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.
SeriesTreatment of cancer in sub-Saharan Africa
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 (83)
- et al.
Expansion of cancer care and control in countries of low and middle income: a call to action
Lancet
(2010) - et al.
Improvement of pathology in sub-Saharan Africa
Lancet Oncol
(2013) - et al.
Accuracy of visual inspection with acetic acid for cervical cancer screening
Int J Gynaecol Obstet
(2011) - et al.
A new HPV-DNA test for cervical-cancer screening in developing regions: a cross-sectional study of clinical accuracy in rural China
Lancet Oncol
(2008) - et al.
The severity, outcome and challenges of breast cancer in Nigeria
Breast
(2006) - et al.
The role of surgery in the management of oesophageal cancer
Lancet Oncol
(2003) - et al.
Rectal cancer: the sphincter-sparing approach
Surg Clin North Am
(2002) - et al.
Gastric cancer in Africa: what do we know about incidence and risk factors?
Trans R Soc Trop Med Hyg
(2012) Bioequivalence and other unresolved issues in generic drug substitution
Clin Ther
(2003)- et al.
Status of radiotherapy resources in Africa: an International Atomic Energy Agency analysis
Lancet Oncol
(2013)
Role of radiotherapy in cancer control in low-income and middle-income countries
Lancet Oncol
7-year follow up of intra-operative radiotherapy for early breast cancer in a developing country
Breast
Challenge of pediatric oncology in Africa
Semin Pediatr Surg
Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional, countrywide survey
Lancet
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
Optimisation of breast cancer management in low-resource and middle-resource countries: executive summary of the Breast Health Global Initiative consensus, 2010
Lancet Oncol
Cancer burden in the year 2000. The global picture
Eur J Cancer
Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008
Int J Cancer
A “tumour safari” in east and central Africa
Br J Cancer
Surgery and global health: a view from beyond the OR
World J Surg
Aetiological differences in demographical, clinical and pathological characteristics of hepatocellular carcinoma in The Gambia
Liver Int
The pattern of chest radiographs findings in metastatic cancer patients seen in a tertiary hospital in northern Nigeria
Niger Postgrad Med J
The use of ultrasound in endemic Burkitt lymphoma in Cameroon
Pediatr Blood Cancer
How accurate is ultrasound in evaluating palpable breast masses?
Pan Afr Med J
Surgical lymph node biopsies in University of Ilorin Teaching Hospital, Ilorin, Nigeria
Niger Postgrad Med J
An overview of cancer of the prostate diagnosis and management in Nigeria: the experience in a Nigerian tertiary hospital
Ann Afr Med
A review of genitourinary cancers at the Korle-Bu teaching hospital Accra, Ghana
West Afr J Med
Cancer treatment and survivorship statistics, 2012
CA Cancer J Clin
Prostate cancer diagnosis in a resource-poor setting: the changing role of digital rectal examination
Trop Doct
Benign prostatic hyperplasia and prostate carcinoma in native Africans
BJU Int
An overview of the diagnosis and management of prostate cancer in Nigeria: experience from a north-central state of Nigeria
Ann Afr Med
Subcapsular orchidectomy in the management of prostatic carcinoma in Nigerians
East Afr Med J
Cervical cancer as a priority for prevention in different world regions: an evaluation using years of life lost
Int J Cancer
Reducing uncertainties about the effects of chemoradiotherapy for cervical cancer: individual patient data meta-analysis
Cochrane Database Syst Rev
Human papillomavirus-based cervical cancer prevention: long-term results of a randomized screening trial
J Natl Cancer Inst
Diagnostic accuracy of fine needle aspiration cytology of palpable breast masses in Benin City, Nigeria
West Afr J Med
Cancer of the breast: 5-year survival in a tertiary hospital in Uganda
Br J Cancer
Delayed treatment of symptomatic breast cancer: the experience from Kaduna, Nigeria
S Afr J Surg
Psychosocial effects of mastectomy on married African women in Northwestern Nigeria
Psychooncology
Neoadjuvant chemotherapy for locally advanced premenopausal breast cancer in Nigerian women: early experience
Niger J Clin Pract
Preoperative chemotherapy for women with operable breast cancer
Cochrane Database Syst Rev
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