Elsevier

The Lancet Oncology

Volume 14, Issue 4, April 2013, Pages e158-e167
The Lancet Oncology

Series
Treatment of cancer in sub-Saharan Africa

https://doi.org/10.1016/S1470-2045(12)70472-2Get rights and content

Summary

Cancer is rapidly becoming a public health crisis in low-income and middle-income countries. In sub-Saharan Africa, patients often present with advanced disease. Little health-care infrastructure exists, and few personnel are available for the care of patients. Surgeons are often central to cancer care in the region, since they can be the only physician a patient sees for diagnosis, treatment (including chemotherapy), and palliative care. Poor access to surgical care is a major impediment to cancer care in sub-Saharan Africa. Additional obstacles include the cost of oncological care, poor infrastructure, and the scarcity of medical oncologists, pathologists, radiation oncologists, and other health-care workers who are needed for cancer care. We describe treatment options for patients with cancer in sub-Saharan Africa, with a focus on the role of surgery in relation to medical and radiation oncology, and argue that surgery must be included in public health efforts to improve cancer care in the region.

Introduction

Cancer care is rapidly becoming a public health priority in sub-Saharan Africa. Up to 70% of the predicted 24 million people that will be diagnosed with cancer annually by 2050 will reside in low-income and middle-income countries.1 Cancer incidence in these countries is rising because of lifestyle changes, increased life expectancy, and improved treatment of infectious diseases.2 Many countries in sub-Saharan Africa have health-care systems that are struggling to meet the increasing demand caused by the growing number of patients with cancer, since all the necessary components of cancer care are inadequate. Additionally, how to adapt care guidelines from high-income countries to countries in a region with fewer resources, fewer personnel, and in some cases different cancer biology, is unclear. Advances in prevention, detection, and treatment have not translated into success in sub-Saharan Africa. The overall case fatality from cancer (ratio of mortality to incidence) is estimated to be 75% in low-income countries, compared with 46% in high-income countries.3 Cancer mortality in sub-Saharan Africa is high because of poor infrastructure, insufficient numbers of health-care workers, advanced stage at presentation, reliance on traditional therapies, few treatment choices, and poor compliance.

Surgical oncology has a rich history in sub-Saharan Africa. In the 1950s, the Irish surgeon Denis Burkitt embarked on a “tumour safari” and described the clinical manifestations of cancer from west to east Africa.4 Despite being established early on as one of the core diagnostic and therapeutic cancer modalities, few data are available for the role of surgery in cancer care in sub-Saharan Africa. Surgeons are often responsible for all elements of cancer care for patients with solid tumours, including prescription of chemotherapy and palliative care. Although surgery is now recognised as an essential component of public health efforts, poor access to specialist surgical care is a major obstacle for cancer care in the region.5 Additionally, as radiotherapy and chemotherapies are introduced in low-income and middle-income countries, more complex options for surgical oncology interventions emerge. Here, we gather the limited available data for the role of surgery in the treatment of the most common solid tumours in sub-Saharan Africa and discuss it in context with diagnostics and other treatments.

Section snippets

Diagnosis

Clinical assessment is an essential component of cancer diagnosis in sub-Saharan Africa, since advanced equipment is rarely available. Late presentation is commonplace in most countries in the region. However, clinical examination is not as accurate as staging with advanced imaging. Knowledge of regional differences in cancer burden can be useful for generating a differential diagnosis. In The Gambia, for example, 81% of patients with liver cancer present with abdominal pain, hepatomegaly, and

Prostate cancer

Incidence of prostate cancer in Nigeria has in the past 10 years risen to as much as seven times that reported in the 1990s.12 During a 10-year period, 548 genitourinary malignancies were seen at the Korle-Bu Teaching Hospital in Accra, Ghana, with prostate cancer the most common (63·7%).13 In a study in Nigeria, 80 (88·9%) of 90 patients with prostate cancer had locally advanced or metastatic disease.12 No patients were identified by screening. After 3 years of follow-up, 16% of patients had

