Japanese Journal of Clinical Oncology 32:S52-S61 (2002)
© 2002 Foundation for Promotion of Cancer Research
Cancer and the Philippine Cancer Control Program
1Department of Medicine, University of the Phil-Phil General Hospital and Jose R. Reyes Memorial Medical Center, Department of Health and 2Cancer Institute, Philippine General Hospital and Department of Orthopaedics, University of the Phil-Phil General Hospital, Manila, Philippines
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONCANCER STATISTICSCANCER CONTROL IN THE...ASSESSMENT OF THE CANCER...REFERENCES |
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Cancer is the third leading cause of morbidity and mortality in the Philippines. Leading cancer sites/types are lung, breast, cervix, liver, colon and rectum, prostate, stomach, oral cavity, ovary and leukemia. There is at present a low cancer prevention consciousness and most cancer patients seek consultation only at advanced stages. Cancer survival rates are relatively low. The Philippine Cancer Control Program, begun in 1988, is an integrated approach utilizing primary, secondary and tertiary prevention in different regions of the country at both hospital and community levels. Six lead cancers (lung, breast, liver, cervix, oral cavity, colon and rectum) are discussed. Features peculiar to the Philippines are described; and their causation and prevention are discussed. A recent assessment revealed shortcomings in the Cancer Control Program and urgent recommendations were made to reverse the anticipated ‘cancer epidemic’. There is also today in place a Community-based Cancer Care Network which seeks to develop a network of self-sufficient communities sharing responsibility for cancer care and control in the country.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONCANCER STATISTICSCANCER CONTROL IN THE...ASSESSMENT OF THE CANCER...REFERENCES |
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In the Philippines, cancer ranks third in leading causes of morbidity and mortality after communicable diseases and cardiovascular diseases (Department of Health–Health Intelligence Service or DOH–HIS, 1992, 1996) (1). Over the period 1942–96, communicable disease mortality has shown a gradually decreasing trend, in contrast to the increasing trends of heart disease and cancer (non-communicable diseases).
In the Philippines, 75% of all cancers occur after age 50 years, and only about 3% occur at age 14 years and below. If the current low cancer prevention consciousness persists, it is estimated that for every 1800 Filipinos, one will develop cancer annually. At present, most Filipino cancer patients seek medical advice only when symptomatic or at advanced stages: for every two new cancer cases diagnosed annually, one will die within the year.
The Philippine Cancer Control Program, begun in 1988, is an integrated approach utilizing primary, secondary and tertiary prevention in different regions of the country at both hospital and community levels. Six leading cancers (lung, breast, liver, cervix, oral cavity, colon and rectum) are discussed.
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CANCER STATISTICS |
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TOPABSTRACTINTRODUCTIONCANCER STATISTICSCANCER CONTROL IN THE...ASSESSMENT OF THE CANCER...REFERENCES |
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Incidence by Cancer Site
Cancer incidence data are derived from two population-based cancer registries in the country: the Department of Health–Rizal Cancer Registry (DOH–RCR) and the Philippine Cancer Society Inc.–Manila Cancer Registry (PCSI–MCR). The DOH–RCR covers 26 municipalities of Rizal Province and PCSI–MCR covers the four cities of Quezon, Manila, Caloocan and Pasay. From 1980 to 1995, the leading cancer sites/types have remained the same: lung, breast, cervix uteri, liver, colon and rectum, prostate, stomach, oral cavity, ovary, leukemia, thyroid, uterus, non-Hodgkin’s lymphoma, larynx and nasopharynx (Table 1) (2–4).
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The top cancer sites in the Philippines include those cancers whose major causes are known (where action can therefore be taken for primary prevention), such as cancers of the lung/larynx (anti-smoking campaign), liver (vaccination against hepatitis B virus), cervix (safe sex) and colon/rectum/stomach (healthy diet). Except for the liver, the top Philippine cancer sites are also the top cancers worldwide. Table 2 presents the less common cancer sites in the Philippines (2–4).
