Millions of lives could be saved each year if coun-

Policies and managerial tries made use of existing knowledge and the best
cost-effective methods to prevent and treat cancer,
guidelines for national according to a new report from the World Health
cancer control Organization (WHO). Entitled National Cancer Con-
trol Programs: Policies and Managerial Guidelines, the
programs1 WHO report says that one-third of the 10 million
new cases of cancer that are diagnosed globally
every year can be prevented and that another third
can be effectively treated if there is early detection
and treatment. For the last third of cases, suffering
can be greatly relieved through effective palliative
care.
Regardless of the resource constraints that a
country faces, a well-conceived, well-managed pro-
gram can improve the national situation as well as
the lives of those living with cancer. In many cases,
primary prevention, early detection, and palliative
care are neglected in favor of treatment-oriented
approaches, regardless of whether these approaches
are actually cost-effective or whether they improve
patients’ quality of life.

THE BURDEN OF CANCER

Although cancer has often been regarded

principally as a problem of the developed world, of
the 10 million new cancer cases each year, 5.5 mil-
lion of them are in developing countries. Every
year, there are more than 6 million cancer deaths,
accounting for 12% of all deaths in the world. Over
the next 20 years, the number of cancer deaths an-
nually will rise to some 10 million. Contributing to
this projected increase in deaths are the growing
proportion of elderly people in the world, in whom
cancer occurs more frequently than in the young; an
overall decrease in deaths from communicable dis-
eases; the decline in some countries in mortality
from cardiovascular diseases; and the rising inci-
dence of certain forms of cancer, especially lung
Key words: cancer, disease control and prevention,
cancer resulting from tobacco use.
health care economics and organizations, program Among men, lung and stomach cancer are the
development, public health. most common cancers worldwide, while prostate
cancer is largely seen in more-developed countries.
For women, the most common cancers worldwide
1 Based on: 1) World Health Organization. Executive summary: na- are breast and cervical cancer, although cervical can-
tional cancer control programmes: policies and managerial guide-
lines. Geneva: WHO; 2002. Available from:. http://www.who.int/ cer is primarily seen in less-developed countries.
cancer. Accessed 23 September 2002. 2) World Health Organization. Lung, colorectal, and stomach cancer are among the
New cancer report offers hope for patients and communities [press
release]. Geneva: WHO; 2002. Available from: http://www.who.int.
five most common cancers for both men and women,
Accessed 1 July 2002. in both industrialized and developing countries.

366 Rev Panam Salud Publica/Pan Am J Public Health 12(5), 2002

THE NATURE OF CANCER Tobacco consumption can be reduced by a
comprehensive strategy that includes legislative ac-
Cancer arises principally as a consequence of tion to raise taxes on tobacco products and to limit
exposure of individuals to carcinogenic agents in access and promotion as well as smoking cessation
what they inhale or eat and drink, or through expo- programs and education for youth and adults in
sures at their work or elsewhere. Rather than inher- order to promote healthy lifestyles.
ited genetic characteristics, other factors play the In recent years, substantial evidence has
major roles in the etiology of cancer. These include pointed to the link that overweight and obesity have
personal habits such as tobacco use and dietary pat- to cancer of the esophagus, colorectum, breast, en-
terns, occupational exposure to carcinogens, and bi- dometrium, and kidney. It is advisable for individu-
ological factors such as viral hepatitis B infection als to control their weight and avoid weight gain in
and human papillomavirus infection. Knowledge adulthood by reducing caloric intake and by per-
of many of these factors can serve as the basis of forming physical activity. The latter has a protective
cancer control. Vaccination against hepatitis B, for effect in reducing the risk of colorectal cancer. The
instance, can protect against liver cancer. composition of the diet is also important since eat-
Cancer is profoundly associated with social ing fruits and vegetables may decrease the risk for
and economic status. Cancer risk factors are highest oral, esophageal, gastric, and colorectal cancer. High
in groups with the least education. In addition, pa- consumption of preserved meat or red meat may be
tients in the lower social classes have consistently associated with an increased risk of colorectal can-
poorer survival rates than do those in the higher so- cer. Consuming large amounts of alcoholic bever-
cial classes. ages increases the risk of cancer of the oral cavity,
pharynx, larynx, esophagus, liver, and breast.
Conducting a cancer prevention program
THE ELEMENTS OF A CANCER within the context of an integrated noncommunicable
CONTROL PROGRAM disease prevention program is an effective national
strategy. Tobacco use, alcohol, poor nutrition, physi-
A national cancer control program is de- cal inactivity, and obesity are risk factors common to
signed to reduce the incidence and mortality of can- other noncommunicable diseases such as cardiovas-
cer as well as to improve the quality of life of pa- cular disease, diabetes, and respiratory diseases.
tients. A good program would assess how to best Occupational and environmental exposure to
use available resources to achieve effective and eq- a number of chemicals can cause cancer of a variety
uitable outcomes. This would mean finding the of sites; examples include mesothelial cancer (as-
right balance among prevention, early detection, di- bestos), bladder cancer (aniline dyes), and leukemia
agnosis and treatment, and palliation. (benzene). A number of infections or infestations
cause certain types of cancer: viral hepatitis B and C
cause cancer of the liver, human papillomavirus in-
Prevention fection causes cervical cancer, and the bacterium
Helicobacter pylori increases the risk of stomach can-
Prevention involves eliminating or minimiz- cer. Exposure to ionizing radiation is also known to
ing exposure to the causes of cancer as well as give rise to certain cancers, and excessive solar ul-
reducing individual susceptibility to the effects of traviolet radiation increases the risk of all types of
such causes. This approach offers the greatest pub- cancer of the skin. National policies and programs
lic health potential and the most cost-effective long- can be enacted to reduce exposure to these risks
term cancer control prospects. and implement preventive interventions. Care
The present and potential burden of tobacco- needs to be taken to ensure that the public has a
induced cancer is such that every country should clear understanding of these major risks and is not
give its highest priority to tobacco control in its overwhelmed by the minor risks that are frequently
fight against cancer. Tobacco use in all forms is described in the news media.
responsible for about 30% of all cancer deaths
in developed countries, and this percentage is ris-
ing steadily in developing countries, particularly Early detection
among women. The best approach to preventing
tobacco-related cancer is preventing the uptake of Early detection comprises early diagnosis in
tobacco. Tobacco is responsible for 80%–90% of all symptomatic populations and screening in asymp-
lung cancer deaths, and probably some of the tomatic at-risk populations. Increasing awareness
deaths from cancer of the oral cavity, larynx, esoph- of the signs and symptoms of cancer contributes to
agus, and stomach. detection of the disease in less-advanced stages.

