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Cancer and the Philippine Cancer Control Program

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DOI: 10.1093/jjco/hye126 · Source: PubMed

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 Jpn J Clin Oncol 2002;32(Supplement 1)S52–S61

Cancer and the Philippine Cancer Control Program

Corazon A. Ngelangel1 and Edward H. M. Wang2
1Department of Medicine, University of the Phil-Phil General Hospital and Jose R. Reyes Memorial Medical Center,
Department of Health and 2Cancer Institute, Philippine General Hospital and Department of Orthopaedics, University
of the Phil-Phil General Hospital, Manila, Philippines

Received February 2, 2001; accepted August 28, 2001

Cancer is the third leading cause of morbidity and mortality in the Philippines. Leading cancer
sites/types are lung, breast, cervix, liver, colon and rectum, prostate, stomach, oral cavity,
ovary and leukemia. There is at present a low cancer prevention consciousness and most can-
cer patients seek consultation only at advanced stages. Cancer survival rates are relatively
low. The Philippine Cancer Control Program, begun in 1988, is an integrated approach utilizing
primary, secondary and tertiary prevention in different regions of the country at both hospital
and community levels. Six lead cancers (lung, breast, liver, cervix, oral cavity, colon and rec-
tum) are discussed. Features peculiar to the Philippines are described; and their causation and
prevention are discussed. A recent assessment revealed shortcomings in the Cancer Control
Program and urgent recommendations were made to reverse the anticipated ‘cancer epi-
demic’. There is also today in place a Community-based Cancer Care Network which seeks to
develop a network of self-sufficient communities sharing responsibility for cancer care and
control in the country.

Key words: Philippines – cancer – Philippine Cancer Control Program

INTRODUCTION CANCER STATISTICS

In the Philippines, cancer ranks third in leading causes of mor-
bidity and mortality after communicable diseases and cardio-
vascular diseases (Department of Health–Health Intelligence
Service or DOH–HIS, 1992, 1996) (1). Over the period 1942–
96, communicable disease mortality has shown a gradually
decreasing trend, in contrast to the increasing trends of heart
disease and cancer (non-communicable diseases).
In the Philippines, 75% of all cancers occur after age 50
years, and only about 3% occur at age 14 years and below. If
the current low cancer prevention consciousness persists, it is
estimated that for every 1800 Filipinos, one will develop
cancer annually. At present, most Filipino cancer patients seek
medical advice only when symptomatic or at advanced stages:
for every two new cancer cases diagnosed annually, one will
die within the year.
The Philippine Cancer Control Program, begun in 1988, is
an integrated approach utilizing primary, secondary and terti-
ary prevention in different regions of the country at both hospi-
tal and community levels. Six leading cancers (lung, breast,
liver, cervix, oral cavity, colon and rectum) are discussed.
For reprints and all correspondence: Corazon A. Ngelangel, Section Chief,
Medical Oncology, Department of Medicine, University of the Phil-Phil Gen.
Hospital, Taft Avenue, Manila, Philippines 1000
INCIDENCE BY CANCER SITE
Cancer incidence data are derived from two population-based
cancer registries in the country: the Department of Health–
Rizal Cancer Registry (DOH–RCR) and the Philippine Cancer
Society Inc.–Manila Cancer Registry (PCSI–MCR). The
DOH–RCR covers 26 municipalities of Rizal Province and
PCSI–MCR covers the four cities of Quezon, Manila,
Caloocan and Pasay. From 1980 to 1995, the leading cancer
sites/types have remained the same: lung, breast, cervix uteri,
liver, colon and rectum, prostate, stomach, oral cavity, ovary,
leukemia, thyroid, uterus, non-Hodgkin’s lymphoma, larynx
and nasopharynx (Table 1) (2–4).
The top cancer sites in the Philippines include those cancers
whose major causes are known (where action can therefore be
taken for primary prevention), such as cancers of the lung/
larynx (anti-smoking campaign), liver (vaccination against
hepatitis B virus), cervix (safe sex) and colon/rectum/stomach
(healthy diet). Except for the liver, the top Philippine cancer
sites are also the top cancers worldwide. Table 2 presents the
less common cancer sites in the Philippines (2–4).
The problem of childhood cancer in the Philippines is more
significant than in Western countries, because of the relatively
young Filipino population. The overall pattern is, however,
similar and is dominated by leukemia (Table 3). Certain

© 2002 Foundation for Promotion of Cancer Research

 Jpn J Clin Oncol 2002;32(Supplement 1) S53

Table 1. Leading cancer sites, age-standardized rates per 100 000 population, all ages, Manila and Rizal (2–4)

