Oncology services in sudan

The Sudanese Medical Association (SMA) UK & Ireland

Oncology Services in Sudan: Realities and

Ambitions

Conference Report

December 17th

, 2012

Medani, Gezira State,

Sudan

A joint conference of the Sudanese

Medical Association (UK & Ireland) and

the National Cancer Institute in Medani,

Sudan in collaboration with the

Sudanese Oncology Society

1 Oncology Services in Sudan : Realities and Ambitions December 2012

Suggested Citation:

Ahmed M., Ali Z., El Higaya E., Ibrahim N., Flavin A. and Abuidris D.O. (2013). Oncology

Services in Sudan: Realities and Ambitions, Conference Report. Sudanese Medical Association UK

& Ireland.

©Sudanese Medical Association UK & Ireland 2013

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TABLE OF CONTENTS

Table of Contents

2

Abbreviation

4

List of Tables and Figures

5

Introduction

6

Executive Summary 8

Conference Sessions

15

Overview of the NCI

16

Overview of the Rick

19

Overview of Shandi Oncology Centre

20

Cancer Statistics in Sudan and Gezira State 22

Overview of cancer Registry Services In Sudan

23

Overview of the KBCC

24

Cancer Diagnostic in Sudan

24

Advocacy: Cancer Survivors Group

26

Development of a National Cancer Centre Model: Standards and

Challenges

27

Radiotherapy Services in Ireland: What Sudan Can Learn

28

Developing Cancer Strategy in Under-resourced Health System:

Challenges and Opportunities

30


Sudan –Ireland Collaboration: The Potential of Institutional

Partnership to Improve Health Services

32

From Dublin to Madani: The SMA initiatives in Cancer Health Care

34

Conference Recommendations

36

Annex 38

Appendix 1: Conference Programme

39

Appendix 3: Photo Gallery

42

Appendix 2: IAEA Recommendations

46


ABBREVIATIONS

SMA

Sudanese Medical Association

NCI

National Cancer Institute

RICK

Radiation and Isotopes Centre in Khartoum

IARC

International Agency for Research on Cancer

IAEA

International Atomic Energy Agency

WHO

World Health Organisation

U of G

University of Gazira

GCR

Gezira Cancer Registry

SJH

St James’s Hospital , Ireland

NCHD

Non Consultant Hospital Doctor

HLA

Human Leukocyte Antigen

KBCC

Khartoum Breast Care Centre

RCSI

Royal College of Surgeons Ireland

RCPI

Royal College of physicians Ireland


LIST OF TABLES AND FIGURES

Figure 1 Gezira University established 1975.

Figure 2 Map showing the seven localities of Gezira state.

Table 1 Incidence rate of the total number of cancer cases in 2008

Table2 Number of cancer cases treated at Shandi Centre of Nuclear

Medicine and Oncology (2009-2012)

Figure 3 Departments of Shandi Centre of Nuclear Medicine and

Oncology

Figure 4 Contributing data sources to National Cancer Registry

Figure 5 National cancer registry common cancers percentages

(overall and by gender)

Figure 6 Khartoum Breast Care Centre, KBCC

Figure 7 Principles of Irish Oncology Services planning

Figure 8 Conceptual framework for assessing access to health

services (ADAY. L.A. et al 1997)

Figure 9 The six building blocks of health systems

Figure 10 Focus areas for future Sudan-Ireland collaboration.

Figure 11 Initial steps in starting a new partnership


INTRODUCTION

Sudan is experiencing a growing cancer epidemic with major

challenges throughout the spectrum of screening, diagnosis, treatment and follow-

up. Some of the serious challenges in this field include high incidence of advanced,

difficult-to-treat disease at presentation, high cancer burden, limited resources

and an unequal distribution of services in a big country like Sudan.

This conference attempts to evaluate oncology services in Sudan examining all

public and private oncology centres currently operating in the country. This

comprehensive review will involve present realities, gaps in the services and future

plans.

The conference also discussed international models of oncology service

provision in the Republic of Ireland and the United Kingdom with special

emphasis on governance and quality management in the development of oncology

centres. The need to create and maintain external links for standards setting and

accreditation purposes were also highlighted. The conference was held on 17th

December 2012 in Madani Heart Centre, Gezira State, Sudan.

Sudanese Medical association (SMA):

The Sudanese Medical Association- SMA (UK&I) is an independent, non-

governmental academic organization. It was founded in February 2010 and held its

inaugural meeting in the Central Middlesex Hospital. This was attended by

Sudanese healthcare professionals based in the UK and Ireland.

The Association is aiming to be an agent of change and voice of reason by

representing the public face of Sudanese medicine and bringing healthcare

professionals together in working partnership. Membership is open to all healthcare

professionals including clinicians, dentists, nurses, pharmacists and allied healthcare

scientists. Members are committed to upholding professional values away from

political or personal motivations. Their judgment on arising issues is influenced

only by the need to develop efficient healthcare for the people of Sudan.

National cancer Institute (NCI) in Gezira state:


The National Cancer Institute (NCI) is a potential centre of excellence

established in 1992 by the University of Gezira (U of G) (Figure-1) in Wad Madani,

Sudan. U of G is a community oriented university established in 1975 with a main

objective of rural development. University of Gezira is located in the centre of

Sudan in the Gezira State, the most densely populated State after the capital

Khartoum.


EXCEUTIVE SUMMARY

The conference was organised by the Sudanese Medical Association (SMA UK &

Ireland) and the national Cancer Institute, Madani (NCI) in recognition of the

rapidly rising cancer incidence in Sudan in recent years. The objective was to

assess the current situation in the country in relation to cancer and plan for the

future learning from international experience. All the important components of

cancer control including registration, prevention, screening and early detection as

well as diagnosis and treatment were addressed.

National Presentations: An overview was provided by the Sudanese speakers on

the history of the service in Sudan, the current situation, the issue of cancer

registration, gaps in the services and future plans and aspirations.

