The challenges of cancer treatment in Nigeria

Nearly every week, through our communication channels for this page, we receive anguished messages asking where to access different aspects of cancer care. Sometimes, the stories are heartbreaking. To a large extent, the difficulties associated with cancer treatment in Nigeria are probably quite well known.

Still, it is surprising that many more people do not even know where to start when confronted with the probability of such a diagnosis. Cancer treatment in Nigeria faces several significant challenges that affect prevention, diagnosis and patient outcomes.

The most glaring problem facing affected patients remains the issue of late diagnosis, with many patients being diagnosed at an advanced stage of the disease due to several factors. Many of these diagnoses are made late because of certain cultural and religious beliefs that make people rely more on traditional healers than modern diagnostic facilities. There is also limited public awareness of the symptoms of various cancers.

Third is the fact that there is poor access to screening services. Today, there are entire states where even the most basic equipment used for cancer screening is not available. Lastly, there is an understandable fear associated with the diagnosis, not to mention the stigma attributable to it. These factors combine to ensure that cancer diagnosis is made late, when nearly all treatment options are no longer available.

Another major hindrance to securing early diagnosis and treatment centres around the fact that the cost of cancer treatment is very high, and most people are consigned to having payments made directly from their incomes and savings. As a result, even diagnostic tests, where available, can be unaffordable to the vast majority of the people who barely scrape through life on $2 (US) per day.

The statistics are grim, and they make for sorry reading. Yet, this is merely the first step in the long journey in the management of this disease condition. Following the necessary diagnostic exercises, surgery must be arranged in most cases, even if it is only a biopsy to confirm the diagnosis.

Then chemotherapy follows. Many people are barely able to afford this, and if they do, they struggle to pay for the battery of tests that are necessary before each cycle of chemotherapy. When this phase is complete, radiotherapy may be considered necessary depending on the stage at which the diagnosis was made. This must also be paid for out of pocket.

In the end, despite all the expenditure incurred, most of the patients are dead within two years because they presented late at the hospital, institutional delays caused diagnosis to be made later still, and paucity of funds delayed one phase or another of the treatment programme, from investigations, through the necessary surgery, chemotherapy and radiotherapy.

To worsen matters, there is a perennial shortage of the relevant skilled manpower to make and manage the diagnosis. To make an accurate diagnosis of whichever type of cancer is suspected, advanced laboratory and imaging services must be available.

Today in Nigeria, many such facilities are in private hands where patients must pay for services before they get the processes done. Many public hospitals lack adequate numbers of this diagnostic equipment, which leads to delayed or incorrect diagnosis. Worse, nearly all the cancer treatment centres are located in urban areas and major cities, with some cities having multiple sites, whereas people in rural areas must have to travel over long distances to obtain a doctor’s examination followed by diagnosis before a treatment plan is structured.

This further increases the cost of securing treatment and would inevitably delay care and end up in an unsatisfactory outcome. The worst scenario is that even when, for reasons of geography, all these facilities are available within a reasonable radius, there remains the problem of perennial shortages of essential cancer medicines and the frequent breakdown of the relevant equipment.

This is especially true of radiotherapy machines, thus causing delays in treatment, interrupting treatment plans and leading to reduced effectiveness. Nationally, there is a shortage of equipment, manpower and facilities.

A recent survey noted that there are only 27 cancer treatment centres around the country serving a population of about 218 million citizens. Some of these centres exist only on paper, as various governments have often built wonderful edifices in places where the required personnel were unlikely to want to work.

Even in the major cities, there is an enduring insufficiency in the number of pathologists, oncologists, radiotherapists and surgical oncologists. Another speciality, oncology nurses, are almost non-existent. To add insult to the farce, the National Health Insurance Service, often cherry-picks what costs to cover by offering no more than the funding of initial hospital visits and some of the required investigations, thereby leaving most enrollees with a substantial financial burden.

The most common of these cancers in women are breast, cervical and colorectal cancers. In men, the most common are prostate, colorectal and liver cell cancers. The other notable cancers are of the ovary, stomach, lungs and nasopharynx. In children, leukaemias, lymphomas and kidney cancers are also common.

Those who survive are often those who are able to pursue treatment to the very end using their considerable financial resources, including supplementing initial therapy in Nigeria with better equipment available outside the country. Most of the survivors found at five years after diagnosis or more are to be found in these groups.

The major challenges of cancer treatment in Nigeria are late diagnosis, inadequate facilities, high treatment costs, shortage of specialists and unequal access to care. Addressing these problems requires increased funding, stronger healthcare infrastructure, a well-streamlined referral system, improved awareness and expanded screening and treatment services.

For all these reasons, the five-year survival rates across all the cancer types remain significantly lower than it is in high- and middle-income countries. In some cancers, like the ovary, cervix and liver, the rates are dismal. In addition, late presentation in hospital is the norm in nearly all cancers.

