Cancer patterns, trends, and transitions in Peru: a regional perspective

Challenges associated with follow-up care after implementation of an HPV screen-and-treat program with ablative therapy for cervical cancer prevention

BACKGROUND

Cervical cancer is a preventable cancer; however, decreasing its prevalence requires early detection and treatment strategies that reduce rates of loss to follow-up. This study explores factors associated with loss to follow-up among HPV-positive women after implementation of a new HPV-based screen-and-treat approach for cervical cancer prevention in Iquitos, Peru.

METHODS

We conducted semi-structured interviews with "obstetras" (i.e., midwives) (n = 15) working in cervical cancer prevention and women (n = 24) who were recorded as lost to follow-up after positive HPV results. We used the Health Care Access Barriers Model to guide analyses. We utilized manifest content analysis to describe barriers to follow-up according to the obstetras and thematic analysis to report themes from the women's perspectives. We also report the steps and time taken to contact women.

RESULTS

We found an incomplete and fragmented patient monitoring system. This incomplete system, in conjunction with challenges in contacting some of the women, led to structural barriers for the obstetras when attempting to deliver positive results. Women in this study expressed a desire to receive treatment, however, faced cognitive barriers including a lack of understanding about HPV results and treatment procedures, fear or anxiety about HPV or treatment, and confusion about the follow-up process. Women also reported having important work matters as a barrier and reported frequently using natural medicine. Reported financial barriers were minimal.

CONCLUSION

This study highlights the barriers to follow-up after implementation of a primary-level HPV-based screen-and-treat approach. While some barriers that have previously been associated with loss to follow-up were not as prominently observed in this study (e.g., financial), we emphasize the need for screen-and-treat programs to focus on strategies that can address incomplete registry systems, structural challenges in results delivery, cognitive barriers in understanding results and treatment, and work-related barriers.

Proportion of cancer cases and deaths attributable to potentially modifiable risk factors in Peru

BACKGROUND

Limited evidence exists on the population attributable fraction (PAF) of cancer cases and deaths in Latin America. In Peru several studies have been published regarding the PAF of various risk factors and their associated diseases. The objective of this study was to estimate the fraction of cancer cases and deaths attributable to potentially modifiable risk factors in Peru in 2018, before the COVID-19 pandemic in the population of 15 years old and older.

METHODS

An ecological study was conducted using the prevalence of exposure of the Peruvian population to modifiable risk factors for cancer, the relative risk associated with each factor, and the number of cancer cases and deaths in 2018 as inputs. We used the Parkin formula with a Montecarlo statistical simulation model to calculate the PAF and confidence intervals. The number of new cancer cases and deaths attributed to each risk factor was determined by multiplying the number of cases and deaths in each gender by the PAF of each risk factor.

FINDINGS

In Peru, 38.5% of new cases (34.5% in men and 42% in women) and 43.4% of cancer-related deaths (43.4% in men and 43.4% in women) were attributable to modifiable risk factors. The number of cancers attributable was 25,308 (10,439 in men and 14,869 in women) and the number of deaths attributable to cancer was 14,839 (6,953 in men and 7,886 in women). The predominant modifiable risk factors contributing to the highest number of cases and deaths were HPV infection (4,563 cases, 2,409 deaths), current tobacco use (3,348 cases, 2,180 deaths), and helicobacter pylori infection (2,677 cases, 1,873 deaths). Among the risk factors, oncogenic infections constituted the group with the highest PAF (16.6% for cases, 19.2% for deaths) followed by other unhealthy lifestyle factors (14.2% for cases, 16.7% for deaths), tobacco (7.2% for cases, 7.2% for deaths) and ultraviolet radiation (0.5% for cases, 0.3% for deaths).

CONCLUSIONS

Prior to the COVID-19 pandemic, 38.5% of cancer cases and 43.4% of cancer-related deaths in Peru were linked to modifiable risk factors in the population of 15 years old and older. Most preventable cancer cases and deaths were related to oncogenic infections, primarily caused by HPV and helicobacter pylori, followed by tobacco and obesity.

Implementation of new technologies designed to improve cervical cancer screening and completion of care in low-resource settings: a case study from the Proyecto Precancer

BACKGROUND

This case study details the experience of the Proyecto Precancer in applying the Integrative Systems Praxis for Implementation Research (INSPIRE) methodology to guide the co-development, planning, implementation, adoption, and sustainment of new technologies and screening practices in a cervical cancer screening and management (CCSM) program in the Peruvian Amazon. We briefly describe the theoretical grounding of the INSPIRE framework, the phases of the INSPIRE process, the activities within each phase, and the RE-AIM outcomes used to evaluate program outcomes.

METHODS

Proyecto Precancer iteratively engaged over 90 stakeholders in the Micro Red Iquitos Sur (MRIS) health network in the Amazonian region of Loreto, Perú, through the INSPIRE phases. INSPIRE is an integrative research methodology grounded in systems thinking, participatory action research, and implementation science frameworks such as the Consolidated Framework for Implementation Research. An interrupted time-series design with a mixed-methods RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) evaluation framework was used to examine the adoption of human papillomavirus (HPV) testing (including self-sampling), with direct treatment after visual inspection with portable thermal ablation, at the primary level.

RESULTS

This approach, blending participatory action research, implementation science, and systems-thinking, led to rapid adoption and successful implementation of the new cervical cancer screening and management program within 6 months, using an HPV-based screen-and-treat strategy across 17 health facilities in one of the largest public health networks of the Peruvian Amazon. Monitoring and evaluation data revealed that, within 6 months, the MRIS had surpassed their monthly screening goals, tripling their original screening rate, with approximately 70% of HPV-positive women reaching a completion of care endpoint, compared with around 30% prior to the new CCSM strategy.

CONCLUSIONS

Proyecto Precancer facilitated the adoption and sustainment of HPV testing with subsequent treatment of HPV-positive women (after visual inspection) using portable thermal ablation at the primary level. This was accompanied by the de-implementation of existing visual inspection-based screening strategies and colposcopy for routine precancer triage at the hospital level. This case study highlights how implementation science approaches were used to guide the sustained adoption of a new screen-and-treat strategy in the Peruvian Amazon, while facilitating de-implementation of older screening practices.

"Easy women get it": pre-existing stigma associated with HPV and cervical cancer in a low-resource setting prior to implementation of an HPV screen-and-treat program

BACKGROUND

Cervical cancer is preventable with vaccination and early detection and treatment programs. However, for these programs to work as intended, stigma related to HPV and cervical cancer must be understood and addressed. We explored pre-existing stigma associated with HPV and cervical cancer in the public healthcare system and community of a low-resource setting prior to implementation of an HPV screen-and-treat program.