Rev Panam Salud Publica/Pan Am J Public Health 12(5), 2002 367

Where tests for cancer of specific sites are available Care of cancer patients typically starts with
and facilities are appropriate, screening of appar- recognition of an abnormality, followed by consul-
ently healthy individuals can disclose cancer in tation at a health care facility with appropriate ser-
early or precursor stages, when treatment may be vices for diagnosis and treatment. Treatment may
most effective. involve surgery, radiation therapy, chemotherapy,
With early detection, there is a greater chance hormonal therapy, or some combination of these.
that curative treatment will be successful, particu- Optimal treatment of people diagnosed with
larly for cancers of the breast, cervix, mouth, larynx, certain types of cancer detected early, such as can-
colon and rectum, and skin. It is therefore critical cers of the uterine cervix and corpus, breast, testis,
that people are taught to recognize early warning and melanoma, will result in five-year survival
signs of the disease, such as lumps, sores that fail rates of 75% or more. In contrast, survival rates in
to heal, abnormal bleeding, persistent indigestion, patients with cancer of the pancreas, liver, stomach,
and chronic hoarseness, and are urged to seek and lung are generally less than 15%. Some treat-
prompt medical attention. This can be promoted by ments require sophisticated technology that is
public health education campaigns and through the available only in locations with substantial re-
training of primary health care workers. sources. Since the cost of establishing and main-
Another approach to early detection is popu- taining such facilities is high, they should initially
lation screening, with the mass application of sim- be concentrated in a relatively few places in a coun-
ple tests to identify individuals with asymptomatic try, to avoid draining resources that could be de-
disease. However, screening programs should be voted to other components of the national cancer
undertaken only when their effectiveness has been control program. Facilities can be expanded when
demonstrated; when personnel, equipment, and additional resources are available.
other resources are sufficient to cover nearly all of
the target group; when facilities exist for confirm-
ing diagnoses and for treatment and follow-up of Palliative care
those with abnormal results; and when prevalence
of the disease is high enough to justify the effort Despite advances in prevention and treat-
and costs of screening. ment, the majority of people diagnosed with cancer
At present, in countries with high levels of re- will, at some stage, need palliative care. A compre-
sources, screening can be advocated only for cancer hensive approach to palliative care should embrace
of the breast and cervix. Efforts should concentrate the psychological, emotional, and spiritual needs of
on women at greatest risk of developing invasive the patient and also take into account the needs
cancer: those aged 35 years and over for cervical of family and caregivers.
cancer and those aged over 50 years for breast can- Improved quality of life is of paramount im-
cer. In developing countries, organized screening portance to patients with cancer. Pain relief and
should only be considered for cervical cancer. It palliative care can be provided relatively simply
should focus primarily on providing a limited num- and inexpensively. These services should be avail-
ber of screenings with maximum population cover- able in every country and should be given high pri-
age, because the women at greatest risk for cervical ority, especially in developing countries, where
cancer are in general the last to approach the health cure of the majority of cancer patients is likely to re-
care system. main beyond reach for years to come. Health work-
ers and family caregivers can be trained to deliver
palliative care effectively. Primary health care set-
Diagnosis and treatment tings can respond to the majority of patients’ needs.
In addition, in many developing countries with
Cancer diagnosis is the first step to cancer poor infrastructure, home-based care will make an
management. This calls for a combination of care- essential contribution to achieving the necessary
ful clinical assessment and diagnostic investiga- coverage.
tions that include endoscopy, imaging, histopathol-
ogy, cytology, and laboratory studies.
The primary objectives of cancer treatment are MANAGING NATIONAL
cure, prolongation of life, and improvement of the CONTROL PROGRAMS
quality of life. A national cancer control program
should establish guidelines for integrating treat- Although it is clear that objectives and priori-
ment resources with programs for early detection, ties need to be tailored to the specific country con-
and the program should provide therapeutic stan- text, the planning processes to be undertaken in all
dards for the most important cancers in the country. countries should follow four basic steps: 1) assess-

