Nigeria: Financial Toxicity, Major Challenge in Cancer Treatment – Dr Bolanle Adegboyega

·Nigeria has fewer than 10 brachytherapy machines

JANUARY is Cervical Cancer Month, the fourth most common cancer globally and in Nigeria the third and the second most frequent cause of cancer death among women aged between 15 and 44 years.

Research by The Lancet also reveals that more than 44 million women globally stand to develop cervical cancer between 2020 and 2069.

It also warned that deaths from cervical cancer will increase a further 50 per cent by 2040 and that many women, their families, and communities will be impacted.

No wonder the Federal government is pushing for vaccination for young girls. As of December 2023, about 4.7 million Nigerian girls have been vaccinated against the Human Papillomavirus, HPV, in the first phase of the vaccine rollout in the county.

Good Health Weekly spoke to Consultant Clinical and Radiation Oncologist /Head of Brachytherapy at NSIA-LUTH Cancer Centre, Dr Bolanle Adegboyega, who unveiled new methods of treatment for cervical cancer and challenges faced by patients, saying the disease is now commoner in Nigeria.

She said although treatable, financial toxicity remains a major problem, as despite presenting early, it takes patients months or years toraise money for tests and treatment. Excerpts:

What is cervical cancer and how prevalent is it among Nigerian women?

Cervical cancer is a type of cancer that develops in the cervix. The cervix is like the mouth of the womb when a woman is about to deliver, the area doctors measure is called the cervix.

So the cancer that arises from that part of the body is called cervical cancer. It is the second most common cancer among Nigerian women after breast cancer. Up to, like 12,000 new cases are reported annually and about 8,000 result in death because many people present late.

Cervical cancer is generally associated with sexual activity. You see it more in people who are sexually exposed, who have multiple sexual partners, or people who started having sexual intercourse earlier than 13 years of age, and people who have multiple numbers of children because before you give birth, you must have had sex.

Over 95 per cent of causes of cervical cancer are prone to this virus .

Challenges patients commonly face during treatment

Since the cervix is the private parts, so coming to the hospital to see a doctor, especially a male doctor, who would examine the private part might cause discomfort to some patients. And that may be one of the reasons why some patients won’t present early. It’s not something you will be proud to tell people that you have cancer – not cancer on the hand, leg, neck and all – it’s somewhere there.

Another thing is that because of our environment and our beliefs. One of the presenting complaints might be somebody who has entered menopause and just started bleeding again. As Nigerians, we will feel that it is spiritual attack. So, some patients might start seeking divine intervention before they eventually come in late to the hospital for a cure.

The major challenge is cost, because the total cost of treating cancer can be over N2 million to N3 million and how many Nigerians can actually afford that?

Trust me, financial toxicity is a major problem in cancer treatment. Even when patients come in early, it might take them months before they can raise money to do tests, it will take him/her another year to be able to raise money for the treatment. So cancer that had not spread before he/she came might have spread to other parts of the body due to the delay in raising funds.

For others, they don’t have family support while other people lack access to care because we only have less than 10 brachytherapy in Nigeria, meaning that many patients have to travel from Kano to Lagos to access treatment. So accessibility to cancer treatment is also a major issue.

Steps women should take to prevent cervical cancer

The good thing about cervical cancer is that it’s one of the preventive cancers because vaccines can be used to prevent it. As we speak, the Federal Government, and Lagos State government, have rolled out the Human PapillomaVirus vaccines that are given to children 9 to 14 years old. Anybody above the age that is not sexually exposed can also take it.

The major cause, as I told you, in over 90 per cent of cervical cancer is actually with human papillomavirus. So the vaccine is to prevent that virus such as if somebody is taking the vaccine, you are sure that you are not going to get the virus.

Another way that people who are being sexually exposed (for example married women) is that you should do routine pap smear screening and send it to the lab in order to be sure that there are no changes that are occurring towards cancer.

After the test, some people may just need some form of surgery, which may noteven be a major surgery or remove their worm to take care of cancer. Why? Because this cancer comes from the womb if there’s no womb and you have completed your family you are not going to have cervical cancer but the earlier you detect it, the better.

Treatment options available for patients

The treatment ranges from surgery that is done in a very early stage. Surgery can be carried out when it is not yet a full-blown cancer. Unfortunately, we have few people falling into that category but the commonest form of treatment is a combination of chemotherapy and radiotherapy together. Chemotherapy is used to treat it alongside radiotherapy. Radiotherapy is broken into two. There is external radiotherapy and internal radiotherapy. The external is called beam therapy while the internal is called brachytherapy. Brachytherapy treatment actually brought close to the tumour. So, we need the combination of these three – chemotherapy, radiotherapy and brachytherapy – to treat cervical cancer before we can achieve a cure.

Role of brachytherapy in the treatment of cervical cancer

Brachytherapy is a radiotherapy treatment from a short distance. Brachy means short, it is usually taken as close to the cancer itself compared to the other radiotherapy which is external (it is from a distance).

Brachytherapy’s role is that when the big machine (external radiotherapy) has treated cervical cancer to a particular stage, Brachytherapy will treat the remaining part. Your treatment is not complete until you use brachytherapy.

Are there any criteria when selecting patients for brachytherapy?

The major criteria in selecting patients for brachytherapy is that the cancer has not spread out of the affected area because brachytherapy has various types of instruments we use so that is where the selection might come in.

It depends on the type of residual tumour we have or a patient that has done surgery or the other. Those are some of the things that will determine the type of instruments we use but brachytherapy itself is when the cancer has not spread beyond the region we are treating.

How has NSIA- LUTH Cancer Centre evolved over the years in response to advancements in cancer diagnosis and treatment?

NSIA LUTH Cancer Centre is a combination of two bodies. LUTH has always existed and they have always had this department for years but due to the Nigerian factors, governments are not putting money into the health sector. So the departments are equipped with enough machines. The Nigeria Sovereign Investment Authority (NSIA) now brought money to revamp and reequip this department. So it’s a public-private partnership between LUTH and NSIA to have a functional department.

This is the only centre in Nigeria and in West Africa that has at least three radiotherapy machines under one roof and we are the one that has brachytherapy that is image-guided. Other centres that have brachytherapy operate with 2D but ours is 3D such that we are seeing what we are treating on the computer which allows us to determine the dose the patient is getting to each structure.

This way, it limits side effects either early side effects or late side effects. These are some of the technologies that are only in a few or no other places in Nigeria and most West Africa centres.

Advice to recently diagnosed patients

Gone are the days our doctors recommend that cancer patients should travel to India, Ghana, the UK and other countries. Cervical cancer can be treated and cured in Nigeria if they present early because we have the specialists, the machines and all it takes to treat the cancer.

We don’t even limit our knowledge here as we have connections and collaborations with medical experts outside Nigeria. We do a multidisciplinary team approach because cancer cannot be treated by one doctor so we bring and share ideas and we have all the resources. Anybody diagnosed with cancer should come to the NSIA-LUTH and by God’s grace, it will be cured.

If you come in early there are some NGO that support people, but they only want to support healthy people. At NSIA-LUTH, we also have a form of support for some indigent patients one way or the other but if you don’t come, you won’t know.

Anything you are trying, even if it’s a hospital, you are going to. If you have been going for one month for two months and there is no improvement, there is a place for a second opinion. You try another hospital out.

Technology and Cervical Cancer Care in Nigeria

The type of technology we have here, from external beam radiotherapy to brachytherapy, our technology is image-guided, what it means is that we are seeing what we are treating.

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