Cancer site 1980–82 1983–87 1988–92 1993–95

BS M F BS M F BS M F BS M F
Lung 25.8 42.3 11.5 31.0 46.7 14.9 40.0 64.7 18.8 40.0 64.7 18.8
Breast 0.7 40.5 0.7 44.4 0.8 43.2 0.8 43.2
Liver 13.4 20.4 7.3 14.7 20.4 8.0 16.8 25.6 9.0 16.8 25.6 9.0
Cervix uteri 20.5 – 20.5 22.5 – 22.5 26.4 – 26.4 26.4 – 26.4
Stomach 9.6 11.9 7.6 9.6 11.4 7.7 9.6 12.1 7.6 9.6 12.1 7.6
Colon 6.5 7.3 5.7 8.0 8.0 7.7 10.7 11.8 9.8 10.7 11.8 9.8
Oral cavity 5.9 5.4 6.3 6.9 6.4 7.3 8.6 8.5 8.3 8.6 8.5 8.3
Prostate 12.5 12.5 – 14.6 14.6 – 19.3 19.3 – 19.3 19.3 –
Rectum 5.5 6.5 2.8 6.6 7.4 5.6 7.0 8.1 6.2 7.0 8.1 6.2
Leukemia 5.2 5.7 2.9 5.7 5.6 5.5 6.6 7.2 6.2 6.6 7.2 6.2
Nasopharynx 2.5 6.0 1.6 5.2 6.7 3.1 6.2 8.6 4.0 6.2 8.6 4.0
Larynx 1.4 4.3 0.4 2.8 4.4 1.1 3.4 6.2 1.0 3.4 6.2 1.0
Ovary 8.0 – 8.0 9.2 – 9.2 10.8 – 10.8 10.8 – 10.8
Thyroid 2.7 1.3 6.6 5.6 2.7 8.0 6.6 3.1 9.8 6.6 3.1 9.8
Corpus uteri 6.1 – 6.1 5.8 – 5.8 5.2 – 5.2 5.2 – 5.2
Non-Hodgkin’s lymphoma 2.0 2.1 1.6 3.3 3.8 2.6 4.6 5.8 3.6 4.6 5.8 3.6

features are similar to those in other Asian populations (low
incidence of Wilm’s tumor, Hodgkin’s disease and Ewing’s
sarcoma), in contrast to relatively high incidence rates for
retinoblastoma and low rates for neuroblastoma and non-
Hodgkin’s lymphoma (2–4).
were lung, liver, breast, leukemia, stomach, cervix uteri, colon,
liver, pancreas, nasopharynx and prostate (in decreasing order
of frequency). The top three mortality cancer sites among
females were breast, lung and cervix uteri and among males
lung, liver and leukemia.

SURVIVAL FROM CANCER IN THE PHILIPPINES

The survival experience, regardless of treatment, of patients
with top cancer sites diagnosed in 1987 and included in the
DOH–RCR was evaluated as the first population-based sur-
vival data for Filipinos (5). Lung cancer had the lowest sur-
vival and breast cancer had the highest (Table 4). Five-year
survival in excess of 40% was observed for only three cancer
sites: oral cavity, colon and breast. For all other sites, survival
was less than 30%. Owing to the small number of cases in each
category, no distinct impact of age on relative survival could
be perceived for most cancer sites. However, both observed
and relative survival rates were low for breast cancer patients
less than 35 years old (Table 5).
The 1987 cancer survival rates among Filipino patients
imply that there is much to be done for cancer education and
the implementation of all aspects of cancer prevention. In com-
parison, the 1990 5-year relative survival rates, all races, from
the USA National Cancer Institute Surveillance Epidemiology
End-result program reveals higher rates (Table 6) except for
stomach (males) and liver cancers.
MORTALITY FROM CANCER
Data from the 1991/95 DOH–RCR and the DOH–HIS 1992
and 1996 data indicated that the leading cancer site mortalities
CANCER CONTROL IN THE PHILIPPINES
THE PHILIPPINE CANCER CONTROL PROGRAM
It was on the premise that cancer can be largely prevented
mainly as a public health effort that the Philippine Cancer
Control Program (PCCP) was established. The first phase
of program implementation was conducted in 1988, providing
the guidelines for the PCCP, specifying program policy,
components, implementing guidelines and timetable.
The PCCP is a systematic, organized and integrated
approach towards the control of cancer which can significantly
alter or reduce morbidity and mortality utilizing primary, sec-
ondary (community level) and tertiary prevention in the differ-
ent regions of the country aside from rehabilitation activities at
both hospital and community levels. The goal is to establish
and maintain a system that integrates scientific progress and its
practical applications into a comprehensive program that will
reduce cancer morbidity and mortality in the Philippines. The
six Pillars of the PCCP are Epidemiology and Research, Public
Information and Health Education, Prevention and Early
Detection, Treatment, Training and Pain Relief.
S54 Cancer control in the Philippines

Table 2. Other cancer sites, age-standardized rates per 100 000, all ages, Table 3. Childhood cancer, 0–14 years old, age-standardized rates per million,
Manila and Rizal (2–4) both sexes (2–4)

