Cancer: Dealing with high incidence, cost of containment

• How to reduce rise in cancer cases, deaths
• Saving 10m lives, $1.16trn lost yearly to cancer
• Radiotherapy costs N1 million, N20 million needed for chemotherapy, experts say

Every February 4, the World Health Organisation (WHO) celebrates the World Cancer Day. In her message to commemorate the 2023 event, the WHO Regional Director for Africa, Dr. Matshidiso Moeti, said approximately 1.1 million new cancer cases occur every year in the continent, with about 700,000 deaths.

Experts say about 10 million lives and estimated $1.16 trillion lost worldwide to cancer could be saved by implementing resource-appropriate strategies for prevention, early detection and treatment.

According to Global Cancer Observatory: Cancer Today (GLOBOCAN), of the 9.6 million deaths worldwide, 50.6 per cent come from lung, colorectal, stomach, liver and breast cancers. Out of the 18.1 million cases reported in 2018, lungs, breast, colorectal, prostate and stomach cancers accounted for 46.1 per cent.

The report showed cancer kills no fewer than 78,000 Nigerians and 125,000 new persons are infected.

Cancers of the breast, cervix uteri, prostate, non-Hodgkin lymphoma, liver, colon, ovary, rectum, leukemia and stomach are reported to be the top 10 commonest cancers in Nigeria.

GLOBOCAN is an online database, which provides detailed statistics and estimates of incidence and mortality in 185 countries for 36 types of cancer. It helps to provide a comprehensive assessment of the cancer burden worldwide.

Also, recent figures showed high cancer related mortality in Nigeria compared to most nations. For example, cervical cancer mortality ratio is about 51 per cent compared to less than 20 per cent in North America.

According to WHO, cancer is the second leading cause of death worldwide. About 70 per cent of cancer death occurs in low to middle-income countries like Nigeria.

Medical experts, who spoke to The Guardian, decried high cost of cancer treatment in the country, saying there is need to make its treatment affordable and accessible.

The medical experts said Nigeria has just four functional radiotherapy machines serving over 200 million persons across the 36 states of the federation and the Federal Capital Territory (FCT) Abuja, an evidence of low investments in cancer care. They said this is basically out of pocket for individual as the insurance coverage is still less than five per cent.

The medical experts, who spoke, include Professor of Gynaecology and Obstetrics and former Minister of Health, Isaac Folorunso Adewole; a Global Health Consultant/Chief Technical Advisor of E4HDI, Dr. Nnenna Ezeigwe; former Commissioner for Health in Ondo State, Dr. Dayo Adeyanju and Director of Research, Nigerian Institute of Medical Research (NIMR) Yaba, Lagos, Prof. Oliver Chukwujekwu Ezechi.
Reasons for high incidence, mortality.

ADEYANJU said the celebration this year’s brings to the fore, issues of cancer management in Nigeria. He said, each year, cancer claims 72,000, with an estimated 250,000 new cases.

Adeyanju, citing the WHO cancer statistics, said by the disease was responsible for over 78,800 deaths in 2020 and 44,699 in 2021, with women more affected as a result of breast and cervical cancers. It projected that an estimated 28.4 million new global cancer cases would occur in 2040, a 47 per cent rise from 2020.

Adeyanju said 19 per cent of all breast cancer cases in the United States result in mortality; this ratio is 51 per cent in Nigeria. “This is due to late diagnosis, limited treatment options, and poor treatment outcomes. Access to treatment is delayed in 80-90 per cent of patients, resulting in late stages of cancer at the time of presentation and leading to poor prognosis.”

“Nigeria has four functional radiotherapy machines serving over 200 million persons across the 36 states and the Federal Capital Territory, FCT Abuja, which is evidence of low investments as regard cancer care. I remember visiting the radiotherapy unit of National Hospital, Abuja. There are two radiotherapy machines but only one is functional.”

Ezeigwe said the rising cases of cancer in Nigeria are a result of demographic transition and increase in attributable risk factors. According to her, as a non-communicable disease, no single cause has been established for most cancers.

