Karachi Cancer Registry Data--implications for the National Cancer Control Program of Pakistan.

Cancer registries play a major role in providing the data to justify establishment, implementation and monitoring of cancer control programs, therefore stability in cancer registration is of pivotal importance. An erroneous assessment of the cancer burden can have long-term negative implications for the limited health resources of a country. Thus, registries starting simultaneously with cancer control programs clearly cannot be adequate for the purpose. The Karachi Cancer Registry (KCR) is the first population-based registry of Pakistan, with 9 years proven data stability (1995-2003) for Karachi South (KS), a location with a population distribution similar to that for the country in general as regards age, gender, and religion. It also has the distinction of being the only district in the country with representation of all ethnic and socio-economic groups of the country. The primary recommended strategy for the 'National Cancer Control Program' (NCCP), Pakistan based on the assessment of eight common cancers in Karachi and the WHO estimates would be identical. A curb on the epidemic levels of tobacco and areca nut use would reduce malignancies in males by 43.7% and in females by 17.8%. WHO estimates put these figures at 45% and 18.5% for males and females respectively. Primary prevention in the form of diet control, checks on preservatives, dyes, and pesticides; protection from occupational hazards, control of biological agents and solar UV protection would help control of another half of the malignancies. Resource restrictions put high technology methods beyond the scope of Pakistan today. Early detection of cancers of accessible sites, though not an urgent requirement, would be warranted for oral, cervical and breast cancer, after sufficient capacity building, initially in the high-risk groups. In females, this could help target 47.6% (approximately half) of the malignancies and in men 13% of the total. Establishment of equitable pain control and a palliative care network throughout the country is an urgent and essential measure as more than 70% of cancer patients report with very advanced stages of malignancy. The estimated annual incident cancer cases for Pakistan, year 2000 on the basis of KCR data were 138,343 for males and 135,054 for females; approximately twice the number cited by WHO for the same year. The argument that higher KCR estimates reflect an urban catchment population may be justified, the urban: rural ratio being 2:1 in Pakistan. Evidence-based strategies, however,support the counter argument, that the rising incidence of cancer in Pakistan is primarily attributable to risk factors equally prevalent in the rural and urban areas viz. increasing tobacco use, low socio-economic conditions, dietary deficiencies and prevalence of oncogenic viruses. Pakistan has a significant cancer burden and rising trends of risk factors - it is a country in dire need of a Cancer Control Program. KCR data along with WHO estimates can form the initial framework of a NCCP in Pakistan; the lack of a national cancer registration should not deter initiatives. Benefits of an immediate, prompt and targeted implementation established today will be realized after 20-30 years. Otherwise the country should be prepared to face epidemic proportions of the disease in the next decade or two. Prerequisite 'qualification criteria' or 'sincerity of intent test' for NCCP funding by international donors should be legislation against tobacco and areca nuts in Pakistan and stringent evaluative criteria.