The World Health Organization (WHO) estimates a rapid increase of 70% in the number of cancer cases over the next 20 years, with Asia accounting for half of the global burden of cancer.1,2 The increasing cancer burden is more pronounced in low-income countries (LICs).3 Therefore, cancer control management poses a challenge given the socioeconomic and racial/ethnic disparities in cancer globally.4 As such, the implementation of a worldwide standardized “one-size-fits-all solution” for cancer management is not feasible. The benefits of an evidence-based approach towards cancer policy making are evident with the trending paradigm shifting towards a population-based cancer registry (PBCR) in many Asian countries.5 At the ESMO Asia Congress 2019 held in Singapore, expert speakers in Oncology, presented case studies showcasing the decrease in cancer rates in LICs, following the implementation of an evidence-based approach and a population-based registry.
Cancer control management: The WHO perspective
Cancer is the fastest-growing cause of premature death, with 70% of the cancer deaths occurring in low- and middle-income countries.1 Given the high cancer incidence and mortality data in Asia, there is an increasing recognition to formulate sustainable national cancer control plans.2 Implementing an effective strategy is challenging with the existing disparity of the cancer burden loads in Asia due to substantial diversity in social-economic status, human development index, cancer data availability, different cancer patterns, resource availability, political system, health care priorities, and cultural background.3 With the absence of a “one-size-fits-all” solution for improving the quality of cancer care among Asian countries, Dr. André Ilbawi, medical officer at the WHO, discussed the merits of an evidence-based approach as an alternative tool to facilitate the implementation of effective cancer policy.
Challenges in implementing national cancer control plans in LICs
To gain a clearer insight into the limitations encountered, Dr. Ilbawi and his team at WHO analyzed 527 current cancer plans in 158 countries by designing a standard questionnaire.6,7 The data indicated that majority of the problems are consequences of poor policy planning. In light of these findings, Dr. Ilbawi explained the main attributing factors are a lack of evidence to support the formulation of these cancer policies and an absence of costing or monitoring of the cancer control plan. Besides, the other pitfalls observed were, inappropriate interventions, such as screening without treatment (Figure 1), delivering incomplete service packages, providing targeted therapy without pathology, and lack of infrastructure and diagnostic capabilities in deducing the outcome of these therapies. He stated that all these actions led to a misguided expenditure of the cancer budget with no desirable outcomes achieved. He summarized his findings by concluding, “Our hypothesis here with the government is in fact that while we always need more resources for cancer, we can, in fact, look at the efficiency to provide necessary priorities for specific countries.“ In Figure 1, the occurrence of a poorly planned breast cancer screening strategy is mainly seen in LICs predominantly in Asia and Africa.
Supporting parameters for formulating an efficient national cancer control policy
Furthermore, Dr. Ilbawi mentioned that “the government is fully committed to cancer control planning, but through a collaborative approach, we can assure that cancer control plans are appropriately financed and implemented. The focus is on what is value for?” He strongly emphasized that the government is also depending on cancer leaders to play a vital role in shaping up the cancer care planning policy. He further commented that the leaders should consider strengthening the information system by allowing for more harmonization of data. By linking the systems to national cancer planning policy, more stakeholders will be able to contribute significantly to the global discussions about cancer management and access to medicines.8
He ended by highlighting the importance of a reliable and robust data system in providing the framework for cancer registries and policymaking. “Without accurate data, we cannot make informed information. Thus, we cannot monitor what we do not measure,” stated Dr. Ilbawi.
A comprehensive overview of the population-based cancer registries in Asia
Dr. Gouri Shankar Bhattacharyya, a medical officer, at the Department of Medical Oncology, Salt Lake City Medical Centre, Kolkata, India, supported Dr. Ilbawi’s view by commenting, “You can’t measure, you can’t define. You can’t define, you can’t manage. You can’t control, you can’t improve it. You can’t improve what you can’t measure”. He addressed that the data systems serve as a backbone to improve the quality of cancer care.9
He further explained, “Cancer registry is urgently needed for cancer management, prevention and fighting this burden. Actually, you have to know what control programs you need to do and only the registry can tell us this.” As an example, a case study (Figure 2) demonstrated the role of a cancer registry in China to understand the mortality trend in breast cancer and cervix cancer in the female population at different demographic locations (rural and urban).10 The cancer registry allowed the China government to investigate the reason for different mortality patterns, enabling monitoring of the efficacy of this treatment program in mixed populations. In India, the cancer registry showed an exciting finding in which cervical cancer rates in the female population were decreasing without the use of a vaccine, screening program or cancer treatment.11
Despite the conceptual differences between the three registries: PBCRs, hospital cancer registry and pathology registry, the existence of a symbiotic relationship between them is vital in the generation of more useful cancer quality data. To add, Dr. Bhattacharyya focused on the importance of PBCRs for analyzing data about cancer incidence and mortality in a defined cancer population. PBCRs serve to improve cancer control policy in primary cancer prevention, early cancer detection, and screening, and cancer care evaluation. In Asia, an improvement in the three key areas are observed, with the implementation of a PBCRs.12
Optimizing late translational cancer research for cancer drug developments
Dr. Govind Babu, a medical oncologist at Kidwai Memorial Institute of Oncology, further elaborated that a complete cancer registry facilitates an evidence-based personalized cancer development process.
A good cancer registry is not easy to establish and run
Establishing a well-defined cancer registry in Asia remains a challenge due to many constraints. Namely, the lack of knowledge from the government, policymakers, and healthcare professionals, coupled with underqualified staff and financial resources, are all limiting factors. Also, the absence of a well connected transport system in LIC not only hampers data collection but also increases the cost for data verification, consequently diminishing the patients’ ability to receive a fast and efficient healthcare service in Asia. Furthermore, the diverse cultural and religious practices, all add to the social-demographic parameter, subsequently impacting the cancer incidence, survival, and mortality rates.
Given the numerous obstacles present in LIC in allowing for a proper cancer care system, the establishment of a cancer registry is especially important to identify significant cancer risk factors, allowing for the best evidence-based action for a cancer prevention strategy. Moreover, the cancer registry would enable the proper monitoring of the productivity of the existing cancer policy in Asia.
Notably, Professor Soe Aung, Head of Medical Oncology, at the Myanmar Center of Chemotherapy, highlighted the requirements for every global healthcare policy to incorporate the universal ten factors, also known as the “10 rights” as defined in the ASCO-EMSO consensus statement. Ultimately, ASCO-EMSO recognizes that all healthcare plans should meet certain common objectives to ensure access to continuity of quality cancer care. In brief, despite the varying resources and financial options worldwide, cancer patients are entitled to “10 rights” in access to information, privacy, access to medical records, prevention of services, consent to treatment, multidisciplinary cancer care, innovative cancer care, quality cancer care, a comprehensive care summary and follow-up plan after primary therapy and pain management care.
In conclusion, the concept of an evidence-based policy as an approach in establishing a population based-policy with the main objective of reducing and eventually preventing cancer is imperative.
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