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e-session 340
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Tropical haemato-oncology: what’s specific?
Expert: Dr Jean-Pierre Droz, Centre Leon-Berard, Lyon, France
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Discussant: Dr Jerome Fayette, Centre Leon-Berard, Lyon, France
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Tropical Hemato-Oncology:
what’s specific?
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Jean-Pierre Droz, MD, PhD.
Emeritus Professor of Medical Oncology, Claude-Bernard-Lyon1
University.
Consultant, Centre Leon-Bérard. Lyon, France &
French Guiana Oncology Network, French Guiana
Discussant: Jérôme Fayette, MD, PhD
Department of Medical Oncology, Centre Léon-Bérard, Lyon, France
Consultant at the Cayenne General Hospital, French Guiana
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e-grandround 25 february 2016
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Objectives
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Geography of Tropical Areas
Cancer Epidemiology in Tropical Areas
Cancer etiology in Tropical Areas
Cancer management in Tropical Areas
Global Oncology
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• Geography of Tropical Areas
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Objectives
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Cancer Epidemiology in Tropical Areas
Cancer etiology in Tropical Areas
Cancer management in Tropical Areas
Global Oncology
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Tropical areas
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http://www.uri.edu/artsci/ecn/mead/China/Geography.htm
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Tropical areas are different
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commons.wikimedia.org
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Wealth per capita Gross Domestic Product is low
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theguardian.com
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en.wikipedia.org
fr.wikipedia.org
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World population (by countries) is mainly
concentrated in the tropical areas
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http://www.viewsoftheworld.net
Health expenditure is in the northern and
western area
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http://www.viewsoftheworld.net
Populations living with HIV are
concentrated in the tropical areas
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http://www.viewsoftheworld.net
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Pain control is insufficient in tropical areas
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Overall population increase
is located in (tropical) less
developed countries
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Oldest population increase
is located in (tropical) less
developed countries
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imf.org
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Conclusion
• Tropical area are located between the two tropics
• There are different geographical conditions but are
generally frail
• They include a majority of countries with low and
intermediate incomes
• They have been submited to colonization and
complex political evolution
• Populations are various and generally do not fit
with western concepts
• Population (and ageing) is increasing rapidly
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Objectives
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• Geography of Tropical Areas
• Cancer Epidemiology in Tropical
Areas
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• Cancer etiology in Tropical Areas
• Cancer management in Tropical Areas
• Global Oncology
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Incidence and mortality in women in more
and less developed countries
More developed countries
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Less developed countries
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Incidence and mortality in men in more
and less developed countries
More developed countries
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Less developed countries
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Incidence and mortality in the same health care
system (France & French Guiana) in women
Mainland France
French Guiana
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Incidence and mortality in the same health care
system (France & French Guiana) in men
Mainland France
French Guiana
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Conclusion
• There are factors linked to development
• There are factors linked to geography
• But everything interfere together
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– Geography = climate = zoonoses
– Development = zoonoses
– Geography = development
– Development = ressources……
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Objectives
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• Cancer etiology in
Tropical Areas
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• Geography of Tropical Areas
• Cancer Epidemiology in Tropical Areas
• Cancer management in Tropical Areas
• Global Oncology
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Spectrum of AIDS-associated malignant disorders 1
Goedert JJ.; Lancet1998;351:1833-39
Major cancer types with
very high relative Risk (RR):
- Kaposi = RR x 310
- Lymphomas= RR x 113
- Thirty-eight other cancer
types = RR x 1,9
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Spectrum of AIDS-associated malignant disorders 1
Goedert JJ.; Lancet1998;351:1833-39
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RR is increased (it is linked to the
intensity of the immunodepression)
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-Angiosarcoma = x 36,7
-Soft tissue sarcoma = x 7,2
-Hodgkin’s Disease = x 7,6
