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

CCetC Group 17
1 of 7
MD 2 Perez, Shaikh, Ta-aca
• The problem of childhood CA in the Philippines is more
significant than in Western countries, because of
relatively young Filipino population. Overall pattern is,
however, similar and is dominated by Leukemia
• Certain features are similar to those in other Asian
populations (low incidence of Wilm’s tumor (kidneys),
Hodgkin’s disease and Ewing’s sarcoma), in contrast to
relatively high incidence rates for retinoblastoma (eye)
and low rates for neuroblastoma (brain) and Non-
Hodgkin’s lymphoma
TWO POPULATION-BASED CANCER REGISTRIES IN
THE COUNTRY
PHILIPPINE CANCER SOCIETY
• Originally known as the Central Tumor Registry (1959)
• Converted in 1983 into a population-based registry
covering Manila, Pasay, Caloocan, and Quezon City
DEPARTMENT OF HEALTH – RIZAL CANCER
REGISTRY
• The Rizal Cancer Registry is the first population-based
cancer registry in the Philippines
• Established in 1974 as part of the Community Cancer
Control Program in Rizal province
• From passive data collection, measures of registration
have improved throughout the years; in the 1980s,
active registration started
• Covers 26 municipalities within an area of 1,860 sq. km.
CANCER CONTROL IN THE PHILIPPINES
• Philippine Cancer Control Program (PCCP)
Lead by the premise that cancer can be largely
prevented mainly as a public health effort
• Systematic, organized, and integrated approach towards
the control of cancer
Can significantly alter or reduce morbidity and
mortality
Utilizing primary, secondary, and tertiary in the
different regions of the country
Aside from rehabilitation activities at both hospital
and community levels
• Goal:
Establish and maintain a system that integrates
scientific progress and its applications into a
comprehensive program that will reduce cancer
morbidity and mortality in the country
• Six pillars:
Epidemiology and research
Public information and health education
Prevention and early detection
Treatment
Training
Pain relief
CCetC FCM: The Philippine Cancer Control Program (PCCP)
MD 2
LUNG CANCER CONTROL PROGRAM
• Legislation measures:
Critical role in the elimination of the smoking habit
Elimination of advertisements and promotion of
tobacco products, sales to minors with labeling, tax
and price policies on cigarettes
─ All interested sectors (GOs and NGOs) shall
support legislative measures against tobacco
─ Initially can be started through local ordinances
that is acceptable to policy makers and the
public at large
Ex: Iloilo City Anti-Smoking Task Force
(ICAST)
• Intervention
Smoking counseling clinics in strategic localities will
provide service to the identified smokers behavior,
degree of tobacco addiction, and type of social
environment
• Research & epidemiology
Generation and collection of data on all aspects of
smoking carried out through research in the light of
meager information
Lead agencies:
─ DOH – Essential National Health Research
─ Lung Center’s Research and Development
Section
─ PCHRD
─ UP – PGH
─ Colleges of Medicine and Public Health
• Focus on anti-smoking campaign
Covers 85% of all cancer site control campaign
• Specific objectives:
To inform/educate school children and adults on the
hazards of smoking and its known risk of developing
cancer
To prevent the onset of smoking and decrease the
number of smokers
To identify Filipinos at high risk of developing lung
cancer (40 years old and above smokers)
• Example regulations:
On January 28, 1993, a DOH Administrative Order
prohibited smoking in DOH and its premises.
On March 22, 1993, another DOH Administrative
Order laid out rules and regulations on labeling and
advertising of cigarettes.
In 2001, DILG prohibited smoking in its offices and
premises. More specific campaigns were initially
done in government hospitals which are given
incentives or awards given how actively
implemented their smoking drive is. Also,
application form of job applicants includes info. On
his smoking habits
• Quezon City
Was the 1st city to issue a no-smoking policy in
public places ordinance
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 ANTI-SMOKING CAMPAIGN
• Carried out through the following:
Public information and health education:
─ Focus on increasing public awareness on the
hazards of smoking
─ Changing the attitude and behavior among
primary and secondary school children
─ Reaching out to the general public through mass
communication
Dealing with specific target audiences
Through interpersonal communications
Individualized process or group activities
─ Social mobilization important to generate and
sustain participation from all sectors of society
RED ORCHID AWARDS
• PhilHealth Regional Office VI received the DOH’s Red
Orchid Hall of Fame award in its effort to eliminate
th
tobacco use and exposure during the 7 Red Orchid
Awards held at The Oriental Hotel in Tacloban City
• Garnered a 91 – 100% score for implementing a
tobacco-free environment based on the DOH’s criteria,
thus giving them their 3rd Red Orchid Awards
• Criteria for judging includes the display of graphic
warning signs in the office, strict implementation of a 10-
meter radius smoking ban, incorporating health classes
during orientations and assigning personnel to the
smoking cessation clinic in the office
BREAST CANCER CONTROL PROGRAM
• The implementation of a nationwide anti-breast CA
scheme:
Public information and health education
Case finding (secondary prevention)
Treatment (treatment prevention) integrated into the
community health structure and equipped to control
breast CA in a systematic sustained manner
• Focus on early detection, treatment, and healthy lifestyle
• Specific objective
To inform or educate all women 30 - 60 years old on
breast self-examination (BSE) and importance of
doing a regular monthly BSE
To detect the maximum number of early stage
breast cancer by offering yearly breast examination
to all 30-60 years old women attending a health
institutions
To treat and/or rehabilitate detected cases
• Warning signals:
Any breast lump, particularly among women 30
years and older should be medically attended to.
