• Preventive strategies, community involvement, research on cost-effectiveness, increasing equipment recommended

By Ruwan Laknath Jayakody In a review of the cancer care programme implemented in Sri Lanka, local researchers, while noting that said programme is reasonably balanced and expanding, highlighted that further development is needed in this regard. They thus suggested the following measures: Increased attention on preventive strategies pertaining to reducing tobacco smoking, betel quid chewing, and obesity; making cancer a notifiable disease; involving the community in cancer care planning and in preventive strategies; conducting research to evaluate the cost-effectiveness of existing treatment; and increasing the number of radiotherapy machines available. These proposals were made by U. Jayarajah and A.M. Abeygunasekera (attached to the Colombo South Teaching Hospital in Kalubowila’s Urology Department), in a narrative review on “Cancer services in Sri Lanka: Current status and future directions”, which was published in the Journal of the Egyptian National Cancer Institute 33 (13) on 3 June 2021, in which they observed that even though Sri Lanka has a reasonably balanced and continuously expanding programme for the prevention, screening, and treatment of cancer, developments would be required in order to overcome existing limitations and to cater to the increasing burden (financial, social, emotional) due to cancer in a backdrop where the country needs to parallelly strengthen the existing health system to face challenges brought about by both demographic and epidemiological transitions. Background studies The World Health Organisation (WHO) claimed that roughly 70% of cancer deaths occur in low and middle income countries. In the case of Sri Lanka, S. Gunasekera, S. Seneviratne, T. Wijeratne, and C.M. Booth noted in “Delivery of cancer care in Sri Lanka” that the increasing burden of cancer has become a major challenge, as the overall incidence of cancer has doubled over the past 25 years with a parallel rise in cancer-related mortality (the second most common cause of hospital mortality, constituting 14% of all hospital deaths). According to the National Cancer Control Programme’s (NCCP) National Guideline on the Early Detection and Referral Pathways of Common Cancers in Sri Lanka, as well as U. Jayarajah, S. Varothayan, R. Jayasinghe, and S. Seneviratne’s “Present status of cancer burden in Sri Lanka based on Global Cancer Observatory estimates”, it is estimated that 23,530 new cases and 14,013 cancer-related deaths occurred in 2018, and that these figures are expected to increase by 23% per annum until 2030.  In terms of commonality, as per studies, the incidence of breast cancer, oropharyngeal (middle part of the throat behind the mouth) cancer, thyroid cancer, oesophageal cancer, colorectal cancer, laryngeal cancer, lung cancer, and gastric cancers are increasing. The researchers noted this in a context in which the NCCP increased facilities for diagnosis and reporting. The studies cited above include “Incidence trends and patterns of breast cancer in Sri Lanka: An analysis of the National Cancer Database” by A. Fernando, U. Jayarajah, S. Prabashani, E.A. Fernando, and S.A. Seneviratne; “The incidence and patterns of oral cancers in Sri Lanka from 2001-2010: Analysis of National Cancer Registry data” and “The incidence and patterns of carcinoma (cancer that starts in cells that make up the skin or the tissue that lines organs) of the pharynx (throat)” by U, Jayarajah, A. Fernando, and S. Seneviratne; “Incidence and histological (cells and tissues) patterns of thyroid (gland in the neck which secretes hormones regulating growth and development) cancer” by U. Jayarajah, A. Fernando, S. Prabashani, E.A. Fernando, and S.A. Seneviratne; “The incidence and histological patterns of oesophageal (gullet) cancer” by U. Jayarajah, A. Fernando, D.N. Samarasekera, and S. Seneviratne; “The incidence and patterns of colorectal (a tube that connects the small intestine to the rectum, which together forms the large intestine) cancers” by U. Jayarajah, V. Udayanga, A. Fernando, D.N. Samarasekera, and S. Seneviratne; “The incidence and patterns of lung cancer” by U. Jayarajah, A. Arulanantham, A. Fernando, S. Ilangamge, and S.Seneviratne; “The incidence and patterns of gastric (of the stomach) cancers” by U. Jayarajah, A. Fernando, D.N. Samarasekera, and S. Seneviratne; and “The incidence and patterns of laryngeal (voice box) cancers” by U. Jayarajah, A. Fernando, A. Drahaman, and S. Seneviratne.  Cancer services in SL With regard to cancer services in Sri Lanka, there is a national cancer policy on cancer prevention and control (Gunasekera et al., and “Clinical oncology [tumours including cancers] in Sri Lanka: Embracing the promise of the future” by N. Joseph, S. Gunasekera, Y. Ariyaratne, and A. Choudhury), the NCCP, and the islandwide cancer database called the Cancer Registry under it, while Gunasekera et al. further noted that evidence-based strategies have been implemented to prevent and increase awareness regarding such among the public and primary health care personnel. Primary prevention In terms of primary prevention activities, the NCCP and B. Balagobi, K. Indika, W.M.C.K. Samaraweera, K.S.N. Wijayarathna, H.P. Maddumage, K. Sutharshan, S. Suvendran, and A.M. Abeygunasekera’s “Risk factors of renal (kidneys) cell carcinoma in a cohort of Sri Lankan patients: A case control study” noted that the use of tobacco and alcohol, the chewing of betel quid, and obesity owing to physical inactivity, and unhealthy diet are the primary preventable causes of cancer.  