Sunday May 13, 2018
London, UK

his article was first published in Nigeriaworld of Sunday May 13, 2018. I was compelled to retrieve and upgrade it in view of recent events in the health sector in Nigeria. I expect a woman who has gone through counselling and screening at regular intervals, to be able to ride out the storm associated with doctors on strike for a prolonged period. Since nothing has changed since the first publication, I am inclined to believe that a paradigm shift in healthcare delivery is what is needed, granted the prevailing circumstances. Emphasis should be directed towards prevention rather than curative, especially in a system where healthcare attracts the least attention than other sectors.

As was the case during my previous post on the Demystification of Uterine fibroid (Nigeriaworld Feature Article, Sept.17 2013), I am once again compelled to send this post after reading a detailed and well documented account entitled "Undercover Investigation: Cancer is the Disease; Nigeria Health System is the Killer" written by Fisayo Soyombo in Sahara Reporters of 08/05/2018. This article highlighted the pathetic plight of Nigerians in their quest for cancer treatment. With the availability of one or two functioning Radiotherapy machines servicing cancer patients in a country with a population of over 180 million, there is the urgent need to look at ways to prevent or identify cancers in very early stages to avoid the need for adjuvant therapy for full blown cases.

My aim therefore is to look at female genital cancers with a view to advising on ways to grossly reduce the incidence of overt cancers and the need for radiotherapy or chemotherapy. Before this however, permit me to indulge in a bit of a preamble before going to the specifics of the screening and early detection of cancers, from the point of view of women's health.

In the said article in Sahara reporters the ordeal people go through to be seen and treated is mind bugling, a sad situation indeed. A situation where patients are made to wait for well over three months before they get to see an oncologist if they are lucky is unacceptable. Meanwhile, by the time they get seen, the cancer cells have progressed comfortably beyond their point of origin, thereby making the need for adjuvant therapy mandatory. Unfortunately for most of these cases the equipment needed for their treatment are either not available or non-functional at best. To make matters worse, having been seen and treatment commenced, they are made to part with a large chunk of their hard-earned cash and end up dying soon after.

The situation is akin to finding yourself between the devil and the deep blue sea. If armed robbers or terrorists do not get you, cancer will finish you up. Please can anyone come up with an answer as to how a petty-trader with children to look after, afford the thousands that will be needed to initiate treatment should he or she have the misfortune of having cancer? Any wonder therefore there is a proliferation of churches and assorted religious organizations and marabout advocating spiritualism as the only way forward. People get "cured" through miracles and concoctions that at the end of the day yield so much remuneration for these charlatans and all they do is smile all the way to the bank at the expense of their adherents. I am a Christian and I believe in Miracles. Be that as it may, I believe that if one is not well, God has given us the knowledge to be able to take care of things. I daresay that some of the prayers offered by way of Healing Crusades in Nigeria end up bouncing off the ceiling if held in-doors. Here is a country where a few amass so much wealth, enough to last several generations and all they do is wallow in their wealth in the midst of abject poverty. I gathered that some of these ill-gotten wealth gets buried away from prying eyes. The hospitals are left unattended without the necessary equipment to cater for the masses. The privileged few meanwhile hop across overseas to avail themselves the necessary treatment for their minor ailments. I gathered Ghana is now a mecca of sorts for medical tourism for Nigerians. These days, we hear of people disappearing with billions of Naira and in some cases Dollars just for being at the "right place at the right time". Nigeria is happy to receive from the likes of Bill Gates, but I can assure you that are several Nigerians that are richer. Pray, what would it take to make this money go around? A well-equipped and well-staffed General Hospital, offering free medical services to the masses, is all that it will take to grossly reduce the high mortality associated with cancer in Nigeria. Unfortunately, these cancers, especially female genital cancers, have 100% cure rate if picked up early and treated.

To conclude this preamble, I have to say without the risk of contradiction, that Nigerians are among the best doctors there are in the world. I am in a position to say this without equivocation because I have seen Nigerians at work the world over. They are hard working and dedicated to duty. All it will take to transfer their expertise back home is for the politicians to have a rethink and get out all the money buried underground and stashed in foreign banks, to be used for the development of the health sector. This way, the exodus or brain drain of doctors if you like, from Nigeria will be reversed. The several Nigerian oncologists abroad will return home to take care of these cancer patients like they do overseas. Security of life and property must also be assured so that they can sleep with both eyes closed after a hard day's job. The last time I was in Nigeria, I slept with one eye open just in case. I am aware that the first heart transplant surgery in Saudi Arabia was supervised and performed by a Nigerian doctor. What will it take for the Nigerian politician to realize that hiding billions of dollars or Naira for family use gets you severe headache and eventually death. I know some are bound to say, I would rather suffer the headache and have the money than otherwise. All well and good, but all I am saying is keep a little, enough for the family and make the rest available for essential services to benefit others.

Now to the specifics. I will discuss the female genital cancers, looking at the prevention and early detection of cases. There is reduction by up to 70% of cancer of the cervix in the advanced world because of screening. Cancer of the cervix is the most preventable cancer of the female genital tract. Since we cannot cure, why don't we vigorously embark on screening of women within the age group 21 to 65 years to not only reassure women but also to pick up precancer cells and have them treated? Also, young girls between the ages 11 and 14 years are being vaccinated against the Human Papilloma Virus (HPV), a sexually transmitted disease, which has been found to be the main cause of cancer of the cervix. There is no reason why screening for cervical cancer cannot be initiated in all the states of the federation free of charge. A dedicated screening programme and health education are all that will be required. The colposcope is the instrument required for the examination of the cervix and for the examination of suspicious lesions of the vulva.

