Feature Article of Sunday, 10 February 2013
Columnist: Sodzi-Tettey, Sodzi
Need for nationwide early detection and screening now
You have disseminated cancer of the colon!
As bad as that sounded, it was hardly enough to convince Kodwo to accept the chemo-radiotherapy that had been prescribed for its management by his doctors! This was primarily because he did not feel particularly ill at the time of the diagnosis.
“I don’t want to lose my hair,” he reasoned.
After almost two years of keeping his hair, the cancer spread further and hair loss became the least of his worries. In time, the cancer caused an obstruction of his intestines, which obstruction then led to surgery followed by even more expensive treatment regimes, leaving family and friends wondering what difference early detection and aggressive management would not have made. Could Kodwo have been the beneficiary of a health system that started routine personal reminders every year after the age of 35 to routinely screen for colorectal cancer using occult blood in the stool? The disease would be diagnosed earlier, treatment would be prompt and life would be significantly prolonged.
Will young Adzo, diagnosed with obvious advanced breast cancer, but totally refusing any referral for tertiary specialist care on account of morbid fear of surgically losing her precious breasts have benefited from regular habitual self-examination? Will the old lady, reporting only because of back pain and paralysis, but attributing her cancer-eaten breasts to witchcraft have benefited from routine early mammography?
Morbid though the above may sound but true nevertheless, and possibly, our inevitable fate if the current absence of an active nationwide cancer control programme is allowed to persist. The system appears perfectly designed to diagnose only late stage cancers. That is attested to by many clinicians who are constantly distressed about late stage presentation even as Dr. Kofi Nyarko, Program manager for Non Communicable Diseases and focal person for cancer control within the Ghana Health Service laments current “over focusing on treatment to the detriment of primary prevention and a national screening programme.” Thankfully, according to Prof. E.K. Wiredu, Chairman of Trustees of the Cancer Society of Ghana, “Advances in understanding risk and prevention, early detection and treatment, have revolutionized the management of cancer leading to improved outcome for patients.”
According to the World Health Organization, every year “more than two-thirds of the13 million new cancer cases and deaths occur in developing countries where cancer incidence continues to increase at alarming rates.” A national cancer registry is fundamental to any such national cancer control programme. Fortunately, Ghana has developed these registries very well in Komfo Anokye Teaching Hospital and less so in Korle Bu Teaching Hospital. Also quite clearly outlined is a national strategy for cancer control in Ghana (2012 -2016) which appears to be have been bogged down by the lack of resources and/or leadership will in a phenomenon described by the WHO as “struggling to move from commitment to action.”This firmly puts Ghana outside the “17% of the African countries and 27% of the low-income countries that have cancer control plans with a budget to support implementation.”
“Ghana has everything in terms of policy and strategy in place to move. The only thing left is the resources, both human and material. They are no funds for primary prevention and screening. Most of the Ministry of Health’s programs are funded by donors but because no donor is currently into cancer care, we are handicapped”, said Dr. Nyarko. This in his view is further complicated by what he also calls an over focusing on treatment.
“A loan of $ 13.5 M was approved by the Parliament of Ghana but it all went into clinical care; rehabilitation of radiotherapy centres in the Teaching Hospitals because people equate cancer control to the building of such centres.” Acknowledging Ghana’s current reputation as having the best cancer management center in West Africa (with two Teaching Hospitals and a third primary facility in East Legon attracting many patients in the sub region), Dr. Nyarko sounded frustrated that sufficient attention did not appear to be accorded the establishment of a national screening programme to aid early detection and better treatment outcomes.
Further, although Ghana has declared smoking in public places illegal, it has taken no practical steps, current considerations notwithstanding, to drastically raise taxes on tobacco and alcohol as other countries have done to properly establish and fund its national cancer program.
However, with the introduction of the Human Papillovirus (HPV) Vaccination Exercise in 13 pilot districts in Ghana’s Northern and Central regions, there appears to be some hope for cervical cancer, believed to afflict 3038 women every year, 66% of whom die. Further, it is gratifying to note the announcement by the Chief Director of the Ministry of Health about a government commitment to broaden the minimum benefit package of the NHIS to include more comprehensive management of cancers. This is in addition to health education messages put out by authorities calling on women to screen for cervical cancer while reporting any vaginal discharge and/or bleeding after having sex. For years, Battor Catholic Hospital in the Volta Region, under Dr. Kofi Effah’s current leadership has been at the forefront of screening thousands of women for cervical cancer.
To quote Dr. Clement Adusa, Managing Director at the Radiation Oncology, Department of Radiotherapy at Korle-Bu Teaching Hospital, “prevention is the most cost-effective and sustainable way of reducing the global cancer burden in the long-term.” And for the general population, this should immediately translate into the same old things, much talked about, much ignored and yet which if practiced, could make a ton of difference: avoidance of excessive alcohol, smoking, unhealthy diets and physical inactivity.
Further, people are encouraged to take personal responsibility for health screening, learning from the UK’s NHS advise to women to start screening for cervical cancer from the age of 25 and subsequently to be “screened every three years till the age of 49 and subsequently every five years till 64 years.” Similarly, women are invited for their first mammogram at the age of 50 – 53. In addition, women with a family history of breast cancer are encouraged to do earlier tests coupled with regular breast examination for early identification and subsequent investigation of any breast lumps.
Also, given that prostate cancer could well remain symptomless till a very advanced stage, men in their forties would benefit from annual tests for prostate specific antigens (PSA) and digital rectal examinations. PSA is a chemical produced by the prostate and may be raised in cases of benign/ non-cancerous enlargement, infection or cancer. Indeed, “The American Cancer Society recommends regular screenings for prostate cancer for all men over the age of 40. Your doctor may determine that you need testing even earlier, especially if you are a member of a high-risk group (including African-American men and men with a family history of prostate cancer).”
Cancer appears to be such a distant concept till it comes sufficiently close. With urgent coordinated action at both the national and individual levels through the establishment of a rigorous Ghana Cancer Control Programme, it need no longer retain the tag of a death sentence.
6th February, 2013