working to improve the quantity and quality of data from
several African registries – soon, hopefully, to cover several
quite different regions in Africa. Cancer registration also Twinning between institutions in
provides an important foundation for developing cancer the developed and the developing
control programmes, such that simultaneous improvement in countries can be a successful
pathology as well as population-based cancer registration long-term approach
would do much to improve infrastructure in these countries,
so that basic diagnostic and treatment facilities would become
more widely available. Many African countries still contain
large lacunae in such services, and a few lack them altogether.
Although in the developed world the importance of the done by improving infrastructure, and providing the necessary
correct diagnosis is widely recognized, this is still an evolving resources and training in modern diagnostic techniques, as
concept in some of the developing countries, especially in well as reproducible criteria for diagnosis, such as those
Africa. In particular, there are striking differences in the established by the WHO classification of Haematopoietic and
turnaround times from biopsy to report, and in the accuracy of Lymphoid tissues, 20081. Those involved would be able to
lymphoma diagnosis; differences that have a profound impact improve the quality of histology, and to introduce essential
on the patients’ ultimate outcome. The current problems in tools for modern diagnosis, such as immunohistochemistry,
the practice of lymphoma diagnosis include poor quality molecular cytogenetics and other molecular methods.
histology in the minority of cases where biopsies are
performed, and a complete lack of immunohistochemistry and Improving diagnostic accuracy
other investigations in a high proportion of patients. Because Twinning between institutions in the developed and the
of these limitations and a lack of continuing education, it is developing countries can be a successful long-term approach.
generally not possible to apply the current diagnostic criteria However, substantial costs are involved in providing
for most lymphoid malignancies. In Africa, a majority of the infrastructure, manpower, consumables, follow-up and
laboratories still use the Working Formulation for Clinical surveillance programmes and owing to their limited health
Usage, a lymphoma classification from the early 1980s, which care resources, developing countries cannot afford the models
is based on morphology alone and does not include many used in developed countries. Most of the sub-Saharan Africa
entities recognized in the last 20 years. countries have neither the resources nor the capacity to
In addition to inadequacies in diagnosis accuracy, a number organize and sustain any kind of improvement programme.
of additional factors influence patient outcome. These include Twinning between institutions, assuming the partner in the
health service structure, ultimately derived from the national high-income country is willing to support the cost or a grant is
health policy which in turn influences the ability to detect and obtained to provide the necessary funding, is one way of
diagnose cancer at the earliest possible moment, thus giving improving pathology in Africa. In addition, twinning
the greatest chance of cure. Gender, socioeconomic and programmes result in a constant and continuous training of
demographic issues are also relevant. Methods of improving African colleagues, through short courses, audits on
the early diagnosis of cancer will also have an impact on diagnoses, diagnostic referrals and feedback, telepathology
therapy, since the earlier a cancer is detected and diagnosed, and establishing diagnostic centres with greater capabilities.
the simpler, as a general rule, is the therapy likely to be. Thus, This approach can lead to African clinicians receiving constant
early detection programmes could well lead to improved training and the necessary support to deliver high quality
morbidity and mortality, as well as psychological outcomes. clinical services – as long as the programme is sufficiently well
resourced and lasts for a sufficient time.
What can be done? Several twinning programmes relating to childhood cancer
Though an issue of this magnitude cannot be addressed in a treatment have been in place in Central and South America,
simplistic manner (because of the realities of resource Northwest Africa and Southwest Asia for as long as 10 years.
limitations there are some conditions that will, unfortunately, These programmes have reduced the rates of abandonment of
continue to be misdiagnosed for the foreseeable future), there treatment, relapse, and death due to toxic effects of
is much that can be done and some clear targets that treatment, and the investments that they have attracted have
constitute the most pressing issues. First of all, the led to improvements in access to treatment and hospital
improvement of diagnostic accuracy is essential. This may be infrastructure. One such programme that is presently on-
76 CANCER CONTROL 2013