Rengaswamy Sankaranarayanan

Tackling cancer burden in low-income and middle-income countries: Morocco as an exemplar

Examples of successful implementations of national cancer control plans in low-income or middle-income countries remain rare. Morocco, a country where cancer is already the second leading cause of death after cardiovascular diseases, is one exception in this regard. Population ageing and lifestyle changes are the major drivers that are further increasing the cancer burden in the country. Facing this challenge, the Moroccan Ministry of Health has developed a we l planned and pragmatic National Plan for Cancer Prevention and Control (NPCPC) that, since 2010, has been implemented with government financial support to provide basic cancer care services across the entire range of cancer control. Several features of the development and implementation of the NPCPC and health-care financing in Morocco provide exemplars for other low-income and middle-income countries to follow. Additionally, from the first 5 years of NPCPC, several areas were shown to require further focus through implementation research, notably in strengthening cancer awareness, risk reduction, and the referral pathways for prevention, early detection, treatment, and follow-up care. Working together with a wide range of stakeholders, and engagement with stakeholders outside the health-care system on a more holistic approach can provide further opportunities for the national authorities to build on their successes and realise the full potential of present and future cancer control efforts in Morocco.

Population-based cancer screening programmes in low-income and middle-income countries: regional consultation of the International Cancer Screening Network in India

The reductions in cancer morbidity and mortality afforded by population-based cancer screening programmes have led many low-income and middle-income countries to consider the implementation of national screening programmes in the public sector. Screening at the population level, when planned and organised, can greatly benefit the population, whilst disorganised screening can increase costs and reduce benefits. The International Cancer Screening Network (ICSN) was created to share lessons, experience, and evidence regarding cancer screening in countries with organised screening programmes. Organised screening programmes provide screening to an identifiable target population and use multidisciplinary delivery teams, coordinated clinical oversight committees, and regular review by a multidisciplinary evaluation board to maximise benefit to the target population. In this Series paper, we report outcomes of the first regional consultation of the ICSN held in Agartala, India (Sept 5-7, 2016), which included discussions from cancer screening programmes from Denmark, the Netherlands, USA, and Bangladesh. We outline six essential elements of population-based cancer screening programmes, and share recommendations from the meeting that policy makers might want to consider before implementation.

Breast Cancer Screening Program in Morocco: Status of implementation, organization and performance: Evaluation of Breast Cancer Screening Program

Breast Cancer Screening Program was introduced and rolled out in Morocco in 2010. Women between 40 and 69 years are screened at the primary health centers (PHC) with clinical breast examination (CBE). A comprehensive evaluation of the program was conducted in 2016–2017 for quality assurance and mid‐term course correction. The evaluation process involved: in‐depth interviews of program managers; focus group discussions with service‐providers of screening, diagnosis and treatment; supportive supervisory visits to randomly selected PHCs and diagnostic centers; desk review of the national guidelines and other published documents; and analysis of the performance data compiled by the program‐in‐charge. We found that the program has strong political support, a well‐organized management structure and documented national policy and protocol. In absence of a mechanism to identify and invite the eligible women individually, the program is opportunistic in nature. Every PHC is provided with an annual target to be screened. A highly visible annual campaign to educate and motivate women has a major impact on participation. Record keeping and data collection are paper‐based. In the years 2015 and 2016, 1.1 and 1.5 million women were screened, respectively. In the year 2015, 62.8% of the annual target population was covered, CBE positivity was 3.2%, a further assessment rate of screen‐positive women was 34.1% and the breast cancer detection rate was 1.0/1000 women. Systematic paper‐based data collection enabled the assessment of some of the process and outcome indicators. The screening coverage was moderate and the cancer detection rate was low.

