Cancer Treatment in Bangladesh
By Limana Solaiman Mridha
Cancer claims the lives of millions across the world, and it is no different in Bangladesh, where a large number of people die every year from the deadly disease. However, we do not know for sure how many lives we are losing to this disease every year as no national-level research is conducted to identify the number of patients or reasons behind the rise of cancer in this country.
At an international cancer congress held in Dhaka last month, health experts estimated that 300,000 people are affected by cancer every year in Bangladesh, and around 200,000 patients die of the disease here every year. Bangladesh Cancer Society (BCS) organised the International Cancer Congress and Health Fair 2017 in cooperation with International Union for Cancer Control and Global Cancer Institute.
The scenario gets worse when it comes to treatment. There are only about 180 oncologists, or cancer specialists, in the country. And no district or sub-district level hospital has facilities for cancer treatment, diverting the huge number of patients to the major cities where a handful of hospitals and clinics offer specialised treatment.
According to data from the National Institute of Cancer Research and Hospital (NICRH), lung and mouth-oropharynx cancers rank as the two most prevalent cancers in males, while other types such as oesophagus and stomach cancers are also common. Among women, cervix-uteri and breast cancers are the most prevalent, while mouth and oropharynx, lung and oesophageal cancers also affect a large number.
About the prevalence of types of cancer as a whole, Dr Sarwar Alam, chairman of the Department of Oncology of BSMMU (Bangabandhu Sheikh Mujib Medical University) told The Weekend Independent: The most common types of cancer in Bangladesh are lung cancer, breast cancer, lymphoma, cervix and oesophageal cancers, according to statistics released by the Directorate General of Health Services and NICRH. This is the latest data, and since we do not have a national cancer registry, this is the source we depend on for reference. Having a national cancer registry system is necessary for us.. We have a tuberculosis (TB) registry and we are hopeful that the cancer registry will start soon as it will help us to handle cancer. So far, we have been relying on NICRH data as they have patients coming in from all around the country and have specialisation in a large number of oncology practices. Therefore, we consider them to be the authority and use their reference.
About the frightening doctor-patient ratio when it comes to cancer specialisation, Dr Alam said: Oncology/radiotherapy is an old discipline and taught in all the medical colleges in our country, but we do not have the setup to offer post-graduation courses necessary for specialisation in this field. This is one of the reasons for having so few specialists. So far, BSMMU, NICRH, Khawja Yunus Ali Medical College and Rajshahi Medical College have post-graduation courses in this discipline, and BCPS (Bangladesh College of Physicians and Surgeons) offers fellowships. With limited number of places available, we have a handful of new oncologists joining the ranks of the existing meagre number of about 180.
As to why more opportunities are not created to meet the demand of the population of 165 million, Dr Sarwar Alam answered: This is not an undergraduate course, we need advanced setup to train efficient medical practitioners in this field, and we are falling behind in that department.
He, however, praised the present surgical oncologists of the country, saying we do have specialists in fields such as gynae-oncology and uro-oncology, but we just need to expand their numbers and treatment facilities.
Dr Alam went to emphasise that we have only six institutions, including government and private medical centres, which have advanced equipment such as linear accelerators, Co-60 teletherapy and brachytherapy needed for treating cancers. The government is trying to open radiotherapy centres, equipped with cobalt therapy machines and linear accelerators, in public medical college hospitals to meet the treatment needs of the growing number of cancer patients.
He added that if we categorise the treatment of cancer under three broad regimes, such as chemotherapy, surgical oncology and radiotherapy, all are available in Bangladesh, but we need more facilities.
We need at least 20 centres in Dhaka alone, whereas we have only about six all around the country. We need to get over this inadequacy and the government is taking initiatives to procure new equipment, and building of bunkers for housing these sensitive machines are already underway, said Dr Sarwar Alam.
Pharmaceutical companies such as Sanofi Aventis, Novastis, Roche, GSK, Incepta, Beacon Pharmaceuticals, Beximco Pharma, Healthcare and Renata are producing anti-cancer drugs in Bangladesh to make them easily available and more affordable. Beacon Pharmaceuticals is the pioneer local company to come out with cancer-fighting drugs and its contribution has made the high prices of anti-cancer drugs produced by multinational companies go down substantially, making them cheaper for patients.
Still, some lifesaving anti-cancer drugs are too expensive for a large number of people. And although these are available in a limited number, government hospitals such as NICRH and Dhaka Medical College Hospital provide some medication for free to people from lower income groups. Meanwhile, BSMMU gets funding from three different sources, including the Social Welfare Ministry, an in-house fund for destitute patients and a government scheme where patients can get Tk50, 000 as one-time assistance.
Cancer care through a comprehensive cancer control programme has been incorporated into the objective of the National Cancer Control Strategy and Plan of Action 2009-2015, which has been formulated with the assistance of WHO. As part of the action plan, preventive measures are to be taken to reduce incidences of cancer that include reduced tobacco smoking, change of dietary habits, reduced food adulteration, ensuring reproductive hygiene, increased physical activity and reduced occupational hazard.
Most cancer patients seek help when they are terminally ill, and the death rate from cancer is relatively high because early detection and cancer awareness among people is not enough.
