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235. Ugolini, F. et al. WNT pathway and mammary Acknowledgements to tackle this disease. Raising awareness
carcinogenesis: loss of expression of candidate We thank C. Birchmeier and R. Hodge for helpful discussions
tumor suppressor gene SFRP1 in most invasive and improving our text. J. Fritzmann advised us on drugs and of this looming epidemic in Africa is
carcinomas except of the medullary type. Oncogene clinical aspects. The work of our laboratory is funded by the the first step. If the international cancer
20, 5810–5817 (2001). German Research Foundation (DFG), the German Cancer Aid
236. Uematsu, K. et al. Activation of the Wnt pathway in (Deutsche Krebshilfe), and the German Federal Minister of community takes concerted action now,
non small cell lung cancer: evidence of dishevelled Research and Technology (BMBF). working in partnership with the African
overexpression. Oncogene 22, 7218–7221 (2003).
237. Uematsu, K. et al. Wnt pathway activation in DATABASES Health Ministries, another tragedy can be
mesothelioma: evidence of Dishevelled overexpression Entrez Gene: prevented. To establish cancer care pro-
and transcriptional activity of β-catenin. Cancer Res. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=gene
63, 4547–4551 (2003). Apc | armadillo | β‑TrCP | caveolin | CBP | CCL9 | CK1a | CTNNB1 | grammes in African countries requires the
238. Wissmann, C. et al. WIF1, a component of the Wnt dishevelled | DKK1 | FAM123B | FGF4 | FGF18 | Frizzled | FZD10 | integration of clinical and public-health
pathway, is down-regulated in prostate, breast, lung, Hyrax | Indian hedgehog | Int1 | Islet1 | KRAS | Kremen | lef1 |
and bladder cancer. J. Pathol. 201, 204–212 Legless | LRP5 | LRP6 | MYC | Norrin | NRCAM | OLIG3 | porcupine | systems so as to be truly comprehensive,
(2003). Pygopus | SMAD2 | SMAD4 | TP53 | Ultrabithorax | VEGF | WIF1 | and must bring together prevention, early
239. Yoshikawa, S., McKinnon, R. D., Kokel, M. & WNT1 | WNT2B | Wnt5a | Wntless | zeste white 3
Thomas, J. B. Wnt-mediated axon guidance via National Cancer Institute: http://www.cancer.gov/ detection and diagnosis, treatment, pal-
the Drosophila Derailed receptor. Nature 422, colon cancer | hepatocellular carcinoma | medulloblastoma | liative care and the investment needed to
583–588 (2003). melanoma | thyroid tumours | Wilms tumours
240. Tao, Q. et al. Maternal wnt11 activates the canonical deliver these services. This will require
wnt signaling pathway required for axis formation in FURTHER INFORMATION trained staff, equipment, relevant drugs
Xenopus embryos. Cell 120, 857–871 (2005). W. Birchmeier’s homepage: http://www.mdc-berlin.de/en/
241. Li, X. et al. Sclerostin binds to LRP5/6 and research/research_teams/signal_transduction_invasion_ and information systems, supported by
antagonizes canonical Wnt signaling. J. Biol. Chem. and_metastasis_of_epithelial_cells/index.html broad and effective partnerships between
280, 19883–19887 (2005). Avalon: http://www.avalonrx.com/content.aspx?id=36
242. Semenov, M., Tamai, K. & He, X. SOST is a ligand for Curis: http://www.curis.com/pipeline.php local health-care delivery systems, research
LRP5/LRP6 and a Wnt signaling inhibitor. J. Biol. Nuvelo: http://www.nuvelo.com institutions, international organizations,
Chem. 280, 26770–26775 (2005). Roel Nusse’s webpage:
243. Takeda, H. et al. Human sebaceous tumors harbor http://www.stanford.edu/~rnusse/wntwindow.html non-governmental organizations (NGOs),
inactivating mutations in LEF1. Nature Med. 12, The Genetics Company: http://www.the-genetics.com/ national governments in developed and
