Cancer Burden in Africa and Opportunities for Prevention
Ahmedin Jemal, DVM, PhD1; Freddie Bray, PhD2; David Forman, PhD2; Meg O’Brien, PhD3; Jacques Ferlay, BS2;
Melissa Center, MPH1; and D. Maxwell Parkin, MD4,5
Cancer is an emerging public health problem in Africa. About 715,000 new cancer cases and 542,000 cancer deaths occurred in
2008 on the continent, with these numbers expected to double in the next 20 years simply because of the aging and growth of the
population. Furthermore, cancers such as lung, female breast, and prostate cancers are diagnosed at much higher frequencies than in
the past because of changes in lifestyle factors and detection practices associated with urbanization and economic development.
Breast cancer in women and prostate cancer in men have now become the most commonly diagnosed cancers in many Sub-Saharan
African countries, replacing cervical and liver cancers. In most African countries, cancer control programs and the provision of early
detection and treatment services are limited despite this increasing burden. This paper reviews the current patterns of cancer in
Africa and the opportunities for reducing the burden through the application of resource level interventions, including implementa-
tion of vaccinations for liver and cervical cancers, tobacco control policies for smoking-related cancers, and low-tech early detection
methods for cervical cancer, as well as pain relief at the palliative stage of cancer. Cancer 2012;000:000–000. V
C 2012 American Can-
The burden of cancer is increasing in Africa because of the aging and growth of the population as well as increased preva-
lence of risk factors associated with economic transition, including smoking, obesity, physical inactivity, and reproductive
behaviors.1,2According to United Nation’s population estimates,2the population of Africa between 2010 and 2030 is
projected to increase by 50% overall (from 1.03 billion to 1.52 billion) and by 90% for those aged ?60 years (from 55
millionto105 million),the ageatwhich cancermostfrequentlyoccurs.
Although current prevalence of adult cigarette smoking is low in Africa,3there is a concern that the prevalence will
tray smoking as a stylish activity.4In most urban populations of African countries, there have also been changes in repro-
ductive factors toward earlier menarche, delayed childbearing, and lower fertility; in dietary patterns toward high animal
and hydrogenated fat intake; and in activity patterns toward reduced average energy expenditure.5There has already been
some limited evidence for the rising burden of cancers associated with these risk factors. For example, breast cancer inci-
dence rates in Uganda (Kampala) have nearly doubled over the past 20 years,6although the rates still remain less than half
of thoseseenin blackwomen inWesterncountries suchas theUnited States.
Despite this growing cancer burden, cancer continues to receive a relatively low public health priority in Africa,
largely because of limited resources and other pressing public health problems, including communicable diseases such as
acquired immunodeficiency syndrome (AIDS)/human immunodeficiency virus (HIV) infection, malaria, and tuberculo-
sis. It may also be in part because of a general lack of awareness among policy makers,the general public, and international
private or public health agencies concerning the magnitude of the current and future cancer burden and its economic
impact. Previous reviews of the cancer burden in Africa were based on an earlier version of GLOBOCAN estimates, and
the cancer prevention and control aspects were presented in a separate paper.7,8In this paper, we review the current cancer
burden for common cancers in Africa largely based on the updated data (GLOBOCAN 2008 estimates),9and discuss the
opportunitiesforcancerpreventionand controlin theregion.
The numbers and rates presented here were extracted from the GLOBOCAN 20089database of the International Agency
for Research on Cancer (IARC), which presents the estimates of incidence of, and mortality from, 27 major cancers in
184 countries or territories worldwide for 2008. The country-specific cancer incidence and mortality rates were based on
DOI: 10.1002/cncr.27410, Received: August 10, 2011; Revised: October 24, 2011; Accepted: November 10, 2011, Published online in Wiley
Online Library (wileyonlinelibrary.com)
Corresponding author: Ahmedin Jemal, DVM, PhD, Surveillance Research program, American Cancer Society, 250 Williams Street NW, Atlanta, GA 30303; Fax:
(404) 327-6450; email@example.com
1Surveillance Research Program, American Cancer Society, Atlanta, Georgia;
France;3Global Access to Pain Relief Initiative, American Cancer Society and Union for International Cancer Control, Atlanta, Georgia;4Clinical Trial Service Unit,
University of Oxford, Oxford, United Kingdom;5Epidemiological Studies Unit, University of Oxford, Oxford, United Kingdom
2Cancer Information Section, International Agency for Research on Cancer, Lyon,
Month 00, 2012
data reported by 5 national cancer registries and by some
lation (Fig. 1). The local registries generally cover major
cities and are predominantly urban, with 5 (covering
around 1% of the African population) considered to be of
of Cancer Incidence in Five Continents.10No reliable
cancer-specific mortality statistics are available in any
African countries (except Mauritius), and mortality in
GLOBOCAN was estimated by combining correspond-
ing estimates of cancer incidence with survival probabil-
ities predicted from country-specific levels of gross
domestic product. GLOBOCAN 2008 presents estimates
of the incidence and mortality from Kaposi sarcoma (KS)
in Sub-Saharan African countries only, given its relative
rarity elsewhere.11For this paper, however, we computed
an estimate of the incidence and mortality from KS in
Overall, 715,000 new cancer cases and 542,000 cancer
deaths were estimated to have occurred in 2008 in Africa
(Fig. 2). However, the incidence and mortality patterns
vary remarkably across regions (Fig. 3, Tables 1 and 2),
most likely because of substantial regional differences in
the prevalence and distributions of social, cultural, and
other environmental factors, including many of the major
known risk factors for cancers, contrasting levels of eco-
nomic development, and differences in access to health
care and infrastructure that are not captured by economic
development. We briefly describe the burden for select
cancers with high burden, known preventive measures, or
Cervical cancer is the second most frequently diag-
nosed cancer (80,400; Fig. 2) and the leading cause of
Figure 1. Methods of estimation are shown for GLOBOCAN
2008 incidence data.
Figure 2. Estimated numbers of new cases and deaths for leading cancer sites in Africa are shown for 2008. Source: GLOBOCAN
Month 00, 2012
cancer death (50,300) in African women. Rates vary sub-
stantially across regions, with the incidence and death
rates in East Africa and West Africa 5? as high as the rates
in NorthAfrica(Tables1and 2).Notably,some countries
in East Africa, including Zambia, Malawi, Mozambique,
and Tanzania have among the highest cervical cancer rates
of lack of screening services for the prevention and early
detection of the disease.12It is noteworthy that before the
introduction and wide dissemination of Papanicolaou
(Pap) testing in the 1960s in the United States, the rates
of cervical cancer incidence (per 100,000 females) in 10
select metropolitan areas in 1947-1948 (40.1 in whites
and 73.1 in nonwhites)13were the same order of magni-
tudeas thehighestrates foundinEastern Africatoday.
