Health Across Borders, the theme of this year’s Global Health Day, could not be more relevant in the wake of recent outbreaks of Ebola and the Zika virus. But what about cancer? We may not think of cancer as an international problem, but cancer control benefits from international collaboaration just as viral epidemics do. The majority of cancer deaths occur in developing countries where the incidence of cancer is increasing as life expectency is lengthened, but where resources to treat cancer are lacking, especially radiotherapy. Radiotherapy is needed in the curative treatment of about half of cancers, and even more if one counts palliative treatments. The creation of radiotherapy centres has been slow with many developing countries being severely underequipped, if at all. We may be able to find a cure for cancer, but to cure these cancers, we must redouble our efforts to bring adequate treatments to those who need it the most. Collaborations between leading cancer centres and practices in developing countries are essential if we are to bridge this gap. Recently, the International Union for Cancer Control has launched the Global Task Force on Radiotehrapy for Cancer Control (GTFRCC.org, GlobalRT.org) and Radiation Oncology associations worldwide have seen an increase in their global health activities (carointernational.org, the global health arm of the Canadian Association of Radiation Oncology). These movements promote investment in radiation oncology and support small centres as they grow and transition to newer equipments and advanced radiation techniques.
During the 3rd year of my residency training in Radiation Oncology at the University of Toronto, I traveled to Ghana to spend a month at the National Centre for Radiotherapy in the capital, Accra. I had been to Ghana once before, as a medical student working in a tropical hospital in thecountry’s northern region. During that trip I also visited the National Centre for Radiotherapy, where I met the head of the department, Dr. Joel Yarney. Dr. Yarney and I reconnected two years later, when he moved to Toronto for a year-long fellowship at the Princess Margaret Cancer Centre where I had started residency. He invited me to return to Ghana and experience the day to day workings of their cancer centre.I was very excited at this opportunity and convinced my program director to let me travel the following year (even on the tail of the Ebola outbreak, which, fortunately, remained far from us). I was also grateful to receive the first Global Health Scholarship from the International Communications workgroup of the Canadian Association of Radiation Oncology. Organizing the trip was not easy. I was the only radiation oncology resident to have gone on a global health elective in my center’s recent memory. A lot of phone calls, e-mails, and paperwork was needed to resolve questions on medical licensure, liability coverage, local research boards, vaccinations, visas, and evacuation insurance. But once all was settled I hopped on a British Airways flight to the warm and friendly Gold Coast.
After a few nights couchsurfing in the beautiful apartment of a German couple, I moved to the ‘Dean’s guesthouse’, a bed & breakfast near the main teaching hospital of Korle Bu. My elective lasted for four weeks and I divided my time between the clinic and a research project on cervical cancer. Cervical cancer patients in developing nations often present late, with large tumours not amenable to surgery. This means that the mainstay of their treatment is radiation, delivered both externally and internally (called brachytherapy). However, brachytherapy is not widely available in Sub-Saharan Africa; only some centers provide it. We had an opportunity to analyse one of the (if not the) largest cohort of patients treated with this modality in Sub-Saharan Africa. This project is nearing completion and will inform us on the survival of these Ghanaian women compared to women in other, more economically developed countries.
The principles of radiotherapy are the same everywhere in the world. However, the training and practice of radiation oncology differed in several ways from what I was accustomed to in Canada. First, residents trained in both radiation and medical oncology (they are called clinical oncologists, a specialty still common today in some countries, including the UK). Residency training is 4 years after 1-2 years of general medical internship. This is a relatively short time to master both radiation and chemotherapy, and the residents worked very hard, seeing large numbers of patients in clinic per day. The center treats about 1200 patients per year. On the other hand, because of the technology employed, the treatment plans rarely required lengthy delineationof tumours or normal organs, meaning less time spent per patient. There was limited capacity for planning based on CT scans, and newer techniques such as Intensity Modulated Radiotherapy (IMRT) were not available. The centre is equipped with one Cobalt-60 machine but is expecting to add a linear accelerator in the near future. Volume delineation is an important skill to acquire before the arrival of the new machine. Fortunately, Dr. Yuan helped to train the residents in the contouring of various sites. He was a visiting radiation oncologist from China, spending one year at the centre as part of a larger medical collaboration between China and Ghana. Two other Chinese radiation oncologists had preceded him, contributing to the growth and improvement of the center for 1-2 years each. Funding for these visits was provided by the visiting oncologists’ own medical centre. China sends several staff to Ghana each year in the fields of surgery, neurology, radiation oncology, and others. Some Ghanaian staff also spendtime acquiring expertise at Chinese medical centres. Dr. Yuan’s next destination wasthe MD Anderson Cancer Centre for a fellowship in proton therapy.