395–397 (2006). ?menu=therapeutics&sub=wntinhibitors&doc=main
244. Martello, G. et al. MicroRNA control of Nodal developing countries, and the pharmaceuti-
SUPPLEMENTARY INFORMATION
signalling. Nature 449, 183–188 (2007).
See online article: S1 (table)
cal industry. The relevant organizations and
245. Barker, N. et al. Identification of stem cells in small
intestine and colon by marker gene Lgr5. Nature 449, All links are active in the online pdf
individuals must be brought together to
1003–1007 (2007). develop achievable and sustainable national
cancer plans that are evidence-based,
priority-driven and resource-appropriate
for African countries.
S cience and society
Cancer burden
The challenge of cancer control In 2002, 7.6 million people worldwide died
of cancer. This was 13% of the global mor-
in Africa tality burden and, perhaps surprisingly,
more than the number of deaths from
HIV/AIDS, TB and malaria combined
Rebecca J. Lingwood, Peter Boyle, Alan Milburn, Twalib Ngoma,   (~5.6 million)3 (FIG. 1a).
John Arbuthnott, Ruth McCaffrey, Stewart H. Kerr and David J. Kerr The World Health Organization (WHO)
has estimated that the global cancer burden
Abstract | While the world is focused on controlling the spread of diseases such will increase, according to current trends,
as HIV and malaria in the developing world, another approaching epidemic has from 10 million new cases per year in 2000
been largely overlooked. The World Heath Organization predicts that there will to 16 million in 2020. Remarkably, 70% of
these cases will be in the developing world,
be 16 million new cancer cases per year in 2020 and 70% of these will be in the
rising from 5.2 million annually to 8.8
developing world. Many of these cancers are preventable, or treatable when million by 2020, an increase of ~60%. Sub-
detected early enough. Establishing effective, affordable and workable cancer Saharan Africa will account for >1 million
control plans in African countries is one step in the right direction toward of these cases by 2020 (REF. 4).
limiting this epidemic. Although the AIDS epidemic has seen
the relatively indolent tumour Kaposi sar-
coma leap to the top of the cancer league
In the developing world, one-third of developing world, the challenges posed are tables for Uganda, Swaziland, Malawi and
cancers are potentially preventable and substantial (BOX 1). Zimbabwe, FIG. 2 shows the other prevalent
another third are treatable if detected early1. The world is focused on controlling tumour types, with cervical and breast
However, in many developing countries, the spread of HIV, tuberculosis (TB) and carcinoma predominating in women and
governments and institutions face a wide malaria, which are all acknowledged to be prostate and liver cancer in men5.
range of serious health problems and cancer major killers in the developing world, and
is often not a priority in limited-resource huge sums of money are currently available Cancer infrastructure in Africa
settings. Currently, a cancer diagnosis in to help combat these diseases2. Cancer One of the levers used to promote invest-
the developing world means a painful and is set to become the newest epidemic in ment in cancer control in developed
distressing death in most cases. Although the developing world, with the potential countries was the international comparison
there is increasing awareness of the magni- to claim a vast number of lives, but cur- of relative spend and infrastructure in neigh-
tude of the growing cancer problem in the rently there is limited funding available bouring nations, the lobbyists using these

