Elsevier

The Lancet Oncology

Volume 14, Issue 4, April 2013, Pages e142-e151
The Lancet Oncology

Series
Challenges and opportunities in cancer control in Africa: a perspective from the African Organisation for Research and Training in Cancer

https://doi.org/10.1016/S1470-2045(12)70482-5Get rights and content

Summary

Sub-Saharan Africa has a disproportionate burden of disease and faces a major public-health challenge from non-communicable diseases. Although infectious diseases continue to afflict Africa, the proportion of the overall disease burden in sub-Saharan Africa attributable to cancer is rising. The region is predicted to have a greater than 85% increase in cancer burden by 2030. Approaches to minimise the burden of cancer in sub-Saharan Africa in the past few years have had little success because of low awareness of the cancer burden and a poor understanding of the potential for cancer prevention. Success will not be easy, and will need partnerships and bridges to be built across countries, economies, and professions. A strategic approach to cancer control in sub-Saharan Africa is needed to build on what works there and what is unique to the region. It should ideally be situated within strong, robust, and sustainable health-care systems that offer quality health care to all people, irrespective of their social or economic standing. However, to achieve this will need new leadership, critical thinking, investment, and understanding. We discuss the present situation in sub-Saharan Africa and propose ideas to advance cancer control in the region, including the areas of cancer awareness, advocacy, research, workforce, care, training, and funding.

Introduction

Sub-Saharan Africa accounts for a disproportionate amount of the global burden of disease (approximately 24%) that substantially exceeds its fraction of the world's population (about 13%).1 Moreover, the health-care systems of countries in this region are generally poorly equipped to cope with this large disease burden (figure 1). Only about 3% of the world's health-care workers live and work in sub-Saharan Africa.2 Consequently, sub-Saharan Africa is a major focus of international donor efforts aimed at assistance for global health. Of the US$5·7 billion spent on global health by the US Government in 2011, almost 85% was directed towards Africa.2

Although cancers kill more people globally than AIDS, tuberculosis, and malaria combined, this is not the case in sub-Saharan Africa, where AIDS, tuberculosis, and malaria account for about seven times more deaths than does cancer (table 1).3, 4 Cancer in the African Region of WHO accounts for only about 5% of deaths in that region, compared with roughly 20% of deaths in each of the WHO Western Pacific, European, and Americas Regions.

Sub-Saharan Africa has a very young population—more than 40% of the entire population are younger than 15 years old.1 People in sub-Saharan Africa also die at a younger age on average compared with those in Europe and the USA. Roughly 80% of all deaths in the African Region of WHO occur in those younger than 60 years, whereas in high-income countries the opposite is true—ie, about 80% of deaths are in those older than 60 years,5 which has several implications for cancer statistics in sub-Saharan Africa. First, incidence and mortality are lower in populations skewed toward younger ages than in those with higher average ages, because age is a highly significant risk factor for most cancers. Second, the average age at which cancer is diagnosed in Africa is lower than in high-income countries, because the average age of the whole population is lower. Third, paediatric cancers constitute a larger fraction of the cancer burden in populations with high proportions of children than in those with fewer children. In some regions of Africa, 6% of all cancers are paediatric cases, whereas in developed countries, this figure is lower than 1%.6

The cancer burden reported for sub-Saharan Africa might be underestimated7, 8 due to lack of appropriate diagnosis,9, 10, 11, 12 poor access to care,10 limitations in technical workforce and infrastructure,10 and the low quality of cancer data systems in Africa compared with those in developed countries.10, 13, 14, 15 The lower cancer incidence and mortality in sub-Saharan Africa than in other regions could also be partly explained by cancer not being prioritised by international donors or the health ministries in sub-Saharan Africa. Cancer cases are poorly catalogued by cancer registries in sub-Saharan Africa, and even common cancers might be under-reported in many regions.16 Subsequently, the nine programme areas identified by the US Global Health Initiative, which includes the President's Emergency Plan for AIDS Relief, do not mention non-communicable diseases, and this initiative's spending focuses on assistance aimed at AIDS, tuberculosis, and malaria. Two-thirds of people with HIV worldwide live in Africa, and 75% of global deaths from AIDS occur in African people. About 70% of the roughly 2 million new HIV infections every year occur in Africa. Similarly, sub-Saharan Africa has the world's highest tuberculosis incidence and the highest tuberculosis mortality per head. Malaria is the leading cause of death in African children younger than 5 years, and represents about 10% of Africa's total disease burden. Roughly 90% of all malaria deaths worldwide occur in Africa. In 2008, an estimated 421 000 deaths from cancer occurred in Africa, compared with 1·4 million deaths from HIV. At least 50% of deaths due to HIV and 80% of those due to cancer need pain treatment for an average of 3 months.17, 18 However, fewer than 11 countries in sub-Saharan Africa offer access to oral morphine, and functional palliative care or home-based care for terminally ill patients is rare.18, 19 Thus, competing health needs—particularly for tuberculosis, malaria, maternal mortality, and, more recently, the HIV epidemic—are a continuing challenge for cancer control in sub-Saharan Africa.

