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What an Association like MTCC
can do for a Cancer Center and a
non governmental Association
from a developing country ?
Pr Khaled Rahal
Pr Hamouda Boussen
Institut Salah Azaiz. Tunis. Tunisia
What about Tunisia ?
Located in Northern Africa,
bordering the Mediterranean Sea,
between Algeria and Libya
Total Area : 163,610 km2
Land: 155,360 sq km
Water: 8,250 sq km
Slightly larger than Georgia
Total Land boundaries : 1,424 km
Border countries: Algeria 965 km,
Libya 459 km
Coastline:1,148 km
Highest point: Jebel ech Chambi
1,544 m
Natural resources: petroleum,
phosphates, iron ore, lead, zinc, salt
Tunisia demography
Area in square kilometers 154630 (2004)
Total population in thousands 10031 (2004)
% Urban population out of total population 65 (2004)
Crude birth rate per 1000 population 16.8 (2004)
Crude death rate per 1000 population 6.0 (2004)
% Population growth rate 1.1 (2004)
% Population below 15 years 26.7 (2004)
% Population 65 years and over 6.8 (2004)
% Dependency ratio 50 (2004)
Total fertility rate2.0 (2004)
Life expectancy at birth: total population: 74.89 years, male: 73.2
years, female: 76.71 years (2005 est.)
Total fertility rate: 1.75 children
Tunisia economy
GDP (purchasing power parity):$70.88 billion (2004 est.) GDP - real growth
rate:5.1% (2004 est.) GDP - per capita:purchasing power parity - $7,100
(2004 est.) GDP - composition by sector:agriculture: 13.8% industry: 31.8%
, services: 54.4% (2004 est.) Labor force:3.55 million
Budget:revenues: $6.799 billion, expenditures: $7.573 billion, including
capital expenditures of $1.6 billion (2004 est.)
Agriculture-products:olives, olive oil+++, tomatoes, citrus fruit, beef, sugar
beets, dates
Oil - production:72,580 bbl/day (2001 est),Oil - proved reserves:1.7 billion
bbl (2004 est.) Natural gas - production:2.25 billion cu m (2001 est.)
Exports:textiles, mechanical goods, phosphates and chemicals, agricultural
products, hydrocarbons. Partners:France 33.1%, Italy 25.3%, Germany
9.2%, Spain 6.1% (2004)
Imports:$11.52 billion f.o.b. (2004 est.) Imports - commodities:textiles,
machinery and equipment. Partners:France 25.1%, Italy 19%, Germany
8.5%, Spain 5.3% (2004)
Currency (code):Tunisian dinar (TND), Exchange rates:Tunisian dinars per
US dollar 1.3707 (2000)
1200 kms of coasts
Carrefour of civilisations
Roman period
Sites historiques
Arabo-Byzantine era
festivals
International festival of
Carthage (july-august)
International festival of
symphonic music of the
Roman Amphitheatre of El
Jem (august)
Musical october
Jazz in carthage (april)
Inernational jazz festival
(june)
MENA Thanks and Shukran
to
• Samir Khleif, director of the KHCBI
• Sami El Khatib, Research office KHCBI
• Dina and Eman from the research office
• for the organisation and the high level of topics and^presentation
and we hope to see you in Tunisia.
Saadoun Door of Tunis near the ISA
Breast cancer in Tunisia
1st female cancer : 25 %
1977 Incidence : 8/100
000
1994 Incidence : 18,5/100 000 F
Litt Incidence : 16 -
100/100 000
2004 = 1500 yearly cases incidence
of 25 to 27/100000.
