Fifty years of important social and economic changes

In 1956, Mozambique was still a Portuguese colony. Lourenço Marques (today Maputo city) was a commercial and administrative centre and a busy port with a population of about 100 000.8 The city was undergoing the simultaneous process of urbanisation, detribalisation and assimilation of Western culture. Mozambique already had one of the least developed colonial economies when, in 1975, it gained independence. After independence, Mozambique quickly constructed a primary healthcare system based on principles defined at the transformative 1978 Alma-Ata conference,9 but 16 years of civil war destroyed infrastructures, ruined livelihoods and severely hampered agricultural production and economic development.10 The conflict and the subsequent natural disasters (severe floods and droughts) forced the internal and external displacement of many families. Since the first multiparty election of 1994, the economy has been recovering with some of the fastest growth rates in the world.11

Mozambique, a malaria endemic country, has also been hard hit by the HIV and tuberculosis dual epidemic,12 which compromises the country’s social and economic progress. Since the 1990s, the HIV has shown an extremely rapid progression, affecting, in some settings, up to 45% in women aged 28–47 as reported in a recent community-based study in a rural district of Maputo province.13

Despite more than 20 years of relatively stable political context, Mozambique is still one of the world’s poorest countries, with a Human Development Index of 0.461 (ranking at 180 out of 188 countries) and 44.1% of population in severe multidimensional poverty.14 Since the start of the first nationwide education and literacy campaign in 1975, the adult illiteracy rate has notably, but not sufficient, decreased from 97% to 56%.6 15 Life expectancy remains low, although from 1960 to 2008 raised from 35 to 52.2 years.16 Nowadays, the country is facing the consequences of urbanisation and westernisation of lifestyle, which coexist with an extremely high burden of traditional infectious diseases of poverty, a new political crisis, an important economic instability and a fragile and under-resourced health system.1 9 11 17 Since the structural adjustment programme sponsored by the International Monetary Fund to pay back debt in 1987, Mozambique’s health system has been struggling with the huge cuts to public spending and the constraint of foreign aid for strengthening the national health system.9

Cancer patterns and trends in Mozambique

Although cancer surveillance data in Mozambique is still far away from desired standards, the availability of two big cancer surveys in today’s Maputo area for the periods 1956–1961 and 1991–2008 is uncommon compared with other LMIC. As summarised in table 1, there are significant methodological limitations that restrict the comparison and trend analysis of available data; even so, we believe that a cautious analysis can provide valuable information to address the cancer challenges in Mozambique.

Cancer incidence rates have varied considerably during the last decades in Maputo, as shown in table 2. We observe an increase from 169.9 cases per 100 000 in 1956–1961 to 182.7 in 1991–2008 in men and from 95.3 to 186.0 cases per 100 000 in women. Although the different age distributions standards used in both assessments can hinder precise comparisons between different populations considerably, there is no doubt that the cancer notification rates in Mozambique have generally experienced a remarkable increase. Whereas between 1956 and 1961, a total of 600 cancers (403 in men, 197 in women) were registered, between 2003 and 2008, 6743 cases of cancer were identified (2900 in men, 3818 in women and 25 people without gender information).6 7

This startling increase in absolute numbers of more than seven times in men and more than 19 times in women may be related to different processes. First of all, Maputo had a population of about 100 000 in the early 1960s,8 which increased markedly until the 2007 census where it reached 1 094 628 inhabitants. In addition, cancer is an affliction that normally occurs later in life. From 1960 to 2008, the life expectancy in Mozambique raised from 35.0 to 52.2 years. Furthermore, improvements in education and healthcare access and the introduction of new diagnostic techniques may have played a role in increased cancer detection. Prates and Torres6 mentioned that men used healthcare services for general treatment more frequently than women did, although most women stated that if sick they would seek treatment at a clinic or hospital. The authors suggested that the reduced access to healthcare in women could be related to the fact that by that time, before making a decision, women must obtain permission from the head of the family who could have been absent as a migrant labourer. Increased women’s access to maternal and reproductive health services, evidenced by the gradual reduction in maternal mortality, could also explain the increased notification rates in women observed by Lorenzoni and colleagues.7

