High cost of few cancer screening, treatment centres reduces patients’ survival chances

Mrs Nwabufo Chika, (fondly nicknamed ‘Ika’) has been a breast cancer survivor for six years. Unfortunately, last year November, the cancer spread to her spine…. and affected her walking.

Through the continued assistance of Breast Without Spot (BWS), a non governmental organization (NGO), she received an emergency radiotherapy at Abuja that cost N450,000, following a Magnetic Resonance Imaging (MRI) scan.

Chika is responding to treatment but was informed that she needed chemotherapy treatment that would cost her N40,000 per week for 12 weeks.

Chika who is receiving treatment at University of Nigeria Teaching Hospital (UNTH) Enugu is not alone in her travails.

President and Founder of BWS and a foremost oncologist at UNTH, Prof. Ifeoma Okoye, got this message from one of her patients: “Good morning Ma.

Please Ma; do not be angry at this question. Mummy please is there extra money that I can use to upset the hospital bill I incurred from the time I came to Dr. Okwor hospital. I mean the time you sent me for MRI. I have paid some and it is remaining N75,000. He is on my neck. He tried on his part to deduct some money. I paid N50,OOO. I don’t have money to pay for the hospital money.

Feeding my mother and myself is now becoming difficult. Please I wish you would help pay the hospital bill. Let God continue feeding us.”

Also, patients, receiving treatments in National Hospital, Abuja have decried high cost of treatment and called for the government intervention to subsidize the cost nationwide.

They also stressed the need for the government to provide more radiotherapy machine for cancer treatment at every radiotherapy centre in the country.

They made their grievances known when the Tai Aremu Cancer Awareness Campaign Organisation visited cancer patients on Monday in Abuja.

A lady, Helen Ogbonna, who lamented high cost of treatment in the hospital, disclosed that the sum for radiotherapy treatment at the National Hospital is N600,000 everyday for five weeks, while N309,000 is for chemotherapy injection in every 21 days.

According to her, hospitals across the country lacks what it takes to detect cancer early, lamenting that, before it is later detected it has already escalated beyond control.

Cancer is a generic term for a large group of diseases characterized by the growth of abnormal cells beyond their usual boundaries that can then invade adjoining parts of the body and/or spread to other organs. Other common terms used are malignant tumours and neoplasms.

Cancer can affect almost any part of the body and has many anatomic and molecular subtypes that each requires specific management strategies.

Cancer is the second leading cause of death globally and is estimated to account for 9.6 million deaths in 2018.

Lung, prostate, colorectal, stomach and liver cancer are the most common types of cancer in men, while breast, colorectal, lung, cervix and thyroid cancer are the most common among women.

The Guardian investigation showed that an average cancer patient, on regular screening, clinical assessment and chemotherapy, over the course of a year, may accumulate N5 million to N20 million or more in medical bills depending on the type of cancer, the type of treatment and where the treatment is being accessed.

Also, the Federal Government, the State governments and more private hospitals are procuring cancer treatment machine/ linear accelerator (LINAC), which costs about $5 million (about N1.8 billion).

It is estimated that there are over 20 LINAC in Nigeria today, totaling N36 billion.

It was further gathered that Nigeria has not enough comprehensive cancer centres and lacks adequate treatment facilities hence citizens are compelled to spend over $200 million (N72 billion) annually on treatment abroad.

Global burden
The World Health Organization (WHO) said about 24.6million people live with cancer worldwide while about 12.5 per cent of all death is attributable to cancer.

It further estimates that over 100,000 Nigerians are diagnosed with cancer yearly, while about 80,000 die from the disease.

This brings the consequences of the cancer epidemic to 240 Nigerians every day or 10 Nigerians every hour, dying from cancer.

It noted that the country’s cancer death ratio of four in five affected persons is one of the worst in the whole world.

Also, the WHO in a fact sheet said only one in five low- and middle-income countries have the necessary data to drive cancer policy and cancer is a leading cause of death worldwide, accounting for 8.8 million deaths in 2015.

According to the WHO, the most common causes of cancer death are cancers of: lung (1.69 million deaths); liver (78,000 deaths); colorectal (77,000 deaths); stomach (75,000 deaths); and breast (57,000 deaths).

The Guardian also reliably gathered that cost of cancer treatments in teaching hospitals nationwide are cheaper than anywhere else in the country because the Federal Government has subsidized them.

