Pain management and a pilot study on breast cancer management in Africa

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Published: 27 Nov 2013
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Dr Verna Vanderpuye - Korle Bu Teaching Hospital, Ghana

At the 2013 AORTIC meeting in Durban, South Africa, Dr Verna Vanderpuye talks to ecancer about a recent survey on breast cancer management in Africa. Results from the survey found that more countries need access to multidisciplinary breast cancer care and that too many lack important resources such as immunohistochemistry facilities and reliable radiotherapy services.

Dr Vanderpuye also talks about data highlighting the need for examination of drug control policies and the repeal of excessive restrictions that impede this most fundamental aspect of cancer pain management.

There was a survey by a collaborating WHO, ESMO and other companies to assess the availability of pain medications in the whole world, including Africa. The results from Africa, Asia and the Middle East were almost the same in that the actual availability was not as much as they thought and the usage was also limited. The reasons were mainly due to legislature and also refusal by physicians to prescribe the medications because of fear of addiction and other side effects. There are also some social cultural barriers on behalf of the patients – they’re not willing to take the pain medications because they thought it was signs of an end of life situation and they would rather have a lot of pain than take these supposedly end of life medications. So that is what we’ve found mainly in the survey by ESMO.

Did the survey look at what should be done to correct this?

It’s mainly legislature and then governments taking up the flag to change the laws that restrict the importation and the use of these medications and making them more available, maybe even talking about local manufacturing. And then teaching healthcare professionals and other professionals about the use of pain medications.

What were the biggest issues raised by the survey?

The education, for one, and then the availability of the drugs and also the laws governing its use because we’re still old-fashioned and there’s worry about the impact of addiction; we’re scared about old norms about morphine and I think we need a lot of education to change that. Because the patient might be willing but the families and other healthcare givers give the wrong ideas so that makes them want to withdraw from taking pain medications. Education is also largely the biggest issue; making these drugs available and then changing the laws that allow them to be imported and used freely in accredited centres. I know they can’t be used by everybody but it should be available where it’s supposed to be available, to the people who it should be available to. Not just cancer but HIV and other chronic illnesses.

Some family members, we have a lot of… half of the country is illiterate and half is not, for example, in Ghana. So it happens in most other African countries. So the illiterate ones tend to rub off on the semi-literate or the literate ones and they come up with these old norms about what they heard about the use of morphine or in other countries it’s not allowed, it’s not a good drug, it has too many side effects. So the family members have… and sometimes that is our insurance for medical coverage. So if the person who is paying your bills says he doesn’t want you to take the morphine, you really don’t have that many options. So that’s also another big factor.

Is it difficult to get the patients and family members to listen to the physician?

There has to be a lot of education, civil education, on the use of pain medicines, not only limited to morphine but the use of pain medicines because why should the patient suffer? It doesn’t really make any sense. Yes, I think that needs to be tackled and then the morphine comes in. Unfortunately it’s the most effective, there’s not much that anybody can do about that. It affects quality of life a great deal so we need to look into that.

Is palliative care in general affected by this?

You can have effective palliative… palliative care is mainly quality of life, symptom management. You need most of these medications to do that effectively so in the absence of that what kind of palliative care are you really giving? Secondly, we can’t even also expand on our palliative care services because you have to educate other people, teach other people, and then it’s limited because the drugs you have for pain are limited so you really can’t teach that much. So when you’re not there any more they probably also wouldn’t use morphine because it was never really part of the formulary or its use.

Is there a pilot study for breast cancer management?

We did a pilot study in conjunction with AORTIC. There’s a little research group on breast cancer so that was the facet that we could do. We did a survey to see how other people were treating breast cancers across Africa. We didn’t have that many respondents, we’re a little bit disappointed, but it was difficult because you could only ask those questions for somebody that has the full range of oncology services. It would have been unfair to ask somebody who doesn’t have any surgery or radiotherapy to fill in the survey because mainly it was about how you treat with chemotherapy, radiotherapy; the kind of surgery that you did. So it has to be in a place that had expertise, unfortunately there are not too many of those countries so we only got people from fourteen countries. But there was a lot of insight and I was quite excited because there has been a lot of improvement in terms of the use of hormone receptor status in managing. For many years everybody was just put on Tamoxifen blindly, or not, but now people are doing the studies to determine which way to go. In terms of also the HER2 new status it can be difficult because they can’t afford Herceptin but at least it helps you with your prognostication of how well or what drugs to choose, even if they can’t afford Herceptin, also in terms of patient education as well. That was the good part.