Cancer site 1988–92 1993–95 Cancer type Manila Rizal

and Rizal
BS M F M F
1983–92 1993–95
Oropharynx 1.2 1.0 1.2 0.6 0.7
Total 100.8 144.0
Hypopharynx 0.4 0.2 0.3 0.6 0.3
I. Leukemias 48.1 63.7
Pharynx, NOS 1.8 1.0 1.4 0.8 0.4
a. Ac lymphocytic 25.0 31.2
Esophagus 3.2 1.8 2.4 3.0 1.2
b. Ac Non-lymphocytic 8.5 14.0
Small intestine 0.9 0.5 0.7 0.8 0.6
II. Lymphomas 7.1 14.5
Gallbladder, etc. 1.6 1.6 1.6 1.6 1.5
a. Hodgkin’s 0.6 0.5
Pancreas 5.0 4.0 4.5 3.5 3.3
b. Non-Hodgkin’s 3.3 14.0
Nose, sinuses, etc. 1.8 1.2 1.4 1.2 0.7
III. Brain and spinal 9.6 12.6
Pleura 0.1 0.1 0.1 0.6 0.2
a. Astrocytoma 3.0 3.5
Bone 3.0 2.0 2.4 2.7 1.6
b. Primitive ectodermal 2.4 5.6
Connective tissue 3.2 2.3 2.7 2.3 1.8
IV. Sympathetic nervous system (neuroblastoma) 2.3 1.6
Skin 4.2 3.3 3.8 3.5 2.0
V. Retinoblastoma 7.7 8.9
Placenta – – 0.5 – 0.6
VI. Kidney 4.6 5.4
Other genital 0.8 1.1 – 1.7 0.9
a. Wilm’s tumor 3.5 5.1
Bladder 5.0 1.6 3.2 5.1 2.6
b. Renal carcinoma 0.1 0.3
Kidney 4.2 2.6 3.3 4.2 2.4
VII. Liver 2.2 3.0
Eye 0.7 0.5 0.6 0.6 0.4
VIII.Bone 4.0 7.8
Brain 2.8 1.8 2.3 2.9 1.8
a. Osteosarcoma 2.3 4.6
Other endocrine 0.2 0.2 0.2 0.2 0.1
b. Ewing’s sarcoma 0.2 0.8
Unknown primary site 10.6 8.2 9.3 10.2 8.4
IX. Soft tissue sarcoma 4.2 6.7
a. Rhabdomyosarcoma 2.3 4.0
CAUSATION AND PREVENTION BY SPECIFIC CANCER SITE b. Fibrosarcoma 0.8 0.0
X. Gonadal and germ cell 3.6 4.6
1. LUNG a. Non-gonadal germ cell 1.1 0.8
b. Gonadal germ cell 1.7 3.8
CAUSATION c. Gonadal carcinoma 0.3 0.0
The Pulmonary Carcinoma Task Force of the Philippine Veter- XI. Epithelial neoplasm 5.6 3.2
ans Memorial Medical Center reviewed the smoking habits of a. Nasopharynx 0.9 0.5
178 patients with squamous cell/small cell adenocarcinomas XII. Other 1.8 12.1
(1984) (6). There were more cases in (a) smokers compared
with non-smokers, (b) cigarette smokers compared with
smokers of other tobacco products and (c) subjects with 20
compared with <20 years’ smoking history. Furthermore, ing at age 6–9 years. Tan (10) indicated favorable results in his
Mendoza-Wi of the Philippine General Hospital (1984) study on inter-agency collaboration for the teaching of lung
reported that there seemed to be more smokers among cases cancer and its prevention to elementary and high school
with oat cell and epidermoid carcinomas (7). students.
A national smoking surveillance study conducted in 1989 by A study in 1999 (11) estimated 17.9 million Filipinos to have
the Lung Center of the Philippines revealed 46.52% smokers: a history of smoking (46.5% of the adult population). At least
of the adult population, overall 52.69% were smokers, 64.17% another 26.4 million are passive smokers. The economic bur-
among males and 18.75% among females. There was no sig- den resulting from lung cancer, chronic obstructive pulmonary
nificant difference between the proportion of smokers in rural disease, coronary artery disease and cerebrovascular disease
and urban areas (8). adds up to approximately US$ 1 billion (59% from health care
Ayson and Tamesis (9) found 28% smokers among 528 high costs, 39% from premature deaths and 2% from productivity
school students; 85% were classified as experimenters and loss).
15% as current smokers. Smoking was started because of peer
pressure, curiosity and parental influence; 15% had tried smok-
 Jpn J Clin Oncol 2002;32(Supplement 1) S55

Table 4. Survival rates by 1, 3 and 5 years by cancer site, all ages (5)

Cancer site Observed survival, BS Relative survival, BS % Survival rate % Survival rate
at 5 yrs, male at 5 yrs, female
1 yr 3 yrs 5 yrs 1 yr 3 yrs 5 yrs Obs Rel Obs Rel
Oral cavity 52.3 33.9 33.9 54.4 38.3 41.9 20.5 26.1 25.3 30.7
Stomach 25.9 11.6 9.9 26.6 13.1 12.1 14.5 18.5 4.3 5.0
Colon 57.5 38.1 33.9 60.0 42.2 40.3 39.0 46.1 29.1 34.7
Rectum 58.1 31.3 20.0 59.9 34.5 23.7 17.4 21.1 23.0 26.2
Colon–rectum 57.6 35.1 27.6 59.5 38.8 32.7 28.7 34.4 26.5 31.0
Liver 19.9 12.5 12.5 19.3 13.7 14.6 11.1 12.9 16.3 19.1
Lung 25.8 9.9 5.9 27.7 11.1 7.2 5.7 7.0 6.7 7.8
Breast 82.0 57.2 40.4 83.5 60.4 44.4 40.4 44.4
Cervix uteri 66.8 36.5 24.9 67.8 38.3 27.2 24.9 27.2
Prostate 65.9 29.3 15.5 7.0 35.2 21.2 15.5 21.2
Lymphatic leukemia 38.3 28.5 23.8 27.4 29.0 24.5 33.1 33.5 16.0 16.9
Myeloid leukemia 4.1 10.7 10.7 24.0 11.2 11.5 5.4 5.9 16.3 17.3
All leukemia 30.2 18.0 16.3 29.8 18.6 17.8 17.5 18.3 15.3 16.3