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The problem of childhood cancer in the Philippines is more significant than in Western countries, because of the relatively young Filipino population. The overall pattern is, however, similar and is dominated by leukemia (Table 3). Certain features are similar to those in other Asian populations (low incidence of Wilm’s tumor, Hodgkin’s disease and Ewing’s sarcoma), in contrast to relatively high incidence rates for retinoblastoma and low rates for neuroblastoma and non-Hodgkin’s lymphoma (2–4).
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Survival from Cancer in the Philippines
The survival experience, regardless of treatment, of patients with top cancer sites diagnosed in 1987 and included in the DOH–RCR was evaluated as the first population-based survival data for Filipinos (5). Lung cancer had the lowest survival and breast cancer had the highest (Table 4). Five-year survival in excess of 40% was observed for only three cancer sites: oral cavity, colon and breast. For all other sites, survival was less than 30%. Owing to the small number of cases in each category, no distinct impact of age on relative survival could be perceived for most cancer sites. However, both observed and relative survival rates were low for breast cancer patients less than 35 years old (Table 5).
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The 1987 cancer survival rates among Filipino patients imply that there is much to be done for cancer education and the implementation of all aspects of cancer prevention. In comparison, the 1990 5-year relative survival rates, all races, from the USA National Cancer Institute Surveillance Epidemiology End-result program reveals higher rates (Table 6) except for stomach (males) and liver cancers.
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Mortality from Cancer
Data from the 1991/95 DOH–RCR and the DOH–HIS 1992 and 1996 data indicated that the leading cancer site mortalities were lung, liver, breast, leukemia, stomach, cervix uteri, colon, liver, pancreas, nasopharynx and prostate (in decreasing order of frequency). The top three mortality cancer sites among females were breast, lung and cervix uteri and among males lung, liver and leukemia.
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CANCER CONTROL IN THE PHILIPPINES |
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The Philippine Cancer Control Program
It was on the premise that cancer can be largely prevented mainly as a public health effort that the Philippine Cancer Control Program (PCCP) was established. The first phase of program implementation was conducted in 1988, providing the guidelines for the PCCP, specifying program policy, components, implementing guidelines and timetable.
The PCCP is a systematic, organized and integrated approach towards the control of cancer which can significantly alter or reduce morbidity and mortality utilizing primary, secondary (community level) and tertiary prevention in the different regions of the country aside from rehabilitation activities at both hospital and community levels. The goal is to establish and maintain a system that integrates scientific progress and its practical applications into a comprehensive program that will reduce cancer morbidity and mortality in the Philippines. The six Pillars of the PCCP are Epidemiology and Research, Public Information and Health Education, Prevention and Early Detection, Treatment, Training and Pain Relief.
Causation and Prevention by Specific Cancer Site
1. Lung
Causation
The Pulmonary Carcinoma Task Force of the Philippine Veterans Memorial Medical Center reviewed the smoking habits of 178 patients with squamous cell/small cell adenocarcinomas (1984) (6). There were more cases in (a) smokers compared with non-smokers, (b) cigarette smokers compared with smokers of other tobacco products and (c) subjects with 20 compared with <20 years’ smoking history. Furthermore, Mendoza-Wi of the Philippine General Hospital (1984) reported that there seemed to be more smokers among cases with oat cell and epidermoid carcinomas (7).
A national smoking surveillance study conducted in 1989 by the Lung Center of the Philippines revealed 46.52% smokers: of the adult population, overall 52.69% were smokers, 64.17% among males and 18.75% among females. There was no significant difference between the proportion of smokers in rural and urban areas (8).
Ayson and Tamesis (9) found 28% smokers among 528 high school students; 85% were classified as experimenters and 15% as current smokers. Smoking was started because of peer pressure, curiosity and parental influence; 15% had tried smoking at age 6–9 years. Tan (10) indicated favorable results in his study on inter-agency collaboration for the teaching of lung cancer and its prevention to elementary and high school students.
