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SPOTLIGHT ON...
Cuba's National Cancer Control Program
By Rolando Camacho Rodríguez, MD
Second Degree Specialist in Oncology, Associate Professor, Head of the National Oncology Group. Chair, National Cancer Control Commission Email: rcamacho@infomed.sld.cu
Since 1958, cancer has been the second cause of death in Cuba, after cardiovascular diseases, with 20,000 to 25,000 new cases annually, and 13,000 to 15,000 thousand deaths a year.
Since the 1960s, the Ministry of Public Health has made efforts to control cancer, and in 1986, established the National Cancer Control Program (NCCP), following the experiences and recommendations of the World Health Organization (WHO).
The NCCP consolidated activities and programs already in existence and also expanded them, in a single effort.
Important developments in Cuban health care provided the basis for implementation of the new NCCP:
The political priority placed on public health by the Cuban government.
Thus, in 1986, all activities carried out by institutions, individuals and organizations were integrated in what was called the National Program to Reduce Cancer Mortality. The program incorporated Breast Cancer Screening, including mammography beginning in 1990, and pediatric oncology.
This program, with its results and shortcomings, has been described at workshops with cancer control experts WHO headquarters in Geneva (1991), in Canada (1993), and Australia (1996). Twice the program was evaluated by WHO experts (1993 and 1995), with good results, despite the difficulties still faced in its implementation.
In 1992, the program received its current name—National Cancer Control Program (NCCP)—and since then has incorporated actions in palliative care, anti-smoking efforst, pediatric oncology and quality control in chemotherapy and radiotherapy.
The objectives of the program are twofold: lower mortality and incidence rates, and increase global patient survival and survivors' quality of life.
The program guided by a National Commission chaired by the Head of the National Oncology Group, and includes representatives from the National Institute of Oncology and Radiology, National Center for Health Promotion and Education, National Groups of related specialties (Hematology, Gynecology , Surgery, Urology, etc.), the Federation of Cuban Women, the National Divisions of the Ministry of Public Health, and the Chairs of the National Commissions of each of the (sub)Programs.
The NCCP develops its activities in the spheres of health promotion, specific protection, and timely diagnosis and treatment. It is supported by the National Statistics System of the Ministry of Public Health, the National Cancer Registry and by assessments, auditing and reports from the task forces of the National Institute of Oncology and Radiology, the National Cancer Network and other organizations, scientific and/or clinical institutions and other governmental bodies.
Program Policies: Results and Shortcomings
Smoking prevention and control
Actions include mainly education aimed at the general population, in schools at all grade levels and among professionals; legislative action at different levels; and assistance to people who want to stop smoking (smokers' clinics).
The main results are demonstrated in the reduction of smoking in the adult population: from 67.8% in the 1970's, to 36.8% in 1995, and 32.4% in the year 2000.
The main problems are precisely in the slow reduction of smoking (especially among women, where it is increasing), the need for greater restrictive actions in terms of consumption, and a greater coverage of smokers' clinics.
This program is not part of the NCCP, but is aimed at the reduction of Hepatitis B, and is expected to help reduce the frequency of liver cancer. It targets people under 20 and tose persons professionally exposed to the disease. Since the start of this program, hepatitis B has been reduced by over 50%.
This program is now being implemented. It aims to train professionals in communication techniques, and for general public education.
This program has gone through policy changes since its creation, and currently consists of vaginal cytology (Papanicolau test) every three years for all women from 25 to 64 years of age.
The main results include incidence and mortality rates lower that those for Central and South America and the Caribbean; diagnosis of more than 50% of cases as “in situ” carcinomas; and the fact that over 75% of new cases reported to the Registry are in the 0 to 1 stages.
The main problems are found in low coverage in highest risk age groups; sample quality (over 5% of samples are not usable); and difficulties in treatment quality for lack of technical resources (equipment).
At the beginning (1987) the program's policy was to promote Breast Self-Examination (BSE) in women over 30, and annual breast examination by family doctors once a year for the same age group. Mammography was introduced in 1990 as a screening method, in addition to the two physicial examinations.
Likewise, since its introduction, mammography has been used in a variety of ways (e.g. women chosen by risk factor surveys), and today it is used in women between 50 and 64, every three years.
The main results are the use of these techniques in radiology, surgery and pathology, and training of health professionals, volunteers and women in general.
The major problem is low coverage for lack of mammography and other related equipment, and hence no impact on lowering mortality.
The main action in this field is annual examination of the buccal complex in every individual over 15, as passive screening of all patients visiting a dentist for whatever reason, as well as active screening in the community for individuals over 35.
A lower mortality rate in cases of mouth cancer has been recorded, especially among men.
There are still some coverage problems, as in many cases high risk individuals (smokers, drinkers, and people with bad oral hygiene) do not visit their dentist and do not respond to active screening calls.
The basis of this program is to concentrate resources and treatment in nine centers throughout the country, which permits greater specialization of the entire team of medical personnel, and the application of the most current treatments our economy allows. Even though the incidence of cancer in children has not diminished, mortality has been reduced, and in-patient and total populatoin survival has increased. Some difficulties still remain in terms of structure, equipment and new generation medications in the treatment centers.
The main thrust is training personnel (doctors, nurses, psychologists, social workers), and in-home care for patients who need palliative attention. As a result, several provinces show savings of medicines, notable improvements in patient quality of life, and greater availability of hospital beds.
The modest economic recovery has enabled us to introduce new drugs in cancer treatment. Efforts are linked to planning of human and material (equipment, medicine, etc.) resources, guidelines and protocols for diagnosis and treatment, and auditing. This is the only way to continue carrying out more effective actions and to take full advantage of our economic resources.
All rights reserved (c) 2003 - MEDIC - Medical Education Cooperation with Cuba - ISSN: 1527-3172