how large is africa?

Just few words to focus on this stunning eye-opening image I found surfing on the net in the GOOD BLOG (see under the list of blogs on the column on the right side). Its author is Karl Krause.Click on it to see it enlarged. The image really puts the size of Africa into a whole new perspective. Its size is big enough to fit the United States, China, and much of Europe within its borders. Madagascar is as large as UK and Ireland combined. This just reminds us of how important it is to think about the millions of poor people who live there and the number of people in Africa who don't have access to "simple" things such as safe drinking water and health facilities.

Sign now for a cancer free world

The Union for International Cancer Control (UICC) is the leading international non-governmental organisation dedicated to the global prevention and control of cancer. It is set in Geneva, Switzerland, and was founded in 1933. UICC is the “custodian” of the World Cancer Declaration which is a call to action to substantially reduce the global cancer burden by 2020.The declaration was unanimously adopted at the World Leader’s Summit of policymakers, leaders & health experts during the 2008 World Cancer Congress in Geneva. The Declaration calls on the world to take immediate steps to reduce the global cancer burden and outlines 11 targets to be achieved by 2020. These include: 1) development of sustainable delivery systems to ensure that effective cancer control programmes are available in all countries; 2) improved measurement of the global cancer burden and the impact of cancer control interventions; 3) reduction of global tobacco consumption, obesity and alcohol intake levels; 4) effective widespread vaccination of populations in the areas affected by human papilloma virus (HPV) and hepatitis B virus (HBV); 5) improved public attitudes towards cancer by dispelling damaging myths and misconceptions about the disease; 6) improved diagnosis of many cancers when still localized through the provision of screening and early detection programmes; 7) increased access to accurate cancer diagnosis, 8) appropriate cancer treatments, supportive care, rehabilitation and palliative services for all patients worldwide; 9) increased access to effective pain control measures for all cancer patients in pain; 10) increased number of training opportunities available for health professionals in different aspects of cancer control; 11) achievement of major improvements in cancer survival rates in all countries. The declaration can be downloaded from the UICC website in different languages. Currently about 128000 people and 1035 organizations from all over the world have signed it. The reasons why everybody should do so are that cancer kills more people than AIDS, Malaria, and Tuberculosis combined, and the death toll is set to rise dramatically in the coming decades; two-thirds of cancer-related deaths occur in countries where resources available for cancer control are limited or nonexistent; without significant improvement, over 17 million people are projected to succumb from this disease by 2030; many cancers can be prevented, and several cancers can be cured if detected early and treated appropriately. This blog has been provided by a link to allow people to sign the Declaration (see the column on the right) . Let’s support such a call to action!

targeted therapies for advanced cancer or primary prevention of tumors: ethical and economical issues.

Targeted terapies have significantly changed the treatment of cancer over the past 10 years. These drugs are now a component of therapy for many common malignancies, including breast, colorectal, lung, and pancreatic cancers, as well as lymphoma, leukemia, and multiple myeloma. They are a sort of smart bombs designed to target the cancer cells and block or slow the growth of certain types of cancer minimising damage to healthy cells . Most of them, however, improve survival by only a few weeks or months but they don’t cure cancer.

Targeted therapies are incredibly expensive. For example multidrug colorectal cancer treatment regimens containing bevacizumab or cetuximab cost up to $30,790 for eight weeks. In the United States, sales of erlotinib, a drug which is able to prolong survival by few months in a selected fraction (no more than 20%) of lung cancer, totalled $457 million in 2008 (Annual report to shareholders, 2008. Genentech). This is the reason why their use is an opportunity and a threat to every system that simultaneously seeks to improve the health of its members or citizens and to work within ever-tightening budget constraints.

These considerations open additional ethical issues. It is better to invest on a minimal increase in time survival for a patient with highly advanced gastrointestinal or pulmonary cancer or, instead, on the primary prevention of some preventable tumors when this is feasible?. Carcinoma of the cervix uteri represents a good example of preventable tumor. There is, in fact, compelling evidence that vaccination against human papilloma virus (HPV) in young girls allows total prevention of the tumor. Gardasil, the HPV vaccine, is currently being offered for approximately $120 per single dose. Three doses are required over a 6-month period, making the total cost for the HPV vaccine about $360. With the same amount of money which is required to treat a patient with advanced colon cancer administering the above multidrug treatment regimen ($30,790) we could pay for a vaccination campaign against HPV for 87,500 girls (!). While the patient with colon cancer will eventually die, the above population of future women will be be totally protected from carcinoma of the cervix uteri. I am well aware that biotechnological research in pharmacogenomics should not be stopped because it will eventually provide, in the future, the magic drug to stop cancer. At the same time, however, money should be used also for people of the third world to cope the emerging epidemic of preventable tumors at least because this will impact beneficially the life of the whole planet.

Medical expedition to Sakatia and Nosy Be islands: a preliminary report

This is the story of an expedition recently conducted by three medical doctors including me, two anatomic pathologists and one general surgeon, supported by a young medical student, all from Milan, Italy, and volounteers of the Change onlus relief agency. The aim of the mission was to test the incidence of pap-smear cytological abnormalities in a restricted female population which had never been screened before for cervical cancer and is at a presumed high risk of developing this malignancy.

We brought from Milan all the stuff which is required to collect, smear, and stain cytological samples including a light microscope for immediate on site interpretation. Our goal was to work together with a team approach trying to conclude the procedure of screening, including the release of all cytological reports, on a same-day basis.