Table 5. Survival rates by age group by cancer site, both sexes (5)

Cancer site % Relative survival by 15 yrs Relative survival rate ASRS* (%)
£34 35–44 45–54 55–64 65–74 75+ All ages 0–74
Oral cavity – – – 25.1 55.9 44.8 41.9 34.9 32.4
Stomach 20.4 10.3 18.1 14.1 8.6 – 12.1 11.6 13.0
Colon 38.5 31.4 43.5 67.8 26.5 42.0 40.3 42.4 42.6
Rectum – 22.4 15.4 49.1 27.2 – 23.7 29.2 30.6
Colon–rectum 20.2 27.6 32.1 58.2 27.0 27.6 32.7 32.9 36.6
Liver 11.2 31.4 5.7 6.0 9.5 20.4 14.6 12.8 10.9
Lung – 15.4 3.0 8.3 9.2 – 7.2 8.6 8.4
Breast 24.6 44.6 50.3 34.5 52.4 67.2 44.4 48.2 43.4
Cervix 32.6 42.6 22.3 17.8 18.5 – 27.2 25.2 26.1
Prostate – – – 33.5 40.6 10.6 21.2 19.5 37.3
Lymphatic leukemia 26.4 – – – – – 24.5
Myeloid leukemia 14.5 – – 19.2 – – 11.5 16.6 16.0
All leukemia 20.9 – – 19.2 21.0 – 17.8 19.8 20.0

Dashes indicate no cases. *ASRS = age-specific relative survival.

PREVENTION Secondary Education to incorporate cancer prevention mes-

The Lung Cancer Control Program (LCCP) utilizes primary
prevention at the community level (smoking control), tertiary
prevention at special medical centers and rehabilitation activi-
ties at both community and hospital levels. The main activity
of the LCCP is the anti-smoking campaign: public informa-
tion, health education and legislative measures.
The DOH–LCCP implements its trimedia ‘Yosi Kadiri’, ‘No
Sa Yo’ (It Isn’t Cool to Smoke) campaigns. It collaborates with
the Department of Education, Culture and Sports–Bureau of
sages in secondary school health education. Components of its
health education campaign are (a) inclusion in the school
curriculum of smoking as a health problem, (b) social mobi-
lization and (c) establishment of a national information and
counseling center.
On 28 January 1993, a DOH Administrative Order prohib-
ited smoking in the Department of Health and its premises. On
22 March 1993, another DOH Administrative Order laid out
the rules and regulations on the labeling and advertising of
cigarettes. The DOH has also joined multi-sectoral groups in
S56 Cancer control in the Philippines