Statistics from the Nigerian National System of Cancer Registries (NSCR) indicate that over 60 per cent of all cancer cases in Nigeria occur in women and are mainly due to breast, cervical and ovarian cancers.

The figures show that breast cancer in Nigeria has increased significantly with over 100,000 new cases diagnosed yearly which translate into 8,333 monthly, 274 daily or approximately 11 cases every hour.

Statistics from 2009 – 2013 also showed that while men account for 34 per cent, women cancers account for 66 per cent of all cancers documented in Nigeria.

According to the latest figures from the International Agency for Research on Cancer (IARC), the global cancer burden is estimated to have risen to 18.1 million new cases and 9.6 million deaths in 2018.

The GLOBOCAN 2018 database, accessible online as part of the IARC Global Cancer Observatory, provides estimates of incidence and mortality in 185 countries for 36 types of cancer and for all cancer sites combined.

IARC is part of the WHO. Its mission is to coordinate and conduct research on the causes of human cancer, the mechanisms of carcinogenesis, and to develop scientific strategies for cancer control.

An analysis of these results, published in CA: A Cancer Journal for Clinicians, highlighted the large geographical diversity in cancer occurrence and the variations in the magnitude and profile of the disease between and within world regions.

According to the report, one in five men and one in six women worldwide develop cancer during their lifetime, and one in eight men and one in 11 women die from the disease.

Worldwide, the total number of people who are alive within five years of a cancer diagnosis, called the five-year prevalence, is estimated to be 43.8 million.

However, the new data show that most countries are still faced with an increase in the absolute number of cases being diagnosed and requiring treatment and care.

Global patterns show that for men and women combined, nearly half of the new cases and more than half of the cancer deaths worldwide in 2018 are estimated to occur in Asia, in part because the region has nearly 60 per cent of the global population.

Europe accounts for 23.4 per cent of the global cancer cases and 20.3 per cent of the cancer deaths, although it has only 9.0 per cent of the global population.

The Americas have 13.3 per cent of the global population and account for 21.0 per cent of incidence and 14.4 per cent of mortality worldwide.

In contrast to other world regions, the proportions of cancer deaths in Asia and in Africa (57.3 per cent and 7.3 per cent, respectively) are higher than the proportions of incident cases (48.4 per cent and 5.8 per cent, respectively), because these regions have a higher frequency of certain cancer types associated with poorer prognosis and higher mortality rates, in addition to limited access to timely diagnosis and treatment in many countries.

Cancers of the lung, female breast, and colorectal are the top three cancer types in terms of incidence, and are ranked within the top five in terms of mortality (first, fifth, and second, respectively).

Together, these three cancer types are responsible for one third of the cancer incidence and mortality burden worldwide.

Cancers of the lung and female breast are the leading types worldwide in terms of the number of new cases; for each of these types, approximately 2.1 million diagnoses are estimated in 2018, contributing about 11.6 per cent of the total cancer incidence burden.

Colorectal cancer (1.8 million cases, 10.2 per cent of the total) is the third most Commonly diagnosed cancer, prostate cancer is the fourth (1.3 million cases, 7.1 per cent), and stomach cancer is the fifth (1.0 million cases, 5.7 per cent).

Lung cancer is also responsible for the largest number of deaths (1.8 million deaths, 18.4 per cent of the total), because of the poor prognosis for this cancer worldwide, followed by colorectal cancer (881,000 deaths, 9.2 per cent), stomach cancer (783,000 deaths, 8.2 per cent), and liver cancer (782,000 deaths, 8.2 per cent).

Female breast cancer ranks as the fifth leading cause of death (627,000 deaths, 6.6 per cent) because the prognosis is relatively favourable, at least in more developed countries.

For many cancers, overall incidence rates in countries with high or very high Human Development Index (HDI) are generally two–three times those in countries with low or medium HDI.

However, the differences in mortality rates between these two categories of countries are smaller, on the one hand because lower-HDI countries have a higher frequency of certain cancer types associated with poorer survival, and on the other hand because access to timely diagnosis and effective treatment is less common.

In men, lung cancer ranks first and prostate cancer second in incidence in both developed and developing countries.

