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Saturday, January 23, 2010

Cancer care: So costly, so elusive

By Olukorede Yishau

Margaret Shogunro-Pitan, a nutritionist and mother of four, saw, experienced and conquered pain. She really is a lucky woman. Not just because she is a cancer survivor, but hers is one of those few cases of people who had cancer in Nigeria and money did not stand in between them and the treatment of the dreaded disease.Shogunro-Pitan had in 2003 removed her uterus and tubes known in medical parlance as Hysterectomy. She did this because she had multiple fibroids. Not long after she did the Hysterectomy, she started feeling that her body was not functioning properly. She was feeling a lot of discomfort lying face down, especially with her right breast. But as a Christian and minister of God, she was quick to say 'God forbid' each time the reality of it being breast cancer crossed her mind. With time, she decided to take the plunge. She headed for a private diagnostic laboratory for mammogram, a cancer screening test. But she never returned to the laboratory to ask for the outcome of the examination until two months later, when her doctor insisted on it. The test was positive, but it was decided that a second opinion should be sought. And in February 2006, it was confirmed that she had malignant lump. Now, it was time to act fast and deal with the situation at hand.The so-called January pangs are not strange to salary earners most of whom must have received their December salaries as early as the middle of the month. In fact, most companies pay on or before the 20th of the last month in the year. To the management of those companies, they did their workers a great deal of favour. At least, the beneficiary workers would have money to shop for the Christmas and New Year celebrations without having to borrow.
Lucky Shogunro-Pitan is married to a man whose pension plan has a health insurance policy that came to her rescue. Pronto, she went to the Eko Hospital, where only those with fat purse could seek medical assistance for a money-guzzling ailment like cancer. The hospital boasts of referred surgeons and oncologists whose bills are not for every Tom, Dick and Harry to pick.
For 29 days, she was on admission at the A-rate hospital, where she had mastectomy with equipment she said were fully automated. She had to undergo six courses of chemotherapy, 22 sessions of radiotherapy and CT scan. All thanks to her husband’s pension plan!
But what really does it cost to treat cancer? The Nation’s findings show that the prices vary depending on the type of cancer. But one ring cuts across all of them: they don’t come cheap. Before a patient can undergo chemotherapy and radiotherapy, a CT scan may be required. This costs between N30,000 and N40,000. And to ensure all the areas of threat are detected, the CT scan ought to be done for the brain, the chest, the abdomen and the bone marrow. To do all these, no less than N100,000 is required. But since most patients cannot afford this, x-ray, which is less comprehensive is adopted. The MRI scan, which is an higher form of CT scan, goes for at least N60,000. But it is not commonly used.
In the case of breast cancer chemotherapy, a patient may have to take Adriamycin, which, from checks at pharmaceutical stores, cost no less than N2,000 per bottle. But if the patient has heart problem, he or she has to use another variant of the drug known as Eprirubicin, which is said to cost about N10,000 per bottle. A patient is expected to use six courses of this every three weeks. By the time a patient is through with this, he or she must have spent between N80,000 and N100,000 on drugs alone. There is however a cheaper drug, which cost N400 per tablet known as Cyclophosphamaide, which is not commonly prescribed.
In the event that the patient needs surgery, the cheapest known as Lumpectomy, shows our findings, costs not less than N15,000. Mastectomy, which is the removal of affected breast, goes for about N50,000. As for radiotherapy done through linear accelerator machine for breast cancer, 20 sessions are said to cost not less than N100,000 anywhere in the country. The radiotherapy for cervical cancer costs about N50,000 more. If the breast cancer radiotherapy is done with Cobalt 60 machine, it costs less, especially in government-owned cancer clinics. The rate in private cancer clinics is more.
And in case the patient is hormone positive, she has to use anti-hormone drug known as Tamoxifen. A pack equals N600, which lasts one month. But the patient who tests positive to this is expected to use this drug for five years non stop for efficient result. This drug can only be used by women who have not reached menopause. For the five-year period, a patient needs N36,000. Those who are over menopausal age have to use Tamoxifen for between two and three years before combining it with another higher treatment, which comes at more cost.
