Notes From The Head And Neck Cancer Wards II

Originally published The Bangladesh Observer; Dhaka, Bangladesh

ONCE outside the city, based on reports from colleagues, there are possibly no qualified Head and Neck cancer surgeons at any of the regional or provincial health care facilities. The vast majority of patients who develop their head and neck cancer outside the, capital are initially seen by doctors not properly trained in detecting, diagnosing and treating their disease. These patients are exposed to long delays before finally being referred to Dhaka where hopefully suitable treatment can be instituted. The protracted interval can have disastrous consequences for the patient and accounts at least in part for the remarkably advanced and frequently incurable stages of disease routinely seen in Dhaka medical centers. If even one qualified Head and Neck specialist, skilled in all aspect of'' the management of head and neck cancer, including surgery, were pre-sent in each of the regional medical centers in Bangladesh, many more patients could be treated sooner, more effectively and with a better chance for cure. It would also help to reduce the patient load in Dhaka Hospitals as well.

The key is to train more young doctors to become ENT-Head' and neck surgeons, versed in all aspects of managing head and neck cancer with particular emphasis on mastering the difficult surgical techniques and re-constructive procedures involved in treating this disease. One qualified Head and Neck cancer specialist. if actively engaged in "hands-on" teaching and demonstrating of head and neck cancer and reconstructive surgery at the major medical centers in Dhaka. can suitably train as many as 15-20 junior doctors to become ENT-Head and Neck surgeons in a one year period. These additional local Head and Neck specialists can then go to regional centers outside Dhaka and begin the process of training young doctors there.

Training the local surgeons to be-come Head, and Neck specialists in Bangladesh is far more cost-effective than sending young doctors abroad for training. These doctors rarely get "hands-on" experience abroad do not see as many cases and usually opt to stay in their "adopted" country. Also the cost of sending 15-20 young doctors abroad for training in this field, even assuming the unlikelihood that they would all receive good training and would return to Bangladesh, is prohibitive.

Costs

It should be noted that head and neck cancer surgery is not an exorbitantly expensive form of intervention. Relatively low-cost items such as suture material, intravenous fluid. blood replacement and gauze pads are usually all that is required during surgery. Post operatively, the patients usually spend the first night in the intensive care unit and are then transferred to the wards for the same routine nursing care given other patients. They are fed a normal diet through a nasogastric tube. There is rarely, if ever, a need for expensive parenteral hyperalimentation, sophisticated monitoring. unusual nursing care of costly or prolonged medical, therapies (i.e. compared with, for example, kidney dialysis, or immunosuppressive therapy for transplant surgery). If there are no complications. the patients can leave the hospital within 2 weeks of surgery. Periodic follow-up visits are all that are required after surgery unless post-operative radiation therapy is given. Radiation treatment, in off itself, is' not a major expense either. The point' is. development and upgrading head and neck cancer treatment in Bangladesh will not add significant additional costs to a very limited health care budget; however, there will be significant additional benefits.

Other Measures: The cereation of Tumor Boards at each of the major teaching institutions in Dhaka caring for head and neck cancer patients would be useful. All of the various disciplines that are in anyway involved in caring for these patients can meet once a week or month, as required to discuss difficult cases. The formation of a Head and Neck cancer Unit at the Cancer Institute as has been suggested by others would be beneficial. A National Tumor Registry for accurate statistics. follow-up and research is indispensable in Bangladesh is to get a complete picture of the nature and extent of this problem and improve on current treatment. This will also allow for comparison of statistics and results of treatment with other nations and within Bangladesh itself. Inviting Head and Neck Cancer specialists from abroad for lectures and international conferences in Dhaka would be a good opportunity for, exchanging ideas and keeping abreast of evolving concepts and technologies taking place elsewhere.

I have mentioned in a previous article the possible benefit of "rural camps" for head and neck cancer. Seminars for primary care physicians, possibly via the "rural camps" so that all "frontline" doctors can be taught to perform a thorough ENT exam and be familiar with early signs and symptoms of head and neck cancer would be very useful. Hopefully they can be taught to avoid premature biopsies of neck masses before referring the patient to a head and neck specialist. Information on who and where to refer such patients can be dispensed. As mentioned, further development and improvement of already existing regional and provincial health care centres with an ENT-Head and Neck specialist at each region centre will upgrade treatment for head and neck cancer patients.

Educating the public about some of the pre-disposing factors to developing head and neck cancer (i.e. tobacco and betel nut use) and how to recognize the early signs and symptoms is very important for prevention and' early detection. The causes of head and neck cancer are not completely understood although there certainly appears to Be a strong relationship with tobacco and betel nut use. This however is not a satisfactory explanation for the numerous patients I have already encountered in Dhaka that either have no history of tobacco or betel nut use or are too young (i.e. 20's or early 30's) for this to be the only factor. Investigating other possible etiologies such as diet.. oral hygiene. malnutrition and pollution would perhaps shed light. Although not a top priority at this time. in the future cancer research may give insight into the varying etiologies of head and neck cancer in Bangladesh.

A strong 3-pronged attack then including prevention. early detection and upgrading treatment capabilities are worthy commitments very much needed from the government. the teaching centers and individual surgeons and physicians if this problem is to be alleviated.

It is well known in Dhaka that the more well-to-do Bangladeshis. when confronted with a serious health problem, are likely to go outside the country, possibly to Bangkok or London for their treatment. As head and; neck cancer is a matter of life and death it is not unreasonable for those who can afford it to go where they believe they can receive the best possible care. If in the future, it is seen that the people who can go elsewhere for treatment. choose in-stead to stay here. that will reflect a very significant change in the attitudes of people towards their own health care system in this country. I feel it is possible to upgrade the level of head and neck cancer care here so that those Bangladeshi who have the option of going outside the country will indeed make the choice to receive their treatment in Bangladesh Perhaps in the future, the wealthy and important from other nations may opt to come to Dhaka for their treatment rather than the other way around. it is a goal worth striving for, as it will indicate the vast improvement that will have taken place here and the possibility for all patients. poor and rich alike. unfortunate enough to be stricken with this terrible disease, to be treated effectively in Bangladesh.