- Meeting Report
- Open Access
Fight against cancer in Portuguese-speaking African countries: echoes from the last cancer meetings
© The Author(s). 2019
- Received: 20 December 2018
- Accepted: 31 January 2019
- Published: 15 February 2019
Portuguese-speaking countries in Africa include Angola, Mozambique, Guinea-Bissau, Cape Verde, São Tomé and Principe. These countries belong to an interstate organization known as PALOP. In June 2018, PALOP organized a cancer meeting in Praia, Cape Verde, entitled ‘Quality in cancer care, optimization of cancer units, cancer education and training.’ This meeting was supported by faculty from the African Organization for Research and Training in Cancer (AORTIC) and was dedicated to the improvement of cancer care in PALOP countries. The burden of non-communicable diseases, which includes cancer, is increasing rapidly in these countries.. During this meeting, a plan was developed to guide the future strategic actions in this community. The main points of action include to increase access to cancer care, boost HPV and hepatitis B vaccination, improve access to cancer treatment, including radiotherapy and palliative care, amongst others. Efforts will be made to ensure the participation of all of these countries at PALOP meetings, including Equatorial Guinea, a potential new member.
- Portuguese-speaking countries in Africa
- Cancer care
Demographics, economic and social data
PALOP, demographics, economic and social data statistics
Population (millions) 20185
2018 Births per 10005
Population Deaths per 10005
Rate of Natural Increase (%)5
Infant Mortality Rate5
GNI per Capita, PPP 20175
Total Fertility Rate5
GDP (US$) 2017 (million)6
São tomé and Príncipe
PALOP is mostly low or lower-middle income countries with a very young population. Wealth is poorly distributed and there is a high rate of poverty and illiteracy . However, life expectancy at birth according to data from the World Bank is on the rise in all PALOP countries (Angola - 62 years; Mozambique – 58 years; Cape Verde – 73 years; Guinea-Bissau – 57 years and São Tomé and Principe – 67 years) .
Increased life expectancy, urbanization and the continued rise of infectious diseases associated with cancer is what is seen and observed in PALOP countries. Cancer is rising in sub-Saharan Africa and the region is predicted to have an increase in burden of cancer greater than 85% by 2030. The same is expected to happen in Lusophone African countries .
Cancer in PALOP countries: The magnitude of the problem
Cancer incidence and mortality statistics for the PALOP region are estimations by GLOBOCAN and based on data collected from neighboring African countries, because there is no reliable data available for these countries. The exception is Mozambique, where incidence estimations reported by GLOBOCAN considered local data collected from the Beira regional cancer registry and most recently the Maputo cancer registry. However, there is no data on cancer mortality. According to GLOBOCAN the estimated number of cases from 2018 to 2040 for all cancers, both sexes, and all ages in PALOP region will increase from 43,376 to 92,900 cases .
According to the Institute for Health Metrics and Evaluation, cancer in 2017 was the second cause of death in Cape Verde (17.9%), the third in São Tomé and Principe (12.2%), the sixth in Angola (6.5%) and Mozambique (6.1%) and the seventh in Guinea-Bissau (6.4)% . In all countries, there was an increase in the cancer mortality rate .
Published data from Angola is gleaned from the Instituto Angolano de Controlo do Cancer (IACC) hospital-based cancer registry. Among the 4791 cancer patients that attended from 2007 to 2011, the most commonly diagnosed cancers were breast (20.5%), cervical (16.5%), and head & neck cancer (10.6%), followed by lymphoma (7.2%), Kaposi sarcoma (6.1%), and prostate cancer (4%). From these, 75.8% were confirmed histologically. A total of 76% of patients were under 60 years old, and 10% were less than 15 years old. From all cancer patients treated at the IACC, 77.3% lived in the Luanda province .
The Cancer Registry of the Maputo Central Hospital (MCH) studied 1707 cases, 76.6% of which were confirmed histologically. Prostate cancer, Kaposi sarcoma, and liver cancer were the most frequent in men (ASIR: 24.5, 19.8, and 13.3, respectively). Cervical and breast cancers and Kaposi sarcoma were the most common among women (ASIR: 32.4, 11.8, and 9.5, respectively) . Previously, Lorenzoni C et al. studied a total of 12,674 cases of cancer (56.9% females). In males, the most common cancers were those of the prostate, Kaposi sarcoma (KS) and the liver. In females, the most frequent cancers were of the uterine cervix, the breast and KS .
Spencer BH et al. studied 730 cases of cancer from the cancer registry of Agostinho Neto Hospital (ANH), Praia, Cape Verde, and the most frequent malignant tumors were: Breast (27.8%), Cervix (12.6%), Prostate (7.4%), Stomach (6.8%) and Colorectal (6.8%). In this study, the histological confirmation rate was 62.7% .
