The familiar story of an African patient

A real-life case study, presented by the University of Cape Town’s (UCT) Associate Professor Tasleem Ras, spotlight some of the challenges cancer patients face when accessing the public health system in South Africa, and the enormous strain on healthcare workers on the frontline.

His presentation formed part of the third African Awareness of Cancer and Early Diagnosis (AWACAN-ED) Southern Africa School for Cancer Research event, currently under way at the UCT Graduate School of Business (UCT GSB). AWACAN-ED is a global health research group funded by the National Institute for Health and Care Research. It focuses on advancing early diagnosis of cancer in Southern Africa. The team comprises researchers from UCT, the University of Zimbabwe and Queen Mary University of London in the United Kingdom.

Associate Professor Ras used his hour-long presentation to unpack why patients with cancer fall by the wayside and suggested tangible ways on how to change their experience (and hopefully the outcome) and that of their families.

The African patient’s story

The case study that grounded his interactive morning session explored an unfortunate story of a 50-something-year-old woman. The patient hitchhiked to a local clinic in Hopefield on the West Coast in need of medical assistance because she had a non-healing lesion on her left breast, which she thought was an insect bite.  

During a physical examination, Ras said, a healthcare worker (who had been treating the patient’s list of non-communicable diseases for years) found a fungating wound attached to a hard mass on the left breast. Suspecting a cancer diagnosis, she wasted no time, contacted the district hospital and secured an appointment for two weeks later. Sadly, the patient was diagnosed with incurable stage four cancer, and she died in hospice care a few weeks later. She died alone, Ras said, because the nearest hospice facility was roughly 37 km from her home and her family could not afford the cost of transport to visit.

“This is the African story.”

“This is the African story – late presentation [of disease], lack of capacity at the clinic, [and] the referral process [between healthcare facilities] is a bit jumbled. And [when the patient eventually reached a district hospital for care] that was the last time her family saw her [alive],” Ras said.  “In many ways there are certain problems here.”

The pitfalls of care

Ras divided the pitfalls for the Hopefield patient’s care into three factor categories and unpacked each of them:

• Patient factors: the patient was unaware of the lesion’s cancer risk and therefore self-assessed it incorrectly from the get-go; she had no knowledge on how to perform a self-breast examination; and when she eventually visited a healthcare facility, it was too late. The latter is often because of certain cultural beliefs and social norms.
• Healthcare worker factors: nursing practitioners provide generalist care at primary healthcare facilities; due to the high volume of patients who visit clinics, there’s little scope for individual attention; they also receive inadequate training in early cancer detection and diagnosis.
• Health system factors: a lack of cancer education exists in under-resourced communities; there’s no access to screening programmes; the referral process to an appropriate level of care facility is often delayed.

“Our systems are very curative focused. Yes, education is one of the ways to getting our clinicians to be thinking more preventative. And you can train students to think in a particular way, but when they come and work in a health system which doesn’t operate in that way, within two weeks they will be doing whatever everyone else is doing. So, we need to ensure that the curative mindset is continued into [healthcare] services,” Ras said.

Adopt a comprehensive approach to cancer care

He suggested adopting a comprehensive approach to caring for patients who are newly diagnosed with cancer, for those who are in remission, as well as those with metastasis.

This approach to care, he said, should be interdisciplinary and include different role players (treating clinicians, nursing practitioners, social workers) who contribute to patient care in healthcare facilities at different stages of their journey. The approach must be carried out in a dynamic and coordinated manner – to ensure the patient and the family understand the diagnosis and what comes next in the process. Someone should also be on-hand to provide psychosocial support and help the patient and the family navigate the road ahead.

“The system and the humanistic approach to how we practice must be person and relationship centred.”

“Comprehensive cancer care [should] expand all dimensions of care [and should] not just [be] focused on one [form]. If we are thinking about cancer care in general, we are talking about comprehensive care, which spans all dimensions across multiple levels. And it needs to be dynamic [because] the patient’s condition changes. So, the system needs to be nimble enough to manage someone who is in survivorship and now has a recurrence [of cancer] that has spread. There needs to be some level of nimbleness in the system that responds to the patient’s emerging needs,” he said.

“The system and the humanistic approach to how we practice must be person and relationship centred. [This patient] could’ve been your mother and that personal approach to our clinical practice, to our research, to our teaching, bring home how important this type of work is to our community.”