Letter: Evaluating Brain Tumor Surgical Management Capacity in Sub-Saharan Africa

Abstract

To the Editor: Brain tumors (BTs) are defined as anomalous proliferations of brain tissue, whose severity extends on a spectrum from benign to malignant. Within the affected individual, they can manifest through a multitude of symptoms, from systemic fatigue and headaches to focal neurological deficits, seizures, and a plethora of others.1 Their etiology can be varied; they can originate from genetic mutations as a consequence of exposure to radiation or from weakened immune systems secondary to disease.1 From an epidemiological perspective, the prevalence of BTs in Sub-Saharan Africa (SSA) has been low compared with high-income countries (HICs); it is stipulated that this is because of underreporting and inconsistencies with record keeping.2,3 Within the SSA context, underreporting could essentially be attributed to biopsychosocial factors such as lack of diagnostic resources, poor hospital attendance, and the influence of religious and societal norms preventing the uptake of treatment.3 Histologically, the most common types of BTs in the SSA are gliomas, meningiomas, pituitary adenomas, schwannomas, and medulloblastomas.1-3 BTs in SSA have been treated with chemotherapy, radiotherapy, targeted therapy, supportive care, and surgery. However, surgeries are by far the most popular of the abovementioned therapeutic options, owing to their cost-effectiveness and the availability of basic surgical equipment in SSA hospitals. In certain situations, the need for urgent interventions often makes surgery the only available treatment option.2,4,5 In recent years, there has been a notable increase in the utilization of advanced surgical techniques and modern technological interventions for the treatment of BTs in SSA.1,6 These procedures have consequently resulted in better outcomes: a drastic improvement in the quality of life, increased rates of survival, and better symptom relief.6,7 This was particularly evident in a 3-year retrospective study conducted at the Kenyatta Hospital (the largest referral facility in East and Central Africa), where the outcomes of patients undergoing surgical procedures (mostly using advanced surgical equipment, technology, and interventions) superseded those undergoing alternative therapies.7 However, the state of surgical delivery for the resection of BTs in the region remains subpar compared with global standards. Although only a few studies have critically assessed the state of BT resection in SSA, these studies have reported poor outcomes. A number of studies assessing outcomes of PBTs in SSA have elucidated higher rates of postoperative mortality, stemming from a culmination of factors specific to the region, including late presentations, inadequate diagnostic procedures, lack of access to adjuvant postoperative therapies, and a general dearth of neurosurgical care.1,8,9 Postoperative care and follow-ups are rarely available in the rural regions of SSA, and those that are available in urban areas are primarily equipped as general intensive care units with no dedicated neurocritical care staff or equipment.8,10 In addition, the late presentations of most cases in SSA make it extremely difficult to effectively manage them, particularly considering the substandard quality of effective neurosurgery or oncology care in the region. This was particularly highlighted in the study conducted by Stagno et al,8 which reported that most PBT cases required 2 or more surgical procedures, owing to their advanced stage at presentation. The lack of availability of advanced diagnostic equipment in SSA also has a prominent impact on the treatment outcomes of BTs. In general, patient outcomes are largely determined by a delicate concoction of factors, including the availability of equipment, infrastructure, and the expertise of staff at neurosurgical centers. For instance, a cross-sectional study conducted by Ogbole et al11 revealed that only 84 magnetic resonance imaging units served a population of 372 551 411 in West Africa, with Nigeria alone accounting for more than two-thirds of the available units. In total, 77.6% of these units were classified as having low field strength. Furthermore, technical constraints, such as the general lack of modern operative equipment and modern tumor resection surgical techniques, have a notable effect on the quality of SSA operative outcomes.8,10 Minimally invasive neurosurgical techniques continue to improve surgical outcomes and rates of tumor resection in most parts of the world, particularly in HICs. However, the prevalence, distribution, and availability of these advanced techniques are still severely limited in SSA, and most patients are unable to access them.8,10 The general lack of studies available on BTs in SSA demonstrates the need to drastically advance neurosurgical research in the region. This is particularly paramount, considering that surgical outcomes of BTs in SSA have not been adequately discussed or summarized in the literature, and these studies primarily focus on PBTs and not adult BTs. Even with PBT studies, it was observed that only 8 of the 48 SSA countries had reported surgical outcomes of PBTs.1 In addition, there is a lack of BT registries in many SSA nations, severely restricting the ability to grasp the full disease burden, identify risk factors, and develop effective treatments.4,12 Generally, it is difficult to allocate resources and plan for appropriate care without accurate data on the incidence and prevalence of BTs in the region. Despite the high prevalence of BTs in SSA, there are only 102 neurosurgeons available; this results in a poor ratio of 1 neurosurgeon per 2.62 million inhabitants.13 Most of these neurosurgeons are concentrated in urban areas, with most of rural SSA having almost no available neurosurgical workforce. To summarize, increasing the availability of resources in SSA is critical to successfully improving treatment outcomes. Improving public awareness of BT symptoms and deploying diagnostic resources equitably, particularly in rural areas, are critical for mass diagnosis. For improving neurosurgery staff, more neurosurgeons and other nonphysicians involved in treating BTs should be trained locally in their respective SSA countries, and attractive incentives should be provided to keep them after training. Modern and well-equipped specialized centers must be built to improve BT management in SSA. More investments in resilient local research capacities must be prioritized to address the problem of underreporting and poor research on BTs in SSA.

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