A study in 1999 (11) estimated 17.9 million Filipinos to have a history of smoking (46.5% of the adult population). At least another 26.4 million are passive smokers. The economic burden resulting from lung cancer, chronic obstructive pulmonary disease, coronary artery disease and cerebrovascular disease adds up to approximately US$ 1 billion (59% from health care costs, 39% from premature deaths and 2% from productivity loss).
Prevention
The Lung Cancer Control Program (LCCP) utilizes primary prevention at the community level (smoking control), tertiary prevention at special medical centers and rehabilitation activities at both community and hospital levels. The main activity of the LCCP is the anti-smoking campaign: public information, health education and legislative measures.
The DOH–LCCP implements its trimedia ‘Yosi Kadiri’, ‘No Sa Yo’ (It Isn’t Cool to Smoke) campaigns. It collaborates with the Department of Education, Culture and Sports–Bureau of Secondary Education to incorporate cancer prevention messages in secondary school health education. Components of its health education campaign are (a) inclusion in the school curriculum of smoking as a health problem, (b) social mobilization and (c) establishment of a national information and counseling center.
On 28 January 1993, a DOH Administrative Order prohibited smoking in the Department of Health and its premises. On 22 March 1993, another DOH Administrative Order laid out the rules and regulations on the labeling and advertising of cigarettes. The DOH has also joined multi-sectoral groups in lobbying for the anti-smoking Bill in the Senate. The DOH is also the implementing agency of Chapter IV (Labeling and Fair Packaging) of Republic Act 7394 with respect to hazardous substances. Article 94 of the same Chapter provides that all cigarettes for sale or distribution within the country shall be contained in a package which shall bear the following statement or its equivalent in Filipino: ‘Warning: Cigarette Smoking is Dangerous to Your Health’. This warning also appears on television after any cigarette advertisement. Some cities have also issued ordinances implementing a no-smoking policy in public places. Last 23 October 2001, all members of the Philippine Senate co-authored Senate Bill 1859 that seeks to severely restrict cigarette promotion and trade and smoking in public places. Under the bill, a total ban on all tobacco advertisements will be imposed in two years, and entitles any person who acquires illness due to smoking to file a civil suit individually and collectively against the makers, manufacturers, and sellers of cigarettes and other tobacco products for damages.
2. Breast
Causation
The Philippines through the University of the Philippines–Clinical Epidemiology Unit (UP–CEU) is a member of the Collaborative Group on Hormonal Factors in Breast Cancer and has contributed data (12,13) concluding that:
(a) Women who are currently on combined oral contraceptives or who have used them in the last 10 years are at a slightly increased risk of having breast cancer diagnosed (current users, RR = 1.24, 95% CI = 1.15–1.33; 1–4 years after stopping, RR = 1.16, 95% CI = 1.08–1.23; 5–9 years after stopping, RR = 1.07, 95% CI = 1.02–1.13) and additional cancers diagnosed tend to be localized to the breast. There is no evidence of an increased risk 10 or more years after stopping use (RR = 1.01, 95% CI = 0.96–1.05) (12).
(b) Post-menopausal women are at an increased risk of having breast cancer diagnosed while on hormone replacement therapy (HRT) and in the 5 years after stopping use, RR was increased by 2.7% (SD 0.7%) for each year of use. There is no evidence of an increased risk of breast cancer 5 or more years after stopping HRT (13).
A case-control study (14) among Filipino breast cancer cases and their controls (1989–91) revealed longest residence in rural areas [odds ratio (OR) = 2.78], lower than high school education (OR = 1.87), history of benign breast disease (OR = 2.51), infertility (OR = 5.83) and greater than 35 years age at first pregnancy (OR = 18.2) as significant risk factors. Severe dysmenorrhea (OR = 0.24), number of livebirths (OR = 0.88) and breast-feeding (OR = 0.57) were protective factors. The Philippines shows no cancer risk associated with higher socioeconomic status.