METHODS

This study conducted thematic analysis of data collected during implementation of a novel HPV screen-and-treat system for cervical cancer early detection and treatment in Iquitos, Peru. We included 35 semi-structured interviews (19 health professionals, 16 women with cervical precancer or cancer), eight focus groups (70 community women), one workshop (14 health professionals), 210 counseling observations (with 20 nurse-midwives), and a document review. We used the Socio-Ecological Model to organize the analysis.

RESULTS

We identified three main themes: 1. the implication that women are to blame for their HPV infection through characterizations of being easy or promiscuous, 2. the implication that men are to blame for women's HPV infections through being considered careless or unfaithful, 3. HPV is shameful, embarrassing, and something that should be hidden from others. Consequently, in some cases, women refrained from getting screened for HPV. These themes were seen at the individual level among women, relationship level among women, men, and family members, community level among healthcare staff, and societal level within components of cervical cancer guidelines and male chauvinism.

CONCLUSIONS

Cervical cancer early detection and treatment programs in limited resource settings must address stigma entrenched throughout the entire healthcare system and community in order to sustainably and successfully implement and scale-up new programs. Interventions to tackle this stigma can incorporate messages about HPV infections and latency to lessen the focus on the influence of sexual behavior on HPV acquisition, and instead, promote screening and treatment as paramount preventative measures.

Temporal patterns of breast cancer incidence, mortality, disability-adjusted life years and risk factors in 12 South American Countries, 1990-2019: an examination using estimates from the global burden of disease 2019 study

BACKGROUND AND AIM

Breast cancer (BC) is one of the leading causes of cancer deaths in females in South America. This study aims to examine the BC burden in 12 South American countries between 1990 and 2019.

DATA AND METHODS

The estimates of BC burden and risk factors were procured from the Global Burden of Disease 2019 study for the period 1990-2019. Development levels of countries were gauged using socio-demographic index (SDI). Decomposition analysis was employed to categorize the change in incidence between 1990 and 2019 into three factors: population growth, population aging and age-specific incidence rate. Estimated annual percent changes were calculated for each country and bivariate association between country-level age-standardized rates and SDI was examined using pooled regression.

RESULTS

The age-standardized rates of breast cancer were the highest in Uruguay [incidence: 72.65 per 100,000 (55.79-92.57); mortality: 29.97 per 100,000 (27.54-32.27); disability-adjusted life years (DALYs: 810.49 per 100,000 (746.22-884.55)] and lowest in Peru [incidence: 27.63 per 100,000 (20.44-36.85); mortality: 10.79 per 100,000 (8.14-14.11); DALYs: 318.27 per 100,000 (234.47-421.16)]. Mortality-to-incidence ratio (MIR) across countries varied from 0.30 in Colombia to 0.55 in Bolivia in 2019. SDI had a positive and strong association with age-standardized incidence rate [Formula: see text] and weaker positive association with age-standardized mortality rate [Formula: see text] and age-standardized DALYs rate [Formula: see text]. Most countries experienced more than 70% increase in incident cases owing to population aging and age-specific incidence rates. Alcohol Use, diet high in red meat and smoking contributed the maximum DALYs in most countries in 2019 whereas DALYs due to high body-mass index and high fasting plasma glucose increased most substantially between 1990 and 2019.

CONCLUSION

With increasing incidence, high MIR and rising BC burden due to modifiable risk factors, several public health interventions are required in South America focusing on prevention, BC awareness among general public, cost-effective early detection and treatments that suit the socio-economic setup of South American countries.

Temporal Variation of Treatment Patterns and Survival Outcomes of Triple-Negative Breast Cancer Patients: A Real-World Experience From 2000 to 2014

BACKGROUND

Previous studies have reported a higher prevalence of triple-negative breast cancer (TNBC) in US Hispanic/Latina populations. However, survival outcomes and treatment approaches over time in Latin American females are scarcely reported. We aimed to evaluate the temporal variation in treatment patterns and overall survival (OS) outcomes of females with TNBC according to cancer stage.

MATERIALS AND METHODS

We performed a single-center retrospective cohort study on 1840 females from 2000 to 2014. Patients were classified in 3 calendar periods (2000-2004, 2005-2009, and 2010-2014). The Kaplan-Meier method and multivariable regression analyses were employed.

RESULTS

Stage III cancer was identified in half of the population. Five-year OS estimates for cancer stages I, II, and IV remained unchanged across all calendar periods. However, we found worsening 5-year OS estimates in stage III females (49% in 2000-2004 and 31% in 2010-2014; P < .001). Despite increased uptake of overall use of neoadjuvant therapy in stage III females, the time from diagnosis to treatment initiation (P = .013) and time to complete the planned cycles (P < .001) increased over time. Fifty-sex percent of stage IV patients were untreated. Females aged ≥70 years were less likely to receive treatment.

CONCLUSIONS

Survival estimates were lower than those reported in high-income countries. Most females were diagnosed with advanced disease, and the OS for stage III females worsened over time. Our outcomes show difficulties in delivering timely neoadjuvant therapy in an overwhelmed healthcare system. Public health authorities should improve screening practices, develop regional clinical guidelines, and expand trial enrollment.

"Easy women get it": Pre-existing stigma associated with HPV and cervical cancer in a low-resource setting prior to implementation of an HPV screen-and-treat program

Background

Cervical cancer is preventable with vaccination and early detection and treatment programs. However, in order for these programs to work as intended, stigma related to HPV and cervical cancer must be understood and addressed. We explored pre-existing stigma associated with HPV and cervical cancer in the public healthcare system of a low-resource setting prior to implementation of an HPV screen-and-treat program.

Methods

This study conducted thematic analysis of data collected during implementation of a novel HPV screen-and-treat system for cervical cancer early detection and treatment in Iquitos, Peru. We included 35 semi-structured interviews (19 health professionals, 16 women with cervical precancer or cancer), eight focus groups (70 community women), one workshop (14 health professionals), 210 counseling observations (with 20 nurse-midwives), and a document review. We used the Socio-Ecological Model to organize the analysis.

Results

We identified three main themes: 1. the implication that women are to blame for their HPV infection through characterizations of being easy or promiscuous, 2. the implication that men are to blame for women's HPV infections through being considered careless or unfaithful, 3. HPV is shameful, embarrassing, and something that should be hidden from others. Consequently, in some cases, women refrained from getting screened for HPV. These themes were seen at the individual level among women, relationship level among women, men, and family members, community level among healthcare staff, and societal level within components of cervical cancer guidelines and male chauvinism.

