Establishing a Cancer Registry in a Resource-Constrained Region: Process Experience From Ghana

PURPOSE

In a review of cancer incidence across continents (GLOBOCAN 2012), data sources from Ghana were classified as Frequencies, the lowest classification for inclusion, signifying the worst data quality for inclusion in the analysis. Recognizing this deficiency, the establishment of a population-based cancer registry was proposed as part of a broader cancer control plan.

METHODS

The registry was examined under the following headings: policy, data source, and administrative structure; external support and training; and definition of geographic coverage.

RESULTS

The registry was set up based on the Ghana policy document on the strategy for cancer control. The paradigm shift ensured subscription to one data collection software (CanReg 5) in the country. The current approach consists of trained registrars based in the registry who conduct active data abstraction at the departments and units of the hospital and pathologic services. To ensure good governance, an administrative structure was created, including an advisory board, a technical committee, and registry staff. External support for the establishment of the Accra Cancer Registry has come mainly from Stanford University and the African Cancer Registry Network, in collaboration with the University of Ghana. Unlike previous attempts, this registry has a well-defined population made up of nine municipal districts.

CONCLUSION

The Accra Cancer Registry was established as a result of the lessons learned from failed previous attempts and aim to provide a model for setting up other cancer registries in Ghana. It will eventually be the focal point where all the national data can be collated.

Cardiac mortality after radiotherapy, chemotherapy and endocrine therapy for breast cancer: Cohort study of 2 million women from 57 cancer registries in 22 countries

Comparisons of patients receiving different cancer treatments reflect the effects of both treatment and patient selection. In breast cancer, however, if radiotherapy decisions are unrelated to laterality, comparisons of left-sided and right-sided cancers can demonstrate the causal effects of higher-versus-lower cardiac radiation dose. Cardiac mortality was analysed using individual patient data for 1,934,248 women with breast cancer in 22 countries. The median date of diagnosis was 1996 and the interquartile range was 1987-2002. A total of 1,018,505 women were recorded as irradiated, 223,077 as receiving chemotherapy, 317,619 as receiving endocrine therapy and 55,264 died of cardiac disease. Analyses were stratified by time since breast cancer diagnosis, age at diagnosis, calendar year of diagnosis and country. Patient-selection effects were evident for all three treatments. For radiotherapy, there was also evidence of selection according to laterality in women irradiated 1990 or later. In patients irradiated before 1990, there was no such selection and cardiac mortality was higher in left-sided than right-sided cancer (rate ratio [RR]: 1.13, 95% confidence interval 1.09-1.17). Left-versus-right cardiac mortality RRs were greater among younger women (1.46, 1.19, 1.20, 1.09 and 1.08 after cancer diagnoses at ages <40, 40-49, 50-59, 60-69 and 70+ years, 2ptrend =0.003). Left-versus-right RRs also increased with time since cancer diagnosis (1.03, 1.11, 1.19 and 1.21 during 0-4, 5-14, 15-24 and 25+ years, 2ptrend =0.002) while for women who also received chemotherapy, the left-versus-right RR was 1.42 (95% confidence interval 1.13-1.77), compared to 1.10 (1.05-1.16) for women who did not (2pdifference = 0.03). These results show that the relative increase in cardiac mortality from cardiac exposure during breast cancer radiotherapy given in the past was greater in younger women, lasted into the third decade after exposure and was greater when chemotherapy was also given.

Cancers related to lifestyle and environmental factors in France in 2015

BACKGROUND

Cancer is a major cause of premature illness and death in France. To quantify how cancer prevention could reduce the burden, we present estimates of the contribution of lifestyle and environmental risk factors to cancer incidence in France in 2015, comparing these with other high-income countries.

METHOD

Prevalences of, and relative risks for tobacco smoking, alcohol consumption, inadequate diet, overweight and obesity, physical inactivity, exogenous hormones, suboptimal breastfeeding, infectious agents, ionising radiation, air pollution, ultraviolet exposure, occupational exposures, arsenic in drinking water and indoor benzene were obtained to estimate the population attributable fraction (PAF) and the number of attributable cancers by the cancer site and sex.

