3.

02
Dec, 15, 2017
PHILIPPINE CANCER CONTROL PROGRAM
3A Group 6
Department of Family and Community Medicine
Philippine Statistics
INTRODUCTION  Every day in the Philippines, there are 11 new cancer cases.
 Cancer is a generic term for a large group of diseases that can affect  Seven adults die of cancer every hour and eight children die of
any part of the body (WHO, 2017).Other terms used are malignant this disease every day.
tumours and neoplasms.  These alarming statistics, says the Cancer Coalition of the
 One defining feature of cancer is the rapid creation of abnormal Philippines (CCP), show that cancer is a “growing and serious
cells that grow beyond their usual boundaries, and which can then public health concern” in the country and that Congress should
invade adjoining parts of the body and spread to other organs, the give priority to the passage of a law that will increase survivorship
latter process is referred to as metastasizing. among Filipinos (Dizon, 2017).
 Metastases are a major cause of death from cancer.  Cancer incidence is increasing, and is ranked as one of the leading
causes of death among adults and children (Torre villas, 2017).
World Statistics  As of 2012, 189 out of 100,000 Filipinos are afflicted with cancer
 Cancer is the second leading cause of death globally, and was every years.
responsible for 8.8 million deaths in 2015 (WHO, 2017).  At least 3,900 children are diagnosed with cancer every year.
 Globally, nearly 1 in 6 deaths is due to cancer.  The Philippine Statistical Authority (PSA) reports that one in
 Approximately 70% of deaths from cancer occur in low- and middle- every registered death in the country is attributable to cancer.
income countries.  Since 2004, cancers have been the third leading cause of
 Around one third of deaths from cancer are due to the 5 leading death following cardiovascular disease; for child mortality
behavioral and dietary risks: and morbidity, cancer ranked 4th.
1. high body mass index  Survival rates for the most common adult cancers (i.e. lung,
2. low fruit and vegetable intake breast, color, cervical, prostate, liver) are relatively low compared
3. lack of physical activity to other countries in Asia and the world.
4. tobacco use  For females, in all cancer mortality rate, the Philippines ranks
5. alcohol use second highest among 15 counties in Asia, with 124 deaths per
 Tobacco use is the most important risk factor for cancer and is 100,000 population. Compared to Asian countries, the Philippines
responsible for approximately 22% of cancer deaths. has the highest mortality rate for two types of cancer: breast (27
 Cancer causing infections, such as hepatitis and human papilloma per 100,000 population) and prostate cancer (13 per 100,000
virus (HPV), are responsible for up to 25% of cancer cases in low- population).
and middle-income countries.  Lung cancer mortality rates are also high exceeding 40 per
 In 2012, there were an estimated 14.1 million new cases of cancer in 100,000.
the world:  For breast cancer, the Philippines also has the lowest survival (.58
 7.4 million (53%) in males mortality to incidence ratio).
 6.7 million (47%) in females  For childhood cancers, which now has an average survival rate of
 Male:female ratio of 10:9 84 percent in high income countries and a growing number of
 There was a rise in the incidence compared with 12.7 million new middle income countries, average survival rate in the Philippines
cases in 2008. is at a low 30 percent (Torrevillas,2017).
 There are 8.2 million cancer-related deaths in 2012 compared with  Over the period of 1942 to 1996, communicable disease mortality
7.6 million in 2008. has shown a gradually decreasing trend, in contrast to the
 World age-standardized (AS) incidence rate: increasing trends of heart disease and cancer (NCD) in the
 205 new cancer cases for every 100,000 men Philippines.
 165 new cancer cases for every 100,000 women  75% of all cancers occur after age 50 years, and only about 3%
 Incidence rates also vary by human development index (HDI) occur at age 14 years and below.
values.  If the current low cancer prevention consciousness persists, it is
 Males - rates vary around 3-fold between very high HDI countries estimated that for every 1800 Filipinos, one will develop cancer
(316 cases per 100,000) and low HDI countries (103 cases per annually.
100,000)  At present, most Filipino cancer patients seek medical advice only
 Females - rates vary around 2-fold between very high HDI countries when symptomatic or at advanced stages.
(253 cases per 100,000) compared to low HDI countries (123 cases  for every 2 new cancer cases diagnosed annually, one will die
per 100,000) within the year
 More than half of all cancers (56.8%) and cancer deaths (64.9%) in  According to philstar, Colorectal cancer (CRC) is currently
2012 occurred in less developed regions of the world. number one gastrointestinal cancer in the Philippines,
 Worldwide, it is estimated that there were 32.5 million men and overtaking liver cancer, an expert said (Afinidad-Bernardo,
women still alive in 2012, up to 5 years after their diagnosis. 2017).
 The most common causes of cancer death worldwide are cancers  Philippine Society of Gastroenterology or PSG's recent data shows
of (WHO, 2017): that there are over 3,000 new cases of CRC among Filipinos
1. Lung (1.69 million deaths) annually. Of these more than 3,000, over 2,000 die, and these are
2. Liver (788 000 deaths) only based on reported cases.
3. Colorectal (774 000 deaths)  Just last year, a global research even found out that the
4. Stomach (754 000 deaths) Philippines has the highest increase in mortality among the 37
5. Breast (571 000 deaths) countries surveyed. This means, he said, that CRC patients in the
Philippines die faster than those in other countries.

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d. Establishment of National Cancer Center and Strategic