Conclusions

Cervical cancer early detection and treatment programs in limited resource settings must address stigma entrenched throughout the entire healthcare system in order to sustainably and successfully implement and scale-up new programs. Interventions to tackle this stigma can incorporate messages about HPV infections and latency to lessen the focus on the influence of sexual behavior on HPV acquisition, and instead, promote screening and treatment as paramount preventative measures.

Determining the spatial non-stationarity underlying social and natural environment in thyroid cancer in China

BACKGROUND

Light at night (LAN) is a physiological environmental factor related to thyroid cancer (TC). The spatial relationship between the number of TC incident cases, LAN, air pollution and other macro social factors and stationarity needs to be further examined to provide evidence for regional control of TC.

METHODS

Spatial econometrics methods for spatial nonstationarity were used to explore the impacts of LAN, air pollutants, economic factors, and population size on the number of TC incident cases in 182 Chinese prefecture-level cities and the local coefficients were further tested for nonstationarity. Temporally weighted regression (TWR), geographically weighted regression (GWR), and geographically and temporally weighted regression (GTWR) were compared in this study for model selection.

RESULTS

Based on the ordinary least squares (OLS), LAN, air pollutants, and urbanization all significantly affected the number of TC incident cases. GWR had the best goodness of fit, and the coefficients of all the variables passed the nonstationarity test. The strong positive impact of LAN was mainly concentrated in North China, air pollutants in Central China and neighboring regions, and urbanization in the eastern coast of China.

CONCLUSIONS

The locational factors of the prefecture-level city influence the spatial pattern of the number of TC incident cases. Governments should pay attention to this influence, adhere to the Health in All Policies principle, and formulate region-specific policies based on regional characteristics, which this study provides updated evidence for.

Epidemiological Features and Outcomes of HTLV-1 Carriers Diagnosed With Cancer: A Retrospective Cohort Study in an Endemic Country

PURPOSE

Human T-lymphotropic virus type 1 (HTLV-1) is an endemic virus in Latin America that is directly linked to adult T-cell leukemia/lymphoma (ATL). Previous studies have suggested an oncogenic role of HTLV-1 in non-ATL neoplasms and have found higher mortality in HTLV-1 carriers without ATL.

METHODS

In this retrospective cohort study, HTLV-1 carriers were identified through screening at a tertiary cancer center between 2006 and 2019. We compared the overall survival (OS) outcomes of patients with ATL with those with other solid or hematologic malignancies by sex stratification.

RESULTS

We identified 1,934 HTLV-1 carriers diagnosed with cancer. The median age at diagnosis was 62 (range 20-114) years, 76% were female, 60% had no or elementary school education, and 50% were born in the Andean highlands. The most common non-ATL neoplasm was cervical cancer (50%) among females and non-ATL non-Hodgkin lymphoma (26%) among males. With a median follow-up of 66 months, the 5-year OS of HTLV-1 carriers with non-ATL neoplasms (26%-47% for females and 22%-34% for males) was inferior to those reported in the general population. As expected, patients with ATL had a worse prognosis (5-year OS: 10% for females and 8% for males).

CONCLUSION

HTLV-1 carriers with cancer were middle age and from underprivileged settings, suggesting an undetected transmission among vulnerable populations, especially females. Survival estimates of HTLV-1 carriers with non-ATL neoplasms were lower than the regional outcomes. Future research should ascertain how the biology of HTLV-1 and health care disparities affect the outcomes of HTLV-1 carriers, as well as determine the burden of HTLV-1 infection in the cancer population to recommend screening in the outpatient setting of endemic regions.

Epidemiological Characteristics of Deaths from COVID-19 in Peru during the Initial Pandemic Response

BACKGROUND AND AIM

Peru is the country with the highest mortality rate from COVID-19 globally, so the analysis of the characteristics of deaths is of national and international interest. The aim was to determine the epidemiological characteristics of deaths from COVID-19 in Peru from 28 March to 21 May 2020.

METHODS

Deaths from various sources were investigated, including the COVID-19 Epidemiological Surveillance and the National System of Deaths (SINADEF). In all, 3851 deaths that met the definition of a confirmed case and had a positive result of RT-PCR or rapid test IgM/IgG, were considered for the analysis. We obtained the epidemiological variables and carried out an analysis of time defined as the pre-hospital time from the onset of symptoms to hospitalization, and hospital time from the date of hospitalization to death.

RESULTS

Deaths were more frequent in males (72.0%), seniors (68.8%) and residents of the region of Lima (42.7%). In 17.8% of cases, the death occurred out-of-hospital, and 31.4% had some comorbidity. The median of pre-hospital time was 7 days (IQR: 4.0-9.0) and for the hospital time was 5 days (IQR: 3.0-9.0). The multivariable analysis with Poisson regression with robust variance found that the age group, comorbidity diagnosis and the region of origin significantly influenced pre-hospital time; while sex, comorbidity diagnosis, healthcare provider and the region of origin significantly influenced hospital time.

CONCLUSION

Deaths occurred mainly in males, seniors and on the coast, with considerable out-of-hospital deaths. Pre-hospital time was affected by age group, the diagnosis of comorbidities and the region of origin; while, hospital time was influenced by gender, the diagnosis of comorbidities, healthcare provider and the region of origin.

Impact of cancer awareness campaigns in Peru: a 5-year Google Trends analysis

Background

The aim of this research was to characterise the interest on the most frequent cancers in Peru through Google Trends, its geographic and temporal relationship with massive awareness campaigns.

Methods

A temporal trends analysis for the last 5 years was carried out, comparing the Relative Search Volume (RSV) with the dates of mass cancer awareness campaigns in Peru. Google Trends application was used to evaluate the interest in the topics: breast, prostate, cervical stomach and colorectal cancer between 1 January 2016 and 31 December 2020, expressed in RSV. The annual RSV for each neoplasm was compared, as well as its annual variation using the Kruskal-Wallis test. The correlation between the RSV and the estimated incidence for each province was measured using the Spearman test.

Results

The topics with the highest RSV were breast (median: 20, range: 6-100) and prostate cancer (median: 28, range: 9-48). The topic 'breast cancer' showed a cyclical punctual increase in October, its awareness month. Searches for cervical, stomach and colorectal cancer were smaller and did not show peaks of interest. It was observed that the RSV was variable when compared with previous years (p < 0.05 for all the evaluated topics). Geographically, different provincial configurations of interest were observed according to neoplasia. When correlating the RSV with the incidence by province, a non-significant positive correlation (p > 0.05) was found for breast, cervical and colorectal cancer.

