Delivering affordable cancer care in high-income countries

The burden of cancer is growing, and the disease is becoming a major economic expenditure for all developed countries. In 2008, the worldwide cost of cancer due to premature death and disability (not including direct medical costs) was estimated to be US$895 billion. This is not simply due to an increase in absolute numbers, but also the rate of increase of expenditure on cancer. What are the drivers and solutions to the so-called cancer-cost curve in developed countries? How are we going to afford to deliver high quality and equitable care? Here, expert opinion from health-care professionals, policy makers, and cancer survivors has been gathered to address the barriers and solutions to delivering affordable cancer care. Although many of the drivers and themes are specific to a particular field-eg, the huge development costs for cancer medicines-there is strong concordance running through each contribution. Several drivers of cost, such as over-use, rapid expansion, and shortening life cycles of cancer technologies (such as medicines and imaging modalities), and the lack of suitable clinical research and integrated health economic studies, have converged with more defensive medical practice, a less informed regulatory system, a lack of evidence-based sociopolitical debate, and a declining degree of fairness for all patients with cancer. Urgent solutions range from re-engineering of the macroeconomic basis of cancer costs (eg, value-based approaches to bend the cost curve and allow cost-saving technologies), greater education of policy makers, and an informed and transparent regulatory system. A radical shift in cancer policy is also required. Political toleration of unfairness in access to affordable cancer treatment is unacceptable. The cancer profession and industry should take responsibility and not accept a substandard evidence base and an ethos of very small benefit at whatever cost; rather, we need delivery of fair prices and real value from new technologies.     

Burden of Lung Cancer Deaths due to Smoking for Men and Women in the WHO Western Pacific and South East Asian Regions

Introduction: Eighty percent of all smokers live in low and middle-income countries of the Asia Pacificregion but actual estimates of the burden of disease due to smoking in the region have yet to be quantified.Methods: The burden of lung cancer due to smoking for all countries in the WHO Western Pacific and SouthEast Asian regions was calculated from the population attributable fractions (PAFs). Nationally representativesex-specific prevalences of smoking were obtained from the World Health Organization, MEDLINE and/ornational government documents and hazard ratios (HR) for lung cancer due to smoking in Asian and non-Asianpopulations were obtained from published data. The HR and prevalence were then used to calculate PAFs forlung cancer deaths due to smoking, by gender and by country. Results: The national prevalence of smoking in theAsia Pacific region ranged from 18-65% in men and from 0-50% in women. The fraction of lung cancer deathsattributable to smoking ranged from 0-40% in Asian women and from 21-49% in Asian men. In ANZ, PAFs wereas high as 80% for women and 68% for men. Future estimates of the burden of smoking-related lung cancer inAsia were obtained by assuming a continuation of current smoking habits in these populations. Extrapolatingthe higher HR from the ANZ region to Asia, resulted in an increase in the PAFs to 4-90% in women and from62-85% in men. Conclusion: The current burden of lung-cancer due to smoking in the Asia-Pacific region issubstantial accounting for up to 50% of deaths from the disease in men and up to 40% in women dependingon the country. If current smoking habits in Asia remain unchanged then the number of people dying fromsmoking-related lung cancer over the next couple of decades is expected to double. It is known that the majorityof lung cancer is due to smoking. This is the first paper to systematically compare current burdens of lung cancerdeaths due to smoking in countries in the Western Pacific and South East Asia and by gender. Findings fromthis paper demonstrate the number of lung cancer deaths that could be prevented if the prevalence of smokingwas eliminated.     

Cervical cancer prevention in low- and middle-income countries: feasible, affordable, essential

The annual worldwide burden of the preventable disease cervical cancer is more than 530,000 new cases and 275,000 deaths, with the majority occurring in low- and middle-income countries (LMIC), where cervical cancer screening and early treatment are uncommon. Widely used in high-income countries, Pap smear (cytology based) screening is expensive and challenging for implementation in LMICs, where lower-cost, effective alternatives such as visual inspection with acetic acid (VIA) and rapid human papillomavirus (HPV)-based screening tests offer promise for scaling up prevention services. Integrating HPV screening with VIA in "screen-and-treat-or-refer" programs offers the dual benefits of HPV screening to maximize detection and using VIA to triage for advanced lesions/cancer, as well as a pelvic exam to address other gynecologic issues. A major issue in LMICs is coinfection with human immunodeficiency virus (HIV) and HPV, which further increases the risk for cervical cancer and marks a population with perhaps the greatest need of cervical cancer prevention. Public-private partnerships to enhance the availability of cervical cancer prevention services within HIV/AIDS care delivery platforms through initiatives such as Pink Ribbon Red Ribbon present an historic opportunity to expand cervical cancer screening in LMICs.     

