Mauling the malignant

Improving cancer treatment

 

Probably the most serious of handicaps observed, the inadequacy of counseling proved a great hurdle to quick diagnosis, treatment planning and recovery

 

 

This April marks 26 years since the historic groundbreaking of the SKMH, the first ‘hospital’ in Pakistan specialising in cancer. The first cancer center, however, was up as early as 1960 (AEMC, Karachi). Today, with some 21 cancer hospitals, and more being planned, the situation may appear encouraging, if not sufficient. Yet, it takes only a cursory visit to a cancer center to appreciate a myriad of troubles teasing cancer patients. From reporting to discharge, patients undergo a stressful series of delays, cross-desk inadequacies and a constant swing between treatment options, all of which became glaringly obvious during my premed internship at the Nuclear Medicine, Oncology and Radiotherapy Institute (NORI) last June.

Reporting at the scheduled time on a Ramadan Monday, I first noted that many doctors arrived well over an hour late, a pattern that kept recurring for the next two weeks. Trifles. With my own supervisor (a senior consultant) on time, I began recording observations from the 14 cases she handled that day. Except that she didn’t ‘handle’ all cases: many patients were turned back after incomplete protocols or (once) totally incorrect histopathology reports. Radiotherapy was an avoided treatment plan due to the relative unease over using the Linear Accelerator (LA) and the out-dated cobalt-60 machine, as well as toxicity. Internal radiation through implants (brachytherapy) was out of the question. With chemo the only option, nausea, weight loss and hair fall were constant complaints. There were three cases of recurrence in the 10 days of my internship, mostly due to the shortcomings of follow-up evaluations.

The lack of radiology facilities was further augmented by the non-availability of non-invasive scans. The lung perfusion scan facility was undergoing repair, and the renal scans were regularly unavailable. Mammography was usually referred to the Shifa hospital. Breast cancer patients faced greater stress due to the lack of targeted molecular therapy in the form of mabs (monoclonal antibodies) such as trastuzumab (Herceptin), forced to make do with generalised chemotherapy or referral. Leukemia patients also faced trouble due to the dearth of transfusion facilities in the wards.

Tumor boards following diagnosis and staging took exceedingly long to finalise treatment plans, taking anywhere between two weeks and a month. Besides volume visualisation and contouring, finding the primary growth took a toll on the days as well, with some 10pc cases finalised as CUPs (cancer of unknown primary origin). This proved risky for patients with neuromas and other cancers of vital tissues. To prevent poor prognosis (development of disease), neo-adjuvant (simply improvised treatment without a plan) methods were sometimes employed to keep patients symptom-free.

The lack of treatment for major benign tumors was also disconcerting. Normal tumors are harmless, and visits to the oncologist are unnecessary. However, this isn’t the case for brain tumors or large tumors having the potential to displace tissue. When I spoke on this issue, as well as the lack of specialised treatment for paediatric cancers with Dr Faheem (Director NORI) during the last days there, he replied: “As far as potentially fatal tumors are concerned, elastography is the preferred scan needed. At the moment, we don’t have either elastography or specialised pediatric treatment, but with improvement in PAEC funding this could change inside 2-3 years”. Let’s hope you were spot on, doc!

Probably the most serious of handicaps observed, the inadequacy of counseling proved a great hurdle to quick diagnosis, treatment planning and recovery. Doctors frequently lost their cool, plunging disfigured, emotionally disturbed and shocked patients further into despair. It cannot be stressed enough that psychological support is crucial for surviving cancer, especially after diagnosis and during treatment. To avoid greater patient loads, doctors regularly went off-duty, visiting wards or hanging out. The hospital staff, especially the attendants, were highly unaccommodating, shepherding the patients like sheep. My supervisor explained that the general lack of empathy for patients was due to the relatively high mortality for some cancers, especially in the later stages. This high mortality was the prime reason for the lack of oncologists, as med students preferred more ‘financially’ viable fields.

This was the state in one of the 18 medical centers of the PAEC treating cancer. The patients here were mostly underprivileged people who couldn’t afford the exorbitant sums of SKMH (after failing to fulfill support criteria) or AKU. Many were funded by the Bait ul Maal. Patients frequently received financial let-offs in treatment, but this resulted in overcrowding, with more than 50 new patients every day. While the step to make more cancer treatment facilities is laudable (such as the planned fully-fledged 500-bed hospital in Islamabad), up gradation of the existing ones should be a priority as well. Pakistan has a relatively high mortality rate due to cancer (84.74 per 100,000 compared to 70.23 for India, as per World health rankings). Breast, lung and liver cancers are the leading cancers according to a PubMed publication in 2015. If the situation is to be improved, improvement in counseling and tumor boards (such as including psychologists) can improve the situation. Wide spread availability of screening can avert the later stages, especially for breast cancer (40,000 deaths per year). Strict implementation of anti-narcotic legislation can reduce oral and lung cancers as well. Publicizing the PAEC cancer centers can provide an alternative to SKMH, which can improve competition for quality among the various cancer facilities. Lastly, improvement in the remuneration of oncologists and controls for professionalism could improve responsiveness and treatment success, reducing mortality.