By: L Banda1, T Nyirongo1, M Muntanga1
1. Cancer Diseases Hospital, Lusaka, Zambia
Citation Style For This Article: Banda L, Nyirongo T, Muntanga M. Cancer – An Emerging Health Problem:The Zambian Perspective. Health Press Zambia Bull. 2019;3(2); Pp 2-4.
The word “Cancer” has in the recent past become as common in people’s vocabulary as many other diseases. Whereas HIV and AIDS, diabetes, cardiovascular diseases and other communicable diseases such as malaria were the most spoken of diseases, non-communicable diseases such as cancer have now taken centre stage as some of the major causes of morbidity and mortality in the world and in Zambia in particular. According to the chief of the clinical radiation oncology branch at National Cancer Institute, Dr. Bhadrasain Vikram, the more common traditional health concerns of the developing world are infectious disease and malnutrition. Yet over the past two decades, the incidence, disease burden and risk for cancer-related mortality in low- and middle-income countries has increased dramatically [1]. Previously seen as a disease of the rich, cancer and its ravaging effects are now more common place and conspicuous in our communities. According to the Economist Magazine in an article titled “Cancer in the developing world”, Cancer has become more common than TB, Malaria, HIV and AIDS combined.
The National Cancer Institute of America defines Cancer as a name given to a collection of related diseases. It is not one disease, prognosis and response to treatment depend on the nature of the cancer. To understand what cancer is, we have to understand that throughout our lives, healthy cells in our bodies divide and replace themselves in a controlled fashion. Cancer starts when a cell is somehow altered so that it multiplies out of control. A tumour is a mass composed of a cluster of such abnormal cells [2]. Most cancers form tumours, but not all tumours are cancerous. Benign, or noncancerous, tumours do not spread to other parts of the body, and do not create new tumours. Malignant, or cancerous, tumours crowd out healthy cells, interfere with body functions, and draw nutrients from body tissues. Cancers continue to grow and spread by direct extension or through a process called metastasis, whereby the malignant cells travel through the lymphatic or blood vessels, eventually forming new tumours in other parts of the body.
In all types of cancer, some of the body’s cells begin to divide without stopping and spread into surrounding tissues. Cancer can start almost anywhere in the human body. Normally, human cells grow and divide to form cells as the body needs them. When cells grow old or become damaged, they die and new cells take their place. However, when cancer develops, this orderly process breaks down. As cells become more and more abnormal, old or damaged cells survive when they should die, and new cells form when they are not needed. These extra cells can divide without stopping and may form growths called tumours. The cancer is named according to the tissue or organ of origin such as cervical cancer is from the cervix and prostate cancer being cancer that affects the prostate gland.
Factors contributing to the high cancer burden are many and include among others, increased contact with infectious agents such as HPV (which causes cervical cancer), environmental factors such as exposure to chemical and toxins, social factors such as tobacco use, alcohol abuse, sedentary lifestyle, poor diet and others.
Global situation
In 2016, The World Health Organisation (WHO) estimated that of the 56.9 Million deaths recorded in that year globally, 40.5 Million (71%) of the deaths were due to Non Communicable Diseases [3] of which cancer accounted for 9.0 million deaths (22% of all NCDs). The burden of these diseases is rising disproportionately among lower income countries and populations. In 2016, over three quarters of NCD deaths (31.5 million) occurred in low-income and middle-income countries with about 46% of deaths occurring before the age of 70 in these countries. The International Agency for Research on Cancer (IARC) estimates that about 4.42 million women of ages 15 and above are at risk of developing cervical cancer in Zambia. Current estimates indicate that every year 2,994 women are diagnosed with cervical cancer and 1,839 die from the disease [4].
Zambian situation and mortality
In Zambia, the onset of NCDs is often insidious. Patients often present in middle age and when the disease is advanced. Over 80% of mortality from NCDs is also caused by the above mentioned NCDs which are a major cause of disability and premature death and contribute substantially to the escalating costs of health care. Among the four NCDs in Zambia, cancer has had significant morbidity and mortality, especially cancers that affect women namely Cervical and Breast Cancers. Other cancers of prominent incidence include Prostate, Kaposi’s sarcoma. The Zambia National Cancer Registry estimates that in 2018 there were over 12,000 new cancer cases countrywide with 7,380 deaths approximately 60% of all new cases. The most frequently cancers in Zambia in 2018 were cervical cancer with 3,000 new cases, followed by Kaposi’s sarcoma at 1,700, Prostate cancer with 1230 and breast cancer with 900 cases. Children’s cancers commonly diagnosed include Leukaemia (cancer of the blood), Kaposi’s sarcoma, Nephroblastoma and Retinoblastoma [5].
Cancer Diseases Hospital has to date seen over 21,000 cancer patients since inception in 2006. In 2018, the cancer diseases hospital saw 2,734 new cancer patients with cervical cancer leading followed by breast cancer, prostate, lymphomas and Kaposi’s sarcoma in that order. Total admission for the hospital in 2017 was 3967 of which 570 mortalities were recorded. In 2018, there was a reduction in mortality to 424 against total admission of 3718 [6].