The physical clinic space was organized quite differently. There were two clinic rooms: in each, two residents, or a staff and a resident, sat at desks, facing each other. Patients sat on a chair next to the desk, accompanied by family members. This occasionally made for a busy room, with residents, patients and family members, nurses, and occasionally physicists, and administrative personnel coming in and out. There was one examination table servingthe patients of both physicians. Pelvic examinations were done most often in frog leg position because the examination tables were not all equipped with stirrups. Privacy was provided with a curtain that surrounds the table, but in general, I found that there was less of an emphasis on privacy than we are accustomed to in Canada.
Chemotherapy was delivered in reclining chairs, and a hospital bed was available for patients who became ill. Specialized nurses were on site for the delivery of chemotherapy and a chemo teaching session was booked prior to start. There, patients were counselled and had a chance to ask questions about what to expect during treatment.
The practice of radiation oncology did not have the same multidisciplinary dimension as we are accustomed to in large cancer centers. This is in part because the staff are both medical and radiation oncologists, able to manage both radiation and chemotherapy. This is also because there was a shortage of surgical oncologists altogether. For example, there were no specialized gynecological oncologists, so that some early stage cervical cancers that could get surgery were treated with radiotherapy instead. A few multidisciplinary rounds did take place and were quite interesting. Breast tumour boards were attended by breast surgeons and head and neck rounds took place with a surgeon who trained in the UK. During rounds, CT scans were reviewed on plain film, which was an entirely new experience for me!
Paper charts held together all progress notes, x-ray films, pathology and imaging reports, as well as radiation prescription and delivery sheets. Patients were responsible to bring notes, pathology reports and x-rays with them when they came for consultation. They carried some charts with them between different sections of the hospital, while the radiotherapy chart remained in storage at the centre.
The centre was equipped with a Cobalt 60 unit, made in Canada. Patients were simulated on a Varian 2D simulator and beam-modifying cerrobend blocks were made in the mold room.
In the past, cervical brachytherapy was delivered with low-dose-rate sources. The centre had recently upgraded to a high-dose-rate unit using Iridium192. Residents actually performed all the brachytherapy insertions, with the staff there to support them in difficult cases. Applicator verification was done with orthogonal X-rays. Planning and dose calculations took time because the HDR unit had only recently started its operation. As physics staff became more familiar with the process, the time to delivery became shorter during my stay. There was considerable discomfort to the patient nevertheless, since brachytherapy was performed without anesthesia, using pethidine (meperidine) and dormicum (midazolam) instead.
The room pictured here will be the bunker that will house the new linear accelerator, used temporarily for HDR brachytherapy.
Additionally, they had the expertise and capacity for prostate brachytherapy and were beginning to offer this treatment as well.
The Treatment Planning Process
At simulation the patient is marked on the skin with electoral ink. Ink can be in short supply in election years! (We use tattoos in Canada which are permanent but require needles and special ink.) X-ray films are then printed and the oncologist demarcates the areas that need shielding. These films are used to create cerrobend blocks that will be fitted in the head of the machine. Monitor units are calculated by the physicists and the patient is ready to start treatment. Position verification is done using Meavoltage images.