An overview of the current situation and future plans for NCI were presented by

Dr Elhaj. He spoke of the dramatic rise in cancer cases in Sudan since 1999 and

highlighted the national issues related to diagnosis of cancer particularly the lack

of diagnostic facilities. The lack of access of cancer patients to radiotherapy is also

an issue with just one cobalt machine for a population of 4 million catering for

approximately 1300 new patients seen annually. Despite these difficulties the

centre has been at the forefront of epidemiological research and has been involved

in many training workshops with international collaborators. The hospital has

established a regional cancer registry with the support of IARC. Currently in

association with the University of Gezira MSc programmes in Molecular Biology,

Medical Physics and Nuclear Medicine Technology are provided. Plans for the

future include more inpatient beds, establishing surgical oncology, upgrading

radiotherapy equipment, training of staff and strengthening research.


Dr Sedik Mustafa provided an overview of the RICK. The centre has witnessed the

huge rise in cancer incidence in Sudan. When it opened in 1967, 250 patients per

year were seen and treated compared with 7500 in 2011. The staff is well trained,

most having trained in Europe and kept up to date with regional training courses

provided by IAEA and other organisations. There is a lack of radiotherapy

equipment as the centre has only 2 cobalts and 2 linacs to deal with this volume of

patients. A big issue is a lack of ongoing maintenance of equipment which is

crucial to prevent linac downtime. Another issue identified is brain drain of

healthcare professionals

Dr Nabeel Mohamed provided an overview of services in Shandi centre. This

opened in 2009 and has an early detection programme, outpatient chemotherapy

facilities, a nuclear medicine section which has facilities for treatment of thyroid

cancers. Currently patients go to the RICK for radiotherapy although the plan is to

have a cobalt machine with simulator and treatment planning system (TPS) as well

as brachytherapy facilities in the near future. An overview was given of cancer

registration in Sudan by Drs Dafaalla Omer Abuidris (NCI) and Dr Ahmed Hashim

(NCR Khartoum).

Cancer registration was initiated in NCI in 2006 as the first attempt to create a

population based registry in Sudan. The NCI provides most of the data and Dr

Abuidris highlighted the challenges obtaining data from general hospitals as well

as the issues around death certification with many patients who die from cancer

dying at home rather than in hospital. The data collected demonstrates that the

commonest cancers in Sudan are breast, haematological malignancies and prostate

cancer.

Dr Hashim spoke of the National Cancer Registry NCR in Khartoum. This has

been re-established in 2009. The NCR is a population based register in Khartoum

state, the largest state in Sudan. Training has been provided for staff in the


registries with support from international partners. A big issue is the lack of

understanding by policy makers of the importance of cancer registration in terms

of planning for the current and future needs of a country in relation to cancer

control.

Dr Wafaa Elhadi provided an overview of the facilities in the Breast Care Centre

Khartoum. This is a not for profit institute which opened in 2010 and focuses on

diagnosis and treatment of breast cancer. Surgical and chemotherapy treatments are

available. The numbers of patients treated here is gradually increasing.

Professor Ahmed MohaMadani presented an overview of the situation regarding

pathological diagnosis of cancer in Sudan. He focussed on the importance of

accurate diagnosis to the appropriate treatment of cancer. He dealt with the need

for investment in pathology so that immunohistochemistry and cytogenetics as

well as cytology and frozen section are available for therapeutic and prognostic

information. He highlighted the importance of both internal and external quality

assurance in pathology. Currently in Sudan accreditation of pathology laboratories

is voluntary but his view was that standards would be improved by mandatory

accreditation and external peer review.

Mr Ahmed Abuzaid, a cancer survivor presented some of the issues patients have

with access to treatment, overcrowded services. He was positive however about the

fact that treatments are free in the public centres.

The main challenges identified by the local speakers were:

*Lack of a good registration systems for cancer cases

*Lack of access to good diagnostic facilities and good peer review systems to

avoid errors in diagnosis

*Lack of access to radiotherapy due to machine shortage and lack of any

radiotherapy in certain parts of the country


*Lack of maintenance of radiotherapy equipment.

*Brain drain of healthcare staff

The International speakers discussed international models of service delivery and

how Sudan could learn from experience elsewhere in relation to developing a

sustainable service into the future. The need to create and maintain sustainable

external links for setting of standards and developing a quality service was

highlighted.

Mr Ian Carter, Senior Health manager, HSE Ireland discussed the development of

a National Cancer Control Programme (NCCP) from a health manager’s

perspective. He spoke of the importance of planning the development of the

service. The allocation of funding and resources in his view were critical to

success. He highlighted the need to focus on the entire population using evidence

based strategies for all aspects of cancer control from registration to palliative care.

He spoke of the challenges that had been faced in Ireland in the past with a

fragmented service and evidence of poor outcome in comparison with European

neighbours. Centralization of services had been implemented following the

recommendations of the NCCP with cancer centres capable of providing full range

of diagnostic and therapeutic facilities as well as ancillary services needed by

cancer patients such as physiotherapy, dietetics etc.. He emphasized the importance

of maintaining standards within the programme by means of internal and external

quality assurance.

Dr Aileen Flavin, a Consultant Radiation Oncologist spoke on the development of

Oncology services in Ireland and what Sudan might learn from Irish experience.

The outcome of cancer patients in Ireland had been poor in comparison with other

EU countries for many years. In response to this a National Plan for Radiation

Oncology (NPRO) and a National Cancer Control Programme were published in


2006. Recommendations have since been implemented that have made dramatic

changes to the delivery of cancer services in Ireland. Improvements in cancer

survival have been seen in parallel with these changes. The national nature of the

programme which looked at the needs of the population as a whole has been

integral to its success. Political support was critical as funds were allocated and

ring-fenced for cancer. Strong leadership was needed and the appointment of a

director of the NCCP drove many of the changes that were needed to implement

the programme.