Most African countries also had quite a good span of radiological diagnostic equipment which was also quite interesting; the question is how did they use it. But the most important to ask, that we thought was a bone scan, only half of the countries actually did have that but I think over time that will change. Very few people had a PET scan; I think for now it’s only in South Africa so we didn’t put that in our questionnaire at all because we knew that was very limited.

In terms of the chemotherapy most of the chemotherapies were available but we still tended to use the older drugs, the older protocols which is the cyclophosphamide, adriamycin, 5FU, which is good but sometimes when patients have aggressive features you might have to go a little bit more aggressive. The rest we’ll have to do later because we don’t really know how much difference the taxane makes in the African because there really hasn’t been much studies. The results are very good for other countries but we have to do it in Africa because maybe there’s not much difference between giving taxane and the regular old regimen. So that’s something that we have to do. I think that might have to be the big step.

We’re going to have to expand it to see if we can include more countries, probably not. We might not be able to get that much response or maybe we would. Because it’s difficult to generalise the statements from the survey but I think this is the first step. I think we should put it across other cancers, how they treat prostate cancer, how we treat cervical cancer. It’s a starting point to see where the needs assessments are in terms of the training and all that.

Is the epidemiology of the disease different in Africa compared to America for example?

We think so because we have a little bit more triple negative which are known to be aggressive so the kinds of drugs we use really have to be cost effective. Most of us have to pay out of pocket so it has to be a cost effective medication, that’s number one. So maybe even the older drugs might be more efficient than the newer drugs where we haven’t tried them. Some drugs just don’t… we can’t tolerate them as much as other people. There’s a known fact like capecitabine is more tolerable in certain racial groups than others so maybe we can’t tolerate high doses, other people can. So there are a couple of… My experience also is with Vinorelbine which is a weekly dose. We can hardly put in week one, two and three, the best you get is week one and two; we have a lot of problems with neutropenia by the third week. But this is not on paper, this is from experience and I’ve spoken to other oncologists and they have the same problems. But we haven’t written anything like this on paper so I think we need to do a little bit more research to be able to guide our fellow oncologists what to do when it comes to breast cancer in Africa. I think the treatments might be a little different.

Also to say with the ER/PR, those who are hormone receptor positive, they don’t seem to do that well. They tend to feel quite… at a shorter time than expected. So is it because of the bio-availability of the drugs in our diet? That’s not making it because we don’t have bio-availability of the Tamoxifen because of maybe gastric environments, too much fat, too much carbohydrate or what time to take the drug, does it make it any different? We have to look into all these things because they’re the cheaper way of treating ER positive and if we are not responding the other drugs, like the aromatase inhibitors, they’re available now but they’re very expensive. So we have to find ways of improving which drugs to take and how to take them that will make it more efficient for us.

Are there plans for future studies?

There are but research can be quite difficult in Africa because there’s no support financially, institutionally. Most of the time it will probably have to come from external collaboration, that is where we are now. And so we would need to find collaborators and there are a lot of hiccups in the way to getting your research approved and all that. There’s not enough money so it makes it a little difficult but it’s something that we have to try, even with little steps and then maybe somebody else picks up on the bigger steps. If we can by ourselves start up with something small then the collaborator comes in. So we are trying very hard to get up on molecular studies to see what’s different in the cancers in Africa but those need a lot of expertise, labs and all that and it can be quite challenging. But a few have been done and they are working quite well but the people are still afraid of doing research in Africa for so many reasons. But I think times are changing and more people are willing to collaborate, to find new things in Africa and we might be the answer to some of the treatments.