Archives for January 2017

Resource requirements for cancer registration in areas with limited resources: Analysis of cost data from four low- and middle-income countries

Florence Tangka, PhD, Health Economist,
Centers for Disease Control and Prevention

Cost of Cancer Registration in Limited Resource Settings

Cancer is a leading cause of illness and deaths worldwide. In 2012 approximately 14.1 million new cancer cases were diagnosed, 8.2 million people died from cancer, and 32.5 million people were living with cancer. More than 50% of the world’s cancer cases and 65% of cancer deaths occur in limited-resource settings, and more than 48% of cancer survivors live in these areas. In the next two decades, new cancer cases are projected to increase by 70% worldwide, mostly in limited-resource settings.

High-quality population-based cancer surveillance data are needed to describe cancer burden, patterns, and outcomes in order to inform cancer prevention, detection and control activities, and evaluate interventions so that the best approaches to ease burden and suffering are adopted.  There are large inequalities in the existence, coverage, and quality of cancer surveillance systems across the world, with limited information available in limited-resource settings. For example, the percentage of the population covered by cancer registries ranges from nearly 100% in North America to less than 10% in Asia, Central America, and South America, and roughly 2% in Africa (See Figure 1).

Only one in five countries in limited-resource settings have the data needed to inform cancer control plans. To address this gap, the International Agency for Research on Cancer (IARC), a specialized agency of World Health Organization (WHO), has initiated the Global Initiative for Cancer Registry Development (GICR) to establish regional resource centers to provide technical support and guidance for the development and improvement of population-based cancer registries around the world.

IARC has developed a framework for planning and implementing population-based cancer registries. However, lack of information about how much registries cost is a major barrier to planning, implementing, and evaluating cancer registration. Yet, investing in high quality surveillance data is crucial so countries can select the best interventions that are both cost effective and most improve health.

CDC, RTI International and others partner developed a tool and used it to collect standardized cost and resource data from 11 registries in Colombia, India, Kenya, Barbados, and Uganda.  Findings from this study have been published as a series of manuscripts in Cancer Epidemiology.  The study found that partnerships are crucial to developing and sustaining registries. While registries can be expensive, they are less expensive in LMICs and the population level cost is low (less than $0.01 to $0.22 per person). Efficient data collection processes and organizations can cut costs further.

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Information on the cost of establishing, improving, maintaining, and expanding cancer registries is essential to ensure adequate funding is available for cancer registration activities. Accurate and reliable costing data is also critical in supporting country-level and regional efforts to plan, implement and evaluate investments in cancer registration.

The abstract below is from the comparative paper published in the Monograph titled “Resource requirements for cancer registration in areas with limited resources: Analysis of cost data from four low- and middle-income countries.”

Resource requirements for cancer registration in areas with limited resources: Analysis of cost data from four low- and middle-income countries (The abstract below is from The International Journal of Cancer Epidemiology, Detection and Prevention)


The key aims of this study were to identify sources of support for cancer registry activities, to quantify resource use and estimate costs to operate registries in low- and middle-income countries (LMIC) at different stages of development across three continents.

Using the Centers for Disease Control and Prevention’s (CDC’s) International Registry Costing Tool (IntRegCosting Tool), cost and resource use data were collected from eight population-based cancer registries, including one in a low-income country (Uganda [Kampala)]), two in lower to middle-income countries (Kenya [Nairobi] and India [Mumbai]), and five in an upper to middle-income country (Colombia [Pasto, Barranquilla, Bucaramanga, Manizales and Cali cancer registries]).

Host institution contributions accounted for 30%–70% of total investment in cancer registry activities. Cancer registration involves substantial fixed cost and labor. Labor accounts for more than 50% of all expenditures across all registries. The cost per cancer case registered in low-income and lower- middle-income countries ranged from US $3.77 to US $15.62 (United States dollars). In Colombia, an upper to middle-income country, the cost per case registered ranged from US $41.28 to US $113.39. Registries serving large populations (over 15 million inhabitants) had a lower cost per inhabitant (less than US $0.01 in Mumbai, India) than registries serving small populations (under 500,000 inhabitants) [US $0.22] in Pasto, Colombia.

