Catalonia WHO Demonstration Project on Palliative Care Implementation 1990-1995: results in 1995.

A global, comprehensive, publicly planned and financed program to implement palliative care was designed by the Department of Health of Catalonia (6 million inhabitants. Planned in collaboration with the cancer unit of the WHO in 1989, the program was implemented in 1990-1995. It included specific services, measures general resources, education and training, organizational and educational standards, opioid availability, legislation and evaluation. The aims included coverage for cancer, AIDS, geriatric and other conditions, equity, quality, reference, and satisfaction for patients, families, and professionals. The results in 1995 include the implementation of 18 hospital support teams and 19 Units, with a total of 350 beds, 42 home-care teams. The coverage for cancer and AIDS is around 40%, and 44/55 (80%) districts have a specific team. Palliative care implementation has been completely publicly financed, with a total yearly investment of 2,200 million ptas. Eighty percent of this has been saved through radical changes in costs and the pattern of the use of resources. Palliative care implementation has demonstrated efficacy in the care of the patients and families, efficiency in the provision of care, and cost-benefit in the regional global approach. It adds qualitative and organizational values to the health-care system. Its implementation must be prioritized and planned by the health administration, not only to improve the quality of care for advanced and terminal patients, but also to improve the global efficiency and appropriate use of resources in the public health system.

Opioid availability in Latin America: the Declaration of Florianópolis.

This declaration was formulated by consensus of the various government agencies and other organizations involved. It is hoped that it will be widely circulated.

Opioid availability in Latin America: the declaration of Florianopolis.

Between March 27 and 29, 1994, a group of representatives of 32 palliative care programs from eight Latin American countries met under the auspices of the World Health Organization (WHO) Palliative Care Program for Latin America in Florianopolis, Brazil. The participants included physicians, nurses, psychologists, volunteers, drug regulators, hospital administrators, and representatives from the pharmaceutical industry. A comprehensive report by David Joranson (University of Wisconsin-Madison) was followed by a general discussion moderated by Jan Stjernsward, Chief of the Cancer Unit, World Health Organization, and by Eduardo Bruera, Coordinator of the WHO Cancer Pain and Palliative Care Program for Latin America. A number of issues related to opioid availability were identified and discussed. This declaration summarizes the main conclusions of the meeting. The attendants would like to encourage the widest possible distribution of this document.

Design and compliance of HBV vaccination trial on newborns to prevent hepatocellular carcinoma and 5-year results of its pilot study.

A large-scale, controlled study of universal immunization of newborns against HBV infection has been conducted in the high incidence area of hepatocellular carcinoma, Qidong County of China. This area has a stable population, standardized cancer registration system, and an epidemiological base for measurements of liver cancer prevention by vaccine. Randomization was done on the community level. The vaccination and the control group each will consist of 38,000 children by the end of 1990. It is anticipated that the design will provide high statistical power to detect 50% reduction in the prevalence rate of chronic hepatitis among the vaccinees vs. the controls at 6 to 10 years of age, and 50% reduction in the incidence rate of hepatocellular carcinoma at 35 to 40 years of age. The vaccine used is Hep-B Vax, donated by Merck and Co. through WHO. The vaccine was administered at 0, 1, and 6 months after birth, the dosage of 5 or 2.5 micrograms in the pilot study as used before 1985 and of 5 micrograms dose level during the main study starting from January 1, 1985. About 85% of the cohorts have now entered the protocol. The vaccination coverage during 1984 to 1989 was 98.0% (35,064/35,789). Follow-up of the vaccinees and the age-matched controls at 5 years has exceeded 97%. The cumulative mortality in the vaccinated group up to 1988 was 1.29% (354/27,450). No single death nor serious adverse reaction was found that was associated with vaccination. The use of HBV vaccine at a reduced dose was especially important for the developing countries at the present time in order to achieve widespread immunization. Five-year results of the pilot study of this vaccination project showed that significant protection against HBV infection was achieved with the 5 or 2.5 micrograms per dose regimen plus a booster of 5 micrograms given at 3.5 to 4 years of age.(ABSTRACT TRUNCATED AT 250 WORDS)

Supporting cancer care in the developing countries: role of IAEA/WHO.