But the financial implications of all these drugs and treatments pale into insignificance when compared to what it costs to use the new wonder targeted therapy for women with HER 2+ breast cancer. The drug known as Herceptin costs N400,000 to acquire enough dosages for one month and a patient is expected to use it for one year. That means to enjoy the enormous benefit of this wonder drug, which can be an effective treatment both before and after surgery for people with HER2-positive breast, a patient needs N4.8 million!
No wonder Prof. Muheez Durosinmi of the Department of Haematology and Immunology, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Osun State, in a paper published by the International Network for Cancer Treatment and Research, identified high cost of hospital care as the major factor against cancer treatment in the country.
In his word: "The major limiting factors to successful treatment of cancer in Nigeria are the high cost of hospital care and the inability of a majority of the patients to obtain chemotherapy, poor supportive facilities and a high default rate. The unhealthy state of cancer therapy in this country is best illustrated with reference to our experience with the management of 213 patients with Burkitt’s lymphoma over a period of 13 years. Over 75% of patients presented in advanced stages C or D; 132 (62%) of the patients received less than the recommended number of cycles of chemotherapy before voluntary discharge from the hospital and, 41 (31%) of these did not complete a single chemotherapy cycle.
"The default rate was unacceptably high, with 166 patients (77.9%) failing to return for outpatient visits after a median follow-up period of 2.3 months (range = 0,67 months). A five year survival rate of only 1.9% was obtained, compared to almost 50% reported in E. Africa, using a similar combination therapy - cyclophosphamide, oncovin and methotrexate (COM). Our experience with Burkitt’s lymphoma is similar to that of most other cancers, in that a large majority of patients present very late and are unable to purchase anti-cancer drugs."
Investigations reveal that the rate of default by patients in taking their medications is very high. A cancer specialist said this is due to the inability of most patients to afford the cost of the treatment. So, the doctors have no choice than to keep recording in their cards that they have not taken the medications due to financial constraints.
Little relief came when representatives of pharmaceutical giants used to be regular faces at the cancer clinics around the country, where they were selling drugs to cancer patients. This reduced the problem of access to the drugs, even though many could still not afford the prices and had to miss their dosages. But this practice has since stopped in some cancer centres, as the management of the centres decided to take over the responsibility of selling these drugs through its pharmaceutical departments. The Nation learnt that this decision was taken after it was realised that some doctors in the cancer clinics saw in the burden of the people an avenue to make money.
"They were getting cuts, I mean percentages from the representatives of the pharmaceutical companies," said a patient. But has the new system curb the problem? "No," said a source, "it is now more expensive to get the drugs at the pharmacy. A drug, which, for instance, patients used to buy for N40, 000 is now N60,000 at the pharmacy." So, it is like jumping from frying pan to fire.
Another barrier, which the reporter found out in the course of the investigation, centres around the fear of chemotherapy. This has made some resort to alternative medicine products. But what really is chemotherapy? It is the treatment of cancer with drugs that can destroy cancer cells. In current usage, the term "chemotherapy" usually refers to cytotoxic drugs which affect rapidly dividing cells in general, in contrast with targeted therapy. Chemotherapy drugs interfere with cell division in various possible ways, such as the duplication of DNA or the separation of newly formed chromosomes. Most forms of chemotherapy target all rapidly dividing cells and are not specific to cancer cells. Experts say it has the potential to harm healthy tissue, especially those tissues that have a high replacement rate (such as hair, bone marrow and intestinal lining). These cells usually repair themselves after the therapy.
A survivor told The Nation that she lost her hair, was generally weak, felt nauseated and lost appetite as a result of chemotherapy. Another said she was almost unconscious and had to take the last two doses with blood transfusion. Then another one claimed: "My skin darkened, my face was puffed up and swollen and my eye lashes disappeared."
But they all agreed that it is better to experience withered hair and all and stay alive than run away and die a harrowing death. After treatment, they all got their hair back, and puffed up face and disappeared eye lashes returned to normal and they live normal lives.
There is also the problem of denial. When cancer is first diagnosed, not a few first engage in self-denial, looking for reasons why it could not be. Rahama Sani, a cancer survivor and social worker, said she faced this challenge and even latched on to a typographical error in her name to back her position that it could not be her. It was also this that perhaps made Shogunro-Pitan not to go for the result of her test two months after, even though she had premonition that she had cancer.