This study estimates the total cost and resources used for cancer registration across several countries in the limited-resource setting, and provides cancer registration stakeholders and registries-with opportunities to identify cost savings and efficiency improvements. Our results suggest that cancer registration involve substantial fixed costs and labor, and that partnership with other institutions is critical for the operation and sustainability of cancer registries in limited resource settings. Although we included registries from a variety of limited-resource areas, information from eight registries in four countries may not be large enough to capture all the potential differences among the registries in limited-resource settings.

The opinions expressed in this article are those of the authors and may not represent the official positions of NAACCR.

Black Heterogeneity in Cancer Mortality: US-Blacks, Haitians, and Jamaicans

Paulo Pinheiro, MD, MSc, PhD, Associate Professor Epidemiology, University of Nevada Las Vegas (NAACCR Committee Member)

Significant disparities between Blacks, or Americans of African descent, and the majority non-Hispanic white population for cancer incidence, survival and mortality are well-documented. For research purposes, Blacks have been typically aggregated as one large population group, as NAACCR does not collect specific information on descent for non-Hispanic Blacks. However, our colleagues at the University of Nevada Las Vegas ​(UNLV) ​used mortality data from Florida to examine heterogeneity within the Black population, finding surprising differences between US-born Blacks, ​and Jamaicans and Haitians​ (Afro-Caribbean populations) residing in Florida​.

US-born Blacks had exceedingly high mortality rates, nearly double that of their Caribbean counterparts, whose rates were similar to or lower than non-Hispanic whites for many cancers. Haitians in Florida had the lowest mortality for all cancers combined and for the greatest causes of cancer mortality: lung, colorectal, breast, and prostate; Jamaican rates were intermediate between Haitian and US-born Black rates. Perhaps most surprising is that even for infection-related cancers, typically ascribed to immigrant populations, US-born Black men had higher mortality for liver and stomach cancer, and US-born Black women had higher cervical cancer mortality than Jamaicans or Haitians.​ Also, the patterns among Jamaicans and Haitians in the US vary according to cancer site, and these patterns are not always compatible with the widely known “healthy immigrant effect”.​

These results assume great importance for aggregated rates in states such as New York and Florida with significant diversity in the Black population, as the inclusion of these relatively healthier populations has the effect of pulling down the rates and underestimating the true mortality burden for US-born Blacks, shown here to be even worse than previously documented. This work also highlights the importance of better understanding the role of acculturation among immigrant groups in cancer risk.

Read Full Article (Abstract below)


Introduction: The quantitative intraracial burden of cancer incidence, survival and mortality within black populations in the United States is virtually unknown.

Methods: We computed cancer mortality rates of US- and Caribbean-born residents of Florida, specifically focusing on black populations (United States, Haiti, Jamaica) and compared them using age-adjusted mortality ratios obtained from Poisson regression models. We compared the mortality of Haitians and Jamaicans residing in Florida to populations in their countries of origin using Globocan.

Results: We analyzed 185,113 cancer deaths from 2008 to 2012, of which 20,312 occurred in black populations. The overall risk of death from cancer was 2.1 (95% CI: 1.97–2.17) and 1.6 (95% CI: 1.55–1.71) times higher for US-born blacks than black Caribbean men and women, respectively (P < .001).

Conclusions: Race alone is not a determinant of cancer mortality. Among all analyzed races and ethnicities, including Whites and Hispanics, US-born blacks had the highest mortality rates while black Caribbeans had the lowest. The biggest intraracial difference was observed for lung cancer, for which US-blacks had nearly 4 times greater mortality risk than black Caribbeans. Migration from the islands of Haiti and Jamaica to Florida resulted in lower cancer mortality for most cancers including cervical, stomach, and prostate, but increased or stable mortality for 2 obesity-related cancers, colorectal and endometrial cancers. Mortality results in Florida suggest that US-born blacks have the highest incidence rate of “aggressive” prostate cancer in the world, rather than Caribbean men.

The opinions expressed in this article are those of the authors and may not represent the official positions of NAACCR.

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