Table 6. Five-year relative %survival rates, 1990 SEER vs 1987 DOH–RCR was increased by 2.7% (SD 0.7%) for each year of use.
There is no evidence of an increased risk of breast cancer 5
Cancer site 1990 SEER 1987 DOH–RCR or more years after stopping HRT (13).
Males Females Males Females A case-control study (14) among Filipino breast cancer cases
Oral cavity 52 56 26.1 30.7 and their controls (1989–91) revealed longest residence in
Stomach 16 21 18.5 5.0 rural areas [odds ratio (OR) = 2.78], lower than high school
Colon–rectum 60 59 34.4 31.0
education (OR = 1.87), history of benign breast disease (OR =
2.51), infertility (OR = 5.83) and greater than 35 years age at
Liver 5 13 12.9 19.1
first pregnancy (OR = 18.2) as significant risk factors. Severe
Lung 12 17 7.0 7.8 dysmenorrhea (OR = 0.24), number of livebirths (OR = 0.88)
Breast 78 44.4 and breast-feeding (OR = 0.57) were protective factors. The
Cervix uteri 66 27.2 Philippines shows no cancer risk associated with higher socio-
Prostate 77 21.1 economic status.
Leukemia 39 40 17.8 16.3 None of the implicated breast cancer risk factors readily lend
themselves to primary prevention interventions. It is also
possible that reproductive changes in the Filipino population
(decreasing average family size and an increasing average age
lobbying for the anti-smoking Bill in the Senate. The DOH is at first birth, two important risk factors) will lead to increasing
also the implementing agency of Chapter IV (Labeling and Fair incidence rates. These implicated risk factors, however, are
Packaging) of Republic Act 7394 with respect to hazardous unmanageable and the social costs unacceptable (e.g. early age
substances. Article 94 of the same Chapter provides that all at first pregnancy) and since uncertainty prevails regarding a
cigarettes for sale or distribution within the country shall be measurable impact, secondary prevention takes on special
contained in a package which shall bear the following state- importance.
ment or its equivalent in Filipino: ‘Warning: Cigarette Smok-
ing is Dangerous to Your Health’. This warning also appears PREVENTION
on television after any cigarette advertisement. Some cities
have also issued ordinances implementing a no-smoking pol- The Breast Cancer Control Program (BCCP) of the Philippines
icy in public places. Last 23 October 2001, all members of the refers to the implementation of a nationwide anti-breast cancer
Philippine Senate co-authored Senate Bill 1859 that seeks to scheme: public information and health education, case finding
severely restrict cigarette promotion and trade and smoking in and treatment integrated into the community health structure
public places. Under the bill, a total ban on all tobacco adver- and equipped to control breast cancer in a systematic sustained
tisements will be imposed in two years, and entitles any person manner.
who acquires illness due to smoking to file a civil suit individ- Studies have shown a one-third reduction in mortality attrib-
ually and collectively against the makers, manufacturers, and uted to breast cancer screening, mainly due to mammography.
sellers of cigarettes and other tobacco products for damages. However, the importance of annual clinical breast examination
(by nurse, midwife or public health physician) and monthly
2. BREAST breast self-examination (BSE) are to be emphasized, taking
note that (a) sophisticated screening technology (mammogra-
CAUSATION phy) is not easily available or affordable, (b) mammography is
mainly recommended for women ³50 years old, (c) many
The Philippines through the University of the Philippines– breast cancers are found among 35–50-year-old Filipino
Clinical Epidemiology Unit (UP–CEU) is a member of the women and (d) a relatively inexpensive strategy (BSE) involv-
Collaborative Group on Hormonal Factors in Breast Cancer ing physicians as examiners or a referral depot would be
and has contributed data (12,13) concluding that: cheaper and more available than mammography and physician
(a) Women who are currently on combined oral contraceptives time. A simulated cost-effectiveness randomized field trial in
or who have used them in the last 10 years are at a slightly 1994 (15) resulted in the use of BSE and aspiration biopsy/
increased risk of having breast cancer diagnosed (current open biopsy as the most cost-effective strategy in the Philip-
users, RR = 1.24, 95% CI = 1.15–1.33; 1–4 years after pine setting; incurring savings for the government by almost 3
stopping, RR = 1.16, 95% CI = 1.08–1.23; 5–9 years after million Philippine Pesos or US $60 000 (1989 value) per year
stopping, RR = 1.07, 95% CI = 1.02–1.13) and additional per 100 000 women. Other strategies incurred no savings.
cancers diagnosed tend to be localized to the breast. There In 1989, Ngelangel et al. conducted a knowledge–attitude–
is no evidence of an increased risk 10 or more years after practice (KAP) survey (16) in Metro Manila on women’s
stopping use (RR = 1.01, 95% CI = 0.96–1.05) (12). health and childcare. Fifty percent of women had heard/read
(b) Post-menopausal women are at an increased risk of having about breast examination. Only 37% of the women had ever
breast cancer diagnosed while on hormone replacement received a breast check-up from a physician. Medical person-
therapy (HRT) and in the 5 years after stopping use, RR nel had only ever advised 36% on the importance of BSE and

