West Visayas State University – College of Medicine – Batch 2020

FCM
Lecture 1
Block 13
Module 1
02/22/18 Jesus E. de Jesus, MD

TOPIC OUTLINE • For every 1,800 Filipinos, 1 will develop cancer annually
I. Objectives of the Philippine Cancer Control Program if low cancer prevention consciousness persist
II. The Philippine Cancer Control Program (PCCP) • Most Filipino cancer patients seek medical advice only
III. Cancer in the Philippines
IV. Cancer Statistics in the Philippines
when symptomatic or at advanced stages
V. Cancer Control in the Philippines Possible reasons why Filipinos delay getting
VI. Lung Cancer Control Program checked by physicians.
VII. Breast Cancer Control Program ─ Spiritual reasons
VIII. Cervix Uteri Cancer Control Program
IX. Liver Cancer Control Program ─ Fear that their ailment might get worse.
X. Colon/Rectal Cancer Control Program ─ Financial reasons
XI. Healthy Lifestyles ─ Decreased awareness about the disease
XII. Cancer Pain Relief Program
process.
XIII. Current Interventions
XIV. Current Strategies • For every 2 new cancer patients diagnosed annually, 1
Review Questions will die within the year
References
Appendices
CANCER STATISTICS IN THE PHILIPPINES
• Top cancer sites include cancers whose major causes
LECTURER BOOK REFERENCE OLD TRANS
are known:
Lung/larynx
─ Tobacco smoking
OBJECTIVES OF THE PHILIPPINE CANCER
CONTROL PROGRAM Liver
• To reduce the exposure of population to risk related ─ Hepatitis B
factors, primarily smoking, unhealthy diet, physical Cervix
activity and harmful use of alcohol, cancer related ─ Sexual contact
infections, chemical and ultraviolet rays exposure Colon/rectum/stomach
• To increase the number of patients given appropriate ─ Sedentary lifestyle/obesity
screening, diagnosis and treatment of cancer • Except for the liver, the top Philippine cancer sites are
• To increase the number of patients given pain relief and also the top cancers worldwide
support care services with cancer • Leading cancer site mortalities (in decreasing order of
frequency):
THE PHILIPPINE CANCER CONTROL PROGRAM Lung
(PCCP) ─ Easily identifiable cause is cigarette smoking
• Created on April 1990 through DOH AO 89-A as an Liver
amendment to DOH AO 188-A series 1973 Breast
• Program components: Leukemia
Cancer epidemiology and clinical research Stomach
Public information and health education Cervix, uteri
Integration of cancer prevention, and early detection Colon
at the community level Liver
Upgrading cancer management capabilities Pancreas
Hospital Tumor Boards and Hospital Cancer Nasopharynx
Registries Prostate
Cancer pain relief • Top 3 mortality cancer sites in males:
─ Pain relief in the Philippines – sorely lacking Lung – most common
─ Lung CA-Not only in smokers but also hereditary Liver
Leukemia
CANCER IN THE PHILIPPINES • Top 3 mortality cancer sites in females:
• Labeled as "Malignant Neoplasms", cancer ranks 3rd in Breast – most common
leading cause of mortality Lung
• 75% of all cancers occur after 50 years of age Cervix uteri
• 3% occur below 14 years of age

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• The problem of childhood CA in the Philippines is more LUNG CANCER CONTROL PROGRAM
significant than in Western countries, because of • Legislation measures:
relatively young Filipino population. Overall pattern is, Critical role in the elimination of the smoking habit
however, similar and is dominated by Leukemia Elimination of advertisements and promotion of
• Certain features are similar to those in other Asian tobacco products, sales to minors with labeling, tax
populations (low incidence of Wilm’s tumor (kidneys), and price policies on cigarettes
Hodgkin’s disease and Ewing’s sarcoma), in contrast to ─ All interested sectors (GOs and NGOs) shall
relatively high incidence rates for retinoblastoma (eye) support legislative measures against tobacco
and low rates for neuroblastoma (brain) and Non- ─ Initially can be started through local ordinances
Hodgkin’s lymphoma that is acceptable to policy makers and the
public at large
TWO POPULATION-BASED CANCER REGISTRIES IN Ex: Iloilo City Anti-Smoking Task Force
THE COUNTRY (ICAST)
PHILIPPINE CANCER SOCIETY • Intervention
• Originally known as the Central Tumor Registry (1959) Smoking counseling clinics in strategic localities will
• Converted in 1983 into a population-based registry provide service to the identified smokers behavior,
covering Manila, Pasay, Caloocan, and Quezon City degree of tobacco addiction, and type of social
environment
DEPARTMENT OF HEALTH – RIZAL CANCER • Research & epidemiology
REGISTRY Generation and collection of data on all aspects of
