Thursday, November 5, 2009

FINAL DAY OF CANCER CONTROL WORKSHOP






4/11/09
SCHOOL OF MEDICINE AND HEALTH SCIENCE
PORT MORESBY
PAPUA NEW GUINEA





Dr Newton RESEARCH NOTES

QUESTIONS REFLECT CANCER OF THE HEAD AND NECK: 4 PARTICIPANTS
Why late presentation
Aetiology has been answered ; thing about prevention methods
Treatment other than surgery

AETIOLOGICAL STUDY
ENT SURGEON FROM HIGHLANDS
About two new cases per week
Increase in incidence
Identifying other risk factors for head and neck cancers in the highlands. Looking at studying sexual behavior and the role of hpv AND DIET.
Design a questionnaire and find correlation between hpv and cervical cancer and
Involve the wife if husband has oral cancer for

CONFOUNDING FACTORS include tobacco, lime, alcohol

Hpv work has been done by Dr from Bristol. HPV in oropharygeal cancers causes damage to P53 gene. Only 10% have the virus. Only a few had P53 damage. Complex molecular biology.

HPV may be more frequent;

HPV associated with tonsil oropharynx and tongue base tumour. Low association with buccal lip and larynx cancers.

Sexual history is always a difficult area. May be problematic in the qestionaire.

NEWTON

In the west theres change in epidemiology of HPV.

SEXUAL BEHAVIOUR IS A SURROGATE MARKER FOR HPV

A sexual behavior question

GOROKA GYNAECOLOGY
NEED TO MAKE SURE NEW HPV

NEWTON

MEASURING HPV NEEDS COLLORBORATION WITH THE WEST
ENT
CASE CONTROL STUDY
CONTROLS FROM HOSPITAL AND THE POPULATION

NEWTON
NEED A PROTOCOL FOR RECRUITMENT OF CONTROLS
WILL THEY BE FROM HOSPITAL OR GENERAL POPULATION

DR FROM BRISTOL
DIET IS IMPORTANT
IVE FOUND DIET DIFFICULT TO GET A GOOD RESPONSE
IT IS A REALLY COMPLEX AREA

GYNEA FROM GOROKA
WE DO HAVE SOME GENRAL ASSUMPTIONS OF RURAL AND URBAN DIETS


DR GREGORY
COARSE DIET
NOT HAVING TEETH CAN BE A CONFOUNDING FACTOR
CANDIDA CAN BE A CONFOUNDING FACTOR

DENTIST
PERIDONTAL DISEASE MAY BE A CONFOUNDING FACTOR




BRAEST CANCER


CHILDHOOD CANCER

CERVICAL CANCER

KAPOSI SARCOMA

KNOWLEDGE AND ATTITUEDS TO CANCER
NEWTON: WHY?

CHRIS
SOCIETY AND GOVERNMENTS ATTITUDE
ENFORCEMENT OF LAW IN RELATION TO TOBBACO CONTROL
INCLUDE PRIMARY PREVENTION AND EARLY DETECTION AS PART OF NATIONAL HEALTH PLAN
PBL TO FOCUS ON COMMON CANCER SUCH AS ORAL CANCER


DR STEVE
THEY MAY NOT BE PRESENTING IN HIGH AREAS OF PREVALENCE
NEW IRELAND EXPERIENCE SHOWS MANY DO NOT
PALLIATIVE CARE; NOT GOOD CARE IN THE VILLAGE. POOR NUTRITION AND PAIN CONTROL
NEED TO BEAR THAT IN MIND

DR MOREWAYA
POSTER IS A MISLEADING PUBLIC EXERCISE. NEED TO PUT SMALL LESIONS

DR STEVE
CAN BE OUTPATIENT TREATMENT

DR GENDE
KNOWLEDGE IS NOT LACKING
SIMPLE DESIGN
WHY LATE PRESENTATION?
WHAT ABOUT DESCRIPTIVE OR CROSSSECTIONAL STUDIES

HEALTH EDUCATOR
HEALTH IS THE LAST PRIORITY
FIRST SEEK TRADITIONAL HEALERS THEN MODERN MEDICINE

DR NAIPAO
MOST PRESENT AT T3 OR T4 OR STAGE 2 TO STAGE 4.
PNG IS DIVERSE GEOGRAPHICALLY AND CULTURALLY
WE ARE HERE TO SEE OUT BEST
INVOLVE ALL STAKEHODERS AND CHANGE BELIEFS FIRST

AUDIENCE MEMBER
HERBAL MEDICINE IS GIVING FALSE HOPES. NEEDS TO BE REGULATED. MEDICALLY TRAINED PEOPLE ARE INVOLVED

DR STEVE
LIASING WITH TRADITIONAL HEALERS


ISSUE WITH TRANSPORTING CANCER PATIENTS

DR POKI
CANCER IS A PUBLIC HEALTH ISSUE
PREVENTION TREATMEN AND DIAGNOSIS AND PALLIATIVE CARE
GET PRIMARY HEALTH CARE RIGHT
GET PEOPLE TO PRESENT EARLIER

DR STEVE
GEOGRAPHY IS A BIG PROBLEM
TUMOUR REGISTRY GIVES SOME INFORMATION BUT NOW IT IS NOT RELIABLE. BURDEN ON HEALTHCARE OF CANCER IS

LOOK AT DICHARGE RECORDS TO GET A BETTER IDEA OF THOSE NOT REGISTERED

DR GREG: HOW COMMON IS CANCER?
LACK OF DATA RATHER THAN LACK OF PROBLEM
PRIORITY DEPENDS ON NUMBERS. NUMBERS ARE INACCURATE. CANCER IS COMMONLY UNRECOGNIZED AND UNREPORTED

PROF CHIVERS
MANY PEOPLE ARE INTERESTED
THERE ARE RESOURCES ON BIOSTATISTICS AT UNITECH, IMR, AND UPNG AND PROVINCIAL HEALTH AUTHORITIES

IF PROPOSALS ARE SOUND AND ACURATE THEY WILL BE SUPPORTED. EXTERNAL HELP WILL BE SOUGHT

DR GREG
WE NEED TO COLLORBORATE
ITS TOUGH FOR ANYONE TO DEAL WITH THIS IN ISOLATION
COMBINATION OF EXPERTISE IS NEEDED TO ASSIST IN CREATING A STRONG DESIGN OF STUDY AND TO RUN THEM
IT REQUIRES LONGTERM COMMITMENTS
THIS ARE CHALLENGING SO THINK OF SOMETHING SMALLER TO BE A STEPPING STONE FOR BIGGER PROJECTS.
LOOK FOR ASSISTANCE, WORKOUT WHERE THE PEOPLE ARE.

DR NEWTON
SOME RESEARCH IS NEEDED AT EVERY LEVEL TO UNDERPIN THE DESCISIONS MADE
WHAT IS IN THE HOSPITAL IS UNDERSTIMATE OF THE BURDEN OF DISEASE
WHY LATE PRESENTATION? WHAT ARE THE ISSUES?

EDCUCATION OF HEALTH WORKERS IN THE RECOGNITION OF EARLY DIAGNOSIS IS A ISSUE. FOR CERVIX, ORAL AND BREAST CANCER.

NEED FOR BETTER PROTOCAL FOR MANAGEMENT

ALLEVIATING BURDEN OF SYMPTOMS; TRAINING? AVAILABILITY?

VARIOUS AUDIENCE MEMBERS

LACK OF DRUGS, STAFF, AND FACILITIES

IT IS MULTIFACTORIAL.

PALLIATIVE CARE IS UNECONOMICAL. HOSPITALS CANNOT AFFORD TO KEEP PATIENTS.