A small number of cases were done with 3D simulation, using a CT scan. Patients who could afford to obtain a CT for planning were brought by the centre’s vehicle to a private clinic were the CT would be obtained in treatment position (but without in-room lasers). Then, contours and a plan would be generated using the Prowess Panther treatment planning system. The patient wasthen realigned to the isocenter using bony landmarks on the 2D simulator.
Public and Private Care
In Ghana, there is a two-tier medical system with private and public facilities. There are three radiotherapy centres: two ‘public’ ones (although the treatments are not free, but less expensive), one in Accra and one in Kumasi, and a private center in Accra. Treatment costs varies depending on the type of treatment and the need for brachytherapy or chemotherapy. The cost of a cervical cancer treatment with labwork, radiotherapy, chemotherapy, and brachytherapy approachedCAD 1000$. Keeping the public centre operational with adequate funding and staffing was challenging. Like many other developing countries, Ghana experiences a net export of expertise. Several radiation therapists who were sent for training abroad never returned, and at one point, the centre had only one therapist! To counter this effect, they created their own therapy training program and have succeeced in retaining an increasing number of graduates.
A private centre was built in Accra with funds from a collaboration between Sweden and the Ghanaian government. This centre charges a significantly higher cost of treatment, but is equipped with a CT simulator and a linear accelerator, allowing it to deliver high doses with fewer side-effects to organs at risk. It has an expensive-looking interior and every comfort of a modern clinic. The facility employed a Swedish oncologist until one of the recent graduates from the residency program at the National Centre took up the position. One of the staff oncologists from the National Centre also worked there one day a week. I also met Adam there, an American physicist with an interest in global health. He was helping to improve the physics QA and train future physicists while on a 1-year commitment. He is a member of Radiating Hope, a radiation oncology charitable organization (radiatinghope.org).
Talking to Patients
There were many communication challenges in Ghana. Luckily nurses were readily available and would help to translate in the local languages. However, even if the patient spoke English, many patients had little education, and a limited understanding of the diagnosis and the treatment. After a few days there, I realized that I had to make the effort to explain myself in a straightforward manner that could be understood by anyone. I improved the way I vulgarized medical information, remaining careful that my sentences were clear in order to be understood and get my message across. There is a significant power differential between physicians and patients in Ghana, which also meant that patients rarely asked challenging questions to the doctors. Sometimes they underreported symptoms so as not to upset us. I believe that being a foreign doctor further contributed to this phenomenon. I got better at eliciting symptoms from Ghanaian patients as I got to know their culture better. Many initially reported that they are feeling “fine,” almost reflexively. While I took that at face value in the beginning, I learned to probe deeper, to ask questions that were specific, and adopt a tone and manner that would welcome feedback. Many patients had no education at all and it remained difficult to know if they understood the risks, benefits, and the way the therapy worked. Sometimes this led to poor treatment decisions. For example, women who received neoadjuvant chemotherapy to shrink a breast cancer before surgery would sometimes not return for the surgery itself if their lump completely disappeared – why would they? These are some challenges of treating patients in a low income country. Interestingly, when I visited the Sweden-Ghana center, wealthier and more educated Ghanaian patients were very similar in their interactions to what I was used to in Canada. Many openly reported symptoms, worries, and even different diets they were trying.