Breast cancer
Nbr of cases per year
400
350
339
320 325
310 310 320 304
300 292
280
240
220
210 205
180
170 170
135 140 150 150
130
120
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
92
93
94
95
98
99
00
01
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
20
20
Breast cancer
Mean age
A B C D
E F G H
Groupe 69- 75- 81- 92-
1998 1999 2000 2001
74 80 86 95
Age/ 49,2 49,5 49,6 48,3 49,8 50,9 49,1
48,8
years 4 5 8 5 5 0 2
Nber 664 1113 1510 1156 304 325 292 339
Breast Cancer
% before 35 years
Centre René ISA
Angers USA
Huguenin (Paris) (Tunis)
1993 1994
1994 1969-2001
3% 2,5 % 4% 11 %
Breast cancer
Répartition by age
60
50
40
< 35 yrs
30
35 - 50 yrs
20
10 > 50 yrs
0
A B C D E F G H
Institut Salah Azaiz
Pr Najib Mourali, surgical oncologist. First director
Unic comprehensive cancer center since
1969
Unic structure for cancer treatment
since 1992
200 beds
Departments of surgical oncology,
medical oncology, radiotherapy, head
and neck surgical oncology, nuclear
medicine, biostatistics
Institut Salah Azaiz
9 surgical oncologists
6 medical oncologists
8 radiotherapists
5000 new cancers/year
600 new breast cancers
12000 new consultants/year
Institut Salah Azaiz
Department of surgical oncology ;
72 beds, 5 operating rooms.
Department of medical oncology :
40 beds, unit of pediatric
oncology, 5 beds of palliative care
Department of radiotherapy : 2
cobalts, 1 Linac, 35 beds
Institut Salah Azaiz
Department of surgical oncology ;
72 beds, 5 operating rooms.
7000 surgery procedures, 2000
ambulatory.
Breast cancer surgery, cervix,
ovary, colorectal, urology.
Implantable sites insertions
(300/year)
300
250
200
Nb IS
Nb KT
150
Pediatr IS
Pediatr KT
100
50
0
92-94 95-96 97-98 99- 2001- 2003- 2005-
2000 2002 2004 2006
Institut Salah Azaiz
Department of Head and Neck
surgery, 3 operating rooms, 35
beds
Department of radiology : 2
mammographs, 1 CT-scan 16 slices
2 labs of histopathology
Institut Salah Azaiz
Specific epidemiological features
Inflammatory breast cancer : 5-
7% of BC
Nasopharyngeal cancer : incidence
of 3-4/100000
Cancer in young patients (BC,
Digestive, NPC chlidrens++)
True inflammatory forms 5-7% of BC in Tunisia
Inflammatory Breast Cancer
Boussen H et al. Semin Oncol Feb 2008.
Inclusion criteria :
– Patients classified PEV2 and PEV3*, treated
in SAI between January 1976 and
December 1981.
– Patients classified T4d**, treated in SAI
between January 1990 and December
1996.
Exclusion criteria :
– The tumors classified PEV 1.
– The ulcer tumors (T4skin).
* IGR Classification
** UICC Classification of 1988
Inflammatory Breast Cancer
Boussen H et al. Semin Oncol Feb 2008.
3 series :
– Series A : January 1990 till December 1996 breast
cancer classified T4d as per the UICC classification
of 1988 (118 cases)
– Series B : January 1975 till December 1981 breast
cancer classified PEV 2 or PEV 3 as per the IGR
classification and reclassified as T4d as per the
UICC classification of 1988 given the clinical
description reported in the medical folder (175
cases)
Inflammatory Breast Cancer
Comparative Study
The average clinical tumor size is lower
for the patients of series C
Series Clinical tumor
size (mm)
Series A 89,5
Series B 75,5
Series C 58,1
Inflammatory Breast Cancer
Comparative Study
The global survival ratio is better for the
patients of the series C (p=0,0001)
Global survival curves (p=0,0001)
100
Percentage (%) of patients
90
80
70
60 Series A
50 Series B
40
Series C
30
20
10
0
0 10 20 30 40 50 60 70 80 90 100 110 120 130
Time (months)
Inflammatory Breast Cancer
Factors P
Menopauses 0,000
1
Tumor 0,048
6
Coetaneous modification 0,031
4
Symptoms evolution 0,002
7
clinical tumor size 0,000
1
nodle status 0,033
3
Starting Metastases 0,000
Inflammatory Breast Cancer
We propose to consider as
inflammatory tumor :
every tumor presenting with
inflammatory signs, oedema and/or
erythema, that spreads to the half of
more of the breast.
