Essential surgical management for gynaecological cancers

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Published: 17 Nov 2017
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Dr Rahel Ghebre - University of Rwanda, Kigali, Rwanda and University of Minnesota, USA

Dr Ghebre speaks with ecancer at AORTIC 2017 to address questions and misconceptions about surgical interventions in oncology.

She highlights the integral role of surgery in managing and curing cancer, and the importance of early diagnosis.

Dr Ghebre considers the support in place for surgeons from low-resource settings available at global sites to provide training and education towards delivering the best quality care for patients.

We have been focussing mostly in interventions around surgical management of malignancies. The talk I’ll be giving is around essential surgical management for gynaecologic cancers. Our goal really is to raise awareness that surgery is a key component of the comprehensive management of malignancies, including cervical cancer, ovarian cancer, endometrial cancer, cancer of the vulva. There is a thought that surgery is costly and often not achievable in a limited resource setting but there certainly are ways to integrate that. So that is the goal of the paper.

The World Health Organisation has put a focus when it comes to non-communicable diseases in the role that surgery can play and they package that in what’s called the essential surgical package. The thought is that some surgeries are meant for emergent procedures or urgent procedures. So, simply put, people might think about interventions for appendicitis but cancer really is a life-threatening condition and some cancers can be cured with surgery or in combination with chemotherapy the outcomes are just so much better that surgery should be an integral part of it. So we want to discuss about the benefits of surgery really start at early diagnosis and helping primary care GPs understand their role in facilitating the transfer of patients in doing the initial surgical work-up. So that might include a biopsy in the case of breast cancer, for example, certainly a look at the cervix and a biopsy for cervical cancer and really pretty much every cancer’s initial diagnosis starts at the point of first contact with the GPs.

What are some of the main challenges in low income settings?

Our main challenge has been the skill set that is present in the physicians. It’s difficult to call them exactly surgical oncologists at this point or genuine oncologists because we think of that as a subspecialty of fellowship level training. Our ultimate goal is to integrate the advanced training in the home countries in these settings. So we have several international organisations and academic institutions in the US supporting us, primarily the International Gynaecologic Cancer Society is behind us and is helping us to build a curriculum. So we understand that we need to assist countries to train their surgeons, obstetrician gynaecologists, to a slightly higher level to be able to provide the care and then we need to facilitate that process by supporting them, giving them some protected time for the training and also giving an emphasis of how important that process is in terms of comprehensive care. There is a lot of focus on the role of chemotherapy, not understanding that all the steps that lead up to it ultimately allow chemotherapy to be successful, or in some cases radiation therapy. So the surgeon many times comes before chemotherapy and before radiation to facilitate that process and to triage patients who are best managed with one modality or another.

Any final thoughts?

Our concluding point is that we are now implementing pilot studies to enhance this subspecialty or advanced level training. So our main talking point is that we need more stakeholders involved, we need obstetrician gynaecologist societies around sub-Saharan Africa to understand that we exist, to connect with us if they feel that they are ready for that upper level of training and at the point that they are that we are prepared to partner with them.

I think you need first a critical number of obstetrician gynaecologists to be able to even consider the more advanced level of training. The physicians themselves, they don’t sit alone, they sit within a health system so when I really mean ready I don’t mean the individual is ready, what I mean is that the health system, the Ministry of Health and often it succeeds when it sits within an academic institution, so a university level, programme that they begin to integrate some component of that advanced level training. Wherever there is a cancer centre, either in development or existence, you really do need a specialised surgeon, so a gynaecological oncologist, surgical oncologist, to be able to be part of that team.