engleski

How to prevent and detect cancer early?: draft national program

Cancer is the second major cause of death in Croatia, killing almost every forth inhabitant. Both cancer incidence and cancer mortality are on the increase. The number of newly diagnosed patients increased by 62.5% (from 12, 071 to 19, 616) between 1978 and 2002, while the number of deaths increased by 55.3% (from 7, 965 to 12, 373) between 1978 and 2003. The most prevalent sites for cancer in men, with the exception of the oldest population, are lung and colon. In the group aged 75 and over, the most common is cancer of the prostate. In women, the most prevalent cancer site in all age groups is breast, with the exception of the oldest group in which major forms of cancer are breast and colon cancer. In younger groups, aged 30-44 years, cancer of the uterine cervix is equally common. If the current incidence trends continue, almost one half of male and about one third of female population in Croatia will develop some form of cancer during his or her life. The Croatian cancer mortality rates are higher than those in the in EU, Europe and the countries that have been implementing cancer prevention and early detection measures for years. Prevention and early detection of cancer are beyond doubt the most successful tools in the battle against this malignant disease. We do not know how to prevent certain forms of cancer, so we have to rely on early detection, which demands efficient tests and valid screening methods. Cancer is preventable, provided the risk factors and environmental changes are dealt with, particularly smoking (as shown by examples of some developed countries), adequate nutrition, moderate consumption of alcohol, changes in sexual behaviour and reduced exposure to cancer-causing substances in the environment. Scientific research studies reveal that one third of cases might be prevented, primarily by stopping smoking and making changes in unhealthy diet. Early detection may save lives and minimize patient suffering. Introduction of a cancer prevention and early detection program, and permanent quality control of its implementation, should be pursued on a national level and, based on the importance of certain cancer sites and available resources, initiated on a regional level, in counties, which has already become practice in some parts of Croatia. It should be noted that the global experience with the implementation of national programs for prevention and early detection of cervical, breast and colon cancer is very good indicating that the program for prevention and early detection is the most successful and, in the long term, the least costly method for fighting cancer, since it prolongs survival, reduces mortality rates and improves quality of life. Routine screening of prostate cancer is not carried out in most countries although testing for early detection of this malignant tumor, the major form of cancer in men, is rather simple. The objectives of the prevention and early detection of cancer proposed in this program prepared by the Croatian Oncology Society are: to use promotional actions and health awareness to decrease prevalence of risk factors among population, to reduce total cancer-related mortality rates in Croatia by 15% within five years from the program start, to increase percentage of diagnosed pre-clinical and localised cancers compared to percentage of advanced stage disease cases and thus reduce costs of expensive treatment and improve patient’ s quality of life, and to increase early detection coverage by including particular risk groups. To achieve these objectives, the following is proposed: a) Implementation of general preventive measures, including education of general population for cancer prevention starting from the school age, for early recognition of malignant disease signs and need to contact a doctor. The European Code Against Cancer should be implemented: 1. Do not smoke. Smokers, stop as quickly as possible and do not smoke in the presence of others. 2. Avoid becoming overweight. 3. Increase daily physical activity. 4. Increase your daily intake of vegetables and fresh fruits - eat minimum five times a day ; limit intake of animal fats. 5. Avoid excessive exposure to the sun and avoid sunburn especially in children and adolescents. Those who show tendency to sunburns should take active preventive measures during their entire life. 6. Apply strictly regulations aimed at preventing any exposure to known cancer-causing substances. Follow all health and safety instructions on substances which might cause cancer. In health care sector, general preventive measures should include disseminating printed materials by school medical teams, family doctors, and elected gynaecologists. Large contribution is expected from educational institutions, media, Croatian League Against Cancer, and non-governmental organisations. b) Informing general population about cancer risk factors, particularly about the major cancer sites, and about methods for protection against sexually transmitted diseases, which is a task of primary medical protection teams offering individual advise, distributing printed matter and using modern technology. c) Extensive care for persons exposed to increased risk, which includes keeping records of such persons in primary health care, and taking preventive health care measures for persons exposed to increased risk (medical checks, counseling, health awareness, learning about protection and self-protection skills), monitoring of social, family, professional and other risks, implementation of planned preventive actions, proposing necessary measures. Health visitors may also be involved in such activities. d) Use modern communication technologies to inform general population of self-examination and early detection of particular cancer seats and need for regular medical checks, which should be carried out by primary medical care teams, educational institutions, Croatian League Against Cancer, and non-governmental organisations. e) Education of medical staff, particularly in primary health care, for cancer control through organisation of congresses and symposia, and license renewal examinations performed by professional societies and Croatian Medical Association. f) Setting up units for health promotion and prevention of chronic mass diseases within the public health institutes which are to co-ordinate activities in the counties. g) Implementation and monitoring of the prevention program. The Croatian Public Health Institute collects data, monitors program implementation, and prepares documents for the Health Ministry Commission which proposes necessary actions and preventive measures to the Minister. Early detection by screening should be entrusted to the Centres for program implementation. Organisation of invitations, monitoring and evaluation should be based on the following guidelines: a) Each county should select screening centre(s). Family doctors should refer their patients to screening, and the program should be implemented in collaboration and co-ordination with county public health institutes, health centres, and