Professor Kamel Bouzid, president of the Algerian Society of Medical Oncology, provides an insight into the efforts to fight against cancer in Algeria.
Could you please give us an overview of the cancer prevalence in Algeria?
In Algeria, 75 percent of cancers are metastasized cancers, and only 25 percent are localized. In France there is the opposite tendency, 20 percent are stage three and four and 80 percent are localized, thanks to screening, clinical examination and patient information, among others. That money could be used in that context. It could be used to acquire new testing material in molecular biology, in order to allow targeted treatment. This is not the case yet, so we are working on it. For example, Merck markets a hormonal antibody for which the indication can be prescribed only through biological testing. As a result, Merck is also in charge of that test. They do it for free, but they do benefit from it afterwards, as their drug costs 1500 dollars for one unit. We need 10 000 of these per year, so the bill is terrible. These tests can and must be performed here, if only for the Algerian biologists to be at the same level as their colleagues at the international level, but also for the medical oncologists of Algeria to be able to treat their patients as efficiently as anywhere else in the world, with targeted therapies for instance.
Indeed, we are more and more going towards personalized cancer treatments, and relying less on chemotherapy only. These new therapies cost a lot. The pharmaceutical companies justify their staggering prices by their expense on R&D, also known as clinical trials. The scam is that they run those clinical trials in the rich countries: in the USA, in Western Europe, a bit in Eastern Europe, and also in Asia. We, in Africa, are exclusively in the position of the customer: we wait until the drug is approved in the country of origin, and then we use it. In the end, we pay for research and development programs, and that money is never invested in our countries. There are no clinical trials in Africa, except for a few in Algeria. The enormous cost of these drugs is a problem not only for Algeria but also for the entire world. For instance, the medical oncologists in France were warned by President Hollande when it became clear that France could not afford such costs, even though we are talking here of a country with, so to speak, the best healthcare system in the world.
How did personalized therapies evolve in Algeria? How important are they to the new plan against cancer?
We are approaching the turning point. Personalized therapies were introduced here in 2002 as a solution to treat gastrointestinal tumors and in 2005 in metastatic or adjuvant situations. In 2006, kidney cancer could also receive such treatment, and we are adding more as they are discovered, approximately one or two years after their entry on the international market. Except for monotherapies, for which our patients have free access. This is important: for instance, treatment by monotherapy of metastasized kidney cancer costs USD 6,000 per month, and average survival period is seven years. Thus, it is important because in theory, every Algerian has access to this. We make sure that it remains a reality, and that our patients do not have to worry about money.
On the other hand, something that could be enhanced is the role of our Social Security. The people of this institution explain to us learnedly that as cancer is to be treated in hospitals, the drugs are not available in pharmacies but in the PCH (Central Pharmacy of the Hospitals) and in hospital pharmacies. For certain drugs, for instance targeted therapies, they should be available at home and report to the CHIFA system. We can cure cancer when the diagnosis is done early, it is a chronic illness, even when metastasized.
There is another positive item in the Cancer Plan, even though some oncologists are still to admit it, and that is supportive care, which is different from end-of-life care. Supportive care includes everything that surrounds cancer treatment: nausea, vomiting, diarrhea, hair loss and so on. We are working on this, so that that medical oncologists can truly be oncologists and not “mere” chemotherapists.
What do you think of the evolution of medical oncology in terms of capacity? What are according to you the possibilities to enhance the offer in terms of infrastructures and equipment?
