____________________________________________________________________________________________

*Corresponding author: Email: kolabimbo@yahoo.com;

American Journal of TROPICAL MEDICINE &
Public Health
1(1): 1-10, 2011

SCIENCEDOMAIN international
www.sciencedomain.org

Feasible Cancer Control Strategies for Nigeria:
Mini-Review

Kolawole Abimbola Omolara
1*


1
Department of Obstetrics and Gynaecology, Ahmadu Bello University,
Shika-Zaria, Nigeria.



Received 17
th
May 2011
Accepted 24
th
May 2011
Online Ready 4
th
June 2011


ABSTRACT

Globally the incidence of cancer is rising. In 2007 there were 11 million cancer cases, 7
million cancer deaths and 25 million people living with cancer. This is estimated to increase
to 27 million cases, 17 million deaths and 75million people living with cancer in 2050. More
than 50% of these cases occur in developing countries where cancer is the second most
common cause of death. It constitutes 12% of all deaths (after cardiovascular disease);
killing more people than HIV/AIDS, Tuberculosis and Malaria combined. Cancers are
emerging public health problems in developing countries like Nigeria, where they were
previously considered rare. However the epidemiological shift and ageing population make
cancers a challenge. The number of new cancer cases which was initially estimated to be
100,000 per annum increased to about 500,000 in 2010. WHO (2008) estimates that
incidence of cancer in Nigerian men and women by 2020 will be 90.7/100,000 and
100.9/100,000; and the deaths rates 72.7/100,000 and 76,000/100,000 respectively. The
commonest cancers of Nigerian men are cancers of prostate, liver and lymphomas while
cancer of cervix and breasts are commonest in the women. Currently, Nigeria has no
national policy or a comprehensive document on cancer control. There is no organized
national program for cancer prevention. Moreover, control of reproductive cancers is rather
mentioned in the National policy on Reproductive Health and Strategic Framework. The
prevention of Human Papilloma Virus (HPV) may occur within the context of the national
program for control of Sexually Transmitted Infections (STI) and HIV.


Keywords: Cancer; Nigeria; Human Papilloma Virus; HIV; control; prevention;


Review Article




American Journal of TROPICAL MEDICINE & Public Health, 1(1): 1-10, 2011




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1. INTRODUCTION

Cancer, the generic term for carcinoma is the malignant form of uncontrolled growth of cells
and tissues. It is the most dreaded non-communicable disease in developing countries
where it is invariably fatal, due to lack of adequate preventive and curative services. Unlike
in developed countries which have policy, strategies and programs for cancer prevention
and management (WHO, 2002; Thun, 2010; Nnodu, 2010), consequently although the
incidence of cancer is rising globally, the developing countries account for 52% of this
increase (Parkin, 2003) and for 70% of cancer deaths (UICC, 2006) while only possessing
5% of global funds for cancer control and very few human and material resources (Jones,
1999). It is the second most common cause of death; constituting 12% of all deaths after
cardiovascular disease. It kills more people than Tuberculosis, HIV/AIDS and Malaria
combined (WHO 2006a, 2006b). In 2007, there were 11 million cancer cases, 7 million
cancer deaths and 25 million people living with cancer. This is projected to increase to 27
million cases, 17 million deaths and 75million people living with cancer in 2050 (WHO 2005).

The aetiology for many cancers are still unknown, however there are risk factors which are
either modifiable or non-modifiable. The modifiable factors include tobacco use, physical
inactivity, unhealthy diet, obesity, ultraviolet radiation and infectious agents like Human
Papilloma Virus (HPV), Hepatitis Viruses (HBV, HCV) and Helicobacter pylori. The non-
modifiable factors include heredity, sex, ethnicity, immunosuppression and ageing (WHO,
2002; Nnodu, 2010). Moreover, due to the epidemiological shift, increase in ageing
population, high rate of infections and entrenchment of the modifiable risk factors (Thun,
2010), cancers will yet pose significant challenge to Nigeria and other developing countries
which currently lack cancer control programs directed at reducing cancer incidence and
mortality and to improve quality of life (WHO, 2002).There are very few human and material
resources for cancer control in developing countries where cancers occur at younger ages,
70% of cancer deaths occur and only 5% of global funds for cancer control is present
(Jones, 1999).

Africa carries an increasing cancer burden, 75% of the 650,000 annual cases present late, at
younger ages and about 510,000 deaths occur (Ngoma, 2006). The incidence ranges from
70/100,000 to- 100/100,000 people. Infectious agents like Hepatitis B, C, Human Papilloma
Virus (HPV), Helicobacter pylori contribute significantly to cancers in developing countries
(Mackay 2006). The HIV pandemic is changing the pattern and prevalence of cancer
especially in East Africa where AIDS-related cancers like Kaposi sarcoma, lymphomas, anal
cancers and cervical cancers are increasing (Parkin, 2003). Kaposi sarcoma (15.5%) is now
the commonest cancer of men in sub-Saharan Africa and cervical cancer (22.2%) is
commonest in women (Ngoma, 2006).

