By Muhammad Rafiqul Islam, MBBS, MD
I was born in 1980 in Modbaria, a remote part of Bangladesh where people had been deprived of basic health care services. After completing my secondary and higher secondary education, I enrolled at Sir Salimullah Medical College & Hospital and completed my MBBS degree. During my internship in 2004, the suffering of patients with cancer touched my heart, and I decided to build a career as a medical oncologist. In 2008, after entering government service as an assistant surgeon, I was eager to work at the National Institute of Cancer Research and Hospital (NICRH) here in my home country. In 2015, as a part of my medical degree course curriculum, I was attached to NICRH, and my dream came true. I have been working at NICRH since, and I completed my MD in medical oncology from Dhaka University in January 2017. I started as a medical officer, gradually building my career as a medical oncologist through different roles such as registrar, chief medical officer, and currently as an assistant professor of medical oncology. My institute serves more than 30,000 new patients with cancer and more than 200,000 previously registered patients with cancer per year.
Unfortunately, no clinical trials are running at NICRH. Therefore, we are devoid of advanced treatment options as well as training. Moreover, advanced training in medical oncology is not available in my country. Then I found ASCO, the academic platform for sharing knowledge across several different comprehensive cancer management domains. Through ASCO, renowned specialists provide training in research, clinical trials, academic journal publishing, and strategizing and executing international academic conferences worldwide.
I applied for the International Development and Education Award (IDEA) from ASCO and Conquer Cancer, and I was pleased to have been given the opportunity to participate in the IDEA program in 2020. Unfortunately, I could not visit my mentoring institution, the University of Texas MD Anderson Cancer Center in Texas, due to the COVID-19 pandemic. Despite the travel restrictions, I am grateful to my IDEA mentor, Naoto T Ueno, MD, PhD, a professor of breast medical oncology at MD Anderson; with his close support, I embarked on research as a principal investigator. His advice has been invaluable. I am also thankful to James P. Long, PhD, assistant professor of biostatistics at MD Anderson Cancer Center, for his enormous support. I hope to complete my research on “Association between the triple-negative breast cancer and reproductive behavior of Bangladeshi female breast cancer patients,” and I will be honored to share my findings with my colleagues in ASCO and the medical oncology field, hopefully this year.
As my mentor, Dr. Ueno guided me satisfactorily as well as gave me a chance to be part of the weekly tumor board of MD Anderson. Being a part of the tumor board is helping me to boost my knowledge base and enhance my research career. I have attended multiple scientific seminars regarding chemo-resistant breast cancer and other treatment-related challenges of breast cancer. I have also learned about some newer drugs which have not yet reached Bangladesh nor have been approved for use here. My MD Anderson experience helps medical oncologists like me be acquainted with these new drugs and their use, and enables us to advocate for the use of these drugs to our drug authorities. This will help in widening treatment options for patients in Bangladesh. I look forward to learning more about such new medicines and new treatment options. This platform will connect me with scholars and associates across the globe that will raise my chances of accomplishing my academic goals and helping patients with cancer in my country. By exchanging knowledge through ASCO, I will gain deeper insights into the multispectral approach of cancer treatment, which will better inform me of the latest progress and other details with insider views of the contemporary research in my area of expertise. This well-organized platform will enable me to consider new approaches, get an easy explanation and solution to complex problems.
I know it’s an enormous challenge for us to ensure the optimal cancer treatment and guide the future medical oncologists of Bangladesh. In 2040, the senior population will be almost one-fifth of the total population, and the number of patients with cancer will increase. So it’s the right time to start developing the infrastructure and competent human resources for handling the oncologic tsunami of the near future in Bangladesh.