Breast cancer was the most commonly diagnosed
cancer and the second leading cause of cancer death
among women in 2008 in Africa (92,600 cases, 50,000
deaths; Fig. 2). Southern African women have the highest
breast cancer incidence rates of all African regions, in part
because of a higher prevalence of reproductive risk factors
for breast cancer, including early menarche and late child-
bearing among the more affluent predominantly white
population.14For example, the female breast cancer inci-
dence rate in Harare (Zimbabwe) in 1990-1992 was 6?
higherin whites(129.0)than inblacks(20.0).15
Notably, breast cancer has now become the most
commonly diagnosed cancer in women (Fig. 3) in several
Sub-Saharan African countries, a shift from previous dec-
ades in which cervical cancer was the most commonly
diagnosed cancer in many of these countries.16The rea-
sons for this shift are unknown but may include increases
in the prevalence of risk factors for breast cancer such as
early menarche, late childbearing, having fewer children,
obesity, and increased awareness and detection, which are
associated with urbanization and economic development.
In the Ugandan (Kampala) and Algerian (Setif) cancer
registries, breast cancer incidence rates have nearly
doubled over the past 20 years, although the rates still
remain much lower than those in black women in the
It has been known for some time that breast cancer
among black Americans is more likely to be early onset,
higher grade, and estrogen receptor (ER) negative than is
observed among white Americans,17and the same is true
in the black population of the United Kingdom.18Early
been documented in clinical series from Africa, and case
Figure 3. Most common cancer sites in Africa by sex and country are shown for 2008. Source: GLOBOCAN 2008.
Cancer in Africa/Jemal et al
Month 00, 2012
series from several centers in Africa have reported that
hormone receptor-negative cases are predominant19-21;
for example, only 25% of cases in a large multicenter se-
ries of patients from West Africa were ER positive, less
than half that observed in the US black population.19
However, these findings were based on archival materials,
and the role of antigen degradation and false-negative
results couldnot beruledout.22
An estimated 22,400 KS cases in males and 12,400
cases in females were diagnosed in Africa in 2008. More
than 70% (25,000 of 34,900) of these cases were in East
Africa,9,23where it is the most common cancer in males
and the third most common cancer in females (Table 1).
The incidence rates for KS rose several fold in East Africa
and other parts Sub-Saharan Africa during the 1990s,
consistent with the HIV/AIDS epidemic in these
regions.24KS is an HIV-associated cancer caused by
human herpes virus-8.25,26Although KS continues to be a
leading cause of cancer death in most parts of Eastern
Africa, rates are declining because of reduction in preva-
lence of HIV and wider availability of highly active antire-
troviral therapy.6,27In contrast to Sub-Saharan Africa, KS
is less common in Northern Africa, with only 1% of the
totalcases (350of34,900)in Africa.
Liver cancer is the second most commonly diag-
nosed cancer and the leading cause of cancer death in men
and the third most common cancer and the third leading
cause of cancer death in women in Africa (Fig. 2). The
incidence and mortality rates were highest in Middle
Africa followed by Western Africa (Tables 1 and 2).
Chronic infections with hepatitis B virus (HBV) in Sub-
Saharan Africa regions and hepatitis C virus (HCV) in
Northern Africa are the major causes of liver cancer,28,29
accounting for as much as 90% of the total cases.30-32The
high burden of HCV-associated liver cancer in Egypt was
largelybecauseofthe extensivespreadof thevirusthrough
contaminated injection equipment during mass treatment
campaigns against Schistosoma hematobium, a parasitic
Table 1. Age-Adjusted Incidence Ratesafor the Most Common Cancers in Males and Females in Africa, 2008
Rank RateRankRate RankRate RankRate Rank RateRank Rate RankRate
Source: GLOBOCAN 2008. Data for Kaposi sarcoma in Northern Africa were estimated separately (see data sources).
aRates are per 100,000 and age-standardized to the world population.
bExcluding nonmelanoma skin cancer.
Month 00, 2012
trematode that causes chronic inflammation and cancer of
the bladder (see below), during the 1960s and 1970s.33,34
Contamination of staple foods such as maize and ground
nuts with aflatoxins, known hepatocarcinogens produced
by molds during cultivation and inadequate storage of
crops,35,36is another contributing factor to the liver can-
An estimated 37,200 new cases and 30,900 deaths
from non-Hodgkin lymphoma (NHL) occurred in 2008.
Regional variations in incidence and mortality rates for
NHL were not as remarkable as for the other cancer sites
shown in Tables 1 and 2, although the incidence rates in
men are substantially higher in North Africa. NHL
encompasses a variety of histologically distinct forms.38In
some parts of Sub-Saharan Africa, Burkitt lymphoma
(BL) in children and B-cell lymphoma in adults account
for about 70% and 55% of the total cases, respec-
tively.30,39About1=4 of NHL cases in the Sub-Saharan
region are thought to be associated with AIDS,30and the
incidence of this disease in some countries has more than
doubled since the AIDS epidemic began.40-43In the zone
of high incidence of childhood BL in central Africa,
almost all cases are associated with Epstein-Barr virus
clear antigen orEBVDNAin the tumorcells.44However,
because EBV infection is ubiquitous, other cofactors must
be involved. Intense (holoendemic) malaria infection has
long been suspected on the basis of the similar geographic
distribution of BL and malaria; BL cases do seem to have
evidence of more frequent or intense infection with
malaria than control children,45and there is limited evi-
dence that the incidence of BL decreased in parts of Africa
after theimplementationof malariacontrolprograms.46
An estimated 8700 incident cancer cases and 5500
cancer deaths occurred in 2008. The incidence rates are
twice as high in men as in women. The highest incidence
rates are in the Republic of South Africa, and in the coun-
tries of the Maghreb (Morocco, Algeria, and Tunisia).
Table 2. Age-Adjusted Death Ratesafor the Most Common Cancers in Males and Females in Africa, 2008
SiteAll Africa Sub-
Rank RateRank Rate Rank RateRankRateRank Rate Rank Rate RankRate
Source: GLOBOCAN 2008. Data for Kaposi sarcoma in Northern Africa were estimated separately (see data sources).
aRates are per 100,000 and age-standardized to the world population.
bExcluding nonmelanoma skin cancer.
Cancer in Africa/Jemal et al
Month 00, 2012
The moderately elevated risk in North Africa has been the
focus of a search for environmental risk factors, with the
locallypopularspiceharissa beingidentified insomestud-
ies,47,48although it is notable that North African migrant
populations retain a high risk after migration to low inci-
About 27,900 new cancer cases and 26,600 deaths
from esophageal cancer (predominantly squamous cell
carcinoma) were estimated to have occurred in Africa in
2008. Esophageal cancer is a leading cause of cancer death
among both men and women in East Africa and among
men in South Africa. Incidence and mortality rates for
esophageal cancer in these 2 regions are >7? as high as
the rates in Western, Middle, or Northern Africa among
men and >4? as high among women (Tables 1 and 2).
