Based on data from the Cancer Institute of the University of the Philippines-Philippine General Hospital, one in three patients diagnosed with cervical cancer dies within one year. The mortality rate increases to 73 percent within five years. According Dr. Jovelle Fernandez-Laoag, regional director for medical affairs of GlaxoSmithKline (gsk), cervical cancer ranks next only to breast cancer in incidence among female-specific cancers, but the quality of life of women with cervical cancer is worse than that of those with breast or ovarian cancer.

    But hope is on the horizon. At a symposium during the Philippine Obstetrical and Gynecological Society's 60th annual convention, medical professionals were introduced to gsk's hpv vaccine.

    Hpv is commonly transmitted through sexual intercourse as well as skin-to-skin genital contact. "Approximately 50 percent of sexually active women will be infected with oncogenic hpv at some point, said Fernandez-Laoag. "Therefore, every sexually active woman is at risk of oncogenic hpv infection, which may cause cervical cancer."

    Screening through Pap smear is one way to prevent the development of cervical cancer or detect it early. However, Fernandez-Laoag pointed out some of its limitations, including false-negative results in up to 30 percent of cases. There is also no national cervical-cancer-screening program.

    In reducing the burden of cervical cancer, "vaccination will work alongside screening," she said. "In the absence of screening programs, vaccination is an attractive opportunity for the control of cervical cancer," she added, noting that there are now 26 diseases that may be prevented through vaccination, including cervical cancer.

    Gsk has developed a bivalent vaccine against hpv types 16 and 18 that uses the proprietary adjuvant system number four (AS04), which contains both aluminum salt and the 3-deacylated monophosporyl lipid, leading to a better immune response.

    Over 70 percent of cervical cases worldwide are attributed to hpv types 16 and 18; types 45 and 31 account for an additional 10 percent.

    In trials against precancerous lesions associated with types 16 and 18, the vaccine was shown to be 100-percent effective over four and a half years. There was also preliminary evidence of cross-protection against types 45 and 31, with efficacy rates of 94.2 and 54.5 percent.

    A recent study presented at the International Society of Pharmacoeconomics and Outcomes Research ninth annual congress suggested that the vaccine could prevent cervical cancer by up to 80 percent. It was also predicted that the vaccine would result in long-term protection for females 11 to 13.

    "An effective cervical-cancer vaccine must be able to provide a lasting protection against precancerous lesions and stimulate a strong immune response because the natural immunity may not be enough to protect a woman from the human papillomavirus which has been cited as the main cause of cancer," said Fernandez-Laoag. M

Breast-cancer detection below par

Grace Roxas

Contributing Writer

The main thing holding back the quantum leap in promoting secondary prevention for the top kind of malignancy among Filipino women is perhaps the same as with any other diseases in the developing world: grinding poverty and the concomitant ignorance and lack of access to health facilities.

    "We have been advocating early detection since time immemorial but nothing much happens," said Dr. George Eufemio, president of the Philippine Cancer Society. "It all boils down to economics.... It is not very easy for a woman to go every year for a mammograph, which costs more than a thousand pesos."

    Eufemio noted during a recent media forum on breast cancer that even among the economically well off, late diagnosis remains a problem, although the chances of surviving late-stage cancer among middle- to high-income patients have improved much because of access to better treatment options.

    Oncologist Jorge Ignacio said that the development of targeted therapies-biologic therapies focusing on the her2 family of receptors in breast-cancer-cell membranes-makes the present an exciting time in cancer management.

    He said: "Biologics would specifically seek out the cancer cells or affected cells only. This is the wonder drug that we have been dreaming about for many decades. We are now looking at the threshold of the realization behind the coining of the term 'chemotherapy' at the turn of the 20th century."

    These biologic therapies are now being used in tandem with cytotoxic chemotherapy. With fine-tuning of their mechanisms of action in terms of disrupting the receptor-nucleus signaling that leads to cell proliferation and starving a tumor of blood supply, they are expected to totally displace older-generation treatment options eventually.

    Available locally in the past two to three years, they also come with fewer side effects than old treatment options, which are associated with notorious adverse reactions. However, the 20 to 30 percent of patients with aggressive cancer who are candidates for these therapies have to pay a steeper price, thus still limiting their local value for a class-blind disease like cancer.

    Ignacio said that no gold standard of breast-cancer treatment could ever surpass the value of detecting the disease early. He explained: "Being in a third-world country, we often take care of the burden of the tertiary part of medical care. There is no primary prevention for breast cancer but a big chunk of the financial side could be taken out if we go with early detection. It must be the real focus."

    He noted that while other countries are already focusing on gene-based therapies, cancer treatment here is still very much in the milieu of first-generation approaches like examining estrogen receptors and tumor size, and looking at lymph-node status.

Reaching the grassroots

    Statistics showing the Philippines as having the most number of breast-cancer cases in Southeast Asia and its rise up the ranks of top cancers in the country may not be all that alarming per se.

    It might be a question of demographics. With an ageing population, more individuals might be susceptible to breast cancer whose likelihood of incidence peaks with advancing years after age 30.