only about 67% knew the benefits of BSE. Only 54% had ever
done a BSE, of whom only 27% are still practicing it at an
average of 9.2 (SD 5.8) a year. Reasons given for not doing the
BSE included no symptoms, busy, don’t know how, don’t like,
don’t think important, always forget, afraid and not aware.
Similarly, findings from a 1993 study (17) on the determi-
nants of late-stage diagnosis of breast cancer among Filipino
patients indicated that economic factors, non-awareness of the
gravity of breast cancer and fear of being diagnosed with
cancer may be reasons for late diagnosis. Therapeutic and diag-
nostic visits to health care sources were more practiced than
preventive health care consultations. Moreover, in a 1997 field
trial (18) of breast cancer screening (n = 108 102 women) con-
ducted by the DOH–PCCP and IARC–WHO in Metro Manila,
there was a large non-compliance rate (79.1%) among women
found to have breast masses (2.8% positivity rate) in terms of
consulting referral hospitals for re-evaluation and possible
treatment. Reasons such as fear, no money for transport/treat-
ment/medical expenses, indifference, no time, non-awareness
of gravity of the disease and spiritual fatalistic attitudes were
commonly given.
The DOH–BCCP has a long way to go to create breast health
awareness among the Filipino populace. It continues to cam-
paign for monthly BSE and annual physician breast examina-
tions until such time that mammography becomes available
and affordable to most of the target population.
3. LIVER
CAUSATION
In early 1977, the Liver Study Group of the University of the
Philippines (19–21) undertook studies to determine probable
etiological agents linked to hepatocellular carcinoma (HCC).
Among agents looked into were chemicals including sex
hormones, hepatitis B virus (HBV), aflatoxin and alcohol. In
1994, hepatitis C virus (HCV) infection among HCCs was also
studied.
The results of the studies failed to show any significant role
of chemicals and hormones or alcohol, but aflatoxin and HBV
were important etiological factors. Based on dietary history,
HCC patients not only had a higher daily aflatoxin intake but
also higher peak aflatoxin levels compared with matched con-
trols. HCC deaths rose with increasing contamination of food
by aflatoxin in the areas surveyed. Bulatao-Jayme et al. (22)
showed that the total aflatoxin load of 90 HCC cases was 440%
that of 90 controls and none of the various food sources came
close to cassava in the magnitude of contamination of the total
dietary aflatoxin level. Bulatao-Jayme et al. showed a signifi-
cant relationship between the aflatoxin exposure index (AEI)
and the HCC index by region, with Central Visayas having the
highest AEI.
The strongest link was between HCC and previous HBV
infection, more importantly the resulting hepatitis B surface
antigen (HBsAg) carrier rates (19–21). About 98% of HCC
had serological evidence of previous HBV infection compared
Jpn J Clin Oncol 2002;32(Supplement 1) S57
with about 60% of matched controls. More importantly, HBV
infected HCC had a 70% HbsAg carrier rate compared with
13% of controls. The HbsAg carrier rate among males had a
37-fold risk of developing HCC compared with non-carrier
males; for female carriers, the figure was 11-fold. When the
titer of the antibody to the core antigen (anti-HBc) was deter-
mined (a higher titer implying active infection), HCC cases
had higher titers as a group, compared with non-HCC controls.
The HBV–HCC link explains why HCC arises almost
always from previously diseased liver. Seventy per cent of
HCC livers have a post-necrotic background, pathology
associated with HBV-induced cirrhosis. Dalmacio-Cruz (23)
reported evidence on the association of cirrhosis and HCC–
autopsy material from the Philippine General Hospital from
1953 to 1962, and revealed that 72.5% of liver cancers were
associated with cirrhosis and many remaining cases were seen
in livers with varying degrees of fibrosis. The prevalence rate
of HBV infection in the general Filipino population averages
60% (58–68%) and the HbsAg carrier rate averages 10% (8–
16%).
Tiangco-Torres et al. in 1984 (24) examined 533 pregnant
and puerperal women and showed HBV infection rates to be
59.7 and 9.2%, respectively. Munoz et al. (25) also indicated
increased risk association of having a mother or a father who
had been exposed to HBV. Thus, in terms of the root of HBV
infection in the Philippines, maternal–child transmission plays
an important role.
PREVENTION
Aside from vaccination of newborns against HB, prevention
against HBV and HCV infection can also be achieved by
adequate and proper screening of blood prior to transfusion,
avoidance of multiple syringe/needle use, education versus
drug abuse and strict implementation of health check-ups
among commercial sex workers, as per regulations from the
Department of Health.
In the Philippines, mass hepatitis B immunization of infants
(0–12 months of age) at 6, 10 and 14 weeks after birth was
started in 1992, aiming for 90% nationwide coverage by 1997,
but because of cost, only 60% of the needed vaccines have
been freely available (26).
4. CERVIX UTERI
CAUSATION
Limson (UP, Manila), in collaboration with Munoz (IARC–
WHO, France) and the Group on International Biological
Study of Cervical Cancer (involving several countries),
contributed data from a case-control study (1995–98) among
Filipino cervical cancer cases and their controls. The results
revealed that:
(a) Human papillomavirus (HPV) showed a very strong asso-
ciation. After adjusting for the strong effect of HPV, the
following significant risk associations remained: early age
at first sexual intercourse, increased number of sexual
S58 Cancer control in the Philippines
partners and parity and decreased risk with a history of
Pap smear (27).