She said, in addition to genetic predisposition, the other risk factors include use of tobacco and tobacco products, unhealthy diet, physical inactivity, harmful use of alcohol and air pollution.

The global health consultant said these factors are closely related to social determinants of health such as education, health system, occupation, income, as well as living and working conditions.

The lady said the level of air pollution, worsened by a frenzy of generator fumes due to power outage, is particularly worrisome, because citizens cannot protect themselves from the menace.

The physician said governance and socio-economic policies of several government sectors shape and determine these factors.

For former health minister, Adewole, there are about 12,000 new cases, yearly, and the fatality is about 8,000. He said the cost depends on type and stage and extent of treatment, and could run into millions of naira.

Ezechi added the rise in cancers in Nigeria forms part of a larger epidemiological transition in which the burden of chronic, non-communicable disease — once limited to developing countries — is now increasing in developing countries.

He said Nigeria is burdened by cancers attributable to infectious diseases like Human Immuno-deficiency Virus (HIV), Human Papilloma Virus and Hepatitis B. In addition to the risks associated with the adoption of western diet, tobacco use and alcohol intake, lack of exercise from sedentary lifestyle and pollution from hydrocarbon and industrial effluents also lead to cancer.

The clinical scientist also said the high fatality rate in Nigeria and other developing countries owes mainly to poor access to epidemiological data, research, treatment, and cancer control and prevention.

The NIMR boss believes lack of awareness, poor health system, inadequate equipment and infrastructure, inadequate health workers especially oncology team, poor remuneration and brain drain are some of the reasons cancer cases are growing in the country.

“Finally late presentation and detection of the early forms of cancer due to poor health-seeking behaviour and poorly organised cancer prevention and control programmes,” he said.

Policy implementation
FOR Adeyanju, poor funding, poor policy implementation, lack of political will and commitment on the part of government are also responsible for the rising case.

He said in 2018, the Federal Government developed a Cancer Control Plan — a four-year programme with a vision to reduce the incidence and prevalence of cancer over the next five years and beyond. But as usual with successive governments, the document has not got the required attention. This, he said, would have taken care of prevention and control of carcinogens,” Adeyanju stressed.

The physician noted that the absence of enabling laws in Nigeria that lower citizens exposure to carcinogens, such as cigarette usage, alcohol use, food labelling, mandated vaccination, and expiration dates, has led to high prevalence of cancer cases in the country.

Adeyanju said it would have been a great strategy to fight against cancer by increasing knowledge of prevalent carcinogens causing cancer and leading to improved behavioral change.

According to Ezeigwe, “there is failure of primary prevention for the whole population, which requires enacting and ensuring effective implementation of relevant policies. The aim of primary prevention is to shift the burden of protection from individuals to the state through policy. This approach is known to be more successful at population level than individual efforts. I am also aware that as a country we often have good policies but have challenges with effective implementation.”

She said, “due to poor state of social determinants of health, individuals are not able to lower their behavioural risk factors such as unhealthy diet and physical inactivity as expected. Besides, the health system is weak and cannot cope with the needs of the population either for early detection/successful treatment or palliative care.”

Ezeigwe laments the situation where you can count the number of treatment equipment on your fingers in a country of over 200 million. “Many cancer patients actually die before or shortly after diagnosis due to their inability to access care at the time they need it. The physician said there is also the issue of health care financing,” she said, adding, “most individuals pay out of pocket for treatment and only an insignificant proportion of the population can afford it.”

Adewole, a former Vice Chancellor of the University of Ibadan, Oyo State, and President of the African Organisation for Research and Training in Cancer, said cancer is a disease of ageing and is affected by lifestyle changes and environment.

For him, high fatality in Nigeria is as a result of lack of awareness, poor health seeking behaviour leading to late presentation.

Charting a path to cancer survival
ON how to curb cancer spread, Adeyanju is of the opinion there is a need for reasonable regulation, higher taxation on tobacco and alcoholic beverages and improved awareness.