Dr Faisel Mihaimeed, Director of Cancer Surgery in St Barts Hospital, London,

UK provided an overview of the global burden of cancer with a focus on the

situation in low income countries where cancer incidence is dramatically

increasing. He spoke of the disparity between Africa and the developed world in

relation to survival of cancer patients particularly childhood cancers. He

discussed some of the reasons for this including lack of access to radiotherapy

treatment. He spoke of the particular challenges encountered in countries like

Sudan with inadequate registration of cancer cases, lack of awareness of cancer

symptoms due to lack of education of the population, lack of trained personnel to

deal with cancer due to “brain drain” as well as limited access to diagnostic and

treatment facilities. In his view prioritizing cancer prevention is the most important

priority in cancer control in Sudan given the lack of access to diagnostics and

treatment.

Dr David Weakliam, Head of the Irish Forum for Global Health, HSE, Ireland

presented on Sudan-Ireland collaboration and the potential of institutional

partnerships to improve health services. He spoke of the history of Irish-Sudanese

co-operation with Irish involvement in humanitarian programmes in Sudan and

Sudanese healthcare professionals working in the Irish healthcare system. He

highlighted the potential of institutional partnerships to improve healthcare in both

countries. The rapidly increasing incidence of cancer in Sudan in his view made it


an important disease to focus on. He discussed the principles of Irish Aid which

are built on namely partnership, public ownership and transparency, effectiveness

and quality assurance, coherence with a particular focus on creating long term

programme sustainability. He discussed the factors that lead to effective

institutional partnerships with a shared vision being a critical factor. Other factors

leading to successful partnerships included the importance of partners getting to

know each other, developing incrementally and clear communication between

partners. He discussed European Esther Alliance of which Ireland is a member of

whose goal it is to improve health in developing countries.

Finally Dr Mohamed Ahmed, Vice-president of the SMA spoke on the SMA

initiatives in Cancer Control. He provided an overview of the St James Hospital

(SJH) initiative supported by the SMA that aims to build capacity through training

of individuals. He spoke of the potential of an institutional partnership as per

ESTHER alliance model to twin SJH with the NCI. He identified potential sources

of support for this project including the Irish Cancer Society (ICS) as well as the

Irish Forum for Global Health (HSE)

Recommendations from the conference

1: There is an urgent need to provide specialized cancer treatment centres which

incorporate the three modalities of cancer treatment( surgery, radiotherapy and

chemotherapy) to serve the wider population of Sudan particularly areas remote

from Khartoum

2: Funding for establishing these needs to be allocated and ring fenced

3: A strategy needs to be developed to train, employ and retain appropriate cancer

healthcare professionals.

4: In order to plan for the future in terms of planning services a nationwide cancer

registration programme needs to be established.


5: Support should be provided from MOH to establish sustainable institutional

links between NCI and overseas institutions such as SJH for training of cancer

healthcare professionals as well as maintaining standards.


Conference sessions


Dr. Ahmed Elhaj , NCI Madani

In his presentation in the conference; Dr. Elhaj gave an overview about NCI

which was established in 1995 to meet the community needs in the fields of

Oncology, Nuclear Medicine and Molecular Biology. It is one of the clinical and

research medical institutes of the University of Gezira. The institute has six

departments including departments of Nuclear Medicine, Oncology, Molecular

Biology, Medical Physics and Engineering, Diagnostic Imaging and department of

Medical Laboratories.

NCI was established with the following vision:

1- Treatment and prevention of cancer.

2- Use of modern technologies of nuclear, molecular and imaging diagnostics.

3- Research in endemic diseases and cancer.

4- Training of Sudanese and African doctors, scientists, technologists and

researchers.

NCI has a large network of connections with international organizations and

with many similar local, regional and international institutes. This network

includes institutes form; Africa (Egypt, South Africa, Zimbabwe); Asia (Syria,

Jordan, Pakistan, India); and Europe (Italy, France, U.K., Germany, Sweden). NCI

has established relations with the International Agency for Research on Cancer

(IARC). IARC is one of the WHO agencies based in Lyon, France. NCI

Collaborated with IARC in establishing a population-based Gezira Cancer

Registry. NCI has a long standing collaboration with the International Atomic

Energy Agency (IAEA) of the United Nations. The IAEA has kindly provided NCI

with technical support in terms of technology transfer and capacity building of the

human resources of the institute. As a result, NCI has played a significant role in

technology transfer for the service of the community, and is now recognized as a

referral centre for advanced diagnostic methods in nuclear medicine, molecular

biology and medical imaging not only in Sudan but in the whole East African

region. It has been recognized as a central laboratory for HLA typing for Sudan

which enabled NCI to provide the service to other African countries as well.

Overview of the NCI, Madani


Figure 1: Gezira University established 1975.

NCI has designed training programmes for short courses as well as full

degrees. The areas covered so far are; molecular biology, nuclear medicine

technology and medical physics. Three post graduate programmes are approved by

the University of Gezira. These include the following:

1- MSc/PhD in Molecular Biology.

2- MSc in Medical Physics.

3- MSc in Nuclear Medicine Technology.

NCI staff has developed a good expertise in various epidemiological research

of cancer illnesses as well as tropical diseases such as Malaria and Schistosomiasis.

Environmental and genetic determinants of several diseases were the focus of a

number of studies. NCI researchers are extending this knowledge to conduct

epidemiological cancer studies taking into account the potential impact of

infectious diseases on cancer aetiology. In the last five years, NCI has organized a

number of workshops and conferences. Notably, is the conference of the CRTC,

which was held in Madani, Sudan in June 2004. The theme of the conference was:

"CRTC: an Initiative for Cancer Prevention and Advancement of Health Research

in Sub-Saharan Africa". The NCI has also organised short training courses on

recent advances in haematological malignancies in collaboration with consultants

from Queen Elisabeth hospital in the UK. NCI has established the Gezira Cancer

Registry (GCR) with the support of IARC which provided the necessary soft ware

and training for the registry personnel.

