编者按：由中国抗癌协会主办，天津医科大学肿瘤医院、天津市抗癌协会、中国整合医学发展战略研究院承办的“2023中国整合肿瘤学大会（2023 CCHIO）”将于2023年11月16—19日在天津举办。拉丁美洲和加勒比肿瘤医学学会（SLACOM）创始人及首任主席Eduardo Cazap教授将出席本次大会。《肿瘤瞭望》在大会前夕采访了Eduardo Cazap教授，请他分享有关拉美及加勒比癌症诊疗现状的相关问题。

 

Editor’s Note:2023 Chinese Congress of Holistic Integrative Oncology(2023 CCHIO)will be held in Tianjin from November 16th to 19th，2023.Professor Eduardo Cazap，who is the Founder and first president of the Latin American&Caribbean Society of Medical Oncology(SLACOM)，will attend this congress.He was interviewed by Oncology Frontier on the eve of 2023 CCHIO.

 

Prof.Eduardo Cazap：我想从以下两点来回答这个问题，一个是拉丁美洲的流行病学现状，另一个是加勒比地区的癌症诊断与治疗。拉丁美洲的国家包括北美的墨西哥、中美洲和南美洲的国家，以及加勒比地区的众多岛屿和小国。在如此辽阔的地域内，癌症的流行病学特征千差万别。一个明显的特征是大西洋侧和太平洋侧地区之间的不同。

 

在大西洋侧，包括巴西、阿根廷、乌拉圭和墨西哥部分地区，癌症的分布情况与西方和北美国家非常相似。主要表现为女性乳腺癌、结肠癌、肺癌和男性前列腺癌的高发。此外，对于拉丁美洲所有国家的女性来说，宫颈癌也是一个严重问题，主要影响20至40岁之间的女性。然而，在拉丁美洲缺乏对宫颈癌的有效预防方法。因此，宫颈癌在我们这个地区是一个需要优先考虑的问题。

 

在另一侧（太平洋侧），包括智利、秘鲁、哥伦比亚以及墨西哥的部分地区，我们观察到类似的癌症分布模式。不过由于太平洋地区与东方，特别是日本有一定联系，我们观察到以胆囊和胃为主的癌症，在某种程度上与日本人群中的癌症分布情况相一致。此外，肺癌、结肠癌和乳腺癌也值得关注。其中，乳腺癌是拉美国家女性中最常见的癌症，只有巴拉圭是例外，那里宫颈癌居首位，乳腺癌位居第二位。以上是拉丁美洲地区癌症流行病学的简要概述。

 

第二是关于癌症诊疗。需要重点提到的是全球癌症诊疗的三种主要模式。第一种模式，类似于美国实行的模式，主要由个体承担对癌症诊疗，即个人保险起主要作用，政府在此方面提供的帮助相对有限。尽管将来可能会发生变化，但个人承担仍然是癌症诊疗的主体。因此，超过五千、六千甚至七千万美国公民没有这类保险，导致他们在癌症治疗上得不到保障——这比许多拉丁美洲国家的情况更糟糕。另一种癌症诊疗模式则主要有政府承担，类似例子如英国、加拿大、法国、西班牙以及中国的某些地区。我了解到中国为其人民提供了强大而广泛的医疗保障，使其与这些国家的癌症诊疗模式保持一致。在拉丁美洲的背景下，大多数国家采用混合制度。政府通常承担基本诊疗的责任，而额外的保障需要个人通过其他途径获得。

 

除了政府，工会或军队也会提供一些包括手术在内的基本癌症治疗。军队通常拥有独立的医疗保健系统。此外，在联邦制国家，各省也提供医疗保健服务，尽管其贡献通常不超过10%。在墨西哥、巴西、阿根廷，以及秘鲁的部分地区，个人保险也占据了重要地位，不过只有中产和上层人士能够承担。经济条件较差的人群的癌症医疗通常由国家或省级医疗保健系统提供。癌症预防工作一般由政府机构负责，但各国在预防方面的重视程度差异较大。总的来说，用于预防措施的资源分配往往相对较低。政府的重心通常放在建立和管理医院。虽然这是主流做法，但优先考虑预防措施对于形成更有效的全球癌症控制战略至关重要。

 

在拉丁美洲，让人们得到治疗是一个主要的问题。虽然已经建立了相关规范和指南，也明确了医疗保健提供方的责任，但治疗延误和医疗系统超负荷的问题一直存在。在某些情况下，需要接受乳腺切除术或结肠手术等治疗的患者可能需要等上两到四个月，这也暴露了当前医疗系统的严重不足。此外还有医疗资源分配不均的现象。大城市通常拥有发展完善的医疗保健基础设施，而到了小省市和偏远地区，包括丛林地区，医疗资源可能捉襟见肘。地理条件的限制进一步加剧了这个问题。

 

