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- - IMPROVEMENT OF PATHOLOGY IN SUB-SAHARAN AFRICA

Monday, 8th of April 2013

• IMPROVEMENT OF PATHOLOGY IN SUB-SAHARAN AFRICA

 

Full text is at http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(12)70598-3/fulltext

 

 

The Lancet Oncology, Volume 14, Issue 4, Pages e152 - e157, April 2013  

 

Original Text

Prof Adekunle Adesina MD a, David Chumba MD b, Ann M Nelson MD c, Jackson Orem MD d e, Drucilla J Roberts MD f, Henry Wabinga MD e, Prof Michael Wilson MD g h, Prof Timothy R Rebbeck PhD i    

In the coming decades, cancer will be a major clinical and public health issue in sub-Saharan Africa. However, clinical and public health infrastructure and services in many countries are not positioned to deal with the growing cancer burden. Pathology is a core service required to serve many needs related to cancer in sub-Saharan Africa. Cancer diagnosis, treatment, and research all depend on adequate pathology. Pathology is also necessary for cancer registration, which is needed to accurately estimate cancer incidence and mortality. Cancer registry data directly guide policy-makers' decisions for cancer control and the allocation of clinical and public health services. Despite the centrality of pathology in many components of cancer care and control, countries in sub-Saharan Africa have at best a tenth of the pathology coverage of that in high-income countries. Equipment, processes, and services are lacking, and there is a need for quality assurance for the definition and implementation of high-quality, accurate diagnosis. Training and advocacy for pathology are also needed. We propose approaches to improve the status of pathology in sub-Saharan Africa to address the needs of patients with cancer and other diseases.

This is the second in a Series of seven papers about cancer control in Africa

Like other specialties, pathology has historically been faced with extreme shortages of trained personnel and infrastructure in sub-Saharan Africa. However, pathology services have not always been universally poor across the whole region—good services have existed, especially in tertiary care and academic medical centres. Many countries in the region have flagship academic medical centres that compare favourably with similar centres in high-income countries. The existence of strong pathology services in sub-Saharan Africa has contributed to major scientific and clinical advances. For example, Africa-based investigators had a central role in researching the pathogenesis of Burkitt's lymphoma, a cancer first described by Denis Burkitt, a British surgeon at the Mulago Hospital of Makerere University in Kampala, Uganda.1, 2 The Raji lymphoblastoid (Burkitt's lymphoma) cell line was established from the jaw tumour of an 11-year-old boy from Ibadan, Nigeria, by B O Osunkoya of the Department of Pathology at the University of Ibadan.3 This cell line has been used worldwide for many years and has been pivotal in the elucidation of the role of Epstein-Barr virus in carcinogenesis and in lymphoma research.

Why, then, does the state of pathology services in sub-Saharan Africa seem to be worse nowadays than it was 50 years ago? The decline of academic excellence began amid political changes that started in the 1980s in many African countries. The subsequent under-resourcing of the health service sector generally, and research particularly, is still a problem now. In many parts of the region, particularly in small cities and rural areas, pathology is widely perceived to be limited to mortuary practice, autopsies, and forensic pathology. In many ways, this perception is similar to how pathology was perceived in high-income countries before the 1950s. Moreover, the scarcity of education about and marketing of pathology services perpetuates outdated perceptions of pathology in the region. These services are often perceived to be dissimilar to other medical services, since pathology practice is led by technicians or government laboratory supervisors rather than by clinicians in many areas. This situation perpetuates the belief that pathology is not important clinically, and directly or indirectly minimises the needs for professional standards and quality-assured practice. Thus, comprehensive strategies to change perceptions and policies, both in governments and in institutions, are needed to correct these misconceptions, improve recruitment and retention of pathologists, and increase demand for pathology services.

