Eastern Mediterranean Health Journal | Past issues | Volume 22, 2016 | Volume 22, issue 9 | Detection and screening of priority cancers in the Eastern Mediterranean Region

Detection and screening of priority cancers in the Eastern Mediterranean Region

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In its drive to address the importance of early cancer diagnosis,the WHO  Regional Office for the Eastern Mediterranean organized a consultative meeting on early detection of prior- ity cancers in the Eastern Mediterranean Region (EMR)  on14–15  January 2016 in Cairo, Egypt. This expert consultation was based on previous regional meetings that identified breast, colorectal, cervical, prostate  and oral cavity cancers as the most common cancers in the Region that are amenable to earlydetection/screening.

Participants included international experts, regional ex-perts, and members of the WHO  Secretariat, with significant input and engagement from the International Agency for Research on Cancer (IARC), the U.S. National Institutes of Health and National Cancer Institute (NIH/NCI) and other relevant international partners. Professor Anthony B. Miller, Professor Emeritus in the Dalla Lana School of Public Health at the University of Toronto, was selected as Chair ofthe meeting.

The objectives of the expert consultative meeting included:1) reviewing the draft documents and collecting feedback with respect to their content and comprehensiveness; 2) reviewing the evidence  on screening  of the five priority cancers  for early detection in the Region; 3) discussing the proposed strategic approach  for early cancer detection  in the Region, including a matrix of key components  of an early detection programme;4) discussing policy options as applied to the three groups of countries in the Region; and 5) agreeing on the way forward and next steps for implementing evidence-based recommen- dations to strengthen  early detection  of priority cancers.

Dr Asmus Hammerich,  Acting Director  of Noncom- municable Diseases and Mental Health, opened the meeting by welcoming all participants. In his opening statement, Dr Ala Alwan, WHO  Regional Director for the Eastern Mediter- ranean, reviewed previous WHO initiatives relevant to cancer control. Cancer control programmes that had been launched in the 1990s later became integrated components  of WHO’s noncommunicable disease agenda, for which a regional frame- work of action was launched in 2012. This regional framework set four priority actions, i.e. governance; prevention and reduc- tion of risk factors; surveillance, research and monitoring; andhealth care.

Cancer control was an integral component  to each ofthese four areas and thus critical for a range of stakeholders. Furthermore,  it was most relevant to policy-makers within the context of the overarching Sustainable Development Goals adopted by the UN in September 2015, specifically considering the global push towards universal health coverage. As such, the consultation discussed a very specific component of cancer control—early detection. He closed by highlighting two subjects: using cost-effective measures and the best avail- able evidence, including economic evaluation approaches, in light of the health system; and implementation challengeseach country faces.

In October 2013, WHO in collaboration with the IARCorganized a regional meeting on cancer control and researchpriorities in Doha, Qatar, which had the following recommendations:strengthening cancer registration and surveillance;carrying out priority research on cancer causation incollaboration with IARC; and strengthening screening andearly detection of priority cancers. It was concluded thatthe most common cancers in the Region that are amenableto early detection are breast, colorectal, cervix, prostate andoral cavity cancers. Furthermore, a preparatory meeting forthe high-level ministerial meeting to scale up cancer control,held in Cairo in July 2014, identified early detection as a highpriority intervention in the Region, where almost half of allcancers are amenable to early detection and potential curewith adequate treatment and follow-up. Member States alsoindicated the need for strengthening cancer screening programmesand improving technical capacity for early detectionof priority cancers.

Summary of discussions

For this consultation, several documents were presented anddiscussed, i.e. a working paper on early detection of five prioritycancers in the Region; a draft policy statement on breastcancer early detection; and a desk review on early detection ofbreast cancer in the Region.

Dr Anthony B. Miller, Professor Emeritus, Dalla LanaSchool of Public Health University of Toronto, introducedtwo principles for early detection of cancers, i.e. early diagnosistargeting people with early symptoms and signs; andpopulation-based cancer screening programmes targeting asymptomatic people. Both approaches need improvedpublic awareness and professional education, efficient andwell-developed health services and appropriate health carefinancing mechanisms.

