Friday, February 24, 2012

Cancer capacity building in Guatemala

As part of our current training program at Washington University in St. Louis in collaboration with Instituto Nacional de Cancerología (National Cancer Institute, INCAN, Guatemala) (funded by Fogarty International Center, NIH: 1R24TW008820-01), we have held our third annual scientific meeting in Guatemal. 1,2 Our pilot program trained Washington University and INCAN participants in research methodology, cultural competency, and research ethics and simultaneously initiated mentoring relationships and collaborations between diverse faculty and trainees from the two institutions. This experience has informed Institute for Public Health discussions and planning for University-wide global health training, which now embraces goals of culturally appropriate preparation for all global health students across the University campuses and a commitment to bi-directional training; the latter involves bringing trainees to Washington University and sending Washington University faculty and trainings to low and middle income countries (LMICs) to help build capacity on the ground. It is one such training that we are completing today with over 300 medical students, residents fellows and practicing physicians and surgeons in attendance.

Underlying the training in research design and methodology for global health interventions is the evidence-based recommendation that knowledge of ethnicity, socioeconomic and other cultural variables is crucial for interventions that seek to communicate benefits of cancer prevention and control such as the risks of tobacco use and the benefits of tobacco control in ways that distinctive populations can understand and use.3,4 Reflecting this vision, our meeting opened Wednesday evening with Prof Peter Benson reviewing issues on culture and cancer as they can directly impact participation in detection treatment and completion of appropriate cancer therapy.

Cancer in Guatemala
In response to the increasingly important role of non-communicable chronic diseases on global human health and development, the United Nations has set non-communicable diseases, or chronic disease prevention and control as a world-wide priority, with a particular emphasis on developing countries.5 These diseases cause more than 36 million deaths (or about 2/3 of all deaths) world-wide, and they profoundly diminish economic and social development.6,7 While the chronic disease pandemic is attributable in part to poverty, it also contributes to poverty by hindering social advancement;8 this is especially the case in low- and middle-income countries, where an estimated 80% of all non-communicable disease deaths occur.6,9

Guatemala is a middle-income country that struggles with one of the highest poverty rates in Latin America.10 Compounding a fight with inequality on multiple levels, Guatemala is currently undergoing an epidemiologic transition; today it faces the “double burden of disease,” or an increase in chronic diseases, while infectious diseases remain a considerable challenge.11 As its population has aged and the prevalence of risk factors such as smoking and a high-fat diet has increased, Guatemala has experienced a shift in balance between infectious agents and chronic diseases as leading causes of death.12  

The World Health Organization (WHO) estimates that 21% of non-communicable disease deaths worldwide are due to cancer, and that cancer incidence is increasing more rapidly in low and middle-income countries than in higher-income countries. Nearly 20% of the world’s cancer burden is attributable to infectious causes (e.g. human papillomavirus, Helicobacter pylori, and hepatitis virus).6  In Guatemala, cancer causes 11% of all deaths, and the estimated 5-year survival probability following diagnosis is less than 2%.13 The Instituto Nacional de Cancerologia (National Cancer Institute, INCAN) serves as the primary referral site for cancer diagnosis and treatment in Guatemala.  It is also the primary source for the country’s cancer data.  However, as noted by the WHO and its International Agency for Research on Cancer (IARC), cancer data are often unreliable in low-resource countries.6,14 Guatemala’s data collection system is outdated and relies on paper records that may be incomplete and unverifiable.  Yet in the absence of a national surveillance system and/or registry, INCAN’s data provide some useful insights into cancer trends and survival.

Table 1: Leading  cancer diagnoses in Guatemala by gender, 2005
Male Site (%)
Female site (%)
Stomach (10.4%)
Cervical (39%)
Prostate (10.4%)
Breast (14.7%)
Testicular (6.6%)
Ovarian (3.0%)
Non-Hodgkin lymphoma (5.7%)
Endometrial (2.9%)
Colon (3.8%)
Stomach (2.8%)
Source: National Cancer Registry, INCAN
 In 2005 (the year for which most recent data are available) INCAN saw 5,858 new patients, 42% of whom had a malignant neoplasm.  Cervical cancer was the most frequent invasive cancer diagnosed in women, followed by breast and ovarian cancers (Table 1).  In men, stomach, prostate, and testicular cancers were the most frequent diagnoses.  However, these data should be interpreted with caution, since cancer patients may seek care in other parts of the country’s healthcare system, and some cancers are never diagnosed. Thus, INCAN’s data may not be generalizable to all of Guatemala.

Although funding to address non-communicable diseases has traditionally been overlooked by governmental and non-governmental agencies in low and middle-income countries, growing attention by the United Nations and the WHO has motivated some countries to more formally examine this health burden.1