Exceptionally high incidence rates have been recorded in
the East Cape Province (former Transkei) area of South
Africa.50Reasons for the high burden of esophageal can-
cers in several parts of Eastern Africa and Southern Africa
alcohol intake, poor dietary patterns such as consumption
of a maize-based diet that is low in fruits and vegeta-
bles,51-53and contamination of maizewithfungi thatpro-
ducefumonisins, acancer-initiatingagentin experimental
Lung cancer is the leading cause of cancer death
among men in Southern Africa and Northern Africa and
the fourth leadingcause of death amongwomenin South-
ern Africa (Tables 1 and 2). The incidence and mortality
ratesinSouthernAfricain bothmen andwomenaretwice
as high as the second highest rates in Northern Africa
because of the more advanced stage of the tobacco epi-
demic in Southern Africa.3,56Smoking accounts for 65%
of lung cancer cases in South Africa,57not dissimilar from
the features of the tobacco epidemic in the Western
Bladder cancer incidence and mortality rates among
men in Northern Africa are twice as high as those in
Southern Africa, which has the second highest regional
rates (Tables 1 and 2). Egyptian men have the highest
bladder cancer incidence rates worldwide.58A large pro-
portion of bladder cancer cases in Africa are squamous cell
carcinomas, and between 30% and 60% of all bladder
cancer cases in this region are caused by chronic infection
with the parasite Schistosoma hematobium.30,59,60Infec-
tion is acquired when people come in contact with the
free swimming larvae (early developmental stage) in fresh
water containing the intermediate host, a snail of the Buli-
nus genus. In schistosome-free regions such as Europe and
North America, >90% of bladder cancer cases are transi-
tional cell carcinomas, and they are caused mainly by
smoking and occupational exposures to certain industrial
Prostate cancer is the most commonly diagnosed
cancer among men in Southern Africa and Western
Africa, including South Africa, Nigeria, and Cameroon.
However, the incidence rate in Southern Africa is twice as
high as the second highest regional rate in Western Africa
and nearly 7? higher than the lowest regional rate in
Northern Africa. The high incidence rate in Southern
Africa may reflect increased diagnosis, rather than disease
occurrence. However, high prostate cancer rates have
been reported among Western and Southern African
descendents in Jamaica and Trinidad and Tobago,12,62
where prostate-specific antigen testing is not commonly
a role forgenetic
Opportunities for Cancer Prevention
Opportunities for reducing suffering and death from can-
cer in Africa exist across all stages of the cancer control
spectrum, from prevention to early detection, treatment,
Prevention of exposure to cancer-causing agents or
is by far the most feasible and cost-effective approach to
Tobacco use is the most preventable cause of cancer
death, accounting for 20% of cancer deaths worldwide
contribution of tobacco use to cancer deaths in Africa
reflects the early stage of the tobacco epidemic and low
smoking prevalence, especially among women, and the
low life expectancy of the population, which does not
allow time for the carcinogenic effect of smoking to
become manifest. Adult smoking prevalence tends to be
countries, including Nigeria and Ethiopia, the 2 most
Month 00, 2012
populous nations on the continent. However, cigarette
consumption is increasing in parts of this region because
of the adoption of Western behaviors associated with eco-
nomic growth and increased marketing by tobacco
The World Health Organization (WHO) estab-
lished the Framework Convention on Tobacco Control,
which features internationally coordinated provisions to
controlthe tobaccoepidemicthat includeraising theprice
of tobacco products, banning smoking in public places,
restricting tobaccoadvertisingand promotion,counterad-
vertising, and providing treatment and counseling for
tobacco dependence.70However, few African countries
have implemented tobacco control measures or policies
according to the framework.3The worldwide tobacco epi-
demic resulted in approximately 100 million premature
deaths worldwide in the 20th century.3African countries
have a unique opportunity to avoid such tragedy by curb-
ing the tobacco epidemic at this early stage through the
implementation and enforcement of comprehensive
tobacco control strategies proven in the developed coun-
tries to be effective, such as increased excise tax, restriction
of smoking in work places, banning the advertisement of
tobacco products, and counteradvertising. Although the
relative importance and cost-effectiveness of these meas-
ures in reducing smoking prevalence are not known in
African countries, increased excise tax in the early 1990s
in South Africa is thought to be the major contributing
factor to the substantial reduction in smoking prevalence
Unhealthy diets, physical inactivity, and obesity
have been associated with increased risk of several cancers,
including endometrial, colon, postmenopausal breast, re-
nal cell, esophageal (adenocarcinoma), and pancreatic
cancers.72,73The prevalence of obesity and physical inac-
tivity are increasing in several African countries, and espe-
cially in urban areas, as a result of increased consumption
of calorie-dense food and declines in energy expenditures
at work and in daily life.74-78For example, according to a
2003 survey in 4 urban districts of Cameroon, >25% of
and 6.5% of men and 19.5% of women were obese.74
Obesity in Africa coexists with serious hunger and food
shortages. The WHO developed a global strategy to
improve dietary patterns and physical activity through the
development of national, regional, and/or community
level policies and programs that are comprehensive and
Infectious agents are the causes of some of the most
commonly diagnosed cancers in Africa, including cervix,
liver, and bladder cancers and KS. A substantial propor-
tion of these cancers is potentially preventable by vaccina-
tion, improved hygiene, sanitation, and/or treatment. A
vaccine against HBV, which causes the majority of liver
cancer in Sub-Saharan Africa, has been available since the
early 1980s and recommended as part of routine national
infant immunization programs since 1992.80As of 2008,
48 of the 53 African countries included the vaccine as part
of their national infant immunization schedules (Fig. 4).
However, the vaccination coverage was less than optimal
(<80%) in several countries in Sub-Saharan Africa, where
HBVinfectionis more prevalent.
The human papillomavirus (HPV) is another can-
cer-causing infectious agent amenable to prevention by
vaccination. The vaccines are administered to adolescent
girls and offer protection against major subtypes of HPV
infections (HPV 16 and 18) that cause 70% of cervical
cancer in Africa.81Undoubtedly, these vaccines provide
the best opportunity in the future for substantially reduc-
ing the future burden of cervical cancer in Sub-Saharan
Africa, where it is a leading cause of cancer death among
women. However, access to adolescent girls, to administer
the recommended 3 doses of vaccines, especially in rural
Figure 4. Proportion of infants covered by national infant
hepatitis B immunization programs in Africa is shown for
2008. Source: World Health Organization/United Nations
Children’s Fund coverage estimates for 1980-2008, July
Cancer in Africa/Jemal et al
Month 00, 2012
parts of Africa, could be a major impediment in the wide
application of the vaccines in the region.81-83However, a
recent nonrandomized study in Costa Rica showed that 1
or 2 doses of the vaccine could be as effective as 3 doses of
the vaccine in preventing persistent infections from HPV
16 or 18 for 4 years after vaccination of noninfected
women.84This finding, if confirmed in different parts of
Sub-Saharan Africa, will have far-reaching implications in
dissemination ofthevaccinein theregion.
