|Cancer Diagnostic and Treatment Facilities at Atomic Energy Cancer Hospitals, Pakistan 2017|
By Dr. Shamaraz Firdous
Human welfare and development is a basic right of every individual as enshrined in the constitution of the Islamic Republic of Pakistan and the charter of the United Nations. Cancer is considered as one of the deadliest disease and second leading cause of death worldwide. According to estimates from the international agency for research on cancer (IARC), there were 28.2 million new cancer cases and 10.5 million cancer deaths in 2016. The increasing incidence of cancer is mainly due to lack of public awareness, change in life style and environmental factors. Cancer is a rapidly increasing problem in developing countries. Without an understanding of cancer services and access to these services in developing countries, effective cancer control programs cannot be developed or sustained.
Cancer care in Pakistan is in developmental phase facing many obstacles. The major challenges are huge cancer burden, shortage of trained manpower, lack of training opportunities, absence of infrastructure, Un awareness, advanced stage presentation, and lower spending on cancer prevention and treatment. In spite of all these, shortcomings, society has been supportive and helpful in terms of both psychosocial help and financial contribution. Increased government spending and enhanced collaboration between the public, private, and charitable organizations is essential for comprehensive cancer control program in Pakistan
This article provides an overview of oncology health services in Pakistan. Especially cancer hospitals and facilities provided by Pakistan Atomic Energy Commission (PAEC). About 18 Atomic Energy Commission’s Cancer Hospitals (AECHS) are providing diagnosis and treatment facilities to cancer patients in four provinces (details: can be seen in below map). PAEC from its very inception has given high priority to the application of nuclear technology in Biosciences especially Health and Agriculture sector. PAEC, being a member of International Atomic energy Commission (IAEA) adopted a pivotal role in the use of nuclear energy in health sector.
The Chairman PAEC Mr. Muhammad Naeem, Dr. S. M. Javed Akhtar(Member Science), scientists, medical specialists and hospitals staff are devoted to fight against cancer in Pakistan. This is the reason that about13 billion rupees were spent on cancer hospitals up gradation and establishment of two new cancer hospitals at Gilgit and Mardan during last three years. PAEC has set up state-of-the-art Nuclear Medicine & Radiotherapy facilities throughout the country to fight against Cancer. Although, treatment of cancer is expensive and is beyond reach of most of general public of Pakistan, PAEC is providing the facilities to 85% of total cancer patients in the country at no cost or on discounted rates. In addition, establishment of Mobile Breast Care Clinics, Cancer Patients Welfare Societies and Pharmacies, registration of Pakistan in IAEA / WHO Program of Action for Cancer Therapy (PACT) are other contributions / milestones achieved by PAEC. Currently, establishment of new cancer hospital and up-gradation of existing hospitals is under way.
Pakistan is seventh most populous country in the world, Modern civilization, urbanization, industrialization, changes in daily life, population growth and ageing all have contributed to epidemiological changes in many diseases, including cancer, in Pakistan and other countries. Tobacco has been identified as the most important cause of cancer followed by dietary practices, inadequate physical activity, infections due to viruses and other personal behavior. This is the reason that, total number of new cancer cases is increasing rapidly.
Overall cancer incidence is about half that reported in developed countries but the cancer related mortality rate is almost similar. This can be attributed to the late stage diagnosis and limited access to quality treatment. Asia has about half the cancer incidence rate of North America (152.2 cases/100,000 person-years versus 315.6 cases/100,000 person-years). However, the ratio of cancer deaths to the number of new cancer cases in 2016 was much higher in Asia (0.66) than in North America (0.33). Only in Africa are cancer patients more likely to die (0.73). Within Asia, there is great variation in cancer incidence and survival rates. Residents of the western and eastern regions are more likely to get cancer than people in the south-central and south-eastern regions. Researchers suspect differences in drinking and smoking habits play a key role. However, cancer patients in poorer, less developed regions are less likely to survive than in richer, more developed areas due to lack of resources for screening and treatment.
The hallmark of all PAEC Cancer Hospitals is, not only being equipped with most modern equipment, but also operated by skilled teams of doctors, engineers, scientists, physicists and paramedical staff. Highly specialized trainings are required to handle radiation and to use it on the human being. PAEC provide such trainings itself and from abroad to the doctors, scientists and the technical staff. Currently there are 2,494 personnel working in these hospitals including 224 doctors. Atomic Energy Cancer Hospitals are providing teaching and training facilities to postgraduate doctors in the fields of nuclear medicine, radiotherapy radiology, medical oncology and to scientists in the field of medical physics in collaboration with Pakistan Institute of Engineering and Applied Sciences (PIEAS) Islamabad to strengthen specialized human resource for treatment of cancer.
