Print Edition - 2015-02-21  |  On Saturday

A most difficult disease

  • Cancer patients in Nepal suffer from both under-treatment and over-treatment of the disease
- Manish Gautam
A most difficult disease

Feb 20, 2015-

On a March afternoon in 2012, a doctor at Norvic Hospital suspected that Jaya Rani Shah might have cancer. A little lump was protruding just by the side of her left breast and getting bigger by the day. Rigorous tests were conducted for a month, and they confirmed that the lump was indeed cancerous and might have metastasised, and the doctors concluded that Jaya Rani had lung cancer.

Jaya Rani lived in Jhamsikhel, so she decided to see an oncologist at Sarwanga Hospital, Lalitpur. At the hospital, her chemotherapy for the lung cancer began on April 18, 2012. For the next eight months, Jaya Rani underwent intense chemotherapy. Her son, Prajesh Bikram Shah, a former army official, however, felt that his ailing mother was not responding to the treatment because the lump had decreased only minimally. He decided to consult another oncologist only to be told that his mother was probably getting the wrong treatment. “That doctor got a second opinion right away and claimed that the treatment must be wrong,” says Prajesh. “The treatment should have focused on the breasts instead of the lungs.”

Such incidences, where patients are either given the wrong treatment for cancer, and where patients are under-treated or over-treated, for diseases like prostate and breast cancer are not just confined to Nepal. They happen all the time around the world, according to experts. But in a country like Nepal, where diagnostic procedures and tools, as well as doctor-patient communication about treatment regimens, need to be vastly improved, cases such as Jaya Rani’s crop up all the time.

A report on the procedures done on Jaya Rani states that she was “initially treated with chemotherapy” for lung cancer, but that she was “later found to have” breast cancer.

Dismayed and confused, Jaya Rani flew to Rajiv Gandhi Cancer Institute, New Delhi. A PET-scan conducted at the hospital states, “metastatic carcinoma…from primary breast is suggested”—meaning the origin of the disease was the breast and not the lungs.

Dr Sudip Shrestha, who initially treated Shah with chemotherapy for primary origin in the lungs, however, claims otherwise. “The initial reports suggested squamous cell carcinoma, and in this case we were certain that its origin would be in the lungs. Some of the pathology and radiological reports also suggest that it was in the lungs,” says Dr Shrestha. “We gave her the best treatment.”

(All the documents related to the Jaya Rani case have been obtained by the Post. In our consultations with three renowned oncologists in the country, they said that the reports are confusing, but also that Dr Shrestha should have sought a second opinion if he was confused or if the treatment did not show any response.)

Dr Shrestha, however, says he provided whatever was within his means for his patient.

It’s not just tricky cases such as Jaya Rani’s that make cancer treatments difficult. Last Wednesday, Sushma Sharma of Chitwan was brought by her neighbours to the Thankot Hospice Centre. The irony here is that Chitwan houses the country’s biggest cancer hospital, and people like Sharma have not got any treatment for their disease. Doctors believe that Sharma is in the last stages of muscle cancer, or sarcoma. “The girl is just around 19 years old. And now she is at a hospice. There are lumps all over her body,” says Dr Bishnu Dutta Poudel, professor of Oncology at Bir Hospital.

Cases such as Jaya Rani’s and Sharma’s should be cause for concern. According to Globocan, there were 27,768 cancer cases in Nepal. Globocan states that the five most common cancers in Nepal are gynaecological, pulmonary, head and neck (lip and oral cavity, nasopharynx, other pharynx, larynx and thyroid) and various haematological malignancies. According to the National Cancer Registry Programme (NCRP), 7,212 patients present at seven major hospitals in the country with cancer in 2012; in 2000, the number of such patients stood at 3,251. And the number of cancer sufferers in the country may be higher because of the paucity of exact national data and poor reporting mechanism in hospitals. And that means there are even more chances for slip-ups in treating cancer patients.

Sometimes, the problem has to do with over-treatment. “There is little need to undergo radiological procedures or chemotherapy, let alone surgery, for people in the terminal stage of cancer,” says Dr Prakash Raj Neupane, Director of Bhaktapur Cancer Hospital. “But there are many patients who die the next day after chemotherapy or after radiation was administered. Instead of this over-care, terminally-ill patients need hospice care to manage their pain.”

The lack of a substantial number of oncologists in Nepal is also why there are instances of over and under-treatment of cancer, doctors say. The current patient-oncologist ratio means that there is only one oncologist for every 450 patients, meaning the doctors are overworked too, which can lead to lapses in treatment and diagnosis.

The problem with over-treatment, says Dr RP Baral, an oncologist at Bhaktapur Cancer Hospital, is exacerbated by the tendency of people to ask doctors to pull out  all the stops when caring for their loved ones. “If you don’t treat a patient soon enough, you become an incompetent doctor. So instead of counseling people, doctors often opt for overtreatment,” says Dr Baral.

There is no easy way out of the cancer predicament. There are only five hospitals in the country that specialise in cancer treatment, although some new ones are opening soon. The under-treatment of cancer has its roots in the paucity of oncologists in the country; misdiagnosis is mostly a result of the lack of medical equipment or both overwhelmed and underprepared doctors. And overtreatment can be caused by anxious patient parties pushing the doctors to do more than is required. “To tackle these problems, the government needs to create more opportunities for doctors to specialise in oncology. It also needs to find ways to train doctors to communicate with patients better. And it needs to teach the public at large about how cancer can be and should be treated,” says Dr Neupane.

Published: 21-02-2015 07:19

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