    It might even be an index of achievement for proponents of early detection. Said pcs executive director Luzmindo Fajardo: "Let us not forget that the reason the number of new cases have risen from 9,000 to 14,000 in the last five years is there might be a lot more people who are conscious of breast cancer. Therefore, early detection must be contributing also to the rise in statistics. Pcs has several programs, which are geared towards information and education."

    But Fajardo said that sometimes, the necessary information does not reach or comes late to those who need more awareness. "Information efforts are not extensive enough," he said. "The greater you disseminate, the more awareness of the need to have yourself screened grows."

    A recent initiative to reach out to the grassroots via a partnership with the Liga Ng Mga Barangay (League of Barangays) is giving them a better sense of the magnitude of work that still needs to be done in terms of early-detection advocacy, especially among the poor. In a barangay in Solano, Nueva Vizcaya, one of the pcs's two pilot communities for conducting basic cancer-screening services and information dissemination, several advanced cases of the disease have been uncovered.

    The pcs plans to roll out the program in a programmed way to ensure follow-through and map out other areas with the highest incidences of advanced cases as this would indicate lack of access to resources and facilities for early detection.

    Explained Fajardo: "The league can help us have the credentials to move into the communities so that people will start listening to us. We tell them that you can start with self-examination. We could train at the health-worker level in the community on how to conduct breast examination and if there's something notable, then the community health worker can refer them to a mammography procedure."

    Eufemio added: "Breast self-examination in a country like ours is still very useful. Not all women can go for mammography and it should be conducted not only once. If you have a family history of breast cancer, you have to do it every year."

    Nevertheless, he admitted that nothing beats mammography as a tool for early detection because of its ability to trace extremely minute calcifications during screening. Pcs seeks to make mammography at once more accessible and affordable to many through mobile mammography labs that can double as an ultrasound facility.

    Said Eufemio: "Not all regional areas in the country offer mammography services. We can lower the cost of mammography by requesting doctors to lower charging or to volunteer. If you can lower to PhP400 from PhP1,200, that's a big help already."

    Pcs is also looking at reviving the "Reach for Recovery" program, a patient-support network composed not only of breast-cancer survivors but their relatives, friends, and other volunteers. The network will work through group therapy similar to a successful model adopted by the American Cancer Society 30 years ago.

    Support networks such as this can use more support themselves. Television journalist Kara Alikpala, a breast-cancer survivor turned crusader, says that although there are now more than 45 patient groups around the country dealing with women's cancer, they encounter problems turning themselves into foundations and legitimating their status as donor recipients, especially those in the provinces. The law requires a group to have at least a million pesos in the bank for registration as a nonstock, not-for-profit organization.

    "Advocacy here is still in its infancy stage," Alikpala said. "Cancer is not in the consciousness of our national leaders, hence no government body nor big funding organization or corporation is committed to elevate advocacy."

    The success of advocacy for early detection can actually be quantified by determining the average size of breast lumps among patients during initial consultation with the doctor. Alikpala said that abroad, the average lump size at first consultation drastically went down to less than 15 millimeters. In the Philippines, the average is a whopping four centimeters especially among the poor, indicating a very advanced stage of the disease.

    Fajardo said that legislation is the more decisive intervention, but more as a long-term solution. At the core of it will be free or subsidized mammography in communities. He said: "We would like to do it but we haven't tried to actively pursue it yet. The problem with legislation is you need a lot of sponsors to get it through and you may end up with a nice law but no budget." M

A business case for health

Grace Roxas

Contributing Writer

The concept of the triple bottom line (profit, people, environment) in business is one catchy notion that sometimes tends to be a victim of its own success. One finds it adorning cocktail speeches of business executives who may or may not truly understand what it entails.

    This is why groups like the Philippine Business for Social Progress (pbsp), which is focused on corporate citizenship, take pains to add a strong business case to the basic imperative of helping society's underprivileged. Although it is heartening to hear companies doing good for goodness's sake, one wonders how long the largesse can flow in a volatile business environment.

    For health promotion and disease control, companies need look no further than their own backyards to justify doing good, said pbsp trustee Edgar Chua. If charity begins at home, then a company's workforce should be the most logical place to start promoting health.

    "A healthy workforce means a productive workforce," Chua noted. "There [are fewer absences] and for a given amount of time, they will be more creative. This you can actually convert into pesos."

    Plain business sense suffices to put in place, for example, a reward program for people who do not file for sick leaves during the year. Instead of adhering only to the mandatory conversion of unused leave credits to cash, some companies give additional incentives like cash and other gifts for employees who never call in sick.

    On the other hand, studies have shown that it is always healthy to take extended vacations of one to two weeks. To deter unhealthy workaholic habits, some companies only convert a portion of unused vacation leave credits and sometimes add a clause that the employee should have actually utilized his leave credits.

    "The Asian culture is such that we usually take only one-day leaves for birthdays, enrollment, and the like," observed Chua. "But in some advanced countries, vacation leaves are sacred. You take a one-month leave and forget everything. One cannot be reached by phone or computer."

    But that is just one thing. Another is the fact that health realities in today's workplace are far more complicated, and a company cannot, after all, exists in a social vacuum. Pbsp promotes workplace health programs that challenge companies to be more proactive with specific issues that impact their employees and the community.

