Sola Ogundipe and Chioma Obinna
16 June 2008
Lagos — The burden of cancer in Nigeria is appreciable. According to the World Health Organisation, there are an estimated 100,000 new cancer cases in the country each year although observers believe the figure could become as high as 500,000 new cases annually by 2010.
It is feared that by 2020, cancer incidence for Nigerian males and females may rise to 90.7/100,000 and 100.9/100,000 respectively. It is also anticipated that by 2020, death rates from cancer in Nigerian males and females may reach 72.7/100,000 and 76/100,000 respectively.
But this only represents a tip of the iceberg if projections by the World Health Organization (WHO) are anything to go by.
The health organisation recently predicted that global cancer rates could further increase by 50 per cent to 15 million new cases in the year 2020. This is the gloomy prediction by the 2008 World Cancer Report - a 351-page, comprehensive global examination of the disease to date issued by the IARC - part of the World Health Organization (WHO).
As a concise manual, it describes the global burden, causes, and major types of malignancies, early detection and treatment of cancer.
Providing clear evidence that healthy lifestyles and public health action by governments and health practitioners could stem this trend, and prevent as many as one third of cancers worldwide, the report reveals that in recent times, cancer has emerged as a major public health problem in developing countries, matching its effect in industrialized nations. The bottom line of the report is that except urgent action is taken by governments, health practitioners and the general public; cancer rates are set to increase at an alarming rate globally.
Prof. Clement Adebamowo of the Division of Oncology, Department of Surgery, University of Ibadan, discloses that while infectious diseases such as HIV & AIDS are the most significant contributors to disease burden in Nigeria, complex diseases such as cancer are fast emerging as an important health care priority for the future. Adebamowo states that, ironically, while improvements in public health and increased funding for health care initiatives are leading to a decrease in incidence of communicable diseases, the attendant increase in life expectancy is precipitating an increase in the incidence of all cancers, as a higher proportion of the population reaches the complex diseases-bearing age.
His words: "Several other factors are likely to change the pattern and prevalence of cancer in Nigeria in the coming decades: greater awareness of cancer, improved access to health care through new programmes such as the National Health Insurance Scheme, empowerment of women, and steadily improving economic and social factors will increase rates of cancer diagnosis, at the same time that an increased rate of obesity, reduced physical activity, and more "Westernized" diets are likely to contribute to the development of more types of cancer."
Worse still, clinical services for cancer are grossly inadequate and poorly distributed. Only a few centers have functioning radiotherapy equipment. Radiologic services are generally available, but access is seriously limited by high cost.
The same argument of high cost goes for chemotherapy. Pathology services are generally available, but the scope of services is limited. Molecular diagnostic methods are not widely available. Surgery is often performed by surgeons whose primary clinical practice is not oncology, and there is a very limited scope for multidisciplinary cancer care.
There is increasing awareness of modern palliative care and pain management, which is particularly useful as patients often present with advanced disease, and physicians have limited access to treatments that offer the prospect of prolonged survival.
But it's not all gloom. A Consultative Committee on National Cancer Control exists to formulate policy guidelines relating to the prevention and management of cancer in Nigeria. But even with existence of professional bodies such as the Nigerian Cancer Society, the Society of oncology and Cancer Research in Nigeria, and several other local and international bodies actively promoting cancer control and prevention, the incidence of cancer has continued to escalate. So there is ongoing cancer research in Nigeria.
The country is participating in the International Haplotype Mapping Project - a partnership of scientists and funding agencies from Canada, China, Japan, the United Kingdom, and the United States designed to develop a public resource that will help researchers find genes associated with human disease. There are collaborating centers to increase access to high-quality cancer clinical trials for Nigerian patients with cancer, monitored by a national ethics regulatory infrastructure to ensure that research is conducted according to the highest ethical and scientific standards.
Essentially, the most common cancers documented in Nigeria to date are cancers of the uterus and breast for women and liver and prostate cancers for men. Medical records indicate that cancer registration in the country officially began in 1960 but it was not until 1990 that a National Headquarters of Cancer Registries was established in Ibadan. But the institution has witnessed little or no activity. According to the International Association of Cancer Registries (IACR) publication Cancer Incidence in Five Continents, Volume III, the Ibadan Cancer Registry was initiated in 1960 and covers all persons with cancer diagnosed in the different clinics and hospitals in the city.
It notes that coverage is achieved by notification of cases to the Registry by the clinics and hospitals, and regular visits to all the hospitals and treatment centres in the city by the Registry staff. "The lists of surgical operations and surgical pathology records are consulted and visits made to wards.
The majority of cancer patients and all biopsies taken from cancer patients are referred to the University College Hospital, where the Cancer Registry is based. This hospital is the main treatment and care centre. It is considered that most patients suffering from malignant diseases attending either private practitioners or hospitals will be registered.
Investigations showed that only very few hospitals operate screening programmes for cervical cancer, even then, they are poorly funded, unsystematic, and incomprehensive. The country lacks an established national mammographic screening programme and available mammographic services are hard to come by. The pattern is that most breast and cervical cancer patients present at a younger age than in developed countries. Problems of impeded access to health care, ignorance, poverty and a general lack of coordination of issues of health education complicate matters.
In Nigeria, without doubt, breast cancer is currently the most common malignancy. Adebamowo, who is also Director of the Institute for Advanced Medical Research and Training (IAMRT) at the University of Ibadan notes: "In our 1999 case-control study of 250 consecutive breast cancer cases seen in our Oncology Clinic between 1992 and 1995, we found that breast cancer patients tended to be taller, weighed more, had a later age at onset of first pregnancy and had a higher mean number of children than controls. That last finding was particularly interesting because it is known that multiparity protects against breast cancer.
"However, pregnancy has a complex relationship with breast cancer. On the short term, on account of the stimulatory effect on breast epithelial growth, pregnancy increases short term risk of breast cancer. The protective effect of pregnancy is seen decades after the pregnancy - often after the age of 40 years. In a country with low life expectancy like Nigeria therefore, case control studies are likely to highlight the early pro-carcinogenic effect of pregnancy since few women survive to the age where the protective effect of pregnancy is more prominent."
A retrospective review data of breast cancers between 2001 and 2005 in the University of Maiduguri Teaching Hospital Cancer Registry revealed that a total of 1,216 cases of cancers were registered within the study period and breast cancer accounted for 13.9 per cent. There were 161 females and eight males with breast cancer within the study period, giving a female to male ratio of 20:1. There were four cases of bilateral breast cancers. The ages ranged between 17 and 85 years and the peak age group was 40-49 years which accounted for 61 cases (36.1 per cent). The commonest type of breast cancer was invasive ductal carcinoma (stage 0) which accounted for 82.6 per cent. Conclusion was that breast cancer is on the increase in the environment and therefore necessitated public enlightenment, screening of all women at risk, early detection and proper management in the public health institutions.
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