Page 0063

CANCER MANAGEMENT

62 CANCER CONTROL 2014

cases varied markedly up to 3,000 new cancer cases per year

per oncologist.

4 If cancer treatment is to be improved,

training more oncologists must be one of the highest

priorities.

Cancer may involve any part of the body. Optimal diagnosis

and treatment requires several specialists with different

skills and knowledge, including pathologists who make the

diagnosis,5 and often several cancer specialists, depending

upon the type of cancer. Surgical specialists cover a defined

anatomical region or "system" (e.g., gynaecologists,

orthopedic surgeons, neurosurgeons), but may specialize

further to deal exclusively with cancer in those regions.

Other specialists are expert in particular therapeutic

approaches, such as radiation oncologists (radiation therapy),

medical oncologists (systemic therapy), or clinical oncologists

(trained in both). Determination of the local extent of cancer

and the presence of distant metastases requires evaluation

by imaging specialists. In well resourced countries,

radiologists and nuclear medicine specialists are always

involved in the care of cancer patients. The lesser resourced

countries, however, may have to rely on clinical examination

only, or clinical examination supplemented by ultrasound

and/or simple X-rays to determine optimal therapy.

Computerized tomographic scanners, magnetic resonance

imaging and nuclear medicine scans are in short supply and in

East Africa, for example, available at only a handful of public

hospitals. For-profit private hospitals are more likely to have

such equipment.

Cancer surgery often involves radical procedures that

general surgeons are generally not trained to do. As systemic

therapy continues to improve, however, and is incorporated

into the treatment of cancers formerly treated by surgery (or

sometimes radiation therapy) alone, surgical procedures for

cancer are becoming less radical, and associated with less

morbidity.6,7 Adjuvant (post-surgical) and neoadjuvant (presurgical) systemic therapy

may permit less extensive surgery

since the tumour volume may be much smaller after

chemotherapy since resection margins can be small when

post-surgical systemic therapy is planned. In such cases,

surgery may often be performed by general surgeons,

although it is essential that combined modality therapy of this

kind is managed by an oncology team. Similar considerations

apply when radiation is associated with chemotherapy.

Haematological cancers are treated less and less with

radiation therapy, even when this was the primary modality in

past years8,9 and surgery is rarely indicated, so that cancer

care can be designed exclusively by haematologists, medical

oncologists or clinical haematologists. The very limited

number of radiation therapy units (in Tanzania there are six

machines for 40 million people; four are not yet functional),

and their high capital cost coupled to the need for highly

skilled radiation therapists, physicists and technicians

suggests that as new units are established, one area worthy of

research is the re-examination of the need or extent of

radiation in the modern era of systemic therapy. The

demonstration that radiation can be replaced by systemic

therapy in some diseases or stages of disease, would lead to a

reduction in the number of specialized radiation therapy units

and their associated specialists required. However, a project

of this kind would need considerable development of research

infrastructure and a more scientific approach to cancer care

than presently exists.

The critical importance of early diagnosis

It is generally true (there are exceptions) that patients with

small volume, localized disease can be more effectively

treated (i.e., are more likely to be cured, or at least have

longer survival) regardless of the modality(s) employed. Early

detection, then, should generally lead to better results within

the existing health care system at less cost and

inconvenience. Since early detection requires both a more

knowledgeable public and improved referral patterns for

diagnosis and treatment, an emphasis on education of the

public and medical community may be the single most

important action to be taken if better survival rates are to be

achieved. Moreover, primary cancer prevention also requires

public education, and economies of scale could be obtained

by combining primary and secondary prevention. Organized

approaches to needed education should, therefore, be built

into the cancer control plan, and referral guidelines and

networks developed. Greater efficiency in detection and

diagnosis should be feasible in all countries, but requires

planning and individuals dedicated to developing the

necessary educational tools.

Educating oncologists - the rapid expansion of

training opportunities

Although the training and professional efficiency of cancer

specialists may be assisted by visiting experts, this practice is

highly unlikely to meet the global need for oncologists and

other cancer professionals. Self-sufficient and sustainable

solutions are required.

A partial and time-honoured approach to the training of

specialists is "learning by doing", e.g., gaining experience in the

practice of oncology through working with a recognized

oncologist. The creation of one or more national

organizations comprised of health professionals - "colleges,"

"academies" or "boards" - involved in cancer care, but which

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