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data as the main drive for further inward welcome the support of the international to assess reliably the types and prevalence of
investment. For example, in the UK in the oncology community in tackling the cancers experienced by populations on the
late 1990s, the then Prime Minister and then growing cancer epidemic, but that in African continent, assess changes in these
Health Secretary (A.M.) were swayed by order to deliver comprehensive cancer patterns over time and, therefore, assess the
international league tables suggesting that control to Africa we must integrate with effect of any interventions associated with
the UK was toward the lower end of cancer existing programmes that are tackling the cancer control programme. There are
survival tables and had significantly longer HIV/AIDS, TB and malaria. few cancer intelligence units in Africa at the
treatment waits and fewer cancer special- This was the first collective and defini- moment and those that do exist invariably
ists and treatment facilities than European tive statement by a representative cross- suffer from lack of funds and do not cover
neighbours. This led to the creation of a section of African Health Ministries of enough of the population to allow reliable
funded National Cancer Plan. the urgent need to initiate cancer control extrapolation of data for the whole country.
If we make the comparison, however, programmes. It lays to rest the myth that Cancer registries also form a useful frame-
between developed and developing coun- the only health priorities in Africa are infec- work for evidence-based cancer research and,
tries, the difference is orders of magnitude tious diseases and it follows that there is an therefore, the lack of provision is undermin-
starker. The estimated spend on health opportunity to vertically integrate care of a ing research capacity within African nations.
by investment in the UK National Health chronic disease such as cancer with exist- In common with all other areas of cancer
Service for 2008 is approximately £2,000 per ing programmes. A collective statement, control in Africa, there is a need for infra-
annum per capita of the UK’s population, the London Declaration (see AfrOx URL structure, appropriate software and hardware,
somewhat more (approximately a 500-fold in Further information), was published at human resources and training, together with
difference) than the sum for citizens of the end of this meeting, effectively call- incentives for sustainability. The obvious
Kenya ($8.3 per annum per capita; see ing on the international community to partner to drive this programme forward is
Kenyan Health Ministry URL in Further recognize the impending cancer crisis in the International Agency for Research on
information). the developing world and to work with the Cancer (IARC) — the world leader in this
Health Ministries to coordinate the develop- field. IARC has developed a cost-effective
London declaration on cancer control ment of affordable and sustainable national training programme with scalable capacity to
A summit meeting was organized that cancer control programmes. accommodate more African trainees.
brought together international leaders in
the oncology community, health policy The six elements of cancer control Tobacco control. As we are frequently
makers and African Health Ministries (see Clearly, it would be impossible to super­ reminded by Sir Richard Peto, “tobacco con-
AfrOx URL in Further information). This impose a national cancer plan from, say, sumption is the world’s most avoidable cause
African Cancer Reform convention, aptly the UK to Sierra Leone, given the disparity of cancer”, thought to be responsible for up
held in the Reform Club in London, UK, in wealth and relative health prioritization. to 30% of all cancer deaths worldwide. In
had the following aims: to determine the Therefore, a significant proportion of the Africa, tobacco use is estimated to be related
degree of priority that cancer is afforded African Cancer Reform convention was to only 6% of deaths (lung, throat, mouth,
in national programmes in Africa; to given over to workshops that stripped pancreas, bladder, stomach, liver and kidney
determine the most affordable and effective cancer control programmes down to the cancers), although this might be a hidden
components of cancer control; to decide following bare essentials, which would be but rapidly evolving problem6.
on a clear implementation strategy for expected to return most health gain for Recent evidence suggests an increase in
establishing these programmes in African money invested. smoking in the region, especially among
countries; to design mentorship and train- young people. Further, decreasing markets
ing programmes for African health-care Cancer intelligence units. A cancer intelli- for the tobacco industry in the developed
workers and scientists and engage the sup- gence unit or registry is a vehicle to enable the world will cause the industry to seek new
port of the University of Oxford, UK and systematic collection of regionally relevant markets, such as in sub-Saharan Africa,
the international cancer care community to data on cancer incidence, making it possible where it sees enormous potential for growth.
initiate these programmes; and to identify
a strategy to raise the necessary funds to
enable the implementation of the cancer Box 1 | Barriers to effective cancer planning
control programmes.
• Insufficient political priority and funding among donor agencies and governments of
Given the extraordinary financial pres-
developing countries, which have many competing priorities.
sures on all African Health Ministries,
• Limited ability to counter lifestyle changes following modernization and urbanization.
the most important questions that this
convention posed were “Does your gov- • Fragmented and under-financed health care systems that have not been set up for chronic
ernment recognize the growing cancer disease management.
problem and does it want to develop • A lack of cancer awareness, knowledge and capacity among health workers.
cancer control programmes as a matter of • Lack of diagnostic and treatment capacity.
urgency?” The African Health Ministers • Too few effective cancer medicines that are easy to administer and do not require
and their representatives from the 23 hospitalization.
different nations who presented at the • Weak referral systems.
meeting stated unanimously that they • Limited data on cancer incidence and mortality in developing countries due to a lack of
recognize the impending explosion in functioning cancer registries and limited death certification.
cancer incidence, that they would greatly

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P erspecti v es

a cies and programmes, civil society must be million occur in developing areas and only
Cancer
mobilized in support of this issue. A key to 300,000 in developed countries8. Cervical
Total TB+ this is the nomination of champions who cancer incidence and mortality rates have
HIV+malaria
will promote the cause of tobacco control. In decreased substantially in Western countries
Malaria both the developing and developed world, following the introduction of screening;
HIV/AIDS such individual champions have proved to however, such programmes are either
be essential in influencing policy makers, rudimentary or non-existent in Africa. The
TB
educating civil society and exposing and vast majority of women who suffer cervical
0 1 2 3 4 5 6 7 8 fighting the tactics of the tobacco industry. cancer in sub-Saharan Africa present with
Millions of deaths
b In countries where farmers rely on grow- disease advanced far beyond the capacity
10 ing tobacco for income, support needs to be of surgery or other treatment modalities
New cancer cases (millions)

9 Industrialized countries provided to farmers to encourage planting to offer cure (FIG. 3). Palliative care services
Developing countries of alternative crops, and to establish the are poorly developed and, therefore, these
8
7 infrastructure for distribution of the alterna- unfortunate women are often sentenced to a
6 tive crops. miserable end of life.
5 Surveillance data are needed to track Human papillomavirus (HPV) types 16
4 tobacco use and related behaviours, knowl- and 18 cause 70% of cervical cancer cases and
3 edge and attitudes. Without such data, two vaccines that guard against these HPV
1990 1995 2000 2005 2010 2015 2020 evaluations of tobacco control programmes types have been developed by the pharma-
Year are not possible. ceutical industry. There is a large, interna-
Figure 1 | Global cancer trends. a | The graph tional trials database that suggests that these
Nature Reviews | Cancer
shows the World Heath Organization (WHO) Early diagnosis and prevention. Liver cancer vaccines can offer 100% protection against
data of global mortality in 2002. Worldwide 7.6 (predominantly hepatocellular carcinoma infection by these HPV types (given as three
million people died of cancer and this was 13% (HCC)) is by far the main cause of death by injections over 6 months). The data are
of the global mortality burden, and more than cancer in sub-Saharan Africa in males7. The sufficiently compelling that the UK recently
the number of deaths from HIV/AIDS, tubercu‑ main aetiological agents are chronic infec- announced its commitment to a national vac-
losis (TB) and malaria combined (~5.6 million).
tions by hepatitis viruses, mainly hepatitis B cination programme for all 12–13-year-old
b | WHO has estimated that according to current
(HBV), which is endemic on the continent girls. These remarkable vaccines give us the
trends the global cancer burden will increase
from 10 million new cases per year in 2000 to 16 and present in 8–16% of the general popula- opportunity to eradicate 70% of all known
million in 2020, with 70% of these cases in the tion. The effect of HBV is compounded by cervical cancer within a generation, saving
developing world. Data from GLOBOCAN 2002 widespread exposure to a potent carcinogen, almost 200,000 lives per annum, the vast
database (see URL in further information). aflatoxin, a mycotoxin that contaminates majority in the developing world.
staple diets across the African continent.
Thus, the two main risk factors for HCC are Cure the curable. Although treatment is
Use of chewed tobacco is high in some relatively well known and effective strategies often considered to be overemphasized
African countries, especially in villages in are at hand to reduce their effect. A safe and relative to primary prevention, it has been
rural areas. Efforts must be made to control efficient HBV vaccine has been available estimated that between 2000 and 2020
this more traditional use of tobacco in order since the early 1980s. Simple, behavioural approximately 10 million patients will die
to avert cancers of the mouth and throat. methods to reduce aflatoxin exposure have of cancer in Africa. Although it is crucially
It is possible to avert the epidemic of been tested in the field, with significant important to institute primary preventive
tobacco-related morbidity and mortality improvements on individual contamination. measures, even if all such measures were
manifest in the developed world and much Despite these advances, WHO’s records fully implemented today they would have
of the developing world by acting now in show that <7% of subjects in sub-Saharan little effect on cancer mortality in the next
Africa6. To educate civil society about the Africa actually receive HBV vaccination, and 10–15 years6. Mortality:incidence ratios are
dangers of tobacco use and the benefits efforts to limit aflatoxin exposure are erratic much higher in Africa than in more affluent
of cessation, special efforts are needed to and ineffective. This situation is mainly world regions and therefore improved access
educate young people, health-care practi- due to economic and logistic constraints. to proven, cost-effective therapy, efficiently
tioners and policy makers. It is necessary to Although the cost of the HBV vaccine has delivered, would save many lives. However,
adopt effective policies such as tax and price dropped significantly over the past 15 years as the majority of African patients present
increases on tobacco, which will not only (it is now in the range of $0.30 per dose), it with advanced disease, when cure is unlikely,
lower prevalence but also increase govern- remains too high for many African countries treatment programmes must be undertaken
ment revenues, which can be used to pay for and needs to be supported by international in concert with attempts to diagnose cancer
tobacco control measures and other health efforts. earlier; it is essential, if such programmes are
and social programmes. Other required pol- Worldwide there are more than 273,000 to be successful, that patients diagnosed with
icy changes include the placing of effective deaths from cervical cancer each year and early-stage cancer have immediate access to
warning labels on tobacco products, banning it accounts for 9% of female cancer deaths. care, with a preliminary focus on childhood
advertising and promotion of tobacco use, Mortality rates vary 17-fold between the dif- cancer.
prohibiting smoking in public places, ban- ferent regions of the world. Cervical cancer Cancer treatment should be included in
ning sales of single cigarettes and prohibiting contributes over 2.7 million years of life lost national cancer control plans and afforded
the sales of tobacco to the young. In order among women between the ages of 25 and a proportion of the available resources.
to implement effective tobacco control poli- 64 worldwide, of which, tellingly, some 2.4 Treatment programmes will need to be

400 | may 2008 | volume 8 www.nature.com/reviews/cancer


© 2008 Nature Publishing Group
P erspecti v es

built in the context of the available human 50


resources and infrastructure and sup-
Southern Africa Northern Africa Middle Africa
ported to the degree feasible by in-country 45
resources as well as by external assistance. Eastern Africa Western Africa
Ideally, countries should have at least
one National Cancer Centre with access 40

Age standard rate per 100,000 of the population


to surgery, radiation and chemotherapy.
Radiation programmes might be built 35
on models provided by the International
Atomic Energy Agency (IAEA), and their 30
excellent Programme for Action on Cancer
Treatment (see IAEA URL in Further infor-
25
mation) and chemotherapy regimens based
on simplified regimens using drugs from
the WHO Essential Drugs List. Regional 20
or trans-national networks could be built
on a hub-and-spoke model, integrating 15
vertically with existing AIDS programmes,
and would greatly benefit from the sort of
teleconferencing or telemedicine being pio- 10
neered in India by the Tata Memorial Centre
and its associate centres (see IndOx URL 5
in Further information). In addition, it is
important to exploit modern innovations in 0
delivering chemotherapy in a predominantly
r

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er
ce

ce

ce

ce

ce

NH
nc

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nc
out-patient setting. It should prove possible
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ca

ca

ca

ca
ca

ca
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ix
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al
to design effective treatment regimes that do
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ea

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not require access to costly in-patient beds
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es
and seek to use oral agents when available.

O
One other aspect of such an approach is to Figure 2 | Differential cancer rates in Africa. The graph shows the cancer incidence
Nature Reviews |rates for a
Cancer
consider carefully the clinical pharmacology number of different cancer types in Africa. NHL, non-Hodgkin lymphoma. Reproduced, with
and therapeutic window for each anti- permission, from REF. 5  European Society for Medical Oncology (2007).
neoplastic drug so as to widen the safety mar-
gin as effectively as possible. Conventional
cytotoxic drugs have steep dose–response There is relatively little use of oral mor- regions), priority-driven and resource-
curves, but if we aim to generalize drug usage phine in Africa, although it is a therapeutic appropriate, and, where appropriate,
and widen access then we must think how we mainstay in the developed world, and a aligned with HIV/AIDS, TB and malaria
might train paramedical personnel to deliver process of education, awareness raising and programmes; fourth, to ensure that training
cancer therapeutics with a simplified dosing destigmatization, with due attention paid and education plans are developed such
algorithm that minimises toxicity. Clearly we to cultural sensitivity, will presage its more that they can be rolled out to other coun-
must not carry this utilitarian approach too widespread introduction. tries/regions, thus sharing best practice; and
far, especially when considering treatment fifth, to ensure that education and training
of childhood cancer, but this could be the Training and education. Within the context programmes cover specialist and generic
subject of important research in Africa. of prevalent cancers in the region, it was requirements, from specialist clinical dis-
agreed by delegates at the African Cancer ciplines to research training to healthcare
Palliative care. All delegates at the African Reform convention that training, educa- management and operational/logistical
Cancer Reform convention emphasized the tion and partnership programmes are of healthcare disciplines, as well as initial and
essential role that palliative care must have in primary importance for both civil society continuing needs.
the continuum of cancer care. The workshop and health practitioners if the cancer care Successfully tackling each of these
acknowledged and reiterated that palliative plan is to be successful on a sustainable identified priorities could be considered
care must be a priority component of afford- basis. Priorities have been identified from a major project in its own right, but, of
able and effective cancer care. It should be each component of the cancer action plan. course, sustainable and comprehensive
provided as early as possible after diagnosis These priorities are as follows: first, to integration of the clinical and public health
as it provides pain and symptom control, reduce the prevalent lack of cancer aware- systems requires a parallel approach. The
terminal care and bereavement support. ness; second, to improve knowledge and key to cost-effective and successful imple-
Palliative care greatly improves the quality capacity through effective partnerships mentation of the fit-for-purpose training,
of life of patients and their families facing such that expectations are understood and mentorship and public and professional
problems associated with cancer. It is ideally met and that national plans are sustainable education programmes that are required to
suited to home-based care, where it supports for the future; third, to ensure that national meet the priority objectives is connectiv-
people during illness, enabling them to die plans are evidence-based (that is, based on ity. Connectivity at all levels, namely in a
with dignity. research evidence relevant to the countries/ country, across regions and internationally,

nature reviews | cancer volume 8 | may 2008 | 401


© 2008 Nature Publishing Group
P erspecti v es

recognized elective opportunities in Africa.


The Consortium will also develop sustain-
able training and education in-country
programmes on a cascade model, whereby
African healthcare personnel are trained not
only to deliver healthcare services, but also
to provide initial training to others within
the locality to increase capacity without
draining skilled workers from other sectors,
and also to provide continuing and updated
training to those with a background in the
health sector. Where appropriate, telemedi-
cine will be expanded to include telehealth
(that is, to include non-clinical services such
as medical and public-health education,
administration, data reporting and research
at a distance).
Figure 3 | Cutaneous metastases arising from cervical cancer. Because Nature
of the lack of treatment
Reviews | Cancer Moreover, AfrOx will seek to collaborate
opportunities, funding and awareness of cancer, many cancer patients in Africa present with with the UK National Health Service,
advanced disease that is beyond the capacity of surgery or other treatment modalities to offer cure. which is well placed to provide resources to
Reproduced, with permission, from REF. 5  European Society for Medical Oncology (2007). underpin the cancer care training, educa-
tion and partnership objectives for Africa.
There are 34 cancer networks in the UK
is needed to achieve strong collaborative coordinating, commissioning and developing employing hundreds of cancer specialists
leadership and effective sharing of existing the various (face-to-face and online and other and thousands of cancer nurses and other
and newly created resources. With the forms of remotely delivered) educational health professionals, and polls performed
rapidly rising number of cancers in the activities and partnerships. by the UK Oncology Nursing Society show
developing world, partnerships between The Consortium will forge appropriate there is an eagerness to support the action
existing bodies, health-care organizations partnerships to formalize links between plan for Africa. With the backing of African
and consortia in developed and developing individual health workers, building on exist- national governments and building on the
countries (including local health-care deliv- ing relationships and creating new oppor- UK’s existing networks, AfrOx will support
ery systems, research institutions, inter- tunities for health workers from the UK the development of international Africa-
national organizations, NGOs, national and other non-African nations to exchange focused cancer networks, comprising non-
governments and the pharmaceutical experiences with African health workers. African hospitals and associated community
industry) will be essential. In this way, the Consortium will formalize care with individual African nations,
The Africa–Oxford Cancer Consortium organizational links between hospitals, can- collaborating across the spectrum of cancer
(AfrOx) will provide broad support and cer centres and medical schools, supporting control. Ultimately, the Consortium aims,
guidance on design, delivery and funding various forms of exchange programme, such through partnership links within Europe,
to achieve sustainable national cancer plans, as bilateral staff transfer and training, equip- the United States and throughout the
but also has an important facilitating role in ment sharing and re-use, and provision of Cochrane Collaboration and supported by a
sustainable infrastructure based entirely in
Africa, to establish, pilot and, importantly,
Box 2 | Cancer plan delivery to hand over knowledge services such as
a National Cancer Library for Africa and
• Building capacity of local government and non-governmental organization staff: clinical,
managerial and other training as relevant. Cancer Decision Support Services.
It is crucial, as with all aspects of the
• Strengthening systems and quality assurance: this would include training and management
systems to improve feedback systems, management and quality assurance.
cancer care plan, that the African govern-
ments mobilize real and visible political and
• Community engagement: raising of awareness in the communities and in the health sector,
financial backing for the training, education
enrolment of volunteers in outreach programmes, and so on.
and partnership programmes, especially in
• Infrastructure: there would be limited investment in physical infrastructure. Where possible,
raising awareness in civil society. We discov-
existing buildings and hospitals in the government health-care system would be used.
ered at the Cancer Reform Convention that
• Monitoring and evaluation: the programme would establish monitoring and evaluation systems there are many African cultures that do not
that collect and analyse data that contributes to a better understanding of the cost-
have a word for cancer, immediately mag-
effectiveness of different interventions.
nifying the already difficult task of health
• Supply-chain management: government systems for supply-chain management of drugs, promotion. The vast majority of cancer
laboratory supplies and other essentials would be strengthened and improved in terms of
patients present late with advanced disease
management and responsiveness.
(FIG. 3) and often seek alternative medical
• Policy and sustainability: the programme will involve the relevant departments of the African
advice before accessing more conventional
Ministries of Health, professional associations and key opinion leaders in developing
appropriate policies, based as far as possible on high-quality evidence.
practitioners. One of us (D.J.K.) was puz-
zled to find zigzag marks on examining the