Cancer management can be expensive and constitutes a major problem in many developing countries where management standards are poor due to many factors, including non-availability of sufficient funds, equipment, and trained personnel. The incidence of cancer is rising worldwide. This is more so in the developing countries, many of whom are less equipped to deal with the problems. Radiation therapy is one of the major treatment modalities for cancer, and it is estimated that about 60% of all cancer patients require this treatment at one time or another during the course of their disease. Unfortunately, radiotherapy facilities are lacking or grossly inadequate in many developing countries. Over the past 8 years the IAEA and WHO have shown more interest in the problem and treatment of cancer in the developing countries. This paper reviews the role of these international organizations, with emphasis on research activities, education (seminars, workshops, training courses), and technical assistance programs. These include establishment or upgrading of radiotherapy facilities, provision of experts, etc. Scientific papers are published with a view to disseminating current information and research findings in the developing countries. The achievements up to date are assessed and discussed.

An overview of the situation in radiotherapy with emphasis on the developing countries.

Radiotherapy services are closely linked to the level of medical care which, in turn, is an important component of the overall health care program, with its development related to social, economic, and educational factors. As a basis for understanding the situation regarding adequate coverage of the population by radiotherapy services, general information about the world population (currently 5 billion), age distribution, frequency of cancer occurrence, and causes of death is presented. For an appreciation of the obstacles that must be overcome, the situation with regard to Gross National Product (GNP), transfer of economic resources, and per capita expenditures for health services is shown. For example, in the developing world, most countries spend less than 5% of their GNP for health, and on a macro scale at least 20 billion U.S. dollars per year are being transferred from the poor nations of the southern hemisphere to the northern hemisphere. Information about the wide range of population coverage with radiotherapy resources and the trend regarding high-energy radiotherapy machines is presented. For example, in North America (USA) there are six high-energy machines for each one million persons, and each machine is used to treat about 230 new patients per year. In other parts of the world, such as large areas of Africa and South-East Asia, there may only be one high-energy radiotherapy machine for 20 to 40 million people, and one machine may be used to treat more than 600 new patients per year. Many cancer patients have no access to radiotherapy services. When estimates of the need for radiotherapy services in the developing world as a consequence of cancer incidence are compared with the current health expenditures, it is concluded that a combined effort of national authorities, donor and financial institutions, professional and scientific societies, and international organizations is required. The knowledge, skills, and technology are available in many excellent radiotherapy centers throughout the world. The key issues are priority and the commitment of sufficient resources.

National training of radiotherapists in Sri Lanka and Zimbabwe: priorities and strategies for cancer control in developing countries.

The development of therapy resources should not be done in isolation of other cancer control activities. The right priorities and strategies must be determined in a systematic way, preferably through well-conceived national cancer control programs. If this is not done, it is unlikely that the therapy efforts will have any impact on cancer in the developing countries, as most cancers are incurable when seen for therapy. Therapy efforts must be linked with the search for earlier referral and diagnosis of cancer patients. However even limited resources may have an effect on controlling cancer, provided that the right priorities and strategies are followed. National and regional training facilities with a suitably adapted syllabus in radiotherapy and oncology must be a part of these priorities and strategies. The World Health Organization (WHO) has initiated, in close collaboration with the National Governments, national and regional training courses in radiotherapy and oncology in Sri Lanka and Zimbabwe.

The control of breast cancer. A World Health Organization perspective.

