key: cord-1034227-s1l1hca5
authors: Neugut, Alfred I.; El‐Sadr, Wafaa M.; Ruff, Paul
title: The Looming Threat: Cancer in Sub‐Saharan Africa
date: 2021-09-29
journal: Oncologist
DOI: 10.1002/onco.13963
sha: 99456df27b6cd14d7453b8d7ea800eeda2dfadf7
doc_id: 1034227
cord_uid: s1l1hca5

Recent trends in cancer epidemiology in low‐ and middle‐income countries show the need for urgent action. This article focuses on sub‐Saharan Africa, where populations are showing an increased risk for diseases associated with the Western lifestyle, including cancer.

have left behind more active lifestyles in rural areas, and have adopted more meat rich "fatty" diets associated with depletion of fresh vegetable/fruit "high fiber" diets [4] . All these lifestyle and health access changes have contributed toward an increased risk of chronic noncommunicable diseases [5] .

Mayosi and colleagues have reported that in South Africa, home to the largest population of people living with HIV in the world (approximately 23%), the recent decades have seen a rise in chronic noncommunicable disease rates attributable to the changes in risk factors noted above. In particular, they reported that between 1999 and 2006, the mortality rate from prostate cancer increased by 12%, whereas breast cancer mortality increased by 21% [5] . More recent studies have suggested that these increases in cancer rates have continued and have been observed for other malignancies as well [6] . Increases have also been noted throughout SSA for incidence for various major cancers, including breast, colorectal, lung, and prostate cancers. Recent increases in colorectal cancer incidence rates in South Africa, especially in younger patients, have paralleled increases in socioeconomic changes among ethnic groups [7] . Others have recently suggested that as countries develop economically, the types of cancers observed also evolve from those that are infection-related to those that are not infection-related [1] .

These recent trends in cancer epidemiology compel the need for urgent action. There is an urgent need to put measures in place to address the risk factors for various cancers in order to stem the rise in cancer rates. Unfortunately, tobacco use is increasing in SSA as it stands more than 30% in that region as compared with <15% in the U.S., where lung cancer incidence and mortality rates are falling dramatically. A serious effort to stem the use of tobacco, particularly given the reported increased susceptibility of persons living with HIV to its carcinogenic effects, is called for [8]. The high rates of cervical cancer and other squamous cell malignancies must motivate the urgent necessity to expand vaccination programs for human papillomavirus as well as for hepatitis B virus for the prevention of hepatocellular carcinoma in endemic areas. Vigorous efforts are needed to expand community informational campaigns and provider education regarding cancer prevention measures, such as tobacco cessation, calorie control, and obesity prevention. Although routine cancer screening has proved to be an important cancer control modality for certain cancers in HICs, thus far, the one cancer for which there has been screening efforts in SSA is cervical cancer. With almost no breast or colon cancer screening being conducted in the region, this has limited the information on rates of these cancers. The higher rates of breast cancer in high-income countries may reflect, in part, the increased use of breast cancer screening programs [9] . The costs of mammography or colorectal screening are substantial and beyond the reach of most individuals and programs in SSA. Their use for high-risk groups may need to be prioritized in this context.

Of equal importance is the need for enhanced capabilities for diagnosis and management of cancers in the region. In many ways, although HIV is now considered a chronic manageable condition, cancer is often thought of as a "death sentence." As things stand now, there are limited infrastructure and capabilities for cancer diagnosis and care, such as limited radiation therapy accelerators, inadequate pathology services, palliative and hospice, and social support systems, a paucity of well-trained oncologists and oncology nurses, and a dearth of the resources to secure access to an ongoing supply of modern cost-effective cancer chemotherapeutic agents.

Faced with this threat, combined with limited prioritization of cancer as a public health challenge in SSA and the lack of resources and programs to confront it, we urge that a comprehensive health systems focused approach be adopted to address these gaps. Table 1 shows examples of priority recommendations by health system building blocks, that is, financing, governance, laboratory, commodities, human resources, information systems, service delivery and community.

The global COVID-19 pandemic offers some important lessons learned, particularly with regard to virtual learning for health providers, as well as opportunities for the dissemination of information and provision of mentorship and supportive supervision [10, 11] .

The global mobilization that focused on addressing HIV, tuberculosis, and malaria has made an enormous difference in the lives of people in SSA. However, SSA now faces a double health threat, the continued threat of conditions that have prevailed for decades in LMICs and are now facing those that dominate in HICs. Cancer is emblematic of these new threats. However, there is reason for optimism, as countries in SSA are poised to adapt the strategies they developed to address communicable disease can be adapted to respond to cancer and other noncommunicable diseases. But the reality is that it will take a strong will, national leadership, resource mobilization, and a commitment to working together across continents and borders to advance the health and well-being of the people living south of the Sahara Desert as they face their next health challenge. 

Evaluation of the cancer transition theory in the U.S., select European Nations, and Japan by investigating mortality of infectious-and noninfectious-related cancers

aging and continuity care: Strengthening health systems to support services for noncommunicable diseases in low-income countries

Why reinvent the wheel? Leveraging the lessons of HIV scale-up to confront non-communicable diseases

A comparative risk assessment for South Africa in 2000: Towards promoting health and preventing disease

The burden of non-communicable diseases in South Africa

Distribution of cancer mortality rates by province in South Africa

Costs, affordability, and feasibility of an essential package of cancer control interventions in low-income and middle-income countries: Key messages from Disease Control Priorities

Demographic changes in breast cancer incidence, stage at diagnosis and age associated with populationbased mammographic screening

Global access to technology-enhanced medical education during the COVID-19 pandemic: The role of students in narrowing the gap

Using virtual learning to build pediatric palliative care capacity in South Asia: Experiences of implementing a teleteaching and mentorship program (Project ECHO)