In Morocco , there is a lack in sufficient numbers of Medical Oncologists. Medical Oncology (MO) is a relatively new specialty. MO was recognized as a separate specialty in 1994 but the real taking-off was done only since the 2000s after the creation of the chair of medical oncology in the University of Rabat. The AMFROM (Moroccan Association for training and research in medical oncology) was created in 2008 to assure a high level of qualification for young oncologists and to improve the recognition of medical oncology. In the same way, the GRIOMM (Moroccan group of trialist in medical oncology) was created in 2011. Its first study is Eva-onco which is a national survey about the practice of medical oncology in the public health centers across Morocco [3].

The cancer health system in Morocco includes (2011) seven public hospitals (four university clinics) and seven private centers. In 2011, the AMFROM listed 28 medical oncologists in Morocco. There were more medical oncology positions in public (18) than private practices (6). Few medical oncology positions were located in military hospitals (4).

This first data provided by Eva-onco survey could be used by the Moroccan health authorities aiming to reduce the inequalities between regions and centers concerning medical oncology workforce.

The calculated density of MOs (MOs per 100,000) in Morocco is 0.09/100,000 habitant and is still low compared to the European and North-American countries [4, 5]. The average of 718 new patients per oncologist is very high compared with the national recommendations as defined in the cancer plan against cancer (one medical oncologist for 300 new cases). Using these recommendations, the shortfall of MOs in Morocco in 2011 is about a minimum of 26 oncologists. To our knowledge, there are no international recommendations concerning the number of MOs/habitants even if such countries like UK recommend a density of 1.1 MOs/100,000 habitants [6]. The pipeline of potential medical oncologists depends on the number of residents who complete training in medical oncology. Currently, there are approximately 50 residents who are in training in three university (Rabat, Fes, and Casablanca) so the current shortfall of MO is expected to disappear in the future.

The healthcare financing in oncology is characterized by inequity, the medical insurance covers only 35 % of the population. But demand for medical oncology services is expected to rise rapidly, driven by a medical assistance plan launched in 2010 for the benefit of the low-income populations in aim to give them a free access to all healthcare services provided by the public hospitals. Also, recently, a very active Moroccan NGO (Princess Lalla Salma Foundation for Prevention and Care of Cancer) is providing anticancer drugs to all government-run oncology centers [7].

In Morocco, two cancer registries have been implemented in the greater areas of Rabat [8] and Casablanca [9]. In 2004, the preliminary epidemiologic result of the RCRC (Registre des Cancers de la Region du grand Casablanca ), based on a population sample accounting for 10 % of the Moroccan population [1], has reported a global 35,000 new cases of cancer each year. Unfortunately, treatment reaches only 15,000 of those, leaving many with no treatment at the time of diagnosis. Cancer is responsible for nearly 8 % of death each year.

The most common cancers are breast (36.1 %), lung (31.5 %), cervix (13.3 %), colorectal (12.2 %), and prostate (3.7 %) (Table 3.1).

In a recent study conducted by Tazi et al. [8], 39.9 % of cancer cases are breast cancer patients, this study included all new cases of cancer diagnosed in the resident population of the Rabat area between 2005 until 2008.

Worldwide breast cancer is the most common malignancy in women with nearly a half million deaths each year (IARC Globocan, 2008). In Morocco, breast cancer represents serious public health problem. It’s the first cancer among women and the third one of all registered cancer cases. The interest of studying breast cancer has clearly increased during the last decade in Morocco, and different studies were conducted to characterize breast cancer at epidemiological, molecular, and genetic levels [10]. It’s widely accepted that establishment of the epidemiological profile of breast cancer is essential to provide hypothesis for understanding the etiology of the disease. Overall, the incidence of breast cancer in Morocco have clearly increased during the last decade, the 2012 updated versions of the RCRC (Registre des Cancers de la Region du grand Casablanca) and RCR (Registre des Cancers de Rabat ) have reported a standardized incidence of 39.9 and 49.2 per 100,000 women, respectively (RCRC, 2012; RCR, 2012). Overall, the mean age at diagnosis in Morocco is less than in Western countries where the average age onset of breast cancer is 55 years old [11].

Regarding cancer in children, estimated crude incidence according to the RCRC is 11.34 for 100,000 children. In children, each year, approximately 1000 new cases of cancer are registered. This figure accounts for 3.2 % of all cancer cases collated. Girls are greater in numbers with a proportion of about 53.8 % versus 46.2 % for boys. The most frequent cancers in children are malignant hemopathy (19.8 %), followed by tumors of the brain and meninges (17.1 %), then cancers of bones (12.33 %), adrenal glands (11.3 %), and eye (10.4 %).