-Multiple Myéloma = x 4,5
-Central Nervous System tumors = x 3,5
-Séminoma = x 2,9
-Anal cancer = x 31,7
-Cervix in situ = 1,7
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Importance of epidemiologic transition
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Conclusion
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• The importance of infectious carcinogenesis is
more important than in western countries
• The agents are viral, parasitic, mycotic,
bacterian
• Carcinogenesis is favored by virus induced
immunodepression (HIV and at a less degree
HTLV1
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Objectives
• Geography of Tropical Areas
• Cancer Epidemiology in Tropical Areas
• Cancer etiology Tropical Areas
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• Cancer management
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Tropical Areas
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• Global Oncology
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What occurs (personal cases)
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(Patients gave oral consent for photo)
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Interventions that are highly effective, cost-effective,
and “resource-level appropriate”
• Prevention:
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– Tobacco control
– Vaccination against HBV
– Vaccination HPV
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• Screening: cervix “direct visualization &
cryotherapy” (one shot) or HPV detection /
treatment (two shots)
• Early diagnosis: it allows a curative treatment
“adapted to resources”
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Model: Breast Health Global Initiative (BHGI)
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Key decisions
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• To have decision trees for global management which are
adapted to resources; for all cancers types; but which have
a significant impact on outcome
• To use the BHGI model for curative treatment of breast,
cervix, colo-rectal, head/neck cancers and some cancers in
childhood
• Promote joint ventures between oncologists of the
northern and southern countries to develop decision trees
with grants from various institutions
• To initiate “Centers of Excellence”:
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– There are different organizational solutions
– Having the main objective of efficiency and equity
– Being the reference teaching center in the country
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Therapeutic tools
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• Surgery remains the best curative choice
– A mastectomy is curative; a lumpectomy without
radiotherapy is not curative
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• Radiotherapy is the most active and cheaper
palliative treatment
– Material and technical choices must be adapted but
quality-insurance and formation should never been
neglected
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• Palliative management is very important (late
diagnosis)
– Use of opioids is insufficient (law, sociological aspects,
education)
– Palliative care program should be implemented in the
population
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Public health policy requires a good
knowledge of the facts
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• WHO and IARC: knowledge of incidence, mortality and
some characteristics
• Knowledges of the risks: WHO STEPS program
• Knowledge of death causes: interest of “verbal autopsy”
• Cancer registry
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Conclusion: key words are knowledge and research
Joint venture North-South
Knowledge dissemination through “Centers of
Excellence”
Pragmatism, efficiency, cost/effectiveness, equity
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Access to expansive treatments : it is an
ethical problem
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• A treatment is expansive if it overcomes 50% of
GDP per capita per year
• This is always the case
• Only one solution: definition of limits and
rationalization which need to be managed by a
respected committee of professionals
• Limits: corruption
• This is a question of ethics and equity
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Aknowledgments: Prof. Twalib A. Ngoma – Head Department of Clinical Oncology
Muhimbili University of Health and Allied Sciences Tanzania, INCTR Président ,
Ideas from the chapter: “Cancer control in the tropics”; in JP Droz et al, Tropical
Hemato-Oncology, Springer 2015
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Objectives
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Geography of Tropical Areas
Cancer Epidemiology in Tropical Areas
Cancer etiology Tropical Areas
Cancer management in Tropical Areas
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• Global Oncology
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The concept of “Cancer Control”
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• Every action is aimed to reduce cancer impact:
– Prevention
– Screening
– Early diagnosis
– Diagnosis
– Treatment
– Psychosocial support
– Transcultural mediation
– Palliative care management
• This is done in northern countries but priorities are different
• In southern countries the actors must be diverse (government,
international organization, private initiatives); other actors than
health care professional are involved
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Examples of initiatives
African organization for Research and Training in cancer (AORTIC)
http://www.aortic-africa.org/
Cancer Association of South Africa(CANSA)
http://www.cansa.org.za/
International network for cancer Treatment (INCTR):
www.inctr.org/
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Personal photo
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