2. LITERATURE SURVEY

This is a mini-review of literature and policy documents on cancer control for Nigeria. An
internet search was conducted for publications, policy documents and grey literature using
Google and SCOPUS search engines. The database of PUBMED, Cochrane and
Reproductive Health were searched. Information was retrieved from the websites of
international agencies and non-governmental organizations like World Health Organisation
(WHO), Federal Ministry of Health (FMOH). Additional information was got from hand-
searching some journals.





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3. CANCER SCENARIO IN NIGERIA

Annually, there are about 100,000 new cancer cases in Nigeria, this is estimated to increase
to 500,000 in 2010 (Durosinmi, 2004). WHO (2008) estimates that incidence of cancer in
Nigerian men and women by 2020 will be 90.7/100,000 and 100.9/100,000 (Table 1) and the
deaths rates will be 72.7/100,000 and 76,000/100,000, respectively.

Table 1. Trend of age standardized mortality rates (ASMR) for cancer in Nigeria by sex

Year 1960-69 1999 WHO estimate 2020

ASMR
Male - 78/100,000

Female -105.1/100,000
Male - 63.9/100,000

Female - 74.5/100,000
Male -72.7/100,000

Female -76/100,000
Source: Parkin, 2003;

Cancer currently accounts for 4.4% of all deaths and is likely to increase to 6.8% in 2030
(WHO 2008). Out of 89,000 cancer deaths in 2005; 54,000 of these were younger than 70
years. The commonest cancers of Nigerian men are cancers of prostate, liver and
lymphomas (Parkin, 2003; Globocan 2008; Awodele et al., 2011). In the women, cancer of
cervix and breasts are commonest (Adebamowo, 2007) with minimal regional variation.

Incidence of cervical cancers compared to other cancers in women of all ages in Nigeria has
been shown in figure 2. The Ibadan cancer registry showed a reduction in age standardized
mortality rate from 1960 to 1999 (Tables 1, 2 and 3). This was attributed to introduction of
user fees and reduction in the coverage area. While cervical cancer is commonest in Zaria,
Northern Nigeria (Adewuyi, 2010) as in rest of Africa (Ngoma, 2006), breast cancer has
become the commonest cancer of women in Ibadan, Southern Nigeria (Awodele et al., 2011;
Parkin, 2003). These common cancers should be the focus of cancer control programs in
Nigeria.



Fig. 1. Mortality from Cancer in Nigeria




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Table 2. Common cancers in Nigeria by sex

Registry Male

Female

Ibadan Registry 1999 Prostate 23.5%
Liver 11.6%
NHL 10.3%

Breast 35.3%
Cervix 24.4%
Ovary 4.7%
Zaria Registry 1991/92 Liver 19.9%
NHL 15.9%
Bladder 9.3%
Prostate 7.5%
Cervix 24.8 %
Breasts 20.5%
NHL 7.9%
Nigeria (overall summary)
(Globocan, 2008)
Prostate 18.2%
Liver 15.7%
Colorectum 7.8%
NHL 7.4%
Bladder 4.2%
Breast 30.7%
Cervix uteri 24.6%
Liver 4.6%
Colorectum 3.5%
NHL 3.3%
NHL is non - Hodgkins lymphoma
(Sources Parkin et al 2003, Globocan 2008, Awodele 2011)

Table 3. Summary of cancer statistics for Nigeria

NIGERIA Male Female Both sexes
Population (thousands) 75758 75453 151212
Number of new cancer cases
(thousands)
40.1 61.7 101.8
Age-standardised rate (W) 95.1 128.4 111.7
Risk of getting cancer before age 75
(%)
10.4 13.4 11.9
Number of cancer deaths
(thousands)
33.2 42.1 75.4
Age-standardised rate (W) 81.3 92.4 86.6
Risk of dying from cancer before age
75 (%)
8.9 10.3 9.6

5 most frequent cancers

Prostate Breast Breast
Liver Cervix uteri Cervix uteri
Non-
Hodgkin
lymphoma
Liver Liver
Colorectum Colorectum Prostate
Leukaemia
Non-Hodgkin
lymphoma
Non-Hodgkin
lymphoma
Methods of estimation (summary)
Incidence: Local incidence data: incidence rates were estimated as the weighted average of
the local rates.
Mortality:
No data: the number of cancer deaths was estimated from incidence estimates and site
specific survival estimated by the GDP method.
(Source: Globocan 2008)




American Journal of TROPICAL MEDICINE & Public Health, 1(1): 1-10, 2011




5



Fig. 2. Incidence of cervical cancers compared to other cancers in women of all ages
in Nigeria (Source: Globocan, 2008)

3.1 Epidemiology of Common Cancers in Nigeria

Cervical cancer is caused by persistent infection with high risk Human Papilloma Virus
(HPV) especially genotypes 16 and 18. The other risk factors include early commencement
of intercourse, multiple sex partners, high parity, poverty, smoking and hormonal
contraceptives. Following infection by HPV, invasive cancer develops after 10-15 years
during which pre-cancerous lesions can be identified using screening measures and early
treatment given to prevent progression to cancer (Sloan, 2007; Parkin, 2003).

