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Cancer Care and Control - the role of surgery

By Robert Riviello | 02 Nov, 2010

Four weeks ago, Dr. Farmer et al published in the Lancet "Expansion of cancer care and control in countries of low and middle income: a call to action." (see attached) [1]. As surgeons working in low and middle income countries (LMICs), we would like to congratulate the authors for their call to action to expand cancer care and control in these settings. We whole-heartedly support the call for increased collaboration across sectors and disciplines to mobilize resources to care for cancer patients in low and middle income countries. We also recognize that we are in a climate where surgical services are being undervalued in global health communities – as evidenced by the recent decision of the World Health Organization (WHO) to discontinue funding for its Global Initiative for Emergency and Essential Surgical Care (GIEESC).

In light of the upcoming Surgery and Global Health symposium this Friday, 5 Novemeber, we submit the following commentary and table as a reminder to the authors and the readership of the essential role that surgical services play in a multi-disciplinary approach to cancer care and control.

Yours,

Robert Riviello
John Meara
Selwyn Rogers


We strongly advocate for the critical role that surgical services play in cancer care. Surgical extirpation of the primary tumor is central for cure in almost all solid tumors. Furthermore, surgical intervention plays an important role along the continuum of care outlined by the authors: early diagnosis, prevention, treatment and palliation (Table 1).

In the past, Dr. Farmer and colleagues have championed the treatment of multi-drug resistant tuberculosis for poor patients in LMICs, demonstrating that it could be done cost effectively. They created systems to drive down costs and streamline supply chains. As a byproduct of their investment and innovation in healthcare delivery, they helped to build the healthcare infrastructure in LMICs. A similarly robust approach is needed for scaling up surgical services in the developing world. Surgery has been demonstrated to be more cost-effective than antiretroviral therapy, which is now considered a human right [2].

Rather than a dismissive approach to the role of surgery in cancer care (“Although surgical needs will continue to challenge treatment of cancers…”), concerted global action should include respectful partnerships with global surgical organizations (e.g. the African Colleges of Surgery, Alliance for Surgery and Anesthesia Presence, Canadian Network of International Surgery, Pan African Academy of Christian Surgeons, etc.) and local Ministries of Health to build surgical infrastructure and eliminate the implementation bottleneck for essential surgery. Cancer care should also be coordinated with surgical centers of excellence in LMICs that provide high quality surgical care and training at either free or highly subsidized pricing. [3]

Quoting Dr. Farmer, surgical services have been considered a “neglected stepchild” in the global public health community for too long. [4] Health-system strengthening must include increasing surgical capacity and access for poor patients in the developing world. [5] Greater partnership between leaders in public health, medicine, and surgery is urgently needed in order to overcome the injustice of disparities in cancer care.


Table 1. Role of surgery in LMICs cancer care:

Early diagnosis: screening and diagnosis
- The large majority of endoscopies for oral, head and neck, and gastrointestinal malignancies are performed in the operating theater by surgeons.
- Obtaining biopsy specimens, the foundation of cancer diagnosis, requires surgical delivery capacity.

Prevention
– Colonoscopic polypectomies prevent colon cancer.
– Lumpectomies for ductal carcinoma in situ prevents breast cancer.
– Colposcopy and excision prevents cervical cancer.
– Resection of leukoplakia and erthroplakia prevents oral cancer.
– Resection of actinic keratosis prevents skin cancer.