RESULTS

In 2015, 41% (or 142,000 of 346,000) of all new cancers diagnosed in France could be attributed to the aforementioned risk factors. The numbers and PAF were slightly higher in men than in women (84,000 versus 58,000 cases and 44% versus 37%, respectively). Smoking (PAF: 20%), alcohol consumption (PAF: 8%), dietary factors (PAF: 5%) and excess weight (PAF: 5%) were the most important factors. Infections and occupational exposures each contributed to an additional 4% of the cancer cases in 2015.

CONCLUSION

Today, two-fifths of cancers in France are attributable to preventable risk factors. The variations in the key amenable factors responsible in France relative to other economically similar countries highlight the need for tailored approaches to cancer education and prevention. Reducing smoking and alcohol consumption and the adoption of healthier diet and body weight remain important targets to reduce the increasing number of new cancer patients in France in the decades to follow.

Essential TNM: A Means to Collect Stage Data in Population-Based Registries in Low- and Middle-Income Countries

Background and context: Cancer control requires knowledge of cancer incidence. Information on anatomic extent of disease (stage) at presentation significantly enhances incidence and mortality data in understanding the cancer burden. The most frequently used staging classification of cancer disease extent is the tumor, node, metastases (TNM). Population-based registries (PBCR) in low- and middle-income countries (LMIC) frequently have insufficient information to derive complete TNM data, either because of inability to perform the necessary evaluations or because of a lack of recorded information. Aim: To develop a simplified system of recording extent of disease to facilitate the collection of stage data by PBCR and enhance the utility of data to facilitate cancer control in LMICs. Strategy/Tactics: A working group with representatives from the UICC (Union for International Cancer Control), the IARC (International Agency for Cancer Research), IACR (International Association of Cancer Registries) and the NCI (National Cancer Institute) was formed and Essential TNM was developed. When the T, N, and M categories have not been recorded in the clinical records or if the complete data to determine the categories is unavailable, the cancer registrar can code extent of disease according to the Essential TNM scheme. Once a cancer registrar had identifies the presence of metastatic disease (M1) this is recorded and additional information is unnecessary to establish that stage of disease. If there is no metastatic disease the extent of nodal disease is recorded. In turn if there is no nodal disease the extent/size of the primary carcinoma is recorded. The extent of disease can be summarized in the following order: M, N and T. Program/Policy process: Diagrams and rules for combining Essential TNM elements into stage groups (I-IV) or to be expressed as “distant”, “regional” or “localized” if only the most limited data were available, were developed for breast, cervix, prostate and colon cancers and will be demonstrated. Once the schema were developed they were verified in Georgia (USA) and field tested in Ecuador, Malawi, Cote d'Ivoire and Zimbabwe. Outcomes: There was good agreement between the stage identified through Essential TNM and that within the Georgia State Registry. The field tests however identified three key issues: the underidentification of distant metastases, inaccurate the collection of lymph node data and improved training needs. In particular there was uncertainty in the identification of when lymph node involvement was considered to be distant metastatic or regional. In view of this, refinements to the schemas have been made to simplify the collection of nodal data. The schema have been updated to ensure compatibility with the 8th edition of TNM. Training programs are being developed and Essential TNM is being expanded. What was learned: Essential TNM can be used by LMIC PBCR to facilitate the collection of stage data. Further refinements and training are needed and are underway.

Organization of population-based cancer control programs: Europe and the World

As cancer is to a large extent avoidable and treatable, a cancer control program should be able to reduce mortality and morbidity and improve the quality of life of cancer patients and their families. However, the extent to which the goals of a cancer control program can be achieved will depend on the resource constraints a country faces. Such population-based cancer control plans should prioritize effective interventions and programs that are beneficial to the largest part of the population, and should include activities devoted to prevention, screening and early detection, treatment, palliation and end-of-life care, and rehabilitation.

In order to develop a successful cancer control program, leadership and the relevant stakeholders, including patient organizations, need to be identified early on in the process so that all partners can take ownership and responsibility for the program. Various tools have been developed to aid them in the planning and implementation process. However, countries developing a national cancer control program would benefit from a discussion of different models for planning and delivery of population-based cancer control in settings with differing levels of resource commitment, in order to determine how best to proceed given their current level of commitment, political engagement and resources. As the priority assigned to different components of cancer control will differ depending on available resources and the burden and pattern of cancer, it is important to consider the relative roles of prevention, early detection, diagnosis, treatment, rehabilitation and palliative care in a cancer control program, as well as how to align available resources to meet prioritized needs.