Breast Cancer is commoner in women of age 50years and older. The two primary risk
factors for breast cancer are increasing age and female gender. Other risk factors include
early menarche, obesity, lower levels of physical activity, nulliparity, smoking, alcohol, use of
hormone replacement therapy. It often presents as breast lump or bloody nipple discharge
(Adebamowo, 2007; Barton, 1999). Thus screening can be done through periodic breast
examination and mammography of women above 40 years if available.

Liver cancer is common in men of age 40 years and older (DCPP, 2007). The risk factors
includes infection with Hepatitis B or C viruses (transmitted through infected blood, unsterile
needles and unsafe sex), alcohol use and food contamination by Aflatoxin a fungus (Sitas,
2006). Since early diagnosis and treatment of the cancer is difficult, it is better prevented.

Prostate cancer is commoner in men from 50 years old. Ageing, family history, high
consumption of fat and red meats as well as use of sex hormones are associated risk factors
(Sitas, 2006). Screening is either done through done through prostate-specific antigen (PSA)
levels, trans-rectal ultrasound scan and Digital Rectal Examination (DRE). Lung cancer is




American Journal of TROPICAL MEDICINE & Public Health, 1(1): 1-10, 2011




6

not so common in Nigeria probably because of low smoking prevalence which may however
increase due to increasing advertisement and promotion by the tobacco companies.

3.2 Cancer Control in Nigeria

The aim of cancer control program is to reduce the burden and risk factors for cancer and
improve the quality of life. This is achieved by prevention, early detection/diagnosis and
treatment as well as palliative care and psychosocial support. The program should be
evidenced based, equitable, sustainable, integrated into existing ones and gradually scaled
up (WHO, 2002). There is currently no National policy on cancer control in Nigeria; however,
control of reproductive cancers is included in the National policy on reproductive health and
strategic framework (FMOH, 2004; WHO, 2006b). It is also related to the policies on food
and nutrition and health promotion (FGN, 2003). Currently, Nigeria has less than 100
oncologists about 100 pathologists and four radiotherapy centres, thus cancer control should
focus on prevalent cancer pattern and cost-effectiveness (Durosinmi, 2004).

4. PREVENTION STRATEGIES

Generally 43% of all cancers are preventable using primary, secondary or tertiary measures
(WHO, 2002). Primary measures aim at reducing or eliminating exposure to risk factors or
carcinogens. Secondary ones aim at early detection of cancer or screening for pre-cancer
stages, while tertiary measures are treatment or palliative care given to diagnosed cancer
cases to avoid complications and improve quality of life (DCPP, 2007). One- third of cancers
are preventable by controlling tobacco and alcohol use, improving diet and by immunizing
against Hepatitis B virus. Another third are amenable to early detection and treatment while
the remaining third which are advanced will benefit from palliative treatment (WHO, 2002).
Since Nigeria is a Low-resource country, health promotion should be done for general
cancer prevention and cost-effective measures can be applied initially to at least two or three
of the common preventable cancers as a pilot and later scaled up (WHO, 2002; Jones,
1999).

4.1 Primary Prevention

Health promotion should include increasing level of physical activity of Nigerians and
preventing obesity. This involves promoting cycling, walking, physical fitness in schools and
community (DCPP, 2007). This can be done through housing and environmental policies.
Car and fuel taxes can discourage driving. Also health promotion to promote safe sex,
reduce early onset of sex and number of partners will contribute to decreasing cancer of
cervix.

4.1.1 Dietary control

Poor diet is associated with 20% of cancers. Health promotion should include increase
consumption of fruits and vegetables, while reducing salt, food additives, fat and red meat
consumption which may be risk factors for prostate, stomach and breast cancers (Jones,
1999).








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4.1.2 Tobacco and alcohol control

Tobacco use is underlying risk factor for 30% of cancers. Alcohol consumption seems to
aggravate this effect on cancers of stomach, mouth and mouth. Alcohol can be regulated by
legislation on age and high taxes (WHO, 2002). Tobacco policy should include legislation to
increase tax on tobacco, reduce marketing, banning tobacco adverts, anti-smoking
campaigns, graphic warnings on cigarette packets, reducing young peoples access to
tobacco, restrict smoking in workplace and, public places. Nigeria should implement
measures included in WHO Framework Convention on Tobacco Control (FCTC).