None of the implicated breast cancer risk factors readily lend themselves to primary prevention interventions. It is also possible that reproductive changes in the Filipino population (decreasing average family size and an increasing average age at first birth, two important risk factors) will lead to increasing incidence rates. These implicated risk factors, however, are unmanageable and the social costs unacceptable (e.g. early age at first pregnancy) and since uncertainty prevails regarding a measurable impact, secondary prevention takes on special importance.
Prevention
The Breast Cancer Control Program (BCCP) of the Philippines refers to the implementation of a nationwide anti-breast cancer scheme: public information and health education, case finding and treatment integrated into the community health structure and equipped to control breast cancer in a systematic sustained manner.
Studies have shown a one-third reduction in mortality attributed to breast cancer screening, mainly due to mammography. However, the importance of annual clinical breast examination (by nurse, midwife or public health physician) and monthly breast self-examination (BSE) are to be emphasized, taking note that (a) sophisticated screening technology (mammography) is not easily available or affordable, (b) mammography is mainly recommended for women 
50 years old, (c) many breast cancers are found among 35–50-year-old Filipino women and (d) a relatively inexpensive strategy (BSE) involving physicians as examiners or a referral depot would be cheaper and more available than mammography and physician time. A simulated cost-effectiveness randomized field trial in 1994 (15) resulted in the use of BSE and aspiration biopsy/open biopsy as the most cost-effective strategy in the Philippine setting; incurring savings for the government by almost 3 million Philippine Pesos or US $60 000 (1989 value) per year per 100 000 women. Other strategies incurred no savings.
In 1989, Ngelangel et al. conducted a knowledge–attitude–practice (KAP) survey (16) in Metro Manila on women’s health and childcare. Fifty percent of women had heard/read about breast examination. Only 37% of the women had ever received a breast check-up from a physician. Medical personnel had only ever advised 36% on the importance of BSE and only about 67% knew the benefits of BSE. Only 54% had ever done a BSE, of whom only 27% are still practicing it at an average of 9.2 (SD 5.8) a year. Reasons given for not doing the BSE included no symptoms, busy, don’t know how, don’t like, don’t think important, always forget, afraid and not aware.
Similarly, findings from a 1993 study (17) on the determinants of late-stage diagnosis of breast cancer among Filipino patients indicated that economic factors, non-awareness of the gravity of breast cancer and fear of being diagnosed with cancer may be reasons for late diagnosis. Therapeutic and diagnostic visits to health care sources were more practiced than preventive health care consultations. Moreover, in a 1997 field trial (18) of breast cancer screening (n = 108 102 women) conducted by the DOH–PCCP and IARC–WHO in Metro Manila, there was a large non-compliance rate (79.1%) among women found to have breast masses (2.8% positivity rate) in terms of consulting referral hospitals for re-evaluation and possible treatment. Reasons such as fear, no money for transport/treatment/medical expenses, indifference, no time, non-awareness of gravity of the disease and spiritual fatalistic attitudes were commonly given.
The DOH–BCCP has a long way to go to create breast health awareness among the Filipino populace. It continues to campaign for monthly BSE and annual physician breast examinations until such time that mammography becomes available and affordable to most of the target population.
3. Liver
Causation
In early 1977, the Liver Study Group of the University of the Philippines (19–21) undertook studies to determine probable etiological agents linked to hepatocellular carcinoma (HCC). Among agents looked into were chemicals including sex hormones, hepatitis B virus (HBV), aflatoxin and alcohol. In 1994, hepatitis C virus (HCV) infection among HCCs was also studied.
