Cancer Care in Low-Resource Areas Cancer Prevention and Early Detection: Workshop Summary (2016) / Chapter Skim
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Workshop Summary
Workshop Summary
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2 Cancer prevention efforts discussed at the workshop included tobacco control; obtaining a healthy diet, weight management, and physical activity; cancer vaccines, early detection, and screening for cancer; and experimental approaches (see section on "Cancer Prevention Efforts in Low-Resource Areas")
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The second workshop -- planned for November 14 and 15, 2016, in Washington, DC -- will focus on cancer treatment, palliative care, and survivorship care. The following is a summary of the first workshop, Cancer Care in Low-Resource Areas: Cancer Prevention and Early Detection, which featured invited presentations and panel discussions on topics including • Global cancer trends and geographic disparities in cancer control and outcomes, the rising burden of cancer in low-resource areas, and the gap between what is known about cancer prevention and what is accessed by low-resource communities.
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By including a dual emphasis on domestic and international experiences, workshop participants had the opportunity to discuss what has worked well for specific low-resource settings, to describe some of the challenges that workshop participants have faced and how they have been overcome, and to consider whether similar interventions could be applicable in other settings. Although communities will have unique factors that will need to be considered when implementing cancer prevention efforts, the planning committee thought this framing could be helpful so that international experiences have the potential to inform domestic efforts to improve cancer prevention and early detection, and for domestic experiences to inform international efforts.
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• Seize opportunities within the Affordable Care Act to engage community health workers in the provision of cancer prevention. (Baskin)
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(Massetti) • Build up health systems prior to implementing cancer prevention and screening programs, including necessary pathology services.
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• Train and increase reliance on local community health care workers in cancer prevention and screening programs. (Castle, Kingham, Schmeler)
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. Vivien Tsu, associate director of the PATH Reproductive Health Global Program, noted that deaths from cervical or breast cancers in low- and 4 Although the World Health Organization specifies cancer as a noncommunicable disease, there are some cancers -- such as cervical, stomach, and liver cancers -- in which infections are known to play a role in their development (WHO, 2015a)
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the best quality cancer care, and one of the main determinants of disparities in cancer is the country per-capita income." She said that variation in cancer survival is linked to national wealth, including gross domestic product, total national expenditure on health, and the level of investment in health technology, such as screening, diagnostic, and treatment technologies (see Figure 1)
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. But "income doesn't tell the whole story," Stevens said, because some high-income countries, such as Australia, France, Spain, and the United States have shown a decrease in breast cancer death rates over time, despite increases in breast cancer incidence.
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. Tsu said that the number of breast cancer deaths in 1990 was greater in high-income nations compared to low- and middle-income countries.
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. This could be due to lowincome countries not having the financial resources to link breast cancer treatment to incidence, or higher income countries conducting more breast cancer screening that detects the cancer at an earlier, more treatable stage.
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." Electra Paskett, director of the division of cancer prevention and control at Ohio State University, reported that in the Appalachian region of Ohio, only about one-quarter of women aged 50 to 74 have received a mammogram in the past year. As a result, breast cancer is more likely to be diagnosed at a later stage compared with urban women, she said (Katz et al., 2015)
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. Causes of cancer disparities can include insufficient health insurance or funds to cover health care costs, both on an individual or country-level basis, as well as a lack of education and health literacy, inaccurate cultural beliefs about health, language differences, and other social and cultural factors, which are discussed in more detail in the section on "Sociocultural Challenges in Low-Resource Areas." Cancer risk factors -- such as tobacco and alcohol use, unhealthy diet and a lack of physical activity, as well as some infections -- are another reason for disparities in cancer outcomes (WHO, 2015b)
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. Wendy Demark-Wahnefried, associate director of Cancer Prevention and Control at the University of Alabama at Birmingham, reported that worldwide in 2008, 35 percent of adults were overweight, and 11 percent were obese; these figures have doubled since 1980.
