Cancers

Prioritising and Mobilising
NCD Prevention and Control at
Country level: Cancer Prevention
and Control as an Example
Shu--Ti Chiou
M.D., Ph.D., M.Sc.
Director-General, Bureau of Health Promotion, DOH, Taiwan
Assistant Professor, National Yang-Ming University
Coordinator, Taiwan HPH Network
Vice Chair of Governance Board, International HPH Network
1
Prioritising and Mobilising NCD Prevention
and Control at Country level:
Cancer Prevention and Control as an
Example
Burden of cancers and their risk factors in
Taiwan
Strategies and achievements for cancer
prevention and control
The Way Forward
2
Burden of cancers and their risk
factors in Taiwan
3
Cardiovascular diseases and Diabetes -Death rate
Taiwan has much lower CVD & diabetes death rate than the
other countries.
Male
Thailand(2006)
Spain(2007)
Malaysia(2006)
China(2007)
Germany(2006)
206.6
USA(2007)
190.5
171.2
Singapore(200
Korea(2006)
167.9
UK(2008)
165.7
156.3
Italy(2007)
Taiwan(2010)
136.4
136.3 Australia(2006)
128.3 France(2008)
118.1 Japan(2008)
343.0
327.9
318.7
311.5
400
4
Age-standardized death rate (1/100,000)
300
200
100
Female
280.0
315.2
236.5
259.6
133.7
122.0
108.9
115.2
101.7
102.0
95.6
88.6
69.2
65.0
0
100
200
300
Source：Global status report on noncommunicable diseases 2010. The data for Taiwan include DM
and CVD ( CVD consists of heart diseases, cerebrovascular diseases, and hypertensive diseases) .
Figures were calculated from the 2010 Vital Statistics, adjusted for the 2000 WHO population
400
Chronic Respiratory Diseases -- Death rate
Age-standardized death rate (1/100,000)
Male
Female
118.4
88.7
China(2007)
114.4
29.7
Thailand(2006)
86.6
44.5
Spain(2007)
74.7
42.1
Malaysia(2006)
38.7
UK(2008)
26.5
38.0
USA(2007)
27.8
36.1
12.1
Korea(2006)
25.6 Australia(2006)
24.6
15.5
9.4
Italy(2007)
24.2 Germany(2006)
10.9
22.6 Singapore(2008)
7.2
22.5 Japan(2008)
22.5
150
100
50
8
Taiwan(2010)
7.6
18.8 France(2008)
7.4
0
Source：Global status report on noncommunicable diseases 2010
5
Chinese Taipei：Department of Health, Executive Yuan, Taiwan
50
100
Cancers -- Incidence & Mortality Rate
Cancer is the top leading cause of death in Taiwan. The incidence and
mortality rates are both higher than many other countries
Incidence rate
China
Taiwan
UK
Spain
Italy
France
Australia
Germany
US
Korea
Japan
Thailand
Malaysia
Singapore
181.0
244.1
266.9
241.4
274.3
300.4
314.1
282.1
300.2
262.4
201.1
150.5
142.9
196.0
350
300
250
200
150
Mortality rate
100
50
124.6
120.7
115.8
109.5
110.6
107.3
102.8
105.9
104.1
100.5
94.8
93.6
93.4
90.1
0
50
100
150
Age-standardized rate (ASR), 1/100,000, 2008
Source: 1. GLOBOCAN 2008, IARC
6
2. Chinese Taipei data from 2008 Taiwan Cancer Registry and 2008 Statistics of Major Causes of Death
Top 10 leading causes of death in Taiwan
150
130
110
90
age-standardized
mortality rate
(1/ 100,000)
cancer , 132. 5
Cancer has been the number 1 killer in
Taiwan since 1982, the mortality
remained high, and is much higher than
the other causes of death
70
hear t di s,
47. 7
50
st r oke , 32. 8
30
i nj ur y , 27. 7
di abet es , 26. 6
pneumoni a , 25. 3
l i ver di s, 16. 6
10
sui ci de , 14. 7
COP D , 14. 9
7
19
86
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
Ch. Ki dney Di s , 12. 5
-10
yr
Burden of Cancers in Taiwan
It accounted for 28.1% of total deaths and
10.1% of National Health Insurance
expenditure in 2009.
