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Prof Lynette DennyDepartment of Obstetrics and Gynaecology, University of Cape Town

Inequity is dramatically evident when one considers the fate of cancer patients in Africa. Epidemiological data shows that 80% of deaths from non-communicable diseases (NCD) (cardiovascular and can-cer) occur in Low and Middle-Income Countries.1 In fact, the probability of dying between the ages of 30-70 years from NCD is highest in sub-Saharan Africa. In 2012, there were 14.1 million new incident cases of cancer; of which

60% occurred in Low and Middle-Income Countries.

Among women, cervical cancer is the fourth most important cancer glob-ally, while in Africa it is the second-most important cancer topped by the incidence of breast cancer (Figure 1)2. The mortal-ity of cervical cancer in Africa is higher than breast cancer due to the lateness of presentation in Africa.

There are serious problems with the accuracy of statistics in Africa and other developing countries, because very few deaths (7% in Africa) are medically cer-tified. There is a new drive to establish cancer registries with promising efforts in Zimbabwe, South Africa, Uganda and Gambia. Health expenditure per capita is very low in Africa and since the 1980’s, the policy of stopping free healthcare and

moving to a user-payment system has led to a major reduction in the use of health care. The highest proportion of out-of-own pocket expenditure is found in poor countries and this has resulted in a major reduction in the use of Healthcare; as an example in Nigeria, 62% of total expendi-ture is out-of-own-pocket expenditure, while in the USA out-of-pocket expendi-ture is 12%, in the UK 6%.

Figure 1. top ten cancers in women in Africa

Unknown

Liver

thyroid

Ovary

Uterus

Stomach

Cervix

Lung

Colorect

breast

IncidenceMortality

0 1000000 2000000

CAnCer in AFriCA – whAt Are the ChALLengeS?

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The challenges to treating cancer in Africa are enormous: 2 existing registries in Gambia and Uganda have shown that only between 13-22% of people diagnosed with cancer survived for 5 years.3

Radiation facilities which are required for about 50% of cancer cases are inad-equate in Africa, according to a recent survey (Table 1)4 [Radiation facilities in Africa]. Only 20 out of 52 countries offered brachytherapy which is an essen-tial modality for cervical cancer therapy. South Africa and Egypt are the only African countries which have almost suf-ficient radiotherapy machines with their current capability reaching almost 80% of the international norm.4

Chemotherapy resources in AfricaEffective chemotherapy requires trained oncologists, pharmacists, laboratory sup-port and access to treatment for com-plications. In a study in Tanzania of a German-funded initative5, availability of appropriate chemotherapeutic drugs

was 50%, but over 70% of patients did not receive prescribed chemotherapeutic agents. When these patients resorted to private sources for their therapy, the costs were equivalent to an average 7 months’ income.

Access to surgeryIt is estimated that 2 billion people world-wide do not have adequate access to surgical care. In a study of the availabil-ity of operating theatres per 100  000 of the population in sub-Saharan Africa6,

shows 1-3 operating theatres as compared to Western Europe and Australasia’s 14 operating theatres. South East Asia shows a similar availability as sub-Saharan Africa.

palliation and terminal CareAccess to morphine in Africa is also lim-ited7 because there are only 11 countries that allow reconstitution of oral mor-phine from imported powder (Figure 2)

with 5 countries having access to other types of oral morphine. 38 countries in Africa have no access to opioids.

Further challenges to Africa are the

table 1. radiation facilities in Africa

• IAEAanalysisof52countriesin2010• 23offeredexternalbeamradiotherapyin2010

– 160radiationcentresrecordedonthecontinent

• 80cobalt-60unitsand189linearaccelerators– 92machinesinSouthAfricaand76inEgypt,accountingfor60%ofallradiationequipmentinAfrica

• Only20/52countriesofferedbrachytherapy• Calculatedthatthiscouldonlyprovidetreatmentfor24 300patientsperyear

Abdel Wahab, et al. Lancet Oncology 2013; 14(4):168-175.

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HIV/AIDs epidemic with 70% of cases being in sub-Saharan Africa contributing to the increase in cancer incidence. Health care professionals are insufficient for sub-Saharan Africa needs and there are lim-ited facilities for training in anti-cancer therapies.8

In addition, the focus on increasing the numbers of community health workers is directing resources away from the vital

need to provide leadership in healthcare by giving priority to the education and retention of medical doctors.

Health research is also underfunded in Africa, particularly by pharmaceuti-cal companies who know that they will need to build physical resources before embarking on useful clinical trials in Africa. There is a need to convert knowl-edge into action in Africa.

Figure 2. morphine availability in Africa 2012

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DisclaimerThe views and opinions expressed in the article are those of the presenters and do not necessarily reflect those of the publisher or its sponsor. In all clinical instances, medical practitioners are referred to the product insert documentation as approved by relevant control authorities.

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In conclusion, cancer in Africa is a significant health problem; there is inad-equate per capita expenditure on health resulting in lack of access to treatment, high fatality rates for cancers. Investment in and cancer research on the continent is also totally inadequate.

References1. World Health Statistics 20122. www.globocan3. Sankaranarayan, et al. Lancet Oncol 2010; 111: 163-

173.4. Abdel Wahab, et al. Lancet Oncol 2013; 14(4): 168-175.5. Yohana E, et al. East Afr J Public Health 2011; 3(1):

52-57.6. Funk LM, et al. Lancet 2010; 376c1055-10617. International Narcotics Control Board.8. Lancet 2011; 377: 113-121.9. BMJ 2005 32:705-706.