Malawi National Cancer Control Strategic Plan 2019-2029

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Government Printing Press
In Malawi cancer is of growing concern, causing significant morbidity and mortality due to lack of comprehensive cancer prevention, early detection, treatment and palliative care services. The IARC GLOBOCAN estimates for Malawi indicate total annual new cancer cases at 15,349, with 5966 cases among men and 9383 in women around 2012. Among women, the major cancers were; uterine, cervix (n=3684), Kaposi’s sarcoma (KS, n=997), esophagus (n=895), breast (n=762); among men, the major ones were KS (n=1810), esophagus (n=1094), non-Hodgkin lymphoma (n=695), prostate (n=349) and urinary bladder (n=309). Malawi has the highest age standardized incidence rate (75.9/100,000 women) of cervical cancer in the world, with the risk of one out of 14 Malawian women developing cervical cancer in her life time. The projected cancer burden might be underestimated due to inadequate cancer diagnostic services and underreporting of clinically diagnosed cases given that only 18% of all reported cancers had pathological confirmation. This national cancer control strategy will serve as the policy document for planning and implementing cancer prevention, early detection, treatment, follow-up and palliative care interventions at different levels of governance and for the efficient monitoring and evaluation of the cancer interventions. It outlines a multi-sectoral partnership to address key issues related to specific major cancer types, taking into consideration the disease burden, risk factor prevalence, available resources and a variety of stake holders. This Strategy aligns itself to the efforts of non communicable disease (NCDs), Clinical Directorate and National Health Sector Strategic Plans (HSSPⅡ) (2017-22) and other policy documents. The strategy aims to achieve a state of health for all the people of Malawi with low burden of cancer that would enable them to lead high quality and highly productive lives, boosting national development. It will provide strategic direction in implementing a coordinated and responsive cancer control framework leading to a reduction in incidence, morbidity and mortality and improved quality of life through effective partnerships and collaborations for prevention, diagnostics, treatment, palliation and financing of cancer control activities to improve the wellbeing of Malawians. To achieve the above objectives, planned interventions and monitoring and evaluation are organized into six thematic areas: 1) prevention; 2) screening and early diagnosis; 3) treatment and follow-up care; 4) palliative care and survivorship; 5) governance and financing; 6) cancer control research, monitoring and evaluation. The planned prevention strategies include; avoiding cancer causing chronic infections, tobacco use, reduce alcohol consumption, maintaining a healthy body weight, regular physical activity and consuming healthy diets. Primary interventions encompass those which reduce exposure to potential risk factors associated with cancers as well as immunization against infectious agents commonly associated with cancers such as human papillomaviruses (HPV) and Hepatitis-B viruses. Integrating the various forms of interventions into other programs will likely give optimal public health benefits, with minimal costs and long-term cancer control benefits. Some areas of possible integration include sexual and reproductive health initiatives, human immunodeficiency virus (HIV)/ acquired immunodeficiency syndrome (AIDS) control programs, national immunization programs to improve uptake of HPV and Hepatitis B vaccinations, occupational and environmental health initiatives and other lifestyle modification programs targeting the general public. A multi-sectoral approach is critical in the context of tobacco control, since Malawi has some key challenges as tobacco farming and exports are major contributor to Malawi’s economy and the country has not yet ratified WHO Framework Convention on Tobacco Control. Recently, Malawi has completed HPV vaccination of around 23,000 girls aged 9-13-year-old girls with high coverage and is planning a national scale up is underway. A national HIV prevention strategy for the period 2015-2020 is currently being implemented to achieve the UNAIDS 90-90-90 targets by 2020, which will have important implications for the prevention of Kaposi’s Sarcoma. Cancer detection at its early stages enables treatment that is generally more effective, less complex and more affordable, resulting in long-term survival and high cure rates with good quality of life. Early detection involves two major approaches, namely screening involving detection of preclinical disease in asymptomatic people and early diagnosis involving early detection in symptomatic patients. These two are fundamentally different in resource and infrastructure requirements, impact and costs, but require prompt linkage to treatment and follow-up care without delay. In response to the high incidence and mortality from cervical cancer, Ministry of Health and Population (MOHP), is implementing nationwide visual inspection screening with acetic acid (VIA) for cervical neoplasia as part of the Cervical Cancer Control Program (CECAP) in collaboration with its stakeholders. Efforts are taken to expand and improve the coverage of VIA screening and treatment of screen positive women. With a judicious combination of HPV vaccination and screening, Malawi can anticipate dramatic future reductions of cervical cancer. Infrastructure and trained human resources for major cancer treatment modalities such as surgery, radiotherapy, chemotherapy and hormone therapy are grossly inadequate or lacking in Malawi with consequent poor survival outcomes. Type of cancer, stage at diagnosis and quality of treatment and follow-up care are important determinants of treatment outcomes. Efforts will be taken to improve availability and access to cancer early diagnosis and treatment and it is anticipated that most cancer patients will get optimal, resource appropriate Treatment and care in due course. Cancer treatment in Malawi is anticipated to take new dimension with the development of the National Cancer Treatment Center (NCTC) in Lilongwe which is due to open in 2020. The operationalization of the cancer centre will be the single most important initiative in the national cancer control program of Malawi given the fact that cancer treatment is currently highly fragmented and provided in overextended hospitals with limited infrastructure, consumable supply chain problems and limited skilled and experienced human resources. The cancer center is planned within the campus of Kamuzu Central Hospital (KCH), as a matrix type of cancer centre with its own cancer surgery, radiotherapy, chemotherapy, hormone therapy, palliative care, medical records and hospital cancer registry services and sharing pathology and other allied diagnostic and super-specialty treatment services with KCH. Cancer services are provided with highest quality of care in cancer centres that are autonomous, without administrative and beaurocratic entanglements and hitches. It is important that the proposed National Cancer Treatment Center should be an autonomous body with its own governing and scientific councils for is efficient functioning. Government of Malawi recognizes the importance of palliative care to improve the quality of life and symptom burden for all patients and families affected by life threatening illnesses including cancer. In October 2014, MOHP, Government of Malawi formulated a national palliative care policy to take forward the national agenda for the health sector. The National Cancer Control Strategy will heavily rely on the implementation of the national palliative care policy including appropriate access to immediate release morphine for the treatment of severe cancer related pain to achieve tangible progress in extending high quality appropriately staffed palliative care services across Malawi. The national cancer control strategy and its monitoring and evaluation shall be implemented in a program mode under the supervision of a national cancer control coordinator supported and advised by the cancer control advisory committee. Monitoring and evaluation forms an essential component of the cancer strategy and will seek to link and benefit from existing systems such as population based cancer registration, hospital registries, medical records departments, cross sectional surveys, follow-up studies and case series. The inputs of interventions and the evaluation of outcomes will be monitored and evaluated using short-term (1-2 years), medium term (3-5 years) and long term (5-10) time lines. The National Cancer Control Strategy will risk remaining a paper tiger unless it is linked with planned budget outlays and budget lines to support its implementation and evaluation.