The situation studies has showed the deficiency of healthcare structures and specialized human resources; thus patients have to travel long distances for very belated appointments. The huge difficulty to access to healthcare causes patients to be more often diagnosed at very advanced stage of the disease: for breast cancers the diagnosis is made at stage I in only 6 % of cases versus 57 % of cases in stages III and IV; as for lung cancers, their diagnosis is made at stages I or II only in 4 % of cases, whilst 96 % of the cases are diagnosed at the stages III and IV.

The time length between the onset of the first symptoms and the first medical examination exceeds 1 month in 36 % of cases, this period is even greater than 6 months in 14 % of cases. Furthermore, the period between the first medical examination and the diagnosis of cancer is greater than 3 months in 52 % of cases and greater than 6 months in 27 % of cases.

The absence of standardized protocols for diagnosis and treatment is the cause of the poor quality and the high cost of patient management.

The follow-up period of cancer patients is very low with a high number of lost-to-follow-up. In fact, the follow-up period is below 2 years in 74 % of cases.

Besides, about half of the patients are lost to follow-up after 1 year and almost seven of ten patients are lost to follow-up the second year, 83 % are lost the third year, and 96 % of patients are lost to follow-up at 5 years. Therefore, there is no reliable data to estimate the patient survival at 5 years, which is an essential indicator of the quality of cancer patients’ management.

Pain is an important concern in patients with cancer who are receiving active treatment and in long-term cancer survivors. It is one of the most feared aspects of cancer, and it can have a major adverse impact on quality of life. It has long been recognized that untreated or undertreated pain is common in patients with cancer, with little evidence of recent improvement. Before 1994, end-of-life care in Morocco was nonexistent. Dozen thousands of cancer patients were leaving to suffer needlessly because of the failure to ensure adequate access to pain-relieving drugs. Despite published guidelines by the WHO in 1986, most deaths occurred at home with the dying suffering great pain. The first data released during 1994 about the management of cancer pain paints a shocking picture of unnecessary pain on a national scale. This survey suggests that cancer-related pain may be a major issue of the Moroccan healthcare system where training for palliative care is not included in healthcare education curricula. Even in medical circles, many doctors and other healthcare providers remain unaware of not only pain control but also what palliative care provides more generally. Medical services have all too often focused on preventing death rather than helping people meet death without suffering pain, discomfort, and stress. Patients are stymied by regulatory barriers at multiple steps along this process; the end result being that dozen thousands of patients don’t have access to essential pain-relieving medications. The issue was complicated by the perception that palliative care was often associated with “giving up.” Since that, we were determined to tackle this problem at every level because the quality and availability of care was often absent and policy coordination lacking. Deeper integration of palliative care into our national healthcare was also vital. Palliative care need not mean institutional care, but more training is needed.

The World Health Assembly in May 2014 endorsed a resolution calling for palliative care to be fully integrated into healthcare in every setting, specifically highlighting community settings, and throughout the course of advances illnesses [13]. The Prague Charter also calls for universal access to palliative care [14]. Palliative care at the end of life is realized when strong networks exist between specialist palliative providers, primary generalists, primary specialists and support care providers and the community working together to meet the needs of all people. Palliative care must be available regardless of location, age, income, diagnosis or prognosis, social and cultural background.

A recent 2012 report from the Pain and Policy Studies Group at the University of Wisconsin, and Human Rights Watch pointed this failure. In 2009, a total of 14.278 cancer and 708 HIV patients died. The opioids quota was at this time only sufficient to relieve pain from 31.6 % of these patients. The result was that 11.777 patients died in unnecessary moderate-to-severe pain. The morphine necessary to meet the minimum demand of deaths due to HIV and cancer is 73 kg annually [15], which means that Morocco’s 7.7 kg quota provides for only a tenth of those in need. Clearly, this is an insufficient amount. The main barriers to necessary availability and accessibility are the fear of addiction and the high cost of opioids.

This dramatic situation must be evaluated by the Governmental Division of Medicine and Pharmacy as soon as possible. WHO guidelines could help formulate a national drug control policy , estimate annual requirements, report consumption statistics to be submitted to the International Narcotics Control Board (INCB) , and administer an effective distribution system to patients.