Cancer in Gezira state:

In Sudan, diagnosis of cancer is only performed in Khartoum and Gezira due

to the huge shortage in diagnostic facilities. Cancer treatment is generally


expensive, and most of the patients cannot afford such costs in a health system that

predominantly relies on its finance on out-of pocket payments. Cancer has now

become among the top ten killer diseases in Sudan. Among females, breast cancer

is on the top of the list (34.5%) followed by cervical cancer (14.3%). Among

males, prostate cancer is the top killer. Twenty-fold increase in numbers of

reported cases was observed since the first cancer centre was established in

Khartoum in 1967. National Health Insurance covers only investigations and

surgical procedures for limited number of cancer patients. The Government of

Sudan supports the poor people through social support fund which is currently

covering the chemotherapy cost only. However, public budget is clearly inadequate

for cancer prevention and other treatment modalities, medical supplies and for

provision of sufficient human resources.

Figure 2: Map showing the seven localities of Gezira state.

The total number of patients who attended NCI so far exceeded 20,000 with

about 1300 new patients annually. It covers seven localities in Gezira state as

shown in figure-2 with details of cancer cases and population from the year 2008

in table-1. Future development plans for NCI include; building of 110 bedded

wards, establishing surgical oncology service, strengthening of research

capabilities of the institute, manpower development and the improvement of the

existing facilities for cancer treatment.

Locality Populatin NO of cancer cases Incidence

rate

El Kamleen

401930 66 13


El hasahisa

606389 509 84

El managil

906216 193 21

Madani El kubra

423865 1226 289

Janub Elgezira

555250 866 156e

Sharg Elgazira

463154 327 71

Total

3575280

3265

673

Table 1: Incidence rate of the total number of cancer cases in 2008

Dr. Sediek M. Mostafa, Radiation and Isotopes Centre, Khartoum (RICK)

The Radiation and Isotopes Centre in Khartoum (RICK) was established in

1967 as the first cancer treatment centre in Sudan. The number of new cases seen

in RICK jumped from 250 in 1967 to 7500 cases in 2011. As a result of this

increasing pressure, there was more demand for more specialized centres for

cancer treatment. The NCI Madani was established in 1995. The two centers

(Marawi & Shandi) have building constructed and equipments contracted but

awaiting supply, installation and commissioning. There are planned centers for El-

Fashir (Darfur), El-Obied (Kordofan) and Gedarif. Funding has been secured for

the former of these centres.

During 1960s and 1970s, RICK’s radiotherapists, nuclear medicine physicians,

physicists, engineers, technologists and nurses were trained in Europe. Further

training and techniques updating are generally offered through courses, with IAEA

experts, scientific visits and CME courses. Brain drain of expensively trained

qualified staff remains to be a major problem facing RICK. Equipment

maintenance is another important challenge and despite the emergency funding

Overview of the Service Provision in radiation & Isotope centre,

Khartoum (RICK)


from the government, RICK is still in urgent need for $900,000 to update all

current equipments and replacing deteriorated components and out dated software.

Dr. Nabeel Mohamed, Shandi Centre of Nuclear Medicine and Oncology,

University of Shandi.

Shandi Centre of Nuclear Medicine and Oncology commenced providing

services in September 2009 as the third oncology centre in Sudan, after

considerable efforts from local community leaders, university directors and

political support. The hospital building which consists of four complexes is under

construction since January 2010 figure-3. It consists of four complexes. As shown

in table-2 the centre had treated nearly 500 cases since establishment in 2009.

Tumor Type Number of

Patients

Breast 112

Prostate 85

Thyroid 73

Cervix 57

Nasopharynx 38

Osophagus 32

Rectum 22

Brain 15

A.L.L 11

HCC 7

RCC 4

Lung 3

Total 459

Table2: Number of cancer cases treated at Shandi Centre of Nuclear

Medicine and Oncology (2009-2012)

Overview of Shendi Oncology Centre


The centre provides different health services for people living in River Nile state

through the following five departments as shown in figure-4:

Figure 3: Departments of Shandi Centre of Nuclear Medicine and Oncology

1. Oncology Department (clinic): Started in 2009 bi-weekly referring clinic.

Patients were referred to Khartoum Centre (RICK) to receive radiotherapy.

2. Early Detection Unit: Started in June 2010, mainly breast and uterine cervix

cancers. It consists of: Laboratory, Ultrasound machine and Minor Theater for

biopsy.

3. Chemotherapy Unit: Started in May 2010. It consists of a hall of 10

chemotherapy beds and pharmacy for preparation and dispensing of doses for

patients.

4. Nuclear Medicine Department: Started in March 2010. It consists of imaging

unit with Single Head SPECT Gamma Camera (MEDISO). This department has a

rradioactive Iodine unit with four isolated rooms.

5. Radiotherapy Department: It consists of Cobalt 60, Conventional Simulator,

TPS, and mould room.

Dr. Dafaalla Omer Abuidris, Dean, NCI, Madani

Hospital-based registry gives only rough estimation. There is huge potential to

lose record of many cancer patients in Sudan as some are unable to reach the

scarce cancer centres due to economical or accessibility reasons, others may die

before referral and many may not be diagnosed at all due to cost of diagnostic

Cancer Statistics in Sudan, Gezira State


process and referral system deficiencies. Some patients may be diagnosed but

decline referral and may seek alternative medicine pathways due to cultural beliefs.

Gezira cancer registry (GCR) was established in 2006 as the first attempt to

create a population-based cancer registry in Sudan. Sources of data includes:

Oncology hospitals (NCI & RICK), main general hospitals in Gezira, main state

and private pathology labs and expert reports. The contribution is so far

predominated by the hosting location in NCI as shown in Figure-6. The weight of

data provided by NCI in the cancer registry represents more than half of the data.