In women, incidence rates for breast cancer far exceed those for other cancers in both developed and developing countries, followed by colorectal cancer in developed countries and cervical cancer in developing countries.

Lung cancer is the most commonly diagnosed cancer in men (14.5 per cent of the total cases in men and 8.4 per cent in women) and the leading cause of cancer death in men (22.0 per cent, that is about one in five of all cancer deaths).

In men, this is followed by prostate cancer (13.5 per cent) and colorectal cancer (10.9 per cent) for incidence and liver cancer (10.2 per cent) and stomach cancer (9.5 per cent) for mortality.

Breast cancer is the most commonly diagnosed cancer in women (24.2 per cent, that is about one in four of all new cancer cases diagnosed in women worldwide are breast cancer), and the cancer is the most common in 154 of the 185 countries included in GLOBOCAN.

Breast cancer is also the leading cause of cancer death in women (15.0 per cent), followed by lung cancer (13.8 per cent) and colorectal cancer (9.5 per cent), which are also the third and second most common types of cancer, respectively; cervical cancer ranks fourth for both incidence (6.6 per cent) and mortality (7.5 per cent).

Lung cancer is a leading cause of death in both men and women and is the leading cause of cancer death in women in 28 countries.

The highest incidence rates in women are seen in North America, Northern and Western Europe (notably in Denmark and The Netherlands), China, and Australia and New Zealand, with Hungary topping the list.

Rising cases of cancer
According to the IARC report, the increasing cancer burden is due to several factors, including population growth and ageing as well as the changing prevalence of certain causes of cancer linked to social and economic development.

This is particularly true in rapidly growing economies, where a shift is observed from cancers related to poverty and infections to cancers associated with lifestyles more typical of industrialized countries.

Effective prevention efforts may explain the observed decrease in incidence rates for some cancers, such as lung cancer (example in men in Northern Europe and North America) and cervical cancer (example in most regions apart from Sub-Saharan Africa).

Chief Medical Director (CMD) of Lagos University Teaching Hospital (LUTH) Idi-Araba, Prof. Chris Bode, said: “We are no doubt looking more for diseases like cancer, diabetes, heart diseases and other conditions known as Non-Communicable Diseases (NCDs) now that we are almost conquering many communicable conditions like measles, tuberculosis (TB), diarrhea diseases etc.

“Our increasing adoption of affluent lifestyles and westernized feeding habits is fueling the rise of obesity which is definitely linked to a rise in cancer rates. Living in urban centers with all the air and water pollution also contribute to the rise in cancer while smoking and other unhealthy habits are also to blame. Lastly, we do not mount vigorous campaigns yet to prevent or minimize those we term modifiable risks.”

Director-General, West Africa Health Organisation (WAHO), Prof. Stanley Okolo, said: “Often you find that doctors may be more interested in illness and disease but actually for you to be well and not to go to the doctor, what you do to yourself, what you eat is more important.

Health and wellbeing is one of the mandate of the West African regional organisation and that is why we have a lot of programmes on nutrition, promotion of healthy exercise, not taking too much alcohol, avoiding total if you can tobacco products, those are key.

“For our part we know that there are things that sometimes the population will not be aware of and that is why when you go to buy medicines for your headache or the doctor prescribed antibiotics and you go to get that from the pharmacy you want to be assured that you are taking something that will make you better not worse, and that is part of the things that we have technical people can help with but for individuals, it is vitally important to make sure that you eat healthily, you avoid things that will be detrimental particularly excessive alcohol and smoking and that you have enough exercise. We say a minimum of 30 minutes a day exercise minimum and optimum of an hour a day and it could be walking, it could be running, footballing but whatever get active that is most important.”

Challenges
Okoye who is also Chairperson Association for Good Clinical Practice in Nigeria (AGCPN) –African Clinical Trial Consortium and Nigerian Clinical Trial Technical Working Group said in Nigeria, the rising incidence of cancer and the paucity of institutional facilities and specialist manpower imply that the burden of care rests largely on relatives.

She said: “We assessed the severity of indices of psycho-social and economic burden among relatives of women with breast and cervical cancer; and its relationship with patients’ psychosocial distress.

“The financial burden is more problematic than the effect of caring on family routines; and these two factors significantly predicted global rating of burden.

Thus, in Nigeria apart from the disruption of family life, the colossal amount of funds required for diagnosis and treatment are crippling.