Experiences from countries with differing levels of resources are presented and serve to illustrate the difficulties in developing and implementing cancer control programs, as well as the innovative strategies that are being used to maximize available resources and enhance the quality of care provided to cancer patients around the world.

Sharon Whelan

abstract.

Incidence of cancer in Nairobi, Kenya (2004-2008)

Cancer incidence rates are presented for the Nairobi Cancer Registry, a population-based cancer registry (PBCR) covering the population of the capital city of Kenya (3.2 million inhabitants in 2009). Case finding was by active methods, with standard and checks for accuracy and validity. During the period 2004-2008 a total of 8,982 cases were registered comprising 3,889 men (an age standardized incidence rate (ASR) of 161 per 100,000) and 5,093 women (ASR 231 per 1,00,000). Prostate cancer was the most common cancer in men (ASR 40.6 per 100,000) while breast cancer was the most common among women (ASR 51.7 per 100,000). Cervical cancer ranked the second most common cancer among women in Nairobi with an ASR of 46.1 per 100,000, somewhat lower than those of other registries in East Africa region. Breast and cervical cancers accounted for 44% of all cancers in women. Cancer of the oesophagus was common in both sexes, with a slight excess of cases in men (sex ratio 1.3). Unlike other regions in East Africa, the rate of Kaposi sarcoma was relatively low during the period (men 3.6/100,000; women 2.0/100,000). Although incidence rates cannot be calculated for the early years of the registry, the increase in relative frequency of prostate cancer and declines in frequency of Kaposi sarcoma may indicate underlying trends in the risk of these cancers.

Cancer incidence in Tehran metropolis: the first report from the Tehran Population-based Cancer Registry, 1998-2001

BACKGROUND

There are no population-based data available for cancer in Tehran, a city that includes almost 10% of the Iranian population. This is the first report of cancer incidence in Tehran from a population-based cancer registry for the period of 1998-2001.

METHODS

The cancer registry collects data on all new cases of cancer diagnosed in the resident population of Tehran metropolitan area. Data collection is active and trained abstractors visit close to 120 data sources comprising cancer diagnostic laboratories, secondary- and tertiary-care hospitals, and imaging centers to abstract cancer cases.

RESULTS

During the period of 1998-2001, a total of 34,318 eligible cases were abstracted of which 24% were identified just by death certificates. The overall age-standardized rates (ASR) (adjusted to the world population structure) were 163.0 per 100,000 males and 141.8 per 100,000 females. The most frequently reported malignancies in males were stomach cancer (ASR 19.8), followed by cancers of the prostate (ASR 15.6), lung (ASR 14.9), bladder (ASR 13.3), non-Hodgkin's lymphoma (ASR 7.1), and esophagus (ASR 6.8). In females, the most frequently reported malignancies were breast cancer (ASR 31.4), followed by cancers of the stomach (ASR 10.0), lung (ASR 7.0), ovary (ASR 6.8), and esophagus (ASR 5.3).

CONCLUSION

The data reported by the Tehran Cancer Registry provide information on the cancer profile in Tehran metropolitan area. It clearly shows the breast and stomach, prostate, and tobacco-related cancers as major cancer in this population. The observed cancer rates indicate that Helicobacter pylori eradication, tobacco control measures, and early detection of breast cancer are of importance for cancer control in this population.

