Dr. Kasturi Lal
India is accountable to approximately 30 percent of the world’s gynaecologic cancer patients. Everyday two hundred women die of cancer of reproductive organs. Cancer of breast is number one cancer which even occurs in younger age group.In the last 120 years beginning with 1898 surgery and radiotherapy have been tried for treatment with variable results. In India a culture of blame had promoted the generation of self preservational defensive strategies, not gynaecologic cancer patient care solutions because no one took the lead in visibly seeking system solution as opposed to individual blame. Understandably, the general surgeons who were not equipped with the physiology of reproductive organs placed a major emphasis on the operative surgical aspects to develop their eminent career. Radiation oncologists Took care of patients according to availability of resources and their whims. Gynaecologic oncology services were not available even in a few leading cancer hospitals. It has resulted in gynaecologic malignances being handled by general surgeons than the gynaecologiconco surgeons. The general hospital lacked the allied facilities like radiotherapy and chemotherapy. The sources of services were not sedulous in pursuit and diligent in the application of a care which might have been benefited from a multidisciplinary team approach stretching beyond surgical specialty.
Many gynaecologists now working in unorganized or disorganized cancer departments in peripheral medical institutions have become oncologists by virtue of experience and judgement. The courses for sub specialization where surgical chemotherapeutic and radiotherapeutic skills necessary for comprehensive management of cancer do not exist. The system has not been able to bring many of the finest gynaecologic oncologists and most powerful medical resources together to improve both oncologic profession and welfare of patients. Patient safety which should now be more diffused within team concept dictates that everyone dealing with patients has equal skills for his or her responsibilities and motivations to ensure patient safety.
It is a strange paradox that at a time when knowledge and technology have increased at a staggering rate the skills of the doctors have not rewarded them with the same respect which they used to command. The availability of high quality and cost-effectivemultidisciplinarycare is adversely affected by a mismatch in supply and demand. The non-availability of specialists has restricted the hospitals to care of these patients. While, 25 % of patients with manifested disease receive treatment in a few cancer care centers, 75 % of patients are attended in a general hospital where trained manpower and necessary equipments are not available to treat the patients. Urban population gets better clinical and diagnostic facilities compare to rural population. It has challenged health care providers and centers relentlessly and underscores the need to enhance the organizational methods to improve therapeutic and preventive safety of patients. Overcrowding is another challenge forcing hospitals to keep patients waiting for weeks to months until a hospital bed becomes available. Increasing patient volume in the absence of resources has challenged the timely delivery of hospital-based cancer care nationally. The policy makers have not taken the advantage of adversity for carving opportunities for change. They have not mobilized their resources to try new things to maintain their vigorous requirements for accreditations of institutions that have potentials to train prospective gynaecologic oncologists. These institutions can serve as the referral centers where comprehensive care should be provided. The gynaecologic oncology pipeline has to be filled with the best and the brightest oncologist and the training of gynaecologic oncologists to follow them. The professional organization working in the field of gynaecologic oncology should take a lead in getting super specialty courses like MCH and DNB recognized by MCI and national board respectively. Though, fellowship courses in the specialty have started in some centers MCH and DNB courses are still confined to a few cancer centers. Creation of a gynaecologiconcology wing in the department of gynaecology in all medical institutions can provide a solution to solve the problem of manpower deficit.
One should realize that advanced technology is one tool to improve survival but it will not necessarily match with the place of prevention in cancer control. What cancer is? How it is produced? And how it can be prevented, are questions that need to be addressed. Eighty percent of gynaecologic cancer cases come in late stages because we have not addressed the issue of cancer awareness and its prevention adequately. The latestage of disease leads to high death rate which is unavoidable. Geriatric oncology is a forgotten fact. These patients constitute 20% of OPD attendance.
Because of easy accessibility and visibility of cervix, the cancer of cervix has shown decline by 80% in developed countries. The cytological studies and HPV tests have markedly identified premalignant or early malignant lesions. In developing countries like India specific, religious, geographical and financial problems put preventive oncology to less importance in daily life. Cancer cervix has become preventable disease because of HPV vaccine and genetic engineering procedure.
We have to create public perception that cancer generally occurs in all socio-economic groups. The disease can be prevented and that economic and social return on the investment made in prevention is high. By education of community and by developing skilled human resources the incidents of cancer can be markedly reduce and we can even detect cases in early stage when complete cure is possible. We have to develop a strategy to create awareness among women to seek help in procuring early intervention for prevention of malignances and successful treatment of lesions detected in early stages. We can expect that by 2030 we can achieve 100% cure rate of earlymalignances. Prevention can be achieved by screening which aim to educate population about risk factors in a community and to improve voluntary acceptance. The prevention of occurrence of cancer can thus be achieved by improving the access of these patients to high quality and timely hospital-based cancer care.
It is a hard fact that we go through deepest agony when the patients in terminal stages seek help and we are left with nothing in our capacity to save such patients from agonizing end. Unfortunately, for want of investment in cancer hospitals where the returns are poor, the patients are poor and the disease is protracted we do not have palliation centers in India.
The next generation of gynaecological cancer care system is likely to be considerably different from the one we have now. Future oncologists must be adequately prepared to propose new solutions to the challenges of inadequate preventive and therapeutic coverage for a growing gynaecological cancer care population.
(The author is Director Lajwanti
Hospital For Women)
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