Anesthetic technique for safe laser use in surgery

The use of lasers has simplified, shortened, and made less traumatic many surgical procedures. It has also increased the range of conditions amenable to treatment in all of the surgical specialties. There are, however, potentially serious hazards associated with the surgical use of lasers. The most serious hazards are explosions and fire, particularly during surgery on the airway, where flammable material, i.e., the endotracheal tube, high oxygen concentrations, and the laser, which is a high energy ignition source, are in close proximity. This report deals with techniques of anesthesia delivery that minimize the risks to the patient and operating room environment consequent on laser use in the airway. Laser use elsewhere in or on the body is associated with no greater danger than the use of electrocautery and requires no special anesthetic adaptation.     

Laparoscopic surgery is safe for large adrenal lesions

Introduction

Laparoscopic adrenalectomy has surpassed open adrenalectomy as the gold standard for excision of benign adrenal lesions. The size threshold for offering laparoscopic adrenalectomy is controversial as the prevalence of adrenocortical carcinoma increases with increasing tumour size. The aim of this paper was to assess the safety of laparoscopoic adrenalectomy for large adrenal tumours (tumours ≥60 mm).

Methods

A retrospective cohort study of patients who underwent adrenalectomy in a single unit during the period 1995–2005 was undertaken.

Results

One hundred and seventy patients with 173 tumours were included in this study. Of these, 29 were ≥60 mm in size, and 16 of these patients underwent laparoscopic adrenalectomy. There were 8 adrenocortical carcinomas in the group with tumours ≥60 mm in size. Five of these patients underwent an open adrenalectomy, while 2 and 1 patients had laparoscopic and laparoscopic converted to open adrenalectomy respectively. Four of the patients undergoing open adrenalectomy died of their disease while 1 is alive with recurrence 3 years later. The 3 patients who underwent either laparoscopic or laparoscopic converted to open adrenalectomy are alive without evidence of disease after 18 months follow up.

Conclusion

Our data show that patients with tumours ≥60 mm with no preoperative or intraoperative evidence of malignancy can undergo laparoscopic adrenalectomy without evidence of recurrence on short term follow up. These findings are concordant with the growing body of literature supporting laparoscopic adrenalectomy for potentially malignant tumours ≥60 mm in size without preoperative or intraoperative features of malignancy.     

Public health oncology: a framework for progress in low- and middle-income countries

BackgroundThe problems of cancer are increasing in low- and middle-income countries (LMCs), which now have significant majorities of the global case and mortality burdens. The professional oncology community is being increasingly called upon to define pragmatic and realistic approaches to these problems.Patients and methodsFocusing on mortality and case burden outcomes defines public health oncology or population-affecting cancer medicine. We use this focus to consider practical approaches.ResultsThe greatest cancer burdens are in Asia. A public health oncology perspective mandates: first, addressing the major and social challenges of cancer medicine for populations: human rights, health systems, corruption, and our limited knowledge base for value-conscious interventions. Second, adoption of evolving concepts and models for sustainable development in LMCs. Third, clear and realistic statements of action and inaction affecting populations, grounded in our best cancer science, and attention to these. Finally, framing the goals and challenges for population-affecting cancer medicine requires a change in paradigm from historical top-down models of technology transfer, to one which is community-grounded and local-evidence based.ConclusionPublic health oncology perspectives define clear focus for much needed research on country-specific practical approaches to cancer control.     

Differences in palliative radiotherapy for bone metastases within Western European countries.

PURPOSE: To evaluate the differences in palliative radiotherapy for painful bone metastases amongst different Western European countries. MATERIALS AND METHODS: A questionnaire was sent to 565 radiotherapy centres in 19 Western European countries, based on the 1997 ESTRO directory. In this questionnaire the current local palliative radiotherapy practice for bone metastases was assessed in terms of total dose, fractionation, treatment complexity (use of shielding blocks, frequency of isodose calculations, field set-up) and type of machine used. The differences were analyzed according to the country and to the type and size of radiotherapy centre. RESULTS: A total of 205 centres (36%) returned the questionnaire, of which 198 could be further analyzed. The most frequently used antalgic fractionation schedule is 30 Gy in ten daily fractions of 3 Gy (50%), single fractions and conventional 2 Gy fractions being used in a minority of the centres (respectively, 11 and 9%). Most antalgic treatments are performed on a linear accelerator (67% of the centres uses linear accelerators) and 64% of the centres predominantly uses a two-field set-up. The majority of the centres uses shielding blocks and performs isodose calculations in less than 50% of the patients, (respectively, 88 and 81%). There is a correlation between the centre size and the palliative irradiation practice, the largest centres using more hypofractionation (chi(2): P=0.001; logit: P=0. 0003) and a less complex treatment set up as expressed by the use of isodose calculations (chi(2): P=0.027; logit: P=0.0161). There is also a tendency to use less shielding blocks (P=0.177). The same goes for university centres as compared with private centres: university centres use shorter fractionation schedules (chi(2): P=0. 008; logit: P=0.0094), less isodoses (chi(2): P=0.010; logit: P=0. 0115) and somewhat less shielding blocks (P=0.151). Amongst the analyzed countries different tendencies in fractionation (P=0.001) and treatment complexity are observed (use of isodoses: P=0.014, use of shielding blocks: P=0.001). CONCLUSION: These data suggest that beside work-load and clinical evidence, country-related factors such as tradition and habits, past teaching, the national organization of health care and reimbursement criteria may influence the local practice.     