Nuclear Medicine and Oncology Centers of PAEC are providing state-of-the-art health services to large number of patients across the country. Major services provided at PAEC Cancer hospitals are Diagnostic and Therapeutic Nuclear Medicine, Hormonal Assays, Radiotherapy, Chemotherapy, Indoor Cancer Ward, Breast Care Clinics, Biochemistry, Ultrasonography, Color Doppler, Diagnostic Radiology, Histopathology, Hematology, Molecular Based Diagnostics and Cancer Prevention & awareness Programs
The equipment used at PAEC cancer Hospitals are listed as:
Radiation Oncology started in Pakistan from 1960s, the Pakistan Atomic Energy Commission (PAEC) has established a number of hospitals all over the country that provide cancer treatment. Initially, these focused primarily on the provision of radiation-treatment facilities. Gradually, they have come to deliver chemotherapy in addition to radiation treatment, but do not have surgery or palliative care services. In common with many developing countries, Cancer hospitals tend to be under equipped and have more patients than is ideal for the facilities available. All PAEC cancer hospitals provide high quality care. The problem is due to appearance of the majority of patients to a cancer treatment centre in the late stages of the disease when cure is usually unlikely. About 5-10 percent of women with breast cancer visit hospitals at an early stage when treatment is usually successful. Prevention and screening are not strategies commonly used in Pakistan. Access to cancer treatment suffers from weaknesses of health policy, public awerenence, insufficient financing, as well as inadequate human resources and facilities have resulted in a concentration of services in urban areas. Many people must borrow money to access treatment. A large, unknown number of people in rural areas cannot get treatment at all. Cancer drugs are often very highly priced and out of the reach of poor’s people.
Highly specialized trainings are required to handle radiation and to use it on the human being. PAEC provide such trainings itself to the doctors, scientists and the technical staff. Currently there are 2,494 personnel working in these hospitals including 224 doctors. Various hospitals are also recognized by CPSP and other degree awarding institutes in the fields of nuclear medicine, radiotherapy and radiology for the students of FCPS, MCPS, DMRT and DMRD to complete their trainings and research work. Atomic Energy Cancer Hospitals are providing teaching and training facilities to postgraduate doctors in the fields of nuclear medicine, radiotherapy radiology, and medical oncology and to scientists in the field of Medical Physics in collaboration with Pakistan Institute of Engineering and Applied Sciences (PIEAS) Islamabad to strengthen specialized human resource for treatment of cancer.
PAEC Hospitals caters 85% of the total cancer patient burden of Pakistan. There is a trend of approx., 8-10% increase in patient turnout each year. The figures of cancer patient turnout for new, follow-up and total patients for the year 2017, top ten cancers observed at AECHs hospitals for men and womens during last couple of years, distributions of malagnancies by sex and age group and geographical areas of residence are given below:
Asia follows most global trends for common types of cancers, with some key differences. For example, the most common male cancer in Asia is head and neck cancer, while in the West it is prostate cancer. For Asian women, breast cancer is the most common, but cervical and liver cancers occur more frequently than in other regions. Even though cervical cancer has a long latency period and effective screening methods, more women die from it in Asia than in the West. Over the decades, 8 to 10 percent annual increase in cancer patients has been observed at Atomic Energy Cancer Hospitals. Cancer patient’s data of all 18 AECHs, statistics for different reigns of Pakistan for male and female (2015-16) is given in below figures:
It is predicted that by 2030, the number of new cancer cases will mount to 21.7 million and 13 million suiters of cancer will die owing to the growth and aging of the population. It is estimated that in future the burden of cancer will markedly rise due to the lifestyle adoption, which are linked with increased risk of cancer i.e. smoking, physical in-activity, improper diet and a decreased number of pregnancies in economically developing countries. In case the preventive measures have not been taken, the cancers present in western countries will also start rising in developing countries.
. Therefore, in this article, we provide an overview of the cancer burden, diagnostic and treatment facilities in Pakistan, especially Atomic Energy cancer hospitals services for cancer cure, including the estimated number of new cancer cases and deaths in 2015-2016.
Cancer risk factors are overall similar worldwide. Smoking, insufficient physical activity, alcohol, diet, overweight and obesity, and infections account for a high proportion of cancers worldwide. Prevalence of different risk factors varies by region and country, this is partly why overall cancer incidence rates, and the most common types of cancer, also vary by region and country. Worldwide, 1 billion adults currently smoke cigarettes. Smoking is the single most preventable cause of death in the world, and around a third of tobacco-caused deaths are due to cancer. Alcohol drinking causes an estimated 6% of deaths worldwide, around 1 in 8 of which are due to cancer. Overweight and obesity prevalence is increasing particularly in low and middle income countries. Unhealthy diets, e.g. low in fruit and vegetables and high in salt, are becoming more common in lower-resource countries. Infections cause 18% of the global cancer burden, with a much higher proportion in low-income countries.
