Karachi: Last month I attended a multidisciplinary meeting, called tumour board, in Jinnah Post-graduate Medical Centre, Karachi. The good news is that it was well attended. Cases of patients suffering from cancer were discussed and stage-specific treatment was finalised. Multidisciplinary approach for complicated diseases like cancer is a welcome sign and this approach is being popularised by healthcare professionals in Pakistan.1 Multidisciplinary meetings improve the outcome of the treatment and are prerequisite for accreditation for post graduate training by the American College of Surgeons Commission on Cancer.2
The bad news was that all except one patient were in the advanced stages, where curative treatment including surgery was not possible, despite considerable advancement in the technique. The selection of cases for presentation by postgradautes in the meeting may be biased, but the pattern of clinical presentation in the out-patient department was mostly the same as it was 20 years ago in JPMC, where I worked as professor of surgery.
Prof. Ghulam Asghar Channa
The remarkable difference was that many treatment options are available now. Chemotherapy, immune therapies, newer forms of radiotherapy like cyber knife and robotic surgery are among the options, depending upon molecular diagnosis and stage of the cancer. Surgeons practicing oncology know the limitation, but surgery plays critical role in diagnosis, remedy of the cancer, restoration of function and maintaining the quality of life, provided the cancer is localised in one part of the body. Curative surgery is meant to cure the cancer as defined by National Cancer Institute USA.3 Promotion of multidisciplinary approach to cancer is commendable, especially by postgraduate’s leadership. To reap the benefits of research and advancement, it is mandatory to spread the awareness that cancers are preventable, if treated early, and are curable in cost effective manner. Due to lack of public awareness, social taboos, inadequate health policies for prevention, early detection, and lack of facilities for screening of cancer, majority of the patients ignore the early symptoms and seek medical help only when routine of life is considerably disturbed and the disease has spread to multiple parts of the body. Projected increase in the global burden of neoplastic diseases and rise in the cost of treatment of cancer, the crisis of affordability, and chances for survival are deepening, especially in low- and middle-income countries. Financial support in Pakistan is provided by about 40 philanthropic private welfare and government organisations dedicated to cancer care. In private sector, Shaukat Khanum Memorial Hospital and others are doing noble work providing financial help, serving as a ray of hope to non-affording cancer patients. Significant amount of donation is given to these organisations from within and out of Pakistan.
In the government sector, Pakistan Atomic Energy Commission and its oncology wing and others like JPMC are doing commendable work. Recognising the importance of public awareness and preventive aspect of cancer in Pakistan, National Action Plan for Prevention and Control of Non-Communicable Diseases and health promotion was prepared in tripartite collaboration of the Ministry of Health, WHO, and NGO, founded by Dr. Sania Nishtar, Heartfile in 2004. The goals of NAP-NCD were to prevent and control the prevalence of cancer by mitigating exposure to risk factors, early detection, providing adequate treatment facilities, and palliative care, besides to enable cancer hospitals to conduct research and manage registries and to act for control of cancer. In association with the Oncology Society of Pakistan, in 2010 the government endeavoured to improve the database on national basis.
National Cancer Registry in Pakistan, receives data from eight hospitals in the country since 2015. According to this data, the common cancers in Pakistan are Breast (14%), Oropharyngeal (10%), and cancers of GIT (9%). The rate of new cases is 148,000. According to more detailed information provided by the International Agency for Research on Cancer (IARC) for Pakistan, 0.18 million cases are newly diagnosed and the prevalence of cancer is 0.32 million. Pakistan has significantly high breast cancer prevalence and new case rate, with highest mortality in the region. The annual death rate due to cancer is 118,631. The higher incidence and high cancer mortality as reported must undergo analytical research to find out the genetic, social and environmental factors in Pakistan. Higher mortality and high prevalence may be multifactorial but significant delay in reporting for the treatment may be the reason for higher mortality.
The delay may be due to inequities in cancer services, like availability of screening, clinical, biological, and molecular evaluation, and, most importantly, lack of general awareness and poverty. Cost of therapy, in geo-political and economic crises after the diagnosis of cancer
With more than two hundred different types of cancers, costs of medical care attributed to cancer are variable, but invariably higher than other chronic diseases. Managing the expenses for costly drugs, produces stress and creates negative impact on the patient’s health and that of the family, further impairing the quality of life. Anxiety, stress, depression, and fear of the disease leads to a mental state, called financial toxicity.4 Economic crises, cross border tensions whereas some regional countries have better cancer care, devaluation of currency for importing the drugs exacerbate the impact of cost and stress in Pakistan. In politically unstable countries like Pakistan, the cost of cancer substantially increases every passing day for those who must spend for their health from their own pocket.
In developed countries, due to better health facilities, political, and public awareness, screening and health insurance plans, significant proportion of patient report in early stages to hospitals for treatment. Despite having the steady economies, the cost of cancer therapy keeps on multiplying.