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. Paskett added that inadequate breast cancer screening occurs in Appalachian communities in Ohio because of a number of barriers to care, including a lack of health insurance, poor health literacy, mistrust of the medical system, concerns about costs and the need to travel, and gender roles (e.g., women may be expected to prioritize taking care of children and domestic responsibilities and neglect taking care of themselves)
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Impoverished populations may also lack education, and there may be cultural and language barriers that impede access to cervical cancer screening and treatment services. In addition, those services may be inaccessible due to a lack of insurance coverage and inadequate income to cover health care costs, Massetti said.
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These barriers include a lack of access to breast cancer screening and diagnosis, as well as costs associated with cancer treatment that are not covered (e.g., transportation for radiation therapy and chemotherapy, caregiving responsibilities, and lost income associated with treatment)
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. Inadequate breast cancer screening and early diagnosis is also problematic in Jordan, Khleif reported.
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Based on the expected growth of populations and the rates of cervical cancer in the 49 countries that the United States targets for its global health funding, if cervical cancer rates were brought down to that of high-income nations by 2025, approximately 120,000 deaths from cervical cancer could be avoided from 2014-2025 (Council on Foreign Relations, 2014)
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For example, in developing countries, cervical cancer screening techniques that require little laboratory infrastructure, such as simple visual inspection of the cervix with acetic acid or DNA testing for HPV in cervical cell samples, cost less than $500 per year of life saved. Massetti added that in general, cancer prevention is far more cost-effective than treatment.
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21 Figure 5, broadside FI G U R E 5 D ea th a nd d isa bi lit y du e t o no nc om m un ic ab le d ise as e o ut nu m be r t ho se d ue to in fe ct io us d ise as e, b ut re ce iv e a d isp ro po rt io na te ly lo w in ve stm en t o f h ea lth sp en di ng g lo ba lly .
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. For example, her international cervical cancer prevention programs included teams that involved an anthropologist, epidemiologist, sociologist, and economist, as well as clinicians.
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. All these beliefs are major impediments for people seeking cancer care, Khleif stressed.
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They also started a national cancer awareness program using trained educators for underserved communities, including refugee camps, schools, villages, and other remote areas. The program partnered with several communities and organizations and provided access and navigation services for cancer prevention and early detection.
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Khleif added that religious beliefs that are embedded within many societies may deter people from seeking cancer screening or care, and addressing these beliefs can be critical to the success of cancer prevention programs. Language Barriers and Lack of Trust When people residing in low-resource areas have a different language or ethnic background than that of their clinicians, there can be language and cultural barriers that impede the understanding of cancer prevention, and influence the effectiveness of cancer prevention efforts.
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For example, Palafox noted the extreme isolation of island communities can make the logistics of accessing preventive cancer care difficult. Similarly, Doyin Oluwole, chief executive officer of the Global Health Innovations and Action Foundation, noted that in Zambia it was difficult to access some parts of the country due to bad roads, which was a challenge in implementing a cervical cancer prevention program.
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. These rural challenges to receiving preventive cancer care are significant in the United States, given that about one-fifth of the U.S.
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For example, she noted strong beliefs in many places that cervical cancer is due to promiscuity. In communities with these beliefs, women are less likely to participate in cancer screening or even treatment due to concerns about being stigmatized or blamed for their cancer.
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"This machismo is one of the biggest barriers to any of the work we are doing on early detection or treatment," Knaul said. The traditional expectation that women have sole responsibility for the care of their children is another impediment for women seeking cancer care,
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CANCER PREVENTION EFFORTS IN LOW-RESOURCE AREAS Several workshop speakers described their experiences delivering preventive cancer care and discussed potential opportunities to help reduce the cancer burden in low-resource areas, both currently and in the future. Several types of interventions were described, including • Behavioral modification programs to lower risk factors for developing cancer; • Cancer vaccines for infection-related cancers; • Cancer screening and detection programs that can diagnose precancerous conditions and cancers at an early stage, when they are more likely to be effectively treated; and • Antibiotic and antiviral drugs that might prevent cancers linked to infections.