all units conducting specific screening in a county. All data are to be forwarded to the central register kept by the Croatian Public Health Institute. Breast We do not know how to prevent breast cancer, so its early detection is particularly important. Over 90% of female breast cancer patients can be cured if the disease is diagnosed in an early stage and adequately treated. Mammography, as a recommended screening method, can detect the breast cancer two years before the tumor is large enough to be palpable. The data show reduction in breast cancer mortality in women included in the screening programs. In most countries, screening includes women aged 50-69, although some start with screening at the age of 40. Early breast cancer detection program is aimed at reducing breast cancer mortality by 25% within five years from the program start, and increase percentage of breast cancer detected in initial stage, which will reduce costs of very expensive disease treatment in advanced stage. Target group are women aged 50-69, screened once in two years (minimum recommended by EU), which is 280, 000 women assuming an optimum coverage of 80%. However, screening of women aged 40 and over once a year would be ideal. Screening for breast cancer includes high-quality mammography, clinical examination between screenings and examination of women not participating in the program (done in primary health care/by family doctors). Breast self-examination (BSE) for women aged 20 and over is not promoted, only recommendations are given on its benefits, limitations and restrictions, and the women should decide for themselves whether to do it. Clinical examination of breasts should be a part of periodical medical checks made every three years for women aged up to 40, and every year after that. Women should be made aware that they need to see their doctor whenever they notice any change of their breast. The mammography is expected to reveal 4% of positive patients, which is about 11, 000 women for further examination in a county centre for breast cancer diagnostics and therapy. Croatia has 24 such centres (all county hospitals and four hospitals in Zagreb) and a number of private clinics that perform complete diagnostics and breast tumor surgeries. Uterine cervix Early detection of cervical cancer is part of primary health care program for women, and its implementation has been opportunistic - conventional cervical cytology (smear) has been performed annually on all sexually active women. Such approach resulted in a significant decrease in invasive cervical cancer incidence during the last three decades. However, mortality rates remained unchanged. Cervical cancer is curable if detected in time. Long-term objectives of the national program for early detection include: reduction in invasive cervical cancer incidence by 60% in group from 25 to 64 years of age within nine years from the program onset, and reduction in invasive cervical cancer mortality by 80% in group from 25 to 70 years of age within 13 years from the program launching. Annual invitations, conventional Papanicolau (Pap) testing, and keeping records of test results for women aged 25-64, with minimum coverage of 85%. In the fifth year from the program start, liquid cytology and HPV test would be used for women aged 31-64 every five years. Testing would be continued of women aged 25-30 with conventional or liquid cytology every three years. 85% of women are expected to respond to the screening invitation (about 340, 000 a year), and 2.5% are expected to have cervical lesions which progress to cancer (about 8, 500 a year). Further steps are defined by diagnostic/therapeutic procedure for premalignant cervical changes. Colon Between 1983 and 2002, the number of new cases of cancers of the colon increased from 1, 196 to 2, 663 (125%), and number of deaths from 840 to 1, 558 (85%). Colon cancer incidence increases rapidly for the group aged 60 years and older (78.3%), and for 7.9% in the group age up to 50. Early detection program aims at reducing colon cancer mortality by 15% five years after the program implementation started, and at achieving 75% coverage of early cancer detection of risk population groups by 2015. Specific goals are to determine incidence and prevalence of cancer of the colon in asymptomatic (healthy) population aged over 50, distribution of risk factors, localisation of tumors, degree of spreading and operability ; introduction of endoscopic treatment of early (limited to mucosa) and premalignant tumourous changes (polyp) ; standardisation of surgical and medicinal treatment, and indications for and methods of radiotherapy ; establishment of a Centre for fighting colon cancer in Croatia (co-ordinating body). Target group involved in the program includes men and women aged 50 and over. Feacal-ocult-blood test (FOBT) is performed once a year or every two years (minimum every three years). Patients with positive feacal-ocult-blood test results should undergo colonoscopy in order to determine the cause of bleeding and possible cancer of the column (bioptic sampling and simultaneous endoscopic therapy - polypectomy, if necessary). Individuals with increased or high risk of colon cancer, should be included in early cancer detection program at younger age. The program should be implemented by family doctors and specialists in gastroenterology - endoscopy nurses. In asymptomatic population, the expected average risk for some 42, 000 respondents is about 3% FOBT positive, which is about 22, 300 persons that need to undergo colonoscopy. Prostate Prostate is one of the three major cancer sites in men. Since research studies performed earlier do not offer sufficient evidence that the known screening methods could contribute significantly to reduction in prostate cancer mortality, early detection is recommended for persons with increased risk and in persons aged 50 and over which have no symptoms but require examination. Health education and media campaigns should result in gradual increase in the number of men requesting examination. Early detection of cancer of the prostate is to be performed systematically on the entire national territory for men aged 40 and over, for those with at least one blood relative (father, grandfather, brothers) that had or has prostate cancer, and for men aged 50 and over with symptoms of prostatism. Prostate cancer tests include digitorectal examination, PSA, and FPSA. Examination should be performed once a year if the screening results were normal. 5-10% of the screened patients is expected to test positive, and they will need additional diagnostic treatment (biopsy). The screening (examination and PSA sampling) should be performed by an urologist (urology department) in a county general hospital. In the City of Zagreb, local responsibility of individual hospitals should be agreed upon. Four regional centers should be organised as consultants for urology departments of county hospitals and in charge of performing biopsies.

prevention and early detection of cancer; high-risk population; screening tests

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