A mother of 3 in her forties comes into the cancer clinic worried and eager for answers. She has a right breast lump with associated lumps under her right armpit. She is one of many that come in every week now. Treated at the health centre with antibiotics for several weeks, she was referred for further assessment and management. On clinical assessment she is diagnosed with a breast tumour. Malignancy is a likely diagnosis. She needs a biopsy to confirm. This might take months to a year to get back results in a provincial hospital like Alotau. She and her family cannot afford a biopsy at a private facility. The team can only offer her surgery to remove the breast and lumps and await confirmation of the biopsy. A difficult and costly decision if the tumour turns out not to be malignant. She requests for only a biopsy to be done. The team does the biopsy and waits for the results. Months pass and she returns for review at the clinic. The tumour has now increased in size and has developed a small ulcer. She still wants to wait for the results. They finally come, six months later and breast cancer is confirmed. But it’s too late for her. The cancer has spread to her lungs and she becomes weaker and irritable by the day. She eventually passes away in the ward with her family by her side. A typical picture of breast cancer in most of our hospitals.
Many more like her decide not to wait and go ahead with removing the breast and lumps under the armpit. Many wait till the tumour grows so large they cannot bear it any longer. Some may even resort to herbal or traditional medicine first as they cannot afford to travel to the major district or provincial hospitals. Presenting late is a common issue. Many factors contribute to these delays. But establishing a diagnosis is crucial in the management of these patients. Surgery is not only diagnostic but theraputic and may be the only available treatment option for most of these patients. Chemotherapy drugs are expensive and radiotherapy is not available. This is the reality for not just breast cancer in particular but other cancers that plague PNG.
As global efforts accelerate to implement the Sustainable Development Goals and, in particular, universal health coverage, access to high-quality and timely pathology and laboratory medicine (PALM) services will be needed to support health-care systems that are tasked with achieving these goals. This access will be most challenging to achieve in low-income and middle-income countries (LMICs) such as Papua New Guinea, which have a disproportionately large share of the global burden of disease but a disproportionately low share of global health-care resources, particularly PALM services.(1)
According to the International Agency for Research on Cancer, there were an estimated 14.1 million new cancer cases in 2012. That has increased to almost 20 million new cases of cancer and close to 10 million deaths from cancer in 2022 (2). Nearly 60% of these new cases occur in the developing world with an expected increase to more than 70% in the next 15 years.
Despite these alarming statistics, the proportion of the national budget allocated to health in most low- and middle-income countries (LMICs) is less than 5%. Heads of state of African Union countries pledged to set a target of at least 15% of the national budget being allocated to improvements in the health sector according to the Abuja Declaration of 2001 (3).
In the 2024 budget for Papua New Guinea, approximately 11.2% of the total budget was allocated to healthcare services. The total budget for 2024 is K27.377 billion, marking a significant increase from the previous year’s budget of K24.567 billion (4–6). This allocation demonstrates the government’s commitment to enhancing healthcare infrastructure and services as part of its broader strategy for national development and economic stability. But is this funding enough? Is the funding improving health services or just sustaining what we already have?
Funded by the National Government since 2022 with a total allocation of K105 million, the Papua New Guinea National Cancer Centre (PNGNCC) in the nations capital is set to become operational in 2025, coinciding with Papua New Guinea’s 50th anniversary of independence (7). This centre will rely heavily on pathology services.
Pathology is a key component in the management of patients with cancer. Pathology as a core discipline in the clinical decision-making process encompasses a broad range of specialties such as histology, cytology, hematology, microbiology, chemical pathology, immunology, and molecular pathology. All have a key role in managing cancer effectively. An accurate diagnosis is critical for the treatment of cancer and clearly has implications in the patient’s prognosis and follow-up care.
Critical Role of Pathology in Cancer Management in LMICs(3)
- Accurate pathology of cancer determines diagnosis, therapy, prognosis, progression, and response to therapy.
- Good-quality pathology is key to saving on limited resources within LMICs.