In the last 4 years, the situation has become clearly better in terms of radiotherapy because we now have accelerators, we created anticancer centers. Now the issues are first the operating staff for these machines, second their maintenance because this type of equipment is fragile, and third the organization. Indeed, next September we are opening a center in Adrar, 2000 km away from Algiers, but we need to find doctors, occupational therapists, physical therapists, radio physicists… Either they will be there already, or we will need to send them from Algiers, Oran and other cities, provided they want to go there. This means that we will need attractive working and living conditions, the possibility to visit their city of origin easily to see their families, etc. Yet, at the moment, a flight ticket from there to Constantine costs €200, while a doctor’s average income in Algeria is €600. We need to think through these issues right now, and not after the center is up and running. Otherwise, this will mean that we would have built “white elephants”. We must not increase many fold the number of equipment purchases, as one accelerator costs about 3 million dollars, if they cannot be operated, and if our anticancer centers are not staffed enough. Currently, the anticancer centers in Setif, Anaba, Mina, Algiers and Oran are fully operating. This year, we expect to open new ones in Adrar and El-Oued. This will ensure widespread territorial coverage, which is one of the objectives of the National Cancer Plan, and the will of the President. All of this will be expensive, but it is not a reason to let cancer patients die, like it was the case 20 or 25 years ago.
To your expert opinion, what will be the place of anticancer innovation in the Algerian system in the years to come?
It is rather a question of months. Some of our patients, and even a colleague of mine, need these new drugs urgently or they will pass away within weeks. Access to innovation is possible as long as the authorities, the Ministry of Health, the Ministry of Labor, the Social Security and all the others pay attention to the need for medical staff and take into account the advice of patient associations. To me, this is not really the case, and I have been around for over 10 years now. Instead, they learnedly inform us that we are to be on the payroll of pharmaceutical laboratories, even if they never say it to the face. As they do not listen to us, I consider that they are not doing enough in terms of promoting medical oncology.
What about the National Cancer Plan, you told us that many things have been achieved, but much remains to do. What would that be?
We need to better our strategy to optimally operate our anticancer centers, and that should have been done ten years ago. From a material point of view, it has been taken care of, now we need Human Resources, and a plan to adequately allocate them. We need to achieve two goals: to reduce cancer related mortality, and to reduce cancer incidence, which will happen through prevention. 20 years ago, in France, they launched that famous campaign “if you eat, move” and “eat 5 fruits and vegetables a day”. Everyone would make fun of it, mocked the French, saying “these people are crazy”. Yet, 20 years later, cancer incidence and mortality there have decreased thanks to screening and prevention. That type of action must be done, using the funds that already exist. The Ministry keeps saying that it is expensive, yes, but once the people are ill, it is also very costly. Screening and prevention allow a decrease of costs: when breast cancer is detected early on, it doesn’t require chemotherapy, but partial surgery, that have high rates of full recovery. It costs 300,000 dinars. On the other hand, life expectancy of stage 4 cancer patients, who are treated with chemotherapy, hormonal therapy, targeted therapy and so on, is 25 to 50 percent. Three quarters of patients die. Their treatment costs 500 million dinars. The stakes are very high. The authorities are acting like cows watching trains: as they consider that we are on the payroll of the big laboratories, they do not act.
What is the cancer mortality rate in Algeria?
50.000 new patients per year, and it is estimated around 20.000 fatalities. In 2008, the “Concord” study based on data collected in Setif, Algeria ranked last of 30 countries. Colorectal cancer was fatal within 5 years in 60 percent of cases. Now it is 30 percent. So the situation is much better. Lung cancer is also in a better situation, due to innovation and the efficient treatments that exist today. Metastasized lung cancer can be survived around 15 months, while 10 years ago survival did not exceed 6 months. There are other cancers for which no progress has been achieved, that is the case with pancreatic cancer for instance, and gallbladder cancer, as far as Algeria is concerned.
What do you expect to happen in the next four to five years in terms of oncology and national anti-cancer policy? What objectives do you wish Algeria to achieve?
There is a Monitoring and Evaluation Committee, reporting to the Minister of Health, who reports to the President of the Republic. We are counting on the 2015-2019 report to evaluate objectively what has been done, what is still in progress and what remains to do. So in 2020 we will issue a new Cancer Plan for the 2020-2024 period, with renewed objectives, based on that analysis.