Supporting cancer care in the developing countries: role of IAEA/WHO

Cancer management can be expensive and constitutes a major problem in many developing countries where management standards are poor due to many factors, including non-availability of sufficient funds, equipment, and trained personnel. The incidence of cancer is rising worldwide. This is more so in the developing countries, many of whom are less equipped to deal with the problems. Radiation therapy is one of the major treatment modalities for cancer, and it is estimated that about 60% of all cancer patients require this treatment at one time or another during the course of their disease. Unfortunately, radiotherapy facilities are lacking or grossly inadequate in many developing countries. Over the past 8 years the IAEA and WHO have shown more interest in the problem and treatment of cancer in the developing countries. This paper reviews the role of these international organizations, with emphasis on research activities, education (seminars, workshops, training courses), and technical assistance programs. These include establishment or upgrading of radiotherapy facilities, provision of experts, etc. Scientific papers are published with a view to disseminating current information and research findings in the developing countries. The achievements up to date are assessed and discussed.     

乳腺癌保乳手术安全范围的研究

目的:探讨适合中国女性保乳手术的安全切除范围.方法:对48例切缘阴性象限切除标本大切片观察乳腺内原发癌及癌旁病变累犯范围;并对62例全乳腺切除标本采用免疫组化及分子生物学方法,检测癌和癌旁组织PCNA、p53、C-erbB-2等表达情况,分析癌瘤向周边浸润及周围组织癌变趋向的规律.结果:随距原发癌越远,癌旁发生高危病变、PCNA、C-erbB-2及p53阳性的比例逐渐降低(P＜0.05);近乳头端和肿瘤两侧癌旁危险因素阳性病变较远侧端范围广泛(P＜0.05);癌旁不同范围危险因素比例与乳腺原发癌伴有广泛的导管内癌成分(EIC)、C-erbB-2及p53阳性有关(P＜0.05);原发癌组织学Ⅰ级者癌旁未见危险因素存在.结论:保乳术后复发危险因素绝大多数(95.2%)在瘤缘外2cm以内存在,因此推荐以癌旁2cm作为保乳手术的安全切除范围,远离乳头端可缩小手术范围至癌旁1cm处;同时对原发癌EIC( )、C-erbB-2和/或p53阳性表达者应扩大切除范围,达到切缘阴性,降低局部复发率.     

Trends in stroke and stomach cancer in Austria compared to selected Eastern and Western European countries

The age-adjusted rates of stomach cancer in men and women aged 45-74 years tended to decrease in different countries in Europe between 3.0% and 5.3% per year over the last 10-15 years. East European countries had generally higher stomach cancer death rates than West European countries, and of these Austria and Finland had the highest rates. Stroke mortality decreased in West European countries in a similar way; the underlying factor might be salt intake. Between and also within West European countries a positive association has been found between changes in salt intake and trends in both stomach cancer and stroke mortality. In most East European countries, stroke mortality has increased. The greatest annual increases were in Poland and Czechoslovakia ranging between 2.9% and 4.8%. Thus, although the decline in stomach cancer mortality in Europe suggests a general reduction of salt intake, this alone was not sufficient to result in a decline in stroke mortality in East European countries. The stroke-salt intake association in East European countries might have been modified by other factors such as increased fat intake and obesity causing high blood pressure. Further studies are therefore needed to clarify the role of salt intake as a linking factor of stomach cancer and stroke.     

Systemic inflammatory markers for the detection of infectious complications and safe discharge after cytoreductive surgery and HIPEC

IntroductionCytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) in patients with ovarian peritoneal carcinomatosis may be associated with a high postoperative morbidity. An early discrimination of postoperative complications is crucial for both improving clinical outcomes and proposing a safe discharge.Material and methodsIn a cohort of 122 patients with advanced ovarian cancer (FIGO III-IV), we analyzed the diagnostic performance of three systemic inflammatory markers (C-reactive protein, white blood cell count and systemic immune-inflammation index) between the 5th to 8th postoperative days to prediction postoperative infectious complications. An optimal cut-off value was established in order to discriminate between the group of patients who developed infectious complications or not during the postoperative period.ResultsThe median peritoneal carcinomatosis index (PCI) was 15. The overall infectious morbidity was 25.4% (31 patients out of 122), of which, 32% (10 patients out of 31) had suffered severe postoperative complications (Dindo-Clavien III-IV). The most accurate results for detecting infectious complications were obtained by using C-reactive protein, which presented an excellent diagnostic performance, especially on the 7th and 8th postoperative days (AUC = 0,857 and 0,920; respectively).ConclusionsThese results support that it is safe to discharge patients with C-reactive protein concentrations lower than 88 mg/L and 130 mg/L, on the 7th and 8th postoperative days, respectively.