INCREASING ACCESS TO CANCER SURGERY WILL IMPROVE CANCER CARE

INCREASING ACCESS TO CANCER SURGERY WILL IMPROVE CANCER CARE

By Dr Miriam Mutebi, Consultant Breast Surgical Oncologist at Aga Khan University Hospital

Across the world there is an increasing

incidence and mortality of cancers,

particularly in low and middle income

countries, such as Kenya. The recent

Lancet commission on cancer in sub-

Saharan Africa in 2021, showed that

over the past 30 years, there has been

a doubling in cancer incidence, with

over half a million deaths in 2020.

This number is predicted to double by

2030 thus underscoring a need for

urgent action. This incidence may be

attributed to a combination of factors

such as an increase in life expectancy

combined with the adoption of unhealthy

dietary habits, consumption of tobacco

and alcohol and lack of physical

exercise and environmental factors and

exposure, infections (a quarter of

cancers in Africa are associated with

infectious diseases such as hepatitis B

and c and human papilloma virus) and

genetics.

The Health Cabinet Secretary, H.E,

Susan Nakhumicha, while reflecting on

the recently released ‘Status of Cancer

in Kenya Report’ by the National

Cancer Institute of Kenya, noted that

there are 27,000 cancer related deaths

recorded every year in Kenya, with

about 75 deaths a day. The leading

cause of cancer deaths are esophageal,

followed by cervix, breast and liver

cancers. Breast cancer is the most

commonly diagnosed cancer in Kenya,

with an annual incidence of about 6,000

new cases and 2,500 cancer-related

deaths.

The government of Kenya has made

considerable strides in improving

access to cancer services and has

launched many initiatives to address

this rising cancer burden. The national

hospital insurance fund now covers

some of the costs of treatment such as

chemotherapy and radiotherapy. There

have been commendable efforts to

decentralize access to chemotherapy,

having established 10 fully functional

county-level chemotherapy centers, and

radiotherapy services with the

development of regional comprehensive

cancer centers in Nairobi, Mombasa,

Nakuru and Garissa. There has also been

an increase in the diagnostic

equipment in a number of counties,

including CT-Scans, ultrasonography,

and mammography etc.

There has been an expansion of enabling

policy with the launch of the New

Cancer Control Strategy 2017-2022, by

the Ministry of Health and its current

ongoing revision. This is a national

effort to address the growing burden of

the disease in the country. In

addition, there has been development of

Palliative and supportive care policy,

a national cancer taskforce report and

the launch of a Breast Cancer Action

Plan outlining deliberate steps and

strategies to improve access to cancer

care.

The care and treatment of cancer

involves three major aspects: systemic

treatments like chemotherapy and

immunotherapy, and local treatments

like radiotherapy and surgery. These

are frequently used in combination to

treat and potentially cure or palliate

patients.

The government’s efforts in increasing

chemotherapy and radiotherapy services

are laudable. However, surgical

services continue to lag behind the

progress made in the other aspects of

cancer care. We have also had a

promising expansion in local and

regional training in both medical

oncology and clinical oncology, but

there has not been much surgical

oncology training in the East African

Region.

Surgery is one of the major pillars of

cancer care and control. More than 80

per cent of all cancer patients will

require surgical procedures and one

third of patients will require multiple

surgical procedures thus underscoring

the need to develop these critical

services. Surgery can be preventive,

for instance, removing a polyp before

it turns into a cancer, diagnostic:

when biopsies are performed, curative

when a breast lump or colonic tumor is

completely removed or supportive,

palliative or reconstructive (e.g.

reconstructing a limb or breast after

removal of a cancer.

The Lancet Commission on global surgery

in 2014 showed that nine out of ten

people (5 billion people) have no

access to safe, timely and affordable

surgery with an additional 143 million

more surgical procedures needed in

lower medium income countries every

year, to prevent death and disability.

Safe surgery does not refer to the

actual surgery only, but also includes

the peri-operative care, anesthesia and

diagnostics that help to support

successful surgical outcomes. This is

particularly pertinent in Africa, where

data from the African Surgical

Outcomes Study (ASOS) shows that

patients are twice as likely to die

from routine, planned, common surgeries

as compared to the global standard.

The Lancet Commission on Cancer Surgery

in 2015 showed that less than a

quarter of patients globally had access

to affordable, safe, timely cancer

surgery with 15.2 million new cancer

patients requiring surgery in 2015 and

a projected estimation of 48 million

cancer surgeries being required by

2030. In the sub-Saharan region, there

is a huge deficit in health care

workers and more so in the field of

oncology, and even more so, in surgical

oncology. There is need to train more

cancer surgeons to strengthen health

systems, if we are to offer patients

comprehensive, curative and palliative

cancer services.

Cancer surgery involves a multi-

disciplinary team of surgeons, medical

and oncology radiologists, pathologists

and anesthesiologists. Before any

cancer surgery is done, the team will

discuss and decide on a treatment plan

which is then communicated to the

patient. Sometimes this plan may

involve chemotherapy first to shrink

the cancer and make surgery safer. At

the time of surgery, the intent is

usually to remove the entire cancer,

with a margin of normal tissue, in

order to prevent local recurrence and

is often the definitive (curative)

treatment for many solid cancers like

breast, colon or prostate tumors. Good

cancer surgery is thus a key component

of effective cancer treatment.

In many lower and middle income

countries, general surgeons form the

center of cancer treatment. However,

the training may vary and the skills

sets to do good cancer surgery may also

differ. In many parts of Africa, due

to deficits in both surgical oncology

and medical oncology, general surgeons

are involved in the diagnostics, cancer

surgeries and in some cases, even

administering chemotherapy and giving

follow-up care to cancer patients.

Despite this gap, there have been

little large scale efforts to improve

access to oncological surgical services

and training.

To mitigate this, the African

Organization for Research and Training

in Cancer (AORTIC), the Pan African

Women Association of Surgeons (PAWAS)

and Kenya Society for Hematology and

Oncology(KESHO) in partnership with the

Aga Khan University Hospital have

designed surgical trainings to impart

skill sets to general surgeons to

enable them to operate safely on cancer

patients and to provide a better

understanding of the multidisciplinary

approach to cancer management.

The Pan African Women Association of

Surgeons in collaboration with Kenya

Association of Breast Surgery, through

the Surgical Society of Kenya, have

also been holding a series of training

workshops to educate and empower health

care providers to give quality

surgical services. These initiatives

are in anticipation that with time, a

more sustainable long term training

will be provided.

The Aga Khan University is also in the

process of developing a training

program for general surgeons for breast

cancer surgery locally and in the

region. This capacity building, will

consequently help to bridge some of the

gaps that patients face in accessing

quality and timely surgical cancer care

in our region.