Professor Ngoma at the World Health Summit. Credit: World Health Summit / S. Kugler
Maike Bildhauer, Gavi
Last year, public health experts discussed the burden of cancer and the state of oncology within the African continent at the World Health Summit in Berlin. One of the panelists was Professor Twalib Ngoma, the founder and executive director of the Ocean Road Cancer Institute (ORCI) in Dar es Salaam, Tanzania. After the session I spoke to him about cervical cancer and what the disease means for women in Africa.
What role does cervical cancer play in Africa, and in your home country Tanzania?
When you look at cancers for women in Africa, the number one is cervical cancer, unlike in developed countries, where breast cancer ranks highest. We have the highest incidences for cervical cancer in African countries, up to 50 cases per 100,000 women. In the Ocean Road Cancer Institute 33 % of our patients are women with cervical cancer.
At which stage of the disease do they usually come to the hospital?
The unfortunate thing is that most women come to us when the disease is already advanced. At a stage when treatment outcomes are not as good as they would have been if they had come earlier. They come so late because of several factors. Lack of awareness is one of them. Long distances are another one. And then you also find some delays in making the diagnosis in the health system. Women could go to a health facility and describe their condition, but the health workers don’t think that it’s cervical cancer. So women are given antibiotics and go home, only to come back after a month, and then again and again.
Then there can be also delays from the families themselves. Due to cultural norms a woman has to get permission from her husband to go to the hospital. But he may not give that permission if the woman is the bread earner. And if it’s cultivation season for example, she will delay going to hospital, so that she doesn’t miss this important period.
Some women are also afraid that if they are diagnosed with cancer, they will need radiotherapy. Instead of going to the hospital, they go to the traditional healer, who will also be a source of a delay. By the time the traditional healer says ‘No, there’s nothing I can do, go to the hospital’, it is too late. All these reasons contributing to patients coming to the hospital with the advanced disease.
Can you describe the women who come to the hospital with cervical cancer?
They are between 30 and 40 years old, in the prime of their life. Cervical cancer patients are 10 years younger than those women who come with breast cancer. Our research also shows the lower the socioeconomic status the higher the likelihood of developing cervical cancer. Human papillomavirus (HPV) – the major cause of cervical cancer – is a sexually transmitted disease. When you have multiple partners the chance of being infected with HPV rises. When you have a low socioeconomic status the chances of getting education including health education are also low. So the awareness about cancer is low. Also, when you are poor you cannot access health services as well as somebody who is rich. Even if these services are free, when you are poor you might simply not know about them, or the system is so complicated that it’s not accessible for the poorest.
What treatments do women receive in Tanzania when they are diagnosed with cervical cancer?
Surgery is not possible, because many women come too late. You cannot remove the whole tumour. The only treatment they can have is radiotherapy. In cervical cancer the higher the doses of radiotherapy the higher the likelihood of disease control. Women would come there with a bleeding, discharge and pain. By the time they finish the treatment most symptoms would be alleviated and the pain would be gone. But whether you control the disease a hundred percent, that’s the question. Because if you still have residual disease after the completion of the treatment, then it’s just a matter of time. The treatment is helpful to control the symptoms and to reduce the bulk of the disease. The patients will live for some time, but the cancer will keep on growing.
Is Tanzanian health system prepared for this?
In Tanzania we have one treatment centre for 45 million people. We have one radiotherapy machine in the Ocean Road Hospital and we have another centre near Lake Victoria, in Bugando Mwanza. We have a third coming up in Kilimanjaro, but it has not yet started operating. So we can say we have only two centres that can provide radiotherapy. That’s not adequate. A women who does not live close to a treatment centre would go to her local health centre, and they would refer her to the Ocean Road Cancer Institute. The women would need to travel all the way. That’s why sometimes the patients delay to come to the hospital, because of the system. And then it’s also a question of money. The trip to Dar es Salaam, the loss of income. You need about two months to be away from home for the trip and the stay in the hospital. So even if the cancer treatment is free, the inherent costs might be higher than the direct ones.
Tanzania has introduced the HPV vaccine in regional projects and is now preparing for the country-wide roll-outs. Why did the government decide to introduce the vaccine?
There is strong political will in Tanzania to address this key issue for women’s health. We have a National Cervical Cancer Control and Prevention Program. We have now a lot more data that informs policy makers about the usefulness of this vaccine. And the government is working with Gavito rollout this vaccine.
What would the impact be if all girls in Tanzania received HPV vaccines?
You will not see the impact in the immediate future. But after 15 to 20 years the incidence of cervical cancer will go down. And that’s good news for women’s health, and for the country.