Cancer Care in Bangladesh: An Overview
Bangladesh is a land of 170 million people and can only manage 2.34% of its GDP for health expenditure. Health care in Bangladesh is a mix of public and private health care. In 2018, out-of-pocket (OOP) expenditure on health was 73.9% and growing at an average annual rate of 1.21%.1 Only 0.2% of Bangladeshi citizens have voluntary health insurance in addition to their Medicare entitlement. The health expenditure due to the rise in non-communicable diseases (NCDs) has been catastrophic, pushing over 5 million people below the poverty line every year, creating an impediment to achieving health-related Sustainable Development Goals (SDGs) by 2030.2 NCDs account for an estimated 59% of total deaths in Bangladesh—886,000 deaths a year, where cancer is becoming the second-leading cause of mortality.3According to GLOBOCAN, the age-standardized incidence rate of cancer is 106.2. The country has no existing cancer registry system, but it is believed that the population is about 1.5 to 1.6 million, with 108,990 annual deaths from cancer, and 156,775 newly diagnosed cases annually.4
In Bangladesh, OOP costs are paid for by the patient and family members (direct or distant relatives) and sometimes other stakeholders like the patient’s neighborhood or a charity. As a result, high OOP influences the choice of treatment options and choice of providers; this impacts low-income families more than the rich. In rural areas, most patients with cancer are first taken to private providers, including pharmacies, shops, and traditional practitioners, rather than to a qualified government provider. This is not surprising since cost is the critical factor reported as affecting the choice of provider, and given that visits to government facilities are typically more expensive than the alternative options. The high cost of visits to government facilities is primarily related to the cost of medicines. This cost creates a significant burden and financial barrier for low-income patients and probably explains why poor patients make even less use of public facilities than rich patients.5 Secondly, accessibility to the facilities impacts poor patients, whereas personal preference and quality determine the choice of facilities for rich patients. This article reflects the common barrier to comprehensive cancer management and individual clinician’s experiences in Bangladesh, where both specialties and facilities are limited.
The Experience at NICRH: A Center for Hope
The U.S. president Theodore Roosevelt said, “Do what you can, with what you have, where you are.” This is what we do at NICRH, where we have very limited resources. I am a clinical educator in the only specialized government tertiary cancer care center in Bangladesh. The cancer center is set within a university teaching public hospital and was built for comprehensive cancer care with 23 departments, including medical oncology, radiation oncology, surgical oncology, gynecologic oncology, pediatric oncology, and others. The Bangladesh government funds patient consultations and a significant part of the treatment cost via the health care system in the institute. As a full-time specialist, I work 6 days a week, including both inpatient and outpatient consultations. I am also engaged in academic research.
A 2008 Australian workforce survey set a benchmark of 210 new patients (range, 153 to 339 patients) per annum per full-time equivalent (FTE).6 I work with nine other medical oncologists, and together we fill a total of 38.10 FTE positions per annum, working alongside other oncologists. Unfortunately, due to the scarcity of medical oncologists and no dedicated subspecialties in the medical oncology department, all the medical oncologists have to consult on every type of malignant disease.
Most patients are diagnosed outside our center. A trained and experienced medical officer makes consultation in the outpatient setting, based on proven histologic malignancy, and completes the patient’s metastatic workup. After confirming the staging, the patient’s file is sent to a multidisciplinary tumor board to decide the treatment modalities. Then, a patient who needs adjuvant or neo-adjuvant therapies is sent to medical oncology or radiation oncology for a therapy schedule. When the patient comes to the medical oncology department, the medical oncologist assesses the patient and provides an inpatient/outpatient chemo schedule.
NICRH treats both solid and hematologic tumors; there is no bone marrow transplant unit yet, but it is under construction. Surgical procedures like complex sarcoma surgery,
Fellow oncologists attend daily clinical rounds and monthly central grand rounds as well as a separate disease-oriented multidisciplinary round. In addition, the central roster provides weekend coverage with consultant review. Currently, there are no dedicated subspecialty-based oncology wards, which I believe is a drawback.
A medical oncologist has to work 48 hours weekly, including class lectures, journal club presentation/case presentation, twice-weekly inpatient rounds, administrative work, research activities, and outpatient consultancies. On average, 15 new patients and 50 follow-up patients are seen daily outpatient by one practitioner. Due to the intensity of this clinic workload, we are yet to start or be part of any national or international phase I, II, or III trials. Due to the COVID-19 pandemic, restructuring and allocating existing resources has been made to provide services to patients with cancer with suspected or confirmed COVID-19 positivity.