HIV has long been known to increase the risk of a
variety of cancers, and the diagnosis of some (eg, KS,
NHL,and cancerof thecervix)is takentodefinethe onset
of AIDS in HIV-positive individuals.85Research on HIV
and cancer in Africa has mainly been in terms of compar-
ing the prevalence of HIV infection in patients with dif-
ferent forms of cancer (and sometimes in otherwise
healthy controls); there have been few prospective studies
of the incidence of different cancers in HIV-positive sub-
jects.86As described earlier, the risk of KS and NHL is
increased in the presence of HIV infection, although by
no means as much as in European and American HIV-
positive individuals. Squamous cell cancers of the con-
junctiva were noted as being common in HIV-infected
individuals in Africa, and the link has subsequently been
Transmission of some cancer-causing infectious
agents can be prevented by improving hygiene in the health
care delivery system and by educating people to modify
their high-risk behaviors. Infections that cause liver cancer
can be prevented by screening blood products, sterilizing
injection needles and equipment, and/or stopping injection
drug use. HIV infection can be reduced by practicing safe
sex (condom use, commitment to 1 partner), abstinence,
and circumcision.88More widespread provision of highly
active antiretroviral therapy to HIV-infected persons would
reduce the occurrence of AIDS-related cancers.89Schisto-
soma hematobium, which causes a substantial proportion of
bladder cancer in Africa, can be prevented by avoiding
swimming, bathing, or wading in fresh water areas known
to contain the free swimming stage of the parasite (larvae).
People who are already infected with the parasite can be
successfully treated with the drug praziquantel. The use of
this drug coupled with lower infection rates (probably
because of urbanization) are thought to have contributed to
the substantial decrease in incidence of Schistosoma-associ-
ated bladder cancer in Egypt over the past few decades.90,91
Although there are almost no published data on
stage at diagnosis from population-based registries in
Africa, clinical series attest to the finding that the great
majority of cancer patients come to medical attention late
in the course of disease. For example, at the Ocean Road
Cancer Institute (Tanzania), 91% of breast cancer
patients were diagnosed in stage III or IV,92and in the
major hospitals of Harare (Zimbabwe), 80% of cervical
cancer cases presented with advanced disease (Interna-
tional Federation of Gynecology and Obstetrics stage 2B
or worse).93Earlier diagnosis is essential to providing
effective cancer control. Achieving this using standard
screening methods such as mammography for breast can-
cer, fecal occult blood testing and sigmoidoscopy/colono-
scopy for colorectal cancer, and Pap test for cervical
cancer are not only cost-prohibitive in most parts of
Africa, but they are also not supportable by the existing
health care infrastructure.94However, although Pap
smear-based screening programs for prevention of cervical
cancer have been unsuccessful in Africa, other approaches
based on visual inspection using Lugol’s iodine or acetic
acid, and low-cost DNA tests to detect HPV infections,
have been shown to be feasible and effective in many parts
of Africa, including Kenya and South Africa.81,95-97Stud-
ies based on simulation modeling have reported that
screening once or twice in a lifetime between the ages of
35 and 55 years using these low-cost/low-tech screening
methods can reduce cervical cancer by about 30%.96,98
Cost considerations have meant that to date visual inspec-
tion has been the only feasible approach to screening in
Sub-Saharan Africa, although 1 large randomized trial in
India showed that this method was inferior to HPV test-
ing in reducing late stage disease and death from cancer of
the cervix.99A recent model-based analysis in a high-risk
area of China demonstrated that a rapid HPV-DNA test,
which allows a single-visit screening to be followed by
apy, is cost-effective for cervical cancer prevention.100
Cost-effectiveness analysis for low-cost and low-tech
vs rapid HPV-DNA test) are lacking in Africa. There is an
urgentneed to determine the most cost-effectiveapproach
to screening, because this remains the only viable option
for reducing the high cervical cancer burden in Sub-
Saharan Africa in the next 20 to 30 years, as the current
HPVvaccines arebeinggiventoadolescentgirls only.81
Increasing public awareness of early signs and symp-
toms of cancers of the breast, cervix, oral cavity, urinary
bladder, colorectum, and prostate should increase the
detection of these diseases at earlier stages when there are
more effective options for treatment leading to better
prognosis.101Every effort must be made to expand the
Month 00, 2012
capacity of health care delivery systems to provide timely
and effective treatment to patients diagnosed with early
stage disease for increased awareness initiatives to result in
Surgery and/or radiation are the most important
methods of treating early stage (local) cancers, including
cancers of the breast, colorectum, cervix, head and neck,
esophagus, stomach, and prostate.102However, the avail-
ability of such treatments in Africa is limited because of
lack of skilled manpower, surgical equipment, and radia-
tion facilities. On the basis of data from the International
Atomic Energy Agency (IAEA) that have been updated
through 2010, only 24 of 53 countries in Africa have
reported the availability of radiation treatment centers
(Fig. 5). It is evident that, even where such facilities exist,
the number of centers is inadequate in relation to the size
of the catchment population. For example, >80 million
people in Ethiopia are served by a single radiotherapy cen-
ter in the capital city, Addis Ababa. The actual supply of
radiation treatment in Africa in 2002 was only 18% of the
for Cancer Therapy, has been working with the WHO
and other interested international and national organiza-
tions to establish safe and effective radiotherapy facilities
to deliver high-quality treatment to cancer patients in
Africaand inother developingareas.104
Because of late presentation and inadequate or
unavailable treatment facilities, the prognosis for cancers
that in high income countries are largely curable is rather
poor in Africa.105Table 3 compares the 5-year survival of
patients with cancer from 2 African cities (Harare and
Kampala) with that among US patients diagnosed during
Lack of access to basic pain relief continues to make
living and dying with cancer in Africa a very different ex-
perience from that in developed countries. About 80% of
cancer patients in Africa are thought to be diagnosed at
advanced stages of disease, when pain relief is often the
only choice of treatment. In Sub-Saharan Africa, in
Figure 5. The numbers of people served by a single radio-
therapy center in Africa countries are shown. Sources: Inter-
national Atomic Energy Agency, Directory of Radiotherapy
Centers, http://www.naweb.iaea.org/nahu/dirac/; Population
Division of the Department of Economic and Social Affairs of
the United Nations Secretariat, World Population Prospects,
2008 revision, http://esa.un.org/unpp
Table 3. Five-Year Relative Survival of Cancer Patients Diagnosed in 1993-1997 in Harare
(Zimbabwe), Kampala (Uganda), and the US Surveillance, Epidemiology, and End Results Program
Kampala (Uganda) USA (SEER)
Sources: Sankaranarayanan 2010,105Gondos 2005.106
aAdjusted to the age distribution of black Zimbabwean patients.
bAdjusted to the age distribution of white Zimbabwean patients.