The greatest decrease in breast cancer mortality is likely to derive from applying globally existing therapies at an earlier stage. A high priority of the World Health Organization (WHO) cancer control program is the outreach approach that promotes worldwide access to cancer therapies of proven values. Therefore, the first priority in national health programs for breast cancer is to encourage patients to present for diagnosis and treatment at an earlier stage of the disease. In the development of guidelines for the early detection of breast cancer, the WHO emphasizes the importance of appropriate widespread coverage of high-risk groups as opposed to repetitive screening of low-risk groups, so that early detection will be effective. A WHO/USSR controlled trial of breast self-examination and community-based adjuvant therapy is helping to develop the WHO global recommendations for the control of breast cancer. Depending on the extent of the breast cancer problem, the local resources, and the cultural situation, national health strategies should include all three main elements--public education, early detection, locally available treatment, or a combination of these to a national comprehensive program for the control of breast cancer.

Compliance following referral in the early detection of oral cancer and precancer in Sri Lanka.

An innovative approach for the early detection of oral cancer and precancer within the context of the primary health care system has been field tested in Sri Lanka. The overall compliance in accepting this particular PHC approach for cancer screening, as estimated by arrival at a referral centre manned by consultant staff, was 54.1%. Nearly 80% of those who turned up without needing an additional reminder, did so within the first 2 weeks of case finding. There was a variation in the degree of compliance depending on the primary health care worker who did the screening and referral. Compliance was greater when the screening area was nearer to the referral centre and in subjects who were diagnosed as having a more advanced stage of the disease. Certain practical considerations that contributed to noncompliance were identified. Postal reminders were seen to increase overall compliance by 10.9%.

Cancers of the stomach, lung and breast: mortality trends and control strategies.

Mortality trends for the three most common tumours--stomach, lung and breast cancer--were evaluated for nine countries. Stomach cancer is decreasing sharply and consistently in the countries studied. However, virtually all of this decline can be attributed to improvements in food preservation techniques and the resulting change in diet, rather than any action of the medical community. Lung cancer is rapidly increasing in most countries, especially in women, and is likely to become the dominant cancer worldwide by the end of this century. So far, only comprehensive tobacco-control programmes in the United Kingdom and Finland have succeeded in reversing the upward trend in lung-cancer mortality. Breast-cancer death rates are generally rising, although some recent, but probably short-term, declines have been seen. Effectiveness of the currently available approaches for each of the common cancers is summarized in Table 1. Because about half of worldwide mortality from cancer occurs in developing countries and resources in these countries are severely limited, care needs to be taken in the selection of proper priorities (18). The most effective tool we have at this time to deal with these tumours is the control of tobacco for the prevention of lung cancer. Comprehensive national programmes, consisting of legislative and education measures, are needed. The greatest decrease in breast-cancer mortality is likely to be the result of early detection and prompt treatment of the disease; public awareness of the value of early detection is an important factor here. Fortunately, mortality from stomach cancer is decreasing on its own, as little can be done to control this disease otherwise.(ABSTRACT TRUNCATED AT 250 WORDS)

WHO cancer pain relief programme.

Cancer pain relief is a ubiquitous but neglected public health problem. Every day more than three and a half million people suffer from cancer pain, but only a fraction receive treatment for it. Relatively simple and inexpensive methods of pain relief are available. Adequate pain relief is not reaching a great number of cancer patients in developed countries. In the developing countries, where more than half the world's cancer patients are and where most are incurable at the time of diagnosis, pain relief (often the only relevant human alternative) by and large is not offered. Obstacles to effective cancer pain relief worldwide include poor drug availability, misguided national drug legislation, lack of education of doctors and nurses, underprescribing and underdosing by the professionals, wrong timing of drugs given, fear of addiction and lack of public awareness that pain can be controlled. A World Health Organization (WHO) method has been developed which provides for drugs to be administered immediately if there is pain, to be given 'by the clock' rather than 'on demand' and to be increased from non-opioids (aspirin or paracetamol) to weak opioids (codeine) and then to strong opioids (morphine) until the patient is free from pain--hence the concept of a three-step ladder for cancer pain relief. Field tests have shown that the right drug in the right dose at the right time relieves 80 to 90% of pain. Thus a scientifically valid, relatively inexpensive method suitable for reaching patients at community level does exist.