8
Comparing mortalities of major cancers
between Taiwan, Japan, US and Singapore
As compared with the US., Taiwan has higher mortality from
cancers of liver, colorectum, stomach and oral cavity.
ASR(per 100,000)
35
30
25
20
15
10
5
0
HBV &
HCV
infection
Low
screening
rate
Taiwan
Japan
Betel quid
chewing
Singapore
gu
s
O
es
op
ha
te
sta
Pr
o
av
ity
O
ra
lc
ch
Li
p,
Source: GLOBOCAN 2008, IARC
St
om
as
t
Br
e
ct
um
Co
lo
re
Lu
ng
r
USA
Li
ve
9
Smoked,
salted and
pickled foods
Major fatal cancers and their trends
30
age-stadardized
MR (1/100,000)
25
liver , 26.2
lung , 25.9
20
stomach
15
cervix
colorectum ,
14.8
breast , 10.6
10
oral cavity , 7.6
5
stomach , 7.3
prostate , 5.9
esophagus , 5.0
pancreas , 4.9
cervix , 4.2
19
1986
8
19 7
1988
1989
1990
9
19 1
1992
1993
1994
9
19 5
1996
1997
1998
9
20 9
2000
2001
2002
0
20 3
2004
2005
2006
0
20 7
2008
09
-
10
yr
Up to 2007, among the
leading cancers,
•mortalities from liver,
lung, stomach and
cervix are declining,
but
•those from
colorectum, breast, and
oral cavity are rising.
•The importance of
obesity, unhealthy
diets and physical
inactivity has emerged.
Prevalence of major risk factors
11
Overweight and obesity in adults
Our prevalence of overweight and obesity is lower than Western countries,
but higher than many Asian countries.
Age-standardized prevalence
Male
USA(2007/8)
Australia(2008)
Germany (2005-7)
Spain (1990-2000)
France (2006)
Italy (2005)
Taiwan (2005-8)
Singapore (2004)
Japan (2000)
Malaysia (1996)
Korea (1998)
Thailand (2004)
China(2002)
-70
12
32. 2
25. 6
20. 5
13. 4
16. 1
10. 5
19. 2
6. 4
40. 1
42. 1
45. 5
45. 0
41. 0
42. 5
31. 9
28. 6
24. 5
2. 3
4. 0
20. 1
22. 0
overweight 1. 6
4. 7
17. 7
obesity
2. 4 16. 7
-50
-30
-10
28. 6
30. 9
29. 5
32. 2
23. 8
26. 1
19. 2
22. 6
17. 8
21. 4
23. 4
25. 2
15. 4 3. 4
10
Female
35. 5
24. 0
21. 1
15. 8
17. 6
9. 1
16. 6
7. 3
3. 4
7. 6
3. 0
9. 1
30
Data sources: International Obesity Taskforce (IOTF)
Europe: overweight:25≦BMI＜30；obesity:BMI≧30 (2008, 20+ years old)
Asia: depends on each countries’ standard
Chinese Taipei: Nutrition and Health Survey in Taiwan (NAHSIT).
overweight:24≦BMI＜27；obesity:BMI≧27 (2005-2008, 18+ years old)
overweight
obesity
50
70
Physical inactivity
Our prevalence of physical inactivity is much higher than other countries
Taiwan(2009)
UK(2008)
Malay sia(2005)
Japan(no
Italy (2005)
Spain(2003)
USA(2007)
Australia(2003)
France(2008)
China(no
Germany (2005)
Phillippines(200
Thailand(2008)
63.3
61.4
60.2
54.7
50.2
73.9
43.2
37.9
32.5
31
28 Age standardized percentages
23.7
% of population
19.2
0
10
20
30
40
50
60
70
Insufficient physical activity is defined as less than five times 30 minutes of moderate activity per week, or
less than three times 20 minutes of vigorous activity per week, or equivalent.
