1. Department of radiotherapy. University Hospital Ibn Rochd Casablanca – Morroco Cancer Control Resources in Maghreb countries Pr. BENIDER Marrakech June 19th 2010

2. Maghreb map

3. MAGHREB Epidemiologic transition - Demographic transition - Transformations of the environment - Change of the way of life Non transmissible chronic diseases Health priorities Cancer = Major problem of public health INTRODUCTION

4. 1929: Bergonié Centre -Casablanca Ibn Rochd Oncology Center Historical 1929-1980 1947: Casablanca Mayor inaugurating the hospitalization of the Bergonié center

5. Historical 1929-1980 Treated cancers in Cancer Centre bergonié

6. 1980: First two radiotherapy specialists (Pr.Gueddari - Pr.Kahlain) 1985: National Institute of Oncology-Rabat 1989: First private center - Casablanca Historical 1980-2005 2005: Lalla Salma Association Against Cancer 2010: Cancer Plan (2010 - 2019) After 2005

7. Epidemiological Data

8. Cancer Standardized Incidence In Maghreb All Sites MaleFemale MOROCCO (Casablanca*) 100,3104,2 ALGERIA (Alger**)148,6 151,3 TUNISIA (Tunis***)133,2101,4 LYBIA (Benghazi****) 116,9295,11 * Registre des Cancers de la région du Grand Casablanca Edition 2004 ** Registre des tumeurs d’Alger Edition 2003 *** Registre des Cancers de Nord Tunisie 1999-2003 **** Benghazi Cancer Registry 2004

9. Cancer Standardized Incidence In Maghreb All Sites MaleFemale MOROCCO (Casablanca*) 100,3104,2 ALGERIA (Alger**)148,6 151,3 TUNISIA (Tunis***)133,2101,4 LYBIA (Benghazi****) 116,9295,11 USA (New Jersey)566,2439,2 France (Loire)422,7256 CANADA 398,5308,3

10. COMMONLY CANCERS IN MALE MOROCCO (Casablanca*) ALGERIA (Alger**) TUNISIA (Tunis***) LYBIA (Benghazi****) Lung ProstateColon/RectumBladderColon/Rectum BladderColon/RectumHead  Neck NHLStomachProstateBladder LarynxProstateSkinProstate * Registre des Cancers de la région du Grand Casablanca Edition 2004 ** Registre des tumeurs d’Alger Edition 2003 *** Registre des Cancers de Nord Tunisie 1999-2003 **** Benghazi Cancer Registry 2004

11. COMMONLY CANCERS IN FEMALE MOROCCO (Casablanca*) ALGERIA (Alger**) TUNISIA (Tunis***) LYBIA (Benghazi****) Breast Cervix uteriColon/Rectum ThyroidCervix uteriSkinCorpus uteri Colon/RectumThyroidCervix uteriNHL Ovaries ThyroidCervix uteri * Registre des Cancers de la région du Grand Casablanca Edition 2004 ** Registre des tumeurs d’Alger Edition 2003 *** Registre des Cancers de Nord Tunisie 1999-2003 **** Benghazi Cancer Registry 2004

12. Breast Cancer Comparison of standardized incidence of other countries CountryIncidence MOROCCO (Casablanca)35,04 ALGERIA (Alger)44,5 TUNISIA (Tunis)29,6 USA (New Jersey)129,4 FRANCE (Loire)109,8 CANADA95,5

13. Health facilities

14. Cancer facilities in Morocco Casablanca Public (1) Private (2) Rabat Public (1) Military (1) Private (2) Oujda Public (1) Total : 8 cancer centers Al houceima Before 2005

15. Cancer facilities in Morocco Functional Casablanca (4) Rabat (4) Agadir (1) Oujda (1) Al Houceima (1) Marrakech (2*) Fes (1/1*) Total : 12 (3*) cancer centers Planned Tanger Meknes (2) Safi Laayoune Al houceima After 2005 *Functional soon