Pathology is central to the provision of clinical and public health services for cancer in sub-Saharan Africa.3 Inadequate pathology services can lead to a cycle of ineffective health-care knowledge and practice (figure 1). In clinics and hospitals, inadequate pathology capacity can result in a gap in the ability of clinicians to treat patients. In particular, patients with suspected malignant disease who do not receive an adequate pathological diagnosis could have a benign lesion and yet receive treatment for cancer, they could receive treatment for the wrong cancer, or they might not receive adequate grading and staging even if the correct diagnosis is made by other means.4, 5 Furthermore, pathology contributes more to cancer care than the identification of cancer type. In addition to providing grading and staging, the pathology service must be able to do adequate frozen section diagnosis to guide surgical resections, to track histopathological and cytopathological diagnoses through time to allow for audits of the effectiveness of diagnosis and treatment, and provide advanced autopsy services to improve evidence for the effectiveness of treatments and other outcome data.

  

  

Figure 1 Full-size image (34K) Download to PowerPoint

Central importance of pathology in clinical care, research, and public health

Clinical care at all levels depends on a functional system with referral and feedback mechanisms. Effective primary care must be informed by knowledge of disease prevalence and diagnosis and must be able to refer difficult cases to specialised care. Referral centres need comprehensive diagnostic and treatment facilities. The information generated needs to be tabulated, published, and used to inform policy and practice in all parts of the health system.

Nationally, inadequate pathology capacity is a serious impediment to gaining knowledge about the true incidence of and mortality from cancer. Although many countries in sub-Saharan Africa have tumour registries, most of these do not meet accepted standards for population cancer registries and do not adequately capture the true incidence of cancer in the population. The International Agency for Research on Cancer6—8 has relied on data from only two countries (Uganda and Zimbabwe) to represent cancer incidence for the entire region. These data represent less than 1% of the entire regional population. Because accurate data are so scarce, ministries of health and health-care systems are unable to plan appropriately for specific cancer-related clinical and public health services, including primary care and referral services.9 National cancer plans, where they exist, are generally not optimally informed about the cancer needs of the population.

Provision of cancer care is a multidisciplinary effort that necessitates both anatomical pathology and clinical laboratory services. In many parts of sub-Saharan Africa, some oncology services have functioned without the necessary pathology-based diagnosis or laboratory tests that should be offered by pathology departments.10, 11 Suboptimum pathology input in cancer diagnosis leads directly to inadequate or inappropriate treatment and follow-up, delays in treatment, and increased cancer morbidity and mortality. Policy makers need to understand that cancer care is a comprehensive endeavour that relies on the ability to properly classify the specific type of cancer (and optimally to identify other phenotypic and genotypic characteristics that affect prognosis and guide treatment) and on the availability of tests that can be used to follow response to treatment and to detect tumour recurrence.

Poor pathology data and infrastructure also undermine research in various ways. For countries in sub-Saharan Africa to develop self-sustaining systems to provide adequate cancer care, the development of in-country research programmes that can be used to guide public policy decisions, resource allocation, and to train future generations of providers, health-care administrators, and researchers is crucial.9 One of the reasons that pathology capacity in Africa has not increased much in the past three decades is the scarcity of centres not only for pathology training, but also for the training of care providers and pathologists in research methods. In many parts of sub-Saharan Africa research training is inadequate or non-existent, which forces ministries of health and policy makers to rely on external research efforts. This practice is not sustainable, and could mean that research is done by groups that are not adequately familiar with the needs of cancer care in the region.

Pathology capacity and infrastructure are largely inadequate in most parts of sub-Saharan Africa. In mid-2012, we did an informal survey to identify the number of pathologists who were active in every country in the region, including all pathology subspecialties. The data clearly show that the number of pathologists is not sufficient to provide adequate and effective clinical services (figure 2). With the exceptions of Botswana and South Africa, all countries in the region have fewer than one pathologist (including all practice subdisciplines) for every 500 000 people. Many countries have fewer than one pathologist for every million people, and one country (Somalia) did not have any active pathologists. The number of pathologists per person in the region is at best 10% of that in high-income countries—for example, the USA had an estimated one clinical or anatomical pathologist for every 20 638 people in 2010.12

  

 

Figure 2 Full-size image (118K) Download to PowerPoint

Population per pathologist in sub-Saharan Africa, 2012

The small number of pathologists in sub-Saharan Africa might not only be caused by the general inadequacy of health-care funding and infrastructure in many parts of the region, but also by a poor commitment to provision of adequate diagnostic resources. When we compared the results of our survey (figure 2) with data for relative health expenditure from the World Bank (table),13 we did not see a significant association between the proportion of gross domestic product spent on health care and the number of pathologists per person (Spearman's r=—0·34, p=0·08).