DR NEWTON
CANCER CONTROL IS A LONGTERM PROCESS
HOME BASED PALLIATIVE CARE INFORMATION IS AVAILABLE ON THE INTERNET. GOOGLE HOSPICE AFRICA. THERES A VAST AMOUNT OF INFORMATION

BASELINE DATA IS NEEDED FOR TRIGGERING FURTHER ACTION

AUDIENCE
NEED FOR PALLIATIVE CENTER

MAY NOT BE VIABLE; TRANSPORTING PTS TO CENTER AND REPARTRIATING BODIES

MOBILE DECTECTION BY HEALTH WORKERS IS AN IMPORTANT

DR MAPIRA
WE NEED EVIDENCED BASED MEDICINE
WHATS YOUR EVIDENCE THAT CANCER IS A PUBLIC HEALTH ISSUE WHEN HIV/AIDS AND TB ARE A PROBLEM
CATCH STAKEHPLDERS ATTENTION

DR STEVE
WE DON’T KNOW WHAT THE BURDEN OF CANCER

WHAT IS THE SEMINAL ISSUE OF CANCER THAT

AUDIENCE
NO PUBLISHED REPORTS
HOW WILL DATA BE UTILISED

NEED FOR HUMAN RESOURCE

NEXT SYMPOSIUM EVERYONE MUST HAVE SOMETHING TO PRESENT

DR GENDE
WE HAVE FACILLITTIES
GPS DO 80% OF PALLIATIVE CARE
SPECIALIST PALLIATIVE CARE IS MINIMUM
LEARN TO SAY ‘SORE TUMAS’
NOT TO SAY DISCHARGE TO DIE
QUALITY OF LIFE IS IMPORTANT
UGANDAN EXPERIENCE ‘LEGISLATE FOR OPIATES’

DR NEWTON
INFORMATION FOR PRACTICAL TRAINING FOR PALLITIVE CARE USING ‘HOSPICE AFRICA MODEL’

GYNE GOROKA
HOME BASED PALLIATIVE CARE
START AUDIT AT MY OWN PRACTICE


DR STEVE
AUDIT IN THE CONTEXT OF RESEARCH IS

DR NEWTON
FIRST AND FAST; ASSESSMENT OF BURDEN OF CANCER AND BURDEN OF RISK FACTORS

KEY IS A CANCER REGISTRY
NO HOSPITAL BASED REGISTERS

LONG TERM GAOL IS A POPULATION BASED REGISTER

WHAT CAN WE DO TOMMORROW; HOW DO WE PUT CANCER IN PNG ON THE GLOBAL MAP

DR KAPTIGAU
MAXIMISE EXISTING SYSTEM
DISCHARGE SUMMARY
DEATH CERIFICATE
HISTOLOGY REPORTS

DR MOREWAYA
NEED TO TRANSLATE RAW DATA INTO REPORTS

DR NEWTON
CAN REG SOFTWARE CAN GENERATE REPORTS. AVAILABLE FROM INTERNATIONAL CANCER ORGANISATIONS. AVAILABLE ON WEB. GENERIC CANCER REGISTRATION SOFTWARE ARE AVAILABLE.

VARIOUS SPEAKERS
TYPE OF INFORMATION COLLECTED DEPENDS ON NEEDS
MAY START WITH MPH STUDENTS IN SAMPLING FROM ALL CENTERS GET A PICTURE OF CANCER BURDEN

DR. KAPTIGAU
SURGICAL AUDITS PRODUCE INFORMATION

DEPARTMENTAL HEADS IN ALL SPECIALTIES CAN USE RESIDENTS

FROM GOROKA
DATA CAN BE COLLECTED DURING RURAL VISITS FROM PROVINCIAL HEALTH CENTERS.


PROF CHIVERS

MAKE SURE RECOMMENDATIONS ARE SUSTAINABLE





AFTERNOON SESSION SR MADU’S STORY

DIAGNOSIS MADE IN AUSTRALIA
HOW INDIVIDUALS EXPERIENCE THE DIAGNOSIS IS UNIQUE
WAS TREATED IN AUSTALIA AND CAME BACK
SINCE 2004 HAS BEEN WORKING WITH CANCER PROGRAMS
WOMEN SUPPORT AND COUNSELLING INCLUDING ISSUES SURROUNDING CUFFS
HAS WORKED WITH POM CANCER SOCIETY
2004 PINK RIBBON STARTED
2005 DOCTOR GENDE WAS A SPEAKER
THE MESSSAGE HAS BEEN WELL RECEIVED
BREAST CANCER FOUNDATION REGISTERED IN JUNE
PAMPHLETS AND AWARENESS WORK IS BEING DONE WITH CORPORATE SUPPORT
THERE’S A NEED TO GET INFORMATION ON BREAST SELF EXAMINATION
NEEDS ARE BEING ASSESSED IN TERMS OF TREATMENT
DR GARBETT IS PRESIDENT OF BREAST CANCER FOUNDATION
THERE IS A GREAT VISION FOR THE MEDIUM TERM
PROVIDING ANSWERS TO WOMEN WITH BREAST CANCER

HEALTH EDUCATION
MR ISAAC

1956-1996 WORKED WILL HEALTH DEPT

REPRESENTATION OF PNG AT MALAYSIA
COMMUNICATION
COLOMBIA CONFERENCE ON MALARIA

WHAT ARE SCIENTISTS DOING IN MALARIA VACCINATION
FRUSTRATION ON NEGATIVE RESULTS

PREVENTION MEASURES; CHANGING OF LIFESTYLE AND VACCINATION

LIFESTYLE CHANGES MAY ELIMINATE PROBLEMS

HEALTH SCIENCE CLINICAL LACK OF FOCUS OF EDUCATION





MEDICAL EDUCATION

SCIENCE


TECHNOLOGY


EDUCATION
WHEN HEALTH EDUCATION IS REMOVED. ALL OTHER DISCIPLINES SUFFER
HEALTH PROMOTION AND EDUCATION ARE THE SAME CONCEPTS

ISSUES

HEALTH EDUCATION BOMBARDS PEOPLE WITH HEALTH IDEOLOGY
PEOPLE WILL SEEK HELP ONLY IF THEY HAVE A PROBLEMS
PEOPLE WILL SEEK HEALP ONLY IF THEY HAVE CONFIDENCE IN THE HEALTH SYSTEM

HEALTH DEMAND
CREATE INTEREST IN ACCESSING HEALTH SERVICE
CONVINCE PEOPLE TO COME AND SEEK HELP

HEALTH RESPONSIBILITY

HEALTH


PEOPLE NEVER CHANGE HABITS
DIFFICULT TO ELIMINATE
UNDERSTAND WHY PEOPLE


PSYCHOLOGICAL

THINKING

SOCIOLOGICAL

RELATIONS

ANTHROPOLOGICAL

HOW CULTURES SHAPE BEHAVIOUR?