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As a result, by the time the diagnosis is reached, the disease itself is quite advanced, while the patients usually complicate the picture further by poor adherence to treatment schedules, often due to several other factors such as scarcity of funds, poor accessibility to healthcare facilities and suspicion of modern medical practices.

The aggregation of all these factors make the management of these diseases quite frustrating for healthcare experts. Some 50 years ago, such treatment was free for citizens.

Questions and answers

Sunday Doctor, God bless you, sir. I am a male, 70 years old. For about two weeks now, I have not been able to eat well. I don’t have any cold, headache or fever, but lack of appetite. I have tried several blood tonics like Orheptal tonic and other multivitamin tablets, but with no improvement. I added malaria drugs too, in case it is malaria, but no luck. Help me with what to do, please.                                   0705*******

Good morning, sir. If, in two weeks, you have already used such a variety of medications, it means you have not used any one for long enough. If your only problem is lack of appetite, limit your medication to B-complex tablets and use 2 tablets 3 times a day. It should get better if you do this for up to 2 weeks.

Sunday Doctor, filarial worms’ obstruction and irritation of the lymphatic vessels lead to a distressing condition called filarial lymphangitis (which, fortunately for the patient, often leads to the death of the worms involved). Does this end of trouble apply to all filarial diseases (river blindness, elephantiasis, Loa Loa, etc.)? How long does it take? Thanks.                               +23481*******

No! Not all the worms die. Only the microfilariae are killed. Adult worms survive. Filarial lymphangitis is a side effect of the massive death of microfilariae. The reaction occurs partly due to the body’s response to their foreign protein. The survival of the adult worms is partly responsible for the cyclical treatment of this condition. That is why onchocerciasis, in particular, has been so persistent in Nigeria. As long as adult worms survive, treatment cycles have to go on twice a year for several years before they can be eliminated. Part of the methods of killing the adult worms is the use of doxycycline, which some countries now deploy in their treatment programmes.

Sunday Doctor, please, I was taken to a hospital 2 days ago because I have a terrible sore throat. The doctor checked me and said I have tonsillitis, so he recommended Augmentin 1gm for me. That dose is 98,000 Naira. I cannot afford it. Please, what is the alternative medicine for me to use? Thank you, si.                                         0706*******

It is not possible to determine what alternative medication you should use because we did not examine you. Please go back to the hospital where you were taken and ask for an alternative, or go to another hospital for a reassessment.

Sunday Doctor, Russia uses rats to test drugs when they finish drug production. I think it is okay to use rats to test drugs. Thank you.                                 0806*******

It is not Russia alone that does this. Practically all pharmaceutical companies do this. They use mice, not rats, and the testing phase is done not at the end of production but during clinical trials prior to their use in humans.

Sunday Doctor, good evening. I believe that contraceptive pills are harmful and that women should not be taking them. Why would a 13-year-old girl be using such pills? That leaves me in shock, absolutely. I think it can be harmful in future. What do you think?                                   0803*******

Well, this is a matter for debate. Women can use contraceptive pills under supervision for several years, and millions do so around the world. In the end, every type of medication does have side effects. It depends on how they are used and for how long. The 13-year-old girl is likely unsupervised in her use of the pill and was probably introduced to it by an older sibling, aunt or even mother.

Sunday Doctor, thank you very much for discussing River Blindness. Can filarial lymphangitis be relied on to kill the adult worms instead of using dangerous drugs?           081*******

There is some confusion here. Lymphangitis resulting during this treatment is a side effect of the drug treatment. The body is reacting to the death of the microfilaria, so it cannot be the main treatment to eliminate the adult worms. After several cycles of such treatment over several years at intervals of about 6 months, the adult worms eventually die from a combination of drug-induced damage and the body’s immune response to the worms through the eosinophil component of the white blood cells. Ivermectin, the most commonly prescribed of the antifilarial medications, has proved remarkably effective over time. Older treatments like Diethyl Carbamazine Citrate are not dangerous, nor are newer medications like Albendazole and Doxycycline. With adult worms, in particular, like Wuchereria bancrofti, the reproductive lifespan can be between 10 and 15 years, so only a harmful combination like the one described above can get rid of the adult worms.

Sunday Doctor, I have some questions to ask you concerning my health. I am 43 years old. I had my period last about 3 months ago, and now the left side of my abdomen is seriously paining me. I think maybe it is because I didn’t menstruate. What should I do?  What about the menses that have ceased?           0708*******

Well, at your age, both good and bad things can be responsible for such pain. The easiest thing for you to do is to have an abdominal ultrasound scan done. This will help to determine what is responsible for the pain and the associated amenorrhoea, and you can then be offered the required treatment.