What’s the difference between oncology practice in Nepal as compared with where we are now in France, for instance?

Thank you. Really there is a vast difference. Being a surgeon I have to do a lot of different types of surgery not related to a specific field. For example, I am operating breast the eye cancer, sometimes I do a hysterectomy also, sometimes I do also paediatric surgery also. This thing doesn’t happen in European countries and the United States of America because they have a super speciality. But I am being a surgeon, I have to do different types of surgery, I cannot focus on only one or one. This is one of the major differences in developed countries and in my country.

What is the pattern of management of cancer in Nepal then? How are you handling it? Are you dealing with it all?

Yes, definitely the number one problem is the lack of trained manpower. Sometimes we train the manpower and unfortunately they migrate to developed countries like the US, Canada, United Kingdom, South Africa and Australia. The retention of the manpower is very most important. Anyway we have now in my centre, where I am working, we are working 56 doctors and we are trying our best to properly diagnose and then after making a diagnosis we are trying to treat them surgically, medical oncology and radiotherapy. It will be very surprising to know that we are having only three cobalt machines all throughout the country and only three linear accelerators and only three brachytherapy machines for the whole country. Our population is 28.5 million people.

So, as a surgeon then, you at least can operate but you don’t have a lot of radiotherapy backup.

Yes, we don’t have a lot of radiotherapy and we don’t have a lot of surgical oncologists also. Most of the general surgeons are managing cancer patients and sometimes they may make some small mistakes also. They may not do radical surgery also, that is why the relapse rate, recurrence, is very high in my country. Usually they come to me for the second surgery.

What about diagnosis?

Diagnosis, comparatively for the last eleven years we have done much better than eleven years ago because we have a good number of pathologists working in my centre, eight dedicated pathologists. We have three radiologists and we have a mammography facility, immunohistochemistry facility, CD markers and all these things. This is why in comparison to eleven years ago we have done much better, much better for our patients. Still most of the patients, those who are from rich families, they are visiting Japan, Thailand even in India, these is the real situation. Most of the poor patients are coming to us for treatment.

And can you get adequate chemotherapy?

Yes. Chemotherapy it is expensive the poor person. We are making a subsidised rate of chemotherapy for the patients. Our government is providing a small fund for those patients who cannot afford chemotherapy. Anyway, for breast cancer or the cancers which are curable our government is putting money on them.

What is the pattern of cancer, though, in Nepal as compared with other countries? Which ones are more common?

Here more common is lung cancer, the number one killing disease in our country.

Is that still because of smoking?

Yes, smoking, tobacco chewing, and cancer of the cervix, uterus. Breast cancer is in third and stomach cancer is in fourth. These are the quite common.

So stomach cancer is still quite common in Nepal. What measures, then, in a low resource setting do you think need to be taken? From your experience what are the big priorities finally?

Yes, the treatment part is very difficult for our country because our nation is very poor. That is why, being a surgeon, I am putting focus on prevention, early detection. Prevention and early detection.

And what specific measures are you taking?

Yes, now we are visiting to schools for the high school students we are teaching them what is cancer, how to find it earlier, what are the preventive measures for this. We are training the school teachers also, we are training some journalists, media people also, to advertise about the awareness programme. It is making a really good difference and people are coming with early disease. Now we are getting a result, after ten years we are getting a result. Young women, they are coming to us with a small breast tumour, now we can diagnose it in stage 1. And even lung cancers we are getting early stage. Stomach cancer now people are being convinced to go for endoscopy also. That’s why we are getting some results using our awareness programme, our preventive measures and teaching to the school teachers, schoolboys and media people and working place, to the labourers also. So we are comparatively happy with these results.

So what messages, finally, would you pass on briefly? What’s the take home message for doctors in other resource poor settings, do you think?

Yes, especially cancer, most of the cancer, at least 35-40% of cancers, are preventable. That’s our major focus should be on prevention and early awareness programme to detect early and the cancer in early stages.

And the big measures for prevention or your big priority presumably is smoking first but what next?

Yes, then food habits. Food habits is another major thing to focus on and then early detection. What is the early detection – we have to teach them so cancer can be detected in the early stage. In this case we can cure the patient from the cancer and for the treatment in early stage it is comparatively simple than in the later stage. That is why our focus must be in prevention and early detection of the cancer.

So good for the patient, good for the country.

Yes, and good for doctors also.