Why more Nigerians will die of cancer

*Some patients spend at least N400,000 monthly on tests, drugs, radiotherapy

More reasons have emerged why 80 per cent of Nigerians living with cancer do not survive the disease. Besides late presentation and diagnosis, ignorance and ill-equipped hospitals, most cancer patients cannot afford the high cost of treatment that includes drugs (chemotherapy), radiotherapy, immunotherapy and other newer life-saving procedures.

The Guardian investigation revealed that it costs a cancer patient at least N400,000 monthly for medical tests and diagnosis, sessions radiotherapy and/or Linear Accelerator (LINAC), and drugs (chemotherapy). It was found that the cost depends on the type of cancer, the kind of treatment, the patients body weight and the stage of the tumour; and the cost could be as much as N2 million monthly.

A LINAC is the device most commonly used for external beam radiation treatments for patients with cancer. The linear accelerator is used to treat all parts/organs of the body. It delivers high-energy x-rays to the region of the patient’s tumour.Investigations showed some of the life-saving treatments are not available in Nigeria and some patients who could afford them travel to India, Germany and South Africa for further treatment.

The Guardian investigation revealed a patient with metastatic breast cancer, weighing 89 kg could pay up to N730,000 for a loading dose of chemotherapy and N490,000 for subsequent doses. The Guardian reliably gathered that a patient with metastatic castrate resistant prostate cancer taking oral treatment could pay in the region of N400,000 or much higher depending on the molecule and manufacturer.

According to the latest estimate on the global burden of cancer, released in September 2018, by the International Agency for Research on Cancer (IARC), “There will be an estimated 18.1 million new cancer cases and 9.6 million cancer deaths in 2018. In Nigeria, 115, 950 new cases and 70,327 deaths are predicted…. The country’s cancer death ratio of four in five affected persons (that 80 per cent) is one of the worst in the world.”

Critics say the figures could be more if nothing was done urgently.The high cost of cancer care in Nigeria has led more than half of patients to cut back on some part of their treatment. To save money, some patients said they avoided doctor appointments, had refused treatment, skipped doses of prescribed medications, and had cut pills in half to reduce health costs.

Cancer patients are ending up in debt because they have to cover the costs of treatment as well as other care-related expenses. It was found that more than half of cancer patients spend at least a third of their yearly household income on treatment, as well as on costs such as transport to hospital and childcare.

According to a study published in the journal Nature Reviews Clinical Oncology, high drug prices harm patients — often directly through increased out-of-pocket expenses, which reduce levels of patient compliance and lead to unfavourable outcomes — and harms society — by imposing cumulative price burdens that are unsustainable.

The study is titled, “The high price of anticancer drugs: origins, implications, barriers, solutions.”An investigation showed that the cost of cancer drugs in Nigeria is still significantly lower than the cost of treatment in more developed health care systems but still presents a significant challenge for the majority of Nigerians paying out of pockets. They have to pay out-of-pocket for cancer drugs because treatment for cancer is not included in the National Health Insurance Scheme (NHIS) and government does not fund patients’ care.

Those who cannot afford it patronize quacks, traditional medicine practitioners, and spiritual homes or simply wait to die.The drugs used in the treatment of cancer vary depending on the type of cancer and the stage of cancer. For prostate cancer for instance treatment can include radical prostatectomy, external beam radiotherapy, permanent seed brachytherapy, hormone therapy, chemotherapy, or oral treatments such as Abiraterone.

Not all of these treatments are available in Nigeria. The common treatments in Nigeria tend to be radical prostatectomy, external beam radiotherapy, hormone therapy, chemotherapy and oral treatments such as Abiraterone.

According to the study published in the journal Nature Reviews Clinical Oncology, globally, annual spending on anticancer drugs is around US$100 billion, and is predicted to rise to $150 billion by 2020. In the United States (U.S.), a novel anticancer drug routinely costs more than $100,000 per year of treatment. When adjusted for per capita spending power, however, drugs are most unaffordable in economically developing nations, such as India and China. Not only are launch prices high and rising but individual drug prices are often escalated during exclusivity periods.

However, a consultant pharmacist and President, Pharmaceutical Society of Nigeria (PSN), Ahmed I. Yakasai, confirmed to The Guardian that the cost of treating cancer in Nigeria is significantly lower than the cost of treating cancer in the US, which is “a completely reimbursed market.”