Satellite Cancer Centers
e. Expansion of PhilHealth Z Benefit Package Coverage to Other
Cancer.
PhilHealth Z-Benefit Package for catastrophic
diseases (breast, prostate, cervical cancers and
childhood acute lymphocytic leukemia) is an in-
patient package which includes mandatory
diagnostics, operating room expenses,
doctor/professional fees, room and board, and
medicines.
2. Advocacy and Promotions
a. Cancer Awareness Campaigns
 National Cancer Consciousness Week – January
 Colon and Rectal Cancer Awareness Month – March
 Cancer in Children Awareness Month – April
 Cervical Cancer Awareness Month – May
 Prostate Cancer Awareness Month – June
 Lung Cancer Awareness Month – August
Table 1. Ten leading causes of death in the Philippines (per  Liver Cancer Awareness Month – September
100,000 populations)  Breast Cancer Awareness Month – October
 Cancer Pain Awareness Month - November
PHILIPPINE CANCER CONTROL PROGRAM (PCCP) b. Partnership with DepEd, CHED, DOLE-Bureau of Working
 Over the period of 1942 to 1996, communicable disease mortality Conditions, and Civil Service Commission
has shown a gradually decreasing trend, in contrast to the
increasing trends of heart disease and cancer (non-communicable 3. Capacity Building and Resource Mobilization
diseases) in the Philippines. a. Training of Trainers on Cervical Cancer Prevention and
 Seventy-five percent (75%) of all cancers occur after age 50 years, Control
and only about 3% occur at age 14 years and below. b. Training of Trainers on Palliative and Hospice Care
 If the current low cancer prevention consciousness persists, it is  Palliative and hospice care has been the missing link in
estimated that for every 1800 Filipinos, one will develop cancer our health care delivery system.
annually.  Our Universal Health Care or Kalusugan Pangkalahatan
 For every two new cancer cases diagnosed annually, one will die would not be complete without integrating palliative
within the year. and hospice care into the existing promotive–
 A systematic, organized and integrated approach towards the preventive–curative-rehabilitative continuum of care.
control of cancer which can significantly alter or reduce  It is therefore imperative to institutionalize and
morbidity and mortality utilizing primary, secondary integrate palliative and hospice care both in the
(community level) and tertiary prevention in the different hospitals or health facilities and in community or home-
regions of the country aside from rehabilitation activities at based level.
both hospital and community levels. c. Training of Trainers on Patient Navigation Program
 It was on the premise that cancer can be largely prevented mainly as  Patient Navigation Program / Medicine Access
a public health effort that the PCCP was established. Program: It provides chemotherapy for early stage
 The first phase of program implementation was conducted in 1988, breast cancer and acute lymphocytic leukemia and
providing the guidelines for the PCCP, specifying program policy, other diagnostic standard procedures for eligible
components, implementing guidelines and timetable. patients at no cost.
 Goal: to establish and maintain a system that integrates scientific  This project involves seven (7) government hospitals,
progress and its practical applications into a comprehensive namely: Philippine General Hospital, Jose Reyes
program that will reduce cancer morbidity and mortality in the Memorial Medical Center, East Avenue Medical Center,
Philippines. Rizal Medical Center, Amang Rodriguez Memorial
 In response to this growing and alarming epidemic of cancer, there Medical Center, Philippine Children’s Medical Center
is a need to revisit and strengthen the Philippine Cancer Control and Bicol Regional Training and Teaching Hospital.
Program which started in 1990 through Administrative Order No.
89-A s. 1990, amending A.O. No. 188-A s. 1973. Hence, the National 4. Service Delivery
Cancer Control Committee (NCCC) developed the National Cancer a. Availability of Free Cervical Cancer Screening in all trained
Prevention and Control Action Plan (NCPCAP) 2015-2020. RHUs
b. Availability of cryotherapy equipment in every province (81
National Cancer Prevention and Control Action Plan (NCPCAP) 2015- provinces)
2020. c. Availability and accessibility of screenings for selected
 The National Cancer Prevention and Control Action Plan 2015-2020 cancers in all trained RHUs
shall cover the following key areas of concern: d. School-based HPV vaccination of 9 to 13-year-old females
e. Hepatitis B vaccination for all health workers nationwide
1. Policy and Standards Development
a. Development of “National Policy on the Integration of 5. Information Management and Surveillance
Palliative and Hospice Care into the Philippine Health Care a. Establishment of National Cancer Registry (hospital- and
System” population-based)
b. Development and Operationalization of National Cancer b. Development and Operationalization of Cancer Helpline
Prevention and Control Website and Social Media Sites (including Telemedicine)
c. Development of “Comprehensive National Policy on Cancer
Prevention and Control” 6. Research and Development

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a. Establishment of National Research and Development neoplasms per 100,000 population <47.7 47.7
Program for Cancer Control Objective 2: Risk factors associated with lifestyle diseases are
b. Research: Study on the Socio-Economic Burden and Impact reduced
Assessment of Cancer in the Philippines Prevalence rate of tobacco smoking among:
c. Determination of Cancer Incidence in the Philippines 2008-  General population
2013  Adolescents aged 13 to 15 years <34.8 34.8
 Adult male <15.0 15.0
Vision  Adult female <40.0 56.3
 Comprehensive Cancer Care and Optimized Cancer <8.6 12.1
Survival in 2025 Prevalence rate of alcohol intake among:
 Adolescents
Mission  Adults <30 30
 To reduce the impact of cancer and improve the  Older persons <46 46
wellbeing of Filipino people with cancer and their <22 22
families Objective 3: Early detection and screening for degenerative and
lifestyle related diseases is increased
Goals / Objectives Proportion of women of reproductive age
1. To reduce premature mortality from cancer by 25% in 2025 and older who practice monthly breast self- 50% 44%
2. To ensure relative reduction of the following risk factors for examination
cancer: Proportion of women 35 to 40 years old
a. 10% harmful use of alcohol who have breast examined by a physician 20% 5%
b. 10% physical inactivity every 1 to 3 years
c. 30% tobacco use Proportion of males aged 50 years and older
3. To guarantee the availability of the following services for submitting to digital rectal examination at 20% 2%
selected population: least every 3 years
a. Selected cancer screening Proportion of women 18 to 65 years old
b. Human Papilloma Virus and Hepatitis B vaccination who have 1 Pap smear or visual acetic acid 50% 5%
c. Access to palliative care screening at least every 3 years (Pap
d. Drug therapy and counselling smear)
Table 2. PROGRAM INDICATORS
Strategies
1. Promotion of healthy lifestyle 6 Pillars of PCCP
 Increase avoidance of the risk factors done in coordination  The Six Specific Objectives, also called the “6 PILLARS” of the PCCP
with the National Center for Health Promotion are:
 Vaccinate against Human Papilloma Virus (HPV) and Hepatitis
B Virus (HBV) not in nationwide scope but done by 1. Cancer Epidemiology & Research
professional societies among children who can afford HPV o To assess the impact of cancer in the community,
Vaccination elucidate causal factors, identify high risk groups, and
 Control occupational hazards done in coordination with the assess the effects of preventive and therapeutic
Environmental and Occupational Heath Office programmes.
 Reduce exposure to sunlight o To conduct relevant research on the Prevention,
2. Improve screening/diagnosis and treatment Diagnosis, and Treatment of cancer as well as Supportive
3. Improve rehabilitation and palliative Care Care and Rehabilitation of cancer patients.
4. Improve cancer registry 2. Public Information & Health Education
o To conduct continuing public information campaign on
Strategic objectives affected: the prevention and early detection of cancer.
 Reduce morbidity, mortality, and disability due to non- o Under this pillar, the National Cancer Consciousness
communicable diseases (NCDs) Campaign year-round is the primary strategy, which
 Enhance capacity of stakeholders in NCD prevention and includes the development and maintenance of an e-
control campaign against cancer.
 Ensure the development and implementation of evidence- 3. Cancer Prevention & Early Detection
based policies, standards, and guidelines o To carry out a multi-sectoral activity that will aim to
 Ensure relevant and efficient capability building promote relevant Cancer Prevention Programmes, as well
 Strengthen collaboration with stakeholders on NCD programs as the early detection of specific cancer types/ sites.
 Ensure reliable, timely, and complete data and researches o Under this pillar, the Cervical Cancer Screening Program
is an example.
Program Indicators 4. Cancer Treatment & Training (Strengthening Cancer
 The PCCP has three objectives: Treatment Capabilities of Regional Medical Centers)
1. Mortality from all forms of malignant neoplasms is reduced o To carry out a well-coordinated treatment program by
2. Risk factors associated with lifestyle diseases are reduced the various medical disciplines involved in the treatment,
3. Early detection and screening for degenerative and lifestyle supportive care and rehabilitation of cancer patients.
related diseases is increased. o To design and implement Training Courses related to all
 The corresponding indicators along with the targets and baselines aspects of Cancer Control for the personnel of the DOH
for each objective are presented in Table 2. and other institutions.
o Under this pillar, the oncology training programs in
Indicator Target Baseline medical oncology and radiotherapy were set up in Jose R.
Objective 1: Mortality from all forms of malignant neoplasms is Reyes Memorial Medical Center (a DOH hospital), Manila,
reduced to complement the training programs similarly given by
Mortality rate from all forms of malignant