The death of a cancer patient often means the loss of a breadwinner or total impoverishment of survivors due to high cost of treatment which often drains the resources of victims and their family members.”

Head Clinical Oncologist at HCG, Dr. Madhusudan N said the major challenges toward cancer control in Nigeria are inferior health infrastructure, lack of advance treatment technology and procedure, the right training for human resource and equipped screening centres.

Besides this, he said, late detection of cancer is also one of the reasons contributing to deteriorating survivorship in the country.

“To give an example, as per the international atomic energy board, at least there should be one radiotherapy unit per million populations but at present Nigeria has only nine external beam units and majority of them are non–functional.”

Bode said: “Diagnosis, treatment and care of cancers are expensive because of the exacting nature required at each of the stations you have mentioned. Unlike a fever, which you may wonder whether it is caused by a common cold or malaria while treating, cancer must be specifically diagnosed and confirmed before you commence treatment.

A doctor cannot say you have cancer today, commence treatment and then say sorry, it’s not cancer tomorrow. He must make sure beyond suspicion and confirm the diagnosis. That costs more.

Specialized treatment and expensive drugs are also needed to treat cancers. Equipment setup is prohibitively expensive as most are made only on order and not bought off the shelf. The relentless course of the disease in many cases discourage any meaningful inclusion on the NHIS list of coverable conditions insurances will not for.”

The cancer treatment centre in LUTH was shut down last year due to dilapidation. Over 100 cases were coming to the LUTH cancer centre daily for treatment when only one machine was all they had. Patients came to LUTH from as far as Sierra Leone and Congo. How far with the refurbishment?

The CMD said: “The new Advanced Cancer Treatment Centre in LUTH was built through a Public Private Partnership (PPP) arrangement between the Nigeria Sovereign Investment Authority and LUTH. It was completed with eight months of its commencement and it is to be commissioned this week by President Muhammadu Buhari. It is the best of such facilities in West Africa and has some of the latest equipment in a Africa, ranking with anywhere in the world.”

Going forward
Each year on 4 February, World Cancer Day (WCD) empowers people across the world to show support, raise collective voice, take personal action and press governments to do more.

WCD is the only day on the global health calendar where people can all unite and rally under the one banner of cancer in a positive and inspiring way.

The theme for 2019 is “I am and I will.”

On the way forward, Helen Ogbonna, a cancer patient, said: ‘’Government should try as much as possible to provide another machine, because only one machine cannot serve the whole of Nigeria, there is another one they call CT scan that one is faulty, a patient was asked to go and come back for scan in two weeks, before the two weeks the person died’’

‘’This nation is blessed by God, we need more machine because it is very possible fore the government to provide this machine for every state in the federation, in this hospital if we have up to four of this machine it is not too much because people will not be suffering, at times while waiting the machine will break down and patients will not be attended to’.

‘’I see no reason why patients will be coming from Ibadan and other part of the country to Abuja and the hospital will start complaining that the machine has broken down and requires servicing.’’

Head of the Section of Cancer Surveillance at IARC, Dr. Freddie Bray, said: “Best practice measures embedded in the WHO Framework Convention on Tobacco Control have effectively reduced active smoking and prevented involuntary exposure to tobacco smoke in many countries.

“However, given that the tobacco epidemic is at different stages in different regions and in men and women, the results highlight the need to continue to put in place targeted and effective tobacco control policies in every country of the world.”

IARC Director, Dr. Christopher Wild, said: “These new figures highlight that much remains to be done to address the alarming rise in the cancer burden globally and that prevention has a key role to play.

“Efficient prevention and early detection policies must be implemented urgently to complement treatments in order to control this devastating disease across the world.”

Bode said many cancers can be cured if diagnosed early and promptly treated. He explained: “Our culture, religious orientation and inclination to fear cancer however often prevent early diagnosis and prompt treatment. In our part of the world, any condition that is painless, that allows you to eat and that is not bleeding is not a serious matter. Thus, many cancers would have grown big and become late-stage before we seek help. Even when tumors become obvious, we first seek alternate, many times, ineffective remedies which then convert the early curable lesion into something that has festered and spread to become incurable.”

Okoye said early detection and utilization of ‘vaccinations against cancers’ saves lives. “But like the Gospel, don’t be selfish after you get converted and do your screening or receive your vaccination. Inform others. Support others, support communities, support your sphere of influence, to get screened, and or vaccinated.”

