The agenda for this year’s London Global Cancer Week was to talk about cancer presentations and treatments in light of the COVID-19 pandemic. Cancer was the second leading cause of death globally, responsible for nearly ten million deaths, in 2018. Now, two-thirds of all cancer deaths occur in Africa and Asia where there is often a lack of access to healthcare which results in late presentation of cancer and poor outcomes. Despite the above, it is estimated that only 2.7% of global investment in cancer research is spent on research which is directly relevant to low and middle income countries.
This year AORTIC were invited to put together a one-hour session to lead off global events. That task fell to me as European Vice-President of AORTIC and I selected as the theme cancer treatment in the COVID-19 pandemic in sub-Saharan Africa. The programme was on 16th November 2020 and comprised of three talks with four speakers. There was Dr Bello Abubakar who is the President of AORTIC and chief consultant, clinical and radiation oncologist at the National Hospital in Abuja in Nigeria. His talk was followed by a joint presentation by Dr Yehoda Martei, who is an associate professor of medicine at the Hospital of the University of Pennsylvania, and her colleague, Miss Tara Rick, who is a physician assistant and is currently a PhD candidate at Erasmus University in Europe. The final presentation was from Miss Kwanele Asante who is the Secretary General of AORTIC. She’s a lawyer and a bioethicist from South Africa.
If we start with Dr Bello Abubakar’s presentation, he started off by presenting data from GLOBOCAN 2018 demonstrating that the main cancers in Nigeria are breast cancer, cervical cancer, prostate cancer and colorectal cancers. Now, when lockdown commenced in Nigeria in March 2020 patients were unable to readily access hospitals. There was anxiety and fear from both patients and their doctors. The patients in particular feared attending hospitals due to the perceived risk of acquiring COVID-19 infection. There was an increase in patients communicating directly with their consultants by phone or by text. I noted that this is different to, for example, in the UK where patients do not have ready access to the consultants’ phones; in Nigeria it’s different.
Planned cancer treatments were delayed and supplies of cancer drugs dwindled. There was a problem with personal protective equipment, otherwise known as PPE, and very sadly many healthcare professionals acquired the COVID-19 infection and several died.
The hospitals developed guidelines in terms of social distancing, face masks, hand sanitisers and hand washing. Just to give you an example of some numbers, on 18th June 2020 in that 24 hour period Nigeria reported 745 COVID-19 cases. Dr Abubakar told us that the poorer health systems were unable to cope without external support. However, countries should look to develop their own pharmaceutical industries rather than be completely reliant on external supplies. Indeed, the Nigerian government is working to produce internally drugs that are on the essential list. Of course, there was an economic impact of lockdown.
Dr Abubakar made certain recommendations to conclude his presentation. For example, he said that the African Union must develop a plan to support member countries in such a pandemic and that international organisations should help African countries develop comprehensive approaches to dealing with the cancer burden. Also, there was a clear need for more cancer centres to be established within Africa so as to avoid overcrowding of the current centres.
The second presentation was by Dr Martei and also Tara Rick from the States. They presented on the impact of COVID-19 on cancer care delivery in Africa, a cross-sectional survey of oncology providers in Africa. Their work was conducted between June and August 2020 and there were multiple collaborators and contributors to what was a cross-sectional survey that they distributed. They started off by reminding us that COVID-19 cases are going up in Africa despite initially being relatively few cases. They confirmed that cancer care globally has been disrupted by COVID-19 and we need to reach a balanced position where COVID-19 is controlled alongside continuing cancer care. Even pre-COVID in Africa the majority of patients who develop cancer will succumb to it, whereas in Europe and in the USA most people with a cancer diagnosis will survive it.
The main aim of their study was to characterise the scope of COVID-19 and cancer care specific strategies employed by African countries. This was a web-based cross-sectional survey. Initially they approached 122 healthcare professionals but in the end 79 ended up providing complete or partial data. This encompassed 19 countries; Nigeria and Zambia provided the most data. The biggest participant group of the healthcare professionals were oncologists.
The response strategies elicited were divided into patient-facing strategies and provider-facing strategies. Common to both were social distancing, face masks, temperature screening and hand washing. The use of telemedicine was noted, as was drone technology, in Rwanda for example, for delivering medicines. So this was one of the innovations that they elicited.
What was very common was postponing surveillance visits and delayed initiation of cancer treatments. Furthermore, there were modifications in all the treatment modalities, for example delaying radiotherapy. 94% of the cancer centres remained open but three-quarters of them reported a decrease in patients and over half documented staff shortages. Of concern was that 76% of these respondents reported a shortage of personal protective equipment. In addition, cancer medicines and analgesic shortages were noted.
Another interesting thing that they did was expose certain myths that abound in sub-Saharan Africa, such as Africans are less susceptible to the virus and that if you have a strong enough faith you will be protected from the virus.
There were limitations to their study, in particular the small sample size, and there were concerns over how reliable the institutional data on COVID-19 was.
The third presentation was from Kwanele Asante from South Africa. Her talk was entitled COVID-19: Ethical and Legal Issues. This was in relationship to how cancer care was conducted during this time period. She noted that COVID-19 had exposed gaps in African health services. Looking at human rights, health is a fundamental human right and that African states must ensure that everyone’s right to health is in line with international norms, not to mention that under Article 16 of the African Charter on Human and People’s Rights, everyone has a right to enjoy the best attainable physical and mental health.
She went on to say that due to resources being diverted to COVID-19 the question can be asked, are cancer patients COVID collateral damage? The means of her asking this is that cancer was not included as part of essential health services in national COVID responses. In Gauteng Province in South Africa the major hospitals that dealt with non-communicable diseases such as cancer were converted into COVID-19 hospitals so this, not surprisingly, led to delays in diagnosing cancer resulting in more advanced disease that required treatment. So cancer treatments were halted altogether or at least they were delayed.
To add to this, the oncology nursing staff and the palliative care specialists were reassigned to care for COVID patients. The mental health of cancer patients suffered throughout this period and, as we’ve heard earlier, she also documented that access to hospitals was challenging in the lockdown period. The private sector was less hard hit than the government sector.
The latter part of her presentation was on equity in COVID-19 vaccine distribution. She said that a fair allocation is necessary to quell growing vaccine hesitancy and mistrust in science.
After the presentations there was time for a few questions which were on the chat function. All in all this was a well-attended Zoom session to lead off Global Cancer Week. What was confirmed was that the response in terms of the cancer care in Africa was not dissimilar to other places in the world. Thank you.
Are there other AORTIC related updates you’d like to talk about?
The update, really, and what came out of some of the chat afterwards was that where you already have challenges in dealing with cancer, having COVID-19 on top of that is a catastrophe essentially and that comprehensive cancer plans need to be developed and the general level of healthcare improved so you can withstand some of these challenges that will happen from time to time. So COVID-19 has exposed the inequities in cancer care. The sub-Saharan African countries need to learn from this and develop more robust services that don’t collapse when faced with such a pandemic.