Cancer survivor narrates ordeal
“Honestly, cancer is a lifetime pain but one has to continue living as long as you can.” These are the words of Rahama Hamzah Sani.Sani is a stage three-breast cancer survivor of almost 14 years but the narrative changed when she was re-diagnosed of cancer of the spine in 2010 and another recurrence in the spine again recently.

Rahama Hamzah Sani is the chief psychiatrist social worker with Aminu Kano Teaching Hospital (AKTH), Kano State.Sani recounted her ordeal on the ongoing battle against the dreaded ailment and the journey so far. According to Sani: “Usually after my menses, I do self-breast examination. When I examined myself I saw a lump, there was a friend with me, I asked her to examine me too and she said there was a lump but I should pray about it because we were observing Salat.”

Sani decided to see an oncologist in Shika Zaria who confirmed to her that the cancer was in stage three.Sani said: “I cried so much and told so many of my friends around because I thought I was going to die. I was in pains, but as a social worker, well informed about the disease, I consoled myself, as a psychiatrist medical social worker who counselled others to accept, pray and move forward so I began to enquire about a way forward.”

She narrated the tremendous support by all especially the family colleagues and even in the hospital by the Chief Medical Director (CMD).“I did surgery in AKTH Kano November 15, 2005. I did chemo radiation in Ahmadu Bello University Shika Zaria and completed it in 2006 June.

“In 2010 I noticed pain at the lower back and inability to hold little urine due to pressure and cannot bend to observe Salat. I was terribly sad and thought the end had come because some said once it spread to bone no cure but it is the easiest one to cure. I had removal of lymph nodes in left armpit 2012 in Tata memorial in Mumbai.”

Sani frowned on the expensive nature of cancer drugs citing that most cytotoxic drugs are not available easily in the country. She thanked the Muslim Public Affairs Commission, Lagos for sponsoring her trip to Dhramshila Hospital in 2010.

She said: “During my time, I usually get the drugs from India. Most modern equipment for cancer management are not available in Nigeria. We just have seven radiotherapy machines cut across the country and they are old models giving toxicity to patients not cure and eventually hasten their death. Most of them have even broken down.”

The social worker reiterated the need to declare an emergency in the health sector so that we can review matters relating to cancer to have a policy statement like cancer bill as it applies to Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) programme.

The survivor urged Nigerians to know that cancer exists as a physical illness, not a spiritual issue and should be treated so, as it affects all ages, gender, race and every socio-economic status, and as a global epidemic we are supposed to take precaution by going for screening because early detection leads to cure and good quality of life

“Let have a policy statement cancer bill that spells out what to do for anyone with cancer, to be addressed holistically as in screening, treatments, social support because this will assist in reducing the cancer burden and its stigma,” she said.
Reasons for rising cases and deaths

Yakasai said: “Late presentation is a significant challenge in the Nigerian context. The majority of patients present at late stages; when survival chances are much lower. In addition, Nigeria is predominately a self-pay market, which means that the majority of patients, cannot afford cancer treatment. Those who are able to seek care are also faced with a healthcare system that is overwhelmed.”

The Head of Department, Radiotherapy and Consultant Oncologist, Lagos University Teaching Hospital (LUTH), Idi-Araba, Dr. Muhammad Habeebu, said there was a global increase in cancer with many presenting late. He added that this was due mainly to the insufficient equipment for cancer treatment and low level of awareness.

“Ignorance is a major factor in late presentation. Patients only see the hospital as the last alternative, usually after they have sought spiritual help, most times at stage three and four where the treatment can only be palliative.

“The belief that cancer is spiritual and some even resolve to use alternative or traditional medicine is another issue of concern. There should be increased awareness on breast examination and likely changes to look out for,” he said. According to the expert, there is incidence of up to hundred thousand new cases of cancer annually with breast cancer the most common cancer today consisting of one third of all cases.

“Prostrate is the commonest in male and cervical cancer is the second most common cancer in women and this can be prevented by immunization against Human papillomavirus infection (HPV). Cervical cancer just like breast cancer is rare below age of 20 or below age of puberty. However, the incidence of cancer increases with age up to about sixth decade of life.

“Screening for breast is of three ways, the self-breast examination which can be done by the woman herself, the clinical breast examination which can be done by an expert and the mammography/ultrasound scan which is an imaging procedure which can be done to the breast tissues to roll out any malignancy.”