OUR CULTURE IS VERY RICH
CULTURE IN CONTACT IS CULTURE IN CONFLICT



A TUMOUR REGISTRY FORM

ADDRESS TO THINGS

1. DIAGNOSIS
2. REPORTING

HISTOLOGIC AND CLINICAL FINDINGS NEED TO BE COMBINED

WHAT NEEDS TO BE THE FIELDS

SPECIALIZED FORMS FOR SPECIFIC TUMOURS
BETTER DEATAILS

ISSUE OF DELAY
DELAY IN SENDING SPECIMEN
DELAY IN EXMAINATION
DELAY IN REPORTING


ACCESSIBLE DATABASE
DATA ACCEESSED BY ALL STAKEHOLDERS
B
HOW TO INVESTIGATE BURDEN

1. WORK/CLINICAL BURDEN TO BE MONITORED BY CLINICIANS WITH CONNECTIONS TO TUMOUR REGISTER
2. IMR COORDINATED POPULATION BASED SURVEY OF TUMOURS

BURDEN OF RISK FACTORS
• PROVINCIAL RESEARCH GROUPS/ INVOLVE PROVINCIAL HEALTH WORKERS LOOKING AT RISK FACTORS
• IMR BASED CANCER RESEACH GROUP
• ADDITIONAL USEFUL CLINICAL GUIDELINES WITH INFORMATION ON RISK FACTORS

DELAYED TREATMENT

1. NOTE STAGE OF DISEASE
2. RECORD DURATION OF PROCESSES AND ISSUES THAT CAUSE DELAY
3. DELAY IN REFERRAL TO SPECIALIST/ CURRENTLY A RANDOM PROCESS. WHAT ARE THE PROBLEMS. ARE THERE SYSMENS TO FASTRACK REVIEW
PALLIATION

• ACCEPTABLE VILLAGE BASED CARE MECHANISMS SUCH AS TREATMENT CARDS AS IN TB AND LEPROSY
• WHAT ARE THE ACCEPTABLE SUPPORT MECHANISMS. ORGANISED FROM WITHIN THE ONCOLOGY UNIT. INCLUDED FOLLOWUP AND SUPPORT

TO BE DONE LOCALLY AS THE
C
INTEGRATION INTO NATIONAL HEALTH POLICY AND PLAN

1. EMPOWER TECHNICAL COMMITTEE AND ESTABLISHMENT OF CENTRAL COORDINATING BODY
2. ENDORSE THE CURRENT FORM. TO BE STANDARDISED
3. ANGAU AS THE REGISTRY CENTER
4. SATELLITE REGISSTRY IN REGIONAL HOSPITAL. PROCESS AND CODE INFORMATION. MUST HAVE CAPACITY TO HANDLE
5. INVEST IN TELEPATHOLOGY;
6. HUMAN RESOURCE CAPACITY. MORE COLLORBORATION WITH PARTNERS INTERNALLY AND EXTERNALLY. POSSIBLE ROLE
7. GOVERNANCE MECHANISMIONAL LEGISLATIVE AND POLICY FRAMEWORK;
D
PALLIATIVE CARE AND SUPPORT

• NEED FOR MANPOWER TRANSPORT CONSUMABLES AND NUTRITIONS
• CASE DEFINITION IS NEEDED TO CLASSIFY PALLIATIVE CARE PATIENTS

1. PALLIATIVE CARE PROTOCAL IS NEEDED
2. TRAINING OF STAFF IN FOUR REGIONAL CENTERS BEGINNING IN PORT MORESBY
3. EDUCATION OF PATIENTS AND CARE GIVERS
4. ADOPT AFRICAN HOSPICE CONCEPT
5. MONEY FOR CANCER BE USED TO PROVIDE LOGISTICS FOR PATIENTS
6. PROVIDE MORPHINE TO HEALTH CENTERS. ENABLING LEGISLATION IS NEEDED
7. NUTRITION SUPPORT. NEED FOR DIETICIANS TO EDUCATE PATIENTS AND CARERS
8. COMMUNICATION
9. COMMUNITY AWARENESS/EDUCATION TO BE DONE WHEN PATIENTS ARE IN HOSPITALS. PROVIDE AWARENESS MATERIAL



PROJECTS CAN BE STARTED IN PROVINCIAL LEVELS

MORPHINE NEEDS RECATEGORIZATION AND REFORMULATION

PROJECTS MUST BE SUSTAINABLE



DISCUSSION

DIVOLUTION OF POWERS TO LOCAL AREAS MEANS THAT FUNDING AND PLANNING A PROVINCE BASED

NDOH ONLY PROVIDES GUIDELINES


REPATRIATION IS THE ROLE OF REFFERING HOSPITAL


IMR IS WELL SUITED TO LEAD CANCER RESEARCH. SIMILAR TO QIMR


HOW COMPREHENSIVE ARE WE SUPPOSED TO BE

WHAT WILL THE DISTRIBUTION OF THE DOCUMENT FROM THIS WORKSHOP BE LIKE

A LOT OF ISSUES CAN BE ADDRESSED BY EXISTING SYSTEMS

ORGANISING COMMITTEE TO DIRECT INFORMATION TO RELEVANT AUTHORITIES

ONCOLOGY GROUP TO PROGRESS THINGS

PROVINCES NEED TO IMPROVE HISTOPATHOLOGY, CHEMOTHERAPY, RADIOTHERAPY. NEED TO BE SPEARHEAD

WHAT THINGS CAN PROVINCES GROUP

WRAP UP

HOW CAN WE ADDRESS ALL THIS LITTLE PROBLEMS

PREVENT THE PROBLEMS

THE HUNDRED PERCENT WAY TO PREVENT CANCER IS NOT TO BE BORN

WE CAN ALL MINIMIZE RISK

MY NOTES FROM CANCER CONTROL WORKSHOP IN PNG






3/11/09
DAY 2
PORT MORESBY
SCHOOL OF MEDCINE AND HEALTH SCIENCE
UNIVERSITY OF PAPUA NEW GUINEA


SPEAKER MODEL
ROSS HYNES ACKNOWLEDGED ORGANISERS AND PARTICIPANTS
CANCER AFFECTS FAMILIES
CANCER DOES NOT RESPECT AGE
CANCER CAN BE SURVIVED
MOST PEOPLE HAVE AHD CLOSE CONTACT WITH CANCER PTS AND SURVIVORS
CHREO MODEL; TISSUE DIFFERENTIATION AND TRANSFORMATION IN EMBRYO
EPIDEMIOLOGY OF CANCER IS CHALLENGING AND FASCINATING
WHAT ARE THE LINKS BETWEEN CAUSES OF CANCER
LOTS OF QUESTIONS NOT MANY ANSWERS
WHAT ARE THE SIGNIFICANCE OF TOXIC SUBSTANCES
CONCEPTS FROM ECOLOGIC THEORIES CAN BE EXPLORED
WHAT IS THE SIGNIFICANCE OF CULTURAL, GENETICS OF PEOPLE
WHAT IS THE ROLE OF GIS
WHAT MATHEMATICAL MODELS CAN BE USED
NECESSARY TO RIGOROUSLY AND VIGOUROUSLY REGISTER CANCER




PROF KEVAU WELCOME ALL
NAME CHANGES
VARIOUS COURCES
NEARLY 600 STUDENTS
STAFFING NUMBER HASN’T CHANGED
WE HAVE VERY POOR HEALTH INDICATORS
UNEXPECTED STATISTICAL FLUCTUATIONS INDICATE POOR DATA COLLECTION
LIFE EXPECTANCY OF 55 IS POOR
POOR MORTALITY RATES
1 DOCTOR PER 15000 PEOPLE
CLINICAL SPECIALIST HIGHER RATIO
RESOURE CONSTRAINTS
MMED IS EQUIVALENT TO FELLOWSHIP
LOCAL ACTION TO CREATE CANCER PROGRAM SIMILAR TO BURI KIDU
COMMUNICATE AND COLLOBORATE WITH INTERNATIONAL PARTNERS
TAKE INITIATIVES, DEFINE PROBLEMS AND SHARE WITH OVERSEAS PARTNERSHIPS
HOPE THIS NOT THE 1ST AND LAST WORKSHOP
CHALLENGE TO CREATE MMED IN CANCER MEDICINE
BE PIONEERS IN GETTING THE AGENDA STRAIGHT IN CANCER MEDICINE





DR THOMAS Established the causes of oral cancer

Talk on oral cancer and Burkitts lymphoma

Oral squamous cell carcinoma in PNG behaves in a different way
The association with buai is well known
Numbers of people who die from climbing buai is same as dying of oral cancer
Daka USE is unique to PNG
Tours in PNG are very different
Lime burns the mouth
Role of smoking was not yet known

Aetiologic study
HPV
Areca
Lime
Smoking

Tumour registration form: garbage in garbage out

Has a lot of information; name age; sex;

