsel people; they should be Compared with classical cytology-based screening, the made aware of their responsibility and be trained to HPV technology offers a valid and possibly more cost- monitor, educate and convey targeted messages. effective strategy in secondary prevention of cervix can- The increased risk of breast cancer in emerging economies is seen as the direct expression of econom- cer in low-resource settings, because the sensitivity and ical development; yet, our understanding of the modifi- specificity of available HPV tests in exfoliated cells are able causes of the disease is still very limited leaving much more reproducible than those of cytology which little room for primary prevention beyond avoiding strongly depends on human expertise and skill [7]. In excessive body weight. Improving access to timely treat- fact, to maintain high quality standards of screening by ment of early palpable tumours is likely to result in a cytology in developing countries has proved difficult, greater benefit to the population. Etiological research in costly, and too often ineffective. populations still at low or intermediate risk for the dis- In a large randomised trial in Kerala, India, Sankara- ease offer instead powerful opportunities to test hypoth- nayan and colleagues [8] assessed the efficacy of a single eses based on observations made in the high-risk examination by three screening modalities —HPV test- ing by Hybrid Capture II for 16 high-risk types, cytology Western world. and visual inspection with acetic acid (VIA) — in redu- Finally, an area that is often overlooked among pre- cing mortality from cervix cancer compared with back- ventive actions in low-resource countries is the uncon- ground rates achieved by usual care. The intervention trolled use of carcinogens in industrial processes and was designed to maximise compliance of positive economical activities, often imported from technologi- women with diagnostic follow-up and treatment, given cally advanced economies where regulations impose local living conditions and infrastructure. Colposcopy uses that are safe for workers and the environment, but and biopsy of all suspicious lesions were performed dur- less profitable. Any attempt to estimate the magnitude ing the screening visit; small lesions were treated by of the current and future disease burden due to poten- cryotherapy or loop electrosurgical excision in primary tial carcinogens newly introduced under uncontrolled health units. Eight years after a single screen examina- conditions would be highly controversial as lack of regu- lations implies also lack of monitoring of the amount, tion, mortality from cervix cancer was halved in those usage and disposal of hazardous substances. Nonethe- HPV-tested. Smaller reductions were found in women less, whatever the size of the problem, ethical principles screened by the other two modalities. This project impose the inclusion in any cancer control programme proves that screening for HPV combined with the see- Pisani Environmental Health 2011, 10(Suppl 1):S2 Page 4 of 4 http://www.ehjournal.net/content/10/S1/S2 References of actions to prevent occupational exposure and envir- 1. World Health Organization: Cancer control: knowledge into action. Guide onmental contamination with carcinogens. As a first for Effective Programmes, http://www.who.int/cancer accessed May 2010. step in this direction both rich and poor countries 2. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM: GLOBOCAN 2008, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. should be encouraged to sign up to the Rotterdam Con- 10 [Internet]. Lyon, France: International Agency for Research on Cancer 2010 vention whose objectives are to promote shared respon- [http://globocan.iarc.fr]. sibility in the international trade of hazardous chemicals 3. World Health Organization: Tobacco Atlas (The). Nonserial Publication, WHO, Geneva;Mackay, J., Eriksen, M 2002. and to contribute to their sound use [10]. Bodies sub- 4. Shafey O, Eriksen M, Ross H, Mackay J: The Tobacco Atlas. American Cancer scribing to the Convention commit to disseminate infor- Society. 3rd edition. Atlanta, USA; 2009. mation on the characteristics and hazards of substances 5. Viviani S, Carrieri P, Bah E, Hall AJ, Kirk GD, Mendy M, Montesano R, Plymoth A, Sam O, Van der Sande M, Whittle H, Hainaut P: Gambia traded among parties. Hepatitis Intervention Study. 