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the University of the Philippines-Philippine General Top 10 Cancers Causing Mortality for Males
Hospital (a non-DOH hospital). Rank Cancer Type No. of cases
o This pillar includes provision of radiotherapy facilities in 1 LUNG 6987
strategic places over the country (Baguio & Cabanatuan in 2 Liver 5102
the North; Metro Manila; Cebu & Tacloban in Visayas; 3 Colon and Rectum 1690
Davao & Zamboanga in Mindanao).
4 Prostate 1410
o There is also a plan to strengthen pain clinics and hospice
care facilities in DOH hospitals in the country, for the 5 Leukemia 1340
implementation of the DOHCancer Pain Control Program. 6 Stomach 1381
o This also includes provision of anti-cancer drugs in 7 Brain/CNS 1069
oncology capable DOH hospitals. 8 Pharynx 804
o This also provides for the strengthening of screening & 9 Pancreas 598
early detection facilities of DOH hospitals. 10 Non-Hodgkin Lymphoma 389
5. Hospital Tumor Board & Tumor Registries
o Under this pillar, the Manila, Rizal, Davao, Cebu Top 10 Cancer Sites for Females
population-based cancer registries are currently ongoing. Rank Cancer Type No. of cases
o There is a mandate for development of Hospital Tumor
1 BREAST 12262
Registries of DOH hospitals.
o Hospital Tumor Boards are a must in surgery-training 2 Cervix 4812
accredited hospitals in the Philippines 3 Lung 2686
6. Cancer Pain Relief & Palliative Care 4 Colon and Rectum 2579
 DOH provides free morphine for indigent patients of its hospitals, in 5 Ovary 2165
addition to palliative and rehabilitation care beds within the medical 6 Liver 1809
wards of the hospital. 7 Uterine corpus 1760
8 Leukemia 1484
LEADING CANCER SITES IN THE PHILIPPINES 9 Thyroid 1474
Top 10 Cancer Sites for Both Sexes 10 Stomach 1209
Rank Cancer Type No. of cases
1 BREAST 12262 Top 10 Cancers Causing Mortality for Males
2 Lung 11458 Rank Cancer Type No. of cases
3 Liver 7331 1 BREAST 4371
4 Colon and Rectum 5787 2 Cervix 2197
5 Cervix 4812 3 Lung 1984
6 Leukemia 3153 4 Leukemia 1717
7 Stomach 3129 5 Liver 1370
8 Prostate 2712 6 Stomach 1228
9 Brain/CNS 2236 7 Colon rectum 1016
10 Ovary 2165 8 Brain/CNS 934
9 Ovary 796
Top 10 Cancers Causing Mortality for Both Sexes 10 Uterine corpus 450
Rank Cancer Type No. of cases
1 LUNG 9184 SUMMARY
2 Liver 6819 SEX CANCER TYPE
3 Breast 4371 Both sexes
4 Colon and Rectum 2609  Leading cancer site BREAST
5 Leukemia 2609  Leading cancer mortality LUNG
6 Stomach 2274 Males
7 Cervix 1984  Leading cancer site LUNG
8 Brain/CNS 1855  Leading cancer mortality LUNG
9 Prostate 1410 Females
10 Ovary 1016  Leading cancer site BREAST
 Leading cancer mortality BREAST
Top 10 Cancer Sites for Males
Rank Cancer Type No. of cases SPECIFIC CANCER PROGRAMS OF DOH
1 LUNG 8772 LUNG CANCER CONTROL PROGRAM
2 Liver 5522  Geared towards the control of lung cancer in reducing its morbidity
3 Colon and Rectum 3208 and mortality by utilizing primary prevention at the community
4 Prostate 2712 level (smoking control), secondary and tertiary prevention at special
5 Stomach 1920 medical centers and rehabilitation activities.
6 Leukemia 1669  It focuses on anti-smoking campaign (which covers 85% of all
7 Brain/CNS 1236 cancer site control campaign)
8 Pharynx 1145
9 Non-Hodgkin Lymphoma 982 Specific Objectives
10 Kidney 848  To inform/educate school children and adults on the hazards of
smoking and its known risk of developing cancer
 To prevent the onset of smoking and decrease the number of
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smokers  A 1/3 reduction in mortality for breast cancer has been attributed to
 To identify among Filipinos those at high risk of developing lung screening, hence the Breast cancer control program focuses in the
cancer (40 years old and above smokers) importance of screening procedures including BSE, clinical breast
exam and mammography
Anti-smoking campaign:
1. DOH Administrative Order No. 8 s. 1993: prohibited smoking in Department of Health (DOH) and Philippine Breast Cancer Society
the DOH and its premises; DILG followed suit in 2001. (PCBS) continue fight against Breast Cancer
2. Article 94 of Chapter IV of RA 7394: provides that all cigarettes
 Philippines topped other countries in Asia when it comes to the
for sale or distribution within the country shall be contained in a
number of cases of breast cancer. The “Pink Ribbon Day” was
package which shall bear the following statement or its equivalent
celebrated on October 22, 2017
in Filipino – ‘Warning: Cigarette Smoking is Dangerous to your
 Breast Cancer Awareness Month this October to encourage women
Health’.
to have their breasts examined for early detection and early
3. Republic Act 10351 or the “Sin Tax Reform Law”: increased the
intervention
excise taxes on cigarettes by about fourfold (341 percent) to reduce
its consumption
CERVIX UTERI CANCER CONTROL PROGRAM
4. Republic Act 10643 or the “Graphic Health Warnings Law”,
 Focuses on early detection and treatment, and healthy lifestyle
which adds photographs depicting the hazards of tobacco use
accompanied with textual warning in the product package which
Specific objectives:
aims to instill health consciousness through graphic health warnings
 To educate people about cervical cancer, its symptomatology,
on tobacco products
methods of early detection and preventive measures
5. EO 26 by Pres. Duterte nationwide-smoking ban and
 To screen at least 85% of women 25-55 years of age every 3 years
implementation of strict guidelines on designate smoking areas
using acetic acid wash
6. National Lung Month: Lung Cancer Awareness Month is
 To identify early lesions of cervical cancer
celebrated in the Philippines every August
 To establish a practical/ applicable referral system
BREAST CANCER CONTROL PROGRAM  To implement appropriate treatment protocol for the different
 Implementation of a nationwide anti-breast cancer scheme, i.e. public stages of cervical cancer
information and health education, case finding (secondary
prevention) and treatment (tertiary prevention) Program Activities include the following:
 It focuses on early detection and treatment, and healthy lifestyle 1. Public Information & Health Education
2. Professional Education o Primary prevention
Specific Objectives 3. Case-finding with use of acetic acid wash
 To inform or educate all women 30-60 years old on breast self- 4. Diagnosis with use of Pap smear and colposcopy
examination (BSE) and the importance of doing a regular monthly
5. Treatment
BSE
 To detect the maximum number of early stage breast cancer by 6. Research
offering yearly breast examination to all 30-60 years women
attending a health institution Proclamation No. 368, s.2003: celebrates Cervical Cancer Awareness
 To treat and/ or rehabilitate all detected cases Month during the month of May.

