Endemic Non-Communicable Diseases

I agree. I am a FP doc in Papua New Guinea, with no oncology expertise and no one to turn to in my country for help. I have a book with some basic guidelines which I follow, but usually don't have enough chemo meds to treat the pts, as it isn't a priority for the country to stock the meds. I have treated over 30 cancer pts in 3+ yrs, and almost all have died. I try, but my resources are limited, it isn't just meds, but also supportive treatment like blood, platelets, neupogen, etc.

Recently, through the Max Foundation, we have qualified for the GIPAP program and Glivec for CML pts, this has really changed the quality of life for these pts and has been life changing. We now have pts who are living and going back to school and raising their kids, which is great.

Is it worth it? Well it is to the pts who are affected and their families.

Erin Meier

My experience with work in remote areas teaches me that we will never be able to fight cancer or for that matter many such diseases the conventional way.It is not just a question of funds but of a total support system.It is also impractical to shift all patients to cities.The hospitals in cities are already over loaded and there are multiple other issues e.g. if blood donors are needed at a short notice,how will they reach the hospital and who will motivate them to do so.Funds will be needed not only for treatment but transport and stay of attendants.Very often,relatives of a cancer patient will insist on some management even without a biopsy since they find it almost impossible to go to a city even for a diagnostic test.Our insistence on refusing to treat otherwise only drives them to non scientific methods of treatment.
Essentially,we will have to think out of the box and design innovative strategies.An entirely different treatment protocol may need to be written how the same disease will be managed in such areas.While so many well funded trials are done in big institutions,why are ...

I have found this to be true also. Going to the city, for the specialists, isn't feasible when they don't have funds to get there, and just because they go, doesn't mean they will be cared for well.

Innovative strategies and thinking outside the box is definitely important. In 3rd world settings without the resources of 1st world medicine, we can't be expected to be able to follow all the new guidelines, recommended blood tests for monitoring, and doses of meds. Most of my pts will die if they get neutropenia - I can't support them, nor fight all the infections they get when they have neutropenia. For the most part here in PNG, we are using about 3/4 of the dose that would be used in 1st world settings, to balance fighting the cancer and keeping the pt alive.

At times, we do therapy without biopsies, either surgical or chemotherapy, based on what is in front of us. If we have a pt with significant lymphadenopathy, that has failed antibiotics, and doesn't look like tb on bx and it will be 2-3 months before we get the official report back, we may start ...

I have found this to be true also. Going to the city, for the specialists, isn't feasible when they don't have funds to get there, and just because they go, doesn't mean they will be cared for well.

Innovative strategies and thinking outside the box is definitely important. In 3rd world settings without the resources of 1st world medicine, we can't be expected to be able to follow all the new guidelines, recommended blood tests for monitoring, and doses of meds. Most of my pts will die if they get neutropenia - I can't support them, nor fight all the infections they get when they have neutropenia. For the most part here in PNG, we are using about 3/4 of the dose that would be used in 1st world settings, to balance fighting the cancer and keeping the pt alive.

At times, we do therapy without biopsies, either surgical or chemotherapy, based on what is in front of us. If we have a pt with significant lymphadenopathy, that has failed antibiotics, and doesn't look like tb on bx and it will be 2-3 months before we get the official report back, we may start CHOP for lymphoma while we are waiting. The pts are looking for someone who is willing to help them, so we try the best we can with what is in front of us, and explain that to them. We are able to send peripheral smears via digital pics to a pathologist who helps with diagnosis of leukemias which can help guide our treatment.

erin

This is a great discussion. I'm an Oncologist in San Francisco and I'm
working on these issues with Oncologists in Uganda and Ethiopia.

I agree that guidelines for diagnosis, treatment and follow up need to be
specific to the needs and resources of each country and we need to push
ministries of health to develop and write a cancer control programme, even
if it is very basic. A patient with curable NHL, for example, in a setting
without supportive care and without a sustainable supply of drugs, might be
better off receiving 6 months of prednisone to allow at least some
prolongation of survival than to receive one course of CHOP and potentially
die sooner. A person with leukemia, unfortunately, would die a less painful
death with an adequate supply of steroids and morphine than with treatment
which cannot be supported. This is all setting-dependent, of course.

I also agree that we can task shift in the community such that a patient
does not need to travel 8 hours to a large city to receive treatment by an
Oncologist. In East Africa, for example, a patient with Kaposi's Sarcoma
could receive the first dose of Doxil or ...

