Non-Communicable Diseases: The Unheralded Global Epidemic_Tsu_5.12.11

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  • 26% women specific in developed, 30% in LDCs
  • Breast 22% vs 54%; cervical cancer 27% vs 67%
  • This table celebrates the remarkable achievements the world has made in reducing mortality due to pregnancy-related complications (sometimes called “maternal mortality”). But these same mothers also are vulnerable to cervical cancer 10 or 20 years after their first pregnancy and while they still support their families and communities.


  • 1. Women-specific cancers
    Challenges and opportunities
    Vivien Tsu, PhD, MPH
    Associate Director for Reproductive Health
    CORE Group, Spring Meeting
    Baltimore, May 12, 2011
  • 2. Cancer: not just a disease of the rich
    • More than 3.3 million deaths among women globally
    • 3. Despite younger populations, 63% are in poorer countries
    • 4. Women-specific cancers are substantial portion everywhere
  • Trends are worrying
    • Numbers are going up, especially in developing countries
    • 5. Differences between rich and poor are growing
  • Survival difference is dramatic
  • 6. Why is the burden of cervical cancer so high in poorer countries?
    Overall, nearly ½ million cases; more than ¼ million deaths each year
    >80% in developing countries
    Expected to increase to >775,000 new cases per year by 2030, with 99% of deaths in developing countries
    No sustainable, organized screening programs, despite many efforts
    “Competing” health problems
    Prevalence of high-risk HPV infection higher
    Limited awareness of cost-effective approaches to prevention
    Until recently, no vaccine available to prevent infection
  • 7. Breast cancer rates rising in low- and middle-income countries
    Reasons similar to those for many other chronic diseases:
    Increasing life expectancy – women are living longer
    Changing lifestyles – urbanization, less physical activity, higher calorie and fat diets
    Plus Changing reproductive behaviors – fewer children, starting later, less breastfeeding
  • 8. Impact on women, families, communities
    Painful illness, premature death, stigma, and isolation
    Cost of medical care
    Loss of economic contribution and non-income generating work
    Loss of caregiver for children, elderly, sick, and disabled
    Loss of family advisor
    Loss of social and political leaders at prime of life
    Loss of experienced teachers and health workers
    Loss of managers of food security – women produce 75% of food in poor countries
  • 9. Exciting new opportunities
    New prevention options for cervical cancer – screening and vaccine
    New ideas for adapting breast cancer detection and treatment to low-resource settings
  • 10. Cervical cancer screening
    New technologies
    Visual inspection with acetic acid (VIA)
    HPV DNA testing
    New strategies
    Screen and treat, without intervening diagnostic step before precancer treatment
    Services provided by non-physicians with appropriate training
    Samples for HPV testing collected by women themselves
    Once or twice in a lifetime screening for women 30–49 years old
  • 11. $0 $25 $60 $120
    2006 07 08 09 2010
    HPV vaccination
    Human papillomavirus is primary cause of cervical cancer; current vaccines protect against types that cause ~70% of cases (and a portion of other female cancers)
    Will also prevent about half the precancers and reduce costs for future screening programs
    Experience with vaccine is growing – shows vaccination is feasible and acceptable
    Cost of the vaccine is dropping
    rapidly; current PAHO price
    is <$14/dose
  • 12. Breast cancer: early detection is key
    Can’t prevent disease but can improve survival
    Health education can raise awareness of symptoms, overcome stigma, and improve early care-seeking
    Feasible methods like clinical breast exam (CBE) can be done by trained health workers and detect many early tumors
    Early results from study in Mumbai* showed that 71% of cancers in women screened by CBE were early stage, as compared with only 51% among women receiving only health education
    * Mittra I, et al. Int J Ca 2010.
  • 13. Diagnostic and treatment opportunities for breast cancer
    General physicians and nurses can be trained to take needle biopsies and use ultrasound
    Generic tamoxifen is low-cost, taken orally, and generally well tolerated
    Planned study in Africa will assess use of 2–3 month course of tamoxifen where lab testing not available; tumor response will determine whether to continue or not
    Treatment recommendations can be tailored to available resource levels (e.g., use older drugs that still give good benefit at lower cost)
  • 14. Cervical cancer and maternal mortality
  • 15. Information resources
    Breast cancer
    BHGI Library
    National Cancer institute
    Cervical cancer
    RHO cervical cancer library
    WHO/ICO (Institut Català d'Oncologia) Information Centre
    WHO Cervical Cancer
  • 16. Next steps
  • 17. Conclusions
    Cancer burden on women is real and growing – especially among the most disadvantaged.
    Practical solutions already exist – both for prevention and for relieving suffering.
    Investments in obstetric care and HIV are lost if women then succumb needlessly to cancer a few years later.
  • 18. Thank you
    Vivien Tsu, PhD, MPHAssociate Director for Reproductive HealthPATHEmail: