Cancer in Guatemala: First Steps Against a Growing Problem

Issue 20, 2012

Guatemalan Hospital

Like many low-/middle-income countries, Guatemala is in the midst of rapid change - including public health. In fact, this nation of over 13 million people is in the midst of what experts call "epidemiological transition," as patterns of disease shift away from malnutrition and infection in children to non-communicable illnesses, such as cancer, in adults.1

Since 2002, the Pan American Health Organization has identified non-communicable diseases as the leading cause of premature death and disability across Latin America.2 That's certainly true in Guatemala, where these types of illnesses are now estimated to cause nearly half (47 percent) of deaths.3,4

An increase in certain risk factors isn't helping: smoking and sedentary lifestyles are on the rise in Guatemala, even as the country struggles with one of the highest levels of both poverty and income inequality in Latin America. More than half of Guatemalans (56.2 percent) now live on incomes of less than US $1.60 per day.5

In this context, a cancer diagnosis is often dire. Most cases are diagnosed in an advanced stage and there is often a long waiting list for treatment.6 Cancer currently contributes to 11 percent of deaths overall, and more than 98 percent of cancer patients die within 5 years of diagnosis.1

Accurate statistics on the disease remain elusive. The Instituto Nacional de Cancerologia (National Cancer Institute, INCAN) serves as the primary referral site for cancer diagnosis, treatment, and data. Its data collection system is outdated and relies on (sometimes incomplete and inconsistent) paper records, yielding information with somewhat questionable accuracy. Nevertheless, in the absence of a national surveillance system and/or cancer registry, INCAN's data are the best available means to monitor the country's cancer trends and survival.

Those cancer trends differ from those seen in the United States and other more affluent countries. For example, cancers of the cervix and stomach remain the leading causes of cancer death in Guatemala, while breast cancer is rapidly increasing.6

New strategies

Guatemalan People in Market

So what's to be done? Cancer control in Guatemala is within reach through modification of risk factors such as smoking or lack of exercise, and through better access to cancer screening and treatment.7 But cancer control in Guatemala will also require a comprehensive approach that's based on locally relevant data.

All of this can only be accomplished if the country invests in research and researchers to generate and translate data into practice (both clinical and public health). Unfortunately, research is still woefully underfunded in Guatemala. Government and private sector investment in research has remained unchanged over recent years. In 2003, it was only 0.03 percent of the GDP and in the latest year for which data are available (2009) it was 0.05 percent.8

Guatemala also lacks the human resources to conduct the surveillance and research that will support cancer control. For example, in 2009 the National Council on Science and Technology only had 58 registered healthcare researchers compared to 300 agricultural researchers.8

But there are signs for hope. In December 2003, the Guatemalan Ministry of Health established the National Program on Non- Communicable Diseases (NCD) and the Integral Commission for the Attention of NCDs. The Commission, which includes medical schools, NGOs, and public and specialty hospitals (including INCAN), established the NCDs National Prevention Plan. Although underfunding is still a major issue, the formation of these initiatives validates governmental interest in cancer surveillance, research, program planning, screening, and prevention.

Non-governmental entities are also seeking to fill the gap. To help build cancer research capacity in Guatemala, we have established two postgraduate research-training programs in collaboration with Washington University in St. Louis. The programs provide a one year research training opportunity for clinicians interested in non-communicable diseases and cancer control. The Chronic Disease Control Research Fellowship Program, established in 2009 and funded by the Canadian International Development Research Centre, has already trained 8 fellows and generated data that are relevant to noncommunicable diseases control policy.9-13

Guatemalan People at a Hospital

In addition, the Cancer Control Research Summer Training Institute, established in 2011 and funded by the Fogarty International Center of the US National Institutes of Health, has trained five INCAN faculty and led to five research protocols that were chosen and developed by the Guatemalan trainees, thereby representing a bilateral collaboration that reflects local needs. The projects include research into the use of electronic medical records, rural Guatemalan women's knowledge of cervical cancer screening, and the use of hormone therapy for breast cancer patients.

Both programs include training in research methods and rely on mentoring as a means of building Guatemala's research capacity. By building this type of "mentoring culture", we aim to increase research capacity and create a group of mentors for the next generation of cancer researchers.

Cancer prevention and control in Guatemala demands a comprehensive approach based on data that's relevant to local populations. But we can only achieve this if the country invests in research and researchers to generate and translate data into sound clinical and pubic health practice. In doing so, Guatemala will be ready to avert the future burden of cancer disease and death.

Joaquin Barnoya, MD, MPH

Joaquin Barnoya, MD, MPH
Division of Public Health Sciences, Department of Surgery
Washington University in St. Louis and
Research Department
Cardiovascular Unit of Guatemala

References

1. Pan American Health Organization. PAHO Plan of Action for Cancer Prevention & Control: Cancer Stakeholders Meeting. Fact Sheet. Washington, DC; 2008.

2. Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization. Circulation. 2001; 104(22): 2746-53.

3. Estrada Galindo G. El sistema de salud en Guatemala, 9: Sintesis; 2008.

4. World Health Organization. NCD Countries Profiles, Guatemala. Geneva, Switzerland; 2011.

5. Pan American Health Organization. Health in the Americas. Washington, D.C.: PAHO; 2007.

6. Instituto de Cancerologia I. Registro Nacional de Cancer. Guatemala, Guatemala: Liga Nacional Contra el Cancer; 2007 Julio de 1999.

7. Beaglehole R, Bonita R, Magnusson R. Global cancer prevention: an important pathway to global health and development. Public Health. 2011; 125(12): 821-31