Mohamed Alorabi, MBBCh, MSc, MD
Hagar Elghazawy, MBBCh, MSc, MD
Egypt is a country of 1,010,408 km2 located on the northeast corner of Africa with a population exceeding 100 million. In 2018, there were about 134,632 new cancer cases and 89,042 cancer-related deaths in Egypt. Liver and breast cancers are the most common tumors in terms of incidence and mortality.1 The country has trained medical staff in oncology and a more advanced infrastructure than other African countries for cancer diagnosis, surgical treatment, systemic therapy, and radiotherapy services.2,3
Patients with cancer in Egypt receive their treatment in General Authority for Health Insurance hospitals, in Ministry of Health and Population or university hospitals at the government’s expense, or in the private sector at their own expense or with personal insurance coverage. Nongovernmental organizations also help patients with cancer in different ways, supporting governmental hospitals, providing treatment services in their facilities, or providing emotional support to patients directly.4,5
To remodel the health-care system, Egypt endorsed the Universal Health Insurance (UHI) law in 2018 to achieve universal health coverage as part of the Transforming Egypt’s Healthcare System Project. The UHI law aims to cover the whole population by securing funding through new, diversified financing mechanisms. The establishment of Egypt’s UHI law reflects the country’s progress toward achieving universal health coverage, crowning the expended and coordinated efforts between the Egyptian government and key stakeholders, including the World Health Organization (WHO). The first of six phases is ongoing, and the full implementation will take 15 years.6
In oncology, there have been many efforts made over the years to improve cancer prevention, screening, and early detection in Egypt, all of which play a role in improving health care. Herein, we illustrate these aggregate efforts and the implemented action plan for cancer management that could aid other countries with limited resources.
Egypt National Multisectoral Action Plan, 2018–2022
In Egypt, noncommunicable diseases are responsible for 85% of deaths, with cancers representing the second most common cause of mortality (14%) after cardiovascular diseases (46%). Egypt has an ambitious plan for preventing and controlling noncommunicable diseases, including cancer, which was initiated in 2018 (known as the Egypt National Multisectoral Action Plan for Prevention and Control of Noncommunicable Diseases).
This plan’s primary goal is to achieve a 15% reduction in premature mortality from noncommunicable diseases by 2022, by decreasing the exposure to risk factors and improving early detection and effective treatment of these diseases. It includes a target of 70% availability of essential medicines and necessary technologies to treat major noncommunicable diseases. A national cancer committee has been established with a remit to develop and implement a national plan for cancer control and early detection, mainly for breast cancer and cervical cancers, as well as national guidelines for the diagnosis and treatment of patients with cancer.7
The plan also focuses on improving the National Cancer Registry Program of Egypt, which was established in 2007 through a protocol of cooperation between three ministries: Communications and Information Technology, Health and Population, and Higher Education and Scientific Research. The first step of this project was to develop a national population-based cancer registry for calculating incidence rates, which ended in 2014, followed by the inclusion of hospital-based cancer registries to achieve a public domain cancer database that could help researchers and policymakers.7,8
“In oncology, there have been many efforts made over the years to improve cancer prevention, screening, and early detection in Egypt, all of which play a role in improving health care.”— —MOHAMED ALORABI, MBBCH, MSc, MD, AND HAGAR ELGHAZAWY, MBBCh, MSc, MD
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Palliative care is an integral part of cancer treatment, especially in its advanced stages. Unfortunately, there are a limited number of centers that provide palliative care services in Egypt, so it is crucial to increase interest in palliative care by establishing more specialized centers, training medical personnel, and providing home palliative care services. It is also essential for the government to ease restrictions on the dispensing of opioid substances, such as morphine, and make them more available to patients who need them.9,10
Cancer Prevention Programs and Policies
Over the years, the Egyptian government has issued many laws and legislation related to carcinogens, such as smoking prevention, an asbestos ban in industrial fields, prevention of organochlorine pesticides in Egyptian agriculture, and efforts to combat air and water pollution.11 In addition, the practical and convenient treatment of schistosomiasis, using social marketing and mass media in public and medical education, has contributed dramatically to the primary prevention of bladder cancer in Egypt.12