There is significant difficulty obtaining data from general hospitals. Moreover,

information on mortality is difficult to trace as most patients with cancer die at

home in the absence of structured palliative and terminal care institutions and

hospices. One of the possible future solutions is to establish regional registries.

This requires provision of sufficient budget and human resources. Ongoing work in

registry will improve the quality of data and mortality can become easy to estimate

through use of advanced telecommunication technologies.

Figure 4: Contributing data sources to National Cancer Registry

As shown in Figure-7 findings from the five-year registry report in Sudan

(2011) showed that total number of cases is 5762, of which 3177 were females.

The most common tumor was breast cancer (1012) which constituted 17.6% of all

cancers and just more than 30% of female cancers. Hematological cancers were the

second commonest. The second commonest solid tumor was prostate (368) which

constituted 14.3% of all male cancers.


Figure 5 National cancer registry common cancers percentages (overall and

by gender)

Dr. Ahmed Hashim, Cancer Registry in Khartoum

The first national cancer registry started in 1967 in Khartoum with data

collected through the department of Pathology in the Faculty of Medicine,

University of Khartoum. This cancer registry functioned well until the early 1980s

when it stopped due to lack of funds. Cancer registry unit was launched at the NCI

in 2006, and the National Cancer Registry (NCR) was re-established in 2009 as

there was a necessity for cancer registries in all 17 states as a prerequisite for the

national cancer control programme. The NCR is a population-based registration in

Khartoum State as the biggest state and the capital of the Sudan. The main

objective of the NCR is to develop a system that will facilitate all the steps and

processes of creating and maintaining local and regional cancer registries and

pooling them into a single central and accessible system. Reporting sources

includes passive case finding through hospitals and Radiotherapy centers that

employed registry officers to report cases with cancer & send the data to NCR.

Active case finding is done through data obtained from private clinics and

pathology laboratories that allow the registry officers to identify and access

relevant data during routine visits. In April 2010 a dedicated building was allocated

Overview of the Cancer Registry Services in Sudan


for national cancer registry and may health facilities in Khartoum state were

surveyed & focal points for these facilities were designated for registration of

cancer cases. Subsequently a universal registration form was designed & piloted

and registration booklets were distributed to private health facilities.

Training was provided for statisticians in Khartoum, River Nile, Northern

Kordofan and Northern states. Further training was also provided for registry cadre

in France, England and South Africa in cancer registration. A new branch of cancer

registry was established in Northern state.

The building of a comprehensive cancer registry is faced with many problems

including poor awareness of policy makers in Sudan about the importance of

cancer registration, the lack of funding for expanding cancer registration in remote

states; the poor capacity of cancer diagnosis in remote states e.g. lacks of standard

pathology services and the lack of funding for surveys and screening of cancer.

The future plans aim to achieve the following targets including training of human

recourses (data management staff, registration officers, medical registrars).

establishment of information networking with regional and international

organizations, cancer registries and databases, expansion of cancer registry in all

other states, production of regular biannual report, development of standardized

pathology reporting system and improvement of cancer registry information

system.

Dr. Wafaa N Elhadi;

KBCC started in October 2010 and it is not-for-profit institution. There has been a

significant increase in number of patients served by Khartoum Breast cancer centre

(KBCC). This is clearly reflected in the increased number of patients who received

chemotherapy (164 in 2011 compared to 330 in 2012). During 2012, a total of

2789 new patients were seen, investigated and provided with treatment compared

to 1814 in 2011.

Overview of the services in Breast Care Centre , Khartoum


Figure 6: Khartoum Breast Care Centre, KBCC

Prof. Ahmed MohaMadani ,Gezira University

Regional reference laboratories are needed (one in each state). Intermediate

laboratories (at least 50 km apart) and all highly specialised tests are done in

regional laboratories. The private sector is definitely providing great help. The

laboratory services needs accreditation which is so far voluntary but essential. It is

better to seek international recognition and accreditation. It involves regular visits

and subsequent certification with reaccreditation is done periodically (every 3-4

years). The cost is a main barrier and needs national and international support.

Laboratory techniques relevant to cancer care that need equipment, training and

standardisation were discussed including cheap and quick tests as cytology which

is needs a lot of experience and frozen section that needs special equipment ready

to provide intra-operative assistance to expensive tests as Cytogentics that needs

especial training and equipment, is becoming essential for accurate classification

for prognostic and therapeutic decisions. Immunohistochemistry tests were also

discussed with their two types including tests performed to determine cell

differentiation and used for diagnostic purposes and tests that are not related to

morphology but are used for prognostic and predictive purposes as (HER2/neu,

ER/PR).

Cancer Diagnostics in Sudan

Advocacy : Cancer Survivors Group


Mr. Ahmed Abuzaid

Mr. Abuzaid explored the difficulties faced by Cancer patients in Sudan such

as access to services, waiting times and overcrowded services. He also illustrated

the benefits that patients receive such as free radiotherapy and chemotherapy

interventions in public oncology centres in Sudan. Mr. Abuzaid showed a

documentary film of recovery stories of a number of patients with cancer in Sudan.

Mr. Ian Carter, Senior Health Manager, Health Services Executive (HSE),

Ireland

Mr. Carter started his talk by the description of a model for a National

Cancer System that addresses issues including National Control planning, Funding

and resource allocation, overall systematic design (top down, focus on population

as whole, adoption of evidence-based strategies for prevention, early detection,

diagnosis, treatment and palliation, selection of treatment options with their cost

implications comparing efficiency and effectiveness of different modalities,

establishing a National data registry that can help in subsequent outcome and

performance evaluation and Impact analysis through a National clinical audit

programme.

Development of a National Cancer Centre Model: Standards and

Challenges


Mr. Carter also discussed guidelines for establishing a model that should

adopt a population-based health system approach that recognises and addresses

inequalities with emphasis on health promotion, prevention and early detection. It

should recognize key areas of focused interventions as tobacco control, and

addresses the provision of population based and opportunistic screening

programmes adopting simple, safe, precise, validated & cheap tests with prompt

linkage to a treatment pathway if test was positive through a system that provides

effective treatment and interventions with multimodality coordination of Surgery,

Chemotherapy and Radiation Oncology. Optimally, the service setting should

allow for analytical ability through randomised trials to detect effectiveness of

interventions.