The chewing of betel quid and the sale of betel quid, tobacco, and areca nut products have since been banned in healthcare facilities and Government institutions, along with the bans imposed on smoking tobacco in public places and advertising tobacco products in the media. However, Jayarajah and Abeygunasekera pointed out that even though smokeless tobacco and betel chewing are major predisposing factors for cancers, owing to cultural beliefs and habits where betel is considered a sign of prosperity and good luck, practical issues have posed a challenge when it comes to banning them.  Elsewhere, under the national immunisation programme, girls between the ages of 10 and 11 years are vaccinated against the human papillomavirus (HPV – a viral infection of the reproductive tract that spreads through contact with skin) through a school-based vaccination programme so as to reduce the number of cervical (lower, narrow end of the uterus that forms a canal between the uterus and vagina) cancers, which according to U. Jayarajah, A. Fernando, M. Rishard, and S. Seneviratne’s “The incidence and histological patterns of cervical cancer: a Joinpoint (statistical software) regression analysis of National Cancer Registry data” contributes to 5% of all cancers. In parallel, vaccination against hepatitis B (liver infection) which is a part of the national vaccination schedule has achieved a target of 99%, as per the WHO. “Although there is emphasis on the reduction of exposure to carcinogens (agent with the capacity to cause cancer), more emphasis is needed to control metabolic (biochemical processes) risk factors such as obesity, physical inactivity, and unhealthy diet, which are major modifiable risk factors for cancers such as breast and gastrointestinal (relating to the stomach and intestines) cancers, and therefore, educating the public through the mass media and social media, and encouraging a healthy lifestyle is necessary for prevention,” Jayarajah and Abeygunasekera added. Screening On screening programmes for selected cancers such as breast cancer, oral cancer, and cervical cancer, these services are delivered by the NCCP, as per Gunasekera et al. The NCCP has also published guidelines for the early detection and referral of seven common cancers. That said, Jayarajah and Abeygunasekera emphasised, however, that with regard to screening for breast cancer, Sri Lanka does not have sufficient machines and adequate personnel to induct a countrywide mammographic (specialised medical imaging that uses a low-dose x-ray system to see inside the breasts) screening programme (at present, such is done in 18 state hospitals and a few centres in private hospitals). Breast self-examination is also promoted in this regard. Jayarajah and Abeygunasekera also noted that even though clinical breast examination is offered free at community-based clinics for women, these facilities remain underutilised, while A. Amarasinghe, U. Usgodaarachchi, and N. Johnson noted in the “Evaluation of the utilisation of primary health care staff for the control of oral cancer: a Sri Lankan experience” that the same is the case with screening for oral cancer, where even though screening facilities for such are available at community-based health centres, their utilisation remains suboptimal.  Hence, Jayarajah and Abeygunasekera noted the need for studies to be conducted to quantify the usage of these resources and to identify measures to improve the situation. Also, pap smear (procedure in which a small brush or spatula is used to gently remove cells from the cervix) screening for the early identification of cervical carcinoma in women is done through community-based clinics (as of 2016, there were 850 well women clinics and women aged 35 and 45 years are the target groups for screening). Jayarajah and Abeygunasekera explained further that even though prostate (gland located between the bladder and the penis and in front of the rectum) cancer is the fifth most common cancer among men, there is no nationally accepted screening programme using serum (fluid and solute component of blood which does not play a role in clotting) prostate specific antigen (PSA – a protein produced by normal and malignant cells of the prostate gland), despite facilities to test the serum PSA level being available in Government and private laboratories. “The utility of colonoscopy (a test to check inside the bowels) after acute appendicitis (swelling of the appendix) in those over 40 years” by U. Jayarajah, O. Basnayake, and S. Sivaganesh observes that currently, around 60% of prostate cancers are diagnosed at the metastatic (spread of cancer