Distribution
Age
Sex
Anatomic site

Method
Incidence study
Case definition of sites

17% of all tumors
52% had age
40-60
Increase with age
Predominant males
Cheek more than floor

Island Papua Momase: buccal
Highlands tongue and floor

Patterns emerge showing highlands site distribution to be similar to use where smoking and alcohol are the causes of oral cancer

Descriptive studies can be interpreted differently

Patterns can be over interpreted due to differences even within same geographical location

If you bought lime you were at higher risk of getting cancer than if you made your own

Areas of higher rate have association with higher use of industrial lime

Problems of migration movements

Problems with diagnosis depends on availability of trained staff to make that diagnosis

Gender differences are not significant in terms of access to treatment

Good record keeping can overcome issues associated with duplicated

Use of statistical data can hide or elaborate on differences

Crossectional study
People can tell you if people died of mouth cancer

5 x higher incidence in new Ireland

3 fold increase in risk of oral cancer if you have leukoplakia

Relative frequency of cancer is 17 to 18 %

More younger people may be getting oral cancer

More common in females

Male to female ratio has changed

Data for highlands show an increase


Burkitts lymphoma

1958 to 1987

297 cases
71% histological diagnosis
Rest clinical

There are lots of ways of defining a case

Tumour registry should link with census office

Burkitts variates with altitude and rainfall

Areas continuously hot and wet have higher Burkitts

There are differences that are derived from



TO DO CANCER CONTROL YOU NEED GOOD FIELD WORK

Q. WHITEMAN: COMMON KOWLEDGE OF RISK OF BUILDERS LIME

A. NOT SURE.
LIME IS BOUGHT FROM COAST

C. HOW DO YOU USE THIS DATA IF IT IDENTIFIES POTENTIAL POINT OF INTERVENTION? EG. SMOKING. FOR HEALTH EDUCATION WE NEED KNOWLEDGE. LEGISLATION ABOUT MARKETTING AND DISTRIBUTION. THERE ARE MANY ELEMENTS TO ANY NATIONAL CANCER CONTROL PROGRAM. WHATS HAPPENED AND HOW DO MAKE THINGS HAPPENED. WHAT ARE THE PRIORITIES/. THERE ARE DIFFERENT.

A. SEWRAGE LIME IS IN USE. OVER LAST 10 YEARS HIGHLANDERS HAVE OVERTAKEN COASTAL PEOPLE.

DR WESTERN. 1993 MT HAGEN SEEN A CASE OF ORAL CANCER. MILNE BAY HAS MODERATED. HIGLANDS HAS MORE NUMBERS IN TERMS OF CHEWERS.

A. INCREASING INCIDENCE IN THE HIGLANDS

THERPEUTIC INTERVENTIONS SUCH AS SURGICAL EXISION OF LESIONS MAY MODIFY INCIDENCE.

Q. IS THERE A ROLE OF IMMUNITY

POSSIBILITY OF SUBSITUTING MAGNESIUM FOR CALCIUM





DR NEWTON How much can be achieved with very simple epidemiology

Dennis Burkitt described it in 1958

1st tumour that was identified to be caused by an infectious agent

1st curable cancer

Tumour lysis syndrome
Chromosomal translocation

Used simple tools

Characterize the geographical distribution of the tumour

Recognized role of falciparum malaria

Use of ecological evidence not direct evidence

EBV was seen by Anthony Epstein

Risk of Burkits increases with the increase in EBV titres

Risk of Burkitts increases with increase in malaria titres

Both are synergic

Insecticides and bed nets prevents Burkitts by 80%

Simple methods used

It’s quite hard to do a registry well

HIV associated cancers
Kaposi
Hl nil
Ca cervix
Anal ca
Conjuctival ca

Kaposi sarcoma caused by human herpes virus hhv-8

HIV ca study
Hire nurses
Take blood and id cancer markers
Questionnaire; bio data, risk factors
HIV test; id cancers associated with Kaposi sarcoma.
Recruit from hospital
controls a pts with other ca

We don’t really know what the factors that affect the distribution of cancers

Conjuctival carcinomas is associated with HIV

Case control study design uses other cancer patients as controls.

Suggestion
Think about fairly simple epidemiologic studies.

1. Hospital based studies
2. Questionnaire
3. Age/sex/diagnosis/ HIV status
4. Sociodemographics
5. Smoking alcohol buai
6. Sexual history
7. Reproductive history
8. Contraceptive history
9. Blood sample

With about 1000 to 1500 patients you can answer public health questions with-in 12 to 18 months.

Academia is directly relevant in answering important questions and inform policy making

Data and results can drive government and NGOs to act on cancer

Q. Mapira. Is hospital based study representative

A. Newton. No. People with different cancers come from different areas. Cancers come from different areas of the country
It can be a starting point even if it may not be representative of different populations
If you’re starting from a point where there is very little published start with what you have

A. simplicity must be underpinned by serious thought. Understand what you’re doing and don’t overreach yourself. Though plus clarity are important.









DAVID WHITEMAN _QIMR
STUDY DESIGN IN EPIDEMIOLOGY
Some designs work better than others

Epidemiology is the study of the distribution and determinants of diseases a population.

Also look at risk factors
The what where when who and why

It is an applied science use mathematics statistics and systematic methodology

The power of epidemiology to improve the health of people improves the economy

Simple experiments can lead to development of a country

Study designs

Cross-sectional studies (case report, series) [weak]

Case control

Cohort studies

Randomized control trials (best)

Descriptive vs. analytical

Observational vs. experimental


Descriptive studies
Describe the people time and place of a disease in a population
Answer the who where when and why
They throw up new questions

Associations
E.g. Kaposi sarcoma and HIV
Blindness and high concentration of oxygen
Cataracts and rubella
Many studies use routine data

Case reports
Rare disease reports

Case series
Start to see a pattern. Characterization of a disease in a group of people
Advantages
Rare disease
Source of hypothesis idea
Disadvantages
Bias

Cross-sectional study
Capture in one survey everything in a defined population that is exposed at the same point in time
Classify individuals and compare prevalence
Uses
Prevalence information, inexpensive
Challenge is that you don’t know which came first
Other factors may contaminate analysis
Can’t measure new cases over time

Co relational studies
Compare and use data from other sources
Look at a same population at a different time
Cannot draw strong conclusions
Ecological fallacy; use of proxy data and not specific
Ecological studies are quick and easy

Analytic studies
Capture information about exposure and risk factors that interfere with the patterns of disease

Case control studies
Relationship between exposure and disease;
Cigarettes and smoking
Obesity and esophageal cancer
Hair dyes and connective tissue disease

Key is that investigator goes out to meet people who meet the case definition. And the control is one who doesn’t have the condition
This is followed by an interrogation process. Inquiry is retrospective.
There are incidental and prevalent cases

Who sank the boat. Work out how the condition arose. Using historical information
Suited for chronic and rare diseases
Challenges
Recall bias; the very fact that someone has the condition may alter
Selection bias; type of responses won’t be representative

Cohort studies
Aim is to assess relationship between disease and risk factors
Prospective studies of people who don’t have the disease
Long term 15 to 25 years
Identify exposed and unexposed and follow up over time
Timing and sequence is in sync
Valuable when looking at rare diseases
Not constrained on outcomes
Order of timing is not a constraint
Challenge
Validity affected by loss of follow-up
Inefficient for evaluating

Who's at risk


Experimental studies
The investigator decides whether some is exposed.
Interventions in terms of drugs, or public health measures

Randomized control studies
Interventions to determine who is exposed and who isn’t
Follow up like cohort
Key is that the interventions are randomized

Observational studies
The investigator is neutral and records whether or not someone does something






Q can the studies be integrated
A. Yes. Refer to oral cancer study
Cross-sectional studies can then develop into cohort studies
There’s a snowballing effect once results start being released

How can research integrate with clinical activity. Working clinicians are too busy t do research

Mapira; design affects analysis.

