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

Listing of World Bank classification of low and middle income economies

8 ways to prevent breast cancer

Literature cited

1.         Arnold L, Benson P, Colditz G, Stamatakis K, Beers C, Barnoya J. Development of an interdisciplinary cancer research training program for Guatemala. American Public Health Association Meeting. Washington, DC2011.

2.         Barnoya J, Kennedy R. Increasing chronic disease research capacity in Guatemala through a fellowship program. American Public Health Association Meeting. Washington, DC2011.

3.         Kohrman M, Benson P. Tobacco. Annual Review of Anthropology. 2011.

4.         Nichter M. Smoking: what does culture have to do with it? Addiction. May 2003;98 Suppl 1:139-145.

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.

9.         World Health Organization. Mortality and burden of disease estimates for WHO Member States in 2008. Geneva, Switzerland2010.

10.         Pan American Health Organization. Health in the Americas. Washington, D.C.: PAHO;2007.

11.         Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization. Circulation. Nov 27 2001;104(22):2746-2753.

12.         Estrada Galindo G. El sistema de salud en Guatemala, 9: Sintesis2008.

13.         Pan American Health Organization. PAHO Plan of Action for Cancer Prevention & Control:  Cancer Stakeholders Meeting.  Fact Sheet. Washington, DC2008.

14.         Curado M, ed Cancer Incidence in Five Countries. Lyon, France: International Agency for Research on Cancer,; 2007. IARC, ed; No. IX.

15.         Anderson GF. Missing in action: international aid agencies in poor countries to fight chronic disease. Health affairs. Jan-Feb 2009;28(1):202-205.

16.         Arbyn M, Castellsague X, de Sanjose S, et al. Worldwide burden of cervical cancer in 2008. Annals of oncology : official journal of the European Society for Medical Oncology / ESMO. Apr 6 2011.

17.         Yang BH, Bray FI, Parkin DM, Sellors JW, Zhang ZF. Cervical cancer as a priority for prevention in different world regions: an evaluation using years of life lost. International journal of cancer. Journal international du cancer. Apr 10 2004;109(3):418-424.

18.         US Center for Disease Control and Prevention. National Breast and Cervical Cancer Early Detection Program (NBCCEDP). 2011; http://www.cdc.gov/cancer/nbccedp/about.htm. Accessed November 17, 2011.

19.         Peto J, Gilham C, Fletcher O, Matthews FE. The cervical cancer epidemic that screening has prevented in the UK. Lancet. Jul 17-23 2004;364(9430):249-256.

20.         Maine D, Hurlburt S, Greeson D. Cervical cancer prevention in the 21st century: cost is not the only issue. American journal of public health. Sep 2011;101(9):1549-1555.

21.         Gakidou E, Nordhagen S, Obermeyer Z. Coverage of cervical cancer screening in 57 countries: low average levels and large inequalities. PLoS medicine. Jun 17 2008;5(6):e132.

22.         Lochhead P, El-Omar EM. Gastric cancer. British medical bulletin. 2008;85:87-100.

23.         Peleteiro B, La Vecchia C, Lunet N. The role of Helicobacter pylori infection in the web of gastric cancer causation. European journal of cancer prevention : the official journal of the European Cancer Prevention Organisation. Aug 22 2011.

24.         Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA: a cancer journal for clinicians. Mar-Apr 2011;61(2):69-90.

25.         Greenberg ER, Anderson GL, Morgan DR, et al. 14-day triple, 5-day concomitant, and 10-day sequential therapies for Helicobacter pylori infection in seven Latin American sites: a randomised trial. Lancet. Aug 6 2011;378(9790):507-514.

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.

Transdisciplinary Energetics and Cancer (TREC)

Obesity and cancer?

Why are we meeting in Philadelphia?

These are question not commonly asked on our CNiC blog. Let me explain a little of our new center on obesity and cancer, and link you to our related resources.

NCI convened the first meeting of funded centers working together on issues relating energy balance, obesity, and cancer. My role at this meeting with Sarah Gehlert, leading our TREC at Washington University in St. Louis was to provide an overview of our Center and the projects we have embarked upon to address obesity and cancer, with a particular focus on translating our findings to the burden of cancer in Missouri. See our web site. 