cells) stage. Furthermore, at present, owing to cost and resource-related limitations, there are no endoscopic (insertion of a long, thin tube into the body to observe an organ or tissue) programmes to screen for gastrointestinal malignancies (presence of a malignant tumour [groups of abnormal cells that form lumps or growths]/ cancerous growth) such as upper and lower gastrointestinal tumors, Jayarajah and Abeygunasekera noted. Diagnosis and treatment Concerning diagnosis and treatment, Gunasekera et al. pointed out that even in private sector hospitals, specialised in-patient health, cancer care services, and facilities providing systemic therapy are limited to a few major sites, as out-patient services and surgical treatment are prohibitive in terms of the high cost. However, facilities at tertiary care hospitals have been improved to manage all cancers in an evidence-based manner and to improve the overall quality of cancer care. As J. Balawardena, T. Skandarajah, W. Rathnayake, and N. Joseph explained in “Breast cancer survival in Sri Lanka”, medical oncology units with facilities for systemic therapy have been established in each district’s general hospitals. Further, chemotherapeutic (used to directly or indirectly inhibit the uncontrolled growth and proliferation of cancer cells) agents are also available. Specialised surgical oncology units have been established in nine provincial hospitals, as per Balawardena et al. However, Jayarajah and Abeygunasekera added that radiation oncological facilities are only available in seven provincial hospitals. Balawardena et al. stated that while there are four linear accelerators available at present, steps are being taken to procure more machines and establish a radiation oncology centre with facilities in each province. Only two private sector hospitals in Colombo have facilities for radiation therapy. It must be noted that Sri Lanka requires at least one radiotherapy machine per a population of one million, and therefore 10 to 12 more such machines are required, as per Gunasekera et al. and Joseph et al. who also explained that the limitation of radiation therapy to a few selected hospitals has led to long waiting times for patients in need of these services. When patients from rural areas are forced to travel long distances, this may in turn lead to, as Jayarajah and Abeygunasekera observed, a high default rate.  According to K. Sutharshan, B. Balagobi, S. Gajasinghe, S. Sasikumar, A. Weligamage, M. Ishak, H. Maddumage, and A.M. Abeysunasekera’s “Clinicopathological (signs and symptoms manifested by a patient, and the results of laboratory studies) profile of malignancies treated in a urology (dealing with diseases of the urinary tract) unit over a period of five years”, it is noted with regard to facilities for minimally invasive radiologically (diagnostic images of anatomic structures made through the use of electromagnetic radiation or sound waves and treatment of diseases through the use of radioactive compounds) guided tissue sampling methods, that immunohistochemistry (laboratory method that uses antibodies to check for certain antigens [toxin or other foreign substance which induces an immune response in the body]/ markers in a sample of tissue) facilities help in the histopathological (diagnosis and study of diseases of the tissues) diagnosis and reporting of complex malignancies so that appropriate therapy can be selected. Nevertheless, U. Jayarajah, B. Balagobi, D. Gunasekara, and A.M. Abeygunasekera’s “Management of renal malignancies in Von Hippel Lindau syndrome (rare, inherited disorder that causes tumors and cysts [sac-like pocket of membranous tissue that contains fluid, air, or other substances] to grow in certain parts of the body): Lessons learnt from a series of six patients from Sri Lanka” noted that facilities for molecular diagnostics is severely restricted in state hospitals and limited to the basic facilities available at the Medical Research Institute. Hence, Jayarajah and Abeygunasekera recommended the establishment of a few such centres in premier state hospitals. The NCCP noted that multidisciplinary cancer care is less commonly practiced, as various specialities function independently when managing the same patient, especially when patients are referred to a different unit to treat the same condition.  In an ideal situation, S. Wijayarathna, S. Suvendran, M. Ishak, A. Weligamage, A. Epa, S. Munasinghe, and A.M. Abeygunasekera noted in the “Outcome of retrograde (directed or moving backwards) ureteric (long, narrow duct that conveys urine from the kidney to the urinary bladder) stenting (tiny tube that is inserted into a blocked passageway to keep it open – done in this instance when there is an obstruction to the flow of urine from the kidney to the bladder, or when such an obstruction is very likely to occur) as a urinary drainage procedure in ureteric obstruction related malignant lesions (damage or abnormal change in the tissue of an organism)” that a formal agreement should be reached regarding the treatment plan with input from all relevant specialities in different centres, while formal pathways for referrals should be established, and proper documentation should be given to the patients once treatment is completed and they are referred back.  