Endoscopy or the Mirror Exam: Guideline Adaptation in Oncology Care in Botswana

Shekinah Nefreteri Elmore, MD, MPH

Resident, Harvard Radiation Oncology Program

PGY3

I was thrilled to be back in Botswana in the oncology department at the Princess Marina Hospital, the large Ministry of Health facility in the Gaborone. I had traveled there once before during my intern year for a month long rotation project. While I already came to the experience with more than a year at an oncology facility in Rwanda, I hadn’t yet begun my radiation oncology residency, and thus had had little formal oncology instruction. Coming back with nearly a year behind me did wonders, both for how helpful I was able to be to the clinical oncologists in their consultations, but also how I saw the system and my project. Tasked with helping to think through how complex, international cancer care guidelines could be simplified to meet the needs of oncologists and their patients in Botswana was both more enriching and more nuanced after a year in my training program.

Sitting with one of the clinical officers in the outpatient oncology clinic, we met a lovely, older patient with a head and neck cancer. He was my first such patient, as my rotation in this specific anatomic site would take place in the next academic year. But, with all of the teaching conferences and articles that we benefit from, I knew some basics and could help and follow along with the more experienced doctor.

We proceed to a physical exam after getting a close history, feeling lymph nodes in the neck carefully and looking at the dusky, white, plump tonsil that harbored the cancer with the help of a tongue depressor and pen light. Though I’d never done it or seen it, I knew that the next step was the completely but baroquely named nasopharyngolargyngoscopy, or passing a thin, fiberoptic camera scope through the patient’s nostril and down to the precipice above their vocal chords. This would allow us to see what path of local travel the cancer had taken and hone down on our treatment recommendations. Asking the doctor if the scope would be done, she said that it had been broken for some time.

Guidelines are a complicated series of hopes and certainties, in this sense. While it is fine and likely appropriate to recommend an endoscopy for staging in a head and neck guideline in Botswana, because technically there is a scope unlike in some more resource-constrained settings, recommending this as the only means of staging would be an unfortunate omission of other possibilities. The more viable options and the more creativity we can bring to this process, the better.

For example, while endoscopy has become a mainstream practice, this is very recent. Previously, a “mirror exam” or use of a simple dental mirror, light source, and head mirror provided physicians with a comparable view of the same terrain. Both options should be included in such guidelines. And, further, an assessment of how often one or the other is performed could be captured over time to document the true availability of advanced technologies such as endoscopy and to trouble shoot their breakdowns. It would have been easy to write a guideline that included endoscopy as the only option, simple because no time on site, no time in clinic with the actual care providers had taught me any better.

My time in Botswana reinforced the lesson of global health and implementation that I learn again and again: we must always work in partnership to know what is realistic while still championing what is ideal.