What is an effective national cancer control plan?

Cancer remains a leading cause of mortality worldwide, accounting for nearly one in six deaths in 2020. While there are promising trends - such as cancer survival continuing to increase across high-income countries - global disparities persist. There are also gaps in prevention, treatment and equitable access to services and medicines, which could be better addressed in many countries with more effective planning. 

A national cancer control plan (NCCP) offers governments the strategic tool to improve the prevention of cancer and ensure that appropriate treatment and supportive care are available based on the country’s specific needs and resources.  

The development and implementation of NCCPs are critical for a country to translate objectives into action and to reduce their national burden of cancer. 

UICC speaks with Lisa Stevens, Director of the Programme of Action for Cancer Therapy at the International Atomic Energy Agency (IAEA) and Geraldine Arias de Goebl, Head of the IAEA’s Cancer Control Review and Planning, about the importance of national cancer control planning, the designing of an NCCP and the challenges to implementation. 

What are the building blocks of an effective national cancer control plan? 

A national cancer control plan is a strategy document designed at the highest level of government to set cancer control priorities, or the actions the country should take, for the prevention, diagnosis, treatment, palliation, survivorship care, data collection and monitoring of cancer. 

These actions must be founded on an evidence-based assessment of the country’s cancer burden, in other words the number of cases, the mortality rate, the most prevalent types of cancer, and the general stage of diagnosis. An effective NCCP also addresses issues related to human resources, such as staffing, workforce expertise, training as well as research. 

Furthermore, a NCCP can only be implemented if the appropriate resources are allocated to it. The costing and financing strategy must be developed when the NCCP is designed – to determine the most resource-efficient actions to address the most urgent priorities. WHO has developed costing and other tools to help achieve this goal. And more specifically, for countries with specific plans to expand radiotherapy, the IAEA has the tools to estimate the required financial resources. 

Finally, a country needs to look at the implications of any decisions made along the cancer continuum. For instance, a country where cancers are often detected late could benefit from routine screening programmes to detect cancers earlier. However, if there are not sufficient treatment services, then increasing screening will only result in more cancer cases being diagnosed – but with no access to treatment. In this case, the country should first focus on expanding treatment facilities, while improving prevention and clinical expertise in recognising the early signs and symptoms of patients so that they can be directed to the appropriate specialist and treatment pathway. 

Essentially, the implementation strategy for a NCCP looks at how to budget for and finance the necessary measures to reduce cancer mortality and morbidity, and in what order they should be set up. 

An effective cancer plan depends on knowing and addressing a country’s specific cancer burden. For that, reliable data is essential. How does a country gather that data? 

Data collection starts at the hospital level, with clinics recording the disease types and characteristics to establish a population-based registry. A cancer registration is essential to identify the types of cancer prevalent in a country, the number of cases, the mortality, the populations most affected and other information, which is important not only to design an effective strategy but also to monitor the impact of any cancer plan. 

The International Agency for Cancer Research (IARC) works with countries and national partners to assess local cancer data and expand data collection to cover all populations. 

Understanding a country’s cancer burden is so fundamental to developing an efficient cancer plan that all countries should start by strengthening their registries and enhancing data collection. This can be started in year one and feed into the revision of cancer plans as the data becomes more and more representative and reflective of the state of health of the population.  

What are other essential aspects to building a cancer control plan? Who are the key stakeholders in planning and implementing a NCCP? 

Typically, the design of a NCCP is led by the Minister of Health as it is a strategic document but also an operational document that requires budget allocation and high-level approval. There is often a department or unit within the ministry dedicated to cancer control, and that would need to involve other departments and expertise – family planning unit, women’s health, surveillance and statistics and data collection departments to ensure that data collection efforts are not being duplicated. 

A NCCP must also involve civil society and non-government organisations involved in implementing the programme. These organisations provide inputs based on their experience and best practice and are often key implementers in areas such as prevention and palliative care. Academia is also important as it leads on research and clinical trials and implementation builds on lessons learned by academia clinicians and research. Finally, it is important to bring in partners from the international community who can provide additional external resources for implementation. 

When you have all these stakeholders’ input, it gives more of a level of ownership and validity than if it were just in the hands of one person such as the director of the cancer unit at the ministry of health. Not only do far more people have a vested interest in seeing the plan implemented and can hold each other accountable, but also if government changes, there is a far better chance of continuity in implementation. It is a national strategy, not one person’s project. 