NICRH still largely runs on paper records and does not have a system-wide electronic health record (EHR). Some individual departments have their own personal data management systems, but they are not coordinated centrally. Services like chemotherapy prescriptions, care plans, communication with the pharmacy, clinical review dates, and take-home medication advice are done on paper. Follow-ups or clinical review visits are required for patients to come physically (although telemedicine is available, it is not a popular option). Patients are seen on a case file basis, which is then included in the weekly clinical audit program. A number of indications for admissions, chemotherapy dosing, toxicity grading, and allergy documentation are discussed. Working with a team of medical oncologists who embrace reflective practice and patient-centered quality improvement is another excellent feature of the unit in which I work. A biweekly continuous medical education (CME) program is arranged centrally for clinical case presentation and discussion with related departments.
The lack of EHR facilities in the center creates challenges due to inadequate integration with allied departments, compromising comprehensive cancer care.
Challenges for Medical Oncologists in Bangladesh
Low detection rate: Bangladesh faces a serious challenge with a high cancer incidence of 106 per 100,000 with a low detection rate. The actual incidence may be much higher than the reported due to:
- No national cancer registry
- High frequency of under-diagnosis
- Delayed diagnosis due to inadequate screening facilities or screening participation lower than 10%7
Population and aging: In 2012, Minarul Haque et al estimated the projected Bangladeshi populations for 2030 and 2035 at 193.3 million and 205.9 million, respectively,8 while the elderly population grows at a rapid rate (2.2% per annum).9 The male-to-female ratio for people age 24 or younger is 104.25 males per 100 females; for people age 25 to 69, it is 100.91 males per 100 females; and for people age 70 or older, it is 96.31 males per 100 females. The overall male-to-female ratio of Bangladesh fell gradually from 109.25 males per 100 females in 1950 to 102.25 males per 100 females in 2020.10 An increased population, an aging population, and a changing sex ratio will become cornerstones for increased cancer incidence.
Risk factors: Increased exposure to known cancer risk factors is another challenge to overcome.
- Smoking: According to a nationwide Global Adult Tobacco Survey (GATS), the overall prevalence of smoking was 23% in 2009, which increased up to 35% in 2019.11,12
- Meat consumption: Meat consumption per capita increased by 6.13% from 2002 to 2017.13
- Obesity: Over the last 33 years, rates of being either overweight or obese doubled among Bangladeshi adults. In 1980, 7% of adults were overweight or obese. In 2013, those rates had climbed to 17% for adults.14
- Air pollution: The densely populated capital of Bangladesh, Dhaka, dominates the list of world cities with the worst air quality. On February 26, 2021, Dhaka occupied the first position as the most polluted city in the world.
- Alcohol consumption: The estimated frequency of alcohol users in the general population of Bangladesh is about 1.9%. The yearly rise in permits issued for alcohol use to people age 15 or older from 2006-2007 to 2010-2011 is 49%, indicating that consumption is increasing.15
- Menstrual hygiene: Studies in rural Bangladesh found that 69.0% of adolescent girls were using old pieces of cloth or even no protection during menstruation,16 which may increase the risk of cervical cancer.
We believe that increased exposure to these risk factors contributes to the increased cancer incidence in Bangladesh.
Consultations and Challenges at NICRH
Number and time: Medical oncologists have about 8,000 new outpatient consultations and 150,000 follow-up consultations yearly. Among them, breast cancer predominates in women and lung cancer in men. Most patients have an education level of less than 5 years of school, so comprehensive management is very hard to provide due to difficulties with limited understanding of their disease. It becomes difficult to establish a healthy patient-physician relationship due to the high volume of patients and their difficulties in understanding their disease.
Financial issues: Around 70% of the attending patients have a monthly income of less than $120 (US). The government system offers common chemotherapy drugs with rationing, but the system does not provide advanced drugs (such as trastuzumab, bevacizumab, pembrolizumab, etc.). We don’t have health insurance coverage, so most of the patients who require advanced drugs that are not supplied by the system cannot bear their cancer treatment expenditure and are unable to continue their cancer management plan.