Egypt had the highest prevalence of hepatitis C virus (HCV) infection in the world as a result of the prevalence of schistosomiasis and its mass treatment by unsafe intravenous injections in the 1950s and 1960s. Thus, it is not surprising that liver cancer, mainly hepatocellular carcinoma (HCC, which constitutes about 70.5% of all liver cancers), was the most common cancer among men (33.6%) and was the second-most common cancer among women (13.5%) after breast cancer in the National Cancer Registry Program.13,14
Obesity and type 2 diabetes are becoming increasingly prevalent worldwide, and both are associated with increased cancer incidence and mortality. Egypt has the highest obesity rate among the world’s 20 most populous countries, and the prevalence of diabetes in Egyptian adults is around 15.6%.15,16
The Egyptian government presented a successful model for how routine testing and treatment of infectious and chronic diseases for an entire country could be achieved. In 2018, Egypt embarked on an extensive disease screening and treatment campaign for hepatitis C, hypertension, diabetes, and obesity called the 100 Million Healthy Lives program. As a result of this campaign, Egypt has the most extensive national HCV screening and treatment program in the world.
“Egypt has the highest obe sity rate among the world’s 20 most populous countries, and the prevalence of diabetes in Egyptian adults is around 15.6%.”— —MOHAMED ALORABI, MBBCh, MSc, MD, AND HAGAR ELGHAZAWY, MBBCh, MSc, MD
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With this screening program and mass treatment effort, Egypt is on a fast track to eliminating HCV and has the potential to be the first country to achieve WHO disease elimination targets.17 We expect these advances to decrease the number of patients with cancer, especially HCC among patients who have obtained a sustained virologic response after antiviral therapy for hepatitis C.18
Robust Breast Cancer Screening
In Egypt, breast cancer is the most common malignancy in women, accounting for 38.8% of cancers in this population, with the estimated number of breast cancer cases nearly 22,700 in 2020 and forecasted to be approximately 46,000 in 2050.14 It is estimated that the breast cancer mortality rate is around 11%, being the second cause of cancer-related mortality after liver cancer.3
Age and stage at diagnosis of breast cancer in Egypt were compared from the Gharbiah Cancer Registry (GCR) with the U.S. Surveillance, Epidemiology, and End Results (SEER) Program database (for 2004–2008). It was found that GCR cases were a full decade younger than that of SEER cases (mean age = 51.0 vs 61.4 years), with nearly 19% of GCR cases aged ≤ 40, compared with only 6% of SEER cases. Moreover, there was a clear difference in stage at diagnosis between the two populations. GCR cases were diagnosed at more advanced stages, with nearly 5%, 39%, 44%, and 12% diagnosed at stage I, II, III, or IV, respectively, compared with 48%, 34%, 12%, and 5% of SEER cases diagnosed at stage I, II, III, or IV, respectively.19 This highlights the importance of taking the specific disease criteria into consideration when planning a breast cancer early detection program.20
Early diagnosis (in symptomatic populations) and screening (in asymptomatic populations) are the two main components of cancer early-detection programs, as defined by the WHO, to reduce the incidence of advanced cancer and mortality.21 In low- and middle-income countries, where cancer is diagnosed in advanced stages and allocated resources are limited, it is highly recommended that cancer control programs include the following elements: (1) targeted outreach/education promotion and (2) efforts to encourage clinical breast examination for at-risk groups, with or without opportunistic mammographic screening. This is to keep with the goal of downsizing symptomatic disease and/or asymptomatic disease in high-risk groups.22
In Egypt, the first national screening program, the Women Health Outreach Program, was initiated in October 2007. It was a government-funded program that offered free mammograms for Egyptian women aged > 45 and screening for diabetes, hypertension, and obesity. This was approached using mammography vans, equipped with a full-field digital mammography machine, and a dedicated computer system linked to the National Breast Screening Center. Free treatment was offered for cases in which breast cancer was detected. From October 2007 to February 2009, 20,098 women in three governorates were screened for breast cancer.23,24 (Egypt is divided into 27 governorates, the highest tier of the country’s jurisdiction hierarchy.)
