Navigating the challenges of neuro-oncology in Africa: addressing diagnostic and treatment barriers in the region: a correspondence

Abstract

The brain and spinal cord tumors constitute a significant global health burden1. The central nervous system (CNS) is affected by over 100 histologic subtypes of neoplasms, including both primary and metastatic tumors, with metastases being more prevalent2. The pediatric population is particularly affected by malignant tumors, with an age-adjusted incidence rate of ~3.55 per 100,000 individuals3. The incidence of brain and spinal cord tumors in Africa has been estimated to be 226.98 per 100,000 population from 1960 to 20174. There is a significant difference in the distribution of CNS tumors across Africa, with Nigeria having the highest number of cases, followed by Egypt, Uganda, Morocco, Kenya, Ghana, Sudan, Ivory Coast, and Namibia4. Commonly diagnosed tumors in the region include meningioma and astrocytoma, affecting mostly young adults. These tumors have significant public health implications, affecting individuals at the national, community, and familial levels. Despite the historical perception of brain tumors being relatively uncommon in Africa due to environmental and genetic factors, they have become a major cause of mortality and morbidity in the region, reflecting the increasing incidence of noncommunicable diseases in the area3. Access to comprehensive neuro-oncology care in Africa is limited due to a shortage of trained professionals such as neuro-oncologists, neurosurgeons, and radiologists, with a single neurosurgeon serving roughly 9 million people in East Africa and 1 neurosurgeon for every 2.4 million people in Nigeria5. This scarcity has contributed to a higher cancer mortality rate in the region. In addition, there is a lack of data and information on the status of neuro-oncology in Africa due to the absence of infrastructure for research data collection. This paper aims to review the challenges facing neuro-oncology in Africa, efforts being made to address these challenges, and the current state of research and advancement in the region. Challenges facing neuro-oncology in Africa To provide effective treatment for various neuro-oncological illnesses, a multidisciplinary approach to care is essential. This approach involves considerations for human and infrastructural resources, equity in health care access, palliative care, innovation, and clinical research. Despite the importance of this approach, its adoption in the field of neuro-oncology in Africa is hindered by a lack of development in the region. Shortages of human and infrastructural resources, including neurosurgeons, medical oncologists, diagnostic tools such as magnetic resonance imaging (MRI), immunohistochemical stains, computed tomography, therapeutic facilities, cancer registries, radiation oncologists, and telemedicine, among others, negatively impact the management of neuro-oncological diseases in Africa6. These resources play a crucial role in patient care, therapy, postoperative intensive care, epidemiological research, and diagnosis and significantly impact other oncological diseases in the region. An estimated one neurosurgeon per 3.3 million people is available on the African continent, according to a study published in 20187. A review of 84 low- and middle-income countries showed a deficit of 61.4%, 38.9%, 68.4%, and 66.5% in radiation machines, radiation oncologists, medical physicists, and radiation therapy technologists, respectively8. A large delay in the detection of brain tumors in Africa is also due to the lack of radiation therapy in most low- and middle-income countries, with Ethiopia, Uganda, and Madagascar having the lowest access at 2.4%, 2.5%, and 4.0%, respectively, according to a report by Datta et al9,10. The underdiagnosis of pediatric brain tumors is also a result of a lack of resources for diagnosis and treatment11. The delivery of palliative care, which aims to improve the quality of life (QoL) of patients and their families, faces significant challenges in Africa due to the underdevelopment of its services12. Access to pediatric palliative care is particularly limited, with only 3% of patients accessing these services in the region13. A study by Atlas for palliative care in Africa reported that the availability of palliative care services was low across the continent, with the highest number of service outlets located in South Africa, Nigeria, and Malawi, with 20, 10, and 7, respectively14. The major obstacles to the provision of palliative neuro-oncology care in Africa have been identified as cultural attitudes of both patients and health care providers, a lack of awareness among health care professionals, and a shortage of human and infrastructural resources, such as palliative care specialists, bereavement specialists, cancer registries, and palliative care physicians15. Clinical research in Neuro-oncology plays a crucial role in determining the incidence and prevalence of the disease through epidemiological studies and identifying innovative therapeutic options. However, Africa is facing major setbacks in advancing clinical innovation and research. This is mainly due to a lack of support from the government and the absence of facilities and training for researchers5. A study by Adekanbi et al in 2019 highlighted the scarcity of Neuro-oncology studies in Nigeria, with most of these studies appearing in low-impact journals16. Furthermore, the inadequate availability of human and infrastructure resources has resulted in limited innovative therapeutic options for brain tumors in Africa. Efforts to address challenges The management of brain tumors remains a significant challenge in many African countries, where access to specialized neuro-oncology care is limited17. This limitation is due to a combination of factors, including a shortage of trained medical professionals, inadequate infrastructure and resources, and limited availability of specialized equipment. The development of mobile brain tumor clinics is one solution that has been proposed to address these challenges and improve access to care for patients with brain tumors in Africa. A mobile brain tumor clinic typically consists of medical professionals, including neurosurgeons, neurologists, and radiation oncologists, who travel to various locations to provide care18. The team brings essential equipment such as imaging machines, surgical instruments, and radiation therapy equipment, allowing for comprehensive diagnosis and treatment in the field. The primary benefit of mobile brain tumor clinics is improved access to care for patients living in remote or underserved areas. These clinics can provide patients with the opportunity to receive a diagnosis and treatment close to their homes, reducing barriers such as transportation and cost. Furthermore, by providing on-site training and education, mobile brain tumor clinics can help to build capacity in the local health care system and improve long-term outcomes for patients with brain tumors. The limited access to specialized medical facilities, shortage of trained neuro-oncologists, and inadequate funding for research and treatment in the region are among the major barriers that need to be addressed19. To overcome these challenges, efforts must improve the diagnosis and treatment options for patients with brain tumors in Africa. Increasing public awareness about the disease, developing community-based screening programs, and investing in the training of local health care professionals are key strategies to achieve this goal. Effective training programs for local health care professionals, including doctors and nurses, are