Breast changes that persist such as a lump,
thickening, swelling or dimpling are the most
common presentation.
Breast cancer is generally painless
• Program strategies:
CCetC FCM: The Philippine Cancer Control Program (PCCP)
MD 2
Full integration of basic cancer control measures
with the governments basic medical health services
and other NGOs through primary health care
approach
Operationalization of bilateral health care referral
system
Making more intensive use of information, education
and communication activities
Standardization recording and reporting with a
built-in monitoring and evaluating system
Establishment of regular and frequent supervision
Adopting postsurgical adjuvant chemotherapy
regimen for 6 months for all premenopausal and
hormonal receptor negative postmenopausal
patients as well as adjuvant hormonal regimen for 2
- 5 years for hormonal receptor positive
postmenopausal patients
Provision of adequate logistical support for public
health and hospital services
Making available breast examination training
programs, residency and post-residency training
programs, hospital services and anticancer drugs
• Case finding – breast examination
In the Philippines, only a few have had the
opportunity to learn about the possible benefits of
regular BSE, physician examination, and even
mammography.
BSE appears to protect against dying from breast
cancers (RR of 0.30 to 0.48) especially for the elder
women and women who have been screened twice.
In the unscreened group, cancer tends to be
detected at a later stage than the screened group.
The stage of the disease at diagnosis affects the
prognosis and thus mortality
A 1/3 reduction in mortality has been attributed to
screening
BSE
─ For a smooth glide, do it while skin is still wet.
─ Done in front of the mirror to easily visualize
shape, color of breasts, size of lump, pendulous
or not.
• As screening procedures, PE and mammography both
detect cases not detected by the other, but the
contribution of mammography is substantially greater
• The importance of annual clinical breast exam (by
nurse, midwife, or public health physician) and monthly
BSE are to be emphasized, taking note that:
Mammography is not easily affordable or available
Mammography is mainly recommended for >/= 50
years old
Many breast CA are found among 35 - 50 years old
A relatively inexpensive strategy (BSE) is more
available
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 ABCS OF BREAST HEALTH
• Adult women of all ages are encouraged to perform
BSEs at least once a month
• BSEs can be done in 3 ways
In the shower
In front of a mirror
Lying down
• Contact you healthcare provider if there are any
changes
CERVIX UTERI CANCER CONTROL PROGRAM
• Focus on early detection and treatment, and healthy
lifestyle
• Specific objectives:
To educate people about cervical cancer, its
symptomatology, methods of early detection and
preventive measures
To screen at least 85% of women 25 - 55 years of
age every 3 years using acetic acid wash
Acetic acid wash
─ Use vinegar to detect erosion in cervix
─ ↑Sensitivity but not specificity (do a punch biopsy
for specificity)
─ Erosions- friable
─ Cheap
─ Spatula- rotate around cervix, inform px that it
might be an uncomfortable procedure
To identify early lesions of cervical cancer
To establish a practical or applicable referral system
To implement appropriate treatment protocol for the
different stages of cervical cancer
• Program activities:
Public information & health education
Professional education
Primary prevention
Case-finding with use of acetic acid wash
Diagnosis with use of Pap smear and colposcopy
Speculum- used to visualize cervix and adnexae
Treatment
Research
• Example regulations:
From DILG CAR – Memo Circ. No. 99-28 (Feb 10,
1999):
─ The Department of Health, through the Philippine
Cancer Control Program, will be implementing
the Cervical Cancer Screening Project with the
view to provide opportunities toward the early
detection and control of cervical cancer.
The Cervical Cancer Prevention Advocacy Program
was initiated through Proclamation No. 368, s.2003
which celebrates Cervical Cancer Awareness Month
during the month of May.