In Ireland Oncology services structural reform requirements generally entail that

hospital cancer centres to have internal capacity and capability to satisfy

population base of 500,000 with provision of full range of general medical and

surgical services including pathology, laboratory, radiology, critical surgical

subspecialty services, medical oncology, curative and palliative therapies working

within multidisciplinary teams. It should also provide a full range supporting staff

as Full Range Palliative and Specialist Nurses, Dietetic, Physiotherapy Services,

Counselling Services, Clinical and Compounding Pharmaceutical Services, Social

Work Services. It should be able to provide training facilities for specialty training

for health professions and research facilities including clinical trials. It should have

the capacity to measure adherence and compliance with treatment protocols;

maintain satisfactory quality assurance process, active engagement in accreditation

a close linkage with higher education institutions and an effective linkage with

Primary Care. Future collaboration can cover the following areas

• International Cooperation, collaboration and partnership.

• Comparison and evaluation of incidence & treatment outcomes.

• Quality Assurance Collaboration, licensing, accreditation and external

validation.

• Research partnership and education and learning opportunities.

Radiotherapy Services in Ireland: What Sudan might learn from

Ireland


Dr. Aileen Flavin; Consultant in Radiation Oncology, Cork University

Hospital, HSE, Ireland

Dr. Flavin started her presentation by giving an overview of the main seven

principles on which Oncology services development plans were based in Ireland

shown in figure 8. She described the transformational plan of cancer service

development that focussed on the establishment of four supra-regional centres

including two in the capital Dublin, one in Cork city in the south and a fourth in

Galway city in the west. Each centre will have access to all three modalities of

treatment (surgical, medical and radiation Oncology) in multidisciplinary care with

access to acute services. Regarding the radiotherapy component each centre should

have at least four radiotherapy treatment Linac units with a total of just below 40

Linacs in the country whole country serving a population with over four millions.

The current Radiation Oncology services in Ireland are provided by 28 Radiation

Oncologists treating 29,745 patients per year achieving a 5-year survival rate of

about 55%.

Figure 7: Principles of Irish Oncology Services planning

The National Plan for Radiation Oncology in Ireland (NPRO) 2006

recommended to have a national network of six facilities providing services under


four large centres: two in Dublin and one in each of Cork and Galway with two

integrated satellite centres in Waterford and Limerick (managed by Cork and

Galway, respectively). Patients in the North-West region can have their care

affiliated to Belfast in North Ireland. Since the publication of NPRO in 2006

access has improved and national approach and collaboration in many areas such

as prostate brachytherapy and stereotactic radiotherapy has been developed with

collaboration with research: Radiotherapy trials portfolio and in 2012, National

Guidelines radiotherapy was developed for common tumours.

Dr. Flavin showed that although Ireland has a good cancer registry, cancer

outcome in Ireland is worse than European neighbours and radiotherapy services in

Ireland are under-utilised with some difficulties in access and lack of

multidisciplinary working in some centres. Private centres in Ireland are not

completely integrated in the national network so far. She then proposed potential

areas that can be adopted by Sudan from Irish experience including the necessity

for a national approach in the context of national cancer control plan. She flagged

the concern improving radiotherapy may not have a major impact as high

percentage of cancers would be advanced at the time of diagnosis. It is essential to

have a functioning updated National Cancer Registry that helps in knowing extent

of the problem to aid planning for future services with appropriate infrastructure

with particular attention to equal access. The assistance of IAEA and WHO should

be sought in developing a national cancer control plan for which the WHO

document (Developing a National Cancer Control Plan) is an important resource.

Dr. Faisal Mihaimeed: Director of Cancer Surgery, Barts Health NHS Trust,

London, UK

Dr. Mihaimeed gave an overview of global cancer burden accounting for

12.5% of all deaths worldwide with more cancer attributed deaths than those die as

result of HIV/AIDS + TB + Malaria combined with the expectation of annual

incidence of 15 million new cases every year diagnosed globally by 2020. 70% of

the newly diagnosed cases will be in developing countries, where governments are

least prepared to address the growing cancer burden. Survival rates in developing

countries (such as Sudan) are often less than half those of more developed

Developing Cancer Strategy in the under resourced Health

System: Challenges & Opportunities


countries. Over one third of cancer deaths are due to preventable causes such as

viral infection, poor nutrition and widespread tobacco use. In Africa, on average

5% of childhood cancers are cured, compared to nearly an 80% cure rate in the

developed world.

Life-saving radiotherapy is available in only 21 of Africa’s 54 countries, or to less

than 20% of the population of Africa. The combined effects of cancer, poverty,

deprivation and infectious diseases in many African countries, hinder the

development of a sustainable population and consequently a sustainable future.

Efforts to improve these poor cancer-related indicators in developing countries

are faced with considerable challenges including:

1\ Inadequate data collection and registration of diagnostic and therapeutic

procedures and outcomes.

2\ Lack of awareness and education in a population with significant illiteracy rates

needs to be carefully addressed. Efforts need to be made to get the message that

cancer can be treated if it is discovered and treated early.

3\ Human resources shortage is one of the major challenges confronting cancer

services with massive brain drain and frequent immigration to the neighbouring

Gulf States with attractive irresistible financial reward.

4\ Limited access to technology necessary for accurate diagnosis and effective

therapy and even secure data storage and analysis.

In this complicated environment to establish new up-to-date services facing

these challenges that are deeply rooted and difficult to overcome in a context of

poor socioeconomic status, prioritizing cancer prevention activities may be of

greater importance than countries well equipped to address the complexities of

providing a comprehensive cancer care service from early detection, diagnosis,

treatment, follow up and even terminal care. Preventive measures include:

• Improving awareness

• Encouraging people to adopt of healthy lifestyles

• Smoking control interventions as smoking is the single largest preventable risk

factor for cancer.