TableTable image

Population per pathologist and expenditure on health

Several facts are readily apparent with respect to pathology infrastructure in sub-Saharan Africa. First, in places where no pathologists are working, adequate infrastructure will not exist. Second, when funding for pathology services is inadequate, funding for pathology infrastructure will also be inadequate. Third, the unique nature of pathology infrastructure means that many necessary items are not part of most procurement programmes for hospitals and clinics. Maintenance is problematic; almost no hospital in sub-Saharan Africa can afford to employ the expert staff needed to repair and maintain instruments that are unique to pathology services.

Insufficient resources for pathology leads to an inadequate workforce, poor facilities and equipment, and low availability of immunohistology. Several needs must be taken into account to improve the use of pathology in both clinical and research settings. We have divided these needs into three categories—systems needs, quality assurance needs, and workforce needs (panel). Systems needs include an efficient process for acquisition of tissues and disease-representative samples, which depends on surgeons being knowledgeable about disease processes and keen to understand the pathological processes behind diseases. Clinical and outcome considerations must drive the need for a correct pathological diagnosis. Several steps are necessary in the process: obtaining of samples, transportation, reporting, and archiving. First, diligence is needed to obtain the most representative tissue sample; a process informed by experience, training, and tutoring. Second, communication entails an element of timeliness in moving samples from surgery to pathology departments for processing. Third, efficient transfer of material to pathology services depends on a system for appropriate and timely processing and fixation of samples for routine and special procedures. Fourth, prompt reporting is important to maintain support for pathology services. If pathology reporting takes an unacceptable amount of time, many clinicians will deem pathology irrelevant to their practice and no longer request pathological input. Fifth, a reliable system of archiving and storage of samples and results is necessary for continued care and research. The archival system must ensure the safe storage of materials, patient confidentiality, and ease of retrieval for review and reanalysis. Sixth, system support and basic working equipment for tissue analysis and processing are needed. For the system to be efficient and reliable, it must be supported by an uninterrupted supply chain of quality reagents, equipment procurement, and maintenance. Finally, health ministries can provide leadership by designating cancer a notifiable disease, which will acknowledge the importance of cancer to population health for clinicians and pathologists.

Panel

Pathology development needs in sub-Saharan Africa

Systems needs

• Appropriate and timely fixation for routine and special procedures
• Efficient transfer of material to pathology services
• Receipt and documentation of specimens
• Case tracking
• Reporting
• Archiving
• Basic working equipment for tissue assessment and processing
• Uninterrupted supply chain of high-quality reagents, equipment procurement, and maintenance

Quality assurance needs

• Standard operating procedures and training of personnel at all levels
• Quality control of specimen collection, fixation, processing, tissue sections, and staining
• Quality assurance of diagnosis (internal and external review)
• Documentation of errors with remediation
• On-site assessment

Workforce needs

• Advocacy—work with national health services, ministries of health, policy makers and other decision makers, and clinicians to advocate for the importance of pathology
• Develop histotechnology and cytotechnology training
• Provide bursaries for pathologists to attend relevant professional meetings
• Promote opportunities for exchange of slides and other training materials, and create a centre to coordinate this process
• Telepathology—short-term solution for education, training, and consultative and primary diagnostic services (not a panacea)
• Institute policies to ensure retention of trained personnel

Quality assurance and quality control needs are also important (panel). Currently, oversight systems for quality assurance in sub-Saharan Africa are not universally available. Establishment of best practices and a means to assess whether these are being met is a step that could lead to improved pathology services.