(b) The prevalence of all HPV types in the cases was 93.5% in
squamous cell carcinoma, 90.7% in adenocarcinomas and
9.2% in controls (27).
(c) The most common HPV types in decreasing frequency
among cases were HPVs 16, 18, 45, 52, 58 (95% CI OR =
31–392). In squamous cell carcinoma, common types were
HPVs 16, 18, 45, 52 and 58; whereas it was HPVs 16, 18
and 45 in adenocarcinomas; in contrast to normal cervices,
HPVs 16, X, 18, 45, 6, MM4, 31, 52, 11, 54 and IS39 (27).
(d) A single novel HPV designated IS39 was identified which
is closely related to another novel virus, W13B (MM4), and
its variants and HPV 51 (28).
(e) The prevalence of antibodies to HPV 16 virus-like particles
(VLP) is higher in squamous cancers (47%) than in con-
trols (25%) and it is higher in cases where HPV 16 DNA is
detectable in cervical cells (62%). However, the sensitivity
and specificity of the serological assay are lower than that
of HPV DNA (29).
(f) A 9.2% HPV (+) among normal cervices of Filipino
women is similar to other studies. HPV infection in women
with normal cervices varies from 16.8% in Brazil to 4.6%
in Spain, with predominant HPV DNA 16. Despite the
compelling evidence for an etiological role of HPV in
cervical carcinogenesis, when the prevalence rates of HPV
in the normal population are compared with the incidence
of cervical cancer, additional factors must be active in its
carcinogenesis and it may be premature to utilize HPV
testing in the clinical setting (30).
(g) Prevalence of HPV in cervical cancer in 22 countries
including the Philippines indicated that HPV DNA was
detected in 93% of tumors, with no significant variation in
HPV positivity, with common HPVs 16, 18, 45 and 31.
HPV 16 predominated in squamous cell tumors and HPV
18 in adenocarcinoma and adenosquamous tumors. HPV
16 was the predominant type in all countries except for
Indonesia, where HPV 18 predominated. A clustering of
HPV 45 was apparent in western Africa, while HPVs 39
and 59 were almost entirely confined to Central and South
America (31).
PREVENTION
Until recently minimum prevention strategies against cervical
cancer in the Philippines are safe sex and screening with a Pap
smear examination every 3 years. The Cervical Cancer Control
Program of the Philippines recommends regular Pap tests for
all women who are or have been sexually active and who have
a cervix. The interval of Pap smear testing for each patient
should be recommended by the physician based on risk factors
(e.g. early onset of sexual intercourse, history of multiple
partners, low socioeconomic status). Regular testing can be
discontinued after age 65 in women who have had regular
previous screening in which smears have been consistently
normal. Patients at increased risk due to unprotected sexual
activity or multiple partners should receive appropriate coun-
seling about sexual practices.
Only 61% of women (16) had heard or read about the Pap
smear. Only 37% had ever had a smear and for those who have
not had a smear, only 27% have considered having one. Only
20% had ever received advice from a medical person about the
importance of a smear. Reasons given for not undergoing a Pap
smear were busy, not married, no symptoms, expensive, afraid,
too young, ashamed, want a lady doctor, got sick, not yet time,
don’t like, not applicable, not aware. Similarly, Ramiro et al. of
UP–CEU (32) indicated these findings from a KAP study on
Pap Smear Nationwide: lack of knowledge of where to avail of
a Pap smear, lack of supplies/medical expertise/training,
indifference to self-health, influence of husband and lack of
a vigorous campaign on cervical cancer control.
In 1997, Retizos et al. (33) found colposcopy as the most
sensitive diagnostic tool (74.3% sensitivity rate), followed by
Pap smear (56%) and direct visualization (25%), with surgical
histopathology as the gold standard. Gonzales of Santo Tomas
University Hospital indicated there were more women detected
when acetic acid wash of the cervix was included as an adjunct
to Pap smear (34). A 2001 health operations research (35)
compared visual cervix examination with (AA) or without
(MAA) acetic acid wash with aid of speculoscopy; to swab +
spatula (SS) and cervix brush (CB) cytology as screening tools
for cervix cancer, with colposcopy or biopsy as gold standard.
Sensitivity rates (95%; with colposcopy as gold standard)
revealed 50.3 (45.2–55.5), 49.1 (44.3–53.8), 8.5 (5.5–11.5)
and 10.7 (7.0–14.4) for AA, MAA, SS and CB, respectively.
Similar sensitivity rates were derived with biopsy as gold
standard. MAA was shown to be the most cost-effective
screening method. Currently, there is a health policy shift from
Pap smear to visual acetic acid as a nationwide screening
modality choice for a country such as the Philippines. While
the cytopathology facilities and expertise of the Philippines is
being planned to be strengthened, Pap smear will be relegated
as a diagnostic tool for acetic acid positive cervices.
5. ORAL CAVITY
CAUSATION
As early as 1915, Davis (36) studied the association of oral
cavity cancer and betel nut chewing in the Philippines and
noted this cancer to be associated with buyo chewing in 70% of
cases. In 1925, Guazon theorized that a higher frequency of
cancer cases among women was because ‘buyo chewing’ was
more prevalent among females (37). However, Pantangco and
Casals (38) noting in the histories of 157 oral cavity cancer
patients that only 13% were buyo chewers for 20–30 years,
reported that the habit of smoking cigarettes and cigars with
the lit end inside the mouth might explain the development of
the disease. Tolentino et al. in 1963 noted that leukoplakia and
epidermoid carcinoma were most often seen in the palate and
the buccal mucosa and postulated the association of inverted
cigarette smoking and buyo chewing (39).