Conclusions

This study suggests a positive temporal correlation between RSV and awareness cancer campaigns in Peru specially to breast cancer and, to a lesser extent, prostate cancer. Significant variations of interest were demonstrated for each neoplasm among the evaluated years. No significant correlation was found between the incidence rate and the average RSV among Peruvian provinces.

Exposure assessment of 170 pesticide ingredients and derivative metabolites in people from the Central Andes of Peru

The Central Andes of Peru are a region of great concern regarding pesticide risk to the health of local communities. Therefore, we conducted an observational study to assess the level of pesticide contamination among Andean people. Analytical chemistry methods were used to measure the concentrations of 170 pesticide-related compounds in hair samples from 50 adult Andean subjects living in rural and urban areas. As part of the study, a questionnaire was administered to the subjects to collect information regarding factors that increase the risk of pesticide exposure. Our results indicate that Andean people are strongly exposed to agrochemicals, being contaminated with a wide array of pesticide-related compounds at high concentration levels. Multivariate analyses and geostatistical modeling identified sociodemographic factors associated with rurality and food origin that increase pesticide exposure risk. The present study represents the first comprehensive investigation of pesticide-related compounds detected in body samples collected from people living in the Central Andes of Peru. Our findings pinpoint an alarming environmental situation that threatens human health in the region and provide a rationale for improving public policies to protect local communities.

Radiology volunteers to support a breast cancer screening program in Peru: Description of the project, preliminary results, and impressions

Breast cancer is the second most common cancer in Peruvian women. Due to limitations in national breast cancer screening programs, especially in rural areas, more than 50% of cases of breast cancer in Peru are diagnosed in advanced stages. In collaboration with a local clinic registered as a nongovernmental organization (CerviCusco), RAD-AID International aims to create a sustainable diagnostic structure to improve breast cancer screening in Cuzco. With the support of local, national, and international partners that have collaborated in analyzing radiological resources, raising awareness in the population, acquiring equipment, training clinical staff, and building referral networks, our teams of radiologists, included in the RAD-AID team, have participated in training CerviCusco staff in breast ultrasound, thus enabling additional training for radiology residents through a regulated international collaboration.

Cost of community-based human papillomavirus self-sampling in Peru: A micro-costing study

Background

Cost data of human papillomavirus (HPV) self-sampling programs from low-and-middle-income countries is limited. We estimated the total and unit costs associated with the Hope Project, a community-based HPV self-sampling social entrepreneurship in Peru.

Methods

We conducted a micro-costing analysis from the program perspective to determine the unit costs of (1) recruitment/training of community women (Hope Ladies); (2) Hope Ladies distributing HPV self-sampling kits in their communities and the laboratory testing; and (3) Hope Ladies linking screened women with follow-up care. A procedural manual was used to identify the program's activities. A structured questionnaire and in-depth interviews were conducted with administrators to estimate the resource/time associated with activities. We obtained unit costs for each input previously identified from budgets and expenditure reports.

Findings

From November 2018 to March 2020, the program recruited and trained 62 Hope Ladies who distributed 4,882 HPV self-sampling kits in their communities. Of the screened women, 586 (12%) tested HPV positive. The annual cost per Hope Lady recruited/trained was $147·51 (2018 USD). The cost per HPV self-sampling kit distributed/tested was $45·39, the cost per woman followed up with results was $55·64, and the cost per HPV-positive woman identified was $378·14. Personnel and laboratory costs represented 56·1% and 24·7% of the total programmatic cost, respectively.

Interpretation

Our findings indicate that implementation of a community-based HPV self-sampling has competitive prices, which increases its likelihood to be feasible in Peru. Further economic evaluation is needed to quantify the incremental benefits of HPV self-sampling compared to more established options such as Pap tests.

Funding

Thomas Francis Jr. Fellowship provided funding for data collection. The Hope Project was funded by grants from Grand Challenges Canada (TTS-1812-21131), Uniting for Health Innovation, Global Initiative Against HPV and Cervical Cancer, University of Manitoba, and the John E. Fogarty International Center (5D43TW009375-05).

Peru - Progress in health and sciences in 200 years of independence

Peru celebrates 200 years of independence in 2021. Over this period of independent life, and despite the turbulent socio-political scenarios, from internal armed conflict to economic crisis to political instability over the last 40 years, Peru has experienced major changes on its epidemiological and population health profile. Major advancements in maternal and child health as well as in communicable diseases have been achieved in recent decades, and today Peru faces an increasing burden of non-communicable diseases including mental health conditions. In terms of the configuration of the public health system, Peru has also strived to secure country-wide optimal health care, struggling in particular to improve primary health care and intercultural services. The science and technology infrastructure has also evolved, although the need for substantial investments remains if advancing science is to be a national priority. Climate change will also bring significant challenges to population health given Peru's geographical and microclimates diversity. Looking back over the 200-years of independence, we present a summary of key advances in selected health-related fields, thus serving as the basis for reflections on pending agendas and future challenges, in order to look forward to ensuring the future health and wellbeing of the Peruvian population.

Resumen translated abstract

El Perú cumple 200 años de independencia en 2021. Durante estos dos siglos de vida independiente, junto con periodos sociales y políticos turbulentos, incluyendo un conflicto armado interno, hiperinflación y la inestabilidad política de los últimos 40 años, el Perú ha experimentado importantes cambios en su perfil epidemiológico con repercusiones directas en la salud de la población. En las últimas décadas, los indicadores de salud materno-infantil y de las enfermedades transmisibles muestran mejoría importante, pero el país se enfrenta de manera simultánea a una carga cada vez mayor de enfermedades no transmisibles y de salud mental. En cuanto a los sistemas de salud pública, se han realizado esfuerzos por aumentar la cobertura y calidad de la atención de salud en todo el país, apostándose en particular por mejorar la atención primaria. La ciencia y tecnología relacionadas con la salud también han mejorado, aunque si se quiere que la ciencia sea una prioridad nacional, son necesarias inversiones sustanciales. El cambio climático traerá importantes desafíos para la salud de la población, dada la diversidad geográfica y de microclimas del país. Para conmemorar los 200 años de vida independiente del Perú, presentamos un resumen de avances clave en diversas áreas y temas relacionados con la salud. Este repaso sirve como base para reflexionar sobre agendas y desafíos pendientes y futuros, con el fin de asegurar la salud y el bienestar de la población peruana en las próximas décadas.

A preoperative nomogram for predicting long-term survival after resection of large hepatocellular carcinoma (>10 cm)

BACKGROUND

It has previously been demonstrated that a fraction of patients with hepatocellular carcinoma (HCC) > 10 cm can benefit from liver resection. However, there is still a lack of effective decision-making tools to inform intervention in these patients.