• The Rizal Cancer Registry is the first population-based smoking carried out through research in the light of
cancer registry in the Philippines meager information
• Established in 1974 as part of the Community Cancer Lead agencies:
Control Program in Rizal province ─ DOH – Essential National Health Research
• From passive data collection, measures of registration ─ Lung Center’s Research and Development
have improved throughout the years; in the 1980s, Section
active registration started ─ PCHRD
• Covers 26 municipalities within an area of 1,860 sq. km. ─ UP – PGH
─ Colleges of Medicine and Public Health
CANCER CONTROL IN THE PHILIPPINES • Focus on anti-smoking campaign
• Philippine Cancer Control Program (PCCP)
Covers 85% of all cancer site control campaign
Lead by the premise that cancer can be largely
• Specific objectives:
prevented mainly as a public health effort
To inform/educate school children and adults on the
• Systematic, organized, and integrated approach towards
hazards of smoking and its known risk of developing
the control of cancer
cancer
Can significantly alter or reduce morbidity and
To prevent the onset of smoking and decrease the
mortality
number of smokers
Utilizing primary, secondary, and tertiary in the
To identify Filipinos at high risk of developing lung
different regions of the country
cancer (40 years old and above smokers)
Aside from rehabilitation activities at both hospital
• Example regulations:
and community levels
On January 28, 1993, a DOH Administrative Order
• Goal:
prohibited smoking in DOH and its premises.
Establish and maintain a system that integrates
On March 22, 1993, another DOH Administrative
scientific progress and its applications into a
Order laid out rules and regulations on labeling and
comprehensive program that will reduce cancer
advertising of cigarettes.
morbidity and mortality in the country
In 2001, DILG prohibited smoking in its offices and
• Six pillars:
premises. More specific campaigns were initially
Epidemiology and research
done in government hospitals which are given
Public information and health education
incentives or awards given how actively
Prevention and early detection
implemented their smoking drive is. Also,
Treatment
application form of job applicants includes info. On
Training
his smoking habits
Pain relief
• Quezon City
Was the 1st city to issue a no-smoking policy in
public places ordinance

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 ANTI-SMOKING CAMPAIGN Full integration of basic cancer control measures
• Carried out through the following: with the governments basic medical health services
Public information and health education: and other NGOs through primary health care
─ Focus on increasing public awareness on the approach
hazards of smoking Operationalization of bilateral health care referral
─ Changing the attitude and behavior among system
primary and secondary school children Making more intensive use of information, education
─ Reaching out to the general public through mass and communication activities
communication Standardization recording and reporting with a
Dealing with specific target audiences built-in monitoring and evaluating system
Through interpersonal communications Establishment of regular and frequent supervision
Individualized process or group activities Adopting postsurgical adjuvant chemotherapy
─ Social mobilization important to generate and regimen for 6 months for all premenopausal and
sustain participation from all sectors of society hormonal receptor negative postmenopausal
patients as well as adjuvant hormonal regimen for 2
RED ORCHID AWARDS - 5 years for hormonal receptor positive
• PhilHealth Regional Office VI received the DOH’s Red postmenopausal patients
Orchid Hall of Fame award in its effort to eliminate Provision of adequate logistical support for public
th
tobacco use and exposure during the 7 Red Orchid health and hospital services
Awards held at The Oriental Hotel in Tacloban City Making available breast examination training
• Garnered a 91 – 100% score for implementing a programs, residency and post-residency training
tobacco-free environment based on the DOH’s criteria, programs, hospital services and anticancer drugs
thus giving them their 3rd Red Orchid Awards • Case finding – breast examination
• Criteria for judging includes the display of graphic In the Philippines, only a few have had the
warning signs in the office, strict implementation of a 10- opportunity to learn about the possible benefits of
meter radius smoking ban, incorporating health classes regular BSE, physician examination, and even
during orientations and assigning personnel to the mammography.