In 1984, Stitch et al. indicated that the proportion of exfoli-
ated micronuclei cells from the buccal mucosa of 51 Ifugao
chewers of areca nut, betel leaf, tobacco and lime was 3.7%
compared with 0.5% in 17 non-chewing Ifugaos. The propor-
tion of micronucleated cells was related to the site within the
oral cavity where the betel-quid was kept habitually and to the
number of betel-quid chewed per day (40).
In 1985, the Working Group of the IARC stated that there
was sufficient evidence that the habit of chewing betel-quid
containing tobacco is carcinogenic to humans and there was
inadequate evidence that the habit of chewing betel-quid
without tobacco is carcinogenic to humans (41).
PREVENTION
The DOH–PCCP warns the Filipino populace against tobacco
and betel-quid use. Primary care physicians and dentists should
include an examination for cancerous and precancerous lesions
of the oral cavity in periodic health examinations of persons
who chew or smoke tobacco (or did so previously), older
persons who drink regularly and anyone with suspicious
symptoms or lesions detected through self-examination. All
patients, especially those at increased risk, should be advised
to receive a complete dental examination on a regular basis.
All adolescent and adult patients should be asked to describe
their use of tobacco and alcohol. Appropriate counseling
should be offered to those persons who smoke cigarettes/pipes/
cigars, those who chew tobacco and those with evidence of
alcohol abuse.
6. COLON, RECTUM, PROSTATE AND OTHERS
CAUSATION
Cancers of the gastrointestinal tract have been positively asso-
ciated with a variety of dietary exposures, e.g. esophageal
cancer with alcohol consumption (particularly combined with
tobacco use), stomach cancer with a high intake of foods pre-
served with salt, colorectal cancer with dietary fats and liver
cancer with aflatoxin-contaminated foods. Inverse associations
with some of these cancers (e.g. stomach and colorectal) have
been noted for other dietary components.
In a 1996 KAP survey (42), Ramiro and Perez showed that
the lack of knowledge about a healthy diet was not a problem
among Filipinos: the gap was between knowledge and practice.
The majority assessed their current dietary practice as satisfac-
tory to poor, with a good number unsure of giving up unhealthy
practices. The age group 14–21 years had the least mean
knowledge scores on healthy diet (5.3 on a scale of 10), but the
most favorable mean attitude score towards healthy diet (3.3
on a scale of 4).
PREVENTION
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 and sig-
Jpn J Clin Oncol 2002;32(Supplement 1) S59
moidoscopy every 3–5 years. Digital rectal exam (DRE) aug-
ments the effectiveness of FOBT and sigmoidoscopy and can
be an alternative to non-availability or inaccessibility of sig-
moidoscopy and/or FOBT. In prostatic cancer, DRE serves as
a diagnostic rather than a screening tool.
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 moderation in the inclusion of salty
foods, implemented through diet counseling health service
facilities. The DOH–PCCP also campaigns for digital rectal
examination to detect early rectal and prostate cancers (‘pa
D.R.E. Campaign’).
CANCER PAIN RELIEF PROGRAM
It is estimated that 30–50% of cancer patients in all stages of
the disease will experience pain and 70–95% with advanced
disease will have significant pain, but only a fraction of these
patients receive adequate treatment. In a study on cancer pain
among Filipino patients, 73% had pain related to their disease,
60% of which was persistent (43).
The DOH–PCCP identified cancer pain relief as a priority
activity in 1989. It was the first activity that led the way to the
Outreach Patient Services (the Hospice-At-Home Concept),
pioneered by the Philippine Cancer Society. It primarily imple-
ments the WHO analgesic ladder, in a modified way cutting
the ladder down to two steps (using opioid-like tramadol HCl
in the second step).
ASSESSMENT OF THE CANCER CONTROL
PROGRAM IN THE PHILIPPINES
In 1996, the Asian Development Bank (ADB), working with
the Philippine Department of Health (DOH), undertook the
Philippine Adult Health Project. International and domestic
consultants (S. Havas and C. A. Ngelangel) assessed preven-
tion and control efforts in the Philippines for several existing or
emerging health problems including cancer (44,45).
The audit confirmed that mortality from cancer had
increased substantially over time and was likely to continue
increasing. Significant shortcomings in six areas were identi-
fied: (1) existing data and data gaps, (2) programmatic efforts,
gaps and problems, (3) medical education, (4) policy issues,
(5) treatment guidelines and problems and (6) quality control
of testing and screening services (44).
Recommendations were made for each of these areas and it
was urged that all of the recommendations should be imple-
mented within 5 years. Effectively and efficiently imple-
mented, these recommendations could prevent the huge toll of
premature death, disability and costs from cancer that will
otherwise be forthcoming (45).
THE COMMUNITY-BASED CANCER CARE NETWORK
Responding to a call by the Department of Health–Philippine
Cancer Control Program (DOH–PCCP) for partnership initia-
S60 Cancer control in the Philippines
tives at both the national and local levels for joint program
undertakings and resource sharing between concerned private
and government institutions, the Community-based Cancer
Care/Control Network (CCCN) was begun in 1998 (46). It has
the vision of a self-sufficient network of empowered commu-
nities sharing responsibility for total quality cancer care and
control in the Philippines and its mission is to organize, inte-
grate and nurture such a network.
The CCCN is built around the idea that when many organi-
zations and individuals pool their expertise, skills, resources
and experience and cooperate to achieve a common goal, they
become a powerful force. The CCCN is envisioned to be a
multi-sectoral strategic approach to improve and redesign the
implementation strategy of anti-cancer control/care in the
Philippines. It provides a venue to:
1. continuously update government cancer control program
implementers, oncology graduates and care givers on the
advances and experiences in anti-cancer practice (CONTIN-
UING MEDICAL EDUCATION AND TRAINING);
2. establish a comprehensive community- and hospital-based
Filipino cancer patient data and information base, based on
the paradigm of quality care and evidenced-based care
(MONITORING AND INFORMATION);
3. serve as the Philippine Cooperative Cancer Study Group
(RESEARCH AND EVALUATION); and
4. provide continuity of cancer control/care from primary, sec-
ondary, tertiary to hospice care, from the community to the
hospital to the community (PUBLIC HEALTH AND CLINI-
CAL MANAGEMENT).
The CCCN is composed of local community-based cancer
control groups called Local Cancer Control/Care Networks
(LCCAN) or Nodes that will network with each other towards
a common goal. Each Node will center on a tertiary govern-
ment hospital; and each Node is composed of a network of
satellites, including NGOs, GOs and individuals. The DOH–
PCCP Unit will be the lead agency and the major cancer con-
trol-related NGOs in the locality will be the lead NGO agency.
These Nodes will be self-sufficient and self-reliant. Since
1998, several Network Nodes have been organized and now
collaborate with the Regional DOH–PCCP Coordinator and
the area oncologist. In 2000, the CCCN started to implement a
registry software (CCCN Hospital Tumor Registry) for the
different component hospitals of the Network and the DOH–
PCCP.
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