According to American Cancer Society, with 1.8 million new cancer cases, the estimated cost for cancer care is 5.6 billion dollars. According to National Cancer Institute, the cost will grow to $246.6 billion by 2030. This estimate does not account for loss of work hours, travelling to treatment centres, and hiring care givers, and generalised functional disability.
The financial burden of cancer for the patient and the family is four times higher than other chronic disease and it is staggering. According to NCI estimates, on average the annual cost of care can be divided in three phases.
• Initial care after diagnosis (first 12 months after diagnosis).
$ 43,516
• For continuing care (the period between initial care and end of life) $ 5,516
• In the last year of life (end of life care) $109,727
The annual average cost varies considerably depending on the site and (size) stage of the cancer.
Cancer care and universal health in Pakistan
Every country has different health care system. Implementation of health policies remain under continuous review based on data, research, feedback and funding for improving the systems.
Pakistan’s health care system faces stagnation, due to lack of implementation and sustainability of comprehensive health policies. After the National Action Plan for Prevention and Control of Non-Communicable Disease and health promotion in 2004, Pakistan government undertook many initiatives in collaboration with foreign funding agencies. Recently the government introduced from its resources, universal health coverage by introducing Sehat Suhulat Programme. Politicians assured the public that it will extend help for cancer patients as well as patients suffering from other chronic diseases.
Pakistan spends US$ 38 per capita on health care. With new cases at the current rate and prevalence, with estimates from the developed counties and key health financing indicators in Pakistan, there is adequate evidence that it is not possible to provide free treatment to all the patients suffering from cancer and other chronic diseases. There is obvious lack of awareness about preventive aspect of cancers, both among public and the politicians, resulting in poor infrastructure, non-availability of trained manpower, and facilities for screening. The investment in the improvement of these facilities is critical for improvement in health, and decrease the agony of advanced cancers. For example, avoidance of risk factors like beetle nut and eradication of benign infections like H. Pylori significantly reduces the prevalence of carcinoma of oropharynx, carcinoma of stomach and colon, respectively. Elimination of papilloma virus, early detection by Pap smears with minimal expenditure can detect curable cervical cancer in the early stages with proper awareness among public health, single dose of quadrivalent HPV, vaccination may lead to global elimination of cervical cancer. Similarly, many cancers can be either prevented, detected early, and cured with minimal cost with rapid development in cancer research, leading to early detection, accurate diagnosis, and multiple modalities of treatment, survival has increased substantially in the developed countries and in those patients who can afford the costly treatment.
Despite tremendous progress in the treatment of cancer, the oldest modality, surgery remains the most effective in diagnosis and treatment of many solid tumours. With multidisciplinary approach, improved perioperative care, targeted therapies, and neo-adjuvant chemotherapy, most of the tumours once considered inoperable can be cured now; multidisciplinary approach addresses the key questions in the management of cancer.
Awareness among people of different socio-cultural practices and socio-economic status for avoidance of exposure to risk factors, reporting for screening at appearance of initial symptoms is essential.
The logical progress in this direction is only possible by participation of governments for implementation and consistency in comprehensive health policies, providing facilities for early detection, diagnosis on molecular basis, and better treatment facilities. In the new era of digital revolution and AI, where genomic and immunologic advances are speeding up, there is a need to establish National Registry, collaborate with well-established regional and international research and service centres to face the burden of cancer. Failure to act by the government is a missed opportunity at the cost of lives and misery of millions of people. Better health is the best economy. The responsibility of surgeons and physicians is much more than surgery. The advocacy for mobilisation of strong political will is essential. Students’ leadership role in arranging multidisciplinary approach is appreciated. Similarly, the student leadership force can be used for creating awareness among the public, among health policy makers, and generating political will in the government for comprehensive policies, consistency in implementation, collaboration, and readiness for improvement in health system based on research.
- Rao U.J, Tahir E, Rehman M. A, Khan J, Sohail K, Khan A.M.H, et al. Student-led Establishment of Multidisciplinary Tumour Boards In Pakistan: Our Experience; Conference: World Cancer Congress At: Geneva, Switzerland October 2020 available (PDF) Student-Led Establishment of Multidisciplinary Tumour Boards in Pakistan: Our Experience (researchgate.net) Accessed July 19/2024
- Nancy L ,Mary B. L, Elizabeth B. L, Samuel R. B, Lawrence N. S, Barbara J. McNeil. Tumour Boards and the Quality of Cancer Care; J Natl Cancer Inst. 2013 Jan 16; 105(2): 113–121. Published online 2013 Jan 15. doi: 10.1093/jnci/djs502,
- https://www.cancer.gov/publications/dictionaries/cancer-terms/def/curative-surgery
- . Qasim SMH, Arjun G, Stacie B. Financial Toxicity of Cancer Treatment: JAMA Oncology May 2022 Volume 8, Number 5 (P 788). Downloaded from jamanetwork.com by Ghulamasghar channa on 07/01/2024, Published Online: March 10, 2022. doi:10.1001/jamaoncol.2021.7987
- https://progressreport.cancer.gov/after/economic_burden)
*Former VC SMBBMU Larkana – Sindh.