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"We do very little on tobacco control internationally and we certainly can do more," he said. Massetti added that despite known programs and policy measures that can decrease tobacco use, "they are not used or they are not applied consistently in low- and middle-income countries.
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Eriksen noted that the FCTC specifies four main types of evidencebased, anti-tobacco policy measures: taxes on tobacco products, bans on tobacco advertising, clean indoor air laws, and graphic warning labels on tobacco products (more information on tobacco control and cancer prevention efforts can be found in the workshop summary Reducing TobaccoRelated Cancer Incidence and Mortality [IOM, 2013]
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Schmeler added that MD Anderson Cancer Center recently adopted a policy that prohibits all new employees from smoking and requires that new employees be tested to confirm that they comply with the no smoking policy. However, Eriksen said he opposed the policy of not hiring smokers, because smoking is an addiction that is difficult to overcome and often begins during teenage years.
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Examples of these graphic labels include a picture of lungs blackened by tobacco smoke, or faces that have been damaged by oral cancers, and BOX 2 Anti-Tobacco Efforts in Guam and the Philippines Ulysses Dorotheo, director of the Framework Convention on Tobacco Control Program at the Southeast Asia Tobacco Control Alliance, reported on some of the anti-tobacco efforts in Guam and the Philippines. Guam passed a law in 2010 that increased taxes by $2 per pack, with nearly three-quarters of that tax revenue allocated for the U.S.-wide Healthy Futures Fund designated for tobacco, alcohol, and drug prevention, health promotion, and tobacco cessation; 15 percent of revenues were earmarked to the Guam Cancer Trust Fund; and 1 percent of revenues were allocated to fund the Guam Cancer Registry.
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The United States has not yet instituted graphic warning labels, due to legal battles that the tobacco industry has waged. Countering Tobacco Industry Efforts Eriksen said that legal and public relations mechanisms are often used by the tobacco industry to oppose any country attempting to implement bling of their budgets, Dorotheo noted, calling the tax a win for finance, public health, and the poor.
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that's in place in a country. The advocacy that exists, the lawyers that are available to help defend countries against these assaults by tobacco companies, all go into that mix." Bialous noted the FCTC specifies "In setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law." This section of the FCTC also states "there is a fundamental irreconcilable conflict of interest between the tobacco industry and public health," she said (WHO Framework Convention on Tobacco Control, 2008)
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. Bialous suggested integrating tobacco cessation with cancer screening programs by asking all patients if they smoke, and offering cessation therapy if they respond affirmatively.
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Almeida added that independent from physical activity, sedentary behavior also influences cancer risk. Almeida reported that both the American Cancer Society and the American Institute for Cancer Research have recognized the importance of physical activity for cancer prevention and both have devised guidelines (Kushi et al., 2012)
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to implement public health education programs. But as Almeida noted, program recommendations from both these sources are heavily resource intensive and may not be feasible for lowTABLE 1 Physical Activity Recommendations for Cancer Prevention American Cancer Society American Institute for Cancer Research • Adults -- 150 minutes of moderate or 75 minutes of vigorous physical activity per week • Children and Adolescents -- 1 hour of moderate or vigorous physical activity per day • Limit sedentary behavior • Be physically active for at least 30 minutes every day • For maximum health benefits, 60 minutes or more of moderate or 30 minutes or more of vigorous physical activity per day • Limit sedentary behavior SOURCE: Almeida presentation, October 26, 2015.
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One of the programs in Brazil that Almeida and his colleagues developed was a program promoting physical activity for older adults. The researchers worked with the local health department and various community health agents across the city of Santa Catarina to develop and implement walking groups.
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But he added that "If literacy levels are an issue, you just talk about how if you move a little more, if you have a more active lifestyle, you're going to have all of these different types of health benefits." Multilevel Programs for Health Promotion, Cancer Prevention, and Early Detection Some cancer prevention programs for low-resource communities apply multiple interventions, including physical activity, diet, weight management, as well as participation in cancer screening programs. These multilevel programs aim to lower cancer risk and improve health outcomes in general.