• Excessive alcohol consumption is strongly linked to an increased risk of several

cancers.

• Vaccination is now available specifically for cervical cancer.


Figure 8: Conceptual framework for assessing access to health services (ADAY.

L.A. et al 1997)

Dr. David Weakliam; Chair of the Irish Forum for Global Health, HSE, Ireland

Dr. Weakliam started his presentation by the stressing the importance of a

functioning health systems that is essential to deliver health services and

interventions and the need for capacity building of key health institutions as a

critical element in developing cancer services. He suggested that there are

opportunities for Sudan-Ireland collaboration to provide an example for a North-

South institutional partnership as an effective means to build the capacity of health

institutions in developing countries. He described the six building blocks of a

health system shown in Figure-9.

Sudan-Ireland collaboration: the potential of institutional

partnerships to improve health services


Figure 9: The six building blocks of health systems

Dr. Weakliam discussed the opportunity for partnership with Sudan in the

development of cancer services with emphasis on the need for leadership

involvement and commitment as vital prerequisite, supporting the national

strategy, provision of prevention and early detection services, diagnosis and

treatment facilities and palliative care. He also addressed need for partnership in

organisation and management aspects and sharing learning on best practice

particularly from model centres of excellence that can provide guidelines,

protocols and tools for information to be nationally used in satellite branch centres.

He described eight areas of focus for the potential future collaboration as shown in

figure-10. And described initial steps required when building a new partnership as

shown in figure-11

Figure 10: Focus areas for future Sudan-Ireland collaboration


Figure 11: Initial steps in starting a new partnership

Dr. Mohamed Ahmed; Vice president of the SMA Ireland

Dr. Ahmed gave an overview of St. James’ Hospital (SJH) Initiative that aims to

build institutional capacity through training of individuals. SJH could assist in

providing guidance in many areas including identification of strengths, planning to

improve provision and utilisation of resources, accreditation cycle through training,

support and peer review, mutual visits and placements for Sudan health

professionals in SJH, providing a twinning model similar to the European

ESTHER Alliance model that Ireland joined in Feb 2012 and provides institutional

capacity building activities through twinning between hospitals of the North and

hospitals in developing countries. The twinning should meet certain criteria and

allows provision of some funding. This conference is a platform to create such

links for the future twinning between the Oncology divisions in SJH-Ireland &

NCI, Madani-Sudan. Potential support can be sought through the Irish Cancer

society. Irish Cancer Society is a charity organization and a strong advocate for

improving Irish cancer services. It is the main provider of cancer information for

prevention, detection, treatment and support in Ireland. It provides large numbers

of information leaflets & booklets in simple language. The SMA UK & Ireland got

Irish cancer Society permission to translate all of their Cancer info material into

Arabic. Translated booklets and leaflets will be available in Sudan in both

From Dublin to Madani: The SMA initiatives in Cancer Health

Care


electronic and paper formats. The Irish Forum for Global health will provide

logistic & advisory support to the project in Ireland.


CONFERENCE RECOMENDATIONS

There is an urgent need to provide more specialised cancer treatment centres (with

3 modalities of treatment) to serve the wider population of Sudan especially in

areas distant from Khartoum such as Kordofan, Darfur and East of Sudan.

Funding for establishing such centres should be provided and ring fenced.

Human resources policy to train, employ and retain health professionals in the area

of cancer treatment.

A nationwide cancer registry programme should be established in Sudan in view of

the current fragmented registry services in Khartoum and Madani.

The National Cancer Registry should undertake epidemiological studies

investigating prevalence and burden of cancer diseases.

The outcomes of such studies should help in planning cancer services in a cost-

effective model.

Sudan is developing a national cancer control strategy and this provides an

appropriate framework for collaboration. Support provided by Irish institutions

should be in line with Sudan's national strategy.

There are good reasons to establish a direct institutional link with the NCI. It

already serves a large population base. It is well placed to develop services with

the new hospital being built, good institutional leadership, committed doctors and

strong community/political support. Its throughput is less that of RICK so there is

plenty of scope to expand services. In order to achieve better outcomes there is a

need to shift from late treatment/palliation to early detection and treatment.

While there are many institutions in Ireland which could provide support it makes

sense for NCI to establish a strong link with one institution, i.e. SJH. Through this

link connections can be made with other centres and organisations as indicated

(e.g. National Cancer Control Programme, Cancer Registry)


It is appropriate to focus initially on oncology services. However opportunities to

support the full range of services should also be considered over time - i.e.

including prevention, early detection and palliative care.

In order to develop an appropriate programme to support services development at

NCI, it would be important for senior clinical staff to visit and get exposure to

cancer centres and services in Ireland. SJH (Ian Carter) has offered this invitation

and will further communicate with NCI. We should be mindful that Sudan will not

exactly follow the Ireland model - for instance nursing and AHP staff play a more

limited role in Sudan and it will take some time to strengthen their role and

develop a multidisciplinary team approach. Through a visit to Ireland, NCI

clinicians will get insights into what can be strengthened in Sudan and a

programme can be tailored accordingly.

An institutional linkage with SJH offers the potential for a range of service quality

improvement measures, from individual training to institutional accreditation. Up

skilling of existing staff is a priority as the IAEA report identified that current

staffing levels are adequate. Training could include short visits to learn a

particular skill (few weeks - month) or longer for more formal training

programmes (e.g. certified nursing course).

Access to specialist training for doctors in oncology/radiation oncology is not

feasible due to the very limited places in Ireland. An option worth exploring is

whether Sudanese doctors could be facilitated to fill vacant service posts on a time

bound contract and get some recognition for experience and participation in

training activities. There would be a reciprocal benefit to Ireland through the

filling of vacant NCHD posts. This would require discussion with the HSE and the

respective training bodies (RCSI, RCPI and Sudan Medical Specialisation Board).