David: key is that it is measureable. You have to be able to measure it.












Dr David
The design model for a relatively rare disease like cancer is case control study.
What kind of methodology can be used to detect the disease earlier.
A cross-sectional study can be integrated and evolve into a cohort study.
The key issue is to respond to questions or issues that arise as a result of initial research.
Firstly, hypothesize on the associations/relationships of the research. E.g. Dose response of smoking and alcohol on oral cancer.
POWER. The study has to be of sufficient size to make the analysis valid. There is a threshold and limitation. But it what you collect that is important.
A questionnaire can be a useful tool. Develop a questionnaire where activities are quantifiable or have a pattern. In detail and bring out a picture that people will recognize. It is getting that detail which is important. Indirect information such as number of times you chew as opposed to the number of buai you chew.
Sometimes data samples are too small to analyze so modification can be made.
You’ve got to have interviewers who know what they are asking. Otherwise you will get all sorts of information.
Sometimes assumptions can interfere with collecting data. E.g. some who claims to chew 1000 buai is trying to express the enormity of their habit so to ignore this will lead to loss off perspective.
There s big variation in tar content of air cure and kiln cured tobacco of 1:2 or 50mg:100mg
Calculate risk for each of your sample and adjust for effect of other risk factors.
There is an important relationship between smoking and oral cancer.
Malas is the Tidak word for mouth cancer. If you want to kill someone you poison the kambang. There is a cottage industry of traditional healers.
The is a relationship
Descriptive methods can be used to represent data. A map or a mouth
A pH above 10 produces a burst of free radicals. Presence of Fe2O2 enhances free radicals. Manganese does the opposite.
Collaborate with partners to do various analysis of raw data. People are willing to help out of curiosity.
Crossectional study: use a common roll. In a defined population get information of everyone who lives there. Adapt methods to the situation. E.g. Quantifying betel nut numbers based on the New Ireland basket.
When we are asking questions we need to know “what is the next question to ask?”
Dose response is significant in estimating risk significance
Identify the threshold beyond which there is increased risk and how risk factors are adjusted.
How you document death is an important issue. In PNG you can be fairly confident of the causes of death.
Someone with leukoplakia has three times more risk of developing cancer. About 10% of the New Ireland population has leukoplakia.
The dose response curve on betel quid chewing is about the same in PNG.
MAJOR PUBLIC HEALTH INTERVENTION IS IN SMOKING AND ALCOHOL.

Q. IS THER A LINK BETWEEN TOBBACCO CHEWING AND ORAL LESSIONS
Chewing tobacco is linked with mouth cancers and leukoplakia
Q. WHY DO ADJUSTMENTS TO RESULTS
Adjustments done statistically account for issues such as age alcohol tobacco to look at the effect of each risk factor and to separate out the effect of each.






DR CHRIS BAIN PRINCIPLES IN DISEASE CONTROL AND CANCER CONTROL.
Cohort studies help in identifying the multiple effects of single exposure to risk factors
Counting cancer to support Public Health planning
Epidemiology is a discipline of utility
We want to know about diseases and how we can control and prevent them
Randomized trials a useful in evaluating strategies
Our first question has to be smart one.
There’s no point in asking the same question again
There has to be a reasoning to know about the prevalence of a disease in our population
Studying health transition and changing risk patterns help in developing a public policy response
Incidence is the occurrence of a disease as it emerges
Mortality is affected by treatment as well as incidence
Without the incidence or mortality data it is difficult to make arguments about trends in disease patterns. E.g. changes in CHD in Queensland
The big question in planning is “how do we maximize the returns on money spent on a disease?”
Epidemiology provides a transparent logic and alternative explanations to issues
Descriptive Data
Standardized incidence ratio is adjusted for differences in population such that the final number compares like for like. So that data is not confounded by the difference. E.g. Taking age into account
What do we know what’s upon a population. How do we find out what has occurred?
Given particular exposure what is the effect on the population. How do we
Evaluation should be based on the totality of evidence that is out there so that we can answer important public health questions
Epidemiologists need whole lot of specialty skills to understand driver of the problem and palatable intervention strategies
Minor Public Health campaigns can have a cumulative effect
How common is the exposure. Exposure to small population may not need a Public Health response compare say to cigarettes.
How much risk?
E.g. Highest users of HRT have higher incidence of breast cancer. Such simple descriptive studies show much more information than a randomized control study.
Theoretical projections can help make arguments for Public Heath interventions.
STUDY QUALITY
Internal validity. How close to the truth are we. How much planning can we do based on the data.
External validity. How can we apply this to the population
Bias and error
4 forms of error
Chance: variability and small sample
Bias
Faults in design. Make comparisons. Are the controls good comparisons. Have we got like for like
Measurements: how do we make measurements
Confounding
Other factors that interfere with the outcome

Increasing sample size is relevant only to dealing with chance
SELECTION BIAS
Volunteers of a study can have hidden agendas for joining the study
Comments on control selection
Population based controls can be difficult
Use hospital based controls may have limitations. But use patients who don’t have diseases that are being studies. Use patients and guardians. Potential issue is that habits may be similar.
Population sample from cross-sectional studies do differ from hospital controls. Population is more likely to smoke. Urban vs. rural show differences. Urban dwellers are more likely to drink and smoke. Buai is more available in urban areas than rural.
All studies are flawed. Don’t wait for the perfect study. But work through the problem and compare with other studies. Imperfect control selections but thoughtful consideration allows for interpretation. Random misclassification if evenly applied elsewhere there is no significant measurement error. The truth is somewhere further from the null hypothesis.
Different samples tell us different things, that is selection bias as long as the measurement method is the same.
Randomized trial can go wrong if high risk patients are inadvertently selected out.
IDEAL CONTROL
You want to be a case they would appear in your case series.
Differential error in a measurement error
CONFOUNDING
To confuse or muddle
Could smoking confound the relationship between chewing and the occurrence of oral cancer.

Exposure Disease

Confounder

Measure the risk factor and confounders well
Compare like for like and identify associations
Work out the odds ratios
Formulate an adjustable estimate, adjusting for the confounder

CONTROL OF A CONFOUNDER IN A RANDOMISED CONTROL STUDY
BASELINE FIGURES ARE THE SAME SHOWING GOOD RANDOMISATION
MANY PERSONAL ATTRIBUTES CANN’T BE MEAUSRED SO RANDOMIZATION SOLVES THIS
STRATIFICATION OF DATA CAN VERIFY THE SIGNIFICANCE OF A COUNFOUNDER.

THERE WILL ALWAYS BE ERRORS
GETTING THE BACKGROUND KNOWLEDGE AND ASKING A SPECIFIC QUESTION
IN ANY RESEARCH PILOTING FIRST TO GET THE RIGHT QUESTIONS






David Whiteman
DATA COLLECTION IMPLEMENTING A STUDY
WHAT IS THE PROCESS
What they think is causing a disease
Results may be negative
Collaborators
Approval
Protocol document; data collection sheet
Procedures; knowing what to get
Instruments; measurement tools
Database
Pilot all systems

A data file contains the set of variables for components

WHAT IS A VARIABLE
The things we measure. An analyses tool. Ids and values. Unique id for each sample.

e.g. exposure
risk factor
feature
characteristic
determinant
predictor

conceptual: the thing you think is the confounder of cause

Operational measure: a proxy measure. What you
u can measure

practicality: how well the exposure measure can relate to the real world

ACCURACY AND PRAGMATISM

TYPES OF COLLECTION

Self administered questionnaires
Telephones
Face to face
Internet survey
Observation

Documents

Hospital records
Clinical records
Registers

Extraction must be specific. Use closed ended questions. Missing doesn’t mean didn’t happen.

*Use questionnaires that have been piloted extensively

Any piece of paper should have the patients’ i.d.