Regarding to the specific cancer burden profile, today Mozambique presents, as many other LMIC, a dual burden with a still high incidence of cancers associated with infectious diseases and an increasing incidence of cancers related to lifestyle risk factors. In the last decades, the country has experienced important downward trends in infection-related cancers such as primary carcinoma of the liver or cancer of the urinary bladder, but unfortunately, HIV-related cancers have experienced a substantial increase. As expected due to the westernisation of lifestyles, some of the most common cancers in high-income countries, such as prostate or breast cancer, have experienced enormous increase in Mozambique. Such trend has not been observed in lung cancer incidence, which remains still low. Prates and Torres (1956–1961) recorded the highest incidence of primary carcinoma of the liver for any part of the world, with age-standarised rates (ASR) per 100 000 of 109.7 for males and 14.1 for females. Cancer of the liver affected mostly the young men population between ages 15 and 44. Age-specific incidence rate reached 264.0 per 100 000 in males between 40 and 44 years and 81.5 in women of the same age. Aflatoxin contamination of foodstuffs and chronic carriage of hepatitis B virus (HBV) were considered as major factors to develop cancer of the liver.18 In the last decades, incidence of liver cancer in Maputo has shown a marked continuous decrease, being the ASR, for the period 2003–2008,  28.8 and 8.3 per 100 000 in men and women, respectively. In a study conducted in 1985 in Mozambique and in the former Republic of Transkei, the aflatoxin levels observed in food samples were the highest ever recorded in any part of the world.18

Aflatoxin levels continue to be high in Mozambique.19 Its exposure may have decreased through (1) campaigns about the dangers of mouldy food, which is likely to have resulted in increased selectivity during the preparation of foodstuffs, (2) the reduction of peanuts consumption due to economic pressure18 and (3) nutrition transition, incrementing animal source food consumption, which probably has replaced groundnuts as the traditional main protein source.20 21 Although aflatoxin alone does increase the risk of liver cancer, the risk is much greater in carriers of HBV.22 HBV vaccination was introduced in Mozambique in 2001 and according to WHO, estimations of National coverage rates range from 74% to 76%. It may be too early to evaluate the effectiveness of this intervention, but a further decrease in the incidence of liver cancer should be expected in the upcoming years.

Cancer of the urinary bladder  was the second most frequent cancer in males and third in females in the 1956–1961 period, with most of the cancers being squamous cell carcinomas, a histological variety closely associated with urinary schistosomiasis infection.23 Interestingly, this cancer has shown a marked decrease, which could be related to the reduction in the prevalence of schistosomiasis, which has been recently described in southern Mozambique.24

Unquestionably, the HIV epidemic has had a significant impact on Maputo’s cancer profile. AIDS-defining neoplasm such as cervical cancer and Kaposi’s sarcoma (KS) have constantly increased since 1990.7 Cancer of the uterine cervix was the second most frequent cancer in women in the 1950s and has become the most frequent neoplasm in the 2000s with an ASR per 100 000 of 62.2, one of the highest cervical cancer rates worldwide.1 The social disruption caused by the civil war in the 1970s and 1980s may have favoured the spread of human papillomavirus (HPV) infection and other sexually transmitted infections (STI). Although unusual, KS had already been detected in the Mozambican population in the 1950s, similar to other countries in Africa. However, in the 1950s, it was of the typical ‘endemic’ pattern, involving the skin, particularly the legs, and affecting males, with the risk rising progressively with age.25 The enormous increase in the incidence of this cancer since the earlier periods,26 together with the narrowing of the sex ratio has previously been reported in Uganda.27

Improvements in the control of HIV and in other STI, such as increased HIV testing and antiretroviral therapy coverage or HPV vaccination (to be implemented nationally in the coming years), and increased coverage of population screening should stagnate and decrease current numbers of HIV-related and STI-related cancers.

Prostate cancer is the most commonly diagnosed cancer among men in Southern Africa and Western Africa. In Maputo, prostate cancer was rarely diagnosed in the 1950s, whereas in the 2000s, the incidence reaches 61.7 cases per 100 000, four times the rate reported for sub-Saharan Africa. Being a cancer that almost always appears late in life, life expectancy can doubtless explain part of the big rate increase. Screening programmes are unlikely to have played a role, but it is possible that increased awareness and use of diagnostic and therapeutic procedures in patients with persistent urinary symptoms have contributed to the increase observed in its occurrence. Due to the observed racial disparities in prostate cancer risk with higher rates reported among African descendants, genetic susceptibility has been suggested to play a role.28

