imPACT Review Cancer Control Capacity and Needs Assessment Report submitted to the Ministry of Health, Nutrition and Indigenous Medicine Sri Lanka November 2019 Table of Contents ACRONYMS AND ABBREVIATIONS............................................................................. 3 EXECUTIVE SUMMARY ................................................................................................. 4 PRIORITY RECOMMENDATIONS ................................................................................ 10 1. THE REVIEW.............................................................................................................. 16 1.1. PURPOSE............................................................................................................................................................ 16 1.2. REVIEW TEAM COMPOSITION .......................................................................................................................... 16 2. REVIEW FINDINGS AND RECOMMENDATIONS ................................................... 18 2.1. HEALTH SYSTEM OVERVIEW ........................................................................................................................... 18 2.2. BURDEN OF DISEASE ........................................................................................................................................ 21 2.3. NATIONAL CANCER CONTROL PLANNING AND GOVERNANCE ...................................................................... 23 2.4. REGISTRATION AND SURVEILLANCE................................................................................................................ 27 2.5. PREVENTION...................................................................................................................................................... 32 Tobacco Control ................................................................................................................................................. 32 Alcohol Control .................................................................................................................................................. 35 Physical Activity and Diet.................................................................................................................................. 36 Immunization ...................................................................................................................................................... 36 2.6. EARLY DETECTION ........................................................................................................................................... 38 Oral Cancer and Precancerous Lesions ........................................................................................................... 38 Cervical Cancer.................................................................................................................................................. 39 Breast Cancer ..................................................................................................................................................... 41 Thyroid Cancer................................................................................................................................................... 41 Other Cancers..................................................................................................................................................... 42 2.7. DIAGNOSIS ........................................................................................................................................................ 44 2.7.1 Pathology and Laboratory Services......................................................................................................... 44 2.7.2 Diagnosis Imaging and Nuclear Medicine (including treatment) ......................................................... 47 2.8. TREATMENT ...................................................................................................................................................... 52 2.8.1 Medical Oncology ..................................................................................................................................... 52 2.8.2 Radiation Oncology .................................................................................................................................. 56 2.8.3 Surgical Oncology..................................................................................................................................... 60 2.8.4 Paediatric Oncology ................................................................................................................................. 64 2.9. PALLIATIVE CARE............................................................................................................................................. 65 2.10. CIVIL SOCIETY ................................................................................................................................................ 69 2.11. RADIATION SAFETY CONSIDERATIONS.......................................................................................................... 72 2.12. RADIOACTIVE MATERIAL SECURITY CONSIDERATIONS ............................................................................... 74 ANNEX 1: MISSION AGENDA ................................................................................................................................... 77 ANNEX 2: BACKGROUND INFORMATION ON IARC, IAEA AND WHO ................................................................. 89 ANNEX 3: DESCRIPTION OF IMPACT REVIEWS ...................................................................................................... 92 ANNEX 4: COUNTRY SPECIFIC CANCER CONTROL RESOURCES ............................................................................ 93 Acronyms and Abbreviations ASR Age Standardized Rate CME Continuous Medical Education CSO Civil Society Organization CT Computed Tomography EPI Expanded Programme of Immunization EPHS Essential Package of Health Services FCTC Framework Convention on Tobacco Control (WHO) GAVI Global Alliance for Vaccines GICR Global Initiative for Cancer Registry GNI Gross National Income HBCR Hospital-Based Cancer Registry HBV Hepatitis B Virus HIV Human Immunodeficiency Virus HPV Human Papillomavirus IAEA International Atomic Energy Agency IARC International Agency for Research on Cancer LMI Low and Middle Income (countries) MRI Magnetic Resonance Imaging NCCP National Cancer Control Plan NCD Non-Communicable Disease NGO Non-Governmental Organization ORL Otorhinolaryngology PACT IAEA Programme of Action for Cancer Therapy PBCR Population-Based Cancer Registry PSA Prostate-Specific Antigen RT Radiotherapy STEPS STEPwise approach to Surveillance (WHO) US Ultrasound VIA Visual Inspection with diluted Acetic Acid WHO World Health Organization WHO-PEN World Health Organization Package of Essential Non-Communicable Diseases WWCs Well Women Clinics HLCs Healthy Lifestyle Centres 3 Executive Summary According to GLOBOCAN estimates (2018), each year 23 530 new cancer cases and 14 013 cancer related deaths are recorded in Sri Lanka. The most common cancers among women are breast, cervix, thyroid and ovary. In men, the most common cancers are oral cavity, lung, oesophagus and colorectal. In terms of number of new cases and most prevalent types of cancer, national data are very similar to GLOBOCAN estimates, though latest data are available from 2014. The Ministry of Health statistics from the same year, ranks cancer as the second leading cause of hospital deaths after ischaemic heart disease, with 24 mortality cases per 100,000. National cancer surveillance system relies on two major population-based cancer registries: the Sri Lanka Cancer Registry (SLCR) and the Colombo District Cancer Registry (Colombo PBCR). Both generate minimum incidence rates, very limited mortality data, no survival rates data and therefore don’t fulfil all the essential elements of a population-based cancer registry. Cancer is not a notifiable disease in the country, which would help with regular, accurate and timely reporting at national and regional levels. The opportunity to improve the system includes focusing on the wide list of institutions possessing relevant cancer data. In addition to hospitals, this includes health insurance agencies, cancer screening programmes and the vital statistics office. All these stakeholders should be considered while drafting the cancer registry legal framework to establish cancer as a notifiable disease. Healthcare in Sri Lanka is delivered via a hybrid system, mainly composed of public and private sector. Allopathic medicine is predominant compared to indigenous traditional medicine. The public sector model offers free services at all levels of health care. 90% of in- patient care is delivered within the public sector. Outpatient care is delivered more equally between the public and the private health sector. Although cancer-specific data are not available, it is assumed that a similar distribution exists. An important challenge of the health system are the inequities in availability of cancer services across provinces. Geographical access is a constraint for patients living outside major health centres. The health system response to cancer is translated into the main Government health policy, the National Cancer Control Plan (NCCP, 2015). The plan is well structured, and its scope and objectives are still relevant for the context. An important missing component