The results of the studies failed to show any significant role of chemicals and hormones or alcohol, but aflatoxin and HBV were important etiological factors. Based on dietary history, HCC patients not only had a higher daily aflatoxin intake but also higher peak aflatoxin levels compared with matched controls. HCC deaths rose with increasing contamination of food by aflatoxin in the areas surveyed. Bulatao-Jayme et al. (22) showed that the total aflatoxin load of 90 HCC cases was 440% that of 90 controls and none of the various food sources came close to cassava in the magnitude of contamination of the total dietary aflatoxin level. Bulatao-Jayme et al. showed a significant relationship between the aflatoxin exposure index (AEI) and the HCC index by region, with Central Visayas having the highest AEI.
The strongest link was between HCC and previous HBV infection, more importantly the resulting hepatitis B surface antigen (HBsAg) carrier rates (19–21). About 98% of HCC had serological evidence of previous HBV infection compared with about 60% of matched controls. More importantly, HBV infected HCC had a 70% HbsAg carrier rate compared with 13% of controls. The HbsAg carrier rate among males had a 37-fold risk of developing HCC compared with non-carrier males; for female carriers, the figure was 11-fold. When the titer of the antibody to the core antigen (anti-HBc) was determined (a higher titer implying active infection), HCC cases had higher titers as a group, compared with non-HCC controls.
The HBV–HCC link explains why HCC arises almost always from previously diseased liver. Seventy per cent of HCC livers have a post-necrotic background, pathology associated with HBV-induced cirrhosis. Dalmacio-Cruz (23) reported evidence on the association of cirrhosis and HCC–autopsy material from the Philippine General Hospital from 1953 to 1962, and revealed that 72.5% of liver cancers were associated with cirrhosis and many remaining cases were seen in livers with varying degrees of fibrosis. The prevalence rate of HBV infection in the general Filipino population averages 60% (58–68%) and the HbsAg carrier rate averages 10% (8–16%).
Tiangco-Torres et al. in 1984 (24) examined 533 pregnant and puerperal women and showed HBV infection rates to be 59.7 and 9.2%, respectively. Munoz et al. (25) also indicated increased risk association of having a mother or a father who had been exposed to HBV. Thus, in terms of the root of HBV infection in the Philippines, maternal–child transmission plays an important role.
Prevention
Aside from vaccination of newborns against HB, prevention against HBV and HCV infection can also be achieved by adequate and proper screening of blood prior to transfusion, avoidance of multiple syringe/needle use, education versus drug abuse and strict implementation of health check-ups among commercial sex workers, as per regulations from the Department of Health.
In the Philippines, mass hepatitis B immunization of infants (0–12 months of age) at 6, 10 and 14 weeks after birth was started in 1992, aiming for 90% nationwide coverage by 1997, but because of cost, only 60% of the needed vaccines have been freely available (26).
4. Cervix Uteri
Causation
Limson (UP, Manila), in collaboration with Munoz (IARC–WHO, France) and the Group on International Biological Study of Cervical Cancer (involving several countries), contributed data from a case-control study (1995–98) among Filipino cervical cancer cases and their controls. The results revealed that:
(a) Human papillomavirus (HPV) showed a very strong association. After adjusting for the strong effect of HPV, the following significant risk associations remained: early age at first sexual intercourse, increased number of sexual partners and parity and decreased risk with a history of Pap smear (27).
(b) The prevalence of all HPV types in the cases was 93.5% in squamous cell carcinoma, 90.7% in adenocarcinomas and 9.2% in controls (27).
(c) The most common HPV types in decreasing frequency among cases were HPVs 16, 18, 45, 52, 58 (95% CI OR = 31–392). In squamous cell carcinoma, common types were HPVs 16, 18, 45, 52 and 58; whereas it was HPVs 16, 18 and 45 in adenocarcinomas; in contrast to normal cervices, HPVs 16, X, 18, 45, 6, MM4, 31, 52, 11, 54 and IS39 (27).
(d) A single novel HPV designated IS39 was identified which is closely related to another novel virus, W13B (MM4), and its variants and HPV 51 (28).