Prof.Eduardo Cazap：I would like to address two distinct points for this question:one focusing on the epidemiology in Latin America，and the other discussing the diagnosis and treatment of cancer in the Caribbean.Latin America encompasses many countries，including Mexico in North America，various Central American countries，South American nations，as well as numerous islands and smaller countries in the Caribbean region.Within this vast region，there exists diverse epidemiological characteristics about cancer.A prominent feature is the notable distinctions between the Atlantic and Pacific sides of the continent.On the Atlantic side，which includes countries like Brazil，Argentina，Uruguay，and parts of Mexico，the distribution of cancer is very similar to that of Western and Northern nations.Predominantly，there are high incidences of breast cancer in women，colon cancer，lung cancer，and prostate cancer in men.Additionally，cervical cancer is a significant concern for women across all Latin American countries.Unfortunately，the region is lack of effective prevention methods for this particular type of cancer.Sadly，it predominantly affects young women，aged between 20 and 40.So，cervical cancer is a priority in our region.On the other side of the continent，including Chile，Peru，Colombia，and parts of Mexico，we observe a similar cancer distribution pattern.However，due to the Pacific region’s connection to the Orient，particularly Japan，there is a prevalence of cancers such as gallbladder and gastric，aligning with the distribution seen in the Japanese population.Additionally，lung，colon，and breast cancers are noteworthy.Among these，breast cancer ranks as the most prevalent cancer among women in all countries of the region，except for Paraguay，where cervical cancer holds the first position and breast cancer follows closely as the second.This provides a concise overview of the cancer epidemiology in the Latin American region.

 

The second point pertains to diagnosis and treatment，and it is crucial to acknowledge the three major models of cancer care worldwide.In one model，which is like the paradigm in the US，the primary responsibility for care rests with the individual.Here，personal insurance plays a pivotal role，as government protection is relatively limited.Presently，though there may be changes in the future，personal responsibility remains integral to receiving care.Consequently，over 50，60，or even 70 million US citizens find themselves without insurance，leaving them without coverage for cancer treatments—an even worse situation than in many Latin American countries.Another model of cancer care places the maximum responsibility on the government.This is exemplified by countries like the UK，Canada，France，Spain，and certain regions of China.My understanding is that China has a robust and widespread coverage for its population，aligning it with this group of countries.In the context of Latin America，most nations operate on a mixed system.The government typically shoulders the responsibility for the basics，while additional coverage may be obtained through private means.

 

Basic cancer treatments，including surgery，are also covered by various structures，such as unions or the armed forces，in addition to the government.The armed forces often have their own independent healthcare system.Additionally，in federal countries，provinces may play a role in healthcare provision，though their contribution is usually less than 10 percent.Private insurance plays a significant role in Mexico，Brazil，Argentina，and part of Peru.However，this is primarily accessible to the middle and upper economic classes of the population.Typically，populations with lower economic means are covered by national or provincial healthcare systems.Government bodies usually oversee prevention efforts，but the level of emphasis on prevention can vary significantly from one country to another.In general，the allocation of resources for prevention measures tends to be relatively low.The primary focus of government efforts often lies in the establishment and management of hospitals.While this is the prevailing approach，prioritizing prevention measures is crucial for a more effective global cancer control strategy.

 

In Latin America，access to treatment is a major concern.While there are established norms and guidelines，as well as responsibilities for healthcare providers，the issue often lies in delays and system overload.In some cases，individuals in need of procedures like mastectomies or colon surgeries may face delays of two to four months.This represents a significant limitation in the healthcare system.Additionally，healthcare provision is not uniform across the board.Larger cities generally have well-developed healthcare infrastructure，while provinces and remote regions，including jungle areas，face challenges in providing optimal care.Geographical constraints further compound the issue.

 

Prof.Eduardo Cazap：我认为对于“全球性”这个概念可能存在一些误解。目前的全球互联性使得我们实现远距离的“面对面”交流，这无疑是一个全球性的成就，连接着世界各地人们的网络和信息。然而，健康并不能如此简单地进行全球互联，因为它在各个国家的情况不尽相同。将一个通用的健康质量标准应用到全球各地是不可行的。在几乎99%的情况下，癌症诊疗由各个国家的个人和政府来承担。纵观全球，拉丁美洲在癌症诊疗高度组织化这方面可能无法与欧洲比肩。因此，我认为我们需要一个多维度的战略，包括自上而下、自下而上的方法。

 

世界卫生组织（WHO）、泛美卫生组织（PAHO）、里昂国际癌症研究机构（IARC）以及奥地利核医学国际原子能机构（IAEA）等国际组织在制定一般性决策方面发挥着引导作用。然而，每个国家都有必要制定并实施自己的癌症控制计划，权衡自身经济和医疗资源，并建立癌症登记制度。这包括两个基础的方法：全国性的癌症登记制度，用于准确统计患者人数和疾病发病率数据，以及国家癌症计划，用于有效实施策略。虽然我们目前已经在全球健康方面做出了许多努力，但可能并不如人们所期望的那样全面。2010年，联合国大会发表了关于全球癌症控制的一些建议。然而，在过去的12至13年里，情况发生了相当大的变化。因此，个体国家的政府和公民社会，包括拉丁美洲在内，都有责任采取积极措施来解决各自地区的癌症控制问题。

