What an Association like MTCC ca

					 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

				
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