(e) The prevalence of antibodies to HPV 16 virus-like particles (VLP) is higher in squamous cancers (47%) than in controls (25%) and it is higher in cases where HPV 16 DNA is detectable in cervical cells (62%). However, the sensitivity and specificity of the serological assay are lower than that of HPV DNA (29).
(f) A 9.2% HPV (+) among normal cervices of Filipino women is similar to other studies. HPV infection in women with normal cervices varies from 16.8% in Brazil to 4.6% in Spain, with predominant HPV DNA 16. Despite the compelling evidence for an etiological role of HPV in cervical carcinogenesis, when the prevalence rates of HPV in the normal population are compared with the incidence of cervical cancer, additional factors must be active in its carcinogenesis and it may be premature to utilize HPV testing in the clinical setting (30).
(g) Prevalence of HPV in cervical cancer in 22 countries including the Philippines indicated that HPV DNA was detected in 93% of tumors, with no significant variation in HPV positivity, with common HPVs 16, 18, 45 and 31. HPV 16 predominated in squamous cell tumors and HPV 18 in adenocarcinoma and adenosquamous tumors. HPV 16 was the predominant type in all countries except for Indonesia, where HPV 18 predominated. A clustering of HPV 45 was apparent in western Africa, while HPVs 39 and 59 were almost entirely confined to Central and South America (31).
Prevention
Until recently minimum prevention strategies against cervical cancer in the Philippines are safe sex and screening with a Pap smear examination every 3 years. The Cervical Cancer Control Program of the Philippines recommends regular Pap tests for all women who are or have been sexually active and who have a cervix. The interval of Pap smear testing for each patient should be recommended by the physician based on risk factors (e.g. early onset of sexual intercourse, history of multiple partners, low socioeconomic status). Regular testing can be discontinued after age 65 in women who have had regular previous screening in which smears have been consistently normal. Patients at increased risk due to unprotected sexual activity or multiple partners should receive appropriate counseling about sexual practices.
Only 61% of women (16) had heard or read about the Pap smear. Only 37% had ever had a smear and for those who have not had a smear, only 27% have considered having one. Only 20% had ever received advice from a medical person about the importance of a smear. Reasons given for not undergoing a Pap smear were busy, not married, no symptoms, expensive, afraid, too young, ashamed, want a lady doctor, got sick, not yet time, don’t like, not applicable, not aware. Similarly, Ramiro et al. of UP–CEU (32) indicated these findings from a KAP study on Pap Smear Nationwide: lack of knowledge of where to avail of a Pap smear, lack of supplies/medical expertise/training, indifference to self-health, influence of husband and lack of a vigorous campaign on cervical cancer control.
In 1997, Retizos et al. (33) found colposcopy as the most sensitive diagnostic tool (74.3% sensitivity rate), followed by Pap smear (56%) and direct visualization (25%), with surgical histopathology as the gold standard. Gonzales of Santo Tomas University Hospital indicated there were more women detected when acetic acid wash of the cervix was included as an adjunct to Pap smear (34). A 2001 health operations research (35) compared visual cervix examination with (AA) or without (MAA) acetic acid wash with aid of speculoscopy; to swab + spatula (SS) and cervix brush (CB) cytology as screening tools for cervix cancer, with colposcopy or biopsy as gold standard. Sensitivity rates (95%; with colposcopy as gold standard) revealed 50.3 (45.2–55.5), 49.1 (44.3–53.8), 8.5 (5.5–11.5) and 10.7 (7.0–14.4) for AA, MAA, SS and CB, respectively. Similar sensitivity rates were derived with biopsy as gold standard. MAA was shown to be the most cost-effective screening method. Currently, there is a health policy shift from Pap smear to visual acetic acid as a nationwide screening modality choice for a country such as the Philippines. While the cytopathology facilities and expertise of the Philippines is being planned to be strengthened, Pap smear will be relegated as a diagnostic tool for acetic acid positive cervices.
