Table 5:
Challenges, successes, and opportunities in cancer care in SSA
| Challenges | Successes | Opportunities | |
|---|---|---|---|
| Screening and diagnosis | High cost of screening and diagnostic equipment such as mammography devices; low number of specialists, such as pathologists, to operate sophisticated equipment for screening and diagnosis; low sensitisation and awareness among health-care providers about availability and the importance of cancer screening; low standards of living do not permit people to spend money on screening services in the midst of other urgent financial obligations; a lack of health insurance to cover screening means that people must pay upfront and out of pocket; inadequate access to specialised ancillary testing in cancer (examples include immunohistochemistry, flow cytometry, molecular testing, and PET-CT); poor-quality metrics such as turnaround times and specimen handling for cancer diagnosis need to be improved to have a meaningful impact; minimal investment in cancer diagnostics | Wide use of a visual inspection method to screen for cervical cancer, a method that bypasses sophisticated laboratory infrastructures; countries are now developing national guidelines for screening and diagnosis eg, in Cameroon and Tanzania; in Tanzania, screening, early diagnosis, and treatment using cryotherapy is done in every district for free; countries such as Kenya have developed national specimen handling guidelines specifically for cancer; use of postal transport services in Uganda for streamlining specimen transport to referral centres; provision of support through telepathology to pathologists and technologists in Rwanda to build local capacity in cancer diagnosis; inclusion of crucial cancer tests eg, oestrogen receptor, progesterone receptor, and HER2 (also known as ERBB2) for breast cancer in WHO’s 2nd Essential Diagnostics List148,149 | Develop cancer screening audiovisual aids in local languages; integrate cancer screening into routine outpatient care; more research into cancer screening and diagnosis; widespread implementation of telepathology to support pathologists; use of mobile health applications to improve turnaround times for cancer diagnosis; strengthen national population-based cancer registries to inform investment in cancer diagnostics; use of artificial intelligence algorithms for cancer screening (eg, mammographical breast cancer screening); investment in centralised specialist diagnostic centres; expand the range of cancer tests in the next version of WHO’s Essential Diagnostics List |
| Medical therapy | High cost of cancer medicines; low purchasing power of countries; high out-of-pocket expenditure for cancer medicines for patients; waste of resources by prescribing low-value, high-cost cancer medicines; weak procurement systems; low capacity of pharmaceutical regulatory companies leading to poor pharmacovigilance and influx of poor-quality generic medicines; centralised medical oncology services; influence of some traditional and faith healers (eg, faith healers sometimes spend a long time praying for the patients and might only encourage them to go to the hospital when it is already too late) | Initiation of cancer medicines access programmes (assisted by the Clinton Health Access Initiative); in Tanzania, the government is financing treatment and patients are receiving chemotherapy and radiotherapy for free; universal national health insurance is covering cancer care (in Rwanda) and part of cancer drugs, surgery, chemotherapy, and radiotherapy (in Kenya); harmonisation of guidelines for SSA; an increase in local training programmes for oncologists and nurses in the past 10 years | Leveraging on the cancer medicines access programmes and pooled procurements can drive costs of cancer medicines down; pooled funding that can be directed to specific cancer care aspects; use of WHO’s essential medicines list and the European Society of Medical Oncology’s magnitude of clinical benefit scale to prioritise cancer drugs to ensure maximal use of resources; decentralisation of medical oncology with task shifting and supportive supervision |
| Surgical management | Insufficient skilled training in surgical oncology; lack of homogeneity in skill sets of surgeons; out-of-pocket payments for treatment; poorly motivated surgeons in terms of remuneration; lack of opportunity to scale up their surgical skill after training; lack of access to multidisciplinary teams | Regional oncoplastic breast surgery training facilitated by the Pan African Women’s Association of Surgeons and the Surgical Society of Kenya supported by the Association of Breast Surgery; breast and colorectal surgical preceptorships; the African Research Group for Oncology Collaboration–Colorectal Consortium to enhance training and research in cancer; the building of a urology network to improve urology surgery in francophone countries in SSA; cancer surgery is free in Ghana; improved access to diagnostic facilities—colonoscopy, CT scan, and MRI in parts of Africa such as Ghana and Côte d’Ivoire | Leveraging surgical oncology training through regional colleges; development of collaborative networks with national, regional, and international surgical oncology societies; introduction of minimally invasive surgical techniques to cancer management; introduction of organ-sparing surgery |
| Radiotherapy | Access to radiotherapy is low or not available in many countries; lack of skilled personnel; limited access to teaching and training; high cost of maintenance of equipment leading to frequent downtime; high cost of user fees limits access for patients in some regions | Increased access to linear accelerator-based radiotherapy in many regions; expansion of training programmes; remote radiotherapy planning hubs provide support for centres with limited access to skilled personnel; International Atomic Energy Agency support for training on the continent; universal health care covering radiotherapy costs in some regions; decentralisation of radiotherapy services in different countries and government support for treatment eg, in Tanzania and Rwanda | Regional cooperation to provide access to treatment; regional training centres increase throughput of skilled oncologists, radiographers, and physicists; research networks to develop appropriate guidelines and treatment pathways in Africa |
| Safety, quality, and value of care | Few standards in care delivery that are enforceable | Quality assurance teams are in place in Tanzania, and help to improve quality of care given in public institutions; international accreditation of different hospitals in SSA as quality metrics eg, Joint Commission International Africa in Kenya and South Africa; development of harmonised guidelines by the African Cancer Coalition and the National Comprehensive Cancer Network; the ChemoSafe initiative to improve the quality of preparation of chemotherapeutic agents and the safe delivery of chemotherapy by nurses; Choosing Wisely Africa published in 2020124 | Implementation of harmonised guidelines; implementation of the Choosing Wisely initiative; dissemination of quality metrics matrices to inform national and regional centres of cancer care provision |
SSA=sub-Saharan Africa.