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To help ensure sustainability of the program, "once the grant runs out," the researchers provide local community organizations with curriculum manuals, Baskin added. Baskin suggested increasing efforts to target rural communities for cancer prevention research and practice.
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. in the provision of preventive services." Khleif reported on another multifocal cancer prevention program he developed at the Georgia Cancer Center at Augusta University.
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"The investment in vaccination is really key, and many low- and middle-income countries have not embraced it as much as they could, especially given the cost of screening," said Mona Saraiya, associate director of the Office of International Cancer Control at CDC. Countries eligible for support from Gavi, the Vaccine Alliance, are most likely to benefit from the HPV vaccine, according to Saraiya.
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Early Detection and Screening for Cancer A number of workshop speakers described opportunities for cancer screening and early detection, including those for cervical, breast, colorectal, and stomach cancer. Saraiya suggested that the "best buys"10 for cancer screening in low- and middle-income countries include screening programs for cervical and colorectal cancers, but there is ongoing debate about whether screening for breast cancer is cost-effective (WHO, 2010)
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46 Figure 8, broadside FI G U R E 8 Th e aff or da bi lit y of c er vi ca l c an ce r p ro gr am s, to ta l a nd p er c ap ita , i n Af ric an c ou nt rie s.
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Cervical Cancer Schmeler noted that some people have suggested more effort be devoted to developing and implementing HPV vaccination programs rather than screening programs for cervical cancer and she suggested that HPV vaccination needs to be the primary goal of cervical cancer prevention programs. But she stressed that in countries such as the United States, as well as some low- to middle-income countries in which HPV vaccination rates are not 100 percent, screening will still be needed.
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Cervical cancer was the most common newly diagnosed cancer in women in Botswana in 2012, and nearly one-third of Botswana women are afflicted with it, she noted. There were numerous challenges to developing an HPV vaccination program, she said, including competing priorities with overworked Expanded Program of Immunization staff, who were more focused on other childhood immunizations, and a lack of a national injection safety policy.
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To carry out the program, there is a dedicated national program manager funded by the government of Botswana. The national cervical cancer control program is embedded in the national budget, and an evaluation of the first few years of the program will be used to plan for the next 5 years, with support by the U.S.
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Researchers at Rice University have developed another low-cost "see and treat" approach to cervical cancer screening that they hope will have fewer false positives. This method uses an inexpensive high-resolution
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Schmeler is currently conducting tests of this cervical cancer screening method in Brazil, El Salvador, and Houston. In Brazil, practitioners are administering the screening to women in rural areas via a mobile van that travels to their communities.
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programs, including CDC's National Breast and Cervical Cancer Early Detection Program and the Health Resources and Services Administration's Community Health Centers program (see Box 4 for an overview of CDC's cancer prevention and control programs) ,11 but despite the investment, coverage remains low, Saraiya noted.
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CDC is offering technical assistance. Oluwole reported on the successful implementation of a cervical cancer prevention and treatment program in Zambia (see Box 5)
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The Jordan Breast Cancer Program started in 2006 and its objectives were to • Increase public awareness and education; • Improve availability and accessibility of screening services across Jordan; • Establish national unified protocols and guidelines that cover all processes of a comprehensive early detection and screening program; BOX 4 Overview of the Cancer Prevention and Control Activities at the Centers for Disease Control and Prevention Mona Saraiya, associate director of the Office of International Cancer Control at the Centers for Disease Control and Prevention (CDC) , provided an overview of the four major cancer prevention and control activities that CDC undertakes nationwide as well as in U.S.
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• The Colorectal Cancer Control Program is one of the few organized colorectal cancer screening programs in the United States that places a major emphasis on ensuring quality, according to Saraiya. To improve screening rates, all 31 grantees are partnering with health systems to implement priority strategies.