5. Oral Cavity
Causation
As early as 1915, Davis (36) studied the association of oral cavity cancer and betel nut chewing in the Philippines and noted this cancer to be associated with buyo chewing in 70% of cases. In 1925, Guazon theorized that a higher frequency of cancer cases among women was because ‘buyo chewing’ was more prevalent among females (37). However, Pantangco and Casals (38) noting in the histories of 157 oral cavity cancer patients that only 13% were buyo chewers for 20–30 years, reported that the habit of smoking cigarettes and cigars with the lit end inside the mouth might explain the development of the disease. Tolentino et al. in 1963 noted that leukoplakia and epidermoid carcinoma were most often seen in the palate and the buccal mucosa and postulated the association of inverted cigarette smoking and buyo chewing (39).
In 1984, Stitch et al. indicated that the proportion of exfoliated micronuclei cells from the buccal mucosa of 51 Ifugao chewers of areca nut, betel leaf, tobacco and lime was 3.7% compared with 0.5% in 17 non-chewing Ifugaos. The proportion of micronucleated cells was related to the site within the oral cavity where the betel-quid was kept habitually and to the number of betel-quid chewed per day (40).
In 1985, the Working Group of the IARC stated that there was sufficient evidence that the habit of chewing betel-quid containing tobacco is carcinogenic to humans and there was inadequate evidence that the habit of chewing betel-quid without tobacco is carcinogenic to humans (41).
Prevention
The DOH–PCCP warns the Filipino populace against tobacco and betel-quid use. Primary care physicians and dentists should include an examination for cancerous and precancerous lesions of the oral cavity in periodic health examinations of persons who chew or smoke tobacco (or did so previously), older persons who drink regularly and anyone with suspicious symptoms or lesions detected through self-examination. All patients, especially those at increased risk, should be advised to receive a complete dental examination on a regular basis. All adolescent and adult patients should be asked to describe their use of tobacco and alcohol. Appropriate counseling should be offered to those persons who smoke cigarettes/pipes/cigars, those who chew tobacco and those with evidence of alcohol abuse.
6. Colon, Rectum, Prostate and Others
Causation
Cancers of the gastrointestinal tract have been positively associated with a variety of dietary exposures, e.g. esophageal cancer with alcohol consumption (particularly combined with tobacco use), stomach cancer with a high intake of foods preserved with salt, colorectal cancer with dietary fats and liver cancer with aflatoxin-contaminated foods. Inverse associations with some of these cancers (e.g. stomach and colorectal) have been noted for other dietary components.
In a 1996 KAP survey (42), Ramiro and Perez showed that the lack of knowledge about a healthy diet was not a problem among Filipinos: the gap was between knowledge and practice. The majority assessed their current dietary practice as satisfactory to poor, with a good number unsure of giving up unhealthy practices. The age group 14–21 years had the least mean knowledge scores on healthy diet (5.3 on a scale of 10), but the most favorable mean attitude score towards healthy diet (3.3 on a scale of 4).
Prevention
The DOH–PCCP recommends screening for colorectal cancer for all persons aged 50 years or over. Effective methods include fecal occult blood test (FOBT) annually and sigmoidoscopy every 3–5 years. Digital rectal exam (DRE) augments the effectiveness of FOBT and sigmoidoscopy and can be an alternative to non-availability or inaccessibility of sigmoidoscopy and/or FOBT. In prostatic cancer, DRE serves as a diagnostic rather than a screening tool.
In 1996, the DOH launched the ‘Iwas Sakit Diet’ (‘shun illness diet’) and ‘Tia Kulit’ (‘concerned aunt’), promoting consumption of foods rich in fiber, avoidance of high fat/cholesterol foods and moderation in the inclusion of salty foods, implemented through diet counseling health service facilities. The DOH–PCCP also campaigns for digital rectal examination to detect early rectal and prostate cancers (‘pa D.R.E. Campaign’).