Questionnaire may be detailed to answer the hypothesis questions. It depends on what hypothesis you are trying to test.

There are different types of responses in open text fields on questionnaires.

Numerical fields; e.g. age

Categorical fields; force people to put themselves in a category for testing complex variables

Who fills out the questionnaire ; if there are differences in data collection it brings about differences in analysis

Observation
Biological samples need additional infrastructure and cost

Qualitative observations can give other insights

Systematic features of recording provide useful ways of collecting data; e.g. histopathology; describing a slide

The bottom line in study is cost skill and equipment.

Consider the burden you put on the people. By losing people you introduce bias. Do not put too much burden on people

Always check quality of data. By training and reviewing performance and response rate

Mistakes happen and can be minimized by communicating

Garbage in garbage out



DATA MANAGEMENT

EPI INFO FROM WHO
CODING
ENTRY
AUDIT
MANAGE
WORKOUT CONFOUNDERS AND NOISE

FIELDS
NUMERIC
CATEGORICAL
OPEN TEXT

COLLECT AND CHECK. VERIFY

KEEP A DICTIONARY OR CODE BOOK. ANALYSE DATA

KEEP RECORD OF STORAGE

CHECK AGAIN FOR MISTAKES


KEEP ANALYSIS SIMPLE
LOGIC TABLE
SEE WHERE THE PATTERNS ARE

AFTER THAT DO THE FANCY STATISTICS

IF YOU HAVE A BIG ENOUGH SAMPLE AND ENOUGH INFORMATION LOOK FOR COMBINED EFFECTS

IDENTIFY THE RISKS ASSOCIATED WITH THE VARIABLE BEING TESTING AFTER ADJUSTING FOR CONFOUNDING FACTORS

CALCULATE THE EXCESS RISK



Q. WHAT IS ODDS RATIO

A. MEASURES OF ASSOCIATIONS SUCH AS RATES OF RELATIVE STUDIES CAN BE STUDIED IN THE PROSPECTIVE.

THE ODDS OF BEING EXPOSED TO THE RISK
RISK RATIO

TECHNICAL ISSUES CAN BE ANSWERED LOCALLY. THE WORKSHOP IS BROAD

Q. CONTEXT OF CANCER IN PNG

A.
WE DON’T KNOW SO MUCH ABOUT THE DISTRIBUTION OF CANCER AND THERE ARE MANY DIFFERENCES.
WE NEED TO DEFINE THE THINGS WE DON’T KNOW
WHAT ARE THE PRIORITY AREAS

HOW DO WE TREAT BETTER?

SOME DECISIONS ON CANCER POLICY ARE MADE AT THE NATIONAL LEVELS

IT IS A SHAME THAT WE DO NOT HAVE ANSWERS ABOUT THE CONTEXT OF CANCER IN PNG



PROF CHIVERS SIMPLE RESEARCH CAN BE DONE
OBSERVATIONS ON SCURVEY AND PLAGUE SHOW THE SIGNIFICANCE OF SIMPLE STUDIES
THERE IS A NEED FOR COMPREHENSIVE CANCER REGISTRY
THERE IS NEED FOR INTERNET
NO SMOKING NO BUAI CHEWING

NOTES FROM THE RECENT CANCER CONTROL WORKSHOP






DAY 1 2/11/09
SCHOOL OF MEDICINE AND HEALTH SCIENCE

ICRETT TRAINING WORKSHOP

NOTES OF THE MEETING

PRESENTER REMARKS

DR MOREWAYA: TUMOUR REGISTRY IN PNG
















































Prof Crouch • TUMOUR REGISTRY BEGAN IN 1958 ITS BEEN 51 YEARS SINCE.
• 50 YEARS NO NOTICE OF THIS REGISTRY BEING IN PLACE IN ORDER TO DEVELOP IT
• ESSENCE OF WORKSHOP IS TO INTEPRET THE FIGURES WE HAVE
• THERE IS ANEED FOR PROPER REGISTRY STAFFING AND THE SPECIALIST MEDICAL TRAINING
• SPECIAL FOCUS ON SQUAMOUS CELL CARCINOMA AS SQUAMOUS CELL ARE FOUND IN ALL BODILY ORIFICES
• REGISTRY MODEL WAS DEVELOPED BY FARAGO IN 1962
• KENSY SYSTEM OF REPORTING INVOLVED REGIONAL REPORTING TO A NATIONAL TUMOUR REGISTRY
• REPORTING INCLUDED SOLOMON ISLANDS
• CURRENT RECORDING INVOLVES FEW STAFF AND STORAGE OF FILES AND SPECIMEN IS INADEQUATE _ ITS IN A TERRIBLE STATE
• IT IS WITHIN THIS CONTEXT THAT 4000 TO 6000 SPECIMEN ARE RECEIVED
• MALIGNANT AND NON MALIGNANT FILES ARE SORTED OUT AND SEPARATED
• TISSUES STORED IN PARRAFIN AND FOR TOO LONG THEY BECOME DAMAGED
• SOME SPECIMEN GET LOST
• PROBLEMS WITH STORAGE AND ACCESS TO FILES
• EMPHASISE THE IMPORTANCE OF HAVING CANCER REGISTRY MAKES IMPORTANCE OF HAVING REPORTING OF YEARLY CANCER INCIDENCE MUCH EASIER
• REQUIREMENTS FOR A CANCER REGISTRY- MEDICALLY TRINDE STAFF, BETTER NOTIFICATION SYSTEM, A BUILDING AND FUNDING
QUESTIONS
Whiteman- Are there tumour registration forms issued or in use; including age, sex, occupation other clinical details?
Ans- Yes but currently not efficiently used by clinicians.
Very little clinical details are recorded

PMGH Sister
How are the figures of incidence of cancer in PNG getting to the global attention?
From clinical reporting of tumours diagnosed

Dr Poki

Any recording of the files on computers so far?
Ans: Yes only since 2005 when computers were donated but very little clinical details
Ms Becky
Length of time taken to receive pathology reports?
Ans:
Problem of turnover time
Lack of availability of resources- histology machines
Sr PMGH
Visits to regional reporting centres?
Ans- Not sure; currently not happening at PMGH



Review of all the reviews; Work since 1950s
• Geography- isolation of many societies up to 80 years ago; cancer distribution varies
• 1960s-1970s: Docs in base hospitals; One pathologist
• 1962-1965: oral skin cancer; female genitalia cancer
• Data not population based but incidental based
• Presumed oral cancer due to betelnut chewing
• Skin SCC due to tropical ulcer
• Cervial cancer predominates
• Children lympjosarcoma, eye cancer
• Lung cancer due to tobacco smoking
• 1974- Cnacer review
• Infrequent compared to infection
• Oral cancer 10X lower in the highlands
• Males more than females perhaps due to males seeking more medical help
• Betelnut chewing now more widely distributed
• Betelnut trade more extensive
• Areas of lime application leads to leukoplakia development
• Alcohol role still unknown but may act as solvent of carcinogens
• 1974- SCC ; lowland
• Chronic ulcer
• M>F
• 20 year period neede
• 100X more common in white males
• Basal cell Ca more common in highlands
• Kaposi Sarcoma rare
• •






PRESENTER REMARKS

DR LAKA 1. National Health Plan 2010 onwards will be consistent with Medium Term Development Strategy and the National Development Strategy.
Institution of national cancer center
2. Cancer budget of 3 million next year is inadequate
3. Radiation treatment. 1 radio-oncologist
4. Plans for one more unit
5. Lack of availability of radio-oncologist
6. Need to boost district level services and ask for assistance from
7. Residence spaces unavailable in provincial hospitals despite medical school production
8. We have the data but it is relative. Entry is independent and different, although trying to produce same information.
9. Yes its there but they don’t know how to retrieve and process it to answer questions we are asking.
10. To make an impact on cancer the national cancer control program
11. Abolishment of aid-post to be replaced by community health post
12. Upgrading health centers to district hospitals
13. Minimum standards. Doctors dilemma of dealing with patients with lack of equipment. To doctors regarding minimum standard equipment list. Cost packages for different health settings, possible kit hospitals

