Establishing of cancer units in low or middle income african countries: angolan experience - a preliminary report

Introduction The number of cancer cases and related deaths worldwide is expected to double over the next 20-30 years. African countries will be the most affected by the burden of cancer. The improving economic situation of Angola creates conditions for an increase in life expectancy which by itself is associated with an increased risk of oncological diseases. Because cancer therapy requires a multidisciplinary approach, trained health professionals, satisfactory infrastructure and appropriate facilities, the availability of effective cancer therapy is a difficult task that requires support. The aim of this article is to share our experience achieved in the establishment of cancer units in Angola and to validate our checklist for this action. Methods The survey method was a questionnaire addressed to Angolan cancer units, in order to evaluate the usefulness and feasibility of a checklist developed by the authors - The Cancer Units Assessment Checklist for low or middle income African countries - which was used previously in the establishment of those units. Afterwards, the crucial steps taken for the establishing of the main sites of each cancer unit considering, facilities, resources and professionals, were also recorded. Results All cancer units reported that the checklist was a useful tool in the development of the cancer program for the improvement of the unit or the establishing of cancer unit sites. This instrument helped identifying resources, defining the best practice and identifying barriers. Local experts, who know the best practices in oncology and who are recognized by the local heads, are also important and they proved to be the major facilitators. Conclusion The fight against cancer has just started in Angola. The training, education, advocacy and legislation are ongoing. According to our results, the assessment checklist for the establishment of cancer units is a useful instrument.


Introduction
In the 2014 World Cancer Day the WHO African Regional Director said: -Every year, nearly 8 million people die of cancer but many of these deaths can be avoided with greater public awareness, increased government support and funding for prevention, detection and treatment. Cancer is not a disease affecting the affluent and elderly people, and developed countries alone. It is a global epidemic, affecting all ages, in low, middle and high income countries. The number of cancer cases and related deaths worldwide is expected to double over the next 20-30 years. African countries will be the most affected by the burden of cancer, but are of all developing countries the least able to cope with the challenges cancer presents‖. In this sense it is very important to build the capacities for cancer control [1].
Cancer control is understood as the main public health action designed to reduce incidence and mortality as well as to improve the quality of life of patients. It also includes the systematic implementation of evidence-based strategies for: prevention; early detection, diagnosis, treatment and palliative care.
In the fifty-seventh session of WHO Regional Committee for Africa held in Brazzaville, at 27-31 August 2007 the attendees underlined that most countries in Africa do not have the satisfactory infrastructure and facilities for cancer treatment, which includes surgery, chemotherapy and radiotherapy. Because cancer therapy requires a multidisciplinary approach, trained health professionals, satisfactory infrastructure and good facilities, the availability of effective cancer therapy is often an unrealistic objective [2].
However, in the last seven years, according to this point of view, several African countries have developed serious approaches in creating resources to treat cancer patients. Angola is one of these countries [3].
Since 2010, using 2008 Angola Globocan data, the National Health Plan and international published advocacy, the health authorities started to develop a strategy for cancer control. Meanwhile our research team identified existing resources for cancer diagnosis and treatment and described the needs, in order to help the development of cancer units in Angola [4]. Based on these data, we drew up a checklist form, The Cancer Units Assessment Checklist for low or middle income African countries, which we will address in this article.
Angola pointed out their Health Plan, entitled PNDS (Plano Nacional de Desenvolvimento Sanitário), to outline a more specific set of priorities over a medium-term. The PNDS adopted new incentives for health sector professionals; implemented new technologies, acquired adequate and sustainable finance and a modern and efficient management system. These priorities will be achieved through 47 ‗projects' that address the technical and administrative challenges affecting the Angolan health sector today. The 14 th project is dedicated to cancer control and addresses the establishing of cancer units [5].
A cancer unit is a health facility that is capable of managing patients within a defined range of cancer, according to contemporary We evaluated and recorded the activities undertaken to improve conditions at the NOC and to establish GC and SEC cancer units, according to our checklist. Documents were required to support the given answer on each specific question to the participating units.
According to the answers received, an action plan should be developed taking into account what actions or changes will occur, who will carry out these changes, when they will take place and what resources are needed.
In each participating hospital , the most prevalent cancers, the crucial steps developed for the establishing of cancer unit's sites, facilities, professionals and resources, were recorded.

Results
Two years after the start of this study the profile of the units developed is as follows:

National Oncology Centre
Each year about a thousand new patients were admitted (Table 1), assessed within a multidisciplinary approach and it was possible to start treating patients with radiotherapy (Figure 1 Table 1). During the period of construction and organization of chemotherapy preparation and infusion area, which will start working soon, GC had the support of NOC in accordance with a cooperation protocol previously established. A home care program for patients in palliative setting was developed and is fully implemented.

Sagrada Esperança Clinic
SEC decided recently to build a cancer unit, given the increasing number of cancer patients seeking treatment per year ( Table 1).
The first activity was to create a hospital-based cancer registry and Therefore, we consider that the utilization of this systematized toolthe assessment checklist -associated consultants experience and the partnership with certificated cancer centers recommendations/guidelines must be taken into account. In this sense, there are models of collaborative partnerships between a combination of low, middle and upper-income countries' cancer centers. These models could provide useful pointers for improving cancer prevention and control capacity, in low resource settings [13]. The assessment checklist will be filled in by the head of oncologic team with the support of others services involved as well as by the quality control department when available, or by the external advisers.

Accuracy of the diagnostic services
An accurate diagnosis is the first step for an appropriate treatment plan, therefore, in this survey, we evaluated the cancer diagnostic services of NOC, GC and SEC. A critical lack of image-guided needle sampling of suspicious lesions and advanced pathology procedures in order to optimize systemic management, still remains as also mentioned by El Saghir NS et al. [14]. Additionally magnetic resonance imaging and diffusion analysis , when available, are important tools for the evaluation of cancer staging and treatment response, especially in middle and low income nations as Angola.

Surgical therapy
The ability to perform oncologic surgery is the mainstay of locoregional treatment. Surgical training in LMICs is fundamental, since surgeons have less experience to perform these procedures.
Increasing access to quality cancer surgery is crucial [15]. According to our survey it is essential to develop training programs in surgical oncology to harmonize the knowledge and improve the quality of cancer surgery.

Radiation oncology
The availability of radiation therapy has a major impact on local tumor control for early and locally advanced disease. Effectiveness and safe radiation therapy can also improve overall survival rates.
GS cancer unit has one of the most advanced radiotherapy cancer

Conclusion
The fight against cancer has just started in Angola. The Training, education, and legislation are ongoing. According to our results the assessment checklist for the establishing of cancer units is a useful tool in African LMIC. The evaluation of the progress of these units will only be conducted two years after their full operation.