Providing treatment for the population successfully will do little to control the rise of cancer in the country. We need to work towards raising awareness about what cause cancer and how to bring it under control. It is possible to control one-third of cancers with primary prevention and another one-third can be treated successfully. The rest are life threatening and cannot be cured, palliative care is necessary for those. To bring the situation under control effectively, we need to take a holistic approach in solving the problem. We need to upgrade our treatment facilities, improve manpower, and we also need to spread awareness though campaigns and research. Until or unless we educate the people about what cause cancer and take preventive measures, ensuring the best treatment for everyone will not solve the problem. More funds should be allocated for campaigns and prevention programmes, said Dr Habibullah Talukder, associate professor and head of the Department of Epidemiology at NICRH, who works actively for awareness building and media campaigns by organising general people, opinion leaders, and both boy and girl Scouts.
NICRH is not there to provide treatment to patients, the work of this institute is to provide training on cancer treatment to other hospitals and institutions working towards curing cancer. We are here to develop manpower and treatment strategy for the entire country through research and training. But alas, we do not have a national cancer registry, but only in this research institute we have a hospital-based registry system, which I started. Based on this small scale registry, we have published reports that are used as reference. Lot of voluntary organisations, such as Bangladesh Cancer Society, Breast Cancer Awareness Forum, Ashic Foundation, Ahsania Mission Hospital and many others work actively for raising awareness and I try to work with them as much as possible for preventing cancer. But the power and reach of the government is much greater than all these organisations put together and, therefore, awareness programmes by the government will be more effective, Dr Talukder added.
Treatment for cancer is available in private hospitals, such as Square Hospital, United Hospital, Enam Medical College and Hospital, and Bangladesh Specialised Hospital. Delta Medical College and Hospital is the forerunner among private hospitals to introduce specialty treatment for cancer, along with installing all the necessary equipment needed for radiotherapy and chemotherapy. About their cost of treatment, Dr Rezaul Sharif, head of the Department of Oncology at Delta Hospital, said: Treatment cost in our hospital is affordable for patients, and we prescribe chemo medication according to the affordability of the patient as these are available in different price range. For poor patients, we waive charge for administering medication which is within a doctors reach. In case of radiotherapy, we have cobalt and linear accelerators and high-dose brachytherapy machines. We charge comparatively less than other private centres, and in case of radiotherapy for lung cancer, we can give treatment within Tk35, 000 to Tk40, 000. We have an in-house fund that poor patients can avail, but it is quite limited.
Palliative care for cancer patients is available in limited medical institutions only. Delta Medical College and Hospital is one of the few private hospitals in the country that has such a unit. Dr NM Nazmul Kabir, in-charge of Palliative Care Unit of the hospital, said: About 75 percent of our patients are eligible for palliative care, but we have only six beds _ three for males and three for females _ which cater to the needs of only a paltry number among the thousands of patients in need of this care. We are the second hospital in Bangladesh to start this care unit after BSMMU. United Hospital has this provision in their outpatient service, but it is very expensive and it is my personal opinion that this care should not be expensive as people need this as a last measure when they have already tried all other treatments, which are also expensive. In most cases, patients spend a lot for treatment and when palliative care is necessary, they have already spent most of what they have. Therefore, it is only humane that palliative care be least expensive.
The palliative care unit at BSMMU can accommodate 18 patients, nine males and nine females. They have a daily outpatient service, a 24-hour telephone service, homecare programmes six days a week and a lymphedema clinic. Our homecare programme is very limited and we have a single team that can provide service to a maximum of three to four patients in a day, said Dr Nezamuddin Ahmad, professor of Palliative Medicine at BSMMU. As it is free, it is still in a skeletal stage and we need to strengthen it. We are running this service with benevolent funding and we do not get any funds from the university. We need participation of the community to make this service available at a larger scale. We need recognition by the state health service and we need to create a place for palliative care in the national health policy for strengthening this service, he added. Palliative care is an evidence-based medicine and has been recognised since 1984 as a speciality in 26 countries and Bangladesh is the latest member of that club.
To learn more about the state of treatment from a patients perspective, this correspondent talked to some family members of patients at Delta Hospital.
Mostofa Kalam, whose mother has been suffering from tongue cancer, said: She was diagnosed with this disease seven months ago and had to undergo radiotherapy first. The previous doctor we saw asked us to choose surgical option. But this time, Dr Rezaul Sharif told me to go for chemotherapy and each session costs about Tk22,000 and she needs eight sessions. I am a bit confused as to what we can do. She underwent 33 radiotherapy sessions and after that she was tested and the cancer is still there. Now we have to decide as another doctor told us to go to Tata Memorial Hospital in India.
Outside the palliative care unit, Mohammad Amirul Islam said: I am here to say hello to the in-charge of this unit as he is a kind person and was there for my brother during his last hours. He died at the age of 32 and was suffering from stomach cancer. We got to know he was suffering from cancer a year ago and we sought treatment in Gopalganj, where we live. We came to Dhaka and went to Popular Medical and they suggested surgery. We then took him to Vellore in India, but he did not get well, he underwent a single chemo session, but couldnt handle more.
About referring patients to hospitals abroad, Dr Badrul Islam, who was once the director of NICRH, said: The state of cancer treatment in Bangladesh has improved substantially over the years, but I guess suggesting that a patient go abroad for treatment may depend on a variety of reasons. Many patients think they will get better treatment abroad, therefore, a doctor might suggest that. Another reason can be the fact that not every treatment option is available in a single facility here, or better quality is available elsewhere.
Photos: Courtesy