Habeebu continued: “Prostate cancer is common in men and it is rare before puberty and fourth decade of life and the incidence increases with age. However most prostate cancers are asymptomatic, they do not have symptoms. Screening for prostate cancer is usually done using the Prostate Specific Antigen (PSA) a form of blood test. Digital erectile examination can also be conducted by an expert and prostrate scan can also be used to screen for prostrate malignancy. Screening should be done at least once a year or as prescribed by physician.”
State of emergency

With recent statistics released, showing an indication of an alarming increase in the burden of cancer in Nigeria, medical experts have called for a state of emergency to proffer cost-effective ways to prevent and treat the disease.Expressing worry at the scary statistics and projections during the yearly Doctors’ Conference organised by Lakeshore Cancer Centre, held recently at the National sickle Cell Centre, Idi-Araba, Lagos, the experts warned that there is cancer epidemic brewing at the doorstep of Nigeria, adding that the country must act now to effectively combat it.

Speaking at the conference, the Chief Executive Officer, Lakeshore Cancer Center, Prof. Chukwumere Nwogu, stressed that cancer is an enormous contributor to the burden of non- communicable diseases on the Nigerian population, which is clearly documented to be growing at an alarming rate.

The cancer epidemiologist and thoracic surgical oncologist said since Nigeria’s cancer registration is marked under-developed, which is probably a significant under-estimation of its cancer burden, with limited expenditure on healthcare, it is therefore crucial the country strive to maximize the impact of cancer control through less financial demanding alternatives that exist.

Nwogu, in his presentation titled: “Cost Effective Cancer Care – The Public Health Perspective” pointed out that lifestyle modifications, vaccination, screening, early/accurate diagnosis, appropriate treatment and palliative care are all critical components of effective cancer control to reduce the scourge in Nigeria.

“Breast, cervical, prostate and colorectal cancers are the four most common cancers currently in Nigeria. There is a compelling opportunity to engage working collaboratively with the public and private healthcare institutions, physicians, nurses, pharmacist, allied healthcare workers, researchers, non-governmental organizations and the citizenry at large, which can make a huge difference,” Nwogu said.

Meanwhile, the Chairman, National Programme on Cancer Management, Prof. Francis Abayomi Durosinmi- Etti, noted that cancer prevalence in Nigeria is on the rise, saying, “it is not going down and it is frightening.”He said emphasis in Nigeria should be placed on finding means of supporting the cancer patients in cost-effective care, which is why this symposium is very important in addressing this looming and dreadful issue.

he consultant clinical oncologist lamented that cancer treatment has always been very expensive for the patients and their families, which he said is yet to be covered by the NHIS.“If the country finds a means of getting the money whether through the NHIS or even some other means of support, then patients can get treatment at a proper price and also service will be kept going,” Durosinmi- Etti said.

Professor of Surgery and Oncology at Roswell Park Comprehensive Cancer Centre in Buffalo, New York, US, Stephen Edge, while speaking on “Key Breast Cancer Treatment Practice for Cost Effective Care”, said breast cancer is an increasing problem around the world, especially in Africa, noting that the major problem is late presentation.

Recommendations
Yakasai said it will become increasingly important for the Federal Ministry of Health and other stakeholders such as the teaching hospitals earmarked as centres of excellence to consolidate demand in order to enter into price/volume discounts with manufacturers. In addition, he said, action must be taken to curb the impact of Nigeria’s free pricing policy of the price of oncology drugs to the patient.

The pharmacist said government should consider capping margins that can be applied to oncology medicines by local players in the value chain and it should consider removing customs and duties fees on oncology medicines, as has been done in Ghana. The PSN President said more awareness is needed of life style modifications, which can reduce the risk of cancer. “In addition, studies need to be conducted to understand if there is any relationship between population and cancer. For instance, anecdotally, it is believed that cancers present earlier and much more aggressively in places where you have pollution. Research needs to be conducted to understand whether there is a casual link between cancer incidence and environmental factors like pollution,” he said.

Yakasai added: “Preventative measures are extremely important. Citizens must become more aware of how to reduce the risk of cancer. Nationwide screening programmes are also very important. The Federal Government and other interested stakeholders should also continue to focus efforts on building the capacity of the eight Oncology Centres of excellence to provide patient-centered care. The healthcare practitioner to Patient ratio in these centres must also be improved over time, with strong referral networks created with General Practitioners (GPs)/other Primary Health Care Practitioners and with religious organisations and traditional healer. Finally, cancer care cannot continue to be paid for out of pocket, Governments must continue to find novel but sustainable ways of ensuring access to treatment.