METHODS

We analysed a comprehensive set of clinical data from 234 patients who underwent liver resection for HCC >10 cm at the National Cancer Institute of Peru between 1990 and 2015, monitored their survival, and constructed a nomogram to predict the surgical outcome based on preoperative variables.

RESULTS

We identified cirrhosis, multifocality, macroscopic vascular invasion, and spontaneous tumour rupture as independent predictors of survival and integrated them into a nomogram model. The nomogram's ability to forecast survival at 1, 3, and 5 years was subsequently confirmed with high concordance using an internal validation. Through applying this nomogram, we stratified three groups of patients with different survival probabilities.

CONCLUSION

We constructed a preoperative nomogram to predict long-term survival in patients with HCC >10 cm. This nomogram is useful in determining whether a patient with large HCC might truly benefit from liver resection, which is paramount in low- and middle-income countries where HCC is often diagnosed at advanced stages.

Policy Considerations to Promote Equitable Cervical Cancer Screening and Treatment in Peru

Background:

Cervical cancer is one of the leading causes of death among Peruvian women. Women seeking screening or treatment services experience delays in receiving screening results provided at community clinics or district hospitals, and lack sufficient resources to pay out-of-pocket to travel to the capital city of Lima for specialized treatment. Continued disparities in health outcomes and systemic barriers to accessing services suggest there are gaps between policy measures and implementation.

Objectives:

We aim to understand why national policies and clinical pathways that are aligned to global standards have been insufficient in improving cervical cancer screening and treatment in Peru, particularly among women who experience systemic exclusion from health services.

Methods:

We conducted a policy analysis based on a literature review (2005–2020), in Spanish and English, on PubMed, Global Health, Scopus, EconLit, Lilacs, and Scielo using a value-based care framework.

Findings:

The main barriers included unequal distribution of health infrastructure and health care workforce, and differences in access to health insurance. Additional barriers, including limited political will and support, limit efforts to prioritize the implementation of cervical cancer policies. We propose policy considersations in redesigning payment models, expanding healthcare workforce, generating costing and policy evidence, and reviewing policies for point-of-care technologies.

Conclusions and Recommendations:

The barriers identified in this literature review are applicable not only to cervical cancer care, but to primary health care in Peru. Systematic policy changes that address root causes of health inequities and are implemented at scale are needed to advance health reform efforts.

Radiology volunteers to support a breast cancer screening program in Peru: description of the project, preliminary results, and impressions

Breast cancer is the second most common cancer in Peruvian women. Due to limitations in national breast cancer screening programs, especially in rural areas, more than 50% of cases of breast cancer in Peru are diagnosed in advanced stages. In collaboration with a local clinic registered as a nongovernmental organization (CerviCusco), RAD-AID International aims to create a sustainable diagnostic structure to improve breast cancer screening in Cuzco. With the support of local, national, and international partners that have collaborated in analyzing radiological resources, raising awareness in the population, acquiring equipment, training clinical staff, and building referral networks, our teams of radiologists, included in the RAD-AID team, have participated in training CerviCusco staff in breast ultrasound, thus enabling additional training for radiology residents through a regulated international collaboration.

High altitude and cancer: An old controversy

Ecological studies have found that individuals that live at high altitude regions and in places where ultraviolet radiation is maximal, have lower rates of different types of cancer. However, there is evidence that in these same regions, genetic mutations that are prooncogenic, develop, as they are needed to increase human adaptability to hypoxic environments. Debate has arisen between researchers who consider high altitude environments as suitable for human longevity because of its protective effects against malignancies, and scientists that have reported an increased incidence of different type of cancers in these same regions. Evidence is presented that altitude is related to the development of genetic alterations in micro RNAs, p53 protein, lymphocyte activity, decrease in Fas Ligand and other proapoptotic molecules, as well as increase in prometastatic VGEF an HIF. Notwithstanding, higher vitamin D and ultraviolet B levels, and a better metabolic profile, taken together with lower pollution levels hves been related to lower incidence and mortality rates from malignancies in a series of epidemiological studies.

The role and utility of population-based cancer registries in cervical cancer surveillance and control

Population-based cancer registries (PBCR) are vital to the assessment of the cancer burden and in monitoring and evaluating national progress in cervical cancer surveillance and control. Yet the level of their development in countries exhibiting the highest cervical cancer incidence rates is suboptimal, and requires considerable investment if they are to document the impact of WHO global initiative to eliminate cervical cancer as a public health problem. As a starting point we propose a comprehensive cancer surveillance framework, positioning PBCR in relation to other health information systems that are required across the cancer control continuum. The key concepts of PBCR are revisited and their role in providing a situation analysis of the scale and profile of the cancer-specific incidence and survival, and their evolution over time is illustrated with specific examples. Linking cervical cancer data to screening and immunization information systems enables the development of a comprehensive set of measures capable of assessing the short- and long-term achievements and impact of the initiative. Such data form the basis of national and global estimates of the cancer burden and permit comparisons across countries, facilitating decision-making or triggering cancer control action. The initiation and sustainable development of PBCR must be an early step in the scale-up of cervical cancer control activities as a means to ensure progress is successfully monitored and appraised.

Challenges to Bringing Personalized Medicine to a Low-Resource Setting in Peru

We provide an overview of the challenges that low-resource setting cities are facing, including a lack of global implementation of cancer screening programs, accurate data and statistics that may aid the health authorities and guide future public health activities, as well as reorient strategies, interventions and budgets to promote lifestyles that help prevent disease. Current cancer care does not fully reflect ethnic, cultural, environmental and resource differences. Herein, we described a snapshot of the cancer mortality and morbidity from a hospital that cares a rural and low-income population from Peru, called Chimbote (316,966 inhabitants) and showed the limitation of access to oncological care and genetic services. The city is located in the region of Ancash, which is a department of Northern Peru. Of note, we identified a greater proportion of cancer cases than previously described, with a young age of onset and differential profile of the most frequent cancers. With the emergence of increasingly effective interventions, it becomes paramount that populations living in resource-limited settings have access to cancer services and participate in genetics and genomic research.

Prevalence of high-risk human papillomavirus genotypes in two regions of Peru

OBJECTIVE

This study aims to discover the most prevalent high-risk (hr) HPV genotypes in the regions of Loreto and La Libertad, Peru.

METHODS

In 2015, cervical cell samples were collected during pelvic examinations from women in the geographically distinct regions of Loreto and La Libertad, Peru. In 2017, additional samples were collected in La Libertad. A total of 429 women between the ages of 18 and 65 years living in these regions were enrolled in the study. All samples were analyzed by polymerase chain reaction for the hrHPV genotypes 16, 18, and 35.

