More than 18 months ago, the American Society for Clinical Pathology (ASCP) set out to design a humanitarian program of major proportion. At the time, ASCP CEO E. Blair Holladay, PhD, SCT(ASCP)CM, called it “herculean.” The endeavor was to bring rapid cancer diagnostics to severely resource-limited countries in sub-Saharan Africa and the Caribbean nation of Haiti.
Approximately 650,000 people in Africa develop cancer annually, and about 510,000 cancer deaths occur annually due to limited treatment. More than one-third of the cancer deaths in Africa are from cancers that are easily preventable and/or treatable, if detected early. Histotechnology laboratories are a major gap in many African countries, which prevents many people from getting the diagnosis and treatment they need.
Since it was announced in October 2015 by the administration of former President Obama, Partners for Cancer Diagnosis and Treatment in Africa has achieved several major milestones. Last fall, it introduced advance histotechnology and telepathology to the Butaro District Hospital, in Butaro, Rwanda. The telepathology connection is enhanced by the simultaneous installation of a fully automated tissue processing system, which has transformed the capacity of the laboratory toward 1,000 blocks per day and allows for same day turnaround on biopsies. The Partners Initiative has also entered into an agreement with Rwanda’s Minister of Health to move forward with augmenting a second laboratory site and providing cancer diagnosis and treatment education to clinicians in 47 different hospitals.
Partnership with Mutombo
In December 2016, ASCP announced a partnership with NBA Hall of Famer and philanthropist Dikembe Mutombo to provide patients in his homeland, the Democratic Republic of Congo (DRC), access to rapid cancer diagnostics and appropriate care and treatment. Plans call for building a new histopathology lab, which will be used by Biamba Marie Mutombo Hospital in Kinshasa, DRC, and will add to the existing histopathology laboratory capacity in the DRC.
In March 2017, ASCP leaders visited Kenya, Uganda, Tanzania, Rwanda, and the DRC to meet with the stakeholders and conduct assessments to determine country readiness to open more telepathology laboratories. As a result:
- ASCP has completed planning for telepathology services at the Rwanda Military Hospital (RMH) to serve RMH, Kigali Central Teaching Hospital, and King Faisel Hospital in Rwanda. Deployment began in May 2017.
- The Uganda Cancer Institute (UCI) is planning implementation for telepathology with ASCP in Kampala to serve UCI, Mulago Hospital, and Makere University in Uganda, with deployment scheduled for August 2017.
- The Kenyan National Public Health Laboratories is installing a national anatomic pathology reference lab in Nairobi, which will serve all patients in Kenya through referral networks and hubs and which ASCP plans to support with telepathology.
- The Kilimanjaro Christian Medical Center is planning implementation for telepathology with ASCP in Moshi, Tanzania, to serve the 15 million-plus catchment area of patients for diagnostics of cancer.
The rapid pace at which the Partners Initiative has been moving forward would not have been possible without three key elements: partnerships, country assessments, and funding. The process itself began by connecting with partner countries to understand the perceived needs, assessing the situation on the ground to determine the actual needs and what is most feasible and plausible within that location, and then creating an implementation plan.
ASCP hopes that observers do not look at the second element of the Initiative, the country assessment, and consider it to be patronizing—affluent folks in the United States responding in a condescending way to people in “underprivileged” countries. That’s not what ASCP and its partners are doing, and to say otherwise would be a bad rap. The fact is, it is common for people of any nation who ask for help in pathology not to—well, not to be pathologists. Therefore, some mutual discussion and education about pathology is often required to get a team all on the same page. The real challenge then comes in the implementation that follows. This is where partners come in—so challenges can be met and unforeseen issues can be dealt with.
It’s important to keep in mind that ASCP can’t do it alone, and it’s critical to have buy-in from the country partners, including the Minister of Health, the pathologists, the hospitals/health centers, and the financial backers for the effort. Each country is unique regarding who these partners are.
The Partners for Cancer Diagnostics and Treatment in Africa Initiative includes a medical education steering committee as well as partners who have education as their mission. Part of the process includes an assessment of a country’s current and future needs. Initiative leaders work with in-country schools and partners to insure that there is a plan in motion to create the sustained workforce needed to do the work going forward.
Meeting financial challenges
Then there is the issue of funding, the third element in the Initiative. Whether through donations of equipment or money, there must be fiscal support for a project because pathology is expensive in terms of personnel, reagents, equipment, and time. The Initiative has reached out to establish critical industry partnerships, as well as with leaders in several countries in sub-Saharan Africa and in Haiti. Sakura Finetek provided histopathology instruments to the laboratory for preparing biopsies. Pfizer provided funding support. Global health expert Paul Farmer, MD, and his team from Partners in Health (PIH) make care and treatment available for patients post-diagnosis. Other prestigious partners include Roche Diagnostics, GE Healthcare, the National Cancer Institute, and the Union for International Cancer Control (UICC).
The Partners Initiative is also supported by more than 600 ASCP members who have volunteered their time to review slides and make diagnoses, via cloud technology. A team of ASCP volunteer pathologists in the U.S. will use the telepathology equipment to perform rapid diagnostics and review patient specimens for therapy in conjunction with the one pathologist stationed in Butaro. The system has multiple uses, including primary diagnostics (when pathologist is absent), secondary consultation, clinical correlation conference, and teaching Rwandan pathology residents.
Recruiting new partners
All the solutions for cancer in Africa exist. We just have to get them to Africa in an efficient and timely manner to start seeing impact. We need everything for standard pathology including grossing hoods, tissue processors, embedding stations, microtomes, slide stainers, and coverslippers. We need microscopes. We need storage equipment for blocks and slides. We need computers and software to manage the laboratory. We need reporting systems to get the diagnoses back to the patients and care givers.
We have identified partners who are helping or can help us with these items, but no single partner can provide sufficient numbers of any one item to meet all of the needs. We need clinicians in-country to be trained to identify cancer; surgeons to be able to biopsy/remove lesions; oncologists to be able to act on our diagnoses; and a cadre of ancillary health workers to support and care for our patients. Again, we have identified partners, but do not have enough to cover what we could do. So, our major challenge is to either recruit duplicate partners to expand what we can do or publish what we are doing in a “how to” manner so that others can create and execute similar approaches. This is not a competition and not a process to seek glory. This is providing care for people who need it—a moral obligation in a time when cancer does not have to be a death sentence.
Dan A. Milner, Jr., MD, MSc(Epi), FASCP, is chief medical officer of the American Society for Clinical Pathology (ASCP) and oversees the Society’s global healthcare initiatives. He came to ASCP in September 2016 from Harvard Medical School, Boston, where he held the positions of Associate Professor of Pathology and Associate Professor in the Department of Immunology and Infectious Disease at the Harvard T. H. Chan School of Public Health.