Department of Health, Philippines. Administrative
Order No. 2005-2006:
CCetC FCM: The Philippine Cancer Control Program (PCCP)
MD 2
─ Establishment of a Cervical Cancer Screening
Program 10 February 2005.
LIVER CANCER CONTROL PROGRAM
• Focus on hepatitis B vaccination, in collaboration with
Immunization Program of the DOH
• DOH Circ. No. 242s 10 Dec 1990 “Implementing
Guidelines on the Integration of Hepatitis B into the
Expanded Program on Immunization”
Hepatitis B vaccine was introduced in 1992
targeting 40% of infants, with planned coverage by
10% every year thereafter until 100% coverage by
1999 is reached
Not fulfilled due to insufficient funds
• RA No 7846-2006 “Compulsory Hepatitis B
immunization among infants and children less than 8
years old”
Goal was to reduce chronic infection of hepatitis B
to <1% among birth cohorts from baseline levels of
10-12%
• DOH AO N 0015-2006 “Implementing Guidelines on
Hepatitis B immunization for infants” – implementation
of RA 7846
Goal is to reduce the chronic hepatitis B infection
rate by HBsAg prevalence to <1% among 5-yr-old
children born after routine Hep B vaccination at birth
started (providing 3 doses of routine Hep B vaccine
among infants including birth dose)
DOH to procure 75% of Hep B needs for 2007 and
100% starting 2008 and onwards to provide all 0-11
months old with 3 doses of Hep B vaccine in the 1 st
year of life free of charge in all health facilities and
other institutions providing immunization services
for children nationwide
Units in 1 shot of Hep B vaccine
─ Adult : IM Basic course consists of 3 doses: 2nd
and 3rd doses given 1 and 6 mth after the 1st
dose respectively. Dose depends on the product
used. Typical doses: 10 or 20 mcg. Given via SC
administration in haemophiliacs. mims.com
─ Child: Basic course includes 3 doses; 2nd and
3rd doses to be given 1 and 6 mo. after the 1st
dose respectively. Deltoid area is preferred in
older children while anterolateral thigh is the
preferred site in neonates, infants and younger
children. Dose depends on the product used.
Typical doses are 5 or 10 mcg. mims.com
─ Monovalent Hepatitis B vaccine given at birth:
10mcg/0.5mL. Philippine Drug Price Index 2013
• RA No 10152 June 2011 “Mandatory Infants and
Children Health Immunization Act”
Includes Hep B vaccine free to infants within 24
hours of birth
• 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
in prostatic cancer
Manual stool extraction
─ 1-3 clean gloves
─ Newspapers/ paper towels/ wet wipes/ lubricant
─ Wastebag
─ Inform px why you’re doing it
Good result
─ Good sphincter tone
─ - feel prostate at tip of finger; -feel uterus at
tip of finger; there should be no mass felt, if there
is one, determine if it is from rectum, stool
(mushy, like chicken nuggets if frequent
impaction), etc.
─ Done with respect/ finesse; if rude, can be
perceived as opportunistic or disrespectful
• In 1996, the DOH launched the ‘Iwas Sakit Diet’ (‘shun
illness diet’) and ‘Tia Kulit’ (‘concerned aunt’)
Promoting consumption of foods rich in fiber,
avoidance of high fat/cholesterol foods and
moderate salt intake, implemented through diet
counseling health service facilities
HEALTHY LIFESTYLES
• Health Care Intervention Strategies in the diseases
associated with risky lifestyles are:
Information dissemination & Education campaign -
avoidance of lifestyle
Counseling
Screening
Case-finding and Treatment
Disease-specific clinical management
Rehabilitation
Supportive care
CCetC FCM: The Philippine Cancer Control Program (PCCP)
MD 2
Figure 1. Healthy lifestyle by Cangelangel.
CANCER PAIN RELIEF PROGRAM
• Started in 1989, leading the way to Hospice-At-Home
concept.
• Focuses on cancer pain relief and support groups,
rehabilitation, and hospice care
• This program primarily implemented the WHO analgesic
Ladder, in a modified way cutting the ladder to a 2-step
(skipping 2nd ladder - weak opioid) from an original 3-
step. The main analgesic concepts implemented are:
Use of oral drugs, allowing hospital discharge and
home care
Analgesics are given on a regular basis
─ 'by the clock'
Choice of analgesic agent given is
─ 'by the ladder'
If pain is bearable, initially give (1) Paracetamol
(Tylenol/Acetaminophen-US)
─ Mefenamic acid and Celecoxib- discouraged
─ (2) Codeine (in Singapore, banned in PH)
─ (3) Tramadol
─ (4) Morphine (Gold Standard)
Morphine given for
─ Cancer pain
─ Dyspnea/ respiratory distress of small cell lung
CA
• The Dangerous Drugs Board on October 19, 1989
through Board regulations No. 6, 6-A, 7,8 have changed
the regulations on the use of morphine exclusively for
cancer patients, effectively achieving the following:
Facilitated the process of obtaining an official
prescription (DDB Form No. 1-72) and a local
purchase form (DDB Form No. 8-72). Regional
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
448 mg morphine IV
─ For local purchase
1.68 mg morphine oral
896 mg morphine IV
• The Philippine quota for the annual importation of
morphine has been increased by the International
Narcotics Control Board from 1 kg to 25 kg. There is a
current move to increase the quota further to 50 kg.