Despite the launching of the National Plan of Cancer Prevention and Control (NPCPC) , the Moroccan government’s recognition of palliative care as a policy priority and the model care offered by the Moroccan Society of PC as well as dealing with clinically complex patients, specialist palliative care has a role to support and train generalists and to help develop palliative care in the community. Such care nonetheless remains out-of-reach to the majority of Moroccans in need. The most relevant act recently is the amendment in last July 2014 of the obsolete law of 1952 about the number of 7 days of prescription of morphine. Recently, this prescription is for 28 days as needed. Nonetheless, the major reason discouraging the generalization of palliative care across all the country is the lack of government funding for end-of-life care. Actually, advocates of end-of-life care point to evidence that palliative care can be cheaper than traditional medical treatment for patients at the end of their lives. Certainly, by increasing the proportion of community and homecare, end-of-life care can reduce costs associated with hospital stays and emergency admissions.

Moroccan’s population generally has a poor understanding of cancer and end-of-life issues.

A survey was conducted to identify perceptions of cancer and its treatment among the general public, patients, and caregivers in Morocco in 2008.

This population-based survey on knowledge, perceptions, and attitudes toward cancer shows many misconceptions and that the terms mostly used to refer to cancer are “Li makaytssamach” (unnamed) , “Al mard el khaib” (bad ill) , and “Laâdou ” (the enemy).

Some evocations linked to the term “cancer” and the symbolic associated to the disease are fear, isolation, divine punishment, curse, death, a ) disease that causes havoc in the family, family disintegration, incurable disease, very costly disease with death at the end even when treated. In rural areas, the disease gives rise to the following comments: “it is better to save one’s property and one’s cattle and leave them to one’s children, since the patient is going to die anyway.”

The most widely known cancers are those of breast, uterus, throat, lung, and prostate. Symptoms are often mixed up with treatment side effects (hair loss, nausea, and browning of skin). The main disincentives for early detection are lack of financial resources and absence of health insurance, ignorance of early signs of the most frequent cancer forms, ignorance of the fact that early diagnosis can increase the possibilities of remission and finally ignorance of where to turn for advice and support.

Among the reasons for the more or less significant hesitation period between the discovery of the first signs, the first examination, even after the diagnosis and the start of treatment, there is the fact that the formulation of the disease by the physician is often felt with strong resentment by the patient because of its ambiguity. This medical behavior does not seem to contribute to the mobilization of the patient. Certain patients declared to have “preferred to know the reality of their disease so that they can become psychologically armed with a strong will to fight it .”

Since 2005, date of the creation of the Foundation Lalla Salma of Prevention and Control of Cancer (FLSPCC) , cancer care in Morocco has improved and became a public health priority. This national NGO works hand in hand with all its partners, to make of the fight against cancer a public health priority in Morocco and the region.

The FLSPCC aims at setting up a national plan dedicated to fight cancer which will apply the best clinical practices, by implementing a strategy using an innovative and participative approach adapted to the specificities of the country.

Created at the initiative of Her Royal Highness Princess Lalla Salma, the FLSPCC is working ceaseless to improve the patients’ care, to promote the prevention and to make of the fight of cancer a public health priority in Morocco. Furthermore, the FLSPCC made a commitment in terms of scientific research, hence multiplying partnerships in Morocco and worldwide.

The FLSPCC adopted a participative and multidimensional approach to figure out the cancer issue. The Foundation Lalla Salma is officially recognized as a nonprofit organization and pretends not to replace any public, private, nor foundation institution. The FLSPCC acts in concert with all its partners, working together at implementing a ) national health-system dedicated at fighting cancer that would be modeled on the best international practices.

The FLSPCC has always been privileging the well-being and the comfort of the patient, who is at the center of all its concerns. The FLSPCC is fortunate to rely on the never-ending and active implication of all and every one of the private and corporate partners, working out to meet the cancer challenge in Morocco.

In less than 3 years since its founding, the FLSPCC has mobilized efforts to raise public cancer awareness throughout Morocco launched an ambitious building campaign, organized the first national cancer registry, and linked arms with an array of international partners in the fight against cancer. Inspired by the vision and leadership of HRH Princess Lalla Salma , the NGO is already making significant inroads in improving the quality of cancer management and the ensuring that all Moroccan patients have access to a high standard of cancer care. Early detection projects in breast and cervical cancer are underway, and the Foundation oversees a program of tobacco control is partnership with the Ministry of Health and business and education leaders. In 2006 the Foundation became associate UICC member.

A number of “Houses of life” were built near the different center of oncology by the FLSPCC with many humanitarian objectives: