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Article Cancer in a Developing Country: Opportunities
and Formidable Challenges
Pakistan is a developing country with a population of 150 million people. Average life expectancy is 62 years. It is estimated that 160,000 new cancer cases are diagnosed annu.ally. The total expenditure in the health sector by the government was 0.7% of GNP for the year 2002-03. Health care services are provided to the public through a vast infrastructure of health care facilities, which include government hospitals, private hospitals, basic health units and dispensaries. Less than 5% of the population is fully or partially covered by health insurance. The major health priorities of the government are communicable diseases and maternal and child health. Thirty percent of the population live below the poverty line (defined as a GNP per capita of less than US$ 480) - earning less than US$140 per annum. Of these, 32% belong to the rural population while 19% live in urban regions. The overall literacy rate (defined by the ability to write one’s name!) is 50.5 % (63% males and 38% females). Rural and urban literacy rates are between 30% and 70%. Malnutrition, infectious diseases, poverty, hunger and environmental hazards are some of the major problems faced by the poor. They are locked in a vicious cycle that keeps them poor, backward and deprived of basic rights, both socially and politically. Cancer Epidemiology in Pakistan According to WHO, 80% of all cancers in developing countries are
due to environmental factors, infectious agents and diet. Smoking
has become a major health hazard in developing countries. In Pakistan,
a conservative estimate is that 50% of males and 9% of females are
habitual smokers. This does not include children, particularly in
the lower socio-economic groups, among whom smoking has increased
tremendously. Tobacco-related cancers are increasing rapidly in
incidence because of the dramatic rise of tobacco smoking in developing
countries. Betel-leaf and tobacco chewing is common in South Asia,
and contributes to the relatively high incidence of head and neck
cancers. The prevalence of Hepatitis B & C ranges from 3.5%-18.6%
and 4%-25.6% respectively, such that one of the consequences of
infection with these viruses, hepatocellular carcinoma, is relatively
common in males. In addition, aflotoxins, derived from a fungus,
are commonly found in stored food grains. They are believed, together
with malnutrition, to contribute to the increasing incidence of
liver cancer. H.pylori infection (a bacterium associated with peptic
ulceration, gastric cancer and gastric lymphoma) is common in developing
countries, with infection rates ranging from 80-100%. Indiscriminate
use of cheap and expired pesticides by farmers in the heavily agricultural
province of the Punjab may account for the relatively high prevalence
of lymphomas and leukemias, which have been shown, in the USA and
elsewhere, to be associated with exposure to herbicides and other
chemicals.
There are no population-based cancer registries in Pakistan except the Karachi Cancer Registry (KCR). The true magnitude of the cancer problem is therefore unknown. In women, breast cancer is the most common cancer throughout Pakistan, and according to KCR, the age-standardized rate is 56.6 per 100,000 women per year. No identifiable risk factors are present, however, in 75% of patients with breast cancer. Gall bladder cancer is the fifth most common cancer in our female population. Contributing factors include gall stones, diet, infections and a sedentary lifestyle in this group of patients. In the developing world, more than 80% of all cancer patients are incurable by the time they are diagnosed. This is particularly true for patients from the less affluent strata (>60%) where multiple factors operate, among which are economic constraints, illiteracy and poor access to health care facilities. Other contrib.utory factors are ignorance of patients and health professionals and disease stigma. The prior use of alternative medicines, hakims (traditional medicine practitioners) and homeopaths also delays appropriate cancer care. This is especially common in the rural areas as such approaches are a cheap alternative to the costly conventional health care systems. Co-morbid conditions like tuberculosis, hepatitis and malnutrition are common in the poorer patients with cancer. Large family size, small living quarters and poor hygiene cause recurrent infections. Our data on breast cancer treatment and survival outcome reveals that 75% of patients from the upper strata have early disease and their outcome is similar to their counterparts in the developed countries. Patients belonging to the lower strata (80%), on the other hand, present with advanced disease and exhibit inferior survival. Similar observations have been made in developed countries in patients belonging to the lower socio-economic strata. Cancer Treatment in Pakistan Facilities for treatment of cancer patients are available in a
few larger cities in both public and private hospitals. There are
18 radiotherapy centers with 65 practicing radiation oncologists;
the quality of these centers is extremely variable depending on
the expertise of the physician and available equipment. There are
only 15 medical oncologists practicing in major cities. State-of-the-art
surgical oncology is practiced in only a few hospitals, and as a
result, the majority of patients undergo sub-optimal surgery.
In Pakistan, profound differences exist with respect to the availability
of medical care to different segments of the population. Good quality
hospital care is available to the affluent class, either from a
small number of excellent public sector hospitals, or from the private
sector. The less affluent classes are provided free services in
the government hospitals but again, the quality of these services
is extremely variable, depending on the available resources and
trained personnel. The financial burden of treatment is borne by
the patients, which makes it difficult for the poor to receive state-of-the-art
treatment. They are supported by monetary donations from individuals
as well as government funds and Zakat, a tax that the more wealthy
Muslims pay specifically to help the poor. These contributions tend
to be insufficient and erratic. Clearly these resources are inadequate
to deal with the ever increasing economic burden of cancer patients.
It is estimated that fewer than 30% of patients receive the minimal
recommended treatment for their disease.
What Can Developing Countries Do? The absence of population-based tumor registries is a major drawback. Information about cancer is largely extrapolated and no formal policies for cancer control have been made. Data from the hospital-based tumor registries are not organized, information is fragmented, and it is likely that regional variations in cancer incidence and types occur. It is essential that governments in developing countries use their meager resources to develop population-based cancer registries, form policies on prevention of preventable cancers, provide optimal training of their personnel, and develop regional sites for cancer treatment with good diagnostic facilities. Education Education is essential to improving the results of cancer treatment as it will result in early detection of cancers and possibly cure in some patients. It has to be done at three levels. Community education, physician education and patient education are all essential to creating cancer awareness and improved treatment options. Education should also focus on smoking hazards, environmental pollution, infectious diseases and use of sub-standard materials in our diet, etc. The younger generation, which comprises the majority of the population, should be targeted. Public education can be achieved through printed matter, television and radio. Cancer Prevention and Early Detection WHO estimates that one-third of cancers can be prevented and one-third could be treated if diagnosed early enough, and if access to knowledge and treatment were widely available. The majority of cancers, which are related to lifestyle and environment, can be prevented or their incidence decreased by such measures as educating people about the dangers of smoking, and vaccinating them against Hepatitis B, etc. These measures should be targeted to schoolchildren and young adults. Early detection of several cancers such as breast, cervix, colon and other sites that can be effectively treated in their early stages would significantly increase survival rates. Breast self-examination and clinical breast exam.ination are important and much less expensive potential alternatives to mammography. Direct visualization of pre-invasive cervical cancers is also a cheap and highly effective means of preventing invasive cancer. For screening programs to be established, we need to allocate resources to the common cancers in our region and to use our resources pragmatically. Treatment Options Cancer patients are treated with a variety of protocols developed in developed countries. These protocols may not always be appropriate for patients living in the less developed countries. It is important that indigenous protocols are developed, keeping in mind resources, the biology of the disease and the patients’ biology. It is also important that treatment should be provided to the maximum number of patients given the financial constraints. Last but not least, at present the vast majority of patients require palliation for their symptoms and maximum comfort should be provided to them. Herculean efforts are still needed to see the proverbial light at the end of the tunnel. Zeba Aziz, Professor of Oncology, Allama Iqbal Medical College,
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