He said advocacy and social mobilisation are other strategies for reducing cancer incidence in Nigeria. The physician said advocacy for behavioral change to reduce the risk factor associated with cancer and increasing awareness to encourage early presentation, reducing barriers to cancer control with use of social media, existing print and electronic media.

“I have always advocated that best cancer prevention is through primary healthcare. The community health workers can also help in cancer awareness campaigns. Such campaigns will serve as a vehicle for identifying and addressing harmful behaviours and cultural attitudes to reduce the negative influence on our society. This will help mobilise the entire community in a sustained fight against cancer. This will help greatly in the early detection that can improve the outcome of treatment. There are lots of devices that can help pick for example cervical cancer at the primary health care level. There will also be effective referral to the next level of care,” he said.

Adeyanju said there is a need to make treatment of cancer affordable and accessible.

“Radiotherapy costs about N1 million per person per treatment cycle. The average cost of treating cancer comprehensively for one individual is estimated at N20 million for chemotherapy. This is basically out of pocket for individual as the insurance coverage is still less than five per cent,” he said.

Ezeigwe said with advances in medicine and technology some cancers can now be cured if detected early.

She said it is very important to prioritise screening of high-risk individuals because even when outright cure is not achieved, progression of the cancer can be slowed down with more fruitful years for the patient.

She said at the individual level, everyone should avoid the risk factors mentioned earlier. Ezeigwe said female children aged nine-13 years should get immunised against the papilloma virus responsible for cervical cancer. She said adult females should undergo periodic screening for breast and cervical cancers, especially those with family history. She said every doctor should make it a point of duty to recommend screening for these and other cancers such as prostate cancer and colorectal cancer as appropriate.

Adewole said 40 per cent are curable especially when they present early, while 40 per cent are preventable through lifestyle modifications,” he said.

The medical doctor said exercise, regular checkup or screening, vaccination against liver and cervical cancers are recommended.

The physician urged the Federal Government to make vaccines free, equip more centres and support educational and awareness creation initiatives.

Ezechi said cure depends on the type and stage of the cancer, the type of treatment received, and other factors. He said while some cancers like cancer of the cervix are curable if detected early, some other cancers cannot be cured yet, but can be managed to improve the quality of life of the patient.

“Each cancer needs to be treated differently. There isn’t one cure for all cancer,” he said.

On what Nigerians can do to prevent the development of cancers, Ezechi said increasing access to prevention services could help avert the risk of developing cancer.

He said more than half of cancer occurring in the country is preventable by applying available knowledge in terms of lifestyle changes, scaling up treatment options and preventive services.

Ezechi said early diagnosis increases the chances for successful treatment; it can also reduce the risk of developing invasive cancer.

“Access to cancer screening and diagnostic services is the most important aspect of cancer care,” he said.

To prevent the development of cancer, Ezechi said Nigerians should practice lifestyle modification through maintenance of healthy weight, eating healthy diet, regularly exercise, reduction of alcoholic intake, and prevention of lead to reduction of the risk of developing cancer.

He said there should be increase in awareness, vaccination and screenings of cancers of common cancers. Ezechi said vaccination of young girls with Human Papilloma Virus (HPV) vaccine and high-risk HPV testing can prevent the development of cervical cancer.

The clinical researcher said improvement of the health system, infrastructure and increase in health workforce including capacity strengthening

On recommendations to the government on how best to control cancer, Ezechi listed the following: health education of the public to improve awareness; introduction of HPV vaccination of young girls in the public vaccination programme; establishment of an organised cancer screening programme; build and maintain health infrastructure; capacity strengthening of staff; improve staff welfare; and support research to provide critical data that important for policy and guidelines development.

The WHO said more than 40 per cent of cancer-related deaths are preventable as they are linked to modifiable risk factors, such as smoking, alcohol use, poor diet and physical inactivity. At least one-third of all deaths related to cancer could be prevented through routine screening, early detection and treatment.

Moeti called on governments to develop/update national cancer control plans, provide sustainable financing, incorporate cancer care into essential benefits packages and national health insurance systems and invest in cancer registration.