IAEA mission recommends way forward for cancer control in Pakistan

Islamabad
The Programme of Action for Cancer Therapy (imPACT) mission of the International Atomic Energy Agency (IAEA) has delivered for Pakistan, a comprehensive roadmap for cancer care and control. In recommending measures, the Agency has urged the country to establish and officially endorse a multi-disciplinary National Cancer Control Steering/Advisory Committee; to develop a National Cancer Control Plan (NCCP); to ensure that all cancer registries aim to produce and provide quality incidence and mortality data on a regular basis; and to substantially increase taxes on tobacco.
The recommendations of the IAEA are currently resting with CA&DD, which received advice regarding areas of cooperation by the IAEA in December 2014, a year after the first review mission of imPACT team visited Pakistan.
“In 2013, the health wing of CA&DD was able to convince the imPACT mission of the IAEA of its professional commitment to fight cancer. The Medical Directorate of the Pakistan Atomic Energy Commission (PAEC), which is running the 18 purpose-built cancer hospitals in the country, was the catalytic factor to earn this support,” Dr. Minhaj-us-Siraj, the focal person for cancer control at CA&DD stated while talking to ‘The News.’ He maintained that the minister of state for CA&DD is keenly monitoring the progress of the initiative.
Dr. Minhaj informed that the foremost requirement of a population-based cancer registry for data collection has been addressed, and the Pakistan Medical Research Council (PMRC) has embarked on the project at local hospitals in Islamabad under CA&DD and with support from the Norwegian government, through the IAEA initiative. “Work has already started on conducting a feasibility study for cancer registration system in Islamabad,” he stated.
With reference to cancer control planning, the IAEA has called for the establishment of a multi-disciplinary National Cancer Control Steering/Advisory Committee with representatives from all areas of cancer control (cancer information/ registration, prevention, detection, diagnosis, treatment, palliative care, training, education, research and civil society).
The Agency has also called for the development of a National Cancer Control Plan to ensure that the plan clearly defines activities, milestones, timeline, budget, measurable indicators and a monitoring mechanism to meet the short- and medium-term objectives in a five-year action plan. It has suggested the establishment of a Cancer Control Committee and the development of cancer control plans at the provincial level as well.
With reference to cancer registration, the IAEA has recommended that all cancer registries should aim to produce and provide quality incidence and mortality data on a regular basis with the intention that the same will be published by the International Agency for Research on Cancer (IARC). “It should also establish several regional population-based cancer registries as a national priority to understand the cancer burden and cancer profile in different regions and to support planning and evaluation of cancer control actions in the domains of prevention, early detection and treatment,” the document states.
Coming to prevention, the IAEA has called for effective implementation of the existing tobacco control ordinance; strengthening of the ‘Tobacco Smoke-free Capital’ and its replication in the provinces; and implementation of sustained health education programmes on the harmful effects of tobacco use in schools and among the general public.
“Tobacco taxation should be substantially increased so that the excise taxation on finished tobacco products reaches above 80% of the retail price. A proportion of the increased tobacco tax revenue should be allocated to support cancer prevention, early detection and treatment services,” the recommendations add. Alcohol control, healthy dietary habits, and regular physical activity are also recommended.
With reference to early detection, the IAEA has called for measures to raise public awareness on breast, cervical and oral cancer; and to strengthen education on cancer signs and symptoms among first-line healthcare providers in Primary Care Units (PCUs). It has also called for increasing the number of breast clinics in tertiary hospitals and PCUs.
In terms of diagnosis and treatment, the IAEA has advised Pakistan to consider restructuring processes for the delivery of comprehensive cancer diagnosis and treatment by integrating and consolidating cancer care services at the population level. This process should also involve the private sector to optimise the cancer care services.
According to the recommendations, Pakistan also needs to install needed diagnostic and therapeutic (radiology and nuclear medicine) equipment at major comprehensive cancer care centres; and to enhance training of nuclear medicine physicians, pathologists, medical physicists, nuclear medicine technologists, intervention radiologists and radiation oncologists for diagnosis and treatment of cancer.
All cancer care in Pakistan, as per the IAEA recommendations, are in need of qualitative and quantitative improvements. With reference to palliative care, the country needs to develop a National Palliative Care Action Plan, including the development of home-based care, the training of health professionals and access to adequate levels of morphine and/or analgesic drugs free of charge. “All cancer hospitals should establish a palliative care unit and provide palliative care services to cancer patients,” the IAEA recommends.
In conclusion, the recommendations call for the establishment of a network of civil society and NGOs in the planning, implementation, and evaluation of the cancer control programme in Pakistan.
Pakistan roughly has only one qualified cancer treatment specialist doctor for a population of 0.5 million. One assistant professor (oncology), two medical officers, and 12 hospital beds at the Pakistan Institute of Medical Sciences (PIMS) constitute the total dedicated capacity of federal government hospitals to fight cancer.
While key cancer control stakeholders at the federal and provincial levels are firmly convinced of the urgent need for state-level planning, coordination and implementation mechanisms for cancer control, the reality on ground betrays a totally reverse scenario.
Pakistan has no national or provincial cancer control plan, budget, or a designated programme coordinator. It also has no population-based cancer registries, which document all cancer cases occurring within a particular region, providing information on how often cancers occur, and how many people survive their disease. Cancer registration is an essential part of any rational cancer control programme. These data are needed for planning and monitoring cancer control strategies and identifying priorities in public health.
Pakistan also has no organized population-based screening programme for either breast, cervical or oral cancers, while only limited opportunistic cervical cancer screening and tests, mainly Pap smear, are available. Visual inspection with acetic acid (VIA) and HPV testing is scarcely performed. Public awareness campaigns in schools and through television programmes have been initiated by physicians, NGOs and some private organisations on a voluntary basis. Furthermore, there is limited cancer awareness among healthcare workers as well.
The country has adequate number of conventional nuclear medicine equipment; however, there are limited PET/CT services, both in terms of numbers and geographical coverage. Again, while there are generally a sufficient number of nuclear medicine physicians and radiologists, continuing education and training is limited. There is a lack of interventional radiologists and physicians with sub-specialty in oncology imaging.
Pakistan has cancer surgery, paediatric oncology, radiation oncology, nuclear medicine, and some palliative care services. However, there is a general lack of adequate human resources (e.g., for radiotherapy, cancer surgery, etc.). There are a limited number of hospital-based multi-disciplinary tumour boards (MDBs).
Pakistan has 30 radiotherapy centres with a total of 48 radiotherapy units, of which 25 units are in the public sector. The country also does not have a National Palliative Care Programme. It only has inadequate palliative care services, almost no home-based palliative care (PC) assistance, and merely 3-4 hospices in all of Pakistan to provide end-of-life care.
Current cancer patterns in Pakistan indicate that a significant proportion of cancer cases and deaths can be prevented through appropriate planning and implementation. Pakistan also needs to strengthen its health services capacity for the timely response and control of cancer. It is about time the country is seen as taking the first steps towards cancer control.