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Professor Robert Burton has worked as a leader in cancer control planning for both the World Health Organization (WHO) and the International Union Against Cancer (UICC). For more than ten years, he was involved in developing and implementing cancer control plans for his native Australia.
In May, Professor Burton was invited to Vienna to discuss his work as an advisor to PACT on cancer control planning. Here, he shares his views on the importance and challenges of cancer control planning in low-income countries.
How serious is the cancer burden in the developing world and what can be done to help?
We can say with some confidence that over the next forty to fifty years, if we do nothing, cancer will account for around 30% of all deaths worldwide. In primary prevention, if governments do nothing else but tackle tobacco exposure, it would make a real difference. Otherwise, according to estimates, one billion people will die prematurely this century of smoking-related diseases — about two-thirds from cardio-vascular disease and one third from cancer.
We cannot decrease the proportion of the increase in cancer incidence, which is being driven by increasing longevity worldwide. But we can do something about the tobacco-related cancers, and we should. We can do something about primary cancer of the liver, by vaccinating all newborns against Hepatitis B, and we should. We can do something against cervical cancer by vaccinating all 12-year old girls against the two strains of HPV that the vaccines cover, which cause about three-quarters of all cervical cancer, and we should.
Can a national cancer control plan help?
Most countries would benefit from comprehensive national cancer control planning. But it requires a lot of stakeholder involvement — whether you do it from the bottom up, involving all the stakeholders from the word go and the plan emerging from them, or whether you do it from the top down. In some countries, especially hierarchical countries, you have to work from the top down. But you must get the people who are going to implement the plan to buy in. I would say to get an agreed, workable first draft of a national cancer control plan it generally takes about two years, minimum.
What are the essential components of effective cancer control planning?
When I go to a country the first thing I do is try to find out if the government is motivated to develop and implement a national cancer control plan. The second is to make sure I have good data to do the planning — that's data about the actual burden of cancer, the stage at which it's being diagnosed, the risk factors, etc. The third question I ask is, what resources the country has for cancer control at the moment, and what resources could it realistically acquire, either by getting new money or reassigning funds? What about the health profession, what incentives or disincentives do they have to support national cancer control planning and implementation? Finally, are there cultural barriers around gender, age or treatment? For example, you can't plan for pain relief using oral morphine if narcotics are not available in a country. There may be a culture of strong traditional healers; so many cancer sufferers may first seek them out for help. So they would be the four major areas I'd look at.
What would you say is the main obstacle to setting up a national cancer control plan?
Resources are always the single common restraint. Because if you haven't got the resources, however much a government might want to implement cancer control, it just will not be possible.
Can anything be done to help those countries with extremely limited resources fight cancer?
A comprehensive national cancer control plan should cover cancer research, prevention, early detection, diagnosis, treatment and palliation for the country. But even a developing country, with very little in the way of resources and no cancer treatment programmes at all, can do primary prevention and they can do palliation. They should also try to develop one good cancer treatment centre based on a radiotherapy unit, where they can begin to train and plan for the future. Most of their population may be under 21 years of age, so their heaviest cancer burden is still twenty to forty years away.
Why is palliative care important in poorer countries?
In developing countries, three quarters or more of cancer cases are often incurable when they get to a medical system. So these patients are going to need help with their symptoms. And one of the most feared symptoms, and rightly so, is chronic, intractable pain. But there is a lot more to treating someone with a progressive disease than just giving them oral morphine. When developing a national cancer control plan, palliative care medicine should be included. With properly planned palliative care, patients can have a much more comfortable life and a death with some dignity.
What role does radiotherapy play in palliative care?
Radiotherapy is extremely useful for many kinds of cancer-caused pain, and other symptoms. Palliative radiotherapy is perhaps the single most effective medical modality you can use. It shrinks tumours. And the best thing about it is that, for example, a patient can come from way out in the countryside in pain, receive three or four fractions of radiotherapy, and a few days later the pain is gone and they can go back home. Compare that to getting a regular supply of oral morphine to them, which can be logistically impossible, or they may live in one of the countries of the world where narcotics are forbidden, so they can't even obtain oral morphine. In my opinion, providing palliative radiotherapy is an enormous step forward for countries looking to do something about the suffering of people with cancer.
How important is early detection in national cancer control planning?
When you talk about having a national programme of early detection, you're talking about a primary health care and hospital system for the population, including skills in pathology, surgery and medicine, which is accessible, competent and affordable for most people. Early detection programmes depend upon this medical system. It's absolutely essential. Personally, I think it is unethical to have an early detection system if you can't follow up and do something about the cancers detected early. And that may occur in countries which do not have a distribution network of competent hospitals, physicians and surgeons to treat the patient with early cancers. In these countries early detection can begin in cities or regions, perhaps as demonstration projects.
How can international agencies such as IAEA/PACT help developing countries devise and implement effective cancer control plans?
For a national cancer control plan to be implemented it needs commitment and it needs to be sustainable. If a government asks the IAEA to come and introduce radiotherapy or improve radiotherapy systems, that represents supporting a structure, and a commitment to sustainability. So, of all of the agencies that have a mission to control cancer, IAEA is one of the best placed to be part of the introduction of sustainable, affordable cancer control programmes. But its expertise is in radiotherapy, and it has to be effective there. So it is both symbolically and practically important for the IAEA through PACT to work with other agencies, including government and non governmental. WHO and its Regional Offices, as well as its International Agency for Research on Cancer (IARC), is obviously the most important UN partner, but there are other agencies working in the NGO area helping countries to develop and implement national cancer control plans.
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