Chemotherapy

The use of chemotherapy in sub-Saharan Africa has progressed over many decades (panel). Traditionally, chemotherapies have been prescribed by surgeons, because the few oncologists in the region focused on haematological malignancies. Without coordination with oncologists, surgery as initial therapy, which is often indicated, is done by physicians without experience in cancer care, which results in residual disease or early recurrence. As multidisciplinary cancer management is adopted by many

Radiotherapy

The use of radiotherapy to treat patients with cancer in sub-Saharan Africa is limited by poor medical infrastructure. Radiotherapy cannot replace inadequate surgery or chemotherapy, so its use relies on improvements in medical infrastructure. Additionally, few trained radiation oncologists and technicians work in the region. Of 52 African countries, only 23 offer radiotherapy.59 South Africa and Egypt, however, account for roughly 60% of all radiation therapy resources in the continent.

Paediatric oncology

Paediatric oncology is not well developed in sub-Saharan Africa, partly because of the higher priority given to infectious diseases and malnutrition, and the poor health-care infrastructure. The available scientific literature from the region suggests that some specific cancers are especially prevalent in children: Burkitt's lymphoma (50% of childhood cancers),64 nephroblastoma, retinoblastoma, non-Hodgkin and Hodgkin's lymphomas, rhabdomyosarcoma, and Kaposi's sarcoma.65

As with adults,

HIV/AIDS

Patients with AIDS in sub-Saharan Africa have increased risks for Kaposi's sarcoma (30–90 times), lymphomas (five times), and cervical cancer (double the risk). Treatment of HIV-associated malignancies with chemotherapy in the absence of antiretroviral therapy often does not provide benefit.67 In resource-rich regions, incidence of cancer in HIV-infected people is several times higher than would be expected in age-matched and sex-matched individuals from the general population.68 Although

Challenges

The shortage of physicians and poor health-care infrastructure in sub-Saharan Africa has been well documented.71 The capacity to provide multimodal cancer care is limited by an insufficient number of health-care workers trained in oncology. That there are insufficient numbers of surgeons has been noted in many countries in the region.72 The disparity between the need for surgical care and the existing surgical infrastructure is exemplified by Sierra Leone, where 25% of the population have a

Conclusions

Issues of cost, infrastructure, inadequate workforce, cultural barriers, and scarcity of data all limit cancer care in sub-Saharan Africa. There are basic standards of cancer care that even low-income countries can, but often do not, meet. Even with a massive influx of supplies and workers, cost would still probably be a major limiting factor for the maintenance of adequate cancer care. Universal coverage for cancer care could be the only mechanism by which patients with cancer in low-income

Search strategy and selection criteria

References were identified through searches of PubMed, with the search terms “surgery”, “cancer”, “Africa”, “chemotherapy”, “radiation therapy”, “breast cancer”, “prostate cancer”, “cervical cancer”, “esophageal cancer”, “gastric cancer”, “colorectal cancer”, and “liver cancer”, from January, 1980, to June, 2012. Only papers published in English were reviewed. The final reference list was generated on the basis of originality and relevance to the broad scope of this report.

References (83)

  • MB Barton et al.

    Role of radiotherapy in cancer control in low-income and middle-income countries

    Lancet Oncol

    (2006)
  • KJ Baatjes et al.

    7-year follow up of intra-operative radiotherapy for early breast cancer in a developing country

    Breast

    (2012)
  • LG Hadley et al.

    Challenge of pediatric oncology in Africa

    Semin Pediatr Surg

    (2012)
  • RS Groen et al.

    Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional, countrywide survey

    Lancet

    (2012)
  • L Schwentner et al.

    Survival of patients with bilateral versus unilateral breast cancer and impact of guideline adherent adjuvant treatment: a multi-centre cohort study of 5292 patients

    Breast

    (2012)
  • BO Anderson et al.

    Optimisation of breast cancer management in low-resource and middle-resource countries: executive summary of the Breast Health Global Initiative consensus, 2010

    Lancet Oncol

    (2011)
  • DM Parkin et al.

    Cancer burden in the year 2000. The global picture

    Eur J Cancer

    (2001)
  • J Ferlay et al.

    Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008

    Int J Cancer

    (2010)
  • D Burkitt

    A “tumour safari” in east and central Africa

    Br J Cancer

    (1962)
  • PE Farmer et al.

    Surgery and global health: a view from beyond the OR

    World J Surg

    (2008)
  • NJ Umoh et al.

    Aetiological differences in demographical, clinical and pathological characteristics of hepatocellular carcinoma in The Gambia

    Liver Int

    (2011)
  • SA Adewuyi et al.

    The pattern of chest radiographs findings in metastatic cancer patients seen in a tertiary hospital in northern Nigeria

    Niger Postgrad Med J

    (2011)
  • S Marjerrison et al.

    The use of ultrasound in endemic Burkitt lymphoma in Cameroon

    Pediatr Blood Cancer

    (2012)
  • MA Gonzaga

    How accurate is ultrasound in evaluating palpable breast masses?

    Pan Afr Med J

    (2010)
  • BA Ojo et al.

    Surgical lymph node biopsies in University of Ilorin Teaching Hospital, Ilorin, Nigeria

    Niger Postgrad Med J

    (2005)
  • AA Ajape et al.

    An overview of cancer of the prostate diagnosis and management in Nigeria: the experience in a Nigerian tertiary hospital

    Ann Afr Med

    (2010)
  • GO Klufio

    A review of genitourinary cancers at the Korle-Bu teaching hospital Accra, Ghana

    West Afr J Med

    (2004)
  • R Siegel et al.

    Cancer treatment and survivorship statistics, 2012

    CA Cancer J Clin

    (2012)
  • M Ahmed

    Prostate cancer diagnosis in a resource-poor setting: the changing role of digital rectal examination

    Trop Doct

    (2011)
  • D Dawam et al.

    Benign prostatic hyperplasia and prostate carcinoma in native Africans

    BJU Int

    (2000)
  • K Bowa

    An overview of the diagnosis and management of prostate cancer in Nigeria: experience from a north-central state of Nigeria

    Ann Afr Med

    (2010)
  • GA Magoha

    Subcapsular orchidectomy in the management of prostatic carcinoma in Nigerians

    East Afr Med J

    (1989)
  • BH Yang et al.

    Cervical cancer as a priority for prevention in different world regions: an evaluation using years of life lost

    Int J Cancer

    (2004)
  • Reducing uncertainties about the effects of chemoradiotherapy for cervical cancer: individual patient data meta-analysis

    Cochrane Database Syst Rev

    (2010)
  • L Denny et al.

    Human papillomavirus-based cervical cancer prevention: long-term results of a randomized screening trial

    J Natl Cancer Inst

    (2010)
  • DE Obaseki et al.

    Diagnostic accuracy of fine needle aspiration cytology of palpable breast masses in Benin City, Nigeria

    West Afr J Med

    (2010)
  • A Gakwaya et al.

    Cancer of the breast: 5-year survival in a tertiary hospital in Uganda

    Br J Cancer

    (2008)
  • AY Ukwenya et al.

    Delayed treatment of symptomatic breast cancer: the experience from Kaduna, Nigeria

    S Afr J Surg

    (2008)
  • VI Odigie et al.

    Psychosocial effects of mastectomy on married African women in Northwestern Nigeria

    Psychooncology

    (2010)
  • SN Anyanwu et al.

    Neoadjuvant chemotherapy for locally advanced premenopausal breast cancer in Nigerian women: early experience

    Niger J Clin Pract

    (2010)
  • JS Mieog et al.

    Preoperative chemotherapy for women with operable breast cancer

    Cochrane Database Syst Rev

    (2007)
  • Cited by (172)

    • A giant metastatic low-grade endometrial sarcoma requiring surgical management

      2022, International Journal of Surgery Case Reports
      Citation Excerpt :

      Their treatment is largely surgical. Late presentation of cancers is commonplace in most low-income countries in sub-Saharan Africa [6]. We here report the surgical management of a 58-year-old woman presenting at the National University Hospital of Cotonou (Benin) with a giant metastatic LG-ESS with an embolic complication.

    View all citing articles on Scopus
    View full text