In the years 1970
Data of the Institut Salah Azaiz 1968 to 1985
Mean Clinical tumor size of 58,1 mm
21,3% of initial metastases
44% of PEV
% of PEV3 increas with size (10cm)
IDC = 67%, CLI = 2,3%
7% associated to pregnancy
Cancer features at the ISA
Data of the Institut Salah Azaiz. Boussen et al. (Semin Oncol Feb 2008)
Inflammatory breast cancer 5-7%
Reassesment of the true incidence of
IBC (differentiat T4b from T4d)
600 new breast cancers
Mean clinical tumor size of 40mm
Mean histologic size of 35mm
10% < 35 years.
What news about epidemiological transion of
nasopharyngeal carcinomas ?
Boussen et al. EMC Oto-rhino-laryngologie [20-590-A-10]. 2007.
Clinical presentation of NPC
Boussen et la. EMC Oto-rhino-laryngologie [20-590-A-10]. 2007.
Cancer features in Tunisia 2004
Cancer registries
BC(25%) > Cervix(6%) > Gallbladd > CRC
Lung > H and Neck > Bladder > CRC
% of young patients varying from 5 to
15%(NPC in childrens)
1 comprehensive center, 2 units of
oncology(Med + Radioth) in 2 university
hospitals of Sousse and Sfax
Pilot screening-early detection project in one
state of Tunis capital(Ariana)
Cancer projects in Tunisia
National cancer plan 2007-2010
Collaboration with French Institut
National du Cancer(INCa)
Collaboration with Italy (projects of
Gafsa and Jendouba)
mammographs-histopathology units-BC
early detection-medical plus paramedics
training
What MTCC can do
for us ?
Proposition 1 for MTCC
Good clinical practices in oncology
Evaluation of quality of practice in surgical
oncology
Certification of the practice in surgical oncology
Procedures of accreditation
Parameters of evaluation : Nb, rate of success,
complications………………
Treatment guidelines
Proposition 2 for MTCC
What Cursus of surgical oncology, medical
oncology and radiotherapy ?
What cursus in other mediterranean
countries ?
Duration and type
Schedule of evaluation
Theorical program
Practical program
Proposition 3 for MTCC
Training for fellows or confirmed
specialists (short duration) in surgical
oncology, medical oncology and
radiotherapy
Constitution of study groups in surgical
oncology (IBC, young patients,
innovations……….)
Epidemiological survey for inflammatory
breast cancer
Proposition 4 for MTCC
ATAMCS (Association Tunisienne d’Assistance
aux Malades de Cancer du sein)
Created in 2005, board mixing cured patients
and oncologists
Psyschosocial plus financial support to patinets
affected by BC
Lobbying techniques
Network with breast cancer NG associations
Europa donna
Propositions 5 for MTCC
Sustain for screening of colorectal cancer in
Tunisia. Previous experiences in Europe and
mediterranean countries.
Not done presently in Tunisia
Preliminary cost-study benefits
Problem of cost-benefit of HPV vaccine in
Tunisia
Training in medical epidemiology and
biostatistics
Telemedicine with mediterranean centers
developping a network
Prostate cancer in Tunisia
Predominating cancer in aged male
5th cancer in man for the cancer of
registry of Norhern Tunisia = 139
cases in 1994
Crude Incidence of 6,4
Standardised Incidence of 7,7
7% of cancers
What does MTCC looks like
for its developping part ?
MTC role in our countries
Counselor for advanced projects
Viability of projects
Auditing the ended projects
Links with international and European
associations (scientific, NG…………)
Reliable contact with the official
authorities (min health, research………)
Thanks to MTCC
Shukran
Ekkharisto
Hvala
Grazie
Gracias
Merci