4.1.3 Vaccination

Improving coverage of Hepatitis B vaccination especially as part of childhood immunization
will contribute to reduction of liver cancer. Other measures include safe injection and blood
transfusion practices as well as promotion of universal health precautions (DCPP, 2007).
Proper storage of grains will prevent aflatoxin mould another cofactor for liver cancer. The
HPV vaccine will hopefully be accessible to Nigerians within ten years if the price can be
subsidized by international organizations such as (Global Alliance for Vaccines and
Immunisations) GAVI. This can cause 70% reduction in cervical cancer (WHO, 2002). The
MOH should prepare to integrate this into existing cervical cancer prevention measures.
Research on prevalent local HPV genotypes is needed and pilot prevention programs can be
initiated.

4.2 Secondary Prevention

Screening programs in Nigeria should start with cervical, breast and prostate cancers, since
screening for liver cancer without effective treatment measures will not reduce mortality
(DCPP 2007). The cervical cancer screening should be coordinated and emphasis should be
shifted to using cheaper alternatives like Visual Inspection with Acetic acid (VIA) or Visual
Inspection with Lugols Iodine (VILI) for screening at community levels at high coverage.
Cytology may continue in teaching hospitals. Nigeria is believed to have capacity to annually
screen the estimated 8000 women of reproductive age and to manage lesions found
(Adewole, 2005). According to Katz (2006) and WHO (2008) a National program can
commence with once in a lifetime screen especially of 35-40 year old women which can
reduce cervical cancer by 25-35%. Later ten-yearly or thrice-in a lifetime screening of
women between 15-64 years old can start. HPV DNA testing is another cost-effective
measure but not feasible in Nigeria for now due to cost and non-availability.

Although, mammography for all Nigerian women over 40 years is currently not feasible, few
hospitals with the machine can start pilot studies and opportunistic screening. However,
Periodic Breast Examination (PBE) should be promoted for all women especially above 25
years. Clinical Breast Examination (CSE) with 54% sensitivity and 94% specificity is effective
for early diagnosis (Barton, 1999). Screening for prostate cancer in men over 50 years old
using Prostatic Surface Antigen (PSA) and trans-rectal ultrasound can commence as pilot
program, while Digital Rectal examination (DRE) continues as opportunistic screening
(WHO, 2002).








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4.3 Tertiary Prevention

4.3.1 Early treatment

Cancers of cervix, breast and prostate are potentially curable if detected early and
adequately treated (WHO 2002). Currently they are managed in Nigerian tertiary hospitals
usually with no national treatment protocols and expertise is restricted by low volume of
cases. There is need for specialized cancer centres in the six geopolitical zones. These will
be referral centres providing specialized care, training and conducting research. They should
be equipped to provide investigations, radiotherapy, chemotherapy and radical surgery.
They should collaborate with other cancer centres in developed countries (Adebamowo,
2007).

4.3.2 Palliation

The quality of life of cancer patients with terminal disease or when treatment is unavailable
can be improved by providing analgesics using a step ladder approach from simple drugs
like aspirin to opiates (WHO, 2002; Sloan, 2007). Analgesics are given orally and timed not
waiting for patient to demand it. Nigeria will need to relax some drug regulation laws in order
to increase access to these drugs. Palliative care requires collaboration with counsellors and
religious leaders. It can be provided at hospices or at home so that pressure on health
system can be reduced.

5. CONCLUSION

Cancer incidence and mortality are emerging public health problems in developing countries
like Nigeria. This is due mostly to increasing ageing population, high prevalence of cancers
associated or caused by infections including HIV and entrenchment of the modifiable risk
factors in the populace. In view of the paucity of human and material resources, the Nigerian
government will need to urgently work on cancer control policy, strategies and programs
especially for common cancers of breast, cervix, prostate, liver and prostate. Cancer
prevention should commence at community level with cost-effective measures directed
initially at two or three of the common preventable cancers chosen for pilot programs.
Subsequently as resources improve, this can be scaled up. There should be concerted effort
to introduce the HPV vaccine, whilst improving coverage for Hepatitis vaccinations. Also, the
activities of various hospitals, NGOs, government and researchers should be coordinated by
a central (national) body. There should be improvement in on-going surveillance for cancers
and their risk factors through community surveys and regional cancer registries. Finally,
there is need to build capacity of personnel and facilities involved in cancer care, these will
contribute to reducing the burden of cancer in Nigeria.


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________________________________________________________________________
2011 Kolawole; This is an Open Access article distributed under the terms of the Creative Commons Attribution
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