UK Medical Student Visits Tanzania

Tim Spruell, a medical student from the University of Birmingham in the UK, recently spent a six week elective period in Tanzania – on the oncology ward at the Bugando Medical Center in Mwanza and on the pediatric oncology ward at Muhimbili National Hospital in Dar es Salaam. Tim provided an in-depth report about his elective period.
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Children playing in Mwanza

Introduction
This report follows a six week elective placement in Tanzania which I undertook as a medical student at the University of Birmingham in the UK. I spent five weeks working on the oncology ward at Bugando Medical Center (BMC) in Mwanza and one week working on the pediatric oncology ward of Muhimbili National Hospital (MNH) in Dar es Salaam. My duties in Mwanza ranged from attendance of ward rounds and clinics to research and audit work using hospital records. Apart from clinical activities, there were plenty of chances to get involved in the lighter hearted moments of ward life – the children being treated by the ward were always keen to have a go at colouring and drawing, or to play the odd game of hide and seek! My duties in MNH were similar, and volunteers there play an important role in the administration and smooth running of the ward. Volunteers in MNH may find themselves chasing up blood results, ordering investigations and taking notes on ward rounds. Again, there were plenty of opportunities for fun and games – I often found myself kicking a ball round in the courtyard, and with the older children, playing cards or helping with homework! All children in the pediatric ward at MNH were able to go to school thanks to an initiative by the organization, Children in Crossfire.

BMC, Mwanza
BMC is a large tertiary referral centre in Western Tanzania, on the shores of Lake Victoria. The oncology department was formally opened in January 2009, and receives referrals from a population of over 11 million people. The unit is staffed by a dedicated medical oncologist, as well as a medical registrar, junior doctor and specialist oncology nurses. There is also an English speaking oncologist from Italy rotating on a monthly basis as part of a charitable initiative. The ward has 16 beds in two bays. Children are also treated on the ward. Many other patients are treated on an outpatient basis. At the time of my visit, radiotherapy was not available, but a new radiotherapy unit is under construction and is expected to open later this year.

Epidemiology of Cancer at BMC
In order to gain an impression of the cancer burden at BMC, I examined admission records for the year 2010. The total number of cancer patients treated on the oncology ward was 291. Patients who were readmitted or who came for follow-up appointments were not included in this figure. The most frequently treated cancer was Burkitt Lymphoma (BL), with 82 cases in 2010. This was followed by breast cancer and retinoblastoma with 21 and 20 cases, respectively. Kaposi’s sarcoma was also relatively common (19 cases). The mean age of cancer patients treated during 2010 was 28 years. Unfortunately, the age for 19 patients was not documented, apart from being designated as adults, and these patients were assumed to be aged 56 years old, the overall life expectancy in Tanzania.

Children represented a substantial proportion of the cancer cases treated at BMC. The total number of children treated for cancer who were less than 15 years of age was 123 (42% of all cases). Of these, 60 were aged 5 years or younger.

Diagnosis and Treatment of Cancer at BMC
Many patients presented at an advanced stage of disease and had commonly been symptomatic for many months or even years prior to admission. The use of traditional medicine was common. This practice not only delayed presentation, but was often harmful, particularly when methods were employed such as scarification which involves cutting of tumor sites with razor blades.

The staging and diagnosis of cancer is challenging in BMC. Imaging studies for staging are presently limited to x-rays and ultrasounds. Although there is a CT scanner, it has been out of service for many months. An MRI facility is unavailable. Immunohistochemistry cannot be performed at BMC, but samples can be sent abroad for analysis.

Despite government subsidies, treatment for chronic diseases such as cancer is not free in the Mwanza region, and the hospital charges for its services. There is some provision of chemotherapy drugs for children with BL less than 5 years of age thanks to a Catholic charitable initiative, but the costs of treatment-related services such as medications required for supportive care, imaging studies, hospital fees and transportation costs must be paid for by all patients. Unfortunately, comprehensive treatment is therefore unaffordable for many patients.

Failure to complete treatment, particularly in pediatric cancer patients is common. In addition to high treatment costs, other factors contributing to this problem include long travel distances to the hospital for multiple outpatient visits, advanced stage of disease at presentation and a lack of understanding of the need for cancer treatment by patients. Although radiotherapy is available in Dar es Salaam, the cost of travel is too high for many patients. During my time in BMC, I completed a clinical audit of all children with retinoblastoma treated by the unit since 2009. Although 50% of retinoblastoma patients were found to undergo enucleation, 73% were lost to follow-up and did not complete treatment. Eighty one percent of patients lost to follow-up had not attended scheduled appointments within three weeks of their last visit.

Currently, there is no dedicated palliative care service in the Mwanza region. Although patients were often prescribed palliative medications on the ward, due to the lack of a community-based palliative care network, prescribing of opioid medications could not be continued in the community.

MNH, Dar es Salaam
A pediatric oncology ward has recently opened at MNH in Dar es Salaam and is run by INCTR's Dr. Trish Scanlan. The unit treats patients from all over Tanzania, and acts as a national referral center for pediatric oncology. Patients are exempted from the costs of most investigations and treatment, however, services such as CT scans or MRI have to be paid for. Radiotherapy services are available at the Ocean Road Cancer Institute. Presently, children remain on the ward during their treatment, but a hostel to accommodate children and their families from outside Dar es Salaam in between treatments is currently being made ready for occupancy by Children in Crossfire. This facility will help to increase efficiency of the ward by freeing up space for the care of patients with higher levels of medical need, whilst ensuring that relatively well patients still have ready access to treatment should any complications arise.

Summary
From data acquired at BMC, it appears that the average age at presentation with cancer in Tanzania is low. A high proportion of the cancer burden appears to be in children. Excellent progress has been made in the treatment of childhood cancer in Dar es Salaam thanks to the efforts of Dr. Trish Scanlan and INCTR. Oncology services in other areas of the country have been established more recently, and are also likely to benefit from the support of INCTR and partner organizations, particularly in the area of pediatric oncology, where curative treatment may be a feasible option.

Unfortunatley, many patients in Tanzania present too late for curative treatment. Access to palliative care for untreatable cancer is therefore a priority. Efforts are needed to establish palliative care networks in communities with trained personnel so that palliative care, which is initiated in hospital, can be continued after discharge from hospital.

Strategies to improve treatment outcomes will need to focus not only on medical aspects of care, but also on the social and societal aspects of cancer, including improving support for patients and their families as well as increasing awareness and understanding of cancer amongst the local population. A number of social factors appear to be adversely affecting treatment outcomes, including high costs of treatment and transportation to hospital, late presentation despite symptomatic disease, lack of understanding about cancer treatment and reliance on traditional healers. Medical and social factors need to be addressed concomitantly if overall outcomes from cancer are to be improved.

The pediatric oncology ward at MNH is an encouraging example of what can be achieved in Africa. This success story has the potential to serve as a model for the treatment of cancer in other parts of Tanzania and in other African countries.

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