CANCER CONTROL PLANNING
22 CANCER CONTROL 2014
screening programmes in the reduction of cancer mortality
exists for three cancer sites: the cervix uteri, breast and
colon-rectum.27-29
Cervical cancer screening stands out compared to other
cancer screenings as it allows the recognition and treatment
of precancerous lesions using relatively inexpensive and
minimally invasive tests (Pap smear, visual inspection
techniques and HPV-testing) that can be chosen according to
different country settings. The superiority of HPV-testing
compared to cytology in terms of sensitivity, duration of
negative predictive value and reproducibility of test results
across different diagnostic laboratories has been
demonstrated by a number of randomized clinical trials and
prospective data in high- and low-income countries.30 The
superiority of HPV-testing has been recently recognized in
the new WHO Guidelines for cervical cancer screening31 and
a simple and cheap HPV test, careHPVTM (Qiagen), has proved
to be very accurate. Unfortunately, HPV vaccination and
HPV-testing had been evaluated in the Global Action Plan
against NCDs before the cost of the HPV vaccines and HPV
test started to decrease. They have both been recently
reclassified as best-buys in a re-evaluation of the basic cancer
package32 to which WHO participated.
There remains an important gap between the feasibility of
the secondary prevention of cardiovascular diseases and
cancer. Screening approaches in cancer (early detection of
neoplastic or pre-neoplastic lesions that require surgical
ablation) are more complicated, expensive and potentially
more harmful than those in cardiovascular diseases
(detection and medical treatment of predisposing conditions
such as hypertension and hypercholesterolemia).
Rearticulating cancer control: Therapy and
palliation in low-income settings
Finally, cancer patients require specialized centres in which
accurate diagnoses and multi-therapeutic approaches can be
made available. The Global Action Plan against NCDs
endorsed, however, only essential medicines and
technologies that can be used in primary care settings. The
only clinical intervention for cancer explicitly included was,
therefore, palliative care using oral morphine, a cheap and
simple intervention that is, however, rarely available in lowincome countries because of fears of inappropriate drug
use.33
In an expanded cancer care package not restricted to bestbuys in low-income countries, WHO also included
mammography, breast cancer treatment, screening for
cancer of the colon and oral cavity, and treatment of
paediatric cancers.32 Obviously, screening programmes need
to be tailored to the needs and resources of different
countries. In high-income countries, for instance, the
randomized evidence indicates that around one breast
cancer death would be prevented in the long term for every
400 women aged 50-70 years who would regularly have
mammography over a 10-year period.34 In low- and middleincome countries breast cancer rates
are still lower than in
high-income countries and resources might be better used to
raise awareness and encourage more women with palpable
breast lumps to seek and receive treatment in a timely
manner.35
Treatment of cancer patients is, however, a strong
aspiration in every country. In middle-income countries it is
increasingly common that families are impoverished and
health expenses overcharged by the purchase of sometimes
inappropriate and unnecessarily expensive cancer
treatments. It would be, therefore, essential that WHO and
other UN agencies (including IARC and the International
Atomic Energy Agency) fully articulate the term of "cancer
control" and re-assess which essential medicines and
technologies should be recommended for cancer in the lowand middle-income countries (see Mendis et al,33
for a similar
exercise on the management of cardiovascular diseases and
diabetes).
In conclusion, the mobilization against cancer still requires
much more global and regional coordination of resourcelinked
policy and strategy. At present, individual countries
must often determine their own course of action with varying
degree of success. l
Acknowledgements:
We thank Dr Christopher P Wild for useful comments.
Dr Silvia Franceschi was trained as an MD and gynaecologist
and obtained a Masters degree in Epidemiology at Oxford under
the supervision of Sir Richard Doll. After having led the
Epidemiology Unit of the Aviano Cancer Center, she became
Head of the Infections and Cancer Epidemiology Group at the
International Agency for Research on Cancer (IARC), Lyon,
France in 2000. She led international studies on the relationship
between infectious agents and cancer, most notably human
papillomavirus and HIV. She is the author of over 1,000
publications in peer-reviewed journals. She is Special Advisor to
the IARC Director for the collaboration with the World Health
Organization and other United Nations agencies.
Dr Freddie Bray is Deputy Head of the Cancer Information
Section at IARC. He has worked previously at IARC 1998-2005
and at the Cancer Registry of Norway and University of Oslo