Taiwan：
： Insufficient physical activity is defined as less than 3 times 30 minutes of moderate activity per week
13 Source：Global status report on noncommunicable diseases 2010
80
Betel quid chewing rate among adult men,
Taiwan, 2009
The betel quid chewing rate among adult
men used to be high, but has declined in
recent years.
20
18
17.2
16.9
16
14.6
14
12.5
12
10
8
6
4
2
Source ：BRFSS, Taiwan
0
2007
Betel Quids
14
2008
2009
2010
year
Oral cancer patients
endorse anti betel quid
chewing campaign
Strategies and achievements for
cancer prevention and control
in Taiwan
15
Experiences of past successes:
1. Universal HBV vaccination and liver cancer
Taiwan has the world’s first
example of successful cancer
prevention by vaccination.
The HBV mass vaccination for
infants was launched in 1984
Effect:
Infection: HBsAg(+) rate among
childen aged 6 decreased from
10.5% in 1989 to 0.8% in 2007
Incidence: the incidence of
childhood liver cancer also
declined significantly
16
2. Screening and mortality of cervical cancer
in Taiwan
After implementation of Pap smear screening,
mortality from cervical cancers declined by two thirds in 15 years
screening rate
mortality(1/100,000)
70
11.0
10.5
Screening Rate (%)
12.0
10.6
60
10.0
52.5
50
40
M.R.
46.4
60.1
58.6 58.2 57.2 57.8 58.0 57.9 56.9 57.5 59.2
56.6
9.2
10.0
8.9
8.2
8.0
37.8
7.6
8.0
7.2
6.6
5.7
5.8
6.0
4.7 4.2
30
4.4
4.0
20
2.0
10
0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
17
year
Political commitment:
Say NO to the No.1 Killer
Our
current President has declared to reduce
cancer mortality by 10% during his election
campaign in 2007.
National
Plan on Cancer Control 2010-2013
was launced with the goal to reduce age-standardized
cancer mortalty rate from 132.5 deaths/100,000 in
2009 to 119.3 deaths/100,000 by 2015.
18
To reduce cancer mortality in 6 years…
Short term:
1.
Expand the national screening program to cover
new items -- in addition to the preexisting cervical
cancer screening, we also should cover screening for
colorectal cancer, breast cancer and oral cancer.
Continue to improve the quality of cancer Dx and
Tx by the national cancer care accreditation
program;
Long term—prevention:
Reduce use of tobacco and betel quid
Addressing obesity and physical inactivity problems
2.
1.
2.
19
Among all
cancers,
screening has
been proven to
do more
benefit than
harm in 4 sites
of cancers.
WHO, 2007
20
Expected benefits of cancer screening in Taiwan
Effectiveness/Mortality
(screening interval)
Cost per HLY gained
(screening interval)
Pap smear
↓60-90% (every 3-5 years)
12,000 USDs
(every 3 years)
i-FOBT for
colon cancer
↓18-33% (every 1-2 years)
Dominated
(every 2 years)
Oral mucosa
exam for
oralcancers
↓43% (every 3 years)
10,000 USDs
(every 2 years)
Mammography for
breast cancers
↓21-34% (every 1-3 years)
36,700 USDs
(every 2 years)
Screening tool
＊ 90年基隆市社區闔家歡健康篩檢成果發表；＊＊93年社區到點篩檢服務計畫之經濟評估
21
Funding
22
The amendment of Tobacco Hazards
Prevention Act in 2009 doubled the tobacco
surcharge (from 0.33 USD to 0.66 USD);
Allocated 6％ of tobacco surcharge (≒66
million USD/yr) to pay for cancer screening
National goals of cancer screening
2013
Target pop.