Cervical cancer screening in Thailand: an overview

In Thailand, there have been no 'organized' programmes of screening for cervical cancer. For the most part, screening has been unsystematic or provided to women 'on demand'. In 2002, the Department of Medical Services of the Ministry of Public Health proposed the screening of the entire population of women in Thailand at 5-yearly intervals from the ages of 35 to 60 years. As a first step, measures to increase the capacity for obtaining and interpreting papanicolaou (Pap) smears have been put in place. Research studies have examined the effectiveness of screening with Pap smears in Thailand, and confirmed that, as elsewhere, protection is related to the number of previous tests and the time elapsed since the most recent one. Coverage of the population remains low. Other methods of screening are being investigated in Thailand, including visual inspection following acetic acid (VIA), followed by immediate treatment of observed lesions by cryotherapy ('see and treat'). Other research studies have examined the acceptability and performance of self-sampling as a means of obtaining Pap smears, and the use of mobile clinics to increase coverage of at-risk women in rural settings. Human papillomavirus (HPV) testing has been used to identify high-risk women, or to help decide which women with low-grade abnormality on cytology should undergo more intensive follow-up. Prevalence of HPV in normal women in Thailand is 9-20%, but HPV testing has not been used on any systematic basis to date. Current screening programmes in Thailand are not very effective. The national cancer control programme aims to increase the coverage of screening. The population-based cancer registry will provide an effective and economical method of evaluating the impact of early diagnosis and screening at community level.

Geographical patterns and time trends of cancer incidence and survival among children and adolescents in Europe since the 1970s (the ACCISproject): an epidemiological study

BACKGROUND

Cancer is rare before age 20 years. We aimed to use the European database of childhood and adolescent cancer cases, within the Automated Childhood Cancer Information System project, to estimate patterns and trends of incidence and survival within Europe.

METHODS

Comparable, high-quality data from 63 European population-based cancer registries consisted of 113000 tumours in children and 18243 in adolescents diagnosed in 1970-99. Incidence rates and survival were compared by region (east vs west), period, and malignant disease.

FINDINGS

In the 1990s, age-standardised incidence rates were 140 per million for children (0-14 years) and 157 per million for ages 0-19 years. Over the three decades, overall incidence increased by 1.0% per year (p<0.0001) in children (increases for most tumour types), and by 1.5% (p<0.0001) in adolescents (15-19 years; notable increases were recorded for carcinomas, lymphomas, and germ-cell tumours). Overall 5-year survival for children in the 1990s was 64% in the east and 75% in the west, with differences between regions for virtually all tumour groups; 5-year survival was much the same in adolescents. Survival has improved dramatically since the 1970s in children and adolescents, more so in the west than in the east.

INTERPRETATION

Our results are clear evidence of an increase of cancer incidence in childhood and adolescence during the past decades, and of an acceleration of this trend. Geographical and temporal patterns suggest areas for further study into causes of these neoplasms, as well as providing an indicator of progress of public-health policy in Europe.

Incidence and mortality from stomach cancer in Japan, Slovenia and the USA

The mortality and incidence from stomach cancer were compared in Japan (a country with a high incidence where there was full application of mass screening during this period) and 2 countries with no screening policy: the USA (with a very low incidence) and Slovenia (with an intermediate rate). The registered cases of stomach cancer were from the Osaka Cancer Registry, the Slovenian National Cancer Registry and the Surveillance, Epidemiology, and End Results (SEER) registries in the USA. In the period 1975-95, the age-adjusted incidence rate (/100,000) of stomach cancer declined in the 3 countries, as follows: Japan, from 76.0 to 53.0 in men and 38.4 to 21.3 in women; Slovenia, from 40.2 to 24.1 in men and 16.6 to 10.8 in women; and the USA, from 9.5 to 6.9 in men and 4.3 to 2.9 in women. During the same period, the age-adjusted mortality rate declined, as follows: Japan, from 60.2 to 34.2 in men and 30.5 to 14.1 in women; Slovenia, from 37.7 to 21.2 in men and 13.8 to 9.0 in women; the USA, from 5.6 to 4.7 in men and 2.5 to 2.3 in women. In the period studied, specific trends on incidence and mortality with a cohort effect occurred only in Japan: analysis by the age period-cohort model confirmed that the decline has occurred since the generations born in 1910. The trend therefore corresponds to unplanned prevention through changes in environmental factors occurring since the early 20th century. The study of stage-specific incidence rates confirmed the declining trend for regional cancer, whereas there was an increase in the incidence of localized cancer, associated with a period effect in 1975-95. This is attributed to the policy of early detection of stomach cancer, with the inclusion of intramucosal lesions of favorable prognosis and explains why mortality decreased faster than incidence during the period.