Regardless of the limitations of Guatemala’s cancer data, it is clear that the leading cancers among men (stomach) and women (cervix) have known infectious causes and that death from several of the most important cancers (cervical, testicular, breast) can be decreased by proven, cost-effective strategies for earlier detection and/or treatment. Cervical cancer is a disease where an immediate impact can be made.  Worldwide, most cases (86%) and deaths (88%) occur in developing countries.16 Guatemala’s cervical cancer incidence and mortality are among the highest in the Americas, ranking 10th out of 33 countries.16  Furthermore, cervical cancer occurs at a relatively young age in Guatemala and results in proportionally more life-years lost compared to other major cancers.17  In wealthier countries, effective screening programs have led to substantial declines in cervical cancer incidence and mortality.18,19  Cytological testing (Pap testing) has been the mainstay of cervical cancer screening in wealthier countries, but in low-resource settings screening for high risk strains of human papilloma virus (HPV) by DNA testing or visual inspection of the cervix with acetic acid (VIA) may be more practical and cost-effective.20  Following screening, effective treatment must also be available to prevent disease progression and mortality.20  Unfortunately Guatemala is far from implementing a comprehensive cervical cancer control program.  For example, an estimated 49% of women have never had a pelvic exam, and only 40% are considered to have effective screening coverage.21  There is thus a critical need to design, implement and evaluate cervical cancer control programs in Guatemala.  
Stomach cancer is the leading cancer diagnosed among men and the fifth most common among women in Guatemala (Table 1). In many industrialized countries stomach cancer incidence has decreased dramatically in the past 70 years.22  Several factors may have contributed to the decrease, but the decline in prevalence of chronic Helicobacter pylori infection is plausibly the most important explanation.22 In fact, Peleteiro et al argue that H. pylori is the necessary cause and that the induction period is substantially longer than first assumed. 23  As with cervical cancer, most (70%) new gastric cancer cases and deaths now occur in LMICs.24  Guatemala again lacks a comprehensive evidence-based stomach cancer control strategy.  Screening is of unproven benefit and would likely be unfeasible given the limited resources available in Guatemala, so approaches such as H. pylori screening and eradication are worth considering. 23 25

Tobacco use is the most important chronic disease risk factor worldwide,26 and Guatemala ratified the WHO Framework Convention on Tobacco Control (FCTC) in November 2005 to address the tobacco epidemic. Nevertheless, Guatemala’s National Institute of Statistics does not systematically collect data on prevalence of and trends in tobacco use.  Historically speaking, Guatemala has perhaps the oldest tradition of tobacco use.  The ancient Maya occupied most of present-day Guatemala from the third until the tenth centuries A.D., and tobacco was a key element of folklore and ritual in their culture.27  Many components of traditional Mayan culture have persisted across much of rural Guatemala, including languages, religious practices, kinship, clothing, and ritual life, yet there has been surprisingly little research on tobacco use and beliefs about tobacco within Guatemala.  This is especially relevant given that Mayan culture has traditionally regarded tobacco as having special healing and medicinal uses.27 What remains of these cultural factors and what has changed with the acculturation of the Maya to the Ladino (Mestizo) culture and the global expansion of Western-style cigarettes are yet to be determined.  Research into this topic can contribute to a growing literature on cultural factors and tobacco use prevalence and trends.3,4 Tobacco control and prevention are feasible in the Guatemalan context if culturally-relevant evidence-based policies and community interventions are developed and implemented. 

Our recent short course in Guatemala.
Our collaborative approach with INCAN aims to build capacity in Guatemala through in-country short courses and also train a cadre of chronic disease prevention and control scientists from Guatemala and global scholars from Washington University in St Louis. By conducting short courses open to the broader public health and academic community in Guatemala we reinforce bi-directional training and further expand the impact of the program. Bidirectional training, cultural competency and grounding in implementation sciences for resource scarce settings will underpin this program.

In 2010 Drs. Barnoya, Colditz, and Greenberg collaborated to provide a short course on canner prevention and control at INCAN. Subsequently, in 2011 with funding from Fogarty International Center, NIH, a week long program at INCAN focused on building research capacity. Attendees included trainees in our capacity building program from faculty members at INCAN and faculty from Washington University and the SWOG biostatistical coordinating center. Each morning a presentation was attended by 50 or more staff at INCAN. Topics included epidemiology and prevention of cancer; design of clinical trials; culture and its potential impact on cancer care in Guatemala.
In 2012, our training expanded again to bring a focused program on breast cancer that could highlight research design methods and implementation issues in the context of cancer care in Guatemala. The 2012 breast cancer short course included topics from culture and cancer to the growing global burden of cancer; prevention and treatment strategies, grounded in several presentations on biology of premalignant breast lesions and biologic markers and their implications for treatment and survival outcomes after breast cancer. Surgical approaches to breast cancer and therapeutic strategies with new agents and neoadjuvant approaches. 8 faculty members from the breast program at Siteman Cancer Center and Washington University in St Louis spent 2 days in presentations and group meetings to share experience relevant to improving care across the continuum in Guatemala.

Related links

Literature cited

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3.         Kohrman M, Benson P. Tobacco. Annual Review of Anthropology. 2011.
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5.         United Nations General Assembly. Prevention and control of non-communicable diseases.  Report of the Secretary-General. New York: United Nations,;2011.
6.         World Health Organization. Global status report on noncommunicable diseases, 2010. Geneva, Switzerland: WHO;2011.
7.         Beaglehole R, Bonita R, Alleyne G, et al. UN High-Level Meeting on Non-Communicable Diseases: addressing four questions. Lancet. Jul 30 2011;378(9789):449-455.
8.         Geneau R, Stuckler D, Stachenko S, et al. Raising the priority of preventing chronic diseases: a political process. Lancet. Nov 13 2010;376(9753):1689-1698.
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18.         US Center for Disease Control and Prevention. National Breast and Cervical Cancer Early Detection Program (NBCCEDP). 2011; Accessed November 17, 2011.
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26.         Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Correction: Actual Causes of Death in the United States, 2000. JAMA: The Journal of the American Medical Association. January 19, 2005 2005;293(3):293-294.
27.         Robicsek F. The Smoking Gods.  Tobacco in Maya Art, History, and Religion. Oklahoma: University of Oklahoma; 1978.