Dr. Tunde Lalude, a fellow of the prestigious Royal College of Surgeons, Edinburg, is a Consultant Laparoscopic Surgeon, and the Group Medical Director of Reddington Hospital. In an interview with Martins Ifijeh, he said colorectal cancer is on the increase in Nigeria because of lack of adequate treatment facilities and personnel. He further revealed how Reddington hopes to change the narrative through experienced surgeons and state-of-the-art machines
Are we having more cases of colorectal cancer in Nigeria now than decades ago?
Yes. We are having more presentations that suggest colorectal cancer than before. What was being diagnosed those days was heart attacks since they present in a similar way with colorectal cancer. But even with cases of under diagnosis experienced at the time, it was still better documented then because in those days we had better healthcare.
Why is Nigeria having high incidence of colorectal cancer?
I will start from what I think is a very relevant statistics, which is that African Americans have about 20 per cent higher incidence of colorectal cancer ahead of the entire population of the United States, and those African Americans are mostly West Africans, who during their time in Africa had low incidence even though they were genetically prone to it, but became more prone to the disease because of the environment and the western lifestyle.
So, back to Nigeria, you will realise that we are increasingly westernising our lifestyle; our level of alcohol intake, smoking, intake of processed foods, among others have all increased, and this is playing out on our health. In those days there wasn’t obesity; people were walking to the farm and taking traditional foods which are high in fibre. Now we eat a lot of processed food. Even though those more prone to it are from 50 years of age, we are now beginning to have younger people with colorectal cancer
What are those specific factors causing colorectal cancer?
It is a combination of the type of diet we take, smoking, alcohol intake, sedentary lifestyle, red meat intake, among others. A good diet should be high in fibre, low in fat, with average calories and low in salt. Obesity could be another factor.
And then there are hereditary conditions where there is a genetic problem which predisposes to colorectal cancer. For instance, there is a condition called hereditary nonpolyposis colorectal cancer (HNPCC) or lynch syndrome, and people with this are 80 per cent at risk of colorectal cancer.
How many Nigerians are at risk of colorectal cancer?
We don’t have proper documentation unlike in western countries where access to healthcare is captured in a systematic fashion and data is properly obtained and kept. So it is difficult to estimate for Nigeria, but certainly it is on the rise, particularly for young patients in their 30s and 40s. The youngest I saw in the United Kingdom was 25, though I know of a 14 year-old patient.
How long does it take for colorectal cancer to develop in the body?
The generally accepted window for its development is about 10 years, that is why when you look at the screening guidelines in the United States and one of the modalities for screening, it is advisable for everyone to access screening every 10 years as from 50 years of age, although cancer society has recently reduced it to 45 years. The reason for 10 years is because it is believe the evolution of colorectal cancer is at least 10 years.
Some Nigerian oncologists say they don’t have job fulfillment because their patients often present late. Why do we have late diagnosis in Nigeria?
Many of our patients are not educated on the how to tackle cancer diseases on time. The issue with early stages of colorectal cancer is that it does not show symptoms, and if not diagnosed and treated on time, it continues to grow bigger until it spreads elsewhere. Stage one colorectal cancer doesn’t reach the bowel wall and can mostly be removed, but stage two reaches the wall. Stage three involves any involvement of lymph glands, while any distant spread to the liver, lungs, and the likes is stage four. Also, we can have a direct spread when the cancer has gotten to the bowel wall, such that it then spread into the abdomen.
Why is colorectal cancer commonly misdiagnosed by medical experts?
It is like that because some of the symptoms have been subtle. It is important to recognise these presentations. It may be change in bowel habit, particularly having a more frequent stooling. For instance, in the UK, once you have a persistent diarrhea that seems to go on and on, it triggers investigation for colorectal cancer. Any episode of rectal bleeding from the bottom should trigger investigation. The only way to confidently tell reasons for some of these symptoms is to investigate them to ensure there is no other cause for the bleeding. If I see a patient at the age of 21 years, my approach will be different from the approach to the patient of 40 years, so it is important medical experts get it right.
Unexplained weight loss, abdominal pain and iron deficiency anemia could be reasons to trigger investigation for colorectal cancer. The gold standard is that if someone comes up with unexplained anemia, colorectal cancer should be investigated.
But some health issues also have similar symptoms. How can that of colorectal cancer be differentiated?
That is usually the problem because some of those symptoms can represent almost anything. You always need to have a high index of suspicion for you to consider which type of ailment can be responsible. The mistake often made is that cancer is not considered a potential diagnosis. It should also come as a first line of thought.
Is dearth of specialists in this area contributing to misdiagnosis?