No published data exists for Guinea-Bissau and São Tomé and Principe. Therefore, only estimations are available. Currently, there are hospital-based registries in the PALOP main hospitals. Nevertheless, data quality is poor, so they need to improve their record keeping. It is a matter of urgency to establish the population-based cancer registry in Angola, Cape Verde, Guinea-Bissau and São Tomé and Principe. As previously mentioned, Mozambique has two population-based cancer registers, namely in Beira and Maputo, with technical and scientific support from the African Cancer Registry Network.
Control and prevention of Cancer programmes in PALOP
- Preventable tumours (such as those of the lung, colon, rectum, skin and liver): to avoid and reduce exposure to risk factors (such as tobacco use, unhealthy diets, harmful use of alcohol, physical inactivity, excess exposure to sunlight, communicable agents, including hepatitis B virus and occupational exposures), thus limiting cancer incidence;
- Cancers amenable to early detection and treatment (such as oral, cervical, breast and prostate cancers): to reduce late presentation and ensure appropriate treatment in order to increase survival rates, reduce mortality and improve quality of life;
- Disseminated cancers that have potential of being cured or the patients’ lives prolonged considerably (such as acute in childhood): to provide appropriate care in order to increase survival, reduce mortality and improve quality of life;
- Advanced cancers: to enhance relief from pain and other symptoms and improve the quality of life of patients and their families.
In response to the WHA resolution, WHO, in 2008, WHO published guidelines for effective cancer prevention control programmes in six modules: Planning; prevention; Early detection; Diagnosis and Treatment; Palliative care and Policy and Advocacy .
Angola, Mozambique and Cape Verde have issued guidelines, legislation, and decisions in order to build their Cancer Control program as previously stated, but none of these countries officially have an approved and funded program. The other PALOP countries have no information. The common cancers in these countries are Kaposi’s sarcoma, cervical cancer, breast cancer, prostate, liver, esophagus, stomach, colorectal, bladder, head and neck, leukemia and non-Hodgkins lymphoma. Some of these malignancies may be prevented or detected early, but for the moment this does not happen. Screening for cervical cancer, HPV vaccination, and hepatitis B vaccination should be promoted in PALOP countries. Cape Verde has a cervical cancer screening program.
The Instituto Angolano de Controlo do Cancer (IACC) in Luanda, Angola, is the oldest public center for the treatment of cancer patients, with radiotherapy, chemotherapy and surgery facilities. Girassol Clinic has radiotherapy and Sagrada Esperança Clinic offers chemotherapy treatment. However, the treatment is not affordable for most patients in Luanda, especially at the Girassol Clinic. In Luanda, units dedicated to cancer treatment are being developed in large hospitals. Also, they are trying to create a multidisciplinary approach in the treatment of this disease and that will act as sources of information for the registry of cancer . The Government announced recently that they will introduce a program to create public oncology units in other provinces of Angola.
In Cape Verde, the Agostinho Neto Hospital has a unit for diagnosis and treatment of cancer which includes surgery and chemotherapy and also has equipment for the screening of breast cancer. The majority of patients are transferred to Portugal because there is an agreement between the two countries to carry out radiotherapy or more complex treatments.
In Guinea-Bissau cancer patients are treated mostly at the Simão Mendes hospital and the Catholic Hospital of Cumura . The difficulties at these hospitals are extreme. In São Tomé and Principe, patients are treated in Hospital Ayres de Menezes. In Guinea-Bissau and São Tomé and Principe, only a few doctors are engaged in oncology treatment. Portugal has official cooperation protocols through non-governmental organizations to support the treatment of cancer patients in these two countries.
Current oncology practice
Partners on the ground and local community cancer support organizations
The Calouste Gulbenkian Foundation in Portugal developed an oncology patient care program in collaboration with Maputo Central Hospital to strengthen their capacity. This program has now been extended to the Agostinho Neto Hospital in Cape Verde . At the last PALOP cancer meeting, the General Director of Health for Portugal signed an agreement for cancer patients from Cape Verde to be treated in Portugal.
Project ECHO, Mozambique, is a collaborative effort between MD Anderson, three MD Anderson Sister Institutions in Brazil, Maputo Central Hospital (Mozambique) and the Ministry of Health in Mozambique. The Brazilian partners include Barretos Cancer Hospital, Albert Einstein Hospital, and A.C. Camargo Cancer Center . This partnership aims to increase clinical capacity through a comprehensive training program, including regular telementoring, hands-on training workshops, and knowledge-sharing.