368 Temas de actualidad • Current topics

ing the magnitude of the cancer problem, 2) setting general public and health care workers can be made
measurable control objectives, 3) evaluating possi- aware of the early warning signs of cancer and
ble, evidence-based strategies for cancer prevention other diseases. This will ensure that cases are iden-
and control, and 4) choosing priorities for initial tified, referred, and treated early in the course of
cancer control activities. Gauging the magnitude of disease, before they become advanced and incur-
the cancer problem requires analyzing the cancer able. National diagnostic and treatment guidelines
burden and risk factors as well as assessing capac- should be developed, in order to establish a mini-
ity in terms of facilities, personnel, programs, and mum standard of care and to promote the rational
services. The strategies chosen must be feasible as use of existing resources as well as equitable access
well as acceptable and relevant to the society. Pri- to the limited treatment resources. A national can-
ority areas should be classified into two groups: ac- cer control program should also establish a basis for
tivities that can be introduced or improved without pain relief and palliative care of individuals with
the need for additional resources, and activities that advanced disease, to ensure that they maintain
will require extra resources. their quality of life as much as possible.
A flexible approach is needed, as political, so-
cioeconomic, and epidemiological situations can
evolve over time and can vary within a country. A medium level of resources
With this in mind, three separate scenarios are pro-
vided to help guide countries toward what is pos- In countries with a medium level of resources,
sible in line with their level of resources: low, the majority of the population is urban, and life
medium, or high. The scenarios can also be used to expectancy is over 60 years. The country has been
identify specific actions relevant to regions or dif- through the epidemiological transition, and cancer
ferent population groups within a nation. is usually one of the leading causes of disease and
mortality. There is a high exposure to risk factors,
especially tobacco, improper diet, infectious agents,
A low level of resources and carcinogens in the workplace. While infrastruc-
ture and human resources for developing cancer
This scenario refers to low-income countries prevention and control activities are available, there
where resources for chronic disease are completely are limitations in quantity, quality, and accessibil-
absent or very limited. Many such countries may ity. There are weaknesses in organization, priority-
have great political and social instability. A consid- setting, resource allocation, and information sys-
erable proportion of the population is rural. Infant tems for adequate monitoring and evaluation.
and adult mortality rates are high. Communicable Primary prevention and early detection are usu-
diseases and malnutrition are a major cause of mor- ally neglected in favor of treatment-oriented ap-
bidity and mortality, especially for children. Life proaches, without much concern regarding their
expectancy is relatively low. Cancer is not one of cost-effectiveness.
the main health problems, but it can be one of the In general, the primary prevention activities
leading causes of death among those over 15 years needed in this type of setting are tobacco control,
of age. The majority of cancer patients are diag- reduction of alcohol use, and promotion of healthy
nosed in an advanced stage. Exposure to cancer risk diet and physical exercise. Special attention should
factors such as tobacco or environmental carcino- be paid to carcinogens in the workplace as well as
gens other than aflatoxin may be low but almost human papillomavirus and other infectious agents.
invariably rising. Exposure to infectious causes of Awareness of the warning signs for the common
cancer will usually be high (human papilloma- cancers should be promoted. If rates of cervical can-
viruses and hepatitis B virus, and sometimes schis- cer are high, the highest priority for a screening
tosomiasis). Health care services are often delivered program is cervical cytology screening, focusing
by informal means, and alternative medicine is a mainly on covering a high proportion of the women
major component. Infrastructure and human re- at risk. Screening for other types of cancers should
sources for cancer prevention or control are non- be discouraged. Cancer treatment should focus on
existent or very limited in quantity, quality, and cancers that are curable, and clinical trials should
accessibility. be encouraged to evaluate lower-cost approaches
In such circumstances, the first step is to es- that eventually can be provided to all patients irre-
tablish a basis for prevention of cancer and other spective of their socioeconomic condition. More-
chronic diseases by limiting the extent to which sophisticated approaches, such as radiotherapy and
the health scourges of the industrialized world— chemotherapy, should be introduced in specialized
tobacco use and the “Western diet”—can enter the centers. Major efforts should be made to achieve the
country and add to existing health problems. The highest coverage for pain relief and palliative care,