Cancer in Africa/Jemal et al
Month 00, 2012
particular, weak health systems, legal and regulatory
restrictions, inadequate training of health care providers,
concern about diversion, addiction, and abuse, and cul-
tural misperceptions about pain create a web of barriers
that keep safe, effective, and inexpensive opioid analgesics
out of the reach of more than a million people with treat-
In 2008, there were approximately 421,000 deaths
because of cancer9and 1.4 million deaths because of
HIV24in Sub-Saharan Africa. It has been estimated that
50% of HIV deaths and 80% of cancer deaths require
of morphine needed for these deaths alone is approxi-
mately 6413 kg.108However, in 2008, the actual procure-
ment of morphine and equivalent opioids (pethidine,
oxycodone, and hydromorphone) reported by Sub-
Saharan African governments to the International Nar-
cotics Control Board was just 639 kg,109about 10% of
the quantityneeded justforthe terminalmonthsof cancer
and HIV patients, and not considering the need for pain
treatment among those living with cancer, HIV, trau-
matic injury, or chronic pain. These data clearly indicate
that for the vast majority of those in severe pain in Sub-
SaharanAfrica,treatmentis simplynot available.
Although it is the responsibility of each African gov-
ernment to take the lead in making pain relief accessible
to its citizens who need it, the activities of palliative care
organizations and other civil society groups are critical to
supporting government efforts. In several countries, these
groups have been instrumental in getting pain relief on
the agenda of governments, articulating technical solu-
tions, and leading efforts to work across disease areas, par-
ticularly cancer and HIV, to address this issue jointly.
International and national nongovernmental health
organizations have generally been slow to integrate pain
relief into their programs, often believing it is outside of
their disease-specific treatment or prevention mandate. A
reclassification of pain treatment from a separate entity to
a part of comprehensive treatment of cancer and HIV—
and a full recognition of pain-relieving medications as a
cornerstone of the global essential medicines agenda—
would assist governments with a more rational program-
ming ofattentionand resourcestoaddressuntreatedpain.
Establishing and Maintaining Cancer Control
Programs in Africa
The WHO has developed guidelines for evidence-based
regional and national cancer control programs according
ommends cancer control programs in Africa begin in a
stepwise approach by implementing 1 or 2 key priorities
in a demonstration project. Such projects could be sus-
tainable only when African countries take the initiative
and make the political commitment to invest in the pro-
grams with a dedicated budget and required staff,
although international public health agencies and donors
can and should play major roles in strengthening and
When possible, cancer control programs should be
integrated with other established disease control pro-
grams, becausesome diseases sharethe same risk factorsor
routes of transmission. For example, unsafe sexual prac-
tice is a risk factor for both HIV and HPV infections.
Therefore, some aspects of cervical cancer prevention pro-
grams in Sub-Saharan African countries could be inte-
grated with ongoing HIV prevention programs.89The
successful integration of HBV vaccination into infant
immunization programs in Africa and other parts of the
The inclusion of a pledge to halt and reverse the
spread of HIV-1, malaria, and other diseases by 2015 as 1
of the Millennium Development Goals set out by the UN
General Assembly in 2000 has led to impressive levels of
funding through the Global Fund for AIDS, Tuberculosis,
and Malaria and the US President’s Emergency Plan for
AIDS Relief. In addition to the benefit that has accrued in
reducing the incidence of some HIV-related cancers (as al-
ready described), and possibly impacting on the incidence
of BL in areas where malaria is endemic, HIV-related pro-
grams have created treatment and prevention platforms
that can be leveraged for other purposes—for example,
screening or vaccination for cancer of the cervix.112,113
The availability of a high-quality population-based
cancer registration system is an important component of
any evidence-based cancer control program, because can-
cer registration is essential for assessing the burden of can-
cer, setting priorities, and planning and evaluating cancer
control programs.114,115However, only 11% of the Afri-
can population is covered by population-based cancer
registries, and about 1% of the population by registries
that meet the IARC’s criteria for high-quality incidence
(related to indicators of comparability, accuracy, and
completeness) in volume IX of Cancer Incidence in Five
Continents.10,116Therefore, there is a greater need for
establishing or strengthening population-based cancer
registrationin Africa to implement effective and evidence-
basednationaland regionalcancer controlprograms.
In addition to guiding and evaluating cancer control
programs, cancer registries are also useful for studying the
Month 00, 2012
causes (risk factors) of cancer.117There are opportunities
toidentify novelriskfactorsforcancerin Africathatcould
advance cancer prevention measures worldwide in view of
tary patterns, and other environmental factors and the
very limited prior efforts to study the causes of cancer in
Limitation and Summary
The interpretation of the incidence and mortality data
from GLOBOCAN presented in this paper is limited by
the precision of the estimates. Of the 53 countries that
constitute Africa, incidence estimates were based on either
national or regional population-based cancer registries in
23 countries (Fig. 1). For the remaining 30 nations, inci-
dence was estimated from local frequency data (8 coun-
tries) or, where no reliable sources were found (22
countries), from corresponding estimates from neighbor-
ing countries within the region. In compiling the country-
specific mortality estimates, there are very few national
vital registration systems withadequatedata in Africa,and
none was considered to be of sufficient quality to be used
directly in compiling the GLOBOCAN estimates for
2008. Despite this limitation, GLOBOCAN remains the
onlycomprehensivedata sourcefor assessingregionalcan-
cer burden and for promoting cancer prevention and con-
In summary, cancer is an emerging public health
problem in Africa because of the aging and growth of the
population and increased prevalence of economic transi-
tion-associated risk factors for cancers such as smoking,
obesity, physical inactivity, poor diet, and reproductive
factors. There are opportunities for substantially reducing
the growing burden through the application of resource
vical cancers, tobacco control policies, low-tech early
detection methods for cervical cancers, and palliative care.
and government public health agencies, the health indus-
tries, and donors.
No specific funding was disclosed.
CONFLICT OF INTEREST DISCLOSURES
The authors made no disclosures.
1. Boyle P, Levin B, eds. World Cancer Report 2008. Lyon, France:
World Health Organization, International Agency for Research on
2. United Nations Population Division. World Population Prospects,
the 2008 revision. Available at: http://www.un.org/ Accessed No-
vember 8, 2009.
3. Shafey O, Eriksen M, Ross H, Mackay J. The Tobacco Atlas.
3rd ed. Atlanta, GA: American Cancer Society; 2009.
4. Glynn T, Seffrin JR, Brawley OW, Grey N, Ross H. The global-
ization of tobacco use: 21 challenges for the 21st century. CA
Cancer J Clin. 2010;60:50-61.
5. Popkin BM. Global changes in diet and activity patterns as drivers
of the nutrition transition. Nestle Nutr Workshop Ser Pediatr Pro-
gram. 2009;63:1-10; discussion 10-14, 259-268.
6. Parkin DM, Nambooze S, Wabwire-Mangen F, Wabinga HR.
Changing cancer incidence in Kampala, Uganda, 1991-2006. Int J
7. Parkin DM, Sitas F, Chirenje M, Stein L, Abratt R, Wabinga H.
Part I: Cancer in indigenous Africans—burden, distribution, and
trends. Lancet Oncol. 2008;9:683-692.