Mortality from melanoma in migrants to Australia: variation by age at arrival and duration of stay

All death records in Australia during the period 1964-1985 were analyzed to compare mortality from melanoma in immigrants and Australian-born individuals, and to investigate changes in risk in the immigrants according to their duration of stay and age at arrival. About 450,000 deaths were from cancer, and risks of melanoma were estimated by logistic regression relative to those of the Australian-born, with deaths from other cancers used as controls. Estimates were adjusted for age at death, time period, birth cohort, and state of registration of death in Australia. Region of birth was defined as New Zealand, other Oceania, England, Ireland/Scotland/Wales (including Northern Ireland and the Republic of Ireland), Central Europe, Eastern Europe, Southern Europe, Western Asia, or Eastern Asia, bearing in mind that many migrants born in Asia were of European descent. Overall, migrants from outside Oceania were at lower risk than the Australian-born, and the lowest risks in males were in Southern Europeans and Eastern Asians, reflecting the protective effect of a darker complexion. Risk of melanoma was related both to duration of stay in Australia and to age at arrival; although their relative importance cannot be measured, the patterns of change suggested that childhood migration may be more important in determining risk than number of years in Australia. The authors believe this study to be based on the largest data set ever used in migrant studies, and note that the previously found differences in melanoma risk between immigrants and Australian-born remained after adjustment for major temporal and geographic confounders. The results confirm the importance of the interaction between environmental and genetic risk factors in the etiology of melanoma.

Opisthorchis viverrini infestation and endogenous nitrosamines as risk factors for cholangiocarcinoma in Thailand

Cholangiocarcinoma (CCA) is one of the most common cancers in north-east Thailand and has been associated with infestation by the liver fluke Opisthorchis viverrini (OV). Two samples of 12-hr overnight urine (after dosing with proline and ascorbic acid or proline alone) were collected from 20 inhabitants from each of 5 contrasting incidence areas for CCA. The incidence of CCA was not correlated with either the amount of NPRO or other nitrosamino acids, endogenous nitrosation potential (difference in NPRO levels between proline dose and proline and ascorbic dose), or nitrate level. However, when urinary levels of nitrosamino acids were compared in subjects living in high-risk areas, subjects who were positive for OV antibody excreted significantly more (p less than 0.01) NPRO (12.3 +/- 18.7 micrograms/12 hr) after proline ingestion than those who were negative (3.5 +/- 3.2 micrograms/12 hr). After ingestion of ascorbic acid, the NPRO levels in the positive subjects were significantly reduced (p less than 0.01) to 2.4 +/- 2.0 micrograms/12 hr, suggesting that endogenous nitrosation of proline was inhibited. Thus, endogenous nitrosation potential estimated from the difference between NPRO and the sum of nitrosamino acids excreted in the 2 urine samples was significantly higher in subjects positive for the OV antibody. Small amounts of pre-formed nitrosamines were found in fermented fish and pork food items, which are consumed frequently in the high-risk area for CCA. These results suggest that the interaction between chemical carcinogens, especially nitrosamines, and OV infestation may play a role in the development of cholangiocarcinoma in Thailand.

Albumin excretion in children and adolescents with insulin-dependent diabetes

Microalbuminuria has been shown to predict end-stage renal failure in adults with insulin-dependent diabetes. We have measured albumin excretion rates (AER) in 106 normal adults, 64 normal children and 68 children with insulin-dependent diabetes. The median AER's in both groups of children were similar and both were significantly lower than in the adult population. In normal and diabetic children there was a significant positive correlation of AER with age, but not with duration of disease or HbA1 in the diabetic group. We conclude that AER is lower in children than in adults and that the levels of albumin excretion which are predictive of clinical diabetic nephropathy in adults may not be applicable to children.

HLA antigens and growth in diabetic children

HLA types in 121 diabetic children in Newcastle are examined in relation to their growth records. The children's height at the onset of diabetes was normal, but fell away during the course of the disease; there was low mean height velocity and failure of bone development to keep pace with chronological age. The total series shows the expected excess of HLA antigens B8, B15 and Cw3 and deficit of B7. Children with B8 are of smaller stature adjusted for bone age than those without the antigen, while children with B7 appear to do better. The results suggest that within the diabetic spectrum of genotypes the HLA antigens are relevant to growth and development.