The discussion revolved around how could we improve the surgical oncology services in low to middle income countries and we’re looking at how can we improve the services in sub-Saharan Africa. What we were trying to look at is what practical steps can we take to mitigate the gaps that we have in terms of resources, both human and physical resources.
The challenge we’re having on the continent is we do have a deficit; in terms of the surgeries that are required we’re looking at about 143 million surgeries required per year to prevent disabilities. If we narrow that down further and if we look at the interplay between cancers and surgery, you do realise that in terms of projections we are looking at about 15.2 million new cancer patients by the end of this year, 2015, and if we extrapolate that over the next fifteen years we’re looking at requiring about 48 million surgeries; that’s roughly about three times that number to cater to these particular patients. One thing we may not realise is that over 80% of cancer patients at any point of their cancer or oncology management journey are actually going to encounter or are going to have an encounter with surgical services. Some patients may actually have repeated encounters along this. So, with that in mind, we then look at our continent and we see that we have this huge deficit of surgeries that are required and an even greater deficit in terms of the health workers who are available. We do need to be creative and start looking at how can we mitigate this gap. A few factors come into play; there definitely needs to be the support of health systems and investment in that.
One of the key factors that has emerged, and this is the work of several commissions, there’s initially a commission on global surgery and, more recently, the Lancet Commission on global cancer surgery specifically, that has come up with a list of recommendations that we think can be translated to our environment. Part of this is essentially what we call an investment framework approach. The ethos behind this is to encourage governments and institutions to look at investing, rather than thinking of it as health costs, more thinking of it as a health investment that will pay health dividends further down the line. There are several approaches that are required; it is indeed a multi-system, multi-sectorial approach that needs to happen and that dialogue needs to be constantly engaged in order to facilitate improvement of this. But a critical part of what needs to happen, and this is a drive that we, as surgeons, need to take on board, is the whole concept of surgical advocacy. It’s something we don’t necessarily think too much about or focus on but it’s essential for us to act as catalysts for change in our immediate environments. What you usually find is that in low to middle income countries surgeons generally have to wear many hats so you’re not just necessarily involved in the pre-, inter-operative and post-operative care but you’re making diagnosis. Depending on which centre you’re based at you may find that you are administering chemotherapy and are actually actively involved in the follow-up of cancer patients.
So it does require us to bring a new skill set to the table and part of this is through establishing communities of practice and that is building robust multidisciplinary teams involving the whole spectrum of oncology services that can actually improve patient care. Also through extensive networking and developing research systems, systems of documentation. That’s the other thing that we lack – we don’t actually know what’s happening to our patients. So if we’re able to build up healthy, reliable documentation systems, whether it’s through electronic records maintenance and through cross-dialogue across the continent then we’re actually able to use this as a baseline and then conduct research around these concerns we actually would be able to, a few years down the line, reflect on this and use that data to influence our health systems and look at where the areas of intervention would be needed.
Is this linked to the collaborative roundtable?
A collaborative roundtable is, as you rightly said, an extension of the same. The whole thrust of the roundtable is to discuss how to conduct collaborative research around women’s health concerns. What we essentially would be doing is identifying the priorities on the continent. There are a number of competing interests but for the purposes of an initial focus, where do we want to focus our efforts, and then the idea is to identify what the challenges are and how we would go about mitigating those challenges and to identify initial projects and collaborations that we can get off the ground.
What are some of the benefits of a multidisciplinary approach?
The multi-disciplinary model has been shown to work. Part of building up capacity involves setting up centres of excellence and the reasons behind this is, one, you have a focus where there are centralised surgical oncology services and these can be readily translated either at the district hospital or at provincial hospital level. The idea behind this is, from a surgical perspective as well, you want to be in a centre that’s involved with doing high volume work where the surgeons are seeing higher numbers of patients with a certain condition. This would translate into decreased morbidity and decreased mortality amongst our patients which is good for everyone. The whole idea behind the multidisciplinary model is that you’re also able to audit each other’s practice and come up with the best practice for everyone. There’s definitely benefit towards a team approach, exchanging ideas and with always the patient as the centre, as the focus. So ultimately it’s a win-win for the patient. So that’s definitely something that should be advocated at all levels.
What form does this take where you are?
Frequently with the breast clinic, with our patients we tend to get a lot of patients who are lost to follow-up. The idea behind a one-stop multidisciplinary model, and we’re hoping this model can be extrapolated to the rest of the continent is that you are essentially able to have patients come in, have the initial assessment, see the clinicians, get a tentative diagnosis and then have a subsequent management plan all at the same visit.
What happens at our unit in Cape Town is that patients come in, are triaged and they get to see one of the clinicians who is generally either a surgical resident or a surgical consultant. They then, if they do have a clinical examination and are assessed by the physician and they subsequently have biopsies done. After the initial assessment if a patient has a positive cytology which is suggestive of a cancer then they will see the oncologist or the oncology resident at the same visit. After subsequently being reviewed by the oncologist they will then be seen a week later at a multidisciplinary combined breast clinic. This involves all the specialities that are supported for oncology for optimal oncology care and this includes a radiologist, the pathologist, the surgeons and the oncology services and the plastic surgeons as well and the psychologist and we’ll all sit together, discuss each patient on an individual basis and find what is a best fit for each particular patient.
There isn’t necessarily a one size fits all model for oncology care and this is where the concept of personalised care tends to emerge because then, after this vibrant discussion, we’re able to find for this particular patient this would be the optimal treatment for them. But the advantage behind the initial screening with the fine needle aspirate is that we are able to put the patient through the system and have a management plan before discharge. The challenges have been, especially in resource constrained environments, is after the initial biopsy patients may have to wait for a while, maybe 2-3 weeks before they get a diagnosis and they frequently get lost to follow-up for various reasons. It could be financial, lack of communication or just lack of access. All these tend to contribute towards delays in management so there’s definitely an advantage to the one stop breast clinic and there’s a definite advantage towards having a multidisciplinary approach to breast care.