The “Health for All Program”, implemented by IMVF (Instituto Marquês Valle Flor) in close partnership with the Ministry of Health and Social Affairs of São Tomé and Principe, is financed by the Camões Portuguese Institute of Cooperation and Language, Fundação Calouste Gulbenkian and the General Director of Health for Portugal . Several non-governmental organizations operate in Guinea-Bissau in the treatment of cancer patients and screening of cervix and uterus in the Cumura hospital .
Local community cancer support and non-profit organizations are committed to providing support, advocacy and education and hope for all affected by cancer in the PALOP countries. Examples are the Angolan League Against Cancer and the project “Snowball” dedicated to children in Angola, the Association to Fight Cancer in Mozambique, The Cape Verdean Association for the Fight against Cancer and the Cape Verdean League against Cancer in Cape Verde, the Guinean League against Cancer in Guinea-Bissau and the São Tomé Association of Fight against Breast Cancer and cervix in São Tomé and Principe. These organizations promote annual awareness roadshows and encourage positive action amongst the public, health professionals and policy makers.
Cancer education programs
Cancer management requires considerable investment in infrastructure, equipment, and personnel. Country cooperation in this regard is critical and is strategic and cost-effective. Training has been one of the most important aspects of the PALOP region as part of cancer control programs in these countries. Existing oncologists were trained locally or in countries such as Brazil, Portugal, Spain and Cuba. The informal training that stems from irregular activities has hampered the consistency and proficient manner to train oncologists in the various areas. In this regard, several interventions to train Mozambique oncologists have been carried out by hospitals in Brazil, the Calouste Gulbenkian Foundation, MD Anderson Cancer Center from USA (Project ECHO) and others [23, 24]. Similar interventions in other PALOP countries have occurred or are planned to be implemented in the next few years, For example, the Central Military Hospital of Angola will start a training program in medical, surgical and gastroenterology oncology in 2019. This is part of the local residency program to strengthen its team of oncologists in Portugal. Therefore, PALOP oncologists consider that formal training and the development of an educational program in oncology should start at university level or at medical schools, during medical residency training and after residency training . The infrastructure for training and accreditation of oncologists is not well established in PALOP countries. A Subspecialty Certificate in Oncology may be the solution to be adopted by the Colleges of Physicians of each country for each medical area responsible for the program, examination and certification. The same should happen with nurses and other health experts involved in cancer care. Another conclusion of this conference was the suggestion of including training programs (including stakeholder programs) under umbrella experts, such as the PALOP School of Oncology. This will allow the program to be evaluated and impact on local professional careers measured. Delegates at the previous PALOP Congress considered that this topic should be addressed at the next AORTIC Conference that will be held 5-8 November 2019 in Maputo, Mozambique during a session on formal cancer education . It was emphasized that the training of mentors and mentees is imperative and AORTIC’s steering committees of education and training should devote themselves to organize a comprehensive training program for oncology specialists from various specialties that will make up the multidisciplinary oncology team.
Conclusions of the meeting and the plan of action
Cancer awareness and advocacy;
Population-based cancer registries;
Improve access to cancer care (globally);
Screening for cervical cancer and HPV vaccination;
The hepatitis B vaccine should be boosted;
Improve clinical evaluation, diagnosis (radiology and pathology) and staging;
Improve access to cancer treatment (including Radiotherapy);
•Improve the training of nurses, medical oncologists, radiographers and surgical oncologists. The various specialties of the multidisciplinary team also need training;
The establishment of well-resourced, cancer centres is urgently needed. These centres should be where specialised clinicians, surgeons, pathologists, radiotherapists, nurses, radiologists, pharmacists, and laboratory personnel are given the right conditions to comfortably deliver high-quality care to patients with cancer, at an affordable cost;
Improve access to palliative care.
Efforts should be made to ensure that Guinea-Bissau, São Tomé and Principe and Equatorial Guinea (a potential new member) participate effectively in PALOP meetings.
We would like to acknowledge the organization of III AORTIC PALOP cancer meeting in Cape Verde offering the photographic report on publication.
This manuscript had no funding.
Availability of data and materials
Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.
LLS participated in the design, coordinated all contributions, and drafted the manuscript. LLS, HBS, FM, ST, BR and LVL performed critical revisions for important intellectual content of the article. LVL helped with the synthesis. BR corrected the final manuscript. All authors read and approved the final manuscript.
Ethics approval and consent to participate
The organization committee of the PALOP cancer meeting in Cape Verde and its ethics office authorized the publication of this manuscript.
Consent for publication
During the event all the participants authorized the taking of photos and their publication of the time of registration in accordance with the current privacy protection policy. The publication of the remaining photographs has been authorized by the official services that are the owners of these photos, fulfilling what is established internally in its policies of protection for the privacy.
The authors declare that they have no competing interests.
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