In view of the present range of diseases in sub-Saharan Africa, the suggestion that the main focus should move from AIDS, tuberculosis, and malaria towards cancer (or non-communicable diseases in general) is inappropriate. However, although the reported cancer incidence and mortality in sub-Saharan Africa are low, and infectious diseases still plague the continent, Africa is in transition. The proportion of the disease burden in sub-Saharan Africa attributable to cancer is rising, and the region is projected to have more than an 85% increase in cancer incidence by 2030, solely based on demographic changes (ie, a larger and older population than exists presently).20 The actual increase in cancer burden in sub-Saharan Africa is likely to be even larger than predicted because of westernisation of lifestyles that result in more cancers.20 Progress achieved in control of infectious diseases in the region might also result in an increased proportion of the disease burden being linked to non-communicable diseases. During the transition from infectious to non-communicable diseases (which will probably be lengthy), sub-Saharan Africa is experiencing a so-called double burden of disease: infectious diseases remain, and non-communicable diseases are increasing. Presently, about 80% of the low amount of health spending by countries in sub-Saharan Africa is allocated to acute communicable diseases. These diseases have similarly been the overwhelming focus of donors. Although attention was drawn to non-communicable diseases at the UN high-level meeting about non-communicable diseases in September, 2011, the realignment of health budgets and donor interest in these diseases in sub-Saharan Africa will take time, partly because the rise of non-communicable diseases is not seen as an emergency in the same way as are pandemic infectious diseases, such as HIV/AIDS.

Several challenges exist in the movement to address cancer in Africa. State-of-the-art cancer care is expensive: the USA spends more than US$120 billion every year on cancer care.21, 22 Although some costs (eg, labour) are lower in sub-Saharan Africa than in the USA, many countries in sub-Saharan Africa spend less than US$100 per head on all health costs combined (compared with about $8000 in the USA; figure 2). Thus, treatment of an increasing number of patients with cancer will be challenging for most health-care systems in sub-Saharan Africa. Engagement in cancer care needs a substantial infrastructure, which does not exist in many, if not most, sub-Saharan Africa countries. For example, many countries in sub-Saharan Africa have no radiotherapy facilities,24 which is particularly troubling since as many as 50% of all patients with cancer would be expected to benefit from radiotherapy as part of their treatment. Inequities in health-care treatment and access have important socioeconomic consequences. Investment in health should be seen as an essential tool for development, rather than a luxury.25, 26

Another challenge in Africa is the shortage of health-care workers. WHO has identified countries with a severe shortage of health-care workers, most of which are in sub-Saharan Africa. No reliable data exist for numbers of oncology specialists in sub-Saharan Africa, but we can reasonably assume that the numbers of doctors, nurses, pharmacists, and other health-care providers with specialised training in cancer are far lower than the present and future demands for these workers. In view of the insufficient attention paid historically to cancer in Africa, the number of cancer specialists as a proportion of all health-care workers is probably low. Many developed countries (eg, the USA, the UK, and France) are addressing their own shortages of cancer specialists by recruiting appropriately trained workers from less-developed countries, including those in sub-Saharan Africa. In addition to training more health-care personnel, the push-and-pull issues that contribute to movement of African doctors and nurses from sub-Saharan Africa should be addressed to improve the African workforce situation.

Section snippets

Africa's contribution to the global cancer burden

The cancer burden in sub-Saharan Africa is poorly documented for several reasons, including the scarcity of updated, comprehensive, and reliable data. Nevertheless, on the basis of the available data, the cancer burden is rising, particularly in sub-Saharan Africa, where the increasing cancer burden is associated with factors that persistently affect the region, such as infectious diseases, unhealthy lifestyles, poor food supply, conflict, and poverty.27

WHO has estimated that about 551 200 new

Present cancer control strategies in sub-Saharan Africa

Cancer control strategies are inadequate in sub-Saharan Africa. First, cancer surveillance in sub-Saharan Africa is insufficient, with only three population-based registries (the Gambia, Kampala, and Harare) cited in volume IX of Cancer Incidence in Five Continents.35 A high priority for cancer control in Africa is to have more and better cancer registries. Unlike the USA, where more than 80% of the population is covered by cancer registries, only about 1% of African populations are presently

Challenges of cancer control in sub-Saharan Africa

Sambo and colleagues29 identified eight key cancer prevention and control challenges that are responsible for the effect of the cancer burden in sub-Saharan Africa (panel 1). We propose a prioritised list of important cancer challenges in sub-Saharan Africa. To address the challenges of cancer control in sub-Saharan Africa, a careful, well-coordinated response is necessary to promote and ensure a sustainable strategy with clear benchmark indicators to measure success. A strong coalition between

Conclusions

We have drawn attention to several key concepts essential to address the growing cancer burden in Africa. Innovative approaches are needed to place cancer control and care in Africa within existing health systems, while resources should be amalgamated to minimise waste and optimise cost-effective use. This strategy will hopefully obtain legitimacy from the health strategy for Africa, which was approved at the African Union Conference of Ministers of Health.81 Since many challenges exist, a

Search strategy and selection criteria

We did an extensive search of PubMed and Medline, African Journal Online, African Organisation for Research and Training in Cancer policy documents, and WHO, from 2000 to July, 2012, to identify relevant articles, abstracts, policy documents, and reports published in English. The search terms used included: “cancer”, “cancer control”, “cancer prevention”, “cancer training”, and “sub-Saharan Africa”. We also did a manual search of additional references and cross-references to identify

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