There are also no dedicated breast and endocrine (system made up of all the body's different hormones which regulate all bodily biological processes) cancer (such as for thyroid cancer) centres. Also, A.L.A.M.C. Ambegoda, W.A.S. Weligamage, M.C.M. Ishak, U. Gobi, S. Suvendiran, S. Mahadeva, P.K.B. Mahesh, M. Jayawardene, and A. Abeygunasekera observed in “A prospective study to evaluate access to elective surgical services in a urology unit of Sri Lanka” that there are no centralised and dedicated cancer centres for urological malignancies which are manned by urological surgeons specialised in uro-oncology. Jayarajah and Abeygunasekera also point towards the lack of a community-based nursing care service for stoma (opening made in the belly’s wall in order for waste to leave the body if one cannot have a bowel movement through the rectum) management, tracheostomy (an opening created at the front of the neck in order for a tube to be inserted into the windpipe/trachea to help in breathing) care, and wound care. Even though studies such as O. Basnayake, U. Jayarajah, and S. Seneviratne's “Management of axilla (armpit) in breast cancer: the past, present, and the future” and U. Jayarajah, K. Nagodavithane, O. Basnayake, and S. Seneviratne’s “Surgical management of papillary (relating to, being, or resembling a papilla or nipple-shaped projection, mass, or structure) thyroid cancer: review of current evidence and consensus” had shown that cancers are treated based on globally accepted guidelines formulated by well-recognised authorities, certain newer therapeutic modalities related to precision therapy and targeted therapy are not available in Sri Lanka, owing to cost-related constraints. The NCCP has developed brief local guidelines encompassing aspects of the management of cancers including breast cancer, oral cancer, cervical cancer, esophageal (a muscular tube that connects the mouth and the stomach) cancer, colorectal cancer, thyroid cancer, and prostatic carcinoma. However, Jayarajah and Abeygunasekera are of the view that far more comprehensive guidelines covering all key aspects of patient care should be prepared by an established authority. “As a country with a developing economy, we should always try to adopt cost-effective alternatives, despite Western guidelines and pressure from big pharma. For example, despite scientific evidence in favour of surgical orchidectomy (surgical removal of one or both testicles) as a means of androgen (hormones that contribute to growth and reproduction) deprivation therapy for metastatic prostate carcinoma, still much more expensive gonadotrophin (hormone) releasing hormone agonists (drugs or naturally occurring substances that activate physiologic receptors) are used in Sri Lanka,” Jayarajah and Abeygunasekera elaborated. The other aspect is that in reality, the majority of cancer patients seek the services of alternative medical practitioners, as noted by Joseph et al. and A.M. Abeygunasekera and K.H. Palliyaguruge’s “Does cassava help to control prostate cancer? A case report”. Therefore, Jayarajah and Abeygunasekera suggested collaborating with institutes of indigenous medicine to harness palliative aspects of certain native and Ayurvedic treatments, whilst regulating native healers who proclaim ineffective cancer cures. Cancer Registry and research On the matter of the Cancer Registry, the National Cancer Registry database has summarised and published online the incidence of all cancers from 2001 to 2014, while incidence and mortality-related population based data are available for the Colombo District. It is estimated by Gunasekera et al. that while the national coverage was 80% in 2014, the present coverage is likely more. Regardless, Abeygunasekera et al., “Pathological characteristics of primary bladder carcinoma treated at a tertiary care hospital and changing demographics of bladder cancer in Sri Lanka” by S. Sasikumar, K.S.N. Wijayarathna, K.A.M.S. Karunaratne, U. Gobi, A. Pathmeswaran, and A.M. Abeygunasekera, and “Clinical outcomes in a cohort of patients with T1 high grade urothelial (lining of the urinary tract) bladder cancer not receiving intravesical (liquid drug sent right into the bladder through a soft catheter) Bacillus Calmette-Guerin (BCG – vaccine for tuberculosis): a 15 year experience” by S. Goonewardena, U. Jayarajah, S. Kuruppu, H. Herath, D. Fernando, and K. Vickneswaran, observed that prostate and non-invasive bladder cancers are under-reported, primarily because these early cancers are usually treated only by clinicians without referral to cancer centres. Cancer registries are in the process of being established at all tertiary care hospitals and data is gathered from histopathology laboratories. U. Jayarajah, A. Fernando, D.N. Samarasekera, and S. Seneviratne’s “The incidence and patterns of liver cancers” and U. Jayarajah, I. Almeida, A. Fernando, D. Samarasekera, and S. Seneviratne's “Incidence and age-standardised rates of