smoking cessation clinic in the office BSE appears to protect against dying from breast
cancers (RR of 0.30 to 0.48) especially for the elder
BREAST CANCER CONTROL PROGRAM women and women who have been screened twice.
• The implementation of a nationwide anti-breast CA
In the unscreened group, cancer tends to be
scheme:
detected at a later stage than the screened group.
Public information and health education
The stage of the disease at diagnosis affects the
Case finding (secondary prevention)
prognosis and thus mortality
Treatment (treatment prevention) integrated into the
A 1/3 reduction in mortality has been attributed to
community health structure and equipped to control
screening
breast CA in a systematic sustained manner
BSE
• Focus on early detection, treatment, and healthy lifestyle ─ For a smooth glide, do it while skin is still wet.
• Specific objective
─ Done in front of the mirror to easily visualize
To inform or educate all women 30 - 60 years old on
shape, color of breasts, size of lump, pendulous
breast self-examination (BSE) and importance of
or not.
doing a regular monthly BSE
• As screening procedures, PE and mammography both
To detect the maximum number of early stage
detect cases not detected by the other, but the
breast cancer by offering yearly breast examination
contribution of mammography is substantially greater
to all 30-60 years old women attending a health
• The importance of annual clinical breast exam (by
institutions nurse, midwife, or public health physician) and monthly
To treat and/or rehabilitate detected cases BSE are to be emphasized, taking note that:
• Warning signals:
Mammography is not easily affordable or available
Any breast lump, particularly among women 30
Mammography is mainly recommended for >/= 50
years and older should be medically attended to.
years old
Breast changes that persist such as a lump,
Many breast CA are found among 35 - 50 years old
thickening, swelling or dimpling are the most
A relatively inexpensive strategy (BSE) is more
common presentation.
available
Breast cancer is generally painless
• Program strategies:

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 ABCS OF BREAST HEALTH ─ Establishment of a Cervical Cancer Screening
• Adult women of all ages are encouraged to perform Program 10 February 2005.
BSEs at least once a month
• BSEs can be done in 3 ways LIVER CANCER CONTROL PROGRAM
In the shower • Focus on hepatitis B vaccination, in collaboration with
In front of a mirror Immunization Program of the DOH
Lying down • DOH Circ. No. 242s 10 Dec 1990 “Implementing
• Contact you healthcare provider if there are any Guidelines on the Integration of Hepatitis B into the
changes Expanded Program on Immunization”
Hepatitis B vaccine was introduced in 1992
CERVIX UTERI CANCER CONTROL PROGRAM targeting 40% of infants, with planned coverage by
• Focus on early detection and treatment, and healthy 10% every year thereafter until 100% coverage by
lifestyle 1999 is reached
• Specific objectives: Not fulfilled due to insufficient funds
To educate people about cervical cancer, its • RA No 7846-2006 “Compulsory Hepatitis B
symptomatology, methods of early detection and immunization among infants and children less than 8
preventive measures years old”
To screen at least 85% of women 25 - 55 years of Goal was to reduce chronic infection of hepatitis B
age every 3 years using acetic acid wash to <1% among birth cohorts from baseline levels of
Acetic acid wash 10-12%
─ Use vinegar to detect erosion in cervix • DOH AO N 0015-2006 “Implementing Guidelines on