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This cancer can be prevented or diagnosed at an early stage by detecting and removing precancerous growths (polyps) or early cancers BOX 5 Cervical Cancer Prevention and Treatment in Zambia Doyin Oluwole, chief executive officer of the Global Health Innovations and Action Foundation, said that cervical cancer is the most common cancer in Zambian women, and Zambia has the highest rate of cervical cancer deaths in the world.
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The cervical cancer prevention and screening program was able to build on the HIV control programs and clinics established with foreign and national government support. In addition, the Zambian government paid for cervical cancer screening with VIA and treatment of precancerous lesions detected (via cryotherapy or surgery)
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58 TA B LE 2 Th e B re as t H ea lth G lo ba l I ni tia tiv e G ui de lin es fo r I nt er na tio na l B re as t H ea lth an d C an ce r C on tro l– Ea rly D et ec tio n Le ve l o f A va ila bl e Re so ur ce s Ba sic Li m ite d En ha nc ed M ax im al Pu bl ic e du ca tio n an d aw ar en es s D ev el op m en t o f c ul tu ra lly se ns iti ve , l in gu ist ic al ly a pp ro pr ia te lo ca l e du ca tio n pr og ra m s f or ta rg et p op ul at io ns to te ac h va lu e of e ar ly d et ec tio n, b re as t c an ce r ris k fa ct or s, an d br ea st he al th aw ar en es s C ul tu ra lly a nd li ng ui sti ca lly ap pr op ria te ta rg et ed o ut re ac h/ ed uc at io n en co ur ag in g C BE fo r a ge g ro up s a t h ig he r r isk ad m in ist er ed a t d ist ric t/ pr ov in ci al le ve l u sin g he al th ca re p ro vi de rs in th e fie ld Re gi on al a w ar en es s p ro gr am s re ga rd in g br ea st he al th li nk ed to g en er al h ea lth a nd w om en 's he al th p ro gr am s N at io na l a w ar en es s c am pa ig ns re ga rd in g br ea st he al th u sin g m ed ia D et ec tio n m et ho ds C lin ic al h ist or y an d cl in ic al b re as t ex am (C BE )
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This program focused on improving colorectal cancer outcomes in African Americans, who are much more likely to be diagnosed with late-stage colorectal cancers than whites in the state, she said. The program has what she called a "top down and bottom up" approach in which objectives were to not just improve colorectal cancer screening rates among African Americans, but also to ensure timely resolution and treatment when a cancer is diagnosed.
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Colorectal cancer is also a major cause of cancer deaths globally, and the rate of this cancer is rising dramatically in low-income countries, according to Kingham. Saraiya pointed out that most colorectal cancer screening programs in the world are not organized, nor is there uniformity in the type of screening recommended.
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Bialous noted that "there is an increased call to make sure any lung cancer screening is attached to a cessation intervention." She added that tobacco use causes more deaths from heart disease than lung cancer, so a negative lung cancer screen does not reveal all the life-threatening effects of smoking on the body. She suggested that if such screening is done, it should always be linked to information on and access to smoking cessation programs.
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The consortium also plans to initiate some therapeutic trials based on chemotherapy and surgery to see if it can improve outcomes. ARGO has recently branched out to include breast cancer screening.
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The consortium is still attempting to overcome many barriers to colorectal cancer screening in Nigeria, including a lack of funds. "In Lagos it costs $1,000 for a colonoscopy, which is totally impractical for 99.9 percent of the population," Kingham noted.
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The lessons learned focused on several main themes: • The role of policy and advocacy for cancer prevention and antitobacco efforts; • How to plan and implement cancer prevention programs; • Funding and infrastructure for cancer prevention efforts; and • Education and communication. Advocacy Prior to implementing cancer prevention strategies in low- and middleincome countries, several workshop participants stressed the efforts they and local leaders made to advocate for their programs among relevant government officials, as well as in the communities they served.
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Luis Miguel Castilla, the Peruvian ambassador to the United States, noted that the prevalence of cancer can also strengthen advocacy efforts for cancer prevention efforts: "Cancer can touch any person, any household. It does not discriminate in any sense and you need to prevent it." When advocating for cancer prevention programs with government officials, Knaul suggested stressing to them the benefits that the program will have beyond cancer.