Training Future Leaders: Experience from China-ASEAN Cancer Control Training Program

Cancer care professionals are pivotal in translating the knowledge into action in the continuum of cancer control process. Unfortunately, in China and the Association of South-east Asian Nations (ASEAN), limited training opportunities are available for health professionals in the area of cancer prevention and control. Therefore, the Cancer Hospital, Chinese Academy of Medical Sciences (CICAMS), and the International Agency for Research on Cancer (IARC) collaboratively designed and held the China-ASEAN Cancer Control and Prevention Training Program to provide continuing education opportunities for cancer professionals from China and ASEAN countries. The aim of this article is to report on the effectiveness and quality of the program and share our experience. A total of 36 participants from 12 countries completed the whole course including 1-month online learning and 1-week face-to-face workshop and cancer control facility tour in October 2017. After completion of the program, all participants were invited to fill out a questionnaire and to provide their comments on the training course. Out of 36 participants, 33 completed the evaluation form and they rated the training course highly in terms of satisfaction, value, and likelihood of recommending it to other colleagues. Additionally, all participants provided very detailed and practical comments on the course. Such an intensive, short-term, and comprehensive training program is expected to help participants establish a broader view of cancer prevention and control within the wider health services and be involved in national cancer control programs in a more efficient way. This training course could serve as a model for other institutes dedicated to nurturing future leaders in cancer control.

Incidence of cervical intraepithelial neoplasia in women infected with human immunodeficiency virus (HIV) with no evidence of disease at baseline: results of a prospective cohort study with up to 6.4 years of follow-up from India: Incidence of CIN in HIV-infected women

We report the incidence of cervical intraepithelial neoplasia (CIN) among HIV‐infected women who did not have any colposcopic or histopathological evidence of CIN at baseline. Of the 1,023 women without any CIN at baseline, 855 (83.6%) have been followed up to a maximum of 6.4 years contributing 2,875 person years of observation (PYO). Among these 855 women, 54 cases of any CIN were observed resulting in incidence rate of any CIN of 1.9 per 100 PYO. The median time for follow‐up for women with any CIN was 3.0 (IQR 1.6–3.7) years. The cumulative incidence rate per 100 PYO of CIN 2 or worse lesion in women with HPV‐18 infection at baseline was 13.3% (95% CI 5.1–26.8); in women with HPV‐16 infection was 10.8% (95% CI 4.4–20.9); in women with HPV‐31 infection was 4.2% (95% CI 0.9–11.7); and in women with other high‐risk HPV infections was 5.4% (95% CI 2.6–9.7). HPV‐18 infection at baseline contributed highest frequency of incident CIN 2 or worse lesions followed by HPV‐16 infection; however, other high‐risk HPV types were also responsible for substantial number of incident CIN. The elevated risk of CIN2+ disease in the study cohort was non‐significant in women with CD4 count <200, possibly because of the small number of cases. Our results emphasize the need for regular cervical cancer screening of HIV‐infected women and urgent implementation of cervical cancer screening services in HIV programs in India and other low and middle‐income countries.

Author's reply to: Implementation and organization of cancer screening in France: Author's reply to: Implementation and organization of cancer screening in France

Screening Group, International Agency for Research on Cancer, Lyon, France CPO Piemonte and University Hospital “Città della Salute e della Scienza”, Turin, Italy Mass Screening Registry/Finnish Cancer Registry, Helsinki, Finland Departamento de Tocoginecologia, Divisão de Oncologia, Universidade Estadual de Campinas, Brazil Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France Institute of Oncology Ljubljana, Ljubljana, Slovenia Swedish Cervical Screening Registry, Stockholm, Sweden Regionalt cancercentrum Stockholm-Gotland, Stockholm, Sweden Cancer Registry of Norway, Oslo, Norway Finnish Cancer Registry, Helsinki, Finland Research Triangle Institute, International-India, Commercial Tower, Pullman Hotel Aerocity, New Delhi, India

Author's reply to: Cancer screening policy in Hungary

1 Screening Group, International Agency for Research on Cancer, Lyon, France 2 CPO Piemonte and University Hospital “Citt a della Salute e della Scienza,” Turin, Italy 3 Mass Screening Registry/Finnish Cancer Registry, Helsinki, Finland 4 Departamento de Tocoginecologia, Divis~ao de Oncologia, Universidade Estadual de Campinas, Brazil 5 Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France 6 Institute of Oncology Ljubljana, Ljubljana, Slovenia 7 Swedish Cervical Screening Registry, Stockholm, Sweden 8 Regionalt cancercentrum Stockholm-Gotland, Stockholm, Sweden 9 Cancer Registry of Norway, Oslo, Norway; Finnish Cancer Registry, Helsinki, Finland 10 Research Triangle Institute, International-India, Commercial Tower, Pullman Hotel Aerocity, New Delhi, India