─ ↑Sensitivity but not specificity (do a punch biopsy Hepatitis B immunization for infants” – implementation
for specificity) of RA 7846
─ Erosions- friable Goal is to reduce the chronic hepatitis B infection
─ Cheap rate by HBsAg prevalence to <1% among 5-yr-old
─ Spatula- rotate around cervix, inform px that it children born after routine Hep B vaccination at birth
might be an uncomfortable procedure started (providing 3 doses of routine Hep B vaccine
To identify early lesions of cervical cancer among infants including birth dose)
To establish a practical or applicable referral system DOH to procure 75% of Hep B needs for 2007 and
To implement appropriate treatment protocol for the 100% starting 2008 and onwards to provide all 0-11
different stages of cervical cancer months old with 3 doses of Hep B vaccine in the 1 st
• Program activities: year of life free of charge in all health facilities and
Public information & health education other institutions providing immunization services
Professional education for children nationwide
Primary prevention Units in 1 shot of Hep B vaccine
Case-finding with use of acetic acid wash ─ Adult : IM Basic course consists of 3 doses: 2nd
Diagnosis with use of Pap smear and colposcopy and 3rd doses given 1 and 6 mth after the 1st
Speculum- used to visualize cervix and adnexae dose respectively. Dose depends on the product
Treatment used. Typical doses: 10 or 20 mcg. Given via SC
Research administration in haemophiliacs. mims.com
• Example regulations: ─ Child: Basic course includes 3 doses; 2nd and
From DILG CAR – Memo Circ. No. 99-28 (Feb 10, 3rd doses to be given 1 and 6 mo. after the 1st
1999): dose respectively. Deltoid area is preferred in
─ The Department of Health, through the Philippine older children while anterolateral thigh is the
Cancer Control Program, will be implementing preferred site in neonates, infants and younger
the Cervical Cancer Screening Project with the children. Dose depends on the product used.
view to provide opportunities toward the early Typical doses are 5 or 10 mcg. mims.com
detection and control of cervical cancer. ─ Monovalent Hepatitis B vaccine given at birth:
The Cervical Cancer Prevention Advocacy Program 10mcg/0.5mL. Philippine Drug Price Index 2013
was initiated through Proclamation No. 368, s.2003 • RA No 10152 June 2011 “Mandatory Infants and
which celebrates Cervical Cancer Awareness Month Children Health Immunization Act”
during the month of May. Includes Hep B vaccine free to infants within 24
Department of Health, Philippines. Administrative hours of birth
Order No. 2005-2006: • RA No 10526 April 2013 “Liver Cancer and Viral
Hepatitis Awareness & Prevention Month Act”

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 Declares January as liver cancer and viral hepatitis
awareness and prevention month

COLON/RECTAL CANCER CONTROL PROGRAM

• The DOH–PCCP recommends screening for colorectal
cancer for all persons aged 50 years or over. Effective
methods include:
Fecal occult blood test (FOBT)
─ Annually
Sigmoidoscopy
─ Every 3 – 5 years
Digital rectal exam (DRE)
─ Augments the effectiveness of FOBT and
sigmoidoscopy and can be an alternative to non-
availability or inaccessibility of sigmoidoscopy
and/or FOBT
─ Serves as a diagnostic rather than screening tool Figure 1. Healthy lifestyle by Cangelangel.
in prostatic cancer
CANCER PAIN RELIEF PROGRAM
Manual stool extraction • Started in 1989, leading the way to Hospice-At-Home
─ 1-3 clean gloves concept.