8. Sitas F, Parkin DM, Chirenje M, Stein L, Abratt R, Wabinga H.
Part II: Cancer in indigenous Africans–causes and control. Lancet
9. Ferlay J, Shin HR, Bray F, Forman D, Mathers CD, Parkin D.
GLOBOCAN 2008: Cancer Incidence, Mortality and Prevalence
Worldwide in 2008. Available at: http://globocan.iarc.fr Accessed
on November 22, 2010.
10. Curado MP, Edwards BK, Shin HR, et al. Cancer Incidence in
Five Continents. Vol IX. Lyon, France: International Agency for
Research on Cancer; 2007.
11. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM.
Estimates of worldwide burden of cancer in 2008: GLOBOCAN
2008. Int J Cancer. 2010;127:2893-2917.
12. Jemal A, Center MM, Desantis C, Ward EM. Global patterns of
cancer incidence and mortality rates and trends. Cancer Epidemiol
Biomarkers Prev. 2010;19:1893-1907.
13. Morbidity from Cancer in the United States. Variation in Inci-
dence by Age, Sex, Race, Marital Status, and Geographic Region.
Public Health Monograph No. 29. Washington, DC: US Depart-
ment of Health, Education, and Welfare, Public Health Service;
14. Vorobiof DA, Sitas F, Vorobiof G. Breast cancer incidence in
South Africa. J Clin Oncol. 2001;19(18 suppl):125S-127S.
15. Bassett MT, Chokunonga E, Mauchaza B, Levy L, Ferlay J, Par-
kin DM. Cancer in the African population of Harare, Zimbabwe,
1990-1992. Int J Cancer. 1995;63:29-36.
16. Mackay J, Jemal A, Lee NC, Parkin DM. The Cancer Atlas.
Atlanta, GA: American Cancer Society; 2006.
17. Chu KC, Anderson WF. Rates for breast cancer characteristics by
estrogen and progesterone receptor status in the major racial/eth-
nic groups. Breast Cancer Res Treat. 2002;74:199-211.
18. Bowen RL, Duffy SW, Ryan DA, Hart IR, Jones JL. Early onset
of breast cancer in a group of British black women. Br J Cancer.
19. Huo D, Ikpatt F, Khramtsov A, et al. Population differences in
breast cancer: survey in indigenous African women reveals over-
representation of triple-negative breast cancer. J Clin Oncol.
20. Gukas ID, Jennings BA, Mandong BM, et al. Clinicopathological
features and molecular markers of breast cancer in Jos, Nigeria.
West Afr J Med. 2005;24:209-213.
21. Stark A, Kleer CG, Martin I, et al. African ancestry and higher
prevalence of triple-negative breast cancer: findings from an inter-
national study. Cancer. 2010;116:4926-4932.
22. Adebamowo CA, Famooto A, Ogundiran TO, Aniagwu T,
Nkwodimmah C, Akang EE. Immunohistochemical and molecu-
lar subtypes of breast cancer in Nigeria. Breast Cancer Res Treat.
23. Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D.
Global cancer statistics. CA Cancer J Clin. 2011;61:69-90.
24. Joint United Nations Programme on HIV/AIDS, World Health
Organization. AIDS Epidemic Update 2009. Available at: http://
pdf 2009 Accessed on July 14, 2010.
Cancer in Africa/Jemal et al
Month 00, 2012
25. Ziegler J, Newton R, Bourboulia D, et al. Risk factors for Kapo-
si’s sarcoma: a case-control study of HIV-seronegative people in
Uganda. Int J Cancer. 2003;103:233-240.
26. Sasco AJ, Jaquet A, Boidin E, et al. The challenge of AIDS-related
malignancies in Sub-Saharan Africa. PLoS One. 2010;5:e8621.
27. MillsEJ,Bakanda C, Birungi J,etal.Lifeexpectancy ofpersonsreceiv-
ing combination antiretroviral therapy in low-income countries: a
28. Blumberg BS. Hepatitis B virus and the control of hepatocellular
carcinoma. IARC Sci Publ. 1984;(63):243-261.
29. Franceschi S, Raza SA. Epidemiology and prevention of hepatocel-
lular carcinoma. Cancer Lett. 2009;286:5-8.
30. Parkin DM. The global health burden of infection-associated can-
cers in the year 2002. Int J Cancer. 2006;118:3030-3044.
31. Perz JF, Armstrong GL, Farrington LA, et al. The contributions
of hepatitis B virus and hepatitis C virus infections to cirrhosis
and primary liver cancer worldwide. J Hepatol. 2006;45:529-538.
32. Raza SA, Clifford GM, Franceschi S. Worldwide variation in the
relative importance of hepatitis B and hepatitis C viruses in hepa-
tocellular carcinoma: a systematic review. Br J Cancer. 2007;
33. Lehman EM, Wilson ML. Epidemic hepatitis C virus infection in
Egypt: estimates of past incidence and future morbidity and mor-
tality. J Viral Hepat. 2009;16:650-658.
34. Strickland GT. Liver disease in Egypt: hepatitis C superseded
schistosomiasis as a result of iatrogenic and biological factors. He-
35. International Agency for Research on Cancer. IARC Monographs
on the Evaluation of Carcinogenic Risks to Humans. Vol 82.
Some Traditional Herbal Medicines, Some Mycotoxins, Naphtha-
lene and Styrene. Lyon, France: International Agency for Research
on Cancer; 2002.
36. Wild CP, Gong YY. Mycotoxins and human disease: a largely
ignored global health issue. Carcinogenesis. 2010;31:71-82.
37. Wild CP, Montesano R. A model of interaction: aflatoxins and
hepatitis viruses in liver cancer aetiology and prevention. Cancer
38. Hartge P, Wang SS, Bracci PM, Devesa SS, Holly EA. Non-
Hodgkin lymphoma. In: Schottenfeld D, Fraumeni JF, eds. Can-
cer Epidemiology and Prevention. New York, NY: Oxford Uni-
versity Press; 2006:898-918.
39. Naresh KN, Raphael M, Ayers L, et al. Lymphomas in Sub-Saharan
Africa—what can we learn and how can we help in improving diag-
nosis, managing patients and fostering translational research? Br J
Haematol. 2011 Jun 28. doi: 10.1111/j.1365-2141.2011.08772.x.
[Epub ahead of print]
40. Kaaya EE, Castanos-Velez E, Ekman M, et al. AIDS and non
AIDS-related malignant lymphoma in Tanzania. Afr Health Sci.
41. Otieno MW, Remick SC, Whalen C. Adult Burkitt’s lymphoma
in patients with and without human immunodeficiency virus
infection in Kenya. Int J Cancer. 2001;92:687-691.
42. Parkin DM, Garcia-Giannoli H, Raphael M, et al. Non-Hodgkin
lymphoma in Uganda: a case-control study. AIDS. 2000;14:
43. Parkin DM, Wabinga H, Nambooze S, Wabwire-Mangen F.
AIDS-related cancers in Africa: maturation of the epidemic in
Uganda. AIDS. 1999;13:2563-2570.