16. Cancer facilities in Algeria ALGERIA Constantine Algiers Ain-Naadja Blida Ain Misserghin Oran 6 centers......

17. Cancer facilities in Tunisia - 3 functional centers: Tunis Sousse Sfax Jendouba - 3 planned centers: Gafsa Gabes Jendouba

18. Radiation Therapy Equipment in Morocco Before 2005 Linac10 Cobalt7 Simulator (CT)3 Brachy LDR16 Brachy HDR2 TPS10 After 2005 22 (2*) 6 5 (7*) 16 7 28 (14*) * Planned

19. Radiation Therapy Equipment in Algeria Linac9 Cobalt6 Brachy4

20. Radiation Therapy Equipment in Tunisia PublicPrivateTotal LINAC1/4*1/1*2/5* Cobalt459 Simulator32/1*5/1* TPS33 * Planned

21. Comparison of Radiation Therapy Equipment in Maghreb countries MoroccoAlgeriaTunisia Linac22(2*)92(5*) Cobalt669 Simulator (CT) 5(7*)-5(1*) Brachy LDR164- Brachy HDR7-- TPS28(14*)-3 * Planned - No data available

22. 22 Human resources in cancer centers in Morocco Radiotherapy Specialists: 82 Residents: 61 Medical Oncology Specialists:20 Residents:51 Surgical Oncology Specialists:16 Total: Specialists: 118 Residents : 112

23. 23 Human resources in cancer centers in Algeria Medical Oncologists: 250 Radiation Oncologists: 50 Surgeons: 100

24. 24 PublicPrivateTotal Surgical Oncology Specialists11415 Residents13 - Radiotherapy Specialists15419 Residents19- Medical Oncology Specialists201232 Residents32- Total Specialists461864 Residents64 - Human resources in cancer centers in Tunisia

25. 25 MoroccoAlgeriaTunisia Surgical Oncology Specialists1610015 Residents- -13 Radiotherapy Specialists825019 Residents61- 19 Medical Oncology Specialists2025032 Residents51- 32 Comparison of Human resources in cancer centers in Maghreb countries - No data available

26. Moroccan cancer Plan 2010-2019 Conceptual Framework National and international mobilization Prevention Early diagnosis Detection Diagnosis and treatment Palliative cares Legislation Research / Training Social support Communication

27. Moroccan cancer Plan 2010-2019 Health facilities organization Level 1: Basic health centers, General practionners Level 2: Provincial hospitals Diagnosis centers Clinics Level 3: University hospitals, Regional cancer centers Private cancer centers

28. Tunisian cancer Plan 2006-2010 In collaboration with the Institut National Français du Cancer (INCa) Piloting comittee and sub-commissions : - Formation/Research - Epidemiology - Primary Prevention - Screening/Early Diagnosis - Management

29. Recommendations

30. International Resources Standards in Radiotherapy EQUIPMENT 1 device / 250 000 - 500 000 inhabitants. OMS/AIEA recommendations for developing countries : 1 device for 1 million inhabitants.

31. International Resources Standards in Radiotherapy HUMAN RESOURCES 1 Radiation Oncologist / 300 - 400 annual treatments 1 Radiation Physicist / 350 - 500 annual treatments 2 therapy radiographers / each treatment device At least 1 therapy radiographer / simulator At least 1 dosimetrist.

32. Moroccan equipment Requirement in Radiotherapy (cancer Plan 2010-2019) For each cancer center 2 LINACs with MLC 1 Simulation system (standard or CT) 1 TPS with network link HDR Brachytherapy

33. Moroccan Human Resources Requirement in Radiotherapy (cancer Plan 2010-2019) For each cancer center At least 2 radiation oncologists, and above depending on the center activity: 1 radiation oncologist / 400 - 500 patients treated per year At least 2 Radiation Physicists, and above depending on the center activity: 1 radiation Physicist / 600 - 700 patients treated per year At least 12 radiation therapy radiographers At least 2 Brachytherapy radiographers At least 1 dosimetrist, and above depending on the center activity

34. Conclusion Cooperation Governments - NGOs would allow: * Cancer prevention * Cancer treatment * Palliative care * Better quality of life