Good model for business-health linkage

    A member of the Philippine Coalition Against Tuberculosis (Philcat), pbsp is helping develop and expand the TB Directly Observed Treatment Short Course (dots) strategy in the workplace.

    Chua explained: "We see TB as a good representation of how health problems should be addressed in our country because it is not something that can be met only by medication. Proper nutrition and environment are essential to ensure that someone stricken by this disease can recover."

    The holistic approach to TB requires means that promote access to nutrition and medication through providing education and livelihood should also be part of the equation. A well-rounded TB program thus becomes an angle of attack against the underlying problem of poverty.

    Several companies have already adopted the TB program and still more are being invited to implement it. Those who have agreed to adopt it include Aboitiz Transport System, American Standard, Central Azucarera Don Pedro, and Toyota Motor Philippines.

    "Some think that only big multinationals or local companies can implement an effective program. But every company, no matter the size, can implement it. We need to raise the consciousness of companies in this regard," observed Chua, who also sits as country chair of Pilipinas Shell Corporation.

    He noted that each employee has a multiplier effect of at least five. This means that health assistance to, say, 100 members of the workforce will end up benefiting 500 people.

    A company's constructive engagement against TB has repercussions beyond the physical. The stigma against TB patients is not only about social distress. If the patient is employed, stigma is also wound up with the fear of losing one's job.

    "One of the things we think is very important from the workplace point of view is avoiding discrimination against employees with TB," Chua said. "We work very hard to get companies to realize that instead of trying to get rid of an employee who has TB, [they should help the employee], that TB is not that high-risk."

Meeting mdgs

    TB is one of several priority areas for health under the United Nations Millenium Development Goals (mdgs), a set of targets the Philippines has committed to meet by 2015. As the government's lead mdg partner, pbsp formulates its programs in health, education, environment, and poverty alleviation in the context of mdg deliverables.

    Hiv/aids and malaria are two other diseases for priority control under the international accord. Pbsp addresses hiv/aids through a preventive workplace program focused on education. "Hiv/aids in the country is now described as hidden but growing. It is still small in scale so people think there is no cause for alarm," Chua said.

    The prospects concerning the fight against malaria, one of his company's main health-advocacy projects, seem brighter, he said. "For malaria, we secured a global funding of about US$40 million that can greatly assist us in delivering the mdg for this disease."

    The use of technology to fight this tropical disease can also be a model for other disease-control programs, notably TB. Under Shell Foundation's "Kilos Ligtas Malaria" program, the Internet is used as a tool by community-based health workers for consulting with specialists in Manila and elsewhere.

    Said Chua: "We can also organize TB diagnostic committees that way. This is where you can have the partnership between a community's basic health-care providers and experts from wherever through technology."

    He admitted that a lot of work remains to be done before 2015 for the other mdg deliverables in reproductive, maternal, and child health. "We still have a very high mortality rate for women delivering children. And of course, when it comes to reproductive health, you have sensitive discussions about population management and responsible parenthood."

    Generating greater business participation for the mdgs is a key challenge confronting pbsp, especially in getting people behind the health goals, which Chua called the "least sexy" of all. He said that active participation need not entail a huge financial outlay. "Some of this would simply be advocacy and training of the trainers. In pbsp, we are proud to have over 100 competent and dedicated people whose main responsibility is working on our objectives. Even the staff from member companies are there to provide assistance as required."

Business in community health

    With such a heap of concerns on its plate, pbsp and member-companies obviously cannot limit themselves to the workplace in effecting solutions. But a company has little control outside its offices and factories. Is there a place then for the community in the reckoning of business and vice versa?

    Such reckoning demands a longer-range view but remains grounded in reality. "Remember, our employees come from the community, so a healthy community means a healthy pool of manpower," Chua stressed.

    Second, the community is where the customers are, and no one wants a situation where sick customers spend more of their dwindling income on medicines than on everything else. Even drug companies won't be smiling on the way to the bank for long if a community remains too sick to continue affording medication.

    Attracting good talent and gaining a community's mantle of protection are two more compelling reasons. "People would not want to work for a company seen as irresponsible," Chua said. "If the community sees that you care, they will have malasakit as well. They will care for you in return and again, these things you can quantify."

    In return, companies can provide financial muscle and intellectual capital to support community initiatives. They can finance health-education projects and provide facilities, equipment, and even drugs. Of late, the overseas exodus of health workers has also led pbsp to put more stress on community-based training programs for basic-health providers.

    Business also has the management system and discipline to effectively implement programs. For TB-dots, pbsp has a workplace systems framework similar to a typical business chart, with interactive components ensuring a sustainable system for implementation.

    Yet, business cannot play the messiah. Chua cited the need to identify and support more leaders for health in the community, especially among the religious. The religious sector, he said, is usually left out of developmental discussions among the government, ngos, and private sector though it is ubiquitous, especially in remote areas beyond the reach of government and business, and it usually has the right motivations.

    "Business can help fill gaps in the health-delivery system but no one is big enough. Achieving the mdgs involves bringing as many partners to the table who are willing and able to help," Chua added. M