44. Orem J, Mbidde EK, Lambert B, de Sanjose S, Weiderpass E.
Burkitt’s lymphoma in Africa, a review of the epidemiology and
etiology. Afr Health Sci. 2007;7:166-175.
45. Mutalima N, Molyneux E, Jaffe H, et al. Associations between
Burkitt lymphoma among children in Malawi and infection with
HIV, EBV and malaria: results from a case-control study. PLoS
46. Geser A, Brubaker G, Draper CC. Effect of a malaria suppression
program on the incidence of African Burkitt’s lymphoma. Am J
47. Jeannel D, Hubert A, de Vathaire F, et al. Diet, living conditions
and nasopharyngeal carcinoma in Tunisia—a case-control study.
Int J Cancer. 1990;46:421-425.
48. Laouamri S, Hamdi-Cherif M, Sekfali N, Mokhtari L, Kharchi R.
Dietary risk factors of nasopharyngeal carcinoma in the Setif area in
Algeria [in French]. Rev Epidemiol Sante Publique. 2001;49:145-156.
49. Bouchardy C, Parkin DM, Wanner P, Khlat M. Cancer mortality
among north African migrants in France. Int J Epidemiol.
50. Somdyala NI, Bradshaw D, Gelderblom WC, Parkin DM. Cancer
incidence in a rural population of South Africa, 1998-2002. Int J
51. Ocama P, Kagimu MM, Odida M, et al. Factors associated with
carcinoma of the oesophagus at Mulago Hospital. Uganda Afr
Health Sci. 2008;8:80-84.
52. Schneider M, Norman R, Steyn N, Bradshaw D. Estimating the
burden of disease attributable to low fruit and vegetable intake in
South Africa in 2000. S Afr Med J. 2007;97(8 pt 2):717-723.
53. Vizcaino AP, Parkin DM, Skinner ME. Risk factors associated
with oesophageal cancer in Bulawayo, Zimbabwe. Br J Cancer.
54. Gelderblom WC, Galendo D, Abel S, Swanevelder S, Marasas
WF, Wild CP. Cancer initiation by fumonisin B in rat liver—role
of cell proliferation. Cancer Lett. 2001;169:127-137.
55. Isaacson C. The change of the staple diet of black South Africans
from sorghum to maize (corn) is the cause of the epidemic of
squamous carcinomaof the
56. Reddy P, Meyer-Weitz A, Yach D. Smoking status, knowledge of
health effects and attitudes towards tobacco control in South
Africa. S Afr Med J. 1996;86:1389-1393.
57. Sitas F, Urban M, Bradshaw D, Kielkowski D, Bah S, Peto R.
Tobacco attributable deaths in South Africa. Tob Control. 2004;
58. Parkin DM. The global burden of urinary bladder cancer. Scand J
Urol Nephrol Suppl. 2008;(218):12-20.
59. IARC Monographs on the Evaluation of the Carcinogenic Risks
to Humans. Vol 61. Schistosomes, Liver Flukes, and Helicobacter
pylori. Lyon, France: International Agency for Research on Can-
60. Mostafa MH, Sheweita SA, O’Connor PJ. Relationship between schis-
tosomiasis and bladder cancer. Clin Microbiol Rev. 1999;12:97-111.
61. Negri E, La Vecchia C. Epidemiology and prevention of bladder
cancer. Eur J Cancer Prev. 2001;10:7-14.
62. Hsing AW, Devesa SS. Trends and patterns of prostate cancer:
what do they suggest? Epidemiol Rev. 2001;23:3-13.
63. Bock CH, Schwartz AG, Ruterbusch JJ, et al. Results from a pros-
tate cancer admixture mapping study in African-American men.
Hum Genet. 2009;126:637-642.
64. Miller DC, Zheng SL, Dunn RL, et al. Germ-line mutations of the
macrophage scavenger receptor 1 gene: association with prostate can-
cer risk in African-American men. Cancer Res. 2003;63:3486-3489.
65. US Institute of Medicine. Cancer Control Opportunities in Low-
and Middle-Income Countries. Washington, DC: The National
Academies Press; 2007.
66. Ngoma T. World Health Organization cancer priorities in devel-
oping countries. Ann Oncol. 2006;17(suppl 8):viii9-viii14.
67. Lingwood RJ, Boyle P, Milburn A, et al. The challenge of cancer
control in Africa. Nat Rev Cancer. 2008;8:398-403.
68. Ezzati M, Lopez AD. Regional, disease specific patterns of smok-
ing-attributable mortality in 2000. Tob Control. 2004;13:388-395.
69. Shafey O, Dolwick S, Guindon GE. Tobacco Control Country
Profiles. Atlanta, GA: American Cancer Society, World Health
Organization, International Union Against Cancer; 2003.
70. FCTC Convention Secretariat. 2009 Summary Report on Global
Progress in Implementation of the WHO Framework Convention
on Tobacco Control. Available at: http://www.who.int/fctc/
FCTC-2009-1-en.pdf Accessed March 9, 2010.
71. Blecher E. Targeting the affordability of cigarettes: a new bench-
mark for taxation policy in low-income and-middle-income coun-
tries. Tob Control. 2010;19:325-330.
72. Food, Nutrition, Physical Activity, and the Prevention of Cancer:
A Global Perspective. Washington, DC: World Cancer Research
Fund/American Institute for Cancer Research; 2007.
Month 00, 2012
73. Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ. Over- Download full-text
weight, obesity, and mortality from cancer in a prospectively stud-
ied cohort of U.S. adults. N Engl J Med. 2003;348:1625-1638.
74. Kamadjeu RM, Edwards R, Atanga JS, Kiawi EC, Unwin N,
Mbanya JC. Anthropometry measures and prevalence of obesity in
the urban adult population of Cameroon: an update from the
Cameroon Burden of Diabetes Baseline Survey. BMC Public
75. Abubakari AR, Lauder W, Agyemang C, Jones M, Kirk A, Bhopal
RS. Prevalence and time trends in obesity among adult West Afri-
can populations: a meta-analysis. Obes Rev. 2008;9:297-311.
76. Agyemang C, Owusu-Dabo E, de Jonge A, Martins D, Ogedegbe
G, Stronks K. Overweight and obesity among Ghanaian residents
in the Netherlands: how do they weigh against their urban and ru-
ral counterparts in Ghana? Public Health Nutr. 2009;12:909-916.
77. Mokhtar N, Elati J, Chabir R, et al. Diet culture and obesity in
northern Africa. J Nutr. 2001;131:887S-892S.
78. Popkin BM. Global nutrition dynamics: the world is shifting rap-
idly toward a diet linked with noncommunicable diseases. Am J
Clin Nutr. 2006;84:289-298.
79. World Health Organization. Global Strategy on Diet, Physical Ac-
tivity and Health. Available at: http://www.who.int/dietphysicalac
tivity/strategy/eb11344/strategy_english_web.pdf Accessed June 2,
80. World Health Organization. Hepatitis B vaccines. Weekly epide-
miologic record, No. 28. 2004;79:253-264.