pancreatic cancer” noted that the low incidence of hepatobiliary (related to the liver, bile ducts, and gallbladder) cancers may be due to the lack of histological diagnosis and reporting. Since collecting data regarding patients treated in private sector institutes is difficult, Jayarajah and Abeygunasekera have suggested making cancer a notifiable disease, thus making reporting mandatory for private sector hospitals. The NCCP has initiated a user-friendly electronic technology data-gathering system using mobile applications to cheaply and effectively collect cancer data, as mentioned by A. Ambegoda, M. Jayawardene, M. Kumara, C. Sosai, S. Parthiepan, and A. Abeygunasekera’s “Cancer audit of a urology unit from a teaching hospital in Sri Lanka – 2019.” Accordingly, Jayarajah and Abeygunasekera have recommended that measures should be taken to expand this system to all dedicated oncology centres and clinicians. On the other hand, Jayarajah and Abeygunasekera noted that timely research and audit programmes (timely audit of cancer epidemiology and treatment outcomes guides primary prevention and screening programmes, the allocation of resources, and the revisions of guidelines) are lacking. With regard to the characteristics of malignancies in South Asia and Sri Lanka being unique to this region, the extreme rare case of carcinoma in situ of bladder in Sri Lanka has been attributed by Ambegoda et al. and U. Jayarajah, H. Fernando, K. Herath, S. Kuruppu, U. Wickramanayaka, I. Fernando, C. de Silva, and S. Goonewardena’s “Clinicopathological patterns and outcomes of urothelial bladder malignancies in Sri Lankan patients” to the BCG vaccination at birth. Jayarajah and Abeygunasekera further pointed out that there is a paucity of published data to prognosticate the outcome of diseases managed at the National Cancer Institute/ Apeksha Hospital in Maharagama. Also, T. Epa, A. Fernando, S. Colonne, U. Jayarajah, and S. Seneviratne’s “Long-term post treatment psychological outcomes in breast cancer patients from a tertiary care surgical unit in a developing country in South Asia” and “Long term post treatment quality of life in breast cancer patients” noted that studies on the quality of life and psychological impact of cancers are also lacking, and in this regard, it is expected that the research unit of the Apeksha Hospital will address this lacuna. Health literacy and public education In connection with health-related literacy and public education, since it has been found that the improvement of health literacy and public education programmes have reduced the defaulting rate and social stigma associated with cancer, A.S. Prasanth and U. Jayarajah’s “Assessment of the quality of patient oriented information over the Internet on testicular cancer” highlighted the importance of having skilled experts provide health information related to cancers and cancer screening without inducing unnecessary and harmful anxiety. Moreover, R. Jayasinghe, S. Ranasinghe, U. Jayarajah, and S. Seneviratne’s “Quality of the patient oriented web-based information on esophageal cancer” pointed to the lack of quality information available online for cancer patients, as R.H. Waidyasekera, U. Jayarajah, and D.N. Samarasekera’s “Quality and scientific accuracy of patient oriented information on the Internet on minimally invasive surgery for colorectal cancer” and V. Udayanga, U. Jayarajah, S.D. Colonne, and S.A. Seneviratne’s “Quality of the patient oriented information on thyroid cancer in the Internet” showed that such information is unreliable and of poor quality and readability. Therefore, Jayarajah and Abeygunasekera requested the NCCP, which publishes online leaflets on common cancers, to provide more comprehensive material designed by experts on cancers, which describe the available treatment, side effects, and outcomes. And in this regard, Jayarajah and Abeygunasekera also suggested involving the participation of communities in planning cancer care prevention strategies, as it would both demystify treatment and allow online messaging to be developed in terms that are grounded in both community wisdom and terminology. For this purpose, the International Agency for Research in Cancer (IARC) was cited as a resource for evidence-based communication.  Palliative care In conclusion, Jayarajah and Abeygunasekera also dealt with the palliative care aspect of cancer, calling for these services to be significantly improved in the context of the availability of such in selected tertiary care hospitals. In this regard, Jayarajah and Abeygunasekera explained that certain end-stage disease patients are referred back to the local hospitals, which lack both palliative care specialists and resources.  “Hence, a community-based palliative care service with adequate resources would improve the quality of life of these patients. A palliative care team can be attached to every oncology clinic which can coordinate and guide the community-based palliative care service. Narcotic analgesics (painkillers) such as oral morphine could be made available through these dedicated centres,” Jayarajah and Abeygunasekera emphasised.