RESULTS

Sample collection from 126 women in 2015 in Loreto revealed an hrHPV incidence of 15.9% (20 of 126), with 60% (12 of 126) of HPV infections due to hrHPV 16. Samples from La Libertad revealed an hrHPV incidence of 14.5% incidence (44 of 303) (among 303 women). Of these infections, 38% (17) were attributable to hrHPV type 35 and 20% (9) were due to hrHPV type 16.

CONCLUSION

The prevalence of hrHPV genotypes in Peru may differ from those observed in North America and Europe. Loreto appears to follow the prevalence trend observed in North America, with hrHPV type 16 accounting for the majority of cases. However, hrHPV type 35 may account for a greater contribution to the cervical cancer burden in La Libertad. Further research, specifically on cervical tumor specimens, is needed.

Cervical cancer mortality in Peru: regional trend analysis from 2008-2017

BACKGROUND

Cervical cancer is the third leading cause of cancer-related death among Latin American women. Peru has the sixth highest mortality rate for cervical cancer in the region with regional variations. We aimed to determine overall and regional cervical cancer mortality rates and trends in Peru between 2008 and 2017.

METHODS

We performed an ecological study on the number of deaths by cervical cancer in Peru. Deaths were extracted from the Peruvian Ministry of Health mortality database. Age-standardized mortality rates (ASMR) were estimated per 100,000 women-years using the world standard Segi population. We computed mortality trends using the Joinpoint regression program, estimating the annual percent change (APC). For spatial analysis, GeoDA software was used.

RESULTS

Peru showed downward trends in the last decade (from 11.62 in 2008 to 9.69 in 2017 (APC = - 2.2, 95% CI: - 4.3, - 0.1, p < 0.05). According to regional-specific analysis, the highest ASMR was in the rainforest region, although this declined from 34.16 in 2008 to 17.98 in 2017 (APC = - 4.3, 95% CI: - 7.2, - 1.3, p < 0.01). Concerning spatial analysis and clustering, the mortality rates from 2008 to 2017 showed a positive spatial autocorrelation and significant clustering (Moran's I: 0.35, p < 0.001) predominantly in the neighboring North-East departments (Loreto, Ucayali, and San Martin).

CONCLUSIONS

Although mortality trends in the entire population are decreasing, mortality rates remain very high, mainly in the rainforest region. Our results encourage a need for further development and improvement of the current health care delivery system in Peru.

Progress, challenges and ways forward supporting cancer surveillance in Latin America

Population-based cancer registries (PBCRs) are the only means to provide reliable incidence and survival data as a basis for policy-making and resource allocations within cancer care. Yet, less than 3% and 10% of the respective populations of Central America and South America are covered by high-quality cancer registries. The Global Initiative for Cancer Registry Development provides support to improve this situation via the International Agency for Research on Cancer Regional Hub for Latin America. In this paper, we summarize activities (advocacy, technical assistance, training and research) over the last 5 years, their impact and current challenges, including the implementation of new PBCR in four countries in the region. Despite the favorable political support to cancer registration in many countries, the sustainability of cancer registration remains vulnerable. Renewed efforts are needed to improve data quality in Latin America while ensuring maximum visibility of the data collected by disseminating and promoting their use in cancer control.

Berberine Improves Chemo-Sensitivity to Cisplatin by Enhancing Cell Apoptosis and Repressing PI3K/AKT/mTOR Signaling Pathway in Gastric Cancer

Gastric cancer is one of the most common malignancies ranks as the second leading cause of cancer-related mortality in the world. Cisplatin (DDP) is commonly used for gastric cancer treatment, whereas recurrence and metastasis are common because of intrinsic and acquired DDP-resistance. The aim of this study is to examine the effects of berberine on the DDP-resistance in gastric cancer and explore the underling mechanisms. In this study, we established the DDP-resistant gastric cancer cells, where the IC₅₀ values of DDP in the BGC-823/DDP and SGC-7901/DDP were significantly higher than that in the corresponding parental cells. Berberine could concentration-dependently inhibited the cell viability of BGC-823 and SGC-7901 cells; while the inhibitory effects of berberine on the cell viability were largely attenuated in the DDP-resistant cells. Berberine pre-treatment significantly sensitized BGC-823/DDP and SGC-7901/DDP cells to DDP. Furthermore, berberine treatment concentration-dependently down-regulated the multidrug resistance-associated protein 1 and multi-drug resistance-1 protein levels in the BGC-823/DDP and SGC7901/DDP cells. Interestingly, the cell apoptosis of BGC-823/DDP and SGC-7901/DDP cells was significantly enhanced by co-treatment with berberine and DDP. The results from animals also showed that berberine treatment sensitized SGC-7901/DDP cells to DDP in vivo. Mechanistically, berberine significantly suppressed the PI3K/AKT/mTOR in the BGC-823/DDP and SGC-7901/DDP cells treated with DDP. In conclusion, we observed that berberine sensitizes gastric cancer cells to DDP. Further mechanistic findings suggested that berberine-mediated DDP-sensitivity may be associated with reduced expression of drug transporters (multi-drug resistance-1 and multidrug resistance-associated protein 1), enhanced apoptosis and repressed PI3K/AKT/mTOR signaling.

Breast cancer mortality trends in Peruvian women

BACKGROUND

Breast cancer (BC) is the most common malignancy in Latin American women, but with a wide variability with respect to their mortality. This study aims to estimate the mortality rates from BC in Peruvian women and to assess mortality trends over 15 years.

METHODS

We calculated BC age-standardized mortality rate (ASMR) per 100,000 women-years using the world standard SEGI population. We estimated joinpoint regression models for BC in Peru and its geographical areas. The spatial analysis was performed using the Moran's I statistic.

RESULTS

In a 15-year period, Peru had a mortality rate of 9.97 per 100,000 women-years. The coastal region had the highest mortality rate (12.15 per 100,000 women-years), followed by the highlands region (4.71 per 100,000 women-years). In 2003, the highest ASMR for BC were in the provinces of Lima, Arequipa, and La Libertad (above 8.0 per 100,000 women-years), whereas in 2017, the highest ASMR were in Tumbes, Callao, and Moquegua (above 13.0 per women-years). The mortality trend for BC has been declining in the coastal region since 2005 (APC = - 1.35, p < 0.05), whereas the highlands region experienced an upward trend throughout the study period (APC = 4.26, p < 0.05). The rainforest region had a stable trend. Spatial analysis showed a Local Indicator of Spatial Association of 0.26 (p < 0.05).