Workforce needs include both advocacy and needs for education, training, and professional development (panel). Retention of qualified pathologists is a crucial need,9 and a potential outcome of the effective implementation of the other steps in the panel. Telepathology provides a short-term solution for education and training, and an avenue for consultations for primary diagnostic services.14 It can also be effective for consultation on difficult cases and can be used to extend pathology capacity and specialised knowledge geographically (eg, to non-specialist centres). However, telepathology with external specialists should not be seen as the primary solution for meeting the pathology needs of sub-Saharan Africa. Instead, in-country capacity must be built to provide for clinical and public health needs.

The shortage of pathology services could be partly addressed by the development of a three-tiered system of provision of laboratory services. In this system, the pathology services available vary with the care setting. In primary care, point-of-care testing is often very restricted in scope. The scope increases slightly in general hospital care, where a broader range of laboratory tests are available, and is much better in tertiary care and academic medical centres, where specialist pathology services in clinical and anatomical pathology with full autopsy investigations and a wide range of laboratory tests, including surgical pathology and histopathology, haematology, parasitology, microbiology, and chemical pathology services, are generally available. Most of the services available in tertiary care do, however, face serious challenges and constraints.

To get the support of clinicians, hospital administrators, and ministries of health for the development of an improved, cohesive pathology system that provides all of the necessary diagnostic support, training, and research, identification of successful, sustainable, model programmes will be crucial. For example, at Moi Teaching and Referral Hospital in Eldoret, Kenya, a long-standing project provides support to the hospital for patient care, teaching, and research. Some of these efforts come under the system known as the Academic Model for Providing Access To Health care (AMPATH). In addition to the hospital and medical school, partners involved in the programme include several medical schools and universities in the USA and Canada. This system has provided sustained clinical support for patients and health-care providers at Moi for many years (since 1989), improved education and training, and introduced many students and trainees to research methods. In early 2012, Moi University School of Medicine, Moi Teaching and Referral Hospital, AMPATH, the American Society for Clinical Oncology, and the American Society for Clinical Pathology cosponsored a meeting on improving cancer care in Africa. This meeting resulted in the development of a needs assessment followed by implementation of many changes within a few months to improve pathology services. These changes include the creation of a tumour board and development of a slide and block filing system, protocols for taking photographs for electronic pathology consultation in difficult cases, and a frozen section system.

The first and most important lesson to be learned from the AMPATH model is that cancer care is multidisciplinary. Without all of the necessary components, good cancer care is not possible. Second, improvement of pathology services and capacity is only possible when there is strong clinical demand, good support from the hospital or clinic administration, and when pathology services are regarded as an integral component of cancer care. Third, improvement of pathology services is similar to any other effort to build capacity in health care; it needs expertise, resources, and sustained commitment. Fourth, planning and development of pathology services needs a commitment both to immediate patient care needs and to long-term needs such as development of cancer registries, storage of tissue slides and blocks for later consultation or research, and development of training programmes so that departments can eventually become self-sustaining and able to send new trainees to take what they have learned to other places. Finally, external forces have a crucial role, most importantly commitment from ministries of health.

To improve pathology services in sub-Saharan Africa, we need to start with an understanding of existing capacity and infrastructure. Skilled professionals and infrastructure can still be seen all over the continent, and could be incorporated into efforts to build new pathology services. Because little data exist about the state of pathology practices in the region, we propose a survey approach to obtain the relevant data. Accurate information is needed about the number of pathologists currently in practice and the extent of their training and experience (years in practice and years out of training), their anatomical and clinical laboratory responsibilities, regular case loads, and whether they work in public or private practice, and the number of pathologists at each centre. Information is also needed to identify laboratory equipment in use or in need of repair, and the number of pathology assistants and the extent of their training. Some information about quality assurance processes would also be useful. Such information could be used to establish a prioritised list of informed, best practice recommendations.