Q. DR NEWTON
Counting and measuring things is important in public health
Need to publish so that the world starts paying attention
No enough to just collect but to publish

DR TAU
NEED TO DO RESEARCH

Q. UPNG PUBLIC HEALTH DR HEWALI MPH1
HOW MANY PATHOLOGISTS

A. ABOUT 6 PEOPLE. DR JACOB. ONE IN LAE

Q. DR POKI
CHALLENGES OF REPORT TURNOVER. RADIOTHERAPY BROKE DOWN.
INJUSTICE. TRAINING MORE PEOPLE. PNG S NOT LAE AND PORT MORESBY. INVOLVE ALL STAKEHOLDERS

Q. IMR
GENERAL LACK OF INFORMATION. ACCESS TO INFORMATION ON CANCER BY HEALTH PROFESSIONALS IS A PROBLEM. DEVELOPMENT OF INFORMATION RESOURCE FACILLITIES, APPROPRIATE AND UP TO DATE.

DR LAKA.
ICT POLICY IS UNCLEAR

DR NEWTON
CONTROL IS IMPORTANT
EMBRACE DEATH, PALLIATIVE DEATH, HOME BASED
LONG TERM: BOOSTING CANCER FACILLITIES, HISTOPATHOLOGIST
SHORT TERM: ICT: EDUCATION IS AVAILABLE FREE. TELEPATHOLOGY FREE OF CHARGE

DR GENDE:
IT WILL NOT STAND STILL. SERVICES ARE VARIED CHEMOTHERAPY, SURGICAL, RADIOTHERAPY AND PALLIATIVE CARE.
QUALITY OF INFORMATION IS IMPORTANT.

DR LAKA
PPP.

DR GENDE

POM CANCER RELIEF SOCIETY
REHABILLITATION OF SURVIVORS. COUNSELLING OF PATIENTS TO FACE THEIR FEAR. MORE SUPPORT

DR GENDE
WILL IT BE STAND ALONE

DR LAKA
YES. SOMETHING SIMILAR TO IMR. INTEGRATION WITH CLINICAL SERVICES. NATIONAL CANCER CONTROL PROGRAM WILL WORK BETTER IF IT IS STAND ALONE

DR GENDE
HOW WILL UICC HELP

DR NEWTON
UICC HELPS DEVELOP PROGRAMS
EDUCATES AND STIMULATES LOCAL COMMUNITY TO ENGAGE WITH THE WIDER CANCER COMMUNITY
DEALING WITH SURVIVORS HAS SPINOFF IN SPREADING THE WORD ON CANCER SO THAT THERE IS EARLY DETECTION.

DR GENDE
IEAE AND DR GARBETT, TECHNICAL ISSUES OF CANCER IN DEVELOPING COUNTRIES

DR MOREWAYA
OIL SEARCH DONATED DIGITAL MICROSCOPES
DOCTORS SEND SAMPLE TO PROCESSING CENTERS; RABAUL MT HAGEN
CENTERS PRODUCED SLIDE IMAGE ON MICROSCOPY
ONE DAY HISTOLOGY RESULTS

DMS MT HAGEN
CANCER DISPLACED BY HIV
CANCER INSTITUTE TO DRIVE POLICY DEVELOPMENT AND IMPLEMENTATION

FROM BARNETT INSTITUTE
HEP B IMMUNIZATION TO PREVENT LIVER CANCER
IMPROVE IMMUNIZATION COVERATION
COLLOBERATION BETWEEN NDOH AND OTHER PARTNERS

DR MOREWAYA
USE LOCAL KNOWLEDGE FOR COVERAGE. HEPB MORE PREVALENT IN HIGHLANDS

DR NEWTON
REASONS FOR IMMUNIZATION MORE TO DO WITH

DR GENDE
WHAT WE NEED IS QUALITY INFORMATION

















DR NEWTON

GLOBAL BURDEN OF CANCER • HPV TYPES UNKNOWN
• USE TISSUE BLOCKS TO IDENTIFY UNDERLYING CAUSES
• TECHNOLOGY THERE TO MODIFY VACCINE DEPENDING ON KNOWN TYPES
• HOW OLD ARE GIRLS WHEN THEY ARE INFECTED WITH HPV
• IN UK VACCINATION OF 12 YEAR OLDS

• HIV IS AN IMPORTANT CAUSE OF CANCER AND INCREASES RISK OF CANCERS CAUSED BY INFECTIONS

• HIV RELATED TUMOURS INCLUDE LYMPHOMASA AND KARPOSIS SARCOMA.

• KS RELATIVELY COMMON IN PNG

• KS EXISTS IN AFRICA NORTHERN EUROPE AND PNG AND NO WHERE ELSE

• SAME AS LYMPHOMA.


COMPARE BURDEN OF DISEASE ACROSS DIFFERENT POPULATIONS
• AGE AND SEX STRUCTURE
• 6.5 TO 7 BILLION PEOPLE IN WORLD
• MAJORITY ARE POOR. 2 BILLION LIVE ON LESS THAN A DOLLAR
• 60 MILLION DIE EACH YEAR
• NO DISEASE RECOGNIZES NATIONAL BOUNDARIES
• AS A STARTING POINT PUBLIC HEALTH NEEDS TO SEEN WITH LOCAL AND INTERNATIONAL COMPONENTS

POPULATION PYRAMID
• CANCER IS A DISEASE OF OLD PEOPLE
• LIFE EXPECTENCY WORLD:65 DEVELOPED WORLD: 76 DEVELOPING WORLD: 63 AFRICA: 49
• WOMEN LIVE LONGER THAN MEN

MAJOR HUMAN DISEASES
• CARDIOVASCULAR DISEASES 18 MIL
• CANCER 10 MIL
• HIV 5 MIL
• LOWER RESPIRATORY

TOBACCO KILLS MORE PEOPLE THAN HIV/AIDS

CANCER

DEFINED AS AN ALTERED CELL

PATHOLOGICAL
CELL PROLIFERATION
DIFFERENTIATION
DEATH
MONOCLONAL

CARCCINOMAS 90%
SARCOMAS
GLIOMAS
LEUKAEMIA

CLASSIFIED BY ICD
WHO CODING HAS BEEN RECENTLY UPDATED

CODING OF CANCER IS INADEQUATE

CODING IS IMPORTDENT

CANCER 2002: MORE COMMON IN MEN THAN WOMEN

CANCER AS A % OF ALL CAUSES OF DEATH.
HIV 5% (EU) AFRICA 22.6%
CANCER 12.4% (EU) AFRICA 5%

NEW CANCER CASES WORLD WIDE

90% CAUSED BY TOBACCO

LUNG
PROSTATE
STOMACH
COLORECTAL CANCER

WOMEN

REPRODUCTIVE ISSUES

BREAST CANCER
UTERINE CANCER, HELP BY HPV IMMUNIZATION, RELATED TO SEXUAL BEHAVIOUR, CANCER

PREVENTION IS A LONGTERM PROCESS

CANCER IS PREDOMINANTLY A DISEASE OF PEOPLE AS THEY GROW OLDER. MEDIAN IN AFRICA 44-45 (NEWTON)

WHAT ARE THE TWENTY MOST COMMON CANCER IN PNG?

CANCER CONROL IS NOT JUST ABOUT PREVENTION. IT IS IMPORTANT TO MONITOR HOW WELL THE TREATMENT IS. THEREFORE MORTALITY REPORTS ARE DIFFERENT TO INCIDENCE.