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"We need to get cancer societies and professionals a lot more involved in advocating for taxation and price increases on tobacco products that can generate funds for all the other cancer control measures we need," she said. Several workshop speakers also stressed using national and local champions to advocate for cancer prevention programs.
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Several workshop speakers highlighted the importance of primary care clinicians and community health workers as advocates for cancer prevention and early detection. Saraiya said that frontline providers also play a large role as champions for programs: "Their recommendations on vaccination are really key." Dorotheo added that the health community -- and particularly physicians -- were critical advocates for Guam's anticancer tax.
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Program Planning and Implementation Several participants described elements that had been important for successful cancer prevention programs they had worked with, including 12 See http://www.un.org/millenniumgoals (accessed January 21, 2016)
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However, he added that resources for developing comprehensive cancer care across the continuum of prevention, early detection, diagnosis, treatment, rehabilitation and survivorship, and palliative and end-of-life care is often lacking. He said that policy makers and program planners have to decide how resources will be allocated between cancer prevention and cancer treatment.
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But we also need to be rational in our approach or else we will fail." He added, "We need to focus on the ‘low-hanging fruit,' the things that will save the most lives." A participant from the Southeast Asia Tobacco Control Alliance stressed that graphic warning labels on tobacco products are an example of a lowhanging fruit in the cancer prevention arena. Scarinci highlighted the importance of understanding the subpopulations experiencing high cancer burdens and focusing efforts to address these issues.
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Palafox suggested building trust in the communities served by cultivating and maintaining relationships with its residents and having a plan that moves toward social justice, such as achieving health equity. He stressed that participatory community engagement in research and cancer prevention programs means that the community has equal power.
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Tsu responded that often it is difficult to find such health practitioners, and said that when they are available, they may have greater education and income compared with other people in the community, which may create some cultural distance that may need to be overcome. Integration and Synergy Several participants noted the benefits of integrating cancer prevention programs with other medical services, including primary care, and
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Oluwole pointed out that the cervical cancer screening programs Pink Ribbon Red Ribbon helped develop in Africa also provided other medical services women needed so "that the single day they have devoted to health care can be maximized." In addition, Bialous added that primary care involvement is also important when patients undergo outpatient cancer treatment, "because if there is a complication, that will [often] be the first point of entry to get back into health care." Almeida added that increasing physical activity, having a healthy diet, and following other health-promoting behaviors reduce the risks of developing multiple NCDs.
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" Oluwole noted that many countries have substandard cancer treatment centers, so helping to build the capacity for cancer care is critical to the success of cancer screening programs. Another participant added, "it is not screening until you complete the care." There was some disagreement among a few of the workshop participants about whether it is appropriate to conduct cancer screening if there are inadequate resources to provide cancer therapy.
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Oluwole noted that Pink Ribbon Red Ribbon usually tries to only provide screening programs in countries that can also provide treatment. But in Zambia's cervical cancer program, so many women were identified with precancerous and low-grade lesions who needed surgery that treatment needs outpaced the surgical capacity.
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cancer registries do not collect high-quality data on where people are born, which is important information because immigrant populations share part of the cancer burden in the United States. She suggested capturing treatment patterns and surveillance data in immigrant populations to help assess the quality of cancer care and outcomes within various programs.
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CDC is currently conducting pilot studies of this tool in Barbados, Colombia, India, Kenya, and Uganda (Tangka et al., 2016) and has found that most cancer registries are funded by their host institutions, such as universities, ministries of health, or cancer centers, and that most of the costs of a cancer registry are related to labor and data collection.
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Another participant agreed, saying, "While donor funding is doing wonderful support of some surveillance systems, and cervical cancer screening and treatment, it is quite limited in terms of support for the large infrastructure for a variety of other activities. It does need to come from another player and the U.S.