─ Newspapers/ paper towels/ wet wipes/ lubricant • Focuses on cancer pain relief and support groups,
─ Wastebag rehabilitation, and hospice care
─ Inform px why you’re doing it • This program primarily implemented the WHO analgesic
Good result Ladder, in a modified way cutting the ladder to a 2-step
─ Good sphincter tone (skipping 2nd ladder - weak opioid) from an original 3-
─ - feel prostate at tip of finger; -feel uterus at step. The main analgesic concepts implemented are:
tip of finger; there should be no mass felt, if there Use of oral drugs, allowing hospital discharge and
is one, determine if it is from rectum, stool home care
(mushy, like chicken nuggets if frequent Analgesics are given on a regular basis
impaction), etc. ─ 'by the clock'
─ Done with respect/ finesse; if rude, can be Choice of analgesic agent given is
perceived as opportunistic or disrespectful ─ 'by the ladder'
• In 1996, the DOH launched the ‘Iwas Sakit Diet’ (‘shun If pain is bearable, initially give (1) Paracetamol
illness diet’) and ‘Tia Kulit’ (‘concerned aunt’) (Tylenol/Acetaminophen-US)
Promoting consumption of foods rich in fiber, ─ Mefenamic acid and Celecoxib- discouraged
avoidance of high fat/cholesterol foods and ─ (2) Codeine (in Singapore, banned in PH)
moderate salt intake, implemented through diet ─ (3) Tramadol
counseling health service facilities ─ (4) Morphine (Gold Standard)
Morphine given for
HEALTHY LIFESTYLES ─ Cancer pain
• Health Care Intervention Strategies in the diseases ─ Dyspnea/ respiratory distress of small cell lung
associated with risky lifestyles are: CA
Information dissemination & Education campaign - • The Dangerous Drugs Board on October 19, 1989
avoidance of lifestyle through Board regulations No. 6, 6-A, 7,8 have changed
Counseling the regulations on the use of morphine exclusively for
Screening cancer patients, effectively achieving the following:
Case-finding and Treatment Facilitated the process of obtaining an official
Disease-specific clinical management prescription (DDB Form No. 1-72) and a local
Rehabilitation purchase form (DDB Form No. 8-72). Regional
Supportive care Health Directors as agents of the Board to approve
applications of the above forms.
Assigned dispensing to duly-licensed hospital
pharmacies
Increased the number that can be obtained at one
time to:
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 ─ For official prescription
840 mg morphine oral COMMUNITY-BASED CANCER CARE/CONTROL
448 mg morphine IV NETWORK (CCCN)
─ For local purchase • Begun in 1998
1.68 mg morphine oral • Vision:
896 mg morphine IV A self-sufficient network of empowered communities
• The Philippine quota for the annual importation of sharing responsibility for total quality cancer care
morphine has been increased by the International and control in the PH and its mission to organize,
Narcotics Control Board from 1 kg to 25 kg. There is a integrate, and nurture such network
current move to increase the quota further to 50 kg. Built around the idea when many organization and
• The morphine consumption nationwide in 1990 was 6 individuals pool together their expertise, skills,
kg, in 1991 – 1 kg, in 1992 – 5 kg, in 1993 – 18 kg, and resources and experiences and cooperate to
in 1994 – 38 kg. achieve a common goal, they become powerful
• The government hospitals consumed only 30 kg in forces
1991-1994; only 18/ 53 hospitals submit regular reports • Composed of Local Cancer Control/Care Networks or
on morphine consumption. Nodes that will network with each other towards a
• The Bureau of Food & Drugs had approved new common goal
formulations of morphine sulfate tablets that now • Each node will center on a tertiary government hospital,
include 10, 20, 30, and 50-mg tablets. 50 mg tablets are each node is composed of a network of satellites,
not available in the Philippines including NGOs, GO, and individuals
• Regular budget for the purchase of morphine sulfate • DOH-PCCP unit will be the lead agency
tablets was identified in 1990 • Major control-related NGOs in the locality will be the
• The National Drug Council in 1992 approved the lead NGO agency
inclusion of morphine tablet sustained release in the • Nodes will be self-sufficient and reliant
National Drug Formulary • In 2000, CCCN started a Hospital Tumor Registry