Delayed diagnosis and constrained resources: Increased mortality rate is becoming a burning issue due to delayed diagnosis, lack of advanced diagnostic tools, incomplete treatment, or inadequate treatment. A recent study of NICRH showed more than 74% of the patients are diagnosed at stage III or higher irrespective of malignancy and about 50% of the patients did not complete their treatment. The private sector and NGOs are covering only 4% to 5% of the health expenditure, with the rest coming from the household income (about 90%).17 High-cost cancer treatment protocols are completely out of reach for most patients. Access to physical infrastructure and expert medical professionals is challenging for patients, because facilities and providers are few, and are mainly based in urban areas. We have around 300 oncologists for a population of 169 million, and the advanced diagnostic and treatment facilities are only available in the capital city of Dhaka. Awareness is another big challenge to overcome. Social stigma, superstition, or apprehension augments further escalating of cancer-related mortality.
In Bangladesh, academically, medical oncology started its journey in 2004. Since then, only 22 medical oncologists completed their post-graduation in medical oncology. Every year only 6 graduates are eligible for admission to the residency program. Historically, the allied oncology departments have been trying to fill the gaps of the medical oncologists in the country.
Equitable distribution of resources and ease of accessibility are the primary essential conditions for comprehensive cancer management. Mass awareness of cancer screening/prevention and allocation to bear the health expenditure are the secondary conditions. Despite economic hardship, cancer research trials should be well funded, which will ensure the collaborative work that needs to be expanded, both within this country and with other parts of the world. Smaller, multidisciplinary, well-equipped facilities can provide comprehensive cancer care in the underprivileged and rural areas where much of the population remains underserved. Oncology should be integrated with the medical education syllabi for physicians, nurses, and other paramedical professionals.
Dr. Muhammad Rafiqul Islam is an assistant professor of medical oncology at the National Institute of Cancer Research & Hospital in Bangladesh. He is a recipient of the 2020 International Development and Education Award (IDEA) from ASCO and Conquer Cancer, the ASCO Foundation. Disclosure.
- Bangladesh - Out of pocket expenditure as a share of current health expenditure. Knoema. 2018.
- Imam SH. Out-of-pocket healthcare expense pushes 5.0m into poverty a year. The Financial Express. December 13, 2020.
- icddr,b. Non-communicable diseases. 2020.
- Bangladesh. Source: Globocan 2020. International Agency for Research on Cancer. World Health Organization. 2020.
- Chandrasiri J, Anuranga C, Wickramasinghe R, et al. The Impact of Out-of-Pocket Expenditures on Poverty and Inequalities in Use of Maternal and Child Health Services in Bangladesh. Manila: Asian Development Bank; December 2012. Report No.: ARM135434-3.
- Lwin Z, Broom A, Sibbritt D, et al. The Australian Medical Oncologist Workforce Survey: The profile and challenges of medical oncology. Semin Oncol. 2018;45:284-290.
- Bangladesh: Cancer Country Profile 2020. World Health Organization. 2020.
- Haque M, Ahmed F, Anam S, et al. Future Population Projection of Bangladesh by Growth Rate Modeling Using Logistic Population Model. Annals of Pure and Applied Mathematics. 2012;1:192-202.
- Streatfield PK, Karar ZA. Population challenges for Bangladesh in the coming decades. J Health Popul Nutr. 2008;26:261-72.
- Bangladesh - Male to female ratio of the total population. Knoema. 2020.
- Burki TK. Tobacco consumption in Bangladesh. Lancet Oncol. 2019;20:478.
- Islam FMA, Walton A. Tobacco Smoking and Use of Smokeless Tobacco and Their Association with Psychological Distress and Other Factors in a Rural District in Bangladesh: A Cross-Sectional Study. J Environ Public Health. 2019;2019:1424592.
- List of countries by meat consumption. Wikipedia.
- Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384:766-81.
- Dewan G, Chowdhury FR. Alcohol Use and Alcohol Use Disorders in Bangladesh. Asia Pacific Journal of Medical Toxicology. 2015;4:83-90.
- Haque SE, Rahman M, Itsuko K, et al. The effect of a school-based educational intervention on menstrual health: an intervention study among adolescent girls in Bangladesh. BMJ Open. 2014;4:e004607.
- Molla AA, Chi C. Who pays for healthcare in Bangladesh? An analysis of progressivity in health systems financing. Int J Equity Health. 2017;16:167.