I think lack of professional awareness of colorectal cancer can be an issue because we do have cases where people present symptoms which should have suggested to the professional that it may be a case of colorectal cancer, but has not triggered the appropriate response for investigation by the medical expert.
How many of your kind do we have in Nigeria?
To be honest I do not know, but I know quite a number of few colleagues around. However, most are concentrated in urban areas. They are scattered in large cities like Lagos and Abuja. It is very unlikely that a colorectal surgeon will settle in rural areas. One reason is that there are certain things that you need to do your job properly, and they are often non-existent in smaller towns or rural areas.
Also, affordability and environment has a correlation. Many Nigerians living in these rural areas cannot afford to see doctors, pharmacies and all, which means they pray, and at the course of that, things getting worse. We also need to educate Nigerians on the way we deal with health issues.
Who is to blame for the high rise of colorectal cancer; citizens, healthcare professionals or government?
I wouldn’t say anybody should be blamed in particular. It is just that our healthcare system is becoming a big problem nationwide. And I think everyone is to work together and try and spread the education about how we can deal with health issues. We need to address the facilities available in public hospitals. A lot of private hospitals have a handful of facilities, but that is not where the majority of cases are. The government has a big role to play in terms of dissemination of information as part of the preventive care, which is a lot cheaper.
So why is Reddington Hospital involved in the fight against colorectal cancer?
Reddington has a mission to be one of the best hospitals in the country and it has equipped itself for that role. You know we are benchmarked into international standards, which is why we easily get international accreditations. So what we are doing is to try to pay attention to issues that can be addressed, and we see colorectal cancer as one of them.
We are involved in varieties of healthcare, but there is a particular interest in colorectal cancer because I as a colorectal surgeon have worked for more than twenty years in this area. So we have set up a colorectal care unit to provide this care. Every single case of colorectal cancer will come to treatment, and with the increase in incidence level, we had no option considering our position in Nigeria’s healthcare space, other than to set up facilities to help. People die from the cancer type because they are unable to get care from the healthcare system practised in the country. We feel we can bring in a lot of expertise both in preventive strategies in terms of screenings, and also curative care since we have the expertise to do the complex operations that needs to be done. We also have the sophisticated diagnosis here at Reddington.
What internal policies do you have that gives you an edge in colorectal cancer care?
We have a lot of internal processes that put more attention on consumers. For instance, we put a lot of infection control policies in place which has put us at a UK standard for sterilization. We actually expend money employing certain people who are knowledge in their particular areas. We are not just interested in treatment but interested in delivering true excellence, which means sorting excellence on things seen and unseen. In a nutshell, whatever we put our heart to do in Reddington is done with international standard practice. One thing we do is that we put a lot of emphasis on screening generally, and we emphasise on colorectal cancer prevention.
There is the belief that cancer treatment is poor in Nigeria. Can your colorectal cancer unit really provide such treatment?
First of all, it will depend on the type of cancer that you are trying to treat, and as far as colorectal cancer is concerned, our outcome and numbers have been very good. Apart from me, we are in partnership with the best oncologist doctors, and we scrutinise everything we do before uploading to our data base.
Nigerian doctors are good, but their issue is lack of equipment. Won’t the lack of the required machines hamper your work?
There are doctors in Nigeria that are highly competent without machines, but at Reddington, we have the expertise and we have the machines. Once the diagnosis is made we continue treatment. Those doing our operation have been trained. Many of those who have substandard outcome are not trained on the treatment of colorectal cancer. That is why our surgeons here are those well trained with good outcome. One issue in Nigeria’s healthcare system is that we do not have a central body collating data system. Abroad, data gathering is very key, that is when you know specialists with consistently poor outcomes, and such people are stopped from operations.
What colorectal cancer machines do you have?
We have a state of the art endoscopy suit for diagnosis; we have a city scan; and a host of others.
While we know Reddington is for the elites. How do you intend to bring poor Nigerians into your treatment plan?
We can help, but government has to be clear on how to fund healthcare. We have a very low expenditure as regard our population. UK has about 70 million population and they spend about 100 to 140 billion pounds in the national health services. America spends about 18 per cent of their GDP, which is about 3.5 trillion dollars. I don’t know what the Indian health system is saying but they are working on a unitary health system so that the poor can access healthcare with their government supporting with 60 to 70 per cent of treatment cost.
On our part, we are involved in Corporate Social Responsibility, particularly in the area of detection or screening, but for treatment, we will be limited because we will need to buy consumables and other essential things needed. What we can do is assist the government. For instance, we are collaborating with hospitals without equipments, yet they have patients, such that they come use our machines at reduced rates. So it does two things; reduce medical tourism, and help in training personnel. We expose these personnel to machines they don’t have.