She said one could reduce his or her risk for cancer through healthy lifestyle vigilance.

“Exercise at least 45 minutes daily or at least times a week. Shun and avoid sedentary lifestyle. Be intentional about your food choices. Choose natural healthy unprocessed carbohydrates, lentils, fruits and vegetables especially leafy green vegetables and fruits (the more the variety of colours the better). Avoid smoking and hanging around smokers. Reduce Alcohol intake or better still, delete it from your diet. Avoid obesity, especially belly fat. Keep hydrating yourself with water. Adopt better health seeking behaviours.”

The oncologist urged everyone to be a Cancer Control Advocate, pass the message (Each one touch One), support work of cancer NGOs, contribute to patient treatment support funds and screening funds, and join to advocate government/private sector for provision of more cancer detection/treatment/care facilities).

“Finally, find out how to invest as private sector to provide more, screening and treatment centres.”

Okoye urged government at all levels to facilitate better access to cancer prevention/care, especially through

*Better access to cancer drugs (engage with pharmaceutical companies, and utilizing strategy of purchasing bulk from them, to ensure they drop prices and make available accessible/affordable drugs

*Provide more radiotherapy centres (encouraging both private/ public sector -driven facilities)

*Ensure facilities cover cancer management across continuum of care, to include prevention and palliation (ensuring end of life quality of life issues are properly handled)

*Effective provision for vigilant pain management

*Mandatory Universal Health Coverage (UHC)/Health Insurance (HI) and inclusion of cancer drugs in the National Health Insurance Scheme (NHIS).

*Support and promote capacity of all categories if healthcare providers involved in diagnosis, management and care of cancer patients in both horning their skills, Professional development, acquisition/proficiency and research capacity

*Creating enabling environment/support for cancer research, and growth of indigenous drug development (scaling access to clinical trials, to enable our local low-hanging candidates with medicinal potential, get to the market place, if their efficacy is proved

*Establishing more efficient structures for data storage, retrieval and management with a trusted National Cancer Registry. … generating reliable data germane to Nigeria

*Foster more synergy, dialogue and collaboration with NGOs supporting Cancer Control

*Roll out effective cancer vaccination and screening programmes!

Madhusudan said among the many cancer condition prevalent, breast cancer and cervix cancer are the two most common cancers in Nigeria, constituting of about 40 per cent of newly diagnosed cancers in Nigeria and contributing to 36.5 per cent death from all cancers.

The oncologist said: “As an important measure to curb the cancer incidences in Nigeria, especially the preventable and treatable ones, we believe that awareness, right information at the right time and early detection has to be practiced.

Being the specialist in cancer care, HCG proactively is involved in conducting regular cancer screening camps at various locations in the country to detect pre-invasive lumps in the breast and regular Pap smear camps to detect pre-invasive cervical cancers.

“Apart from screening camps, HCG is creating holistic awareness in the general public as well as non-oncology medical fraternity about the importance of self-health examination where people can undergo basic health check on their own at home to locate lumps or sense abnormalities associated with their health. We are also associated with local partners and NGOs to carry out the educative programs on cancer awareness and improve the perception of cancer as a disease.

“We are also working towards encouraging HPV vaccination in sexually active females to prevent cervical cancer. Comprehensive care is what HCG believes in, therefore to provide hope to cancer patients we ensure that we take the cancer survivors to various parts of the country, and share the journey of determination, hope and winning over cancer to the patients and their family members.”

The oncologist said cancer is no more a death sentence. “It is controllable provided we practise patient approach in early stages. Government should set up radiotherapy units in each state and set up tertiary cancer centre at two or three locations in the country.

Government should make cancer treatment accessible and affordable. Implementing rigorous screening strategies; and creating awareness in the public. Setting up mammography units in each state hospitals and make availability of routine Pap smear testing in every state hospital. Allocating separate budget for prevention, control and treatment of cancer.”

According to current evidence from the WHO, between 30 per cent and 50 per cent of cancer deaths could be prevented by modifying or avoiding key risk factors, including avoiding tobacco products, reducing alcohol consumption, maintaining a healthy body weight, exercising regularly and addressing infection-related risk factors.