• Became a reality when the DOH Acting Sec. Jaime software for the different component hospitals of the
Galvez Tan declared Hospice care be incorporated in network and the DOH-PCCP
the Cancer Pain Relief Program of DOH Yellow prescription pad: Max tabs per
Lead agency: prescription pad = 100 tabs; validity= 30 days per
─ Philippine Cancer Society Inc. (PCSI) yellow prescription pad
Support agency: ─ Phenobarbital
─ DOH ─ Phenodiazomorphine
Cancer Px ─ Morphine
─ Paracetamol 500mg 2 tab (1g) every 6 hours by Formulation: Old, 10mg(green), 20mg (blue),
the clock 30mg (pink); New: 10mg, 30mg
─ Morphine – morphine level adds up in body of ─ 3 sheets per prescription: one left with (1)
px, no 1g/ml available in PH, 10mg 1 tab every pharmacy, (2)patient (yellow green) and (3)
4 hours by the clock + 10mg for breakthrough doctor(white)
pain within 4 hours ─ Spell out dosage if you prescribe, for example:
─ Abstral 100-400mg Morphine 10 mg (TEN MILLIGRAMS) additional
─ Fenylcitrate dissolves in tongue, in bloodstream of 10mg 1tab in between 4 hours if there is
after a few minutes, 1 hour effect only breakthrough pain
─ Oxycodone- 2x more potent than morphine ─ Free Morphine Program (2006): Immediate-
─ Fentanyl patches available release tablets; Aquino administration:
─ 10 mg parenteral morphine not equipotent with Extended-release tablets
10mg oral morphine Adjuvant drugs: Lactulose, Senna
─ 10mg parenteral morphine is equipotent to 2- ─ Imperative to write along opioids
3tab of oral morphine ─ Need irritant laxative: Senna tablets (Biguerlai
─ Intrathecal morphine (drops) more potent than tea)
parenteral morphine ─ ↑slippery stool: Bisacodyl
─ If with initial administration of 10mg oral With opioids, colon peristalsis slows down, so
morphine and you have to administer parenteral ↑water reabsorption, ↑harder stool
morphine, don’t push 1 ml parenteral morphine Not given if px is taking opioid
since it might cause respiratory depression or ─ Bulk-forming laxatives: Psyllium contribute
even death distress, retain fluid

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 5. Not true of morphine prescription.
CURRENT INTERVENTIONS a. Spell out dosage
• Package of services: b. 1tab 10mg can be added for
Free cervical cancer screening provided every year breakthrough pain
c. Use of yellow prescription pad is optional.
in 58 DOH Hospitals done during the month of May
d. Inclusion of adjuvant drug is not optional.
to screen women ages 30-45 years of age
Free adjuvant chemotherapy for women diagnosed Answer: 1b, 2b, 3c, 4b, 5c
stage 1 to 3A breast cancer in 4 pilot hospitals REFERENCES
(Jose Reyes Memorial Medical Hospital, East • Dr. de Jesus’ lecture
Avenue Medical Center, Rizal Medical Center, UP- • ADeoS notes
PGH) funded by NCPAM • Vaccine: Hep B.
Free chemotherapy for acute lymphatic leukemia https://www.mims.com/philippines/drug/info/vaccine%2
(ALL) among children with cancer funded by C%20hepatitis%20b/. Accessed February 22, 2018.
NCPAM • The Philippine Drug Price Index 2013. 2nd ed. NCPAM-
DOH.
CURRENT STRATEGIES http://www.doh.gov.ph/sites/default/files/DPR2013.pdf.
• Promotion of healthy lifestyle Accessed February 22, 2018.
Increase avoidance of the risk factors
Vaccinate against human papilloma virus (HPV) and
hepatitis B (HBV)
Control occupational hazards
Reduce exposure to sunlight
• Improve screening/ diagnosis and treatment
• Improve rehabilitation and palliative care
• Improve cancer registry
Emphasis: Early detectionearly
management↑chance of having a better life

REVIEW QUESTIONS
1. Most common CA in males.
a. Breast CA
b. Lung CA
c. Liver CA
d. Cervical CA
2. Dose of Hep B vaccine given at birth.
a. 20 mcg/ 0.5 mL
b. 10 mcg/ 0.5 mL
c. 5 mcg/ 1.0 mL
d. 10 mcg/ 1.0 mL
3. Initially given for pain relief.
a. Mefenamic acid
b. Morphine
c. Paracetamol
d. None.
4. Which is true of RA No. 10152?
a. Also called Mandatory School Children
Health Immunization Act of 2011
b. Includes free Hep B vaccine to infants
within 24 hours of birth
c. Implementation of the Cervical cancer
Screening Project with the view to
provide opportunities toward the early
detection and control of cervical cancer
d. Promoting consumption of foods rich in
fiber, avoidance of high fat/cholesterol
foods and moderate salt intake,
implemented through diet counseling
health service facilities
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