Case example: building cancer diagnostic capacity in francophone Africa
In 2015, Africa experienced a dramatic shift in health trends. That year for the first time, more Africans are estimated to have died from cancer than malaria. Thanks in part to concerted global efforts, the malaria death rate in Africa decreased more than half between 2003 (the year malaria death rates peaked on the continent) and 2017. Conversely, without any global action, deaths by cancer in Africa are projected to increase almost 50% over the next decade — reaching 1 million annual deaths by 2030. This shift in the burden of infectious diseases – such as malaria – to non-communicable diseases – such as cancer – represents a challenge for African health systems as they manage more patients with different needs than in the past.
One area where patient management differs between cancer and other diseases is diagnosis. An accurate and timely diagnosis of cancer can mean the difference between survival and death. Pathology – the identification and characterization of disease by studying cells and tissues under a microscope – is an essential healthcare discipline to render accurate cancer diagnoses, as pathologists determine the precise type and stage (severity) of cancerous tumors. Oncologists (specialists in cancer treatment) use this information to develop appropriate treatment plans, which may include drug therapy, radiation therapy, and/or surgery.
Late diagnosis of cancer is tragically common in Africa, partly due to the lack of trained pathologists and other laboratory professionals. In many sub-Saharan countries there is only one pathologist for every one million patients, a ratio approximately 50 times lower than in high-income countries. Beyond human resources and training, proper diagnosis of cancer requires equipment and materials that can be expensive and difficult to obtain, factors which add to the delay in patient diagnosis.
In response to the challenges cancer poses on the continent, BIO Ventures for Global Health (BVGH) issued a global call to action to address Africa’s cancer crisis with the launch of the African Access Initiative (AAI) in June 2017. Côte d’Ivoire was involved in the initiative from the outset, and is currently one of six AAI participating countries. From the beginning of its partnership with BVGH, the National Cancer Control Program (PNLCa) under the Ministry of Health and Public Hygiene, emphasized the need for improved pathology capacity to achieve their cancer control goals. Nowhere is the need greater than for breast cancer, the most common cancer type in the country.
Pathology is especially important for the proper management of breast cancer. Many breast lesions are not cancerous, and those that are malignant can have different characteristics – distinguishable via pathological assessments – that affect their responsiveness to commonly used drugs. With an estimated 2,700 new breast cancer cases identified each year in Côte d'Ivoire, the augmentation of diagnostic pathology capabilities in the country is critical.
In response to Côte d'Ivoire’s need for breast pathology training, BVGH partnered with the Center for Global Health at the American Society for Clinical Pathology (ASCP), Côte d’Ivoire’s Ministry of Health and Public Hygiene, and the Ivorian Society of Pathology (SIPath) to organize a three-day pathology workshop. The workshop, held in Abidjan, Côte d’Ivoire in April 2019, used didactic presentations, case study discussions, and question-and-answer sessions to teach the techniques used to diagnose and sub-type breast cancer. Three expert trainers from Maisonneuve-Rosemont Hospital in Montreal, Canada led the workshop sessions using training materials customized to the expertise, expectations, and needs of attendees, which were ascertained through pre-workshop surveys. This training provided the participants with up-to-date knowledge of best practices in collecting samples, diagnosing and sub-typing breast cancers, and improving laboratory efficiency, which will lead to patients receiving earlier and more accurate diagnoses.
Maximizing reach across nations
Côte d'Ivoire, like roughly half of the countries in Africa, is Francophone. Healthcare capacity-building programs in Africa are often led solely in English, which hinders countries like Côte d'Ivoire from gaining the skills and expertise they need to improve their healthcare services. The BVGH-ASCP-Ministry-SIPath workshop, taught entirely in French, bridged this international training divide and set the standard for future training programs in the region. The French workshop was met with excitement and anticipation from pathology lab staff located across Francophone Africa. Nearly 100 participants from 10 Francophone African countries – Benin, Burkina Faso, Burundi, Cameroon, Côte d’Ivoire, Guinea, Mauritania, Republic of the Congo, Senegal, and Togo – attended the three-day workshop.
“I think international exchanges are essential in any field, and that includes breast pathology… As trainers, it solidifies our leadership roles. The participants go back to their institutions and become leaders themselves.” – Dr. Marie-Christine Guilbert, Trainer and Breast Pathologist at Maisonneuve-Rosemont Hospital in Montreal
Beyond pathology lab staff, surgeons, oncologists, and medical students also attended the workshop, leading to fruitful discussions regarding the role of a multidisciplinary team in the treatment of breast cancer patients. Pathologists, surgeons, and medical professionals responsible for collecting patient samples discussed best practices for obtaining and preserving high-quality pathology specimens. Several participants noted that they would make changes to their biopsy practices by no longer collecting samples on Fridays to avoid them sitting untouched, and possibly degrading irreparably, over the weekend.
Across the 10 countries represented, more than 13,000 women will be diagnosed with breast cancer each year. The 100 attendees – which, given the paucity of pathologists and laboratory technicians in sub-Saharan Africa, represent a considerable proportion of their countries’ pathology workforce – are now better positioned to properly diagnose cancer patients. This will translate to faster and more accurate diagnoses for women at risk for breast cancer and – hopefully – to more survivors, who can continue to contribute to their communities across the region.
“The future of caring for my patients has improved after this training because now I have a better understanding of what it takes to conduct a high-quality diagnosis. By communicating and working with pathologists, members of the clinical team and I will take action to improve patient care.” – Participant and Medical Resident at the Centre Hospitalier Universitaire de Treichville in Abidjan
A model for the future
Driven by Africa, for Africa, AAI programming – like the breast cancer workshop – is tailored to meet the cancer priorities of African governments and the self-defined needs of African cancer hospitals. BVGH, ASCP, the PNLCa, and SIPath plan to continue their collaboration to bolster Côte d'Ivoire’s diagnosis of cancer patients through additional training opportunities, equipment placements, and programs to ensure consistent access to the materials needed to perform pathology tests.
“Many organizations can provide different components to cancer care. But even in a perfect cancer system, one organization cannot provide all of that care. So when we think about projects or approaches to tackling cancer in Africa, we have to have a collaborative network of partners to make that work.” – Dr. Dan Milner, Chief Medical Officer of the American Society for Clinical Pathology (ASCP)
Ultimately, diagnosis is the first of many steps along the lengthy, often reiterative, cancer patient pathway. Two upcoming workshops organized by BVGH in partnership with the Ivorian Ministry of Health and Public Hygiene will support Côte d'Ivoire’s newly-opened radiotherapy center and foster the country’s multidisciplinary approach to treating prostate cancer.
Through partnerships and collaboration, AAI is mobilizing resources to aid African health systems to meet growing needs and cure more patients, despite the challenges posed by the increasing burden of cancer.
BVGH is grateful to our Ivorian partners and ASCP – for their tireless efforts to make this program a success – and our AAI program partners, Pfizer and Takeda Pharmaceuticals.
Credits:
BVGH: Abidjan, April 2019