Our 5-year funding sets us in motion to bring faculty together across our university and with neighbors across our state to move forward counteracting the burden of cancer due to obesity. We have previously written on just how great this is for our nation.(see Obesity and Cancer. Wolin, et al. 2010.) Now we are linked to colleagues in other centers to learn from our collective efforts. 

The quick summary of our center is available through this link. "Transdisciplinary Center Approach to Examine Multilevel and Multigenerational Associations Between Obesity and Cancer". 


Over the coming months we will add updates on progress as we expand our research and translation to practice to address obesity and prevent cancer.

(Video) Eight Ways to Prevent Cancer - Exercise

Next up in the Eight Ways to Prevent Cancer video series: Exercise.

CNiC's Dr. Kate Wolin walks us through the huge benefits we get from exercise, including a lower risk of heart disease and diabetes, on top of the cancer benefits many people may not be aware of. The video also highlights the fantastic progress of a cancer survivor who went from walking just over a 1,000 steps per week, to over 6,000 steps per day - on her way to an ultimate goal of 10,000 per day.

Wolin's quote sums it up best:  "It's never too early to start being active, but it's certainly never too late."

Timing is everything: Renewing the debate on aspirin

This week on the NY Times Well Blog is a discussion of whether the health benefits of aspirin have been oversold (or the health risks underreported). The spark to this renewed discussion is a Cochrane review of the aspirin data. What gets lost in the debate, is how important timing is when considering the health benefits of aspirin use. As we've previously noted here on CNiC, the benefits of aspirin use for colorectal cancer risk reduction and reduction in colorectal cancer mortality really become apparent after a decade or more of use. With a mean follow-up of 6 years, the latest review by Seshasai et al, wouldn't capture the full benefit of regular aspirin use.

Meat: Not for Dinner Tonight

This week was full of news about meat. The week started with news from the Department of Agriculture that US red meat consumption is expected to be lower in 2012 than it was in 2007. Of course, global meat consumption isn't down, which means the US is continuing the trend we started with tobacco of exporting our bad habits abroad. As Mark Bittman noted in his New York Times OpEd, Americans are choosing to eat less meat, not just because of price changes, but because of the negative health and environmental effects of eating red meat.

Which is good news, since the week is ending with more research on the carcinogenic effects of red meat consumption. We've talked a lot on CNiC about how red meat consumption increases risk of colon cancer. This week, a meta-analysis (i.e., a study of studies) in the British Journal of Cancer reports consumption of red and processed meats significantly increase pancreatic cancer risk. They found a 30% increase in pancreatic cancer risk with red meat consumption in men.

This is exactly the kind of science that is the foundation of the 8 ways to prevent cancer. If you want to learn more about your personal risk for pancreatic cancer, head over to Your Disease Risk.

(Video) 8 Ways to Prevent Cancer (and A Bunch of Other Diseases)

As part of our 8 Ways to Prevent Cancer campaign, the Siteman Cancer Center and the Cancer News in Context team produced a series of videos focusing on practical information and useful tips about each "way."

This is the first in the series, featuring CNiC's Dr. Kate Wolin.

Simple tips.  Big benefits.

Confronting the challenges of 2012 with salads and stairs

In Sunday's New York Times, the editors ask prominent economists to weigh in on how to face the economic challenges ahead of us in 2012.  Richard Thaler, of the University of Chicago, who wrote (with Cass Sunstein) Nudge, the best selling book on behavioral economics argues that employers have the opportunity to tackle one of our biggest challenges, health care spending.  Employers are choice architects - they can make changes in how choices are offered that make one choice easier, or the default.  Thaler argues that by making a few changes, employers can improve workers' health, leading to greater productivity, fewer sick days, and lower insurance costs.


First, Thaler argues, make eating at work easier, by prominently featuring a variety of healthy options and putting in an attractive salad bar before the burger line.  How might this look in real life? Let me use the cafeteria at my office as an example.  

