Elsevier

The Lancet Oncology

Volume 14, Issue 4, April 2013, Pages e152-e157
The Lancet Oncology

Series
Improvement of pathology in sub-Saharan Africa

https://doi.org/10.1016/S1470-2045(12)70598-3Get rights and content

Summary

In the coming decades, cancer will be a major clinical and public health issue in sub-Saharan Africa. However, clinical and public health infrastructure and services in many countries are not positioned to deal with the growing cancer burden. Pathology is a core service required to serve many needs related to cancer in sub-Saharan Africa. Cancer diagnosis, treatment, and research all depend on adequate pathology. Pathology is also necessary for cancer registration, which is needed to accurately estimate cancer incidence and mortality. Cancer registry data directly guide policy-makers' decisions for cancer control and the allocation of clinical and public health services. Despite the centrality of pathology in many components of cancer care and control, countries in sub-Saharan Africa have at best a tenth of the pathology coverage of that in high-income countries. Equipment, processes, and services are lacking, and there is a need for quality assurance for the definition and implementation of high-quality, accurate diagnosis. Training and advocacy for pathology are also needed. We propose approaches to improve the status of pathology in sub-Saharan Africa to address the needs of patients with cancer and other diseases.

Introduction

Like other specialties, pathology has historically been faced with extreme shortages of trained personnel and infrastructure in sub-Saharan Africa. However, pathology services have not always been universally poor across the whole region—good services have existed, especially in tertiary care and academic medical centres. Many countries in the region have flagship academic medical centres that compare favourably with similar centres in high-income countries. The existence of strong pathology services in sub-Saharan Africa has contributed to major scientific and clinical advances. For example, Africa-based investigators had a central role in researching the pathogenesis of Burkitt's lymphoma, a cancer first described by Denis Burkitt, a British surgeon at the Mulago Hospital of Makerere University in Kampala, Uganda.1, 2 The Raji lymphoblastoid (Burkitt's lymphoma) cell line was established from the jaw tumour of an 11-year-old boy from Ibadan, Nigeria, by B O Osunkoya of the Department of Pathology at the University of Ibadan.3 This cell line has been used worldwide for many years and has been pivotal in the elucidation of the role of Epstein-Barr virus in carcinogenesis and in lymphoma research.

Why, then, does the state of pathology services in sub-Saharan Africa seem to be worse nowadays than it was 50 years ago? The decline of academic excellence began amid political changes that started in the 1980s in many African countries. The subsequent under-resourcing of the health service sector generally, and research particularly, is still a problem now. In many parts of the region, particularly in small cities and rural areas, pathology is widely perceived to be limited to mortuary practice, autopsies, and forensic pathology. In many ways, this perception is similar to how pathology was perceived in high-income countries before the 1950s. Moreover, the scarcity of education about and marketing of pathology services perpetuates outdated perceptions of pathology in the region. These services are often perceived to be dissimilar to other medical services, since pathology practice is led by technicians or government laboratory supervisors rather than by clinicians in many areas. This situation perpetuates the belief that pathology is not important clinically, and directly or indirectly minimises the needs for professional standards and quality-assured practice. Thus, comprehensive strategies to change perceptions and policies, both in governments and in institutions, are needed to correct these misconceptions, improve recruitment and retention of pathologists, and increase demand for pathology services.

Section snippets

Pathology and cancer control

Pathology is central to the provision of clinical and public health services for cancer in sub-Saharan Africa.3 Inadequate pathology services can lead to a cycle of ineffective health-care knowledge and practice (figure 1). In clinics and hospitals, inadequate pathology capacity can result in a gap in the ability of clinicians to treat patients. In particular, patients with suspected malignant disease who do not receive an adequate pathological diagnosis could have a benign lesion and yet

Pathology infrastructure

Pathology capacity and infrastructure are largely inadequate in most parts of sub-Saharan Africa. In mid-2012, we did an informal survey to identify the number of pathologists who were active in every country in the region, including all pathology subspecialties. The data clearly show that the number of pathologists is not sufficient to provide adequate and effective clinical services (figure 2). With the exceptions of Botswana and South Africa, all countries in the region have fewer than one

Pathology needs

Several facts are readily apparent with respect to pathology infrastructure in sub-Saharan Africa. First, in places where no pathologists are working, adequate infrastructure will not exist. Second, when funding for pathology services is inadequate, funding for pathology infrastructure will also be inadequate. Third, the unique nature of pathology infrastructure means that many necessary items are not part of most procurement programmes for hospitals and clinics. Maintenance is problematic;

Successful models

The shortage of pathology services could be partly addressed by the development of a three-tiered system of provision of laboratory services. In this system, the pathology services available vary with the care setting. In primary care, point-of-care testing is often very restricted in scope. The scope increases slightly in general hospital care, where a broader range of laboratory tests are available, and is much better in tertiary care and academic medical centres, where specialist pathology

Recommendations for best practice

To improve pathology services in sub-Saharan Africa, we need to start with an understanding of existing capacity and infrastructure. Skilled professionals and infrastructure can still be seen all over the continent, and could be incorporated into efforts to build new pathology services. Because little data exist about the state of pathology practices in the region, we propose a survey approach to obtain the relevant data. Accurate information is needed about the number of pathologists currently

Conclusions

Adequate pathology can benefit cancer control in sub-Saharan Africa in several ways: improving clinical services; informing cancer control efforts; aiding the development and implementation of national cancer control plans; supporting cancer registration; and supporting various types of research, including epidemiology, basic science, clinical trials, and translational research. Education of relevant governmental agency staff, policy makers, and the clinical community about the central role and

Search strategy and selection criteria

We searched PubMed using the terms “pathology” and “Africa”, including all dates in the PubMed database. We did not restrict our results by language of publication. Only primary research articles, reviews, and editorials that focused on pathology activities, resources, and infrastructure related to cancer in Africa were selected. We supplemented these records with work of which we were already aware that did not appear in the search results. We also surveyed active pathologists in Africa

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