crucial in building the capacity of local health care systems. These programs should aim to improve the knowledge and skills of local practitioners in the diagnosis, treatment, and management of brain tumors. International partnerships and collaborations between African and international organizations, as well as between governments and the private sector, can also play a significant role in overcoming the challenges of Neuro-oncology in Africa. Partnerships between African health care systems and international organizations and charities have the potential to play a crucial role in overcoming the challenges of Neuro-oncology in Africa. These partnerships can provide access to much-needed resources, expertise, and support to local health care systems. International organizations and charities can support training programs for local health care professionals, providing access to specialized expertise and equipment. They can also provide funding for research and treatment, helping to increase access to cutting-edge treatments and technologies. Furthermore, these partnerships can facilitate the exchange of knowledge and best practices, improving the standard of care for patients with brain tumors in Africa. Current research and advancements Brain tumors, a significant public health concern, have been largely overlooked and underappreciated in countries with limited resources, particularly in West Africa. This lack of recognition has a negative impact on brain tumor research in the region20. It is increasingly apparent that oncological illnesses are not only a challenge for industrialized nations, as cancer rates are rising in low-income countries21,22. Treatment for cancer in low-income countries is more challenging due to inadequate health care infrastructure. To enhance the accuracy of diagnoses and increase funding for potential breakthroughs in research, it is crucial to raise awareness of brain tumors among African health care providers and the general public23. However, data on the level of awareness of brain tumors in this region is scarce. Brain tumors have been overlooked in low-resource countries, including West Africa, where they are not listed as one of the major cancers, hindering brain tumor research in the region. With the rise of oncological illnesses in low-income nations, the need for improved diagnosis and increased research funding for potential breakthroughs is crucial. Raising awareness among African doctors and the general public can significantly address this issue20. However, in Africa, the belief that supernatural forces cause cancer leads many people to seek spiritual healing instead of conventional medical treatment, resulting in low utilization of health care facilities. To address this, the government and nongovernmental organizations should encourage health education through enlightenment programs, such as weekly or monthly broadcasts on well-known radio stations in local dialects, which have a significant impact due to their extensive coverage and low cost24. There is also a shortage of skilled professionals in brain research in countries with limited resources. Providing training to neuroscientists and neurosurgeons can help raise public awareness and address the scarcity of neurosurgeons in Africa23,25. Investment in improving the current health care infrastructure and developing new infrastructure is crucial to address the lack of facilities and staff to assist with brain tumors in these nations26,27. In the context of brain tumor research in West Africa, it is imperative to address the challenges and limitations that hinder progress in this field. Despite the prevalent cultural beliefs and practices, there is a need to increase interest among West African scientists in this area of research. To this end, research on traditional medicine, including the study of African medicinal herbs, could provide valuable insights into potential therapeutic options for brain tumors. In addition to increasing interest, it is essential to address the issue of funding for brain tumor research in West Africa. The lack of financial support is a major barrier to progress in this field. Efforts must be made to secure funding from various sources, including governments, nongovernmental organizations (NGOs), and private citizens28–30. Moreover, it is necessary to consider the attitudes and beliefs of the African population toward brain tumors and to develop strategies to enhance hospital-based registration and treatment. This can be achieved through health education initiatives, including radio advertising, community leaders’ educational programs, and the training of neuroscientists and neurosurgeons. By increasing interest, addressing funding barriers, and promoting health education and awareness, it may be possible to progress in diagnosing, treating, and managing brain tumors in this region. Importance of addressing diagnosis and treatment barriers in Africa Despite advances in diagnostic and treatment modalities for brain tumors, there are still significant barriers to delivering quality care to patients in many African countries31. The imaging of choice for brain tumors has evolved from computed tomography and traditional MRI to contrast-enhanced MRI and the use of modalities such as positron emission tomography. However, these approaches, which have become standard in other parts of the world, are still novel in many African countries. Adjuncts to surgery, which are crucial for safe and precise resections, are also lacking in many African countries. Personalized treatment, which has become the norm in many developed countries, is far beyond the reach of clinical practice in Africa. The resources and workforce to sustain standardized care, such as awake craniotomy, remain elusive. As the burden of noncommunicable diseases, including brain tumors, continues to rise in Africa, there is a need to properly identify the barriers to optimal care and address them before the burden of brain tumors overwhelms the already over-stretched health care system. Conclusion In Africa, despite the growing burden of CNS tumors, access to neuro-oncology care remains suboptimal due to various factors, including a shortage of skilled professionals, inadequate infrastructure and resources, and a lack of public awareness regarding brain tumors. To address these challenges, there is a need to implement initiatives that raise public awareness and provide education, as well as establish specialized mobile clinics equipped with essential medical equipment. In addition, brain tumors have received limited attention in Africa and have been under-reported, with limited resources allocated to research and a scarcity of tumor registries. To address these issues, there is a need for future research that focuses on the attitudes and beliefs of the general public toward brain tumors and the investment of financial resources by governments, NGOs, and private citizens to support brain tumor research. This can be achieved by establishing dedicated brain research institutions and departments for brain tumor research in academic institutes, as well as by strengthening regional and global alliances focused on brain tumor research and treatment. Only by taking these steps can the field of neuro-oncology in Africa be advanced, and better care is provided to those affected by brain tumors. Ethical approval N/A. Sources of funding None. Author contribution N.A.: Conceptualization. Conflict of interest disclosures The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) None. Guarantor Nicholas Aderinto. Assistance with the study None. Provenance and peer review Not commissioned, externally peer-reviewed.