Treatment
– Most solid tumors are best treated with a multi-modality care plan (surgical resection and adjuvant therapy). Few are curable without resection of the primary tumor. A few examples include the following:

o Head and neck squamous cell
o Retinoblastoma
o Thyroid
o Breast
o Melanoma
o Osteosarcoma
o Soft tissue sarcomas
o Gastric
o Colon
o Bladder
o Prostate
o Cervical / uterine
o Ovarian

Palliation
– A large percentage of patients with cancer in LMICs currently present with advanced incurable disease, due to limited access to therapy. Examples of surgical palliation:
o toilet mastectomy for fungating breast cancer
o enteral and biliary bypass for advanced gastric and pancreatic cancers
o stenting for obstructing esophageal cancers
o hypogastric artery ligation and exfulguration for hemorrhaging cervical cancer
o bypass of obstructing laryngotracheal cancers
o excision of large fungating oral cancers
o bilateral orhiectomy for metastatic prostate cancer





References:
1. Farmer P, Frenk J, Knaulet FM, al. Expansion of cancer care and control in countries of low and middle income: a call to action. Lancet 2010. epub Aug 16, 2010.
2. Ozgediz D, Riviello R. The "other" neglected diseases in global public health: surgical conditions in sub-Saharan Africa. PLoS Med. 2008;5(6):e121.
3. Riviello R, Ozgediz D, Hsia RY, Azzie G, Newton M, Tarpley J. The Role of Collaborative Academic Partnerships in Surgical Training, Education and Provision. World Journal of Surgery. 2010: 34(3):459-65.
4. Farmer P, Kim J. Surgery and global health: a view from beyond the OR. World J Surg. 2008;32:533–536.
5. Funk LM, Weiser TG, Berry WR, et al. Global operating theatre distribution and pulse oximetry supply: an estimation from reported data. Lancet 2010: 376: 1055–61.

Attached resource:
  • Farmer, Lancet - Cancer Care in LMIC (download, 150.2 KB)

    Summary: Four weeks ago, Dr. Farmer et al published in the Lancet "Expansion of cancer care and control in countries of low and middle income: a call to action." (see attached) [1]. As surgeons working in low and middle income countries (LMICs), we would like to congratulate the authors for their call to action to expand cancer care and control in these settings. We whole-heartedly support the call for increased collaboration across sectors and disciplines to mobilize resources to care for cancer patients in low and middle income countries. We also recognize that we are in a climate where surgical services are being undervalued in global health communities – as evidenced by the recent decision of the World Health Organization (WHO) to discontinue funding for its Global Initiative for Emergency and Essential Surgical Care (GIEESC).

    In light of the upcoming Surgery and Global Health symposium this Friday, 5 Novemeber, we submit the following commentary and table as a reminder to the authors and the readership of the essential role that surgical services play in a multi-disciplinary approach to cancer care and control.

    Yours,

    Robert Riviello
    John Meara
    Selwyn Rogers


    We strongly advocate for the critical role that surgical services play in cancer care. Surgical extirpation of the primary tumor is central for cure in almost all solid tumors. Furthermore, surgical intervention plays an important role along the continuum of care outlined by the authors: early diagnosis, prevention, treatment and palliation (Table 1).

    In the past, Dr. Farmer and colleagues have championed the treatment of multi-drug resistant tuberculosis for poor patients in LMICs, demonstrating that it could be done cost effectively. They created systems to drive down costs and streamline supply chains. As a byproduct of their investment and innovation in healthcare delivery, they helped to build the healthcare infrastructure in LMICs. A similarly robust approach is needed for scaling up surgical services in the developing world. Surgery has been demonstrated to be more cost-effective than antiretroviral therapy, which is now considered a human right [2].

    Rather than a dismissive approach to the role of surgery in cancer care (“Although surgical needs will continue to challenge treatment of cancers…”), concerted global action should include respectful partnerships with global surgical organizations (e.g. the African Colleges of Surgery, Alliance for Surgery and Anesthesia Presence, Canadian Network of International Surgery, Pan African Academy of Christian Surgeons, etc.) and local Ministries of Health to build surgical infrastructure and eliminate the implementation bottleneck for essential surgery. Cancer care should also be coordinated with surgical centers of excellence in LMICs that provide high quality surgical care and training at either free or highly subsidized pricing. [3]

    Quoting Dr. Farmer, surgical services have been considered a “neglected stepchild” in the global public health community for too long. [4] Health-system strengthening must include increasing surgical capacity and access for poor patients in the developing world. [5] Greater partnership between leaders in public health, medicine, and surgery is urgently needed in order to overcome the injustice of disparities in cancer care.