This multistakeholder approach is key but sometimes that’s not how ministries of health work. It can be easier if one or two people lead the project, but if there is no broad involvement, then the plan just remains a plan. 

What is the current situation internationally with respect to the number of countries who have developed control plans – and have we seen a positive trend in the past 10-15 years? 

There has been a promising increase in the number of countries which have developed national cancer control plans, from 66% in 2013 to over 80% in 2020. The International Cancer Control Partnership has consolidated all publicly available national cancer control plans from 121 countries and made them publicly available on its website for consultation.  

The challenge for some countries now is implementing the plan, and certainly the pandemic has had a negative impact. Not only health but also administrative staff were often pulled off regular work to refocus on COVID-19. People either could not or were reluctant to go to hospital, and therefore screenings dropped significantly. Patient cancer treatment and monitoring plans were interrupted to prioritise a COVID-19 related response in medical facilities. This will have an effect downstream on mortality, as many cancers have gone undetected and will be diagnosed at a more advanced stage when they are harder to treat.  

There is still a desire to focus health funding narrowly on pandemic preparedness, but it should instead go into strengthening health systems overall, so that not only are we better prepared for a future pandemic and to manage other diseases, but so that we can also address backlogs in the diagnosis and treatment of non-communicable diseases like cancer. 

You mentioned the challenge of implementation – why do some countries develop plans but fail to implement them or do so ineffectively? How can the challenges be addressed? 

As mentioned earlier, it may be because the development of the plan did not include a wide range of stakeholders, so either there is little accountability, or the plan is shelved when the government changes. Or because there are only isolated entities working in siloes, with responsibility over a narrow part of the plan and whose efforts are not coordinated. There needs to be a governance mechanism for cancer planning, with someone in a high-level position of responsibility with convening and decision-making power, the authority to make decisions and to request and allocate funding.  

Furthermore, the overall governance structure has to ensure that different, high-level stakeholders who may otherwise not have authority over each other, such as the different ministries – health, higher education, family planning, for instance – can be convene and collaborate, share data and pool resources.  

Another reason may be the lack of monitoring system to take corrective action if things are going wrong. If the issue that undermined the effectiveness of the strategy is only discovered at the end of the five-year plan, it is obviously too late. 

It may also simply be a question of resources, perhaps a plan that was too ambitious. It is better to have a reasonable, appropriately scaled plan, that aligns the country’s fundamental objectives with existing resources, rather than a wide-ranging plan that requires funding that is unrealistic.  

What are some means at a country’s disposal to finance a national cancer control plan? 

The taxation of unhealthy products that present a cancer risk, such as alcohol or tobacco, is a good source of revenue.  

Governments should also look at including cancer services in basic universal health coverage schemes. This will allow greater participation in vaccine, screening and other prevention programmes. 

Can you give us a couple of examples of successful practices at a national level? 

There has been countries advancing the work on their NCCP with exemplary governance mechanisms in place – with dedicated teams that have the capacity to convene stakeholders, collect and maintain data, and monitor cancer interventions. Another example could be prioritisation, with countries identifying a key gap. If, for example, a country identifies a lack of a well-structured radiotherapy plan, it may focus efforts on generating support and mobilising partners for radiotherapy treatment. 

How does the international community support countries in low-resource settings in developing and implementing a NCCP? 

A main source of support comes from a joint UN programme including WHO, IARC and the International Atomic Energy Agency (IAEA), which provides technical support to Member States who want to develop a cancer plan.  

Before the pandemic, the programme supported one to two countries annually. Since the end of 2020, the number of requests has soared, with about 12 countries now developing plans, particularly in Africa and Latin America. The programme makes an inter-disciplinary team of experts available to the ministries of health, through both in-person and virtual meetings. These experts cover data registration, early detection, diagnostic and treatment. The idea is to guide countries in writing their plans but not write them for them; only in that way can ownership and good chances of implementation be secured.  

Technical assistance through telementoring on implementing plans is also provided by ICCP, which was formed to coordinate efforts between organisations working on the ground and avoid duplication, as well as to help multiple countries at a time. In particular, ICCP now hosts an ECHO supporting countries that are actively implementing their national cancer control plans.  

 

The International Cancer Control Partnership (ICCP) 

ICCP is a unique initiative formed in 2012 to assist countries in developing and implementing a NCCP. The Partnership unites a number of organisations working to support country cancer control planning efforts around the world.