Tests and
intervals
Screening
rate, 2009
cervix
F, 30-69 y/o
Pap smear or
HPV testing,
Every 3 yrs
58%
breast
F, 45-69 y/o
site
Mammography,
Ever, 11%
Every 2 yrs
Regular
Ever
screenscreened
ing rate
70%
-
30%
55%
Colorectum
50-69 y/o
iFOBT,
Every 2 yrs
Ever, 10%
50%
70%
Oral cavity
Smokers or
betel-quid
chewers,
≧30 y/o
Oral mucisa
inspection,
Every 2 yrs
Ever, 28%
50%
70%
23
Number of Cancer Screening Services, 1995-2013
600
（× 10,000 people）
）
iFOBT
Mammography
500
Oral examination
400
Targets of screening
The new plan expected to
achive a growth of 1.4 folds
in volume between 2009 and
2010
4.12million
Pap smear
3.01million
300
200
100
0
1
9
9
5
24
1
9
9
6
1
9
9
7
1
9
9
8
1
9
9
9
2
0
0
0
2
0
0
1
2
0
0
2
2
0
0
3
2
0
0
4
2
0
0
5
2
0
0
6
2
0
0
7
2
0
0
8
2
0
0
9
2
0
1
0
2
0
1
1
2
0
1
2
2
0
1
3
New National Cancer Screening Program
Full coverage of screening for 4 major cancers with
no co-pay since 2010.
Build infrastructure for the new screenings:
Multi-channel devivery system:
25
certification of facilities and labs,
training of personnel,
setting standards of procedures, cutoffs, interpretation
and follw-up.
Quality control of screening performances
All clinical settings such as hosptals, clinics and health
centers, by qualified personnnel and equipments.
Outreached community services in workplaces and
community venues by qualified public health team or
clinical team.
Mailed screening at home: HPV screening, iFOBT
Delivery system: how to increase clinical
and community screening capacity?
Extra budget without extra public health workers.
Extra budget without extra primary care clinics.
An estimate of 60-70% of the target population for
cancer screening had at least one encounter with
hospital(s) in 2008. Re-orientation of hospital
practice may significantly increase the national
screening capacity.
=> Mobilize clinical capacity of hospitals to deliver
more screening services in partnership with public
health sector.
26
Transforming hospital practice to
increase national screening capacity
1.
2.
3.
4.
27
We established a module of transformed hospital
practices with extra personnel, new IT function for
automatic reminding and tracking of results, total
mobilization of providers and patients, and selfmonitoring and analysis of cancer screening
performance;
We offered project-based subsidy for hospitals to
implement the new module;
We implemented external audit, monitoring,
feedback and public reporting on hospital
performances; and
We provide extra payment for good performance in
addition to fee-for-services and project-based
subsidy.
The module of transformed hospital
practices is based on WHO HPH model
28
Management policy supporting organized
screening
Systematic patient assessment on their needs
of health promotion and screening
Providing information and preventive
services
Continuity and cooperation for cancer
screening, Dx and treatmennt
Creating healthy workplaces
Participation Rate
to the hospital cancer control initiative
Characters
All
Outpatient volume, 30+,
persons
29
No. of all
hospitals
No. subsidized
% of all
512
232
45.3
8,163,823
7,469,898
91.5
Training for hospital leaders and
project coordinators
30
30
IT and cancer screening
Automatic reminding in hopsital
information system
Automatic notification of critical test
results to providers and patients
31
Information and education for
patients and visitors
32
Outreach services in
communities
Cancer screening as part of the
community comprehensive
screening for aults
33
Adoption of strategies
Strategy
Reminding system at OPD
Protected time for
screening in OPD
Health education activities in
hospitals
Screening services in communities
Health education activities in
communities
Attendance to training activity
Adoption, Yes (%)
229 (98.7)
224 (96.6)
232 (100)
221 (95.3)
222 (95.7)
218 (94.0)
A total of 1,358 extra F.T.E.s were appointed for
coordination of cancer control in these hospital projetcs.
34
Mass media promotion of good
practices
35