Program Strategies LIVER CANCER CONTROL PROGRAM

1. Full integration of the basic cancer control measures  Focuses on hepatitis B vaccination, in collaboration with
2. Operationalization of a bilateral referral system Immunization Program of the DOH.
3. Making more intensive use of IEC activities
4. Standardization recording and reporting with a built-in monitoring Several Governmental Legislations and Department of Health
and evaluating system Circulars:
5. Establishment of regular and frequent supervision, adopting post-  RA 7846 “Compulsory Hepatitis B immunization among infants and
surgical adjuvant chemotherapy regimen for six months for all children less than 8 years old”
premenopausal and hormonal receptor-negative post-menopausal o Goal was to reduce chronic infection of hepatitis B to<1%
patients as well as adjuvant hormonal regimen for 2-5 years for among birthcohorts from baseline levels of 10-12%
hormonal receptor positive postmenopausal patients  RA 10152 “Mandatory Infants and Children Health Immunization
6. Provision of adequate logistical support for public health and Act” – includes Hep B vaccine free to infants within 24 hrs of birth
hospital services  RA 10526 “Liver Cancer and Viral Hepatitis Awareness &
7. Making available breast examination training programs, residency Prevention Month Act” – declares January as liver cancer and viral
and post-residency training programs, hospital services and anti- hepatitis awareness and prevention month.
cancer drugs.

Case Finding - Breast Examination

 Investigation in literature indicates that screening appears to
protect against dying from breast cancer (relative risk of 0.30 to
0.48)

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COLON/RECTAL CANCER CONTROL PROGRAM o avoidance of risk factors

 Focuses on digital rectal exam/FOBT and healthy diet lifestyle, in o vaccination against HPV and HBV
collaboration with Nutrition Program of the DOH. o control occupational hazards
o reduction of exposure to sunlight
 improving screening/diagnosis and treatment
Healthy Lifestyles
 improving rehabilitation and palliative care
The following model shows the relationship between life-style  improve cancer registry
and degenerative or late-onset diseases, with particular emphasis on
cancer: FUTURE PLAN OF ACTION
 strengthen the implementation of an integrated lifestyle-related
disease control program
 maintain the operation of an integrated chronic non-
communicable disease registry system in all health facilities
 develop a service package for cancer control program
 develop clinical practice guidelines for cancer control program
 develop a strategic framework and five-year strategic plan for
cancer control program

COMMUNITY-BASED CANCER CARE NETWORK (CCCN)