Sani identified access to diagnostic facilities as major barrier to cancer detection and treatment, a development, which she believes is capable of promoting wrong diagnosis. Sani told The Nation that the first three investigations she did failed to show she had cancer. "I did three investigations. I did mammogram, there was nothing. Three investigations, there was nothing, until when the pathologist said they should remove it and he examined it and he confirmed there was cancer. When I got the result, I was like this was not my own because there was a typographical error in my name. But when I went to see the pathologist, he confirmed it was mine. I said we should have a second opinion. This was done by a renowned pathologist in ABU Teaching Hospital, Dr. Rafindadi. I went to see him in Zaria and they did the test again and he confirmed the same result. I was so confused. But he counselled me," said Sani.
All these barriers are compounded by the fact that Nigeria is a developing country with less than 10 percent of the resources for global cancer control and care. In the World Health Organisation (WHO) Technical Report No. 804 of 1990, it was reported that over 50 per cent of cancer victims live in poor nations like Nigeria, where a projection done some years back feared that this year, the figure of new cases could become as high as 500,000 as against the 100,000 cases annually previously. Of this figure, the Nigerian Cancer Society (NCS) says about 32,000 die annually. In 2005, cancer killed 89,000 people in Nigeria with 54,000 of this figure below the age of 70. It is feared further that by 2020, cancer incidence for Nigerian males and females may rise to 90.7/100,000 and 100.9/100,000 respectively. It is also anticipated that by 2020, death rates from cancer in Nigerian males and females may reach 72.7/100,000 and 76/100,000 respectively.
Yet, a WHO statement of July 3, 2002, said that"of the 10 million cancer cases occurring annually, 1/3 can be prevented, another 1/3 can be effectively treated with early diagnosis, and palliative care can improve the quality of life of the last third",
But with a pharmaceutical industry that is at best crawling, it has to depend on the developed world for drugs for cancer treatment. WHO findings show that the third world countries consume only five percent of cytotoxic drugs, while the rest is sold in the richer nations which account for only 39 percent of cancer cases.
Also disturbing is the fact that Nigeria, with a population of over 140 million people, has less than 100 practicing oncologists. The country also has no medical facility which specializes exclusively in cancer treatment and research. The implication of the shortage of cancer specialists, The Nation learnt, is that oncologists take on more patients than they can handle.
Now, more of the grim facts: The country has less than five active radiotherapy centres, representing a ratio of one machine to about 20 million people. This is against the recommended one machine for 400,000 people.
Durosinmi brought the reality of it further home when he revealed: "The available spectrum of anti-cancer drugs is very limited and such drugs are not readily available. Imaging facilities for staging patients with cancer, such as computerized tomography (CT) and magnetic resonance imaging (MRI), are difficult to come by, and when available, the cost of such studies puts them out of the reach of the average citizen. The inability to properly classify the various types of hematological cancers owing to lack of Immunophenotypic, immunocytochemical and cytogenetic diagnostic facilities is of great concern to hemato-oncologists practicing in this part of the world."
These sentiments were shared by the Chief Executive of a breast cancer awareness network, Care Organisation. Public Enlightenment (COPE), Mrs. Ebunola Anozie, at training for health reporters in Lagos last month. Anozie lamented that the country lags behind in terms of having adequate facilities for the treatment of cancer.
Durosinmi and Anozie find good company in the Chairman of the National Consultative Committee on Cancer in Nigeria (NCCN), Prof. Abayomi Durosinmi-Etti, who also said the country lacks qualified personnel and equipment to manage the treatment of cancer and bemoaned the state of cancer treatment in the country.
The sorry state of cancer care facilities in the country has made the rich resort to running abroad for treatment. The late human rights activist and Senior Advocate of Nigeria (SAN), Chief Gani Fawehinmi, who alleged that he was wrongly diagnosed by a doctor in the country, former First Lady, Maryam Babangida and others who late last year died of cancer, sought help abroad. But this is only the exclusive preserve of the rich and those supported by the rich to seek treatment abroad. However, Health Minister, Prof. Babatunde Osotimehin, believes "there is no point travelling abroad for treatment again because there is Tele-medicine in place now."
