To control cancer we must spark surgery activism

Prof Groesbeck Parham and Prof Richard Sullivan -

Cancer control is complex. It requires team effort and coordination for the best possible outcomes.

One of the cornerstones of cancer control is surgery. It’s the intervention that can cure and alleviate the suffering of cancer patients. And unfortunately, it is dreadfully deficient in most countries.

Nearly every country outside high income settings (and a few high-income countries as well) need to increase their surgical and anesthetic workforce for cancer by between 67 to 107% in the next 18 years.

This means we need to train a staggering 277,000 extra surgeons to deal with the rise in cancer surgical need which will increase to over 13 million procedures in low- and middle-income countries (LMICs) by 2040.

An estimated 60% of cancer cases and 75% of deaths will occur in the world’s poorest countries. The vast majority of these will be tumors of the solid type (breast, cervix, prostate, colon). Most will require surgery for cure. Even for patients with advanced disease, surgery is often required to ensure a comfortable, dignified death.

For safe and effective surgical treatment of cancer you need well-trained surgeons but also a functional health system which provides the basics:

• running water and electricity
• clinical space and services
• surgical and anesthesia equipment and supplies
• blood products
• essential medicines
• laboratory/pathology services
• post-operative care.

This must be part of a conscious effort to strengthen weak health systems that are so characteristic of low-and middle-income countries.

The diversity and complexity of cancers requires a diverse and complex set of surgical and anesthetic skills. Capability is important. Capacity is important. And these are part of a system which must deliver both. We now have the policy tools and data to help design national cancer surgical systems.

Better data improves assessment and monitoring of surgical quality, regardless of the income level of the country. In LMICs information can and should be collected on existing resources, problems, gaps, and needs specific to each country/region. This information should be used to plan public health cancer surgery systems, inform how they should be implemented, evaluated, and modified.

In creating such systems, the voice and opinions of all sectors of the society should be heard with emphasis on frontline healthcare providers, patients and their families.

We ought to focus on:

• screening and early detection programs for the most dangerous and high priority cancers
• treating disease(s) that have the greatest burden in the population, and where surgery has been shown to have significant impact
• cancer surgical interventions that can be performed safely and effectively in resource constrained settings.

International guidelines should be widely implemented to reduce the number of advanced tumors and save resources. Competency-based curricula should be used to train mid/senior level surgeons to perform a limited portfolio of high priority surgical procedures. Classic bedside teaching and teaching during operations should be enhanced with computer-based learning, telestration, telementoring, and low-cost virtual surgical simulations.

This will all help to improve and accelerate the transfer of surgical skills but it won’t be enough to make up for the lack of surgeons in many countries. We must consider delegating some low-risk surgical procedures to generalist physicians and non-physicians (licentuates, clinical officers, nurses) under close guidance and monitoring. For example, large loop excision of the transformation zone for precancerous cervical lesions; ultrasound-guided biopsies of the breast and prostate; endometrial, cervical and vulvar biopsies for lesions suspicious for cancer.

New and radical approaches

For most countries the cancer transition will not be a mirror image of high-income countries. Development is uneven. Economies are having to deal with many disease burdens simultaneously (infectious diseases, child and maternal health and non-communicable diseases). And in the post-COVID world, countries will experience even greater economic pressures.

Cancer is one of the most affluent of all disease research domains but most research still comes from high income countries and fixates on ‘innovative’ medicines and the application of laboratory research findings to high-income environments. We need novel and radical approaches to the creation of new knowledge and application of new technologies and cancer medicines in LMICs.

Of all the clinicians that provide care for patients with cancers of the solid type, the surgeon has the most extensive experience and is in the best position to advocate change.

As surgeons, we see and touch cancer. We hear the pain it causes. We smell the odors it sometimes emits as we attempt to remove it from organs and wherever else it has spread. We witness the devastating effects cancer has on the body, mind and human spirit. Shock. Grief. Acceptance. And when the disease comes back, resistant to treatment, we also witness the protracted process of death. We also experience the feelings of hopelessness and despair when broken health systems prevent us from delivering care.

This level of understanding prepares us for another role – the role of public health cancer surgeon.  In this role we must fight to raise public awareness. To increase the resources needed for the expansion of cancer control services. This kind of surgeon understands malignancies as complex diseases that have unique social, economic, and cultural determinants. This kind of surgeon knows that diseases are in fact manifestations of how people live – of their circumstances.

Global health research and capacity building for cancer, serves the global community. It’s vital for saving lives and preventing premature death and disability. It’s about reducing the impact of cancer on people’s lives and the economy.

We need to fight cancer around the world with institutional and social change. With their knowledge, experiences and ideas, surgeons must be the ones to bring it about. To do so they must become activists.