The definition of minimum standards of pathology services that should be available for a population is a crucial step. These standards should be based on the medical services currently available in a specific country. A population served by a small health centre staffed by one health-care worker might be expected to offer a few pathology and laboratory services, with available tests dependent on the disease prevalence. For example, a malaria smear might be necessary and sufficient in one location, a blood glucose test in another. On the other hand, a primary care hospital with at least one physician should offer more tests (eg, complete blood count, HIV, serum creatinine). A referral hospital would be expected to offer more tests still (eg, histology, CD4 cell counts, fine-needle aspirates). Finally, regional centres can be designated to run more complete tests (eg, immunohistochemistry, flow cytometry, microbiology cultures, etc). Specimens from smaller hospitals and health centres would be sent out to regional centres as needed. Networks of pathologists should be developed so that referrals can be done in an efficient and cost-effective manner.

Once minimum standards are set, an external quality assurance programme should be developed to ensure that services meet them. Pathologists in resource-poor settings are often given enormous responsibilities, but often work in isolation and with little support. Ministries of health must assume their rightful place not only in the disbursement of allocated funds to the health sector, but also in monitoring the quality of services.

Adequate provision of high-quality, appropriate laboratory services for patient care will only be possible in the context of a systematic training curriculum that includes residency programmes for pathologists and medical laboratory technology schools for technical staff. Continuing medical education should be supported and improved—novel methods could include free or low-cost subscriptions to journals, online courses, affordable in-country courses, and bursaries to attend established courses abroad. Local pathology associations should also be encouraged to support continued professional education and training. The use of the photomicroscope should be emphasised, since it can improve hospital practice through presentations to clinical colleagues, academic publications, teaching of residents and medical students, and consultation (telepathology).

The ultimate long-term goal is to develop a system of cancer control in sub-Saharan Africa that is sustainable, affordable, and accountable. Sustainability is perhaps the most difficult of these goals to achieve, because building a sustainable health-care system of any type necessitates the integration of professionals from many different disciplines. For example, building a national centre for anatomical pathology needs pathologists, histotechnologists, and cytotechnologists to do the day-to-day work, but behind the scenes might also need procurement staff, economists, public policy experts, hospital administrators, and medical anthropologists to help outsiders to understand local customs and needs as they relate to the provision of health care.

Adequate pathology can benefit cancer control in sub-Saharan Africa in several ways: improving clinical services; informing cancer control efforts; aiding the development and implementation of national cancer control plans; supporting cancer registration; and supporting various types of research, including epidemiology, basic science, clinical trials, and translational research. Education of relevant governmental agency staff, policy makers, and the clinical community about the central role and importance of pathology is crucial to increase support for improved pathology services in the region.

We searched PubMed using the terms “pathology” and “Africa”, including all dates in the PubMed database. We did not restrict our results by language of publication. Only primary research articles, reviews, and editorials that focused on pathology activities, resources, and infrastructure related to cancer in Africa were selected. We supplemented these records with work of which we were already aware that did not appear in the search results. We also surveyed active pathologists in Africa about their practices and needs.

Contributors

All authors wrote some of the report and reviewed the entire text. TRR and AMN produced the figures. TRR collated the data for the table.

Conflicts of interest

We declare that we have no conflicts of interest.

Acknowledgments

We thank the African Organisation for Research and Training in Cancer for its support of the Pathology Special Interest Group in Africa. Support for the Special Interest Group was provided by the American Association for Cancer Research Landon Foundation and the US Department of State Fulbright Program (both to TRR).

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a Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA

b Moi University School of Medicine, Eldoret, Kenya

c Joint Pathology Center, Washington, DC, USA

d Uganda Cancer Institute, Kampala, Uganda

e Mulago Hospital and Makerere University, Kampala, Uganda

f Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

g Department of Pathology, Denver Health Medical Center, Denver, CO, USA

h University of Colorado School of Medicine, Aurora, CO, USA

i Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA

Correspondence to: Prof Timothy R Rebbeck, Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA 19104—6021, USA