Late presentation
As previously mentioned, most of the cases recorded on cervical cancer, as with most other cancers are late presentations. This means diagnosis is made late. The disease is detected late and at the time of diagnosis the diseases may have advanced and spread to other parts of the body. Late presentations are one of the highest reasons for mortality. Patients present late because of a number of reasons. These include among others: lack of diagnostic and treatment facilities close to their homes, centralised treatment facilities only available in Lusaka, Socio-economic, cultural, and other reasons that all lead to patients inability to access services [7].
Poor health seeking behaviour
Poor health seeking behaviour due to lack of information about cancer or fear of the unknown is another reason people present late. In some cases the lack of information by health providers. Socio-economic factors also have a role to play in whether or not a person will seek medical attention immediately they show symptoms of cancer. Issues of long distances to the nearest health facility, poor diagnostic capabilities of health centres in their localities and sometimes unfriendly health personnel who may not have enough information on cancer will in most cases deter a person from seeking medical attention resulting in disease progression and late presentation.
There are unfortunately a lot of social and cultural factors that hinder quick medical diagnosis of cancer. Though some are primarily because of lack of information about the causes, risk factors and treatment of cancer, others are because of beliefs and cultural norms such as seeking the attention of a traditional healer, beliefs that cancer is caused by witchcraft. These myths and misconceptions deter people from identifying the disease for what it is and seeking medical attention for it [8].
In Zambia, cancer is managed using various modalities such as surgery, radiotherapy and chemotherapy, nuclear medicine, and palliative care among others. Management is not without its challenges. Infrastructure, machinery, human capital, supplies and logistics required for effective management of the disease comes at a high cost. Cancer Diseases Hospital provides out-patient, in-patient, radiotherapy, chemotherapy, Paediatric oncology, surgical and gynaecological oncology, nuclear medicine, diagnostic services (radiology and laboratory), nutrition and palliative services. This is the only comprehensive cancer management centre in the country. With plans to decentralise cancer management services to all provinces of the country, which begins in 2019 by construction of the Ndola and Kitwe cancer treatment centres, challenges of distance to treatment facilities will be a thing of the past. This will eventually interpret into better accessibility and subsequent better treatment outcomes.
Some of the interventions that have been embarked on in the effort to reduce the disease burden include among others: Health promotion to raise awareness about cancer, the importance of prevention and screening, early diagnosis and treatment, and palliative care for those that come with advanced and metastatic diseases. As a country, we have prioritised four cancers that include cervical, prostate, breast and retinoblastoma. Beginning this year, vaccinations against HPV will commence for girls aged 9 to 14 years. Together with the cervical screening programme that is in progress, vaccinations will significantly reduce the number of cases the country is recording. It is important to know that cancer is preventable and curable if diagnosed at an early stage. There is need for people to avoid exposure to risk factors of cancer.
cervical, prostate, breast and retinoblastoma. Beginning this year, vaccinations against HPV will commence for girls aged 9 to 14 years. Together with the cervical screening programme which is in progress, vaccinations will significantly reduce the number of cases the country is recording.
It is important to know that cancer is preventable and highly curable if diagnosed at an early stage. There is need for people to avoid exposure to risk factors of cancer.
List of References
1. Vikram B. Cancer: the new challenge for health care in the developing world. URL: https://www.healio.com/hematology-oncology/practice-management/news/print/hemonc-today/%7B1e62b7a5-8940-4fda-8934-51fdbc394b03%7D/cancer-the-new-challenge-for-health-care-in-the-developing-world.
2. National Cancer Institute. Understanding cancer. What is cancer? URL: https://www.cancer.gov/about-cancer/understanding/what-is-cancer
3. NCD Countdown 2030 collaborators. NCD Countdown 2030: worldwide trends in non-communicable disease mortality and progress towards Sustainable Development Goal target 3.4. Lancet 2018;392(10152):1072-88; WHO. Global Health Observatory (GHO) data: NCD mortality and morbidity. URL: https://www.who.int/gho/ncd/mortality_morbidity/en/.
4. World Health organization. Global Health Observatory (GHO) data. NCD mortality and morbidity. URL: https://www.who.int/gho/ncd/mortality_morbidity/en/.
5. Ministry of Health [Zambia]. Zambia National Cancer Registry Report 2018. Ministry of Health: Lusaka, Zambia
6. Ministry of Health [Zambia]. Cancer Diseases Hospital Annual Report 2018. Ministry of Health: Lusaka, Zambia
7. Ministry of Health [Zambia]. National Cancer Control Strategic Plan 2016 -2021. Ministry of Health: Lusaka, Zambia
8. World Health Organization. Beyond World Cancer Day: Raising Awareness, Dispelling Myths About Cancer. URL: https://afro.who.int/news/beyond-world-cancer-day-raising-awareness-dispelling-myths-about-cancer.