CONCLUSION

We found regional differences in the mortality trends over 15 years. Although the coastal region experienced a downward trend, the highlands had an upward mortality trend in the entire study period. It is necessary to implement tailored public health interventions to reduce BC mortality in Peru.

The contribution of specific non-communicable diseases to the achievement of the Sustainable Development Goal 3.4 in Peru

Background

Non-communicable diseases (NCDs) have received political attention and commitment, yet surveillance is needed to measure progress and set priorities. Building on global estimates suggesting that Peru is not on target to meet the Sustainable Development Goal 3.4, we estimated the contribution of various NCDs to the change in unconditional probability of dying from NCDs in 25 regions in Peru.

Methods

Using national death registries and census data, we estimated the unconditional probability of dying between ages 30 and 69 from any and from each of the following NCDs: cardiovascular, cancer, diabetes, chronic respiratory diseases and chronic kidney disease. We estimated the contribution of each NCD to the change in the unconditional probability of dying from any of these NCDs between 2006 and 2016.

Results

The overall unconditional probability of dying improved for men (21.4%) and women (23.3%). Cancer accounted for 10.9% in men and 13.7% in women of the overall reduction; cardiovascular diseases also contributed substantially: 11.3% in men) and 9.8% in women. Consistently in men and women and across regions, diabetes moved in the opposite direction of the overall reduction in the unconditional probability of dying from any selected NCD. Diabetes contributed a rise in the unconditional probability of 3.6% in men and 2.1% in women.

Conclusions

Although the unconditional probability of dying from any selected NCD has decreased, diabetes would prevent Peru from meeting international targets. Policies are needed to prevent diabetes and to strengthen healthcare to avoid diabetes-related complications and delay mortality.

Actualización en cáncer colorrectal hereditario y su impacto en salud pública

Los avances en la investigación clínica, genética y molecular del cáncer colorrectal (CCR) realizados durante los últimos años han permitido su detección temprana, así como su tratamiento oportuno. Sin embargo, uno de los mayores desafíos de esta enfermedad es su naturaleza heterogénea y la participación de diversas vías moleculares en su carcinogénesis. La implementación de las tecnologías ómicas —como la genómica, la proteómica, la transcriptómica y la epigenómica— en la investigación biomédica de pacientes con CCR hereditario ha permitido identificar nuevos genes o polimorfismos de nucléotido único (SNP, por su sigla en inglés) que afectan la expresividad del cáncer.Por otra parte, las herramientas bioinformáticas han contribuido a generar nuevas hipótesis sobre el CCR, orientando el abordaje de estos pacientes hacia una medicina personalizada. Este avance científico y tecnológico tiene un impacto en la salud, tanto a nivel individual como colectivo, por lo que es importante reflexionar sobre la viabilidad de desarrollar estrategias de salud pública para la implementación de un programa integral y genético de prevención y manejo del cáncer en Perú, en especial del CCR hereditario.

Cancer disease progression and death during the COVID-19 pandemic: a multidisciplinary analysis for the Peruvian setting

Since the COVID-19 pandemic began in China in late 2019, infection from the SARS-CoV-2 virus has spread virtually worldwide. This infection has adversely affected several countries; governments have outlined a series of political measures aimed to preserve the health and safety of their populations. In Peru, most actions have prioritised COVID-19 attention, with a subsequent gap in the healthcare facilities needed for other diseases. Cancer, one principal cause of death in the country, is usually diagnosed late. Moreover, in the pandemic context, the prevention and control of cancer have been negatively affected. Therefore, we carried out a multidisciplinary analysis using the Ishikawa diagram to identify the probable factors that contribute to cancer progression and deaths in Peru.

Cancer-related mortality in Peru: Trends from 2003 to 2016

OBJECTIVES

In the last decade, Latin American (LA) countries, like Peru, have undergone an epidemiological transition that has changed the pattern of oncological cases. Given that Peru's oncological pattern could illustrate those of other LA countries, we aimed at determining trends and changes in cancer-related mortality by age and sex in Peru between 2003 and 2016.

METHODS AND RESULTS

A secondary data analysis using national deaths registries was conducted. Categories were created according to the 27 most frequent sites of presentation of cancer. We found that deaths attributed to cancer increased from 15.4% of all deaths in 2003 to 18.1% in 2016 (p<0.001). According to the cancer site, stomach cancer (19.1%) and lung cancer (11.5%) were the most frequent causes of death overall. In childhood (0 to 14 years), the two most frequent fatal cancers were leukemia (54.6% for boys and 53.5% for girls) and brain and nervous system tumors (19.4% for boys and 20.3% for girls). For teenagers and young male adults (15-49 years), stomach cancer (18.1%) and brain cancer (17.4%) were the leading causes of death; in their female counterparts, cervix uteri (20.0%) and breast cancer (16.1%) were the most mortal cancers. In adults (≥50 years), stomach (20.9% for men and 18.6% for women) and lung (12.7% for men and 10.4% for women) were the leading contributors to the burden of cancer deaths.

CONCLUSIONS

Between the years 2003 and 2016, almost one fifth of deaths were attributed to cancer in Peru. Absolute and relative number of deaths due to cancer has increased in this period for both men and women; however, standardized mortality rates due to cancer have declined.

Gastric Cancer Mortality Trends in the Southern Cone: Disentangling age, period and cohort patterns in Argentina and Chile

Although Argentina and Chile are neighboring countries, gastric cancer (GC) is the first cancer death cause in the Chilean male population, while it is ranked in fifth place for Argentinean males. This study is the first to identify the differential time-patterns associated with the age-period-cohort effects for the last few decades (1990-2015) in these Southern Cone countries. Trends of age-standardized truncated mortality rates (ASMR) for GC were analyzed using log-linear Poisson age-period-cohort models, including cubic splines for each component. The ASMR trends for GC decreased in both sexes but more considerably in Chile and more favorably for males (annual percentage changes 2002-2015 = -3.5, 95%CI: -3.9 to -3.1). Moreover, GC age-specific mortality rates were noticeably higher in Chile. A favorable decreasing mortality risk throughout the periods (from 2000) and by cohort was observed for both countries; however, the risk reduction has stabilized in younger female cohorts since 1950-cohort. In conclusion, overall favorable decreasing trends for GC mortality were found; however, when age-period-cohort effects were disentangled, Chile and younger female cohorts showed a more unfavorable scenario. Obesity, lifestyles, and environmental conditions (like altitude) may explain country differences. This analytical approach may be a valuable tool to be replicated in other countries with no population-based cancer registries and acceptable mortality data quality.

Cancer cases detected in the prevention and control service of a private cancer clinic in Peru

Purpose

Describe the characteristics of patients seen at the Cancer Prevention and Control Service at a Peruvian private cancer clinic in 2014.