- Accurate and standardized pathology diagnosis is an integral component of quality cancer registries to inform policy in LMICs.
Clinicians in LMICs might not appreciate the role of pathology beyond “malignant” and “benign.” Key to a transformation of the health care workforce, specifically as related to cancer, is better education about the role and repertoire of pathology in the diagnosis and treatment of cancer (3).
In low- and middle-income countries (LMICs), surgical care can be limited by access to pathology services. In Uganda, the pathologist-to-population ratio is less than 1 to 1 million people and fewer than one pathologist per 500,000 people in sub-Saharan Africa (SSA) compared with one pathologist per 15,000 to 20,000 people in the United States and United Kingdom. In PNG this ratio is roughly 1 to 1.2 million. This is simply not practical and will not be sustainable for the near future.
So, what needs to be done to improve and increase PALM services in LMICs such as PNG?
- The obvious solution is to train more pathologists. This can only be done by increasing the number of doctors graduating from our medical institutions. With the establishment of the PNG college of pathologists this year, this is a step in the right direction. This will take several years as training a specialist doctor in PNG takes roughly thirteen years. In the time it takes to train one pathologist the population will increase by 2 million (22%).
- Employing pathologists from abroad to boost our services. Might be an expensive exercise but the cost to manage cancer is far greater than treating it early. The balance of overstretched resources is tilted toward treatment-intense efforts rather than investing in providing an accurate diagnosis. The economic savings from accurate diagnosis would be sizable and worth the initial expense (3).
- Establishing partnerships with the private health sector to assist in skills, knowledge and expertise as well as lower costs to overcome the challenges faced with scarce resources in public laboratories.
- Training non-pathology medical and paramedical staff to perform simple diagnostic techniques such as fine-needle aspiration to help ease the work load on pathologists.
- With the increasing availability of video conference platforms and network connections, telepathology is an emerging field that can be used by surgeons in LMICs to improve access to pathology services, confirming histological diagnosis of malignancies to ensure appropriate treatment.(8) Solutions such as telepathology need to be used to provide service to those who cannot afford it.
References
1. Wilson ML, Fleming KA, Kuti MA, Looi LM, Lago N, Ru K. Access to pathology and laboratory medicine services: a crucial gap. The Lancet. 2018 May 12;391(10133):1927–38.
2. New report on global cancer burden in 2022 by world region and human development level [Internet]. [cited 2024 Aug 15]. Available from: https://www.iarc.who.int/news-events/new-report-on-global-cancer-burden-in-2022-by-world-region-and-human-development-level
3. Sayed S, Lukande R, Fleming KA. Providing Pathology Support in Low-Income Countries. J Glob Oncol. 2015 Sep 23;1(1):3–6.
4. PwC’s-2024-Budget-Commentary.pdf [Internet]. [cited 2024 Aug 15]. Available from: https://www.pwc.com/pg/en/publications/National_Budget_Commentary/2024-budget-commentary/PwC%27s-2024-Budget-Commentary.pdf
5. 2024 Annual Budget [Internet]. Department of Treasury – Papua New Guinea. [cited 2024 Aug 15]. Available from: https://www.treasury.gov.pg/budget/annual-budgets/2024-budget/
6. PNG BA. Business Advantage PNG. 2023 [cited 2024 Aug 15]. Papua New Guinea’s 2024 National Budget: what’s in it for business? Available from: https://www.businessadvantagepng.com/papua-new-guineas-2024-national-budget-whats-in-it-for-business/
7. Papua New Guinea establishes National Cancer Centre – PNG National Information Centre [Internet]. 2024 [cited 2024 Aug 15]. Available from: https://info.gov.pg/papua-new-guinea-establishes-national-cancer-centre/
8. Kothari K, Damoi JO, Zeizafoun N, Asiimwe P, Glerum K, Bakaleke M, et al. Increasing access to pathology services in low- and middle-income countries through innovative use of telepathology. Surg Endosc. 2023 Sep 1;37(9):7206–11.
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