Jpn J Clin Oncol 2002;32(Supplement 1)S52–S61

Cancer and the Philippine Cancer Control Program Corazon A. Ngelangel1 and Edward H. M. Wang2 1Department

of Medicine, University of the Phil-Phil General Hospital and Jose R. Reyes Memorial Medical Center, Department of Health and 2Cancer Institute, Philippine General Hospital and Department of Orthopaedics, University of the Phil-Phil General Hospital, Manila, Philippines Received February 2, 2001; accepted August 28, 2001

Cancer is the third leading cause of morbidity and mortality in the Philippines. Leading cancer sites/types are lung, breast, cervix, liver, colon and rectum, prostate, stomach, oral cavity, ovary and leukemia. There is at present a low cancer prevention consciousness and most cancer patients seek consultation only at advanced stages. Cancer survival rates are relatively low. The Philippine Cancer Control Program, begun in 1988, is an integrated approach utilizing primary, secondary and tertiary prevention in different regions of the country at both hospital and community levels. Six lead cancers (lung, breast, liver, cervix, oral cavity, colon and rectum) are discussed. Features peculiar to the Philippines are described; and their causation and prevention are discussed. A recent assessment revealed shortcomings in the Cancer Control Program and urgent recommendations were made to reverse the anticipated ‘cancer epidemic’. There is also today in place a Community-based Cancer Care Network which seeks to develop a network of self-sufficient communities sharing responsibility for cancer care and control in the country. Key words: Philippines – cancer – Philippine Cancer Control Program

INTRODUCTION In the Philippines, cancer ranks third in leading causes of morbidity and mortality after communicable diseases and cardiovascular diseases (Department of Health–Health Intelligence Service or DOH–HIS, 1992, 1996) (1). Over the period 1942– 96, communicable disease mortality has shown a gradually decreasing trend, in contrast to the increasing trends of heart disease and cancer (non-communicable diseases). In the Philippines, 75% of all cancers occur after age 50 years, and only about 3% occur at age 14 years and below. If the current low cancer prevention consciousness persists, it is estimated that for every 1800 Filipinos, one will develop cancer annually. At present, most Filipino cancer patients seek medical advice only when symptomatic or at advanced stages: for every two new cancer cases diagnosed annually, one will die within the year. The Philippine Cancer Control Program, begun in 1988, is an integrated approach utilizing primary, secondary and tertiary prevention in different regions of the country at both hospital and community levels. Six leading cancers (lung, breast, liver, cervix, oral cavity, colon and rectum) are discussed.

For reprints and all correspondence: Corazon A. Ngelangel, Section Chief, Medical Oncology, Department of Medicine, University of the Phil-Phil Gen. Hospital, Taft Avenue, Manila, Philippines 1000

CANCER STATISTICS INCIDENCE BY CANCER SITE Cancer incidence data are derived from two population-based cancer registries in the country: the Department of Health– Rizal Cancer Registry (DOH–RCR) and the Philippine Cancer Society Inc.–Manila Cancer Registry (PCSI–MCR). The DOH–RCR covers 26 municipalities of Rizal Province and PCSI–MCR covers the four cities of Quezon, Manila, Caloocan and Pasay. From 1980 to 1995, the leading cancer sites/types have remained the same: lung, breast, cervix uteri, liver, colon and rectum, prostate, stomach, oral cavity, ovary, leukemia, thyroid, uterus, non-Hodgkin’s lymphoma, larynx and nasopharynx (Table 1) (2–4). The top cancer sites in the Philippines include those cancers whose major causes are known (where action can therefore be taken for primary prevention), such as cancers of the lung/ larynx (anti-smoking campaign), liver (vaccination against hepatitis B virus), cervix (safe sex) and colon/rectum/stomach (healthy diet). Except for the liver, the top Philippine cancer sites are also the top cancers worldwide. Table 2 presents the less common cancer sites in the Philippines (2–4). The problem of childhood cancer in the Philippines is more significant than in Western countries, because of the relatively young Filipino population. The overall pattern is, however, similar and is dominated by leukemia (Table 3). Certain © 2002 Foundation for Promotion of Cancer Research

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Jpn J Clin Oncol 2002;32(Supplement 1)

Table 1. Leading cancer sites, age-standardized rates per 100 000 population, all ages, Manila and Rizal (2–4) Cancer site