To reduce the significant disability, suffering and deaths caused by cancer worldwide, effective and affordable programmes in early diagnosis, screening, treatment, and palliative care are needed.

Treatment options may include surgery, medicines and/or radiotherapy; treatment planning should be guided by tumour type, stage and available resources and informed by the preference of the patient.

Palliative care, which focuses on improving the quality of life of patients and their families, is an essential component of cancer care.

Accelerated action is needed to improve cancer care, achieve global targets to reduce deaths from cancer and provide health care for all consistent with universal health coverage.

The key mission of WHO’s work in cancer control is to promote national cancer control policies, plans and programmes that are harmonized with strategies for non communicable diseases and other related health concerns.

“Our core functions are to set norms and standards for cancer control including the development of evidence-based prevention, early diagnosis, screening, treatment and palliative care programmes as well as to promote monitoring and evaluation through registries and research that are tailored to the local disease burden and available resources.”

On WCD 2019, WHO launched a new toolkit to guide countries in the collection and use of standardised data on cervical cancer, to support them in addressing this great threat to women’s health.

Every year, cervical cancer kills over 300,000 women, more than 85 per cent of these deaths occur in less developed regions of the world.

Cervical cancer is one of the most preventable and treatable forms of cancer, as long as it is detected early and managed effectively.

High-quality and timely data are essential for comprehensive cervical cancer control programmes and under-pin effective policy-making.

WHO Assistant Director-General for Non-communicable Diseases and Mental Health, Dr. Svetlana Axelrod, said: “It is unacceptable that every two minutes one woman dies of cervical cancer in a world where we have the proven solutions to prevent and treat this disease.

“The WHO’s Improving Data for Decision-making toolkit will support countries in collecting and using high-quality data to inform, plan, scale up and improve cervical cancer programmes. With data on screening coverage and uptake, interventions can be employed to make sure no woman is left behind. Strong data systems will support global efforts to make this cancer a disease of the past.”

The development of the Improving Data for Decision-making toolkit was rooted in understanding the landscape of cervical cancer prevention and control programmes across the globe.

Contributions to this understanding came from international subject matter experts, as well as from the field experiences of experts in sub-Saharan Africa, Central and Latin America, and Asia.

Also, in September 2018 WHO announced a new effort – the WHO Global Initiative for Childhood Cancer – with the aim of reaching at least a 60 per cent survival rate for children with cancer by 2030, thereby saving an additional one million lives.

This new target represents a doubling of the global cure rate for children with cancer.

The aims of the Initiative are two-fold: to increase prioritization of childhood cancer through awareness raising at global and national levels and to expand the capacity of countries to deliver best practice in childhood cancer care.

Concretely, WHO will support governments to assess current capacities in cancer diagnosis and treatment including the availability of medicines and technologies; set and cost priority cancer diagnosis and treatment programmes; and integrate childhood cancer into national strategies, health benefits packages and social insurance schemes.

Cancer is a leading cause of death for children, with 300,000 new cases diagnosed each year among children aged 0-19 years.

Children with cancer in low- and middle-income countries are four times more likely to die of the disease than children in high-income countries.

This is because their illnesses are not diagnosed, they are often forced to abandon treatment due to high costs, and the health professionals entrusted with their care lack specialized training.

The WHO Global Initiative for Childhood Cancer, which involves development of a WHO technical package to help scale-up capacities within national health systems, will be achieved with support from a host of partners.

Among them is St. Jude Children’s Research Hospital in the United States, the first WHO Collaborating Centre on childhood cancer, which has committed US$ 15,000,000 to supporting implementation of the initiative.

WHO Director-General, Dr. Tedros Adhanom Ghebreyesus, said: “Too many children have their lives cut short by cancer, and survival rates in poor countries are scandalously lower than those in wealthy countries.

“We hope our partnership with St Jude will be a step towards redressing that injustice.”

The Initiative is announced on the heels of the Third Global High-Level Meeting on Non-communicable Diseases, which convened dozens of heads of state and ministers from all countries to prompt more urgent action on non-communicable diseases – among them cancer, diabetes, heart and lung diseases – which kill 41 million people each year.

The event is a milestone in furthering achievement of the Sustainable Development Goals (SDGs) in particular SDG target 3.4 to reduce premature mortality from non-communicable diseases by one third by 2030.