 initiated in 1998
 a network of self-sufficient communities sharing responsibility for
cancer care and control in the country
 established in response to a call by the DOH-Philippine Cancer
Control Program for partnership initiatives at both the national and
 Indicates that unhealthy lifestyles (the 'Sinful Styles or SSs' - smoking local levels for joint program undertakings and resource sharing
to some unknown risky lifestyle) can lead to degenerative or late between concerned private and government institutions
onset diseases on a background of vulnerable genes (self) of the  built around the idea that when many organizations and individuals
individual, including cancer. pool their expertise, skills, resources and experience and cooperate
to reach a common goal, they become a powerful force
 envisioned to be a multi-sectoral strategic approach to improve and
Health Care Intervention Strategies in the diseases associated with risky
redesign the implementation strategy anti-cancer control/care in
lifestyles are: the Philippines
1. Information dissemination & Education campaign - avoidance of
 VISION: a self-sufficient network of empowered communities
lifestyle sharing responsibility for total quality cancer care and control in the
2. Counseling Philippines
3. Screening  MISSION: to organize, integrate and nurture such a network
4. Case-finding and Treatment  OBJECTIVES: to provide a venue to:
5. Disease-specific clinical management o continuously update government cancer control program
6. Rehabilitation implementers, oncology graduates and care givers on the
7. Supportive care advances and experiences in anti-cancer practice
(CONTINUING MEDICAL EDUCATION AND TRAINING)
CANCER PAIN RELIEF PROGRAM o establish a comprehensive community- and hospital-based
Filipino cancer patient data and information base, based on
 Concept that focuses on cancer pain relief and support groups,
the paradigm of quality care and evidenced-based care
rehabilitation & hospice care (MONITORING AND INFORMATION)
 Modified the WHO analgesic ladder, cutting the ladder from 3-step to a o serve as the Philippine Cooperative Cancer Study Group
2-step (skipping 2nd ladder - weak opioid) (RESEARCH AND EVALUATION); and
 Main analgesic concepts implemented are: use of oral drugs, allowing o provide continuity of cancer control/care from primary,
hospital discharge and home care, analgesics are given on a regular secondary, tertiary to hospice care, from the community to the
basis - 'by the clock', choice of analgesic agent given is 'by the ladder. hospital to the community (PUBLIC HEALTH AND CLINICAL
MANAGEMENT)
 CCCN is composed of local community-based cancer control groups
CURRENT INTERVENTIONS/STRATEGIES IMPLEMENTED BY DOH
called Local Cancer Control/Care Networks (LCCAN) or Nodes that
Package of Services will network with each other for a common goal. Each Node:
 free cervical cancer screening in 58 DOH hospitals, annually in the o Is expected to be self-sufficient and self-reliant
Month of May. This includes women ages 30-45 years
o will center on a tertiary government hospital
 free adjuvant chemotherapy for women with stage 1 to 3A
breast cancer in 4 pilot hospitals (Jose Reyes Memorial Medical o is composed of a network of satellites of NGOs, GOs and
Hospital, East Avenue Medical Center, Rizal Medical Center, UP- individuals
PGH), funded by DOH-NCPAM(National Center for Pharmaceutical  DOH-PCCP is the lead agency of the NCCN. Major cancer control-
Access and Management) related NGOs in the locality are the lead non-government agencies
 free chemotherapy for acute lymphocytic leukemia among  Year 2000: registry software called CCCN Hospital Tumor
children with cancer Registry was implemented by the CCCN in the different component
hospitals
Strategies
 promotion of healthy lifestyle

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PREVENTION AND CONTROL OF SPECIFIC CANCER SITES  Adjuvant treatment: increase survival, particularly in (+) axillary
Breast nodes
 2015: leading site for both sexes combined (19%), leading site  The kind of adjuvant treatment is determined by the hormone
among women (33%) receptor status (ER/PR-HER2/Neu)
 3rd leading cause of death due to cancer for both sexes (11%), and o Hormone receptor (+): adjuvant hormonal therapy
the highest among women (23%) o Hormone receptor (-): adjuvant chemotherapy
 At age 30, the incidence rate of breast cancer is said to rise o Hormone receptor (+) ADVANCED cancer: hormonal
steeply, and has been steadily rising since 1980 with an average therapy + judicious and cost-effective palliative care
annual percentage of 1.2%
Lung
Risk Factors  2nd leading cancer site for both sexes combined (13%) in 2015,
 Estrogen – major risk factor; the higher the exposure, the higher leading site in males (21%) and the 4th leading site among
the risk becomes females (6%)
 Early menarche and/or late menopause, nulliparous women, and  Since early detection and treatment is still difficult to achieve,
those with first pregnancy after the ageof 30 survival remains poor even in high-income countries
 Filipino women who have never been pregnant 5x at higher risk
than those with > or equal to 5 pregnancies Risk Factors and Prevention
 Women who went to college 2x the risk than those with minimal  Cigarette smoking, both first-hand and second-hand, is the major
education risk factor
 postmenopausal estrogen replacement therapy (HRT) increases  Other risk factors: family history of lung cancer, exposure to
the risk, especially when combined with continuous progestins asbestos and other chemicals (arsenic, chromium, nickel) and TB
 BRCA1 and BRCA2 gene mutations were present in up to 5% of  Prevention: smoking cessation and preventing non-smokers from
Filipino women with breast cancer being exposed to tobacco smoke
 family history of breast cancer, 2x the risk if there is one first-
degree relative diagnosed. If two first-degree relatives have been Warning Signs
diagnosed, the risk rises to 5x  persistent cough
 NO EFFECT ON THE RISK: OCPs  blood-streaked sputum
 chest pain
Lower Risk  recurrent episodes of pneumonia or bronchitis
 women who have had children and were breast-fed (lactational  hoarseness
amenorrhea)  arm or shoulder pain
 Removal of the ovaries before menopause  weakness
 Tamoxifen and other anti-estrogen drugs may prevent breast  weight loss.
cancer especially among high-risk women
Early Detection
Warning Signs  There is still NO effective early detection method for lung cancer
 Any breast lump particularly in women 30 years and older  Consequently, majority of patients with lung cancer are diagnosed at
 Breast cancer is generally painless; most common presentations an already advanced and incurable stage
are persistent breast changes such as a lump, thickening, swelling
or dimpling Treatment
 For a patient seen in early stage, which is occasional, surgery is
Early Detection the preferred curative treatment
 relatively easier to detect because in most cases, breast masses are  For the majority of cases, who are usually seen at an incurable
palpated by the patient herself stage, judicious and cost-effective palliative care
 Monthly self-breast examination and annual clinical/health
worker-breast examination are the mainstays of early detection in Liver
developing nations  leading site for both sexes in 2015, ranked 2nd among males (13%)
 Suspicious breast masses should be biopsied preferably by needle and 6th among females (4%)
aspiration. Needle aspiration biopsy is accurate, safe and  The incidence rates start to rise beginning at age 35 years among
economical and saves the patient from undergoing an open biopsy males, and 50 years among females
o CNB over FNB if hormone receptor assay is available
 It is the 2nd leading cause of cancer-related deaths in 2010 for both
o Provide information important for treatment options and
sexes.
decisions
 Screening mammography can detect cancers too small to be felt Risk Factors and Prevention
even by the most experienced examiner
 Viral infections: chronic active hepatitis, such as HBV and HCV
o However, not recommended by the WHO as screening
infection, are responsible for most primary liver cancer cases in the
method because of its high cost. Nevertheless, women 50 years
Philippines
and older are encouraged to undergo such on their own
 HBV is most prevalent. Infants and young children who get the
infection and become carriers are at higher risk for liver cancer
 Other factors:
Treatment
o heavy alcohol consumption
 Early breast cancer = primary lesion and the spread in the axillary
o cirrhosis
nodes can be completely removed through surgery, with NO
o diabetes
evidence of spread beyond these areas
o obesity
 Curative surgery for early breast cancer: modified radical
o aflatoxins
mastectomy
o certain inherited liver diseases (hemochromatosis and
 Small cancers: conservative surgery + radiotherapy to the breast Wilson’s disease)
 Most important prognosticator in early cancer: spread to axillary o vinyl chloride exposure
nodes; (+) axillary node  shortened survival o schistosomiasis.
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Warning Signs  In certain instances, adjuvant drugs and/or radiotherapy can