    Table 1. Role of surgery in LMICs cancer care:

    Early diagnosis: screening and diagnosis
    - The large majority of endoscopies for oral, head and neck, and gastrointestinal malignancies are performed in the operating theater by surgeons.
    - Obtaining biopsy specimens, the foundation of cancer diagnosis, requires surgical delivery capacity.

    Prevention
    – Colonoscopic polypectomies prevent colon cancer.
    – Lumpectomies for ductal carcinoma in situ prevents breast cancer.
    – Colposcopy and excision prevents cervical cancer.
    – Resection of leukoplakia and erthroplakia prevents oral cancer.
    – Resection of actinic keratosis prevents skin cancer.

    Treatment
    – Most solid tumors are best treated with a multi-modality care plan (surgical resection and adjuvant therapy). Few are curable without resection of the primary tumor. A few examples include the following:

    o Head and neck squamous cell
    o Retinoblastoma
    o Thyroid
    o Breast
    o Melanoma
    o Osteosarcoma
    o Soft tissue sarcomas
    o Gastric
    o Colon
    o Bladder
    o Prostate
    o Cervical / uterine
    o Ovarian

    Palliation
    – A large percentage of patients with cancer in LMICs currently present with advanced incurable disease, due to limited access to therapy. Examples of surgical palliation:
    o toilet mastectomy for fungating breast cancer
    o enteral and biliary bypass for advanced gastric and pancreatic cancers
    o stenting for obstructing esophageal cancers
    o hypogastric artery ligation and exfulguration for hemorrhaging cervical cancer
    o bypass of obstructing laryngotracheal cancers
    o excision of large fungating oral cancers
    o bilateral orhiectomy for metastatic prostate cancer





    References:
    1. Farmer P, Frenk J, Knaulet FM, al. Expansion of cancer care and control in countries of low and middle income: a call to action. Lancet 2010. epub Aug 16, 2010.
    2. Ozgediz D, Riviello R. The "other" neglected diseases in global public health: surgical conditions in sub-Saharan Africa. PLoS Med. 2008;5(6):e121.
    3. Riviello R, Ozgediz D, Hsia RY, Azzie G, Newton M, Tarpley J. The Role of Collaborative Academic Partnerships in Surgical Training, Education and Provision. World Journal of Surgery. 2010: 34(3):459-65.
    4. Farmer P, Kim J. Surgery and global health: a view from beyond the OR. World J Surg. 2008;32:533–536.
    5. Funk LM, Weiser TG, Berry WR, et al. Global operating theatre distribution and pulse oximetry supply: an estimation from reported data. Lancet 2010: 376: 1055–61.

    Source: Center for Surgery and Public Health - BWH

    Keywords: cancer care, surgery and oncology

Replies

 

Nadine Semer Replied at 1:51 PM, 2 Nov 2010

Thank you for this commentary.

A major challenge for all who are working to improve access to safe surgical services is getting the attention of the large players in the global health community and promoting collaboration between organizations. In addition to Cancer Care, Maternal/Child Health is an example. The “Global Strategy for Women’s and Children’s Health” http://www.who.int/pmnch/topics/maternal/20100914_gswch_en.pdf from the Secretary-General of the United Nations calls for “reducing maternal mortality”, “delivering high quality health services”, and “increasing access to emergency obstetric care”. Surgical services are embedded within the rhetoric as it represents a key component to a integrated program, but does not get specifically mentioned by name. Without this emphasis, surgery gets ignored.

As noted, Dr. Paul Farmer has been outspoken about the need to include surgical services in global health discussions and he will be one of the speakers at this upcoming meeting. http://events.globalhealth.harvard.edu I’m sure some great ideas on how to advance this agenda will be generated.

This Community is Archived.

This community is no longer active as of December 2018. Thanks to those who posted here and made this information available to others visiting the site.