Thursday, May 4, 2017

Cancer Care in Botswana

Daniela Buscariollo, MD
Harvard Radiation Oncology Resident

Cancer Care in Botswana: Entry 1

The morning began with a cup of cappuccino at Dr. Surbhi Grover’s home before we headed to Princess Marina Hospital for Multidisciplinary Gynecologic Oncology Clinic. Dr. Grover is a University of Pennsylvania-trained radiation oncologist working full-time in Botswana, and she is serving as a supervisor during my international clinical elective in Gaborone, along with Dr. Memory Bvochora-Nsingo, a radiation oncologist at Gaborone Private Hospital. Dr. Grover and I first met at the American Society for Radiation Oncology (ASTRO) meeting in San Antonio before my first trip to Botswana in March 2016. When I later expressed interest in returning for an experience focused on clinical care, she helped me work with my residency program to establish an ACGME-accredited international elective modeled after the one available at Penn. Today would be my first time attending the weekly clinic, so Dr. Grover provided an overview of the clinical workflow and also gave me a chance to discuss my goals and expectations for the month ahead. My rotation would primarily involve patient care at Gaborone Private Hospital, which houses the nation’s only radiation therapy facility, attending the weekly Multidisciplinary Gynecologic Oncology Clinic at Princess Marina, and weekly teaching sessions at Princess Marina oncology rounds. 

The Multidisciplinary Gynecologic Oncology Clinic began with a team meeting attended by a radiation oncologist, medical oncologist, gynecologist, pathologist, nurse coordinators, research assistants and trainees, where we discussed the referred patients presenting for consultation that day. We then interviewed and examined the patients, finalized their management plans, and counseled them on our recommendations. Not surprisingly, Dr. Grover and her colleagues have found that implementation of this multidisciplinary clinic has reduced delays in treatment initiation from about 3 months to 1 month. As a visitor, I also found the multidisciplinary clinic to be a wonderful opportunity to learn more about the issues impacting the clinical practice of colleagues in other specialties that contribute to challenges in complex coordination of cancer care in Botswana.   

Multidisciplinary Gynecologic Oncology Clinic Staff; from left to right: Goitsemang Gabaatlholwe, Shekina Elmore (Resident, Harvard Radiation Oncology Program), Kesego Phologo, Surbhi Grover (Attending Physician), Daniela Buscariollo (Resident, Harvard Radiation Oncology Program), Motseiwa Mokalake, Tebogo Othusitse.
In Botswana, cervical cancer is the most common malignancy diagnosed in women, 60% of which are also HIV-positive. Most women present with locally advanced disease and therefore require chemotherapy and radiation for a chance of cure. By comparison, in the United States, where HPV vaccination and cancer screening are widely implemented, cervix cancer does not even fall among the top 10 most common malignancies. Just that morning, I had seen more new cervix cancer cases than I saw during my entire 10-week rotation in Boston.

In addition to the newly diagnosed patients, we also saw follow-up patients who had already completed treatment. Many patients must travel long distances to Gaborone to receive radiation therapy, and the resources required to return on a regular basis for post-treatment monitoring can be prohibitive. As a result, follow-up care in Botswana is often challenging. An important aspect of follow-up care is the management of potential long-term treatment-related toxicities. A commonly encountered side effect of pelvic irradiation is vaginal stenosis, particularly for women who receiving brachytherapy (the vast majority of patients with locally advanced cervix cancer treated with curative intent). Vaginal stenosis cannot only adversely impact sexual functioning, but it can also reduce the quality of pelvic examinations, which is critical to early detection of salvageable recurrences. To address this common toxicity, simple plastic devices called vaginal dilators have become an essential standard component of sexual rehabilitation for gynecologic and gastrointestinal cancer survivors worldwide. Unfortunately, vaginal dilators are not currently available in Botswana, and given the aforementioned barriers to regular follow-up, it is difficulty to deliver longitudinal counseling on other strategies to cope with long-term treatment side effects. In this context, it was not unusual to identify vaginal stenosis to a degree that prevented our ability to visualize and/or directly palpate the cervix.

Based on these experiences, I became motivated to get involved in Dr. Bvochora-Nsingo’s efforts to pilot a vaginal dilator program. During the trip, I helped draft a protocol and patient education materials, and we are working on obtaining funding to secure dilators for the pilot. Our goal is to demonstrate feasibility and benefit for women in Botswana, which would hopefully eventually support development of a sustainable program in collaboration with the Botswana government and Ministry of Health.  

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