1980–82

1983–87

1988–92

1993–95

BS

M

F

BS

M

F

BS

M

F

BS

M

F

25.8

42.3

11.5

31.0

46.7

14.9

40.0

64.7

18.8

40.0

64.7

18.8

0.7

40.5

0.7

44.4

0.8

43.2

0.8

43.2

Liver

13.4

20.4

7.3

14.7

20.4

8.0

16.8

25.6

9.0

16.8

25.6

9.0

Cervix uteri

20.5

–

–

–

–

Lung Breast

20.5

22.5

22.5

26.4

26.4

26.4

Stomach

9.6

11.9

7.6

9.6

11.4

7.7

9.6

12.1

7.6

9.6

12.1

7.6

Colon

6.5

7.3

5.7

8.0

8.0

7.7

10.7

11.8

9.8

10.7

11.8

9.8

Oral cavity

5.9

5.4

6.3

6.9

6.4

7.3

8.6

8.5

8.3

8.6

8.5

8.3

Prostate

12.5

12.5

–

14.6

14.6

–

19.3

19.3

19.3

19.3

Rectum

5.5

6.5

2.8

6.6

7.4

5.6

7.0

8.1

6.2

7.0

8.1

6.2

Leukemia

5.2

5.7

2.9

5.7

5.6

5.5

6.6

7.2

6.2

6.6

7.2

6.2

Nasopharynx

2.5

6.0

1.6

5.2

6.7

3.1

6.2

8.6

4.0

6.2

8.6

4.0

Larynx

1.4

4.3

0.4

2.8

4.4

1.1

3.4

Ovary

8.0

8.0

9.2

9.2

10.8

Thyroid

2.7

6.6

5.6

8.0

6.6

Corpus uteri

6.1

6.1

5.8

5.8

5.2

Non-Hodgkin’s lymphoma

2.0

1.6

3.3

2.6

4.6

– 1.3 – 2.1

– 2.7 – 3.8

6.2 – 3.1 – 5.8

–

1.0

3.4

10.8

10.8

9.8

6.6

5.2

5.2

3.6

4.6

26.4

–

6.2 –

1.0 10.8

3.1 –

9.8 5.2

5.8

3.6

features are similar to those in other Asian populations (low incidence of Wilm’s tumor, Hodgkin’s disease and Ewing’s sarcoma), in contrast to relatively high incidence rates for retinoblastoma and low rates for neuroblastoma and nonHodgkin’s lymphoma (2–4).

were lung, liver, breast, leukemia, stomach, cervix uteri, colon, liver, pancreas, nasopharynx and prostate (in decreasing order of frequency). The top three mortality cancer sites among females were breast, lung and cervix uteri and among males lung, liver and leukemia.

SURVIVAL FROM CANCER IN THE PHILIPPINES

CANCER CONTROL IN THE PHILIPPINES

The survival experience, regardless of treatment, of patients with top cancer sites diagnosed in 1987 and included in the DOH–RCR was evaluated as the first population-based survival data for Filipinos (5). Lung cancer had the lowest survival and breast cancer had the highest (Table 4). Five-year survival in excess of 40% was observed for only three cancer sites: oral cavity, colon and breast. For all other sites, survival was less than 30%. Owing to the small number of cases in each category, no distinct impact of age on relative survival could be perceived for most cancer sites. However, both observed and relative survival rates were low for breast cancer patients less than 35 years old (Table 5). The 1987 cancer survival rates among Filipino patients imply that there is much to be done for cancer education and the implementation of all aspects of cancer prevention. In comparison, the 1990 5-year relative survival rates, all races, from the USA National Cancer Institute Surveillance Epidemiology End-result program reveals higher rates (Table 6) except for stomach (males) and liver cancers. MORTALITY FROM CANCER Data from the 1991/95 DOH–RCR and the DOH–HIS 1992 and 1996 data indicated that the leading cancer site mortalities

THE PHILIPPINE CANCER CONTROL PROGRAM It was on the premise that cancer can be largely prevented mainly as a public health effort that the Philippine Cancer Control Program (PCCP) was established. The first phase of program implementation was conducted in 1988, providing the guidelines for the PCCP, specifying program policy, components, implementing guidelines and timetable. The PCCP is a systematic, organized and integrated approach towards the control of cancer which can significantly alter or reduce morbidity and mortality utilizing primary, secondary (community level) and tertiary prevention in the different regions of the country aside from rehabilitation activities at both hospital and community levels. The goal is to establish and maintain a system that integrates scientific progress and its practical applications into a comprehensive program that will reduce cancer morbidity and mortality in the Philippines. The six Pillars of the PCCP are Epidemiology and Research, Public Information and Health Education, Prevention and Early Detection, Treatment, Training and Pain Relief.

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Table 2. Other cancer sites, age-standardized rates per 100 000, all ages, Manila and Rizal (2–4)

Table 3. Childhood cancer, 0–14 years old, age-standardized rates per million, both sexes (2–4)

Cancer site

Cancer type

1988–92 BS

1993–95

M

F

M

F

Oropharynx

1.2

1.0

1.2

0.6

0.7

Hypopharynx

0.4

0.2

0.3

0.6

0.3

Pharynx, NOS

1.8

1.0

1.4

0.8

0.4

Esophagus

3.2

1.8

2.4

3.0

1.2

Small intestine

0.9

0.5

0.7

0.8

0.6

Gallbladder, etc.

1.6

1.6

1.6

1.6

1.5

Pancreas

5.0

4.0

4.5

3.5

3.3

Nose, sinuses, etc.

1.8

1.2

1.4

1.2

0.7

Pleura

0.1

0.1

0.1

0.6

0.2

Bone

3.0

2.0

2.4

2.7

1.6

Connective tissue

3.2

2.3

2.7

2.3

1.8

Skin

4.2

3.3

3.8

3.5

2.0

Placenta

–

Other genital

0.8

– 1.1

0.5

–

0.6

–

1.7

0.9

Bladder

5.0

1.6

3.2

5.1

2.6

Kidney

4.2

2.6

3.3

4.2

2.4

Eye

0.7

0.5

0.6

0.6

0.4

Brain

2.8

1.8

2.3

2.9

1.8

Other endocrine Unknown primary site

0.2

0.2

0.2

0.2

0.1

10.6

8.2

9.3

10.2

8.4

Total I.

1. LUNG CAUSATION The Pulmonary Carcinoma Task Force of the Philippine Veterans Memorial Medical Center reviewed the smoking habits of 178 patients with squamous cell/small cell adenocarcinomas (1984) (6). There were more cases in (a) smokers compared with non-smokers, (b) cigarette smokers compared with smokers of other tobacco products and (c) subjects with 20 compared with