The most prevalent, frequently diagnosed and top most cause of cancer death in female population of Pakistan is breast cancer. The global variation in the incidence and prevalence rates of breast cancer is due to the differences in risk factors and availability of early detection. Risk factors associated with breast cancer are based on reproductive as well as hormonal factors such as a long menstrual history, never having children and recent use of oral contraceptives. The risk of breast cancer is decreased in lactating women and those giving birth to children. Despite these shortcomings, early detection via mammography may save lives and increases treatment options. In men the Head and Neck and oral cavity cancer is most prevalent, frequently diagnosed and leading cause of cancer death in Pakistan. Main risk factors include tobacco smoke from cigarettes, cigars, or pipes; poor nutrition, drinking alcohol, betel quid and gutka, ultraviolet light, and HPV infection. One point must be kept in mind that the smokers who have received the treatment for oral cavity or oropharyngeal cancer must refrain from smoking, even in case their cancer appears to be cured. If such a person continues to smoke then the risk of acquiring cancer of mouth, larynx, throat or lung increases many folds. The oral tobacco products such as Naswar or chewing tobacco are associated with the cancers of cheek, gums, and inner surface of the lips. Long term usage of oral tobacco products poses a high level of risk. Such products lead to diseases of gums, damage to the bone sockets around teeth, and tooth loss. Similarly, it is quite vital that the people treated for oral cavity or oropharyngeal cancer need to stop using any tobacco containing product Inhabitants of these areas also chew gutka which is made up of betel quid and tobacco. People consuming betel quid or gutka are more prone to the cancer of the oral cavity.
Indoor air pollution resulting from unventilated coal-fueled stoves and cooking fumes contact with certain occupational and environmental cancer causing agents like asbestos, radon, polycyclic aromatic hydrocarbons and arsenic also serve as risk factors for cancer. Majority of the cancers can be evaded through eliminating smoke initiation and promoting smoking cessation among the current smokers. For this purpose an extensive tobacco control program is required which demands increasing the price of tobacco products through excise taxes, prohibiting smoking in public places and supply of tobacco to minors, banning the advertisement and promotion of tobacco, counter advertising and provision of treatment and counseling to the tobacco dependent people. Many populous countries of the developing world such as China, Pakistan and India are just in the initial stages of tobacco epidemic. If more adequate measures are taken by these and other developed countries to encourage the cessation of smoking and to preclude its initiation, then it may not only remarkably decrease the rates of cancer but may also circumvent the burden of diseases related to smoking seen in developed countries.
Early diagnosis, screening and prevention in any sort of malignancy, awareness about that particular cancer or those must be more conscious that have tendency of cancer in their family history. Early detection and population based screening is comparatively expensive in Pakistan, because of the different restraints of well-equipped health care infrastructure, state-of-the-art medical detection machinery. Significant advancements are made in cancer care worldwide, patients in Pakistan still present at an advanced stage. Fewer screening and diagnosing facilities, lack of care, management and treatment of those who are diagnosed with cancer, are serious issues to be addressed without further delay.
Atomic Energy cancer hospitals also launched mobile breast care clinics, comprise of mammography, 3D ultrasound machine and stereo-tactic biopsy, are provided to NIMRA Jamshoro, INMOL Lahore and BINO Bahawalpur. Community outreach is part of cancer prevention & early detection mission, these centers reach medically less privileged women in approximately 95% of their examinations. This program allows these institutions to provide life-saving early breast cancer detection services to women all over peripheral areas. The centers with the help of Cancer Patients Welfare Societies and international organizations like UICC arrange weekly or fortnightly visits of adjoining remote areas to provide free of cost screening as well as creating awareness among general public about importance of early detection and cancer treatment facilities available at these centers.
In order to provide welfare support to the poorest patients at PAEC hospitals. Cancer Patients Welfare Societies have been registered with social welfare departments. These societies have been working at all hospitals in collaboration with hospital managements to help poor and needy cancer patients. The primary objective of these societies is to mobilize the general public to grant donations for the welfare of cancer patients. In addition, the societies aimed to create awareness in general public about cancer through seminars, symposia and visual displays (banners, pamphlets and billboards).
The societies are fully functional and established pharmacies to provide anti cancer medicines to non-affording patients, enriched three times diet to the patients admitted to indoor wards and other essential items to facilitate patients. These societies also provides anti cancer medicines to general public on highly discounted rates through its pharmacy located within the premises of Atomic Energy Cancer Hospitals. Among the other contributions of the society, the prominent ones are the up-gradation of Atomic Energy Cancer Hospitals by providing medical equipment like Computed Radiography (CR) System, Mammography Unit, renovation of buildings, provision of chairs & benches for auditorium, arrangement of cancer awareness drives, establishment of pharmacies, provision of chemotherapy medicines to poor patients, construction of Masajids and Ashyanas and provision of human resource to the centers.