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In addition, the NCI has a Request for Proposal to build a consortia of cancer centers, both from the United States and other countries, to work together in a country or a region on cancer control and treatment or treatment of other NCDs "because we think it is important for people to break down the silos and work together," he said. Trimble also stressed the value of public–private partnerships as a source of funding for global health endeavors.
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Philip Castle, executive director of the Global Coalition against Cervical Cancer, stressed building up health system infrastructure prior to implementing cancer prevention programs. "We can do a lot with cervical cancer because we have great tools, but you are not going to do it even with the simplest program without good pathology, good clinical labs, surgery, etc.
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It has to be done through community health workers." He noted that there are 25,000 midwives in Vietnam and these women provide most of the primary care to women in the country. He suggested that the Ministry of Health in Vietnam could use midwives to collect Pap smears while they are out working in the community, and suggested integrating existing community health workers into cancer prevention programs.
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Tsu added that the patient navigators with whom she worked in a breast cancer program in Peru helped women make their way through a fragmented health care system and made sure they received proper diagnosis and treatment. Knaul produced a training manual and scheme for community health workers, both professional and lay, when she implemented a cancer screening program for Mexican communities.
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One of Paskett's programs provided buses to transport women to receive cancer screening. "When we first started we realized the women didn't even know how to get to the medical clinic to get a mammogram," she said.
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Oluwole noted that the African cervical cancer prevention programs provided information on HPV vaccination to both the community and the providers that served them, and trained health workers on cervical cancer prevention. Morgan noted that the stomach cancer control program in Central America was successful in part because of collaborators in that region that conducted public health campaigns about the risk of stomach cancer.
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Anybody in any aspect of biomedical research science or health care needs to take a class, not just one lecture," she said. Medical professionals in low- and middle-income areas also may need more education and training from others outside their communities to adequately conduct cancer control programs, several participants noted.
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The program also provides hands-on training for some of the providers in the Rio Grande Valley in colposcopy and techniques for removing precancerous cervical lesions. She also established two other ECHO projects: one for cervical cancer prevention and treatment programs in Latin America that is conducted in Spanish, and another for breast and cervical cancer treatment programs in Zambia and Mozambique.
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Such real-life stories are especially important to counter the notion in many lowresource settings that cancer is always a death sentence, Pace said. Thus, cancer survivors telling their stories are essential to inspiring others to participate in cancer prevention activities.
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Knaul said she asked that the manuals the Mexico government provides as part of its social welfare program to include information on breast cancer screening.
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Such research involves topics that are important to the community, with the aim of combining knowledge with action and achieving social change to improve community health and eliminate health disparities. "Academic researchers as well as community members are in this fight together and are equitably talking about the issues we need to focus on and ideal approaches," Baskin said.
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Those links are better established among more prevalent cancer sites, such as breast or colon, but for most cancer sites they remain unknown, he said. Many cancer researchers see the need for a large clinical trial that can assess the importance of exercise and diet for cancer prevention across multiple cancer sites, akin to Diabetes Prevention Program, which found that lifestyle changes or treatment with metformin effectively delayed diabetes in a diverse population of overweight or obese American adults at high risk of diabetes (DPPOS, 2016)
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Surveillance and registries are critical to understanding where and how to invest resources and cancer prevention, she added. The infrastructure needed for programs to be effective can be built by bundling interventions and preventive screening services and sharing resources, perhaps combining with partners focused on other disease areas to offer the full spectrum of preventive health, Massetti added.
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Asian Pacific Journal of Cancer Prevention 16(9)
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2015. Cancer prevention and treatment in developing countries: Recommendations for action cancer control 2015.
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2011. The relevance of fatalism in the study of Latinas' cancer screening behavior: A systematic review of the literature.
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2015. Adherence to multiple cancer screening tests among women living in Appalachia Ohio.
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2012. American Cancer Society guidelines on nutrition and physical activity for cancer prevention.
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2013. Physical activity and primary cancer prevention.
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1993. Prevention of colorectal cancer by colonoscopic polypectomy.
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Au. Attitudes and perceptions about smoking cessation in the context of lung cancer screening.
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