Breast cancer was rarely diagnosed in Mozambique in the 1950s, while its incidence has increased almost 10 times in the 2000s. In many sub-Saharan African countries, breast cancer has now become the most commonly diagnosed cancer. Beyond enhanced detection, reasons for this are unknown, but increases in the prevalence of risk factors for breast cancer such as early menarche, late childbearing, low parity, obesity, which are associated with urbanisation and economic development have certainly played an important role.1 Nonetheless, the ASR of breast cancer in Maputo remains relatively low compared with global figures.29 30

Finally, the increase in the incidence of cancer of the oesophagus observed in both sexes between the 1950s and 2000s is difficult to explain. A similar increase has been observed in Uganda.27 Alcohol, tobacco and cereal-based diets, particularly those relying on maize via nutritional deficiencies associated with such diets or contamination of maize with mycotoxins may have a role in this phenomenon.27

Challenges and limitations of cancer surveillance

High-quality cancer surveillance is crucial to fight the cancer epidemic in LMIC. Vital statistics, risk factor surveys and population-based cancer registries are fundamental for cancer surveillance.31 The vital statistics system of Mozambique has been virtually unchanged for more than 50 years. Although there is a comprehensive system for registering births, deaths and other vital events, its coverage and quality are discouragingly low to merit any attempt to use these data for statistics.32 Digitalisation, more accurate information and coverage enhancement are needed. Coverage might be improved by immediate registration of all births and deaths taking place in hospitals, preliminarily registration of newborn babies who have not been given a name and allowing unmarried mothers to register their child, regardless the father is away, refuses or is unknown. The lack of an address system and the lack of registered data on migrations within Mozambique as well as to and from other countries, make demographic estimates even more difficult.32

Mozambique does not have a national population-based cancer registry. The first Mozambican population-based cancer registry started in Maputo in the 1960s, but disappeared after the independence. After the end of civil war in 1991, the Department of Pathology at the Maputo Central Hospital (MCH, named during the colonial period Miguel Bombarda Hospital) restarted the registration of all cancers with anatomopathological diagnosis. The MCH performed all the pathological testing in the country until 2001, when a Department of Pathology was established at the Hospital Central de Beira, covering the central region of the country. In 2003, the Hospital Central de Nampula, in charge of the north region, also opened a Pathology Department. Today, the city of Beira has a population-based cancer registry and the Department of Pathology at the MCH continues with its registry.

According to the key elements of population-based registries for cancer incidence surveillance proposed by Piñeros et al,31 Mozambique faces several challenges to implement a national population-based registry. First, although after the end of civil war, censuses have been performed in 1980, 1997 and 2007 and intercensual estimates are available, their precision can be questioned because of the long-time periods between rounds or the fluctuating migration patterns. In fact, demographic surveillance platforms were developed in some settings in order to have more accurate population figure.33

As a second key element, existence and development of oncological services, access to medical and diagnostic services and quality of medical information should be improved. According to the Mozambique Poverty Reduction Strategic Programme II,34 only 36% of people have access to a health facility within 30 min of their homes. About 30% of the population is not able to access health services and only 50% have access to an acceptable level of healthcare. There is a need for more investment in health system structures and functions. Many health facilities are in urgent need of renovation and maintenance, with lack of basic commodities such as running water, electricity, transport or communication.35 But the biggest barrier is the lack of trained human resources capacity. Mozambique has one of the lowest health worker densities in Africa, with three doctors and 21 nurses per 100 000 inhabitants.36 There are only seven oncologists in the country and no oncological surgeons. Even so, the country is doing significant efforts to improve cancer diagnosis and treatment through capacity building activities, including increased number of trained specialists, improved infrastructures and equipment.37 As an example, immunohistochemistry was introduced in 1993 and fine needle aspiration biopsy assessment in 1996.

Finally, access to information sources and consolidation of data from multiple sources are needed to achieve an efficient population-based cancer registry. The Health Information System in Mozambique is still facing numerous challenges in terms of quality and use of data, mainly due to insufficient and poorly trained health workers, scarce financial resources, inadequate tools for data management and inadequate supervision and feedback.35 The recent evolution of surveillance of non-communicable diseases (NCDs), including cancer, has emphasised risk factor surveillance rather than disease occurrence,36 which could be improved by strengthening health information systems and health surveys. Mozambique joined the Demographic Health Surveys Program on 1997 and finished the third round on 2011. These surveys provide very valuable data but are mainly focused on communicable diseases and maternal and child health. Incorporation of NCDs and its risk factors would be of paramount importance.