Sadly, the country’s National Health Insurance Scheme (NHIS) offers no hope for cancer patients. Even for less costly ailments, it is, shows findings, having passable effects.
Significantly, in the face of these bumps on the way of cancer treatment, not a few will ask: What is government doing?
As of now, the Federal Ministry of Health has developed a five-year National Cancer Control Plan, which is yet to start working. The Federal Government also recently released $2 million to the International Atomic Energy Agency (IAEA) to help in the comprehensive detection, treatment, control and management of cancer cases in the country. The money is the counterpart fund from the country to expand Nuclear Medicine Services, upgrade and strengthen radiotherapy services in 10 tertiary hospitals. This was revealed by Osotimehin when the Director General of the IAEA, Yukiya Amano, paid him a visit.
The foundation for this was laid when First Lady Turai Yar’Adua led the Nigerian delegation to the 53rd General Conference of the IAEA in Vienna and canvassed among others for Technical Cooperation between the IAEA and her pet project, the International Cancer Centre.
If executed according to plan, the first phase of the Nuclear Medicine projects will be available in the University of Maiduguri Teaching Hospital, University of Nigeria Teaching Hospital, Enugu, University of Port-Harcourt Teaching Hospital, National Hospital, Abuja and the Federal Medical Centre, Gombe. The upgrading of radiotherapy facilities will be carried out in the National Hospital, Abuja, University of Calabar, Ahmadu Bello University, Zaria among others.
Mrs. Yar’Adua last year organised a fundraising event for an International Cancer Centre (ICC), which its promoters say would likely be the best of its kind on the African continent. Over N10 billion was realised at the event, which was attended by prominent personalities in government and business circles. She is credited with donating cancer drugs to the National Hospital, Abuja, UCH, Ibadan and three others to be given free to indigent patients.
The Coordinator of the Cancer Control Programme of the Federal Ministry of Health, Dr. Patience Osinubi, also revealed that as from the first quarter of this year, cancer screening will begin in all the 55 teaching hospitals in the country. She also said that a nationwide cancer registry will be established through the National Cancer Control Programme.
Osinubi said this year a pilot scheme for free cervical cancer vaccination will begin. This, she said, will begin in six states. It is hoped that the concerns of Durosinmi are taken into cognisance in implementing all these programmes. He observed that "lack of human and material resources account, in large part, for the dismal results of cancer therapy in Nigeria, but poor planning and lack of positive political will are also major factors militating against effective cancer care in Nigeria."
It is because of Durosinmi’s concerns that many seem to agree that the nation has a not too solid National Cancer Control Programme.
So, what is the way out? Durosinmi is of the view that "it will be important to adopt preventive measures for many cancers, including education against behaviours associated with an increased, risk and immunization and screening where feasible and cost-effective. For example, cancer of the liver can be effectively prevented through immunization against hepatitis B virus (HBV), as well as through compulsory screening of blood and blood products for HVB and HCV markers and by using disposable needles and syringes. Cervical cancer can be controlled through early detection by a "Pap smear" or by the more sensitive ‘visual inspection technique’ with acetic acid or Lugol’s iodine."
He added: "Vaccines against human papilloma virus (HPV) have already been shown to be effective, and could eventually effectively prevent cervical cancer. Regular self-examination of the breast during monthly periods and regular mammography examination of the breast will facilitate early detection of breast cancer, although mammography is unlikely to be cost-effective as a screening procedure in resource-poor countries such as Nigeria. Prevention could have a major impact on tobacco-related cancers as well as other tobacco related diseases. Lung cancer, a difficult disease to treat, is easily (in theory!) prevented by not smoking, but it is disappointing to note that, following recent aggressive campaigns against the tobacco industry in most western populations, tobacco companies have now shifted their advertisement to poorer parts of the world. Tobacco abuse has reached epidemic proportions in many such countries, including Nigeria, and we can anticipate a major increase in tobacco-related diseases in the coming years."
He also advocated the setting up of a National Cancer Institute, with the objectives of providing clinical and investigative facilities for cancer care and research, monitoring cancer trends in the country, providing postgraduate training in cancer, coordinating cancer control activities in Nigeria and collaborating with cancer centres in other parts of the world.