 abdominal pain increase survival
 weight loss  For advanced cases, judicious and cost-effective palliative care can
 weakness and offer an acceptable quality of life.
 loss of appetite, particularly in someone with liver cirrhosis or is a
known HBV carrier. Uterine Cervix
 In the Philippines, the incidence rate of cervix cancer starts rising
Early Detection steeply at age 30. From1980 to 2007, there was a slight decrease in
 There is still NO effective early detection method for liver cancer the incidence rate, with an annual change of - 0.5%.
 In 2010, cervical cancer was the 5th leading site for both sexes
Treatment combined, and the 2nd among women. It was the 7th leading cause
 For the occasional patient whose liver cancer is still small, surgery of cancer-related mortality for both sexes in 2010
can be curative
 For the majority of cases, who are usually seen in an incurable stage, Risk Factors and Prevention
judicious and cost-effective palliative care can provide an  Cervical cancer is highly preventable.
acceptable quality of life.  Human papilloma virus (HPV): sexually transmitted, can cause
chronic infection of the cervix and cancer
Colon and Rectal  The more numerous the sexual partners of the woman, or the
 In 2015, colon and rectal cancers combined were estimated to be woman’s male partner, the greater the risk of being exposed to
the 3rd leading cancer site for both sexes, 4th among males and the virus
3rd among females.  The prevalence of all HPV types is around 90% of both squamous
 The incidence rates begin to rise steeply at age 50 years in both cell carcinomas and adenocarcinomas. HPV 16 and 18 are the
males and females. From 1980 to 2007, the incidence rates rose most common types.
steadily with an annual increase of 1.3% for both sexes.  Prevention: safe sex, including the use of barrier protective devices
such as condoms, offers the best prevention.
Risk Factors and Prevention  Unfortunately, however, unprotected sexual behavior is still
 Major risk factors: personal or family history of colorectal cancer, practiced by the great majority of individuals. While the World
polyps in the colon or rectum, and inflammatory bowel disease Health Organization is strongly recommending condom use as an
 Lifestyle factors: diet, alcohol consumption and physical inactivity, effective method of preventing HIV/AIDS, the Catholic Church in
account for the differences in incidence globally the Philippines has been consistently in opposition.
 high-fat, low-fiber diet  increased risk  There needs to be a sustained national effort to raise awareness that
 Prevention: healthy lifestyle practices, particularly a healthy diet, safe sex protects against HIV/AIDS, other sexually transmitted
physical activity and decreased alcohol consumption decreases the diseases and cervical cancer. Due to the increasing number of
risk HIV/AIDS cases, the Department of Health is currently increasing
the efforts to make condoms widely available.
 colorectal cancer in the Philippines are NOT associated with
polyps.  HPV vaccines are now available in the Philippines and peri-
adolescent vaccination could be gaining ground among families that
Warning Signs can afford it.
 changes in the bowel habits: recurrent diarrhea and/or constipation
Warning Signs
 accompanied by abdominal discomfort, weight loss, unexplained
 Painless and irregular bleeding not associated with
anemia and blood in the stool
menstruation – intermenstrual, postcoital, post-douching, or
postmenopausal
Early Detection
 unusual vaginal discharge
 Early colon and rectal cancers: asymptomatic
 There is still no efficient method for population-screening
Early Detection
particularly in countries wherein majority of cancers are not
 The development of cervix cancer occurs in a stepwise fashion, with
associated with polyps (e.g. Philippines)
the cells looking progressively worse.
 Aim: early diagnosis of symptomatic patients who complain of
o Dysplasia almost invariably leads to frank cancer.
the above warning signs, particularly among patients who are 50
o If areas with dysplasia are discovered and removed, cervix
years and older
cancer can be prevented.
 By means of fecal occult blood test, digital rectal exam,
 In countries with long-standing cervix cancer screening programs,
protoscopy, protosigmoidoscopy, barium enema and
the incidence of cervix cancer had gone down, and a substantial
colonoscopy
portion of the decrease in incidence had been attributed to
 Public information and education and physician education are
screening.
equally vital.
 Highly effective screening for early detection: Papanicolau smear
o mistaken obsession of our physicians with amoebiasis,
(Pap smear)
other forms of infectious bowel diseases, and hemorrhoids
o (+) abnormal cells in the Pap smear  diagnostic procedure,
 delayed diagnosis of colon and rectum cancer.
such as colposcopy, and biopsy of the suspicious areas.
o wide availability of antidiarrheals, antibiotics, and
 American Cancer Society recommends that:
amoebicides results in their rampant and sometimes
o all women starting at age 21 should undergo screening
dangerous use
o For women aged 21-29 years, Pap smear should be done
o many physicians still insist on prescribing vitamin
every 3 years
preparations and hematinics for chronic unexplained weight
o For women 30-65 years old, co-testing (Pap smear and HPV
loss and anemia without exerting efforts to look for the cause.
testing) every 5 years, OR simply Pap smear every 3 years
o High risk women may be tested more frequently.
Treatment
o Women over 65 years of age who have had regular screening
 Early stage: curable by surgery
in the previous 10 years should stop cervical cancer screening
 small rectal lesions: radiotherapy is just as effective

