Pathology is a Human Right
Battling the ever-growing burden of cancer in Africa requires a global effort
Lawrence Shulman, Claire Wagner, Danny Milner, Jr. |
Infectious disease remains a major challenge in low- and middle-income countries (LMIC); however, political will and global funding mechanisms over the past two decades have resulted in the widespread rollout of advanced diagnostic capacity and drug delivery, especially for HIV/AIDS, tuberculosis, and malaria. Although the problem of cancer existed long before – and mortality from these infectious diseases is reduced – incidence of malignancy and other non-communicable diseases have risen as a proportion of overall disease burden. Moreover, with better control of infectious disease, the populations of all countries are aging, adding to the increase in cancer burden. Policymakers and other public officials are now recognizing more than ever the urgent need to address cancer.
Unlike HIV/AIDS, tuberculosis, and malaria, cancer comprises many heterogeneous diseases and is more complex to diagnose and treat. For example, a highly effective and potentially curative treatment for Hodgkin’s lymphoma will be completely ineffectual in a patient with colon cancer. Therefore, without a specific diagnosis, optimal therapy cannot be determined, and poor outcomes are likely to result. Also, as we know, cancers cannot be definitively diagnosed clinically and require histologic evaluation of biopsied material; so, the pathologist and his/her laboratory play an essential role in cancer care. Likewise, without access to safe and effective therapies, an accurate diagnosis of a patient with cancer is a hollow effort. The patient may know what disease they have but will still die without the appropriate treatment. It is clear that diagnosis and treatment must go hand in hand.
Diagnosing cancer requires, in the traditional workflow, a series of personnel (pathologist included), instruments, and reagents that are expensive and difficult to maintain in harsh environments. Under these challenging conditions, most pathology facilities in LMICs would be deemed limited in both resources and capacity. Further, the evaluations of tissue that are required for responsible patient care go beyond accurate histologic diagnoses. Doctors also need additional tumor-specific data to design a treatment regimen aimed at maximizing the likelihood of survival for the patient (for example, estrogen receptor and HER2 status for breast cancer, or the presence of the t(9;22) chromosomal translocation in chronic myeloid leukemia).
Providing high-quality pathology services is already a formidable task in wealthy countries such as the USA and very much more so in LMICs. Pathologists in any context must be well trained, and, as is the case with all physicians, continuing medical education focusing on new developments and technologies is essential. Working within a peer group and scientific community that provides consultation and support is also critical regardless of the setting. Pathology labs have universal requirements too – for instance, they need the necessary equipment, numerous and inter-dependent reagents, and skilled technicians to process specimens. Machinery must be maintained in excellent functional status and promptly repaired when rendered non-functional. Consumables (including reagents used) must be kept in stock, which means supply chains must be tightly run. The absence of one critical functional machine or reagent will often bring the lab to a grinding halt – the “weak link in the chain” phenomenon. A pathologist without a high-quality laboratory is ineffectual, as is a functioning laboratory without a pathologist.
In many countries in sub-Saharan Africa, and other impoverished regions of the world, there are few if any pathologists. The needs of their lab’s catchment area (sometimes their entire country) and the volume of specimens that need processing, often hugely overwhelm those pathologists who are running labs. There is often little support available to pathologists in processing specimens, producing reports, and assuring the reports get back to the treating physicians. Even if the number of pathologists in training is increasing, there will still be a vast shortage of pathologists for many decades to come.
In these settings, high-quality cancer care is extremely challenging but not impossible. One way that organizations have tackled human resource shortages and weak pathology infrastructure is through global partnerships with academic medical centers in the United States and elsewhere. We have learned that the establishment and maintenance of high-quality pathology in these settings is feasible and can benefit tremendously from support of pathology colleagues from cancer centers with comparatively abundant resources.
Such long-term partnerships can act as a buffer to the drawbacks of one-off pathology training courses that, although essential, are often inadequate for programs to remain sustainable. Ongoing engagement can make the difference between a sustainable program and one that collapses under the weight of unmanageable volume of specimens and other challenges. Accompaniment often takes the form of on-the-ground support by pathologists and technicians, as well as long-term support through telepathology. In all circumstances, continual quality assessment and improvement, as well as peer support through a scientific community, can help guarantee excellence.
Many cancers are curable and many are controllable for years and even decades. Millions of patients worldwide with such cancers – like early-stage breast cancer in a young woman, or chronic myeloid leukemia – die needlessly every year because they lack access to high-quality cancer diagnostics and treatment. One would hope that a four-year-old boy with Wilms’ tumor, who has an 80 percent chance for cure in the US, would not be allowed to die without even a diagnosis, no less treatment. Yet that happens every day in many places in the world. We have a humanitarian obligation to work to provide that child with a chance for cure – a chance for life – with safe and effective therapy. The first step is the capacity to make an accurate diagnosis, and therefore high-quality pathology is part of the human right to health.
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