HAVING GOOD DATA ALLOWS ONE TO PRESENT GOOD INFORMATION AND INTERPRETATION.

DEATH CERTIFICATION PROVIDES BASIC INFORMATION ON CAUSES OF DEATH.

CHILDHOOD CANCERS ARE DIFFERENT FROM ADULT CANCERS AND RESPOND TO TREATMENT DIFFERENTLY.

WHAT IS THE MOST COMMON CANCER IN PNG?

KARPOSI SARCOMA RISE RELATED TO HIV

WHEN YOU PUT WHAT YOU KNOW ABOUT YOUR COUNTRY IN THE GLOBAL CANCER YOU CAN KNOW HOW TO ALLOCATE RESOURCES FOR CANCER CONTROL.

MOST CANCERS ARE AVOIDABLE

GOOGLE GLOBAL CAM AVAILABLE ON INTERNET

VARIATIONS IN INCIDENCE ARE GEOGRAPHICAL NOT GENETIC
EG. COLORECTAL CANCER AMONGST JAPANESE

TAKES ABOUT 20 YEARS TO DIE OF LUNG CANCER

CANCER CONTROL

PREVENTION
LIFESTYLE, LEGAL, VACCINES

SCREENING
EARLY DETECTION, PICKING UP THE TUMOUR MORE QUICKLY
PREVENTION OF DEATH

DISEASE MANAGEMENT
IMPROVEMENTS AND TREATMENT AND QUALITY OF LIFE
CAN BE CURABLE
IMPROVEMENTS IN DIAGNOSTICS

SUPPORTIVE AND PALLIATIVE
CANCER PATIENTS DIE MISERABLY
ARE IN CHRONIC PAIN
TRAIN CARERS
HOME BASED CARE

Q.RELATIONSHIP BETWEEN CERVICAL CA AND HIV
A. HIV IS A CAUSE IN THE SENSE THAT IF YOU ARE MORE LIKELY TO DEVELOP

Q. CANCER SEEN EARLIER NOWADAYS CLINICALLY
A. LIKELYHOOD OF COMING FOR MEDICAL HELP DECLINES AS YOU GROW OLDER
MANY CANCERS SUCH AS HEPB PICKED UP EARLY AND DEVELOP CANCER AT AGE 45 AT

Q. AGREE WITH EARLY DETECTION POINT. LACK OF SCREENING AND EARLY DETECTION. CERVICAL, MOUTH HEAD AND NECK AND BREAST CANCER.
MANY OF THE THIGS THAT CAUSE CANCER CAUSE MANY OTHER DISEASES THAN MALIGNANCY. EG. SMOKERS GET HEART DISEASE AND DIE BEFORE THEY GET LUNG CANCER





DR WHITEMAN
CANCER REGISTRY: WHY SHOULD WE BOTHER COUNTING INFORMATION AVAILABLE FROM INTERNET.

Process of continuing systematic collection of data on the occurrence and characteristics reportable neoplasm

A cancer registry is an organization that collects store analyses and communicates cancer data

TYPES
POPULATION BASED: RECORDS NEW CASES IN A DEFINED POPULATION

HOSPITAL BASED

CANCER REGISTER IS THE FILE/BOOK/

1728 FIRST CANCER CENSUS LONDON
1900 HAMBURG 14TH OCTOBER
1902-08 DUTCH, SPANISH
1930 USA WOOD, MAKE CANCER A NOTIFIABLE DISEASE
1935 CONNETICUT
1941 DANISH CANCER REGISTRY
1946 WORLD CANCER EXPERTS MEETING. COUNTING CANCER IS OF GREAT BENEFIT. STANDARIZED COUNTING.
1950 WHOCANCER SUB COMMITTEE
1965 IACR: COLLECT AND ANALYZE
1966

COMMON CANCERS IN PNG 1953-78
ORAL
SCC
LIVER
CERIVICAL
BREAST

WHY BOTHER?
PROVIDE HEALTH SERVICE INFORMATION
PLANNING
PATTERNS OF MORTALITY
FOLLOWUP AND REMINDERS

QUEENSLAND
1980s BY ACT OF PARLIAMENT

COLLECT DATA TO DESCRIBE THE NATURE OF CANCER IN QUEENSLAND

DATA USED FOR RESEARCH
PLANNING AND ASSESSMENT
MONITORING
EDUCATION OF HEALTH PROFESSIONALS

USED FOR SAMPLING AND STUDY DESIGNS


PRIMARY PREVENTION SECONDARY PREVENTION TERTIARY PRE
CAUSAL FACTORS SCREENING
BIRTH________________________________________________________DEATH
ONSET DIAGNOSIS

IT SEEMS LIKE EVERYTHING PREVENTS CANCER. EPIDEMIOLOGY IS TO IDENTIFY

WHO SANK THE BOAT?

CONTIBUTORS AND TRIGGERS; EPIDEMIOLOGY

CANCER REGISTRY WHY?

DISTRIBUTION IS DIFFERENT IN PNG

QLD
MELANOMA
BREAST CANCER
PROSTATE
LUNG
COLON

WHAT ARE THE FACTORS THAT LEAD NORMAL TISSUE TO BECOME MALIGNANT?

REGISTRY

PERSON AGE +SEX CULTURE/RACE
TIME
PLACE

RESULTS FROM REGISTRY CAN CREATE QUESTIONS
REGISTRY CAN IDENTIFY VARIATIONS OF CANCER DISTRIBUTIONS IN TERMS OF RACE, AGE AND SEX
REGISTRY CAN SHOW CHANGES IN TRENDS IN CANCER FOR DIFFERENT TISSUES, ORGANS
LONGTERM DATA CAN REVEAL PATTERNS THAT LEAD TO IDENTIFYING RISK FACTORS AND CAUSES OF CANCERS
REGISTRY DATA CAN BE USED TO COMPARING POPULATIONS

STATISTICS CAN BE USED TO IDENTIFY PROPORTIN OF PREVENTABLE CANCER.
CANCER REGISTRATION MAKES PEOPLE TO ASK WHY.
CANCER REGISTRY CAN BE USED TO IDENTIFY POSSIBLE MEANS OF REDUCTION BY COMPARING DATA FROM DIFFERENT PLACES

CANCER DATA CAN ALSO IDENTIFY AREAS OF CONCERN

CANCER REGISTRIES LEND THEMSELVES TO VARIOUS EPIDEMIOLOGICAL STUDIES.

MONITORING SERVICES
NATIONAL PLANNING IS NOT POSSIBLE WITHOUT
MEANS TO IDENTIFY PROBLEMS/PRIORITIES
EVALUATE GOALS
MONITORING AND SURVEILLANCE
Q. DR KAPTIGAU: APART FROM REGITRATION IS THERE RECORD OF SURVIVAL RATES
A. YEAH INDIRECTLY. DEATH REGISTRATION BY LINKING
RECORD ALL TREATMENT/ RECURRENCE AND

DR NEWTON: DIFFERENT. YOU CANNT RUN BEFORE YOU WALK. AT THE MOMENT, HISTOLOGY BASED. BUT BIOCHEMICAL OR CLINICAL DIAGNOSIS CAN BE MADE AND RECORDED. ALTHOUGH HISTOLOGY REPRESENTS THE GOLD STANDARD YOU NEED TO BE MORE INCLUSIVE TO DIAGNOSTIC METHODS.

DR WHITEMAN. YEAH IN AUSTRALIA PANCREATIC CANCER IS DIAGNOSED WITHOUT histology.

STATEMENTS: SKIN NOT ISSUED
DEATH CERTIFICATE: INCLUDE CANCER
CLIMATE CHANGE

A. CLIMATE CHANGE MAY OR MAY NOT HAVE AN IMPACT ON SKIN CANCER. MY IMPRESSION IS THAT IT MAY REDUCE ULTRAVIOLET RADIATION