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as long as they haven’t had any serious pre-cancers (like CIN2  Stomach cancer is the 7th leading site for both sexes (4%),
or CIN3) found in the last 20 years 5thamond males (5%) and 10th among females (3%) last 2010.
o Women with a history of CIN2 or CIN3 should continue to have
testing for at least 20 years after the abnormality was found. Risk Factors and Prevention
Women who have been vaccinated against HPV should still  linked to diet, particularly to the prolonged high consumption of
follow these guidelines. foodstuffs preserved or cured using salt, smoke, and certain
 Unfortunately, a national Pap smear screening program is not chemicals
inexpensive to establish and sustain, particularly if the required  A decrease in the consumption of such foods as a result of the
quality control measures are included. increased use of refrigeration is believed to be a major factor.
 Visual inspection with acetic acid wash (VIA) could be more  A diet low in fruits and vegetables resulting in a deficiency of
appropriate in primary and secondary health care facilities. some micronutrients has also been shown to increase the risk
 chronic gastritis caused by Helicobacter pylori may increase risk,
Treatment and the widespread practice of aggressive treatment for H. pylori
 With the use of the Pap smear or VIA, lesions that eventually lead to may be a contributory factor to the decrease in incidence.
cancer can be detected. These can then be diagnosed and removed  While there is no known specific preventive measure for
thereby preventing full blown cervical cancer. stomach cancer, maintaining a healthy diet rich in fruits and
 For early cervical cancer, either surgery or radiotherapy can be vegetables, and minimizing the intake of preserved or cured foods,
curative. is expected to decrease risk.
 The current suggested treatment is concurrent chemoradiation,
BUT: Warning Signs
o difficult for most women in the Philippines.  generally progresses silently to an advanced stage before symptoms
o Radiotherapy is available in only 21 facilities, 13 of which are alert a patient or a physician
in Metro Manila, although there are 104 members of the  indigestion, dyspepsia, loss of appetite, weakness and anemia
Philippine Radiation Oncology Society.  suggestive of an advanced stage: weight loss, difficulty in
o additional problems such as inappropriate dosimetry on swallowing, vomiting and a palpable upper abdominal mass.
account of inadequate facilities, protracted treatment and poor
follow-up in indigent patients. Chemotherapy is costly for most Early Detection
patients.  Due to the very high incidence of gastric cancer in Japan and Korea,
 Advanced cervical cancer requires judicious and cost-effective screening had been practiced in these countries and had improved
palliative care. survival and decreased mortality.
 Unfortunately, mass screening may not be as cost-effective in
Leukemia other countries such as the Philippines
 Last 2010, Leukemias are the 6th in both sexes, 6th in males and 8th  In order to increase survival, earlier diagnosis and effective
in females. Incidence rate of Myeloid Leukemia is slightly higher treatment of symptomatic patients should be the goal.
than that of Lymphoid Leukemia. o Patients 50 years and older who present with nonspecific
 Lymphoid leukemia is highest among children and adults 70 years upper digestive tract symptoms, particularly if accompanied by
and older. Myeloid Leukemia rise from age 50 years. loss of appetite, anemia, weakness or weight loss, should
undergo endoscopic studies and/or upper gastrointestinal
Risk Factors and Prevention radiologic procedures.
 Exposure to high-dose radiation and continuous and prolonged
exposure to certain chemicals (petroleum, hair dyes) have been Treatment
implicated in increasing the risk of leukemia  Early gastric cancer: Surgery
 Prevention: Exposures to such factors must be avoided  Near-total or total gastrectomy: proximal tumors
 Subtotal gastrectomy for distal tumors
Warning Signs  For many patients with advanced cancer, palliative surgery can
 Easy fatigability, pallor, weight loss, easy bruising, frequent improve the quality of life.
nosebleed, or repeated infections, especially among children  For inoperable cases, judicious and cost-effective palliative care
 The symptoms of acute leukemia appear suddenly, while chronic can still improve quality of life.
leukemia may progress slowly with few symptoms.
Prostate
Early Detection
 8th most common in both sexes (3%), and 4th among males (7%)
 no practical screening method for leukemia
 The incidence rate starts rising sharply at age 55 years and
 Early detection of symptomatic patients, particularly children,
continues to rise with increasing age. The incidence rate had
should be aimed for.
increased from 1980 to 2007, with an annual change of 2.1%.
 suspicious cases: peripheral blood smears and bone marrow
examination to confirm the diagnosis
Risk Factors and Prevention
 Increasing age is the most important risk factor
Treatment
 The increasing numbers of Filipino males who are 55 years and
 Some forms, particularly ALL in children, are highly curable by
older is the main reason for the significant increase and expected
chemotherapy
continuing increase in the number of cases
 The public sector should allocate more resources for the
 Evidence for the association between prostate cancer and
management of curable leukemias in indigent children.
unhealthy lifestyles is NOT AS CLEAR compared to certain cancers
 Advanced leukemia: judicious and cost-effective palliative care
 Nevertheless, males who start a healthy lifestyle early in life and are
able to sustain the healthy habits throughout life may lower their
Stomach individual risk of prostate cancer.
 Incidence rates begin to increase steeply starting at age 50 among
males and at age 55 among females.
 From 1980 to 2007, the incidence rates had decreased, with an
annual change of -2.5% in males and -2.3% in females.

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Warning Signs  Pregnancy and oral contraceptives could be protective

 Early prostate cancer: usually asymptomatic  Warning sign: usually detected as abdominal mass
 When symptoms occur, these are usually: difficulty in urination  Detection: annual pelvic exam starting age 40
and increased frequency of urination particularly at night
 Symptoms are similar to those seen in men with benign prostatic Cancer of brain/nervous system
hypertrophy (BPH), a noncancerous enlargement of the prostate  9th leading cause of cancer in both sexes and 7th among males
gland.  Risk factor: previous brain trauma but link is not strong
 BPH is much more common than prostate cancer and occurs in the  Warning signs: headache, dizziness, unexplained weight loss,
same age-group. malaise, fatigue
 Sometimes, the initial presentation of prostate cancer is that of  Detection: through neuro exam, imaging studies such as MRI, CT
bone pain due to spread of the cancer to the bones. scan

Early Detection NINE WARNING SIGNS OF CANCER (C-A-U-T-I-O-N-U-S)