Patients and methods

This retrospective clinical study analyzed the prevalence of 10 cancers and characteristics of patients seen at a private cancer center located in Lima, Peru. The study sample included 7680 adults, and data were collected from de-identified medical records.

Results

The average age of the patients was 44.71 years and 98,82% of them had private insurance. The majority of patients were women (67.69%). Our gross incidence rate of cancer was 35.16 per 100,000 in the Cancer Prevention and Control Service in 2014. Only 0.35% had cancer, and most of those diagnosed with cancer (77.78%) were diagnosed in the early stages, stages I and II. The two most common cancers observed were breast and thyroid cancer.

Conclusions

The high rates of early, rather than late-stage diagnoses at this clinic are dramatically different than national rates. This difference may be because we are analyzing data from a prevention service seeing mainly patients with private insurance as opposed to national data, which consists primarily of patients seen in oncologic services with national insurance.

Helicobacter pylori: History and facts in Peru

Helicobacter pylori (H. pylori) is a cosmopolite bacteria and the main responsible for the high burden of gastric cancer in developing countries, such as Peru. In this review, we describe some historical facts in the H. Pylori discovery, the first researches of this bacterium in Peru, as well as its epidemiology, clinical characteristics, diagnosis, treatments, and outcomes. Our literature and review of real-life data suggest that several efforts should be conducted in our country to deal with antibiotic-resistance and lack of adherence to treatment in order to reduce our incidence of gastric cancer.

Trends and geographic pattern of stomach cancer mortality in Peru

BACKGROUND

Stomach cancer mortality rates in South America are among the highest in the world. In Peru, stomach cancer has the highest absolute number of cancer deaths in both sexes combined. We estimated mortality rates for stomach cancer in Peru by sex and geographical region between 2008 and 2015.

METHODS

We obtained death data for stomach cancer from the Peruvian Ministry of Health database. We estimated the age-standardized mortality rate (ASMR) per 100,000 persons using the direct method and the world standard population.

RESULTS

A total of 25,020 deaths from stomach cancer were identified in the study period. At national level, stomach cancer mortality rates (per 100,000 population) for men ranged from 9.8 in 2008 to 8.8 in 2015 with a percent change of -16%, and for women from 8.8 in 2008 to 7.7 in 2015 with a percent change of -16.8%. The highlands had the highest mortality rates overall, mainly in Huancavelica and Huánuco. The rainforest had the lowest rates and the highest decline in stomach cancer ASMRs. The coast displayed intermediate rates overall.

CONCLUSIONS

Within the study period, mortality rates from stomach cancer in Peru declined by 16%. The highlands had the highest mortality rates as compared to those from the coast or rainforest region. These geographical differences in mortality could reflect a different distribution in stomach cancer risk factors as the prevalence of H. pylori, poor dietary habits, low socioeconomic background of the Andean population and the lack of a decentralized health system.

Prostate cancer mortality rates in Peru and its geographical regions

OBJECTIVE

To evaluate the mortality rates for prostate cancer according to geographical areas in Peru between 2005 and 2014.

MATERIALS AND METHODS

Information was extracted from the Deceased Registry of the Peruvian Ministry of Health. We analysed age-standardised mortality rates (world population) per 100 000 men. Spatial autocorrelation was determined according to the Moran Index. In addition, we used Cluster Map to explore relations between regions.

RESULTS

Mortality rates increased from 20.9 (2005-2009) to 24.1 (2010-2014) per 100 000 men, an increase of 15.2%. According to regions, during the period 2010-2014, the coast had the highest mortality rate (28.9 per 100 000), whilst the rainforest had the lowest (7.43 per 100 000). In addition, there was an increase in mortality in the coast and a decline in the rainforest over the period 2005-2014. The provinces with the highest mortality were Piura, Lambayeque, La Libertad, Callao, Lima, Ica, and Arequipa. Moreover, these provinces (except Arequipa) showed increasing trends during the years under study. The provinces with the lowest observed prostate cancer mortality rates were Loreto, Ucayali, and Madre de Dios. This study showed positive spatial autocorrelation (Moran's I: 0.30, P = 0.01).

CONCLUSION

Mortality rates from prostate cancer in Peru continue to increase. These rates are higher in the coastal region compared to those in the highlands or rainforest.

Frequency and characteristics of gallbladder cancer at a referral hospital in southern Peru, 2009-2014: a descriptive study

INTRODUCTION

Gallbladder cancer is a rare neoplasm, its frequency is variable in the regions of Peru.

OBJECTIVE

To determine the frequency and describe the clinical characteristics of gallbladder cancer in southern Peru.

METHODS

The reports of the anatomopathological department of the Honorio Delgado Regional Hospital were selected from all samples of cholecystectomies performed between 2009 and 2014 and those that had some result compatible with gallbladder cancer were looked for. Subsequently, the clinical histories were searched to obtain the characteristics of these patients.

RESULTS

Of 2991 cholecystectomies, 75 (2.5%) had gall bladder cancer. The most frequent symptom in both groups was pain (96.7%), followed by nausea (87.5%) and vomiting (65.0%). The majority of patients were women (83.3%) older than 60 years (65.0%). The most frequent histological type was the adenocarcinoma (80.0%).

CONCLUSION

The frequency of gallbladder cancer in a reference hospital in southern Peru is 2.51%, higher than that reported in other studies in the central and northern regions of Peru.

The implementation of the Plan Esperanza and response to the imPACT Review

Following the implementation of the National Cancer Prevention and Control Results-based Budget Programme (PpR Cancer-024) in 2011, the Peruvian Government approved the Plan Esperanza-a population-based national cancer control plan-in 2012. Legislation that ensured full government-supported funding for people who were otherwise unable to access or afford care and treatment accompanied the Plan. In 2013, the Ministry of Health requested an integrated mission of the Programme of Action for Cancer Therapy (imPACT) report to strengthen cancer control in Peru. The imPACT Review, which was executed in 2014, assessed Peru's achievements in cancer control, and areas for improvement, including cancer control planning, further development of population-based cancer registration, increased prevention, early diagnosis, treatment and palliative care, and the engagement and participation of civil society in the health-care system. This Series paper gives a brief history of the development of the Plan Esperanza, describes the innovative funding model that supports it, and summarises how funds are disseminated on the basis of disease, geography, and demographics. An overview of the imPACT Review, and the government's response in the context of the Plan Esperanza, is provided. The development and execution of the Plan Esperanza and the execution of and response to the imPACT Review demonstrates the Peruvian Government's commitment to fighting cancer across the country, including in remote and urban areas.