Pakistan Atomic Energy Cancer Hospitals are highly committed for disseminating information to general public regarding awareness about cancer that it is curable if diagnosed at an early stage.
In this regard a number of events like seminars, symposia, conferences, workshops etc are being organized by these centers in collaboration with Cancer Patients Welfare Societies and other medical colleges, universities, hospitals and NGOs for cancer awareness.
For awareness purpose, other activites in which hospitals are routinely involved are delivering of lectures at different hospitals, medical colleges/universities, arranging cancer awareness walks, distributing informative leaflets / brochures, displaying banners among general public and health care providers etc.
Significant challenges exist for the future of oncology within Pakistan. Among the most serious are those related to training of physicians, nurses and allied technical staff. It has become much more difficult, in the last decade, for Pakistani physicians to train overseas, adding impetus to the need for well designed and relevant training programmes within the country. It is essential that the number of training positions in the various oncologic disciplines be increased. The costs of treatment of cancer continue to rise, coupled as they are to ever-increasing drug costs as well as the costs of improving technology, for both diagnosis and treatment.Pakistan is located at the center of the geographical developing world, and is a typical example of a country with great cancer morbidity secondary to limited health resources. About seventy percent of the population resides in the rural outskirts, and disparities in infrastructure both discourage and hinder most people from seeking medical attention leaving them at the mercy of their disease. An unsuccessful formula prevails, with ill-supported efforts on one end, and poor community proactivity on the other. This leaves Pakistanis with little or no knowledge of cancer screening, detection, and diagnosis, let alone the testing journey through treatment. Patients who do manage to seek care are usually beyond cure, adding to the nationwide burden of management of chronic disease.
Surveillance programs and registries are necessary to collect, analyze, and interpret this data specifically to cancer. This would provide the basic essentials to understanding the disease process, including incidence, prevalence, trends, mortality, and survival. A realistic plan based on these statistics would follow, which would not only be cost effective, but sustainable. On the other end of the disease progression spectrum lies palliative care, which plays a major role in the continuum of cancer therapy. Palliative medicine has been reserved as a topic for specialists and intensive care nurses. Introducing the theme into training at all levels can enhance the pain-relieving options a physician can provide. The lack of well-informed health care professionals currently in Pakistan remains the major ironic obstacle in patients receiving analgesia, particularly morphine. Pain and symptom control, coupled with the correct counseling allow patients to die with dignity and families to accept the event.
The need for accurate population-based data on cancer incidence and mortality cannot be overemphasized. The policy-makers expect to make sensible decisions on allocation of precious healthcare resources on availability of patient’s data. The current parlous state of cancer data collection in Pakistan needs to improve.
Research in diagnostic and treatment of cancer remains rudimentary. The time and effort of most oncologists is taken up in dealing with the vast numbers of patients they are required to see, leaving little time for all but the most enthusiastic to devote to research. Cancer research can be difficult and complex to perform anywhere in the world, but these challenges are greatly magnified in developing countries. PAEC cancer hospitals, PIEAS, NILOP and other centres are actively involved in research on cancer and infectious diseases. Serious and sustained efforts to provide healthcare education and screening facilities would have tremendous impact in reducing the morbidity and mortality associated with this disease.
Since 2013, PAEC has received nearly Rs 13 billion from Federal Government (PSDP), and provincial governments to supply up-dated equipment, up-gradation of the existing hospitals, and construction of new center. For the current financial year about 5386.944 million have been approved for up gradation of GINUM, Gujranwala including a diagnostic center in Narowal and up gradation of NORI, Islamabad. Five cancer hospitals have received up-dated equipment through PC1 of Rs 1210 million. Another Rs 2342.783 million has been approved for a new hospital in Gilgit. Moreover Sindh Government disbursed Rs 437 million for up-gradation of NIMRA, Jamshoro and NORIN, Nawabshah. New PC1s for the year 2017-18 are underway.
These activities exhibit the commitment of PAEC to provide best of the available mode of managing cancerous conditions at cost affordable to people of Pakistan. The challenges facing oncology in Pakistan are numerous and multi faceted. Patients appears at last stage of cancer, there are no screening programmes and the national cancer plan. All hospitals have variations in the standards of care, no formal palliative care facilities, a shortage of trained manpower and a lack of training opportunities. The future should involve enhanced partnership between the private sector and charitable organizations or funding agencies. National priorities in this struggle will perhaps to be focused on cancer prevention, early detection,therapy, development of a national cancer registry and collaboration between cancer centres in training as well as in research.