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Q&A with Dr. Dorothy Lombe
Dr. Dorothy Lombe, oncologist and Chair of the Cervical Cancer Technical Working Group at the Ministry of Health, discusses cervical cancer prevention and control programs in sub-Saharan Africa, as well as strategies she and her team put in place to protect staff and patients during COVID-19.
Zambia has one of, if not the most, developed cervical cancer prevention and control programs in sub-Saharan Africa. The Bush Institute is proud to have partnered with the Government of Zambia since 2011, including now through Go Further, to scale up screening and treatment for cervical cancer especially for women living with HIV. Dr. Dorothy Lombe is an oncologist working at Cancer Diseases Hospital in Lusaka, Zambia, Chair of the Cervical Cancer Technical Working Group at the Ministry of Health, a researcher and Fogarty Fellow, and recently authored a paper on strategies she and her team put in place to protect staff and patients during COVID-19.
This interview was edited for length and clarity.
Crystal: Can you tell us how cancer affects women in Zambia?
Dr. Lombe: The most common cancer in Zambia is cervical cancer. And it's particularly sad because this cancer is very preventable at so many levels - through HPV vaccination when girls are young, and screening young women who are sexually active so you can catch the early lesions. It's tragic because it shows how there's lack of access to healthcare.
A lack of a screening program that is robust means that most women present very late and they require a minimum of surgery, most often chemotherapy and radiotherapy. There’s a lack of those resources. We do have a good cohort of survivors, but we also have a lot of sad stories about women who've suffered advanced cancers. We're hoping that in the next decades, we are going to change that.
Crystal: Tell us about a typical patient's journey.
Dr. Lombe: Right now, the cervical cancer screening program is expanding across the country, but the reality is that it will take time. So most likely, a woman would have had symptoms like a discharge, for example, or complaints of painful coitus. And it's not just the woman who is unaware about the cancer, it's also some of the health workers. The woman may just be told, "Oh, it's that woman your husband is having an affair with. She's bewitched you."
And then the next level is being treated for what is thought to be a benign condition when it's actually cancer that's developing. Most women repeatedly tell me, "I went to the doctor almost a year ago and I've been going there, and I've just been told it's normal."
Eventually when they do get to us, there's the challenge of out-of-pocket expenses. Currently to get a biopsy done and processed, patients usually have to pay out of pocket. For a woman in a government institution, that test would be $1, for example. But in private labs, a biopsy would cost $10, which is a lot of money for a Zambian woman. That would be her meals for half the month in terms of groceries.
After women go through the hurdle of diagnosis, they have to come to the cancer center. And whether it's an early cancer that requires surgery or whether it is radiotherapy – because there's only one tertiary center serving 17 million people – you're going to find that the waiting list is long. So you've just joined the queue and you wait your two months or three months before you can get onto the radiation machine.
But having said that, once the women get to us, we are like a family. We usually tell them, "OK, you've come now. It's been a long journey getting to the cancer hospital, but now you are a part of us. And you'll be taken care of."
Crystal: You wrote a piece a few months ago about how the Zambian National Cancer Center has made changes to protect patients and the staff from COVID-19 and improved operations during the pandemic. Can you tell us about a few of those changes?
Dr. Lombe: When the COVID-19 pandemic hit Zambia, within a week or two, one of our staff tested positive. We had to take the staff member’s stress into consideration and try to reduce that stigmatization. And then we had to put in measures. So some of those measures involved basic hygiene, like handwashing. We said, "Hey, we don’t need a lot of money to do that. We just need to be stricter with what we already know.”
Then the fantastic pharmacists put on their thinking caps, looked in their stores at what they had, and made hand sanitizer.
In Zambia, we have makeshift water reservoirs with taps called Kalingalinga buckets. Sometimes we don't have running water, but what we can do is put up these extra buckets all over the institution.
We also made changes in treatment. There's evidence to show that sometimes bigger fractions of the same radiotherapy will cure the cancer with the same level of toxicity and with the same level of side effects but in less time. COVID quickly woke us up and said, "Listen, you can't keep patients for long because of COVID," so we brought down the amount of time patients needed to stay for treatment.
Then another issue that I was very happy about was addressing the mental health of our staff. Working in a low-resource environment in cancer care is already very stressful. And we never really considered that as something we took care of. COVID-19 changed our perspectives, and mental health became a priority.
Crystal: What are your biggest concerns with cancer care going forward, especially for women?
Dr. Lombe: I'm scared of what has happened in terms of the early detection program. It will take time for people to start trickling back to the hospitals and healthcare facilities because they are being told to stay away. We need to keep investing in community education to help with this problem.
Crystal: You work in the Ministry of Health, through chairing the National Cervical Cancer Control Technical Working Group. How does Zambia work with partners on cancer control and treatment?
Dr. Lombe: We did resource mapping and tracking to gather information on all our partners and what they contribute. What we found is that a lot of resources go into the prevention and treatment [of precancerous lesions] and very little into treatment and practically nothing into palliative care. So that's a misnomer because the screening program finds invasive cancers and you've got to do something about those women.
The partners are fantastic. And I think they wait for us as the local people to tell them what we need. So if we tell them we need screening, then that's where they'll be directing resources but if we are able to think as technocrats locally, when the partners come we're able to direct their contribution to particular areas.
Crystal: What are the priorities right now for partner engagement?
Dr. Lombe: Prevention and screening always takes priority and it's important, but treatment is also important. We need to be more pragmatic about how we set out our programs. Locally, as we plan, we need to have it mapped out till the very end, the whole spectrum. I think with the cervical cancer program, what happened is that you’ve got a screening program that's being implemented but you haven't got the capacity in terms of the treatment aspect. You also have a lot of women who require palliative care. What we hope is that partners will be able to invest into these aspects [treatment and palliative care] too.
Then the other thing about women's health is that yes, cervical cancer is the cancer that affects women, but women also get breast cancer, colon cancer, multiple myeloma. They are all women. All the programs need attention to a certain extent. How can we leverage the current partner contribution to make sure that all women in Zambia cared for?
Crystal: What are you optimistic about for the future of cancer care and treatment in Zambia, especially for women?
Dr. Lombe: I'm optimistic that we're going to be the first African country to reach that goal of elimination of cervical cancer as a public health problem. I feel we're going to flip very quickly because of the approach that the team in Zambia has taken. Public health specialists, clinicians, surgeons, everybody's working together. And previously, we were working in silos, but now we are so united and we're speaking in one common voice and capitalizing on the strengths of each program. I feel we're going to accelerate and move faster than we've done in the past 10 years.
The second thing I'm optimistic about is the level of research. The importance of research cannot be overstated. Without a research program, we're really not going anywhere. We're basically not practicing evidence-based medicine and we're extrapolating facts from countries, and, even if it's another African country, it's just not the same. But at the rate that we're traveling now, the way we're working together, I do believe that we'll have some very high-quality research as a country in the next few years.