02 May 2012

Cancer in Africa: Fighting a nameless enemy

In Emanuel Adu's language, Twi, people call the skin cancer that is invading his cheek and nose "sasabro." It means a disease that eats away at you.


In Emanuel Adu's language, Twi, people call the skin cancer that is invading his cheek and nose "sasabro." It means a disease that eats away at you.

The 73-year-old former cocoa farmer has come to the Korle Bu Teaching Hospital in Accra, miles from his home, to be treated with one of the two radiotherapy machines in Ghana.

"I had heavy bleeding and discharge from my nose. The doctor told it me was cancer, a cancer called melanoma, but I had not heard those words before," he explains in the consulting room.

Most of Africa's around 2,000 languages have no word for cancer. The common perception in both developing and developed countries is that it's a disease of the wealthy world, where high-fat, processed-food diets, alcohol, smoking and sedentary lifestyles fuel tumour growth.

Yet Adu's is one of an estimated one million new cancer cases sub-Saharan Africa will see this year - a number predicted to double to 2 million a year in the next decade.

How can a continent hope to diagnose and treat, let alone fight to prevent a disease that has no name?

Cancer kills the poor too

It's a question David Kerr has been struggling with for several years. A cancer specialist based at Britain's Oxford University and former president of the European Society of Medical Oncology, Kerr set up the charity AfrOx in 2007 to help African countries seek to prevent and control cancer.

"There have been some marvelously effective campaigns around Aids, tuberculosis (TB) and malaria, and of course infectious diseases like those are terribly important," he said in an interview. "But already there are more deaths in the world from cancer than from AIDS, TB and malaria combined."

By 2030, according to predictions from the World Health Organisation (WHO), 70% of the world's cancer burden will be in poor countries, a prediction Kerr says leaves most lay people, and even many doctors, "utterly astonished".

Africans living longer to get cancer

"They think cancer is a disease of the wealthy. But the reality is that, in part because of success in tackling infectious diseases, Africans are living longer. It's almost a booby prize that they're now living long enough to get cancer."

For many women in Africa, that means diseases like breast and cervical cancer have become common causes of death before their victims have begun to learn about them, let alone find words for them.

A study published in 2011 found that since 1980 new cervical cancer case numbers and deaths have dropped substantially in rich countries, but increased dramatically in Africa and other poor regions. Overall, 76% of new cervical cancer cases are in developing regions, and sub-Saharan Africa already has 22% of all cervical cancer cases worldwide.

The same research found that some poorer countries saw a rise in breast cancer cases of more than 7.5% a year over the 30 year period studied - more than twice the global rate.

Explosion of cancer

Such data come as no surprise to Verna Vanderpuye, a clinical oncologist and radiotherapy consultant at the Korle Bu hospital where Adu will come for his treatment every day for the next two weeks.

"There's an explosion of cancer here," she said in an interview in her overrun consulting room.

Unlike the diseases she is trained to treat, the oncologist is a rare thing in Ghana. She is one of only six trained cancer doctors who serve a country of 24 million people.

Good quality data are hard to come by, but Vanderpuye says the two main hospitals equipped to treat cancer - hers and another further north in Ghana's second city of Kumasi - are seeing between 5,000 and 7,000 new cancer patients a year.

Cancer a distressing death

"That's just the tip of the iceberg. That's only those who actually come to the health facilities. We don't really know what's really happening across the country," she says.

It seems a drastic situation. But Ghana has come a long way. Until 2007, there were no oncologists at all - and that's still the case in some neighbouring countries. Sierra Leone, for example, has more than 6 million people and no cancer doctors.

"Countries in the region like Sierra Leone, Togo, Guinea have absolutely nothing in terms of cancer care," said Kerr. "That means Ghana's six or so oncologists have to serve neighbouring countries as well."

The result is that the reality for many in Africa is that a cancer diagnosis means a painful and distressing death.

The overwhelming number of cases and the paucity of funds, doctors and treatment mean it's difficult to know where to start, Kerr says. But cancer experts - foreign and African - and patients and advocacy groups say what's needed first is greater awareness.

Knowing the enemy

Ellen Awuah-Darko is doing what she can.

The 75-year-old founder of the Accra-based Jead Foundation for breast cancer says her own experience - of finding a lump and ending up paying tens of thousands of dollars to be treated in the United States - made her to try force change.

"In America I had to put down R542 000 before they'd even talk to me," she said. "I was lucky, I could afford it after my husband died and left me money, but I thought 'why should I get treatment when others can't'."

Now, every Wednesday, Awuah-Darko goes with healthcare workers into communities in the Eastern Region of Ghana to offer women breast screening. It's not the high-tech mammogram or ultrasound scan women in wealthy countries are used to, but a simple breast examination and a lesson in how to self-check.

Cancer is taboo

"Early detection can save your life. I want everybody to know that. It's not something people should be ashamed of or embarrassed about," she said.

But she and the handful of cancer specialists are fighting deep cultural resistance - not only to the idea that cancer affects people here, but also to the idea they must talk about it, look for it and recognise it to start fighting against it.

Even among the young and educated, cancer is often taboo.

"They don't want to use the C-word," says Vanderpuye. "That's also one of the main reasons why someone wouldn't want to come here - because it means she has 'the C'.

Humongous foul smelling tumours

In the chemotherapy ward at Korle Bu, oncology nurse Juliana Tagoe, explains why patients often don't want to talk about cancer.

Many people see the disease as a spiritual punishment, she says. "They think someone has done wrong and this is the effect - God is punishing them. They feel stigmatised."

In rural communities where spiritual and tribal leaders are revered, the use of prayer, ritual and herbal remedies is common. Awuah-Darko says witch doctors tell patients with tumours to "treat it like a boil, and just put some herbs on it". Others are told simply to pray for it to be taken away.

In the months or years that intervene, the tumours spread and grow to sizes barely seen by doctors in developed countries.

Kerr talks of patients in Africa with tumours that protrude through the breast or encircle the whole chest; while Vanderpuye describes patients with "humongous, foul-smelling tumours" she has little hope of treating.

Cancer linked to lifestyle factors

Both Kerr and Corey Casper, who runs the Uganda Programme on Cancer and Infectious Disease associated with the Fred Hutchinson Cancer Research Center in Seattle, say another focus of efforts to tackle this looming cancer epidemic is to try to prevent the cancers caused by infections.

While many cancers are linked to lifestyle factors such as unhealthy diets and smoking, a large number - particularly in Africa - are caused by infections likes hepatitis B and C, which cause liver cancer, and the human papillomavirus (HPV) that causes almost all cervical cancers.

In wealthy countries, having hepatitis vaccines as part of routine childhood immunization programs, and introducing national campaigns programs with new HPV vaccines from drug makers Merck and GlaxoSmithKline has brought rates of liver and cervical cancer down significantly.

Introduce HPV vaccine campaigns in Africa

If such nationwide HPV vaccine campaigns could be introduced in Africa, experts say, the effect on rates of death and disease could be dramatic. Global health groups are working with drug makers on securing a discounted price for HPV shots for poor countries, but getting them to Africa could take years.

Akosua - a name meaning "Sunday" that this patient gives instead of her real name - has no concept yet of how an injection made by a Western pharmaceutical company could have prevented the cancer spreading inside her.

The 48-year-old farmer has cervical cancer and has suffered with a lot of pain and bleeding, but for now the fact that she's come to the hospital and is seeing an oncologist is foreign territory enough.

"But I'm not afraid," she says. "I've been seen by the doctor now. I know I am in the right place to get the right treatment."

(Kate Kelland, Reuters Health, April 2012) 

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