 

Prof.Eduardo Cazap：I believe there may be some misconceptions about the concept of globality.The current level of connectivity，allowing us to communicate over long distances with images，is undoubtedly a global achievement.The networks，information，and connections linking people across the world constitute a global phenomenon.However，when it comes to health，health is not global;it operates on a country-by-country basis.Therefore，applying a universal standard of quality to health becomes less feasible.This is because，in nearly 99%of cases，the responsibility for cancer care lies at the local level，managed by individuals and governments within each country.Yet，within this global scope，there exist regions，and in contrast to highly organized regions like Europe，Latin America may not be as uniformly structured.Hence，I believe we require a multi-dimensional strategy that incorporates top-down and down-top approaches.

 

International organizations like the WHO，PAHO in the Americas，IARC in Lyon，and IAEA for nuclear medicine in Austria play a guiding role in making general decisions.However，it is imperative for each country to develop and implement its own cancer control plan，taking into account its economic and healthcare resources，as well as establishing a cancer registry.These are the two foundational tools:country-level cancer registries for accurate patient counts and disease incidence data，and national cancer plans for the effective implementation of strategies.While global efforts have been made，they may not be as extensive as desired.In 2010，the United Nations Assembly issued recommendations for global cancer control.However，over the past 12 to 13 years，the situation has evolved considerably.Therefore，the responsibility lies with individual governments and civil societies within each country，including those in Latin America，to take proactive measures in addressing cancer control within their respective regions.

 

Prof.Eduardo Cazap：这是一个很好的问题，因为我们的一些成员也曾对与中国合作这件事上感到疑惑。与世界上其他地区相比，中国在文化和国家规模上存在着很大的差异，这可能会引起关注。但是我们需要考虑到，许多癌症研究中的建议和进展都源自如美国、日本、德国、西班牙、英国和澳大利亚等国家，这些研究和发现主要反映了西方世界的观点。那么，我们如何能够确信，将在美国女性中进行研究的癌症治疗方法应用到秘鲁的印度裔女性身上是可行的呢？我们能确定她们的基因构成是相同的吗？癌症的进展预期会是相似的吗？在这个时候，了解各种族群之间的差异至关重要。以拉丁美洲为例，秘鲁拥有大量具有中国和日本血统的人口。因此，收集有关全球不同人群的信息十分关键，特别是移民数量和全球旅行人数的不断增加，这导致了基因多样性相比一个世纪前要更加丰富。

 

例如，与中国方面的同僚合作为我们提供了一个绝佳的机会，可以了解不同人群的情况。与此同时，许多拉丁美洲国家制定的低成本策略能够为中国这个人口基数巨大的国家提供参考。在我们的国家，我们用更为经济实惠、简单直接的替代方法取代了昂贵而复杂的诊断干预措施，这或许能为中国患者的治疗提供帮助。我们期待这种合作能取得丰硕成果，丰富来自中国和拉丁美洲的同行们的知识，共同造福于所有参与国家。

 

Prof.Eduardo Cazap：That is a good question，as some of our members have also wondered about the rationale behind cooperating with China.The vast differences in culture and country size compared to other regions in the world might raise concerns.However，it’s important to consider that many of the recommended guidelines and advancements in cancer research have originated from a handful of countries like the USA，Japan，Germany，Spain，England，and Australia.As a result，the studies and findings primarily reflect Western perspectives.So，how can we confidently apply a cancer treatment that was studied in American women to a woman of，say，Indian descent in Peru?Can we be certain that their genetic makeup is the same?Can we expect the cancer’s progression to be similar?At this juncture，understanding the distinctions between various ethnic groups is crucial.In the case of Latin America，for instance，Peru boasts a significant population with Chinese and Japanese roots.Therefore，gathering information about diverse populations worldwide is essential，especially given the increasing migrations and extensive global travel opportunities，which have contributed to a genetic diversity that is far less uniform than it was a century ago.

 

For example，collaborating with Chinese colleagues offers us a fantastic opportunity to gain insights into different population dynamics.Simultaneously，the low-cost strategies that many Latin American countries have developed may prove beneficial for the Chinese population，potentially impacting millions of individuals.In our countries，we’ve replaced costly and complex diagnostic interventions with more affordable and straightforward alternatives，which could also benefit the Chinese population.We anticipate that this collaboration will be fruitful，enriching the knowledge of our colleagues from both China and Latin America for the collective benefit of all countries involved.