This is a great discussion. I'm an Oncologist in San Francisco and I'm
working on these issues with Oncologists in Uganda and Ethiopia.

I agree that guidelines for diagnosis, treatment and follow up need to be
specific to the needs and resources of each country and we need to push
ministries of health to develop and write a cancer control programme, even
if it is very basic. A patient with curable NHL, for example, in a setting
without supportive care and without a sustainable supply of drugs, might be
better off receiving 6 months of prednisone to allow at least some
prolongation of survival than to receive one course of CHOP and potentially
die sooner. A person with leukemia, unfortunately, would die a less painful
death with an adequate supply of steroids and morphine than with treatment
which cannot be supported. This is all setting-dependent, of course.

I also agree that we can task shift in the community such that a patient
does not need to travel 8 hours to a large city to receive treatment by an
Oncologist. In East Africa, for example, a patient with Kaposi's Sarcoma
could receive the first dose of Doxil or Taxol at a large center, and then
continue treatment in a remote clinic, while the doctors/HCWs communicate by
mobile/SMS/internet.This is already happening between Kampala and Gulu and
other places, I'm sure.

Some of my colleagues are also working on studying how to build a cancer
registry categorizing people according to whether or not they have had a
tissue diagnosis. The old adage "tissue is the issue" does not apply in much
of the developing world as Erin discussed, and treatment should not be
delayed if a clinical diagnosis is pretty certain.

happy to continue the discussion offline!

Cheers,

Vinona


--
Vinona Bhatia, MD MPH
*Medical Director, Wrap Up Africa*
<>

*http://www.wrapupafrica.com/* <http://www.wrapupafrica.com/>
*http://www.wrapupafricafoundation.org/*<http://www.wrapupafricafoundation.org/>

here in png we have some guidelines - in the sense of a Cancer in PNG book. which gives us regimens and tells us what cancers we should try and treat with chemo, radiation, surgery or palliative care. it sure helps a lot, but it doesn't account for not having the meds that are mentioned, or the pts not being able to go for radiation due to funds or no availability where we have our radiation, or not having a surgeon who is willing to do the surgery, etc.

vinona - i am interested in using prednisone by itself, for some survival in lymphoma pts. who would you consider doing this in vs trying CHOP? - thanks

It is encouraging to know some of your experiences on oncology practice in low and middle income countries. These countries like many others are not uniformly low or middle income resourced. There are the poorest of the poor who carry more burden of disease than everyone else. As for cancer in the low-income countries, the issue is much more than the disease diagnosed and its direct medicines! For the greater part, the issue of cancer, its diagnosis and management has to do with the appropriateness (inappropriateness) of health planning/implementations of health programs and community perceptions of cancers,and expected outcomes given conventional treatments amongst others. I practised medicine in very rural areas of Uganda before coming to the city of Kampala in 2004 where I now practise and teach internal medicine and oncology. I suppose mobilization of resources, sensitizations of communities, destigmatizing cancers in communities, demystifying cancer diagnoses and treatments amongst doctors and patients alike, are important approaches to mitigating the cancer epidemic in low income countries. Unfortunately, there are doctors who hold cancers as mysteries and fail to deal with the problem because of this kind of mindset. There are doctors who think cancers need to be managed ...

It is encouraging to know some of your experiences on oncology practice in low and middle income countries. These countries like many others are not uniformly low or middle income resourced. There are the poorest of the poor who carry more burden of disease than everyone else. As for cancer in the low-income countries, the issue is much more than the disease diagnosed and its direct medicines! For the greater part, the issue of cancer, its diagnosis and management has to do with the appropriateness (inappropriateness) of health planning/implementations of health programs and community perceptions of cancers,and expected outcomes given conventional treatments amongst others. I practised medicine in very rural areas of Uganda before coming to the city of Kampala in 2004 where I now practise and teach internal medicine and oncology. I suppose mobilization of resources, sensitizations of communities, destigmatizing cancers in communities, demystifying cancer diagnoses and treatments amongst doctors and patients alike, are important approaches to mitigating the cancer epidemic in low income countries. Unfortunately, there are doctors who hold cancers as mysteries and fail to deal with the problem because of this kind of mindset. There are doctors who think cancers need to be managed in a highly specialized environment that can never be created now in low income countries! There are patients who take cancer diagnosis as a death sentence, maybe they are right! BUT we need to change these mindsets!
Amos