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abdomen of a baby recently diagnosed with intelligence on up to 250 million African 1. Parkin, D. M., Bray, F., Ferlay, J. and Pisani, P.
Global cancer statistics, 2002. CA Cancer J. Clin.
a massively advanced nephroblastoma, to be citizens. Early cancer detection and vac- 55, 74–108 (2005).
told that these were scarifications caused by cination could prevent 100,000 deaths and 2. Abimbola, S. Clinton brokers deal to lower
price of antiretrovirals. Br. Med. J. 334, 1026
the local witch doctor. There is no doubt that the paediatric cancer treatment programme (2007)
the leading international cancer societies could save the lives of 5,000 children. 3. Stewart, B. W. & Kleihues, P. (eds). World Cancer
Report (International Agency for Research on Cancer,
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establish national cancer societies in African will ease the lives of some 100,000 people 4. Parkin, D. M. et al. (eds). Cancer in Africa:
Epidemiology and Prevention IARC Scientific
states and develop these as the bedrock for with terminal cancer. Publications No. 153 (International Agency for
training ‘cancer champions’, increasing rec- The established partnership with African Research on Cancer, Lyon, 2003).
5. Pezzatini, M., Marino, G., Conte, S. & Catracchia, V.
ognition of the problem, naming it as cancer health ministries and NGOs suggests that Oncology: A forgotten territory in Africa. Ann. Oncol.
and supporting the public in attempts to sustainable programmes can be developed 18, 2046–2047 (2007)
6. World Health Organization and International
promote prevention and earlier detection. and delivered in a cost-effective way that Union Against Cancer. Global Action Against
can affect the lives of millions of Africans. Cancer 2005.
7. Boyle, P. The globalisation of cancer. Lancet 368,
Summary of key outcomes Rebecca J. Lingwood is at the Department  629–630 (2006).
The African Cancer Reform convention for Continuing Education, University of Oxford,
8. Yang, B. H. et al. Cervical cancer as a priority for
prevention in different world regions: an evaluation
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time for concerted action against cancer Oxford, OX1 1PT, UK. (2004).
9. Kerr, F. & Kerr, D. J. Do we bear any moral
in Africa had come. Although each of the Peter Boyle is at the International Agency for responsibility for improving cancer care in Africa?
Health Ministries recognized the need Research on Cancer, 150 cours Albert Thomas,  Ann. Oncol. 17, 1730–1731 (2006).
69372 Lyon Cedex 08, France.
to develop national cancer plans, they
requested that these were broken down Alan Milburn is at the Houses of Parliament,  DATABASES
London, SW1A 0AA, UK.
into deliverable workstreams that would National Cancer Institute: http://www.cancer.gov/
bladder cancer | breast carcinoma | cervical carcinoma |
cover the spectrum of necessary activity Twalib Ngoma is at the Ocean Road Cancer Institute, 
Kaposi sarcoma | kidney cancer | liver cancer | lung cancer |
in the well-defined work programmes PO BOX 23175, Dar es Salaam, Tanzania. oral cancer | pancreatic cancer | prostate cancer | stomach
outlined earlier in this article. These must John Arbuthnott, Ruth McCaffrey, Stewart H. Kerr and cancer | throat cancer

be managed in partnerships forged between David  J. Kerr are at the Institute of Cancer Medicine, FURTHER INFORMATION
Department of Clinical Pharmacology, University of AfrOx: http://www.afrox.org/
the African Health Ministries, NGOs, the GLOBOCAN 2002 database:
Oxford, Old Road Campus Research Building, 
pharmaceutical industry and international Old Road Campus, off Roosevelt Drive,  http://www-dep.iarc.fr/globocan/database.htm
cancer communities (BOX 2). Headington, Oxford OX3 7DQ, UK.
IndOx: http://www.indox.org.uk/
International Atomic Energy Agency:
Over the next decade, we predict Correspondence to D.J.K.  http://www.iaea.org/
that relatively modest funding of these e-mail: David.Kerr@clinpharm.ox.ac.uk Kenyan Health Ministry:
http://www.health.go.ke
programmes to the order of around $100 doi:10.1038/nrc2372
All links are active in the online pdf
million per annum will provide cancer Published online 3 April 2008

nature reviews | cancer volume 8 | may 2008 | 403


© 2008 Nature Publishing Group
CORRIGENDUM

The challenge of cancer control in Africa


Rebecca J. Lingwood, Peter Boyle, Alan Milburn, Twalib Ngoma, John Arbuthnott, Ruth McCaffrey,
Stewart H. Kerr & David J. Kerr
Nature Reviews Cancer 8, 398–403 (2008)
The reference for the source of the content of Box 1 on page 399 is missing. The reference shown below should have been
cited.
Reeler, A. V. & Mellstedt, H. Cancer in developing countries: challenges and solutions. Ann. Oncol. 17, 7–8 (2006)