 Prostatic specific antigen (PSA) assay:
 Change in bowel or bladder habits
o accurate enough to be used to detect prostate cancer, either as
a screening method in asymptomatic men or in  A sore that does not heal
symptomatic individuals  Unusual bleeding or discharge
o If positive, a diagnostic biopsy is performed  Thickening, lump, or swelling in the breast or any part of the body
o If the PSA test is not available, biopsy of suspicious areas in the  Indigestion or difficulty swallowing
enlarged prostate, detected by rectal digital examination  Obvious change in a wart or mole
and/or transrectal ultrasound, is done on symptomatic  Nagging cough or hoarseness
individuals.  Unexplained anemia
 Annual transrectal digital rectal examination on asymptomatic  Sudden unexplained weight loss
men who are 50 years or older may detect early prostate and
rectum cancer. LINKAGES
 A substantial number of prostate cancers are very slow growing and 1. United Nations Population Fund
will have no clinical impact. They are discovered as incidental 2. National Cancer Pharmaceutical Access Management
findings during autopsy. - 4 pilot hospitals
 The European Randomized Study of Screening for Prostate Cancer o Jose Reyes Memorial Medical Hospital
showed that PSA-based screening had reduced mortality by o East Ave Medical Center
20% but was associated with a high risk of overdiagnosis. o Rizal Medical Center
 The matter of population-based PSA screening is still being o UP-PGH
discussed in many high income countries, and NOT feasible in most 3. Philippine Cancer Society Inc.
developing countries. 4. International Agency for research on cancer
 For men who are interested to have a PSA test, the current thinking
is that there should be a thorough discussion with a physician on the CANCER REGISTRIES
benefits and possible harmful sequelae, and the decision mutually  Cancer registry is an information system designed for the
met. collection, storage, management, and analysis of data on persons
with cancer, usually covering a hospital or group of hospitals.
Treatment  This is done to search information rapidly and to answer questions
 Early prostate cancer is curable. like: Is the incidence of a particular type of cancer lower this year
 For cancers incidentally discovered during prostatectomy: than last year or in what area does the highest incidence of this
NOTHING more is usually done particular type of cancer.
 For those with capsular invasion or distant spread: hormonal  A cancer registry is a particular type of disease registry and its
manipulation, such as orchiectomy, is the usual first-line treatment major purposes are:
 In certain situations radiotherapy can be beneficial. 1. To establish and maintain a cancer incidence reporting system;
 For advanced cases, judicious and cost-effective palliative care can 2. To be an informational resource for the investigation of cancer
improve the quality of life. and its causes; and
3. To provide information to assist public health officials and
PREVENTION AND CONTROL OF SPECIFIC CANCER SITES agencies in the planning and evaluation of cancer prevention
Prostate Cancer and cancer control programs.
 8th most common in both sexes
Two types of cancer registries
 4th most common among males\
 MOST IMPORTANT RISK FACTOR: INCREASING AGE A. Population-based registry
- aimed to identify all cases of cancer that occur in a defined
 Warning signs
population.
o Difficulty in urination
- an essential component of a fully developed cancer-control
o Increased frequency of urination particularly at night
program
o Bone pain (initial presentation)
- used to monitor programs of prevention, early detection and
 Prostate Specific Antigen – for early detection
cure (treatment)
 Early prostate cancer= curable
- designed to determine cancer patterns among various
 If with capsular invasion or distant spread= Orchiectomy (first-line populations or sub-populations, to monitor cancer trends over
treatment) time, to guide planning and evaluation of cancer control efforts,
to help prioritize health resource allocations, and to advance
clinical, epidemiological, and health services research
Ovarian Cancer
 10th leading site for both sexes and 5th among women B. Hospital-based registry
 Factors to suspect that increase risk: nulliparity, menstrual - aim at the improvement of cancer therapy
irregularities, history of breast or endometrial cancer

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- they collect detailed data about diagnosis, therapy and survival Undersecretary
of the cancer patients (Chair) DOH-Office for Technical Services
- PURPOSE: to serve the needs of the hospital administration, the Director IV (Co-
hospital's cancer program, and above all, the individual patient Chair) Disease Prevention and Control Bureau
- 2 sub-categories of hospital-based registries: Knowledge Management and Information
o single hospital registries Director IV Technology Service (KMITS)
- primary goal of the single hospital (institution) registry is
to improve patient care by medical audit-type evaluation of Director IV Epidemiology Bureau (EpiB)
outcomes Senior Vice
o multi-institution registries President PhilHealth-Health Finance Policy Sector
- the primary goal of collective registries (multi-institution
registries) is to improve patient care by supporting Chairman UP-PGH Cancer Institute
institutional registries with common standards and pooled Executive Director Philippine Cancer Society Inc. (PCSI)
data Health Promotion and Communications Service
- In the Philippines, for almost three decades, cancer incidence OIC-Director (HPCS)
data are derived from two population-based cancer
registries: Chief Lifestyle-Related Disease Division (LRDD)
- the Department of Health–Rizal Cancer Registry Program Manager Lifestyle-Related Disease Division (LRDD)
(DOH–RCR)
- Philippine Cancer Society Inc.–Manila Cancer
Registry (PCS-MCR)
Transers’ Message
STATUS OF IMPLEMENTATION LET’S GO BATCH 2019! 100% PROMOTION! #2019KAKAYANIN
 Universal Health Care Act, 2013 #ROADTOCLERKSHIP
o ensures that all Filipinos, especially the poorest of the poor,
will get health insurance coverage from the Philippine Health
Insurance Corp. (PhilHealth)
o mandates a national health insurance program (NHIP) as
the means for the healthy to help pay for the care of the sick
and for those who can afford medical care to subsidize those
who cannot, and is Compulsory in all provinces, cities and
municipalities, notwithstanding the existing health insurance
programs of local government units

 Implementing the Philippine Medicines Policy

o Implemented by DOH National Center for Pharmaceutical
Access & Management (DOH NCPAM)
o started to improve access to cancer drugs starting with Acute
Lymphocytic Leukemia for children and Breast Cancer for
women

 The PhilHealth Z Benefits

 Z Benefits focus on providing relevant financial risk protection
against illnesses perceived as medically and economically
catastrophic especially affecting Filipinos belonging to the
marginalized sectors of society.
 There are currently Z packages for ALL, breast, cervix and
prostate cancers, at every early stage of implementation
among a few pilot government hospitals.
 Acceptance of the first Z package (breast cancer) was and still
is having resistance mainly due to its low peso amount; the Z
packages on ALL, cervix cancer, and colorectal cancer have not
met as much resistance.

ASSESSMENT OF CANCER PROGRAMS IN THE PHILIPPINES

 Mortality from cancer had increased substantially over time in the
Philippines and was likely to continue to increase.
 Significant shortcomings in six areas were identified:
1) existing data and data gaps
2) programmatic efforts, gaps, and problems
3) medical education
4) policy issue
5) treatment guidelines and problems
6) quality control of testing and screening services.

NATIONAL CANCER CONTROL COMMITTEE

 headed by Department of Health - Office for Technical Services
 co-headed by Disease Prevention and Control Bureau (DPCB)

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