Rev Panam Salud Publica/Pan Am J Public Health 12(5), 2002 369

using low-cost drugs (e.g., oral morphine) and other www.who.int/cancer. That Web site also has an ex-
interventions. ecutive summary of the report available in English,
Spanish, or French.
In the near future, WHO plans to produce a
A high level of resources second volume of the report that will focus more
on the “how-to” aspects of developing comprehen-
In industrialized countries with a relatively sive operational models to implement the report’s
high level of resources for health care, life ex- recommendations.
pectancy is over 70 years, and cancer is a major
cause of death for both men and women. Many ele-
ments of a cancer control program are in place, but
they may not be well integrated into a comprehen-
sive national system. Further, coverage of the pop-
SINOPSIS
ulation may be uneven, with particular groups such
as those in rural areas, indigenous people, and re-
cent immigrants having difficulty accessing ser- Estrategias y directrices de gestión para los
vices. There may also be serious deficiencies with programas nacionales de lucha contra el cáncer
respect to providing easy access to pain relief and
Según un nuevo informe de la Organización Mundial de la
palliative care services. Salud titulado Programas nacionales de lucha contra el
Reorganizing the system could lead to greater cáncer: estrategias y directrices de gestión, cada año se
cost-effectiveness and improved reach and accept- podrían salvar millones de vidas si los países hicieran uso de
ability of services. Comprehensive health promo- los conocimientos existentes y de los métodos más rentables
tion programs, including in schools and workplaces, de prevención y tratamiento del cáncer. El informe afirma
should be implemented. que un tercio de los 10 millones de nuevos casos de cáncer
There should be a concerted effort to promote que se registran cada año en el mundo son prevenibles y que
awareness of the early warning signs for cancer. otro tercio se podría tratar eficazmente si se diagnosticara y
However, national screening programs should gen- tratara precozmente. En el tercio restante se puede reducir
mucho el sufrimiento gracias al tratamiento paliativo. Un
erally only be implemented for cervical and breast
programa nacional eficaz de lucha contra el cáncer debe en-
cancer, since screening for other cancers has not contrar el equilibrio adecuado entre las actividades de pre-
yet been proven to be cost-effective. Implementing vención, detección precoz, diagnóstico, tratamiento y palia-
a comprehensive surveillance system can ensure a ción. Los procesos de planificación deberían seguir en todos
rapid response to changes in disease patterns and los países cuatro pasos básicos: 1) evaluación de la magnitud
to weaknesses in service provision. del problema; 2) fijación de objetivos de control medibles;
Printed copies of the report can be ordered 3) evaluación de posibles estrategias de prevención y control
from the World Health Organization, from: WHO basadas en datos objetivos, y 4) elección de prioridades para
Marketing and Dissemination, CH-1211 Geneva 27, las actividades iniciales de lucha contra el cáncer. Es nece-
Switzerland; fax: 41 22 791 48 57; telephone: 41 22 sario un enfoque flexible, dado que las situaciones políticas,
791 24 76; e-mail: [email protected]; Internet: socioeconómicas y epidemiológicas de un país pueden evolu-
cionar y cambiar con el tiempo. El informe proporciona tres
http://www.who.int/pub/en. The cost of the re-
escenarios distintos para guiar a los países hacia la consecu-
port is Swiss francs 42 (US$ 37.80), with a price of ción de objetivos dentro de las posibilidades acordes con sus
Sw.fr. 29.40 for clients in developing countries. The recursos: bajos, medios o altos. Estos escenarios pueden
report is now available only in English, but WHO is servir también para identificar acciones específicas perti-
preparing editions in Spanish and in French as well. nentes para diferentes regiones o grupos de población de un
Copies of the full report can also be down- mismo país.
loaded for free from the WHO Web site, at http://

370 Temas de actualidad • Current topics