Fig. 1

Women had been invited in advance to be present for a clinical evaluation and pap smear sample collection in the days of September 14th, and 15th, 2010, at the Dispensaire of Sakatia (Fig 1), a first level health facility recently built up by Change onlus organization in that small island at just a 20 minutes boat ride from Nosy Be, and on September 16th, at the Infirmary facility of the Pecherie factory in Nosy Be island (see Fig. 2).

Fig 2

Fifty two women were seen in Sakatia and 42 women in the Pecherie Infirmary. The age ranged between16 to 57. Most of them were multiparous. After filling a questionnaire and providing her precise patient demographics, each woman underwent pelvic examination and pap smear sampling. Smears were then rapidly stained manually according to the Papanicolaou method (Figs 3 and 4).

Fig. 3

Fig. 4

Fig. 5

Microscopic evaluation followed on site and the pathological report was generated according to the Bethesda System, 2001, using a portable personal computer.

Women’s attitude to the gynecological work up was very good and they reacted enthusiastically to our initiative. Fig 6 shows a group of them chatting outside the Sakatia Dispensaire and waiting for their turn.

Fig 6

Results

Diagnosis (Bethesda)	Pecherie	Sakatia	Further work-up
HSIL	1	1	Colp+bp
AGC-neo	1	1	Colp+bp
LSIL	2	2	Colp+bp
ASCUS-HPV	1	3	Colp+ bp+ HPV test
ASCUS		1	P-smear repeat

Legend to the figure: colp = colposcopy; bp = biopsy; P= pap.

HSILs were detected in two women aged respectively 27 and 37, while the women diagnosed as having AGC-neo lesions were 43 and 47 years’ old. The incidence of High grade (HSIL and AGC-neo) and Low grade (LSIL, ASCUS-HPV, and ASCUS) lesions cumulatively reached values which are rather high according to WHO's estimates (see "Comprehensive Cervical Cancer Control. A guide to essential practice", p. 40, World Health Organization, 2006) for previously unscreened population:

SIL	Pecherie	Sakatia	WHO
High Grade	2 (4,76%)	2 (3,84%)	1-5%
Low Grade	3 (6,97%)	5 (9,61%)	3-10%

The 11 women who are candidates to further examination will be examined in November 2010 by a Gynecologist and colposcopist and the results of further tests, including biopsy and viral molecular tests, will be immediately reported on this blog.

Conclusion

Although the number of cases described in this report is fairly small, it is quite evident that women in Madagascar urgently need to be screened for uterine cervical cancer. Our effort will continue and we strongly hope that, under our guide and supervision, in few years the whole female population of the Nosy Be Island will be screened on the basis of a well organized plan and under the support of local Health authorities. We are deeply convinced that before starting to educate local health personnel and medical Doctors to the need of a well planned screening programme, and before teaching them to do theirselves, it is important to work hard locally as actively as possible to show the real advantages of it. In other words we still need to persuade them to the necessity of performing such screening procedure before trying to teach them how to do it. Our operative approach, consisting of a multidisciplinary team of physicians who intensively concentrated their efforts in few days, seems to be the best way to obtain such a result. In future expeditions also a Gynecologist will take part of the team with significant advantages in terms of speed of diagnosis and treatment. Doing first is, at least in this setting, much better than teaching first.

From left to right: Stefania Rossi, MD and MIAC, Anatomic Pathologist, San Paolo University Hospital, Milano; Sofia Bronzato, intern Medical Student at the San Raffaele University Hospital, Milano; Adolf, the local Nurse on duty of the Dispensaire of Sakatia; Franco Silva MD, General Surgeon and Interventional Radiologist, Fatebenefratelli Hospital, Milano; Liza, Translator and patient herself; Giorgio Gherardi, MD, Anatomic Pathologist and Head of Pathology, Fatebenefratelli Hospital, Milano, Italy. Photographs by Andrea Gherardi: website and blog

Cancer of the cervix uteri, a preventable tumor

Cancer of the cervix uteri is the second most common cancer among women worldwide. About 86% of the cases occur in developing countries. Every 10 minutes, a woman in Africa dies from cervical cancer, despite the fact that almost every case is preventable through a programme of screening, treatment and vaccination against the Human Papilloma Virus (HPV). In Madagascar it is the most commonly detected malignancy in females with an incidence >45 cases / 100000 inhabitants per year. According to the African Oxford Foundation "Globally there are over 500,000 new cases of cervical cancer annually and in excess of 270,000 deaths, accounting for 9% of female cancer deaths. 85% of cases occur in developing countries and in Africa Mortality rates vary seventeen fold between the different regions of the world. Cervical cancer contributes over 2.7 million years of life lost among women between the ages of 25 and 64 worldwide, some 2.4 million of which occur in developing areas and only 0.3 million in developed countries. Africa has 9 times the incidence of cervical cancer compared to the USA and 24 times the mortality. Cervical cancer incidence and mortality rates have declined substantially in Western countries following the introduction of screening programmes. Screening programmes in Africa, are however, often rudimentary or non-existent. The vast majority of women who suffer cervical cancer in Sub-Saharan Africa present with disease advanced far beyond the capacity of surgery or other treatment modalities to offer cure. Palliative care services are very poorly developed and therefore these unfortunate women are sentenced to a miserable end of life.