Dr Sankar Rengaswamy, International Agency for Researchon Cancer (IARC), briefly reviewed the burden andpattern of cancers the Region with emphasis on trends inage-specific and age-standardized incidence rates and theprojected burden in 2030. The presentation and subsequentdiscussions focused on the five most common cancers in theEMR, i.e. breast, colorectal and prostate cancers, with high riskin all or most countries, with moderate to high risk of cervixand oral cancer in certain countries/subregions within theRegion. He also introduced the contents of the early detectiondocument that emphasized the different early detection testsavailable for screening and early diagnosis of these cancers andreviewed important regional experiences.

Considering this background, the consultation emphasizedthree major issues, with reference to national perspectivesand experiences. First, participants agreed on definitionand components of early detection. Second, they consideredthe categorization of countries and how best to present recommendationsaccordingly. Third, specific concerns regardingscreening, especially for breast, cervix and prostate cancer, andsubsequent recommendations were debated.

For the first issue, early detection is split into two majorparts: 1) early diagnosis of symptomatic individuals; and 2)screening of asymptomatic individuals. Early diagnosis isbased on awareness (among the public and among healthprofessionals through continued education) of early signs andsymptoms of cancer in order to facilitate more effective andsimpler therapy. Screening is the presumptive identificationin an apparently asymptomatic population of unrecognizeddisease or defects by means of tests, examinations or otherprocedures that can be applied rapidly and easily to the targetpopulation followed by effective treatment of cancers detected.In terms of categorization, EMR countries are commonlycategorized into three health system groups based on populationhealth outcomes, health system performance and the levelof health expenditure.2

Some participants expressed concerns over the categorizationof countries, particularly the categorization of Group Twocountries (as it does not accurately reflect the health service capabilitiesand development and their readiness to implementscreening programmes). This Group is most heterogeneousand present a challenge to experts on how best to fit the recommendations. As such, early diagnosis recommendationsbased on best international evidence and existing regionalexperience must take into account the existing resources, challengesand opportunities for each group of countries.

Participants also discussed the importance of clearlydistinguishing between screening tools and diagnostic toolswithin the context of early detection. For example, mammographyis best used as a diagnostic tool, not as a screeningtool, so breast cancer control programmes must distinguishits use. There was also general consensus that mammographyscreening is not feasible recommended in Group Three (lowincome) countries. The group agreed that all existing screeningprogrammes in the Region be reviewed. Group One (highincome) countries may consider pilot programmes beforenational scale-up with quality assurance as an importantcomponent of all screening programmes. Mammographyscreening may be feasible in some Group Two countries butnational scale-up should be preceded by pilot programmesand review of ongoing screening programmes. Monitoringand evaluation is also a key component of such programmesand must be included.

Furthermore, the interventions and age specificity forscreening and diagnosis were most controversial regardingmammography for breast cancer, human papillomavirusvaccination for cervical cancer and prostate-specific antigen(PSA) screening for prostate cancer. For prostate cancer, therewas general consensus that PSA screening for prostate canceris not recommended.

Finally, all participants agreed that early diagnosis of breast,colorectal, cervix, prostate and oral cavity cancers amongsymptomatic persons is a core early detection interventionand relevant to all countries of the Region.

The experts concluded that population awareness andhealth provider training with skilled physical examination iscritical. Awareness among people and primary care physiciansis vital and prompt referral and investigations are crucial forsuccess of early detection programmes.

Next steps

The following regional documents were considered during theexpert discussions and group work.

Statements on early detection of: breast cancer, colorectalcancer, and cervical cancerStatement on early detection oforal cancer

Steps for early detection of prostate cancer

Scope of early detection interventions for priority cancers bythree groups of countries of the Region

These will be revised in the light of the meeting’s discussionsand circulated to participants for comments, beforebeing finalized.

1 This report is extracted from the Summary report on the Consultative meeting on early detection and screening of prioritycancers in the Eastern Mediterranean Region, Cairo, Egypt 15–14 January 2016 (https://extranet.who.int/iris/restricted/bitstream/1/204645/10665/IC_Meet_Rep_2016_EN_16607.pdf)

2 Group 1: high income countries (Bahrain, Kuwait, Oman,Qatar, Saudi Arabia and the United Arab Emirates); Group2: middle income countries (Egypt, Islamic Republic of Iran,Iraq, Jordan, Lebanon, Libya, Morocco, Palestine, SyrianArab Republic and Tunisia); Group 3: low income countries(Afghanistan, Djibouti, Pakistan, Somalia, Sudan and Yemen)