In the view of Dr. Paul Jubrin, consultant pathologist, head, Department of Histopathology, National Hospital, Abuja, there is also the need to evenly distribute cancer diagnosis and treatment facilities. Jubrin told The Nationthat "the facilities for the treatment of cancer in Nigeria are actually up-to-date. But the problem is that it is not well-distributed. Cancer radiotherapy, one of the latest treatments of cancer, is only in Lagos, Abuja, Ibadan and Zaria. At least, you expect up to two of them in each geo-political zones of the country. If you come to the National Hospital, Abuja, the state-of-the-art equipment are there. We recently introduced nuclear medicine, which you can use to detect cancer in your body and apart from that we have an oncology unit. It is just distribution. National Hospital has started training for oncologists. The screening method for cervical cancer called pap smear is between N2, 000 and N3, 000. It is now available everywhere. Now, we have what we call visual inspection with iodine. You don’t even need a specialist for this."
Sani added: "I hope our government will put in place proper diagnostic facilities so that people won’t be wrongly diagnosed and they can take informed action. We need to improve the diagnostic system. I am sure a lot of people have been wrongly diagnosed."
Executive Director of the African Tobacco Control Regional Initiative (ATCRI), Mr. Akinbode Oluwafemi, told this reporter that effective tobacco control through the passage and implementation of the National Tobacco Control Bill 2009 would go a long way in helping to curb cancer. Akinbode explained that many types of cancer have been linked to cigarette, which contains over 4,000 toxic and carcinogenic agents. The bill, which has passed the second reading at the National Assembly, seeks to domesticate the WHO Framework Convention on Tobacco Control (FCTC), a global treaty that has the potential of checkmating the evil of tobacco use, among which is cancer. Smoking related cancer, he said, accounts for not less than 30 percent of cancer related deaths.
But another interesting angle to the treatment and management of cancer came from a Nigerian cancer investigator at the University of Chicago, Dr. Funmi Olopade, who is of the view that cancer does not just kill because of lack of medical treatment. Olopade said at the last conference of the African Organisation for Research and Training in Cancer (AORTIC) in Dar es Salaam, Tanzania: "In Calabar, Nigeria I met some people and we all decided that we were going to look at what breast cancer was like in Africa. From that meeting in Calabar, we got a revelation that we have to come back to a better understanding of biology in the way we treat breast cancer. When I got back to America, I had to challenge my friend, Otis Brawley, who is now the Chief Medical Officer of American Cancer Society who always said it is because people don’t have access to treatment that they die of cancer and I told him that it is not true, that I just came back from Africa and I have gone to their Pathology Department; that this biology is something else. I advised that they should put money to the study of this biology."
The implication of her findings, she said, is that more researches are crucial to understanding cancer better so as to treat and manage it well. She added: "I hope that this work will be done by members of AORTIC in partnership with all of us who are working in the Diaspora because until we get to the point where we can say we have eradicated cancer from the planet, our job is not done."
For now, in the face of these barriers, beating cancer may appear advisable. Experts say cancer – and by extension the attendant psychological, financial and emotional losses- can be beaten through early detection, avoidance of lifestyles that promote cancer such as smoking, exposure to industrial chemicals, consumption of excess fat and heavy use of alcohol, healthy sexual behaviours, and pursuing a lifestyle or diet that modifies cancer-causing factors.
Along this line, renowned gynaecologist and Medical Director, Medical ART Centre, Lagos, Prof. Oladapo Ashiru, said: "As soon as you attain the age of 40, you should go for a comprehensive medical examination. As from 50 and above, women should be undergoing procedures like a mammogram, ultrasound scan and blood evaluation."
Associate professor and Consultant Obstetrician & Gynecologist at the Oncology & Pathological Studies Unit, College of Medicine (CMUL), Lagos University Teaching Hospital (LUTH), Dr. Rose Anorlu, also advised: "Don’t wait until they have symptoms before going for routine checks yearly for breast cancer, cervical cancer including pap smear and ultrasound scan. Post- menopausal women in particular should go for routine self-breast examination, a mammogram test and a pelvic ultrasound scan to check the ovaries."