• The morphine consumption nationwide in 1990 was 6
kg, in 1991 – 1 kg, in 1992 – 5 kg, in 1993 – 18 kg, and
in 1994 – 38 kg.
• The government hospitals consumed only 30 kg in
1991-1994; only 18/ 53 hospitals submit regular reports
on morphine consumption.
• The Bureau of Food & Drugs had approved new
formulations of morphine sulfate tablets that now
include 10, 20, 30, and 50-mg tablets. 50 mg tablets are
not available in the Philippines
• Regular budget for the purchase of morphine sulfate
tablets was identified in 1990
• The National Drug Council in 1992 approved the
inclusion of morphine tablet sustained release in the
National Drug Formulary
• Became a reality when the DOH Acting Sec. Jaime
Galvez Tan declared Hospice care be incorporated in
the Cancer Pain Relief Program of DOH
Lead agency:
─ Philippine Cancer Society Inc. (PCSI)
Support agency:
─ DOH
Cancer Px
─ Paracetamol 500mg 2 tab (1g) every 6 hours by
the clock
─ Morphine – morphine level adds up in body of
px, no 1g/ml available in PH, 10mg 1 tab every
4 hours by the clock + 10mg for breakthrough
pain within 4 hours
─ Abstral 100-400mg
─ Fenylcitrate dissolves in tongue, in bloodstream
after a few minutes, 1 hour effect only
─ Oxycodone- 2x more potent than morphine
─ Fentanyl patches available
─ 10 mg parenteral morphine not equipotent with
10mg oral morphine
─ 10mg parenteral morphine is equipotent to 2-
3tab of oral morphine
─ Intrathecal morphine (drops) more potent than
parenteral morphine
─ If with initial administration of 10mg oral
morphine and you have to administer parenteral
morphine, don’t push 1 ml parenteral morphine
since it might cause respiratory depression or
even death
CCetC FCM: The Philippine Cancer Control Program (PCCP)
MD 2
COMMUNITY-BASED CANCER CARE/CONTROL
NETWORK (CCCN)
• Begun in 1998
• Vision:
A self-sufficient network of empowered communities
sharing responsibility for total quality cancer care
and control in the PH and its mission to organize,
integrate, and nurture such network
Built around the idea when many organization and
individuals pool together their expertise, skills,
resources and experiences and cooperate to
achieve a common goal, they become powerful
forces
• Composed of Local Cancer Control/Care Networks or
Nodes that will network with each other towards a
common goal
• Each node will center on a tertiary government hospital,
each node is composed of a network of satellites,
including NGOs, GO, and individuals
• DOH-PCCP unit will be the lead agency
• Major control-related NGOs in the locality will be the
lead NGO agency
• Nodes will be self-sufficient and reliant
• In 2000, CCCN started a Hospital Tumor Registry
software for the different component hospitals of the
network and the DOH-PCCP
Yellow prescription pad: Max tabs per
prescription pad = 100 tabs; validity= 30 days per
yellow prescription pad
─ Phenobarbital
─ Phenodiazomorphine
─ Morphine
Formulation: Old, 10mg(green), 20mg (blue),
30mg (pink); New: 10mg, 30mg
─ 3 sheets per prescription: one left with (1)
pharmacy, (2)patient (yellow green) and (3)
doctor(white)
─ Spell out dosage if you prescribe, for example:
Morphine 10 mg (TEN MILLIGRAMS) additional
of 10mg 1tab in between 4 hours if there is
breakthrough pain
─ Free Morphine Program (2006): Immediate-
release tablets; Aquino administration:
Extended-release tablets
Adjuvant drugs: Lactulose, Senna
─ Imperative to write along opioids
─ Need irritant laxative: Senna tablets (Biguerlai
tea)
─ ↑slippery stool: Bisacodyl
With opioids, colon peristalsis slows down, so
↑water reabsorption, ↑harder stool
Not given if px is taking opioid
─ Bulk-forming laxatives: Psyllium contribute
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
CCetC FCM: The Philippine Cancer Control Program (PCCP)
7 of 7
MD 2