There are at least four cafeterias on our hospital/medical school campus and they aren't all run by the same people, so the situation likely looks different on the other side of campus, but this is what it looks like in the cafeteria that sits right under my office and nearest the cancer center.  The first thing you see when you walk in, is the grill/fry-o-later area.  Serving up burgers, hot dogs, fries and onion rings, it invariably has a long line, which makes it easy to miss that there is a sandwich counter immediately to your left.  The sandwich counter is hidden behind a high wall and camouflaged further by shelves of chips and candy, so unlike in many sandwich shops, you can't see the choices.  You can see two featured sandwiches.  Sometimes one is healthy, but not always.  Just past the sandwiches (and around the candy display) is the hot meal counter, which features one Weight Watchers entree each day.  This may reflect my own food preferences, but I rarely find this entree to look very appetizing or particularly healthy (I realize “healthy” can have lots of different meanings, but something high in cheese and refined grains rarely meets my metric).  To the far right of the sandwich bar is the pizza station, which usually features 3-5 types of pizza (most laden with meat) and another cheesy doughy option, like calzone, daily. Across from the sandwich bar is the featured entree special of the day.  The days I've visited in recent memory this has been: nachos loaded with ground beef and processed cheese of the orange variety ( which I confess to finding appealing on Super Bowl Sunday, but I'm not kidding myself about it fitting in the healthy realm and I accept the health consequences of my choice), and beef stir fry laden with sauce of the kind women's magazines regularly tell readers to avoid choosing when dining out, roast beef covered with gravy and accompanied by mashed potatoes. Just past the featured entree is the salad bar. I think most cafeterias these days have a salad bar, but having a salad bar and having an “attractive” salad bar are not the same thing. To their credit, since I started at my office nearly 5 years ago, the cafeteria has added mixed greens and baby spinach as daily options, offering something other than the white-ish iceberg lettuce of the early days. And there are proteins in the salad bar choices - typically hardboiled eggs, one type of canned bean and diced turkey or tuna. But the salad bar is a long way from what I’ve seen else where and a long way from allowing you to create the kind of salad you might get down the street at one of the neighborhood sandwich shops. Dried fruit? Nope. Other kinds of fruit? It is on the other side and is charged at a different rate. Nuts? No, but there are sunflower seeds. Cheese? Yes, there is usually grated orange cheese. I give the cafeteria credit, I can definitely create a greek salad for myself that rivals that fancy sandwich shop on the corner (with the possible exception of the tomatoes that always look a bit iffy) at a fraction of the cost. But it doesn’t look “attractive” and I’ve got to do all the work, which perhaps explains why there is never a line at the salad bar and I am 10 times more likely to see the people in front of and behind me at the checkout with fried chicken than a salad. This, I think, gets to the fundamental point - if you want people to make the healthy choice you have to make it easy and attractive.

What about Thaler’s other suggestions? His second is making exercise easier. The health benefits of exercise, as we have said many times on CNiC, don’t require marathon duration or rigor. Walking is enough. And many employers subsidize gym memberships or arrange discounts, including mine. But you shouldn’t have to leave work to get a little walk in - making stairwells attractive is one way and the suggestion Thaler focuses on. In our conglomerate of old and new buildings, my workplace has lots of unattractive stairwells that are often hard to find. At a previous job, I had the privilege of sitting on a committee that was thinking about how to design a new hospital building and one of the most compelling ideas I heard was to make the stairwells front and center - highly visible and the easiest choice (instead of pushed off into the corner and behind a heavy metal door). One of our newest buildings on campus, which also serves as the home to our outpatient cancer care, has a lovely open stairwell at one end of the building, easily visible from the entrance. I enjoy seeing staff using the stairs and leaving the elevators to our patients, many of whom aren’t well enough to climb the stairs to the upper floors of the building. As we embark on a series of renovations and construction of new facilities as part of the 10 year plan, I look forward to seeing how our leadership makes stair use an easy option. In addition, our campus has launched a series of paths around the area (affectionately called “Tread the Med”) to allow staff and visitors to take walking breaks or have walking meetings (as Thaler plans to do in 2012). We have often used these exact “paths” around campus for our walking interventions during inclement weather and they are a great resource. I applaud the leaders who thought to leverage the bridges and hallways that link our conglomerate of old buildings as a means to promoting activity! Combined with easily located, accessible and attractive stairways, our step counts on campus should continue to rise.

Since most Americans spend more waking hours at work than at home, the role of our employers and workplaces at making healthy choices easy (or at least easier) can’t be underestimated. As part of our new TREC @ WUSTL center, our colleagues are examining just this - workplace policies that impact obesity, diet and physical activity.