Habeebu highlighted the importance of raising awareness about these cancers because they are easier to treat and manage when detected early. “We have just about eight radiotherapy facilities in the country to cater for over 180million Nigerians. However, very recently government has started to improve on radiotherapy in facilities. In LUTH, we are expecting four new radiotherapy machines both for tele-therapy and brachytherapy; this will make LUTH the most equipped centre in West Africa.”

On the high cost of cancer management he said: “Cancer is different from other diseases, the cost of management is high. The treatment continues for a long time. The government should include the treatment of cancer in the NHIS because most people pay out of their pocket for cancer treatment and this also scares patients away from the hospital.”

The expert, on the affordability of drugs for the illness said: “Cancer drugs imported mainly from China and India are not done through the proper way. In LUTH and most of the teaching hospitals, we have pharmacy that makes drugs available the right way, so patients have the opportunity to buy directly from the institution. The prices are high but LUTH has championed cut in price of drugs. One of the drugs cost over N800,000 but in LUTH it is sold for N300,000 in collaboration with the manufacturing company. The populace should go to screening and if you detect anything abnormal the earlier you present to hospital the better the cure and cheaper the treatment.”

On government participation, he said, “Government should declare wavier on cancer diagnosis, drugs or NHIS, so that patients will have access to diagnosis and treatment which would enable them to present early because they will know there is access to treatment when diagnosed.”

Edge added that cost-effective solutions for treatment are available such as appropriate use of radiation, lymph node surgery, and use of neoadjuvant therapy, which he advised must be addressed in the setting of increased efforts to promote early detection and early intervention.

Similarly, Consultant Laparoscopic Upper GI and Bariatric Surgeon at Euracare Multi- Specialist Hospital in Lagos, Dr. Abuchi Okaro, urged Nigerians to consult specialists for proper screening, while he also advised conducting pap smears test and mammogram. Abuchi who also spoke on “Cost Effective Cancer Care – An Upper GI Perspective” noted that early detection would help increase chances of survival, just as he called on government to provide health insurance to subsidise the cost of cancer care in Nigeria, which according to him takes a financial toll on families.

Government efforts
Nigeria has started a process of reducing the cost of cancer drugs by 50 percent in hospitals through direct procurement to ensure availability of quality and cost-effective chemotherapy agents in the country. Minister of Health, Prof. Isaac Adewole, said the government would establish dedicated cancer chemotherapy wards in nine federal tertiary institutions across the country.

Adewole added that the centres would be provided with all necessary equipment to provide adequate supportive care, which has been lacking in hospitals.According to him, the initiatives will make cancer treatment relatively affordable by patients. Adewole admitted that there is no provision for cancer care in the National Health Act but the government is taking care of cancer through some other windows.

On the high cost of cancer drugs, the minister said: “We are also talking to major manufacturers to do bulk purchase and the negotiation at an advanced stage. We hope to reduce the cost of drug to about 60 per cent through the negotiation and we will also build capacity for surgery. We are going to train a cadre of specialist surgeons who will be handling cancers. We are almost there.”

Yakasai said in April this year the Federal Ministry of Health launched a very ambitious National Cancer Control Plan. The vision, he said, is to reduce an incidence and prevalence of cancer in Nigeria, while the mission is to reduce exposure to risk factors of cancer; establish a framework to ensure access to cancer screening, care and improved quality of life of people affected by cancer. Yakasai said the Federal Government aims to do this by:
a) Making screening services and early detection of cancer available for all Nigerians
b) Improving access to quality, cost effective and equitable diagnostic and treatment services for cancer care
c) Achieving best possible quality of life for patients and families facing a life limiting/threatening or terminal cancer
d) Increasing Cancer awareness and advocate for cancer control amongst the populace
e) Conducting and supporting integrated programmes that provide high quality population and facility based cancer data for dissemination, research and planning
f) Ensuring the availability of drugs, consumables and functional equipment for cancer care in Nigeria
g) Ensuring effective coordination and adequate resources for cancer in Nigeria

He said the expected outcomes are: Reduced incidence of common cancers in Nigeria; improved financing from government, private sector, Non Governmental Organisations (NGOs)/Civil Society Organisations (CSOs); and reduced morbidity and mortality through early detection methods.

Yakasai said the Government has already begun the implementation of this plan. He said in addition hospitals like LUTH under the leadership of Prof. Chris Bode are entering in novel Public Private Partnerships (PPPs), which are significantly expanding the capacity of the health care system to treat patients. “And recently National Hospital, Abuja got its second Radiotherapy machine for cancer treatment (Elekta Machine for linear accelerator LINAC).”