20 years into the Gambia Hepatitis Intervention Study: assessment of initial hypotheses and prospects for Cancer care evaluation of protective effectiveness against liver cancer. Cancer Epidemiol Biomarkers Prev 2008, 17:3216-23. In rich countries the combination of early detection and 6. Walboomers JM, Jacobs MV, Manos MM, Bosch FX, Kummer JA, Shah KV, new treatments that can improve disease outcomes have Snijders PJ, Peto J, Meijer CJ, Muñoz N: Human papillomavirus is a contributed to a modest but constant decline in cancer necessary cause of invasive cervical cancer worldwide. J Pathol 1999, 189:12-9. mortality rates that started in the 1980s [11]. The main 7. Cuzick J, Arbyn M, Sankaranarayanan R, Tsu V, Ronco G, Mayrand MH, determinant of such success is not the availability of Dillner J, Meijer CJ: Overview of human papillomavirus-based and other more effective curative drugs but widespread access to novel options for cervical cancer screening in developed and developing countries. Vaccine 2008, 26(Suppl 10):K29-41. health care through comprehensive health systems. In 8. Sankaranarayanan R, Nene BM, Shastri SS, Jayant K, Muwonge R, developing countries, poor infrastructure to intervene Budukh AM, Hingmire S, Malvi SG, Thorat R, Kothari A, Chinoy R, Kelkar R, timely and to deliver even basic care may jeopardize Kane S, Desai S, Keskar VR, Rajeshwarkar R, Panse N, Dinshaw KA: HPV screening for cervical cancer in rural India. N Engl J Med 2009, well-meaning projects directed to specific diseases or 360:1385-94. conditions. Actions directed to specific outcomes, e.g. 9. Chan JC, Malik V, Jia W, Kadowaki T, Yajnik CS, Yoon KH, Hu FB: Diabetes in making treatment for some childhood malignancies and Asia: epidemiology, risk factors, and pathophysiology. JAMA 2009, 301(20):2129-40. early breast cancer available to all cases, should be 10. Harjula H: Hazardous waste: recognition of the problem and response. selected and included in a cancer control plans only if Ann N Y Acad Sci 2006, 1076:462-77. they have high potential impact (high rate of success) at 11. Abegunde DO, Mathers CD, Adam T, Ortegon M, Strong K: The burden and costs of chronic diseases in low-income and middle-income affordable costs. Having this principles in mind, the countries. Lancet 2007, 370(9603):1929-38. development of means to provide pain relief and pallia- 12. Stjernswärd J: WHO cancer pain relief programme. Cancer Surv 1988, tive care to cancer cases and other terminally ill patients 7:195-208. 13. Stjernswärd J, Foley KM, Ferris FD: Integrating palliative care into national is a much cost-effective option (in developing countries policies. J Pain Symptom Manage 2007, 33(5):514-20. two cases in three die from the disease): to reduce the 14. World Health Organization: Global Health Risks: Mortality and burden of suffering is a benefit that all human beings value, it does disease attributable to selected major risks. WHO, Geneva; 2009. not require sophisticated technology, and it is for all doi:10.1186/1476-069X-10-S1-S2 cases. Back in the 1980s, having recognised that lack of Cite this article as: Pisani: The cancer burden and cancer control in developing countries. Environmental Health 2011 10(Suppl 1):S2. access to palliative care in poor countries was a major public health problem, the WHO established the Cancer Pain Programme [12]. Twenty years later, palliative care still struggles to gain priority with policy-makers. Only recently palliative care and pain relief programmes have been considered a necessary component of the mini- mum core services that health systems ought to offer to citizens [13] . Submit your next manuscript to BioMed Central and take full advantage of: Acknowledgements This article has been published as part of Environmental Health Volume 10 • Convenient online submission Supplement 1, 2011: Proceedings of the First Lorenzo Tomatis Conference on Environment and Cancer. The full contents of the supplement are • Thorough peer review available online at http://www.ehjournal.net/supplements/10/S1. • No space constraints or color figure charges • Immediate publication on acceptance Competing interests The author declare no competing financial or non-financial interests. • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Published: 5 April 2011 Submit your manuscript at www.biomedcentral.com/submit

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Published: Apr 5, 2011

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