Cancer Pain Relief Program
It is estimated that 30–50% of cancer patients in all stages of the disease will experience pain and 70–95% with advanced disease will have significant pain, but only a fraction of these patients receive adequate treatment. In a study on cancer pain among Filipino patients, 73% had pain related to their disease, 60% of which was persistent (43).
The DOH–PCCP identified cancer pain relief as a priority activity in 1989. It was the first activity that led the way to the Outreach Patient Services (the Hospice-At-Home Concept), pioneered by the Philippine Cancer Society. It primarily implements the WHO analgesic ladder, in a modified way cutting the ladder down to two steps (using opioid-like tramadol HCl in the second step).
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ASSESSMENT OF THE CANCER CONTROL PROGRAM IN THE PHILIPPINES |
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In 1996, the Asian Development Bank (ADB), working with the Philippine Department of Health (DOH), undertook the Philippine Adult Health Project. International and domestic consultants (S. Havas and C. A. Ngelangel) assessed prevention and control efforts in the Philippines for several existing or emerging health problems including cancer (44,45).
The audit confirmed that mortality from cancer had increased substantially over time and was likely to continue increasing. Significant shortcomings in six areas were identified: (1) existing data and data gaps, (2) programmatic efforts, gaps and problems, (3) medical education, (4) policy issues, (5) treatment guidelines and problems and (6) quality control of testing and screening services (44).
Recommendations were made for each of these areas and it was urged that all of the recommendations should be implemented within 5 years. Effectively and efficiently implemented, these recommendations could prevent the huge toll of premature death, disability and costs from cancer that will otherwise be forthcoming (45).
The Community-based Cancer Care Network
Responding to a call by the Department of Health–Philippine Cancer Control Program (DOH–PCCP) for partnership initiatives at both the national and local levels for joint program undertakings and resource sharing between concerned private and government institutions, the Community-based Cancer Care/Control Network (CCCN) was begun in 1998 (46). It has the vision of a self-sufficient network of empowered communities sharing responsibility for total quality cancer care and control in the Philippines and its mission is to organize, integrate and nurture such a network.
The CCCN is built around the idea that when many organizations and individuals pool their expertise, skills, resources and experience and cooperate to achieve a common goal, they become a powerful force. The CCCN is envisioned to be a multi-sectoral strategic approach to improve and redesign the implementation strategy of anti-cancer control/care in the Philippines. It provides a venue to:
1. continuously update government cancer control program implementers, oncology graduates and care givers on the advances and experiences in anti-cancer practice (CONTINUING MEDICAL EDUCATION AND TRAINING);
2. establish a comprehensive community- and hospital-based Filipino cancer patient data and information base, based on the paradigm of quality care and evidenced-based care (MONITORING AND INFORMATION);
3. serve as the Philippine Cooperative Cancer Study Group (RESEARCH AND EVALUATION); and
4. provide continuity of cancer control/care from primary, secondary, tertiary to hospice care, from the community to the hospital to the community (PUBLIC HEALTH AND CLINICAL MANAGEMENT).
The CCCN is composed of local community-based cancer control groups called Local Cancer Control/Care Networks (LCCAN) or Nodes that will network with each other towards a common goal. Each Node will center on a tertiary government hospital; and each Node is composed of a network of satellites, including NGOs, GOs and individuals. The DOH–PCCP Unit will be the lead agency and the major cancer control-related NGOs in the locality will be the lead NGO agency. These Nodes will be self-sufficient and self-reliant. Since 1998, several Network Nodes have been organized and now collaborate with the Regional DOH–PCCP Coordinator and the area oncologist. In 2000, the CCCN started to implement a registry software (CCCN Hospital Tumor Registry) for the different component hospitals of the Network and the DOH–PCCP.
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FOOTNOTES |
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+ For reprints and all correspondence: Corazon A. Ngelangel, Section Chief, Medical Oncology, Department of Medicine, University of the Phil-Phil Gen. Hospital, Taft Avenue, Manila, Philippines 1000
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REFERENCES |
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Received February 2, 2001; accepted August 28, 2001.
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