Sodom and Gomorrah or The Determinants of Health
There are many competing health priorities in Ghana, from malaria, to infant mortality, poverty and low education. Recently there has been a push to increase hygiene by providing public toilets and improving the open sewage system. Although I focused on cancer, I am deeply aware that the health of a people is a summation of many factors. One needs roads and a bus fare to get to the clinic. Children need clean water, shelter, vaccination, education, good nutrition, and many other things that are self-evident. One day, I read a piece in the Guardian newspaper on a place called Agbogbloshie, a slum that the locals nickname ‘Sodom and Gomorrah’. A young masters student from the university of Ghana who was researching the slum as part of a collaboration with the International Growth Centre volunteered to accompany me inside (it is forbidden to foreigners). There were countless impoverished locals (scrap dealers, dismantlers, etc.) who recycled materials with bare hands and basic tools. Car engines, entire trucks, refrigerators, all recuperated, broken down, transformed, and sold. In fact, Agbogbloshie is the largest e-waste site in the world, where many electronics from the West, sent to ‘bridge the digital divide’, are stockpiled for being broken or unusable. Adults and children alike burn computer cables in toxic pyres to extract the copper wire. They then sell it to a plant outside town. This happens more or less across the road from the hospital, hidden from view by trees and mounds of earth. It is said that many people die of cancer and metal poisoning, but the numbers are not known. At the end of the tour we spoke to the local chief of Agbogbloshie, who was visibly frustrated with usand others who had passed by. He maintained that many foreigners had come, taken photographs, studied the area, but in the end there had been little if any change for them. He said the government would like to throw them out, but this recycling work was their livelihood, even in those despicable conditions. Recently there was a push to clean out the slum after severe floods that engulfed the city were blamed on the clogging of the sewage basin by garbage from Agbogbloshie. Kevin McElvaney, the photographer who published the visual piece in the Guardian, is actively trying to raise awareness of the toxic working conditions with his photographs. His exhibit has been shown in several European countries (derkevin.com).
Witches and Traditional Healers
Traditional healers are popular, as is prayer healing. Many cancers grow while patients delay their diagnosis, sometimes for months. Popular sitcoms often revolve around witchcraft and wizardry (evil spells are usually cast by witches). During a previous trip to the Northern Region, I visited Gambaga’s ‘witch camp’, a place where women ostracized from their communities after accusations of witchcraft found refuge. The chief of Gambaga, rather than assuming they have been wronged, maintains that he has powers to counter the spells of the witches. These women work on his fields often for very little in order to regain their freedom, and some spend decades there, having nowhere to go. Organizations, including Baptist churches, which are quite active in the Northern Region, worked with the women to help re-integrate them in their communities.
Research and Future Collaborations
During my stay I held a focus group that helped design a research mentorship program between the University of Toronto and the radiotherapy centre in Ghana. This mentorship program is nearing its completion and has seen residents actively participate in research activity under the guidance of both Ghanaian and Canadian mentors. My main research interest during my stay was cervical cancer, as I mentioned before. In the next few weeks, we will report on the outcomes after Cobalt 60 teletherapy and LDR brachytherapy of more than 250 patients. That does not sound like a very large number, but often reports on these patients from Sub-Saharan Africa describe suboptimal treatment (without brachytherapy) or simply palliative doses. That is when the patients even return to start. We have found that a significant number of patients who were seen in consultation never returned for their treatment, and were quickly lost to follow-up. We suspect that many of these patients could not afford their treatment, even at the rates of the public centre. This is not particular to Ghana, and many countries struggle to provide adequate cancer care for their patients, even in industrialized nations. While there is a national insurance scheme in Ghana, it often covers no more than basic care, and is unlikely to cover chemotherapy or radiotherapy treatments in the near future. Patients who cannot afford it may have to borrow money, sell property, or work many jobs. Other barriers may include travel time and the need to be away from the children that women care for. There are no radiotherapy facilities in any of Ghana’s neighbouring countries and patients sometimes traveled from far away. Arranging accommodations was also challenge because radiothreapy treatment for cervical cancer often lasted more than two months. There could be other barriers too, less evident ones, such as the need to obtain permission to be away from the household, or a preference for traditional healers. We will explore some of these in our telephone interviews.
I leave my travels around Ghana for another time, they would take an entire blog entry on their own! The people in Ghana have made my stay so wonderful with their kindness and beaming smiles. I hope more residents will follow, especially as the collaboration stemming from our cervical cancer research and the Ghana-Toronto Mentorship Program continues to grow. The CIC workgroup has renewed its Global Health scholarship and is expecting radiation oncology applicants from both the residency and fellowship program. I know that I could not have asked for a more enriching global health experience.
Mole National Park, Northern Region, Ghana
Horia Vulpe, PGY 4
Department of Radiation Oncology
University of Toronto