81. Louie KS, de Sanjose S, Mayaud P. Epidemiology and prevention
of human papillomavirus and cervical cancer in Sub-Saharan
Africa: a comprehensive review. Trop Med Int Health. 2009;
82. Adams M, Jasani B, Fiander A. Human papilloma virus (HPV)
prophylactic vaccination: challenges for public health and implica-
tions for screening. Vaccine. 2007;25:3007-3013.
83. Sankaranarayanan R. HPV vaccination: the promise & problems.
Indian J Med Res. 2009;130:322-326.
84. Kreimer AR, Rodriguez AC, Hildesheim A, et al. Proof-of-princi-
ple evaluation of the efficacy of fewer than three doses of a biva-
lent HPV16/18 vaccine. J Natl Cancer Inst. 2011;103:1444-1451.
85. Mbulaiteye SM, Parkin DM, Rabkin CS. Epidemiology of AIDS-
related malignancies: an international perspective. Hematol Oncol
Clin North Am. 2003;17:673-696, v.
86. Mbulaiteye SM, Katabira ET, Wabinga H, et al. Spectrum of can-
cers among HIV-infected persons in Africa: the Uganda AIDS-
Cancer Registry Match Study. Int J Cancer. 2006;118:985-990.
87. Guech-Ongey M, Engels EA, Goedert JJ, Biggar RJ, Mbulaiteye
SM. Elevated risk for squamous cell carcinoma of the conjunctiva
among adults with AIDS in the United States. Int J Cancer.
88. Gray RH, Serwadda D, Kong X, et al. Male circumcision
decreases acquisition and increases clearance of high-risk human
papillomavirus in HIV-negative men: a randomized trial in Rakai,
Uganda. J Infect Dis. 2010;201:1455-1462.
89. Atashili J, Smith JS, Adimora AA, Eron J, Miller WC, Myers E.
Potential impact of antiretroviral therapy and screening on cervical
cancer mortality in HIV-positive women in Sub-Saharan Africa: a
simulation. PLoS One. 2011;6:e18527.
90. Felix AS, Soliman AS, Khaled H, et al. The changing patterns of
bladder cancer in Egypt over the past 26 years. Cancer Causes
91. Gouda I, Mokhtar N, Bilal D, El-Bolkainy T, El-Bolkainy NM.
Bilharziasis and bladder cancer: a time trend analysis of 9843
patients. J Egypt Natl Canc Inst. 2007;19:158-162.
92. Burson AM, Soliman AS, Ngoma TA, et al. Clinical and epide-
miologic profile of breast cancer in Tanzania. Breast Dis.
93. Chirenje ZM, Rusakaniko S, Akino V, Mlingo M. A review of
cervical cancer patients presenting in Harare and Parirenyatwa
Hospitals in 1998. Cent Afr J Med. 2000;46:264-267.
94. Lambert R, Sauvaget C, Sankaranarayanan R. Mass screening for
colorectal cancer is not justified in most developing countries. Int
J Cancer. 2009;125:253-256.
95. Denny L, Kuhn L, De Souza M, Pollack AE, Dupree W, Wright
TC Jr. Screen-and-treat approaches for cervical cancer prevention
in low-resource settings: a randomized controlled trial. JAMA.
96. Goldie SJ, Gaffikin L, Goldhaber-Fiebert JD, et al. Cost-effective-
ness of cervical cancer screening in 5 developing countries. N Engl
J Med. 2005;353:2158-2168.
97. Sankaranarayanan R, Basu P, Wesley RS, et al. Accuracy of visual
screening for cervical neoplasia: results from an IARC multicentre
study in India and Africa. Int J Cancer. 2004;110:907-913.
98. Alliance for Cervical Cancer Prevention. Preventing Cervical Cancer
Worldwide. Washington, DC: Population Reference Bureau; 2004.
99. Sankaranarayanan R, Nene BM, Shastri SS, et al. HPV screening
for cervical cancer in rural India. N Engl J Med. 2009;360:1385-
100. Levin CE, Sellors J, Shi JF, et al. Cost-effectiveness analysis of cer-
vical cancer prevention based on a rapid human papillomavirus
screening test in a high-risk region of China. Int J Cancer. 2010;
101. National Cancer Control Programmes: Policies and Managerial
Guidelines. 2nd ed. Geneva, Switzerland: World Health Organi-
102. Sankaranarayanan R, Boffetta P. Research on cancer prevention,
detection and management in low- and medium-income countries.
Ann Oncol. 2010;21:1935-1943.
103. Barton MB, Frommer M, Shafiq J. Role of radiotherapy in cancer
control in low-income and middle-income countries. Lancet
104. Programme of Action for Cancer Therapy. Report by the Director
105. Sankaranarayanan R, Swaminathan R, Brenner H, et al. Cancer
survival in Africa, Asia, and Central America: a population-based
study. Lancet Oncol. 2010;11:165-173.
106. Gondos A, Brenner H, Wabinga H, Parkin DM. Cancer survival
in Kampala, Uganda. Br J Cancer. 2005;92:1808-1812.
107. Gondos A, Chokunonga E, Brenner H, et al. Cancer survival in a
southern African urban population. Int J Cancer. 2004;112:
108. Foley KM, Wagner JL, Joranson DE, Gelband H. Pain control for
people with cancer and AIDS. In: Jamison D, Brennan JG, Meas-
ham AR, et al, eds. Disease Control Priorities in Developing Coun-
tries. New York, NY: Oxford University Press; 2006:981-994.
109. Narcotic Drugs: Estimated World Requirements for 2010; Statis-
tics for 2008. Vienna, Austria: United Nations International Nar-
cotics Control Board; 2009.
110. National Cancer Control Programmes. Geneva, Switzerland:
World Health Organization; 2002.
111. World Health Organization. Cancer Prevention and Control.
Report to the Secretariat by the 58th World Health Assembly.
Available at: http://www.who.int/mediacentre/news/releases/2005/
pr_wha05/en/index.html Accessed April 1, 2010.
112. Mwanahamuntu MH, Sahasrabuddhe VV, Pfaendler KS, et al.
Implementation of ‘see-and-treat’ cervical cancer prevention serv-
ices linked to HIV care in Zambia. AIDS. 2009;23:N1-N5.
113. Nakkazi E. Cancer vaccine boosted by infrastructure for HIV care
in Africa. Nat Med. 2011;17:272.
114. Parkin DM. The role of cancer registries in cancer control. Int J
Clin Oncol. 2008;13:102-111.
115. Valsecchi MG, Steliarova-Foucher E. Cancer registration in devel-
oping countries: luxury or necessity? Lancet Oncol. 2008;9:159-
116. Parkin DM. The evolution of the population-based cancer regis-
try. Nat Rev Cancer. 2006;6:603-612.
117. Rastogi T, Hildesheim A, Sinha R. Opportunities for cancer epide-
miology in developing countries. Nat Rev Cancer. 2004;4:909-917.
Cancer in Africa/Jemal et al
Month 00, 2012