A woman in her forties, out there with irregular vaginal bleeding could be seen and a diagnostic test performed to rule out cancer of the womb. An outpatient hysteroscopy which is considered a "one-stop" diagnostic test can be performed and the woman reassured there and then that she does not have cancer of the womb. The setup for this procedure may be expensive but cost effective. It eliminates the need for hospital admission and since it can be performed without anaesthesia, the woman goes home happy. Should any suspicious area inside the womb be seen, a biopsy of the area can be taken during the procedure and sent to the pathology department for examination.

Cancer of the ovary is a different ball game altogether. It usually presents as advanced female genital cancer and cannot be prevented or detected early as in the case of cancer of the cervix and uterus. Only approximately 20% of ovarian cancers are picked up early. Women should therefore be counselled that they should see the doctor should they be bothered by any of these symptoms: Feeling of bloating in the abdomen, Loss of appetite or feeling full soon after starting to eat - otherwise known as early satiety, frequency of passing urine, pain during intercourse, changes of bowel movement, unexplained weight loss. These symptoms in varying degrees may be associated with ovarian cancer and seen at regular intervals. Ovarian cancer is a genital cancer where counselling is important. A woman with a strong family history of ovarian cancer involving two or more direct relatives can be counselled and referred to a geneticist or oncologist for further follow up. Some women in this group would prefer to have their ovaries removed at the completion of their family. Referral can also be made for endo-vaginal ultrasound scan and blood tests if deemed necessary

In the United States, breast cancer awareness month is a regular annual event. During this month, women are reminded of the risk factors, symptoms and signs of breast cancer. They are taught the importance of breast self-examination and are reminded to include the armpit, as the breast extends to this part of the body. Women are encouraged to adopt life-style changes such as stopping smoking, eating well balanced food rich in plant-based antioxidants and less animal based protein. They are also reminded of risk factors, for example, strong family history of breast cancer and previous surgery for breast lumps. Women are advised to seek urgent medical help should the following symptoms and signs develop: breast lump, breast pain and tenderness not associated with cyclical hormonal changes, nipple discharge, breast swelling and changes in shape and a host of other features. The General hospitals I mentioned earlier should be able to offer free mammography as part of early detection of cancer of the breast for women at risk. The radiology unit of the screening unit if staffed by experienced radiologists/radiographers, can offer mammography for patient.

In summary, any gynaecologist in the twilight zone of his or her practice should be able to rake in the naira, just like the politician, simply by establishing a "well- women's" clinic for the purpose of performing cervical screening tests, out-patient hysteroscopy, mammography and counselling. Women should be advised that just as it is mandatory to submit your car for yearly checkup in the United Kingdom, you are required to visit your gynaecologist at regular intervals for checkup. Why wait until you become ill before going to the hospital? For the Gynaecologist, teamwork is advised. You simply cannot do it all alone. Of what use is it, subjecting a woman to hysteroscopy when you are not sure the biopsy obtained will be examined by an experienced Pathologist. Also, an experienced Anaesthetist will be required as part of the team should there be any need to take the woman to theatre. Solo practice should be discouraged. Why rake in the money and offer substandard practice when you can share it with other colleagues.

Finally, since it is obvious that the desire to provide adequate health facilities is lacking, the government can provide facilities for diagnostic and preventive measures as this will on the long run be cost effective. There will still be enough change left for the pocket.

Sequel to the above, hereinunder is my proposal or plan if you like. for the establishment of a well-women counselling and cancer screening clinics in every state in Nigeria. One such center will be more result orientated and beneficial to the masses rather than the proliferation of poorly equipped and nonfunctioning health centers.

This is the layout

  • Women's counselling and education unit. This can be staffed by experienced midwives, nurses, psychologists and counsellors. All women no matter their level of education will be encouraged to attend to have their questions answered and be educated about various aspects of general well-being for women.

  • Endoscopy unit. This unit will include facilities for out-patient hysteroscopy. A procedure that does not require anaeshetics and designed for a one-stop investigation and diagnosis of abnormal uterine bleeding. The beauty of this procedure is that the woman gets to see the lining of her womb with the doctor and goes home reassured. Depending on the availability of staff, diagnostic laparoscopy and laparoscopic sterilization can also be offered in this unit if necessary.

  • Colposcopy unit: This is the unit where women geta their routine or diagnostic smears taken. Using a colposcope, the vulva can be examined for any suspicious lesion which could be precancerous, and biopsies taken. The colposcope is also a useful tool for the examination of the cervix. Majority of precancerous lesions of the cervix can be identified and treated through colposcopy.

  • Radiology Unit: Ultrasound Scans for abdominal and pelvic examination can be performed here. Also available in this unit are the X-ray machines for routine x-rays and mammography.

All these units in one building, is all that it takes to get a well-woman center up and running. As stated earlier, it is no use having all these in place if there are no well-staffed tertiary centers for referral of deserving patients. It's no use taking a biopsy from a suspicious site if there is no pathologist to make a reliable and satisfactory report.

A unit such as this, backed by intensive advertisement using radio, television and all forms of social media will help spread the message around that such a facility exists and are available at little or no costs for all women.

My guarantee is that this unit will not only improve maternal health and reduce maternal morbidity and mortality but also reduce the incidence of overt female genital cancers that can be prevented or cured when picked up early.

This is my last contribution on this matter. The onus is on those in authority, those with the wherewithal and the will to make this happen. I rest my case.

A fellow of the Royal College of Obstetricians & Gynaecologists

Author of:

Pregnancy: A Continuing Source of Sorrow and Pain for Women in Sub-Saharan Africa.

Growing up in Africa: A Destiny fulfilled - A True Story of Courage, Optimism and Determination in the Face of Adversities.

Other publications in Nigeriaworld include - The Demystification of Uterine Fibroids,