With the launch of the 100 Million Healthy Lives national initiative, more efforts were directed to control breast cancer in Egypt. In July 2019, a nationwide campaign was started in 9 governorates (Alexandria, Port Said, Matrouh, Qalyubia, Beheira, Assiut, Fayoum, South Sinai, and Damietta) and extended after 2 months to another 11 governorates (Cairo, North Sinai, the Red Sea, Ismailia, Suez, Kafr El-Sheikh, Menoufia, Beni Suef, Sohag, Luxor, and Aswan), and then after 2 more months, to the remaining 7 governorates (Giza, the New Valley, Gharbia, Dakahlia, Sharqia, Minya, and Qena).25 The main objectives of this campaign are to promote breast cancer awareness and the importance of early diagnosis, screening for breast cancer and treatment of diagnosed cases according to recent protocols. Suspected cases are referred for further investigation and treatment at no cost for the participants.
The media center for the Council of Ministers announced that 8.5 million women had been examined by October 20, 2020, from all over Egypt, with the aim of reaching 31 million women.
This great initiative’s final results are awaited, particularly after the HCV screening program’s success, with its expected impact of lowering HCC incidence. Moreover, an economic evaluation is merited to ensure the project’s future sustainability and to guide other countries with limited resources to establish their breast cancer control programs.
Lessons Learned From the Egyptian Experience
We believe that countries with limited resources could be motivated by the Egyptian experience to improve their health-care systems, noncommunicable disease prevention, and early detection of cancer. The availability of epidemiologic data for the most common cancers in every country and their main risk factors represents the first step for developing practical plans for cancer prevention and early detection. Hence, the existence of national cancer registries provides accurate and complete data to help researchers and health policymakers in planning cancer control programs and projects to improve each country’s quality of cancer care.
The second step is to do a SWOT analysis (strengths, weaknesses, opportunities, and threats) for the health-care system in the country, taking into account all four areas identified by the WHO as integral to the success of cancer control programs: risk factor modification and prevention, early diagnosis, treatment, and palliation. It is important to set plans with SMART objectives (specific, measurable, achievable, realistic, and time-based).
The last step is to cooperate and benefit from the experiences of similar countries and the guidance of international organizations such as the WHO. For example, Egypt is currently providing support and assistance to other African countries in combating HCV based on its experience in this field.
Cancer control strategies in Egypt have benefited from outstanding efforts in recent years. Policy and resources are not directed toward treatment exclusively but also toward prevention and early detection/screening programs. Despite these confident steps, effective long-term control of cancer requires sustained efforts to establish a national cancer registry and awareness campaigns directed at the public, strengthen cancer research, provide access to affordable disease management for diagnosed patients, and enhance palliative care services.
These efforts mandate the fostering of intersectoral coordination and collaboration between the health sector and other fields. The impressive results of the HCV elimination program and the preliminary outcomes of the breast cancer control initiative in Egypt represent a successful model that may be adopted by other countries with limited resources. sA
DISCLOSURE: Drs. Alorabi and Elghazawy reported no conflicts of interest.
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Dr. Alorabi is Lecturer of Clinical Oncology, Hematology and Central Nervous System Unit, Department of Clinical Oncology, Ain Shams University, Cairo. Dr. Elghazawy is Lecturer of Clinical Oncology, Breast Cancer Unit, Department of Clinical Oncology, Ain Shams University, Cairo.