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Inequities in Breast Cancer Treatment in Sub-Saharan Africa
Dr. Haffizulla: Dr. Anderson, can you share with us some of the challenges to delivery of care in Sub-Saharan Africa?
Dr. Anderson: So, Sub-Saharan Africa and our management of cancer in general and breast cancer in specific has been evolving in very exciting ways. My group, the Breast Health Global Initiative, we first started in Sub-Saharan Africa in West Africa, in Ghana and that was back in 2004. And the reason we went there at that time was because we were being challenged to answer the question, does it even make sense to be doing cancer care in Africa? And so, we actually went there at invitation to try to ask the question, what makes them not ready to do breast cancer and while we learned things, at the same time, we recognized they are ready, and things are evolving.
I hate to generalize, but you know people from North America tend to look at Africa as one country, and it’s not. It’s very diverse, and whether you’re talking about Ghana in West Africa or Tanzania or Kenya or Nigeria, they all have, there’s some ways in which the challenges are very similar, and there’s some in which they’re quite different. And so, the role of implementation science is very important.
There’s a big focus now on recognizing that we need to find the cancers earlier in their course, so in most of Africa today, when women come in with cancer diagnoses, they’re commonly very advanced that, to the point that you could literally see them from across the room. And that, it’s a good example of why mammographic screening…why would you do an imaging study to look for a cancer that you can’t see or feel when actually you are still not able to manage the cancers that are? So, I would say that the most important theme that we’re seeing in Sub-Saharan Africa today is how do we link early diagnosis of cancer, where the majority will be diagnosed as stage I or II, how do we link that to appropriate multi-disciplinary therapy, especially drug therapy that the…
Dr. Haffizulla: Sure.
Dr. Anderson: …using practical drugs that can be administered at a primary or secondary level and in ways that are effective.
Dr. Haffizulla: How do some of the barriers differ between or among countries, rather, in this region?
Dr. Anderson: Well, I would say one of the big…it’s hard to say what the biggest problem is, but clearly a major obstacle is the financing of health care. So, health care in Africa has evolved starting with infectious disease and trauma, I think those are the major areas That’s different from cancer because those tend to be episodic. So, I get really sick with malaria or I’m hit by a bus, and I’m brought to the hospital. Either I live or I die, but then I’m discharged, and that ends the episode.
Cancer doesn’t work that way. Cancer requires longitudinal care, so I need to be able to get the patient through the system from beginning to end and administering what they need in a timely and effective fashion. And I would say that that’s really a common theme throughout Sub-Saharan Africa, but there are differences. So, this year I’ve been in Nigeria, Tanzania, and Kenya, and what I came to understand is that actually, Kenya’s pretty advanced. They have…they are ready to make steps that I was not seeing as being quite the same.
We had…I’d say what I’m really excited about is how Africa is mobilizing to be doing this work themselves because the truth is, we can’t fly into a country, go fix something, and leave…
Dr. Haffizulla: Exactly.
Dr. Anderson: …and think that that’s a meaningful step. This is about building capacity, and so I think our training and education programs are improved. In Mozambique last month was the AORTIC Meeting. This is an African meeting. It happens every 2 years, and it’s about cancer research, and it has become a really dynamic, interesting meeting with all sorts of activities. And so what we’re seeing is our African colleagues rising to the occasion.
An example, UC San Francisco has a wonderful global oncology program, and it’s based on how to do research in Africa, but I was fortunate to go to their meeting, and what I was seeing was this was very much about doing training in research such that it won’t need UCSF anymore. That’s the whole idea.
Dr. Haffizulla: Absolutely.
Dr. Anderson: It’s so that it can be happening there without someone else coming in. So, the degree to which Africa and our African countries and regions are taking this on, this is really exciting and noteworthy.
Dr. Haffizulla: That’s phenomenal. Love to hear that. Can you highlight for our viewership some of the resources perhaps that are needed to address treatment inequities in this patient population we were describing?
Dr. Anderson: So, the needs, the inequities are prominent and often unappreciated. You know, when we come from high-income environments, so as you know we’re both clinicians…
Dr. Haffizulla: Yes.
Dr. Anderson: ...and so we tend to think when I show up in my clinic room or my OR, I tend to think about what I’m doing and what I don’t think about is what made this possible. So, when I say, scalpel, and the scalpel is then put in my hand, what I’m not really thinking about is, how did that blade get there?
Dr. Haffizulla: Sure.
Dr. Anderson: And do I have these systems that restock and do all of this, and I would say that actually those healthcare delivery system issues are really quite prominent. So, it’s not just having the mammogram machine or the ultrasound machine, it’s what are you doing with it and are we fixing it, and…
Dr. Haffizulla: Exactly.
Dr. Anderson: …when it’s broken, and that’s a big issue. So, to me, one of the biggest needs right now is in doing situation analyses, that it’s to understand what do we have, where are the gaps, and then how do we take what we have, add in sequential steps the pieces that we need to make this work, and it’s not about everyone getting the Mercedes-Benz.
Dr. Haffizulla: Sure.
Dr. Anderson: It’s actually about how do we get, you have to make the buses system work first, and then and we work our way up. This analytic area I see as essential in the implementation science realm, and it’s something that the Breast Health Global Initiative, my group, is intimately involved with.
Dr. Haffizulla: That’s phenomenal. It sounds like you’re including social determinants of health in a very grander capacity to really interrogate the system and have a personalized approach.
Dr. Anderson: That’s right, and I think one of our goals is that, so we do situation analyses at the request of ministries who are entities; they’re trying to make an impact, and they’re trying to figure out what’s going to work and what doesn’t work. Of course, our goal is to do the task that’s assigned, but we’re trying to learn from them, so that if we can do a situation analysis in a country to sort out where are these gaps, we actually want to take what we’ve learned to see how could we apply this in another area, and even better, could we develop an app for cell phones? Could we develop tools so that they actually don’t need us to do this analysis, that it becomes a much more automated approach but adapted to the specific areas. And I’m very excited by what WHO is doing, the World Health Organization.
Dr. Haffizulla: Yes.
Dr. Anderson: I was just on a conference call this morning, and my colleague Dr. Andre Ilbawi and his team members at WHO in Geneva, they’ve developed a costing tool that can really help ministers assess how much, if we want to do cancer, how much are we talking about, and what tools do we need, and WHO is engaging in ways that they just didn’t before, and that this is, it’s really an exciting time.
Dr. Haffizulla: This sounds very exciting. We’re excited to have you back to discuss some more of those advances.
Dr. Anderson: Thank you very much, I’d love to be here.
Dr. Haffizulla: You’re welcome.
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