Something similar has been tried in the UK.


Annex


Conference Programme




Photo Gallery


Meeting with the Minister of Health in Gezira State

Meeting with NCI Clinical Team


Meeting with the Vice President of University of Gezira

One of the conference sessions


One of the conference sessions

The visit to NCI, Madani


IEA Report


Diagnosis and Treatment of Cancer in Sudan: IAEA Report

Diagnosis and treatment of cancer in Sudan is managed primarily at three centres,

including the Radiation and Isotopes Center Khartoum (RICK), National Cancer

Institute and Shandi Cancer Center. There are some cancer-related services

provided at secondary and tertiary hospitals, and notably less at the primary

level. The referral system for cancer in Sudan is also noted to be weak.

Efforts are being made by the government to scale up cancer services at the

primary health care level, notably in prevention and early detection. A pilot study

is being undertaken from 2012-2013 to integrate cancer services in seven states

into primary health care. Training Tools, provision of supplies and training

courses are included in this plan.

Under its Cancer Advisory Committee within the Federal Ministry of Health,

two standard case management protocols for breast and prostate cancer have been

established. However, it was noted that these have not yet been widely distributed

due to lack of funds for publication

and distribution.

Encouragingly, interest on the part of investors to establish and strengthen

health facilities has been demonstrated recently. For instance, an extension of

RICK (opening of the Amil, or ‘Hope’ Tower) was made possible three years ago

through a US $6.7 million grant from the Islamic Development Bank. Many of

these projects are responsible for inviting foreign experts for short periods of

time to Sudan. However, a challenge facing Sudan is the often dramatic currency


fluctuations that serve as an obstacle to investors.

Most cancer-related services are available for free or are relatively

inexpensive. Missing diagnostic investigations are referred to private centers,

which can be up to 300 times more expensive. Some tests have a waiting list of

up to three weeks. Of the approximately 10 000 new cancer patients diagnosed in

Sudan every year, RICK receives an estimated 7 000 – 8

000 patients while another 1 300 are seen in NCI.

As earlier mentioned, there are published treatment protocols for breast and

prostate cancers. However, these protocols are not widely distributed to

oncologists, and as result, recommendations are often not followed.

Radiation and Isotopes Centre Khartoum (RICK)

RICK is the main referral center, treating the largest number of cancer cases

in Sudan. Almost fifty per cent of female cancers seen at RICK are breast (25-

30%) and cervix (12%). The predominantly prevailing male cancers are 17-20%

prostate, 10-12% head and neck followed by cancers of the oesophagus.

Instituted in 1967, RICK recently underwent an expansion due to a grant

provided by the Islamic Development Bank (IDB). The Amil Tower (‘hope’ in

Arabic) is connected to RICK and was instituted three years ago. There are 100

beds for patients. The department of radiation oncology has four external

beam machines (two linear accelerators, two Co 60). The external beam

machines work in three shifts starting from 6:00 a.m. to 2:00 a.m. for the Co-60

machines (shifts begin at 8:00 a.m. for the linear accelerator). On a typical day,


190 - 200 patients are treated on all machines. The waiting period ranges from

one day to three months depending on curative or palliative intent. Seventy per

cent of patients are treated with palliative intent and the remaining thirty per

cent curative. The department has one HDR brachytherapy BEBIG machine. Staff

at RICK stated that repair and maintaining uptime of radiotherapy equipment

is a challenge. As there is neither a maintenance contract nor budget for

maintenance of equipment, machines can sometimes be out of order for several

months at a time leading to insufficient radiotherapy provided to cancer patients.

A quality assurance programme for radiotherapy is in place at RICK.The staff is

comprised of 25 radiation oncologists, 65 radiation technologists, 10 medical

physicists and 10 biomedical maintenance engineers.

With regards to nuclear medicine, RICK is equipped with a SPECT gamma

camera, a radioiodine facility, isolation rooms, and staffed with four nuclear

medicine specialists and 16 nuclear medicine technologists. In diagnostic

radiology, RICK has two conventional X-ray machines, an ultra-sonography

machine, CT machine, three radiologists and five technologists.

There are an estimated 500 paediatric cancer cases per year in Sudan, of which 40

percent are treated at RICK. There are fourteen paediatric beds available, and

another eight were being prepared to be opened at the time of the mission.

Roughly 30 paediatric patients are seen per day. For chemotherapy, eighty beds

are available for male and female patients. Chemo radiation is being used for 25

patients daily. Overall, 140 - 150 patients receive chemotherapy daily. Cancer

patients requiring surgery are referred and undertake procedures outside RICK.

The clinical pharmacy started in 2007.


National Cancer Institute (NCI)

The NCI at the University of Gezira (formerly the Institute of Nuclear Medicine

Molecular Biology and Oncology – INMO) has been in operation for thirteen

years and provides cancer services. The NCI is based in Wad Madani, roughly

three hours from Khartoum. NCI features two buildings, one of which is

currently undergoing a US $18 million construction for expansion of the

hospital. The new building will be comprised of five floors and 120 beds. Once

completed, the centre will have capabilities in chemotherapy, surgery, radiation,

operation theatres, palliative care and iodine therapy (as a part of nuclear

medicine). The centre also has a hospital-based cancer registry which seeks to

cover the four million people living within Gezira State (of the 30 million total

population of Sudan, as per 2008 census), in addition to surrounding states. The

radiology department is equipped with one MRI scan investigating 20 patients

per day and one ultrasound machine testing 25 patients daily. Conventional

radiology is also available. The radiology staff includes two specialists and six

radiographers.

The nuclear medicine department is equipped with one gamma camera and one

SPECT. The staff is comprised of two specialists, four radiographers, two

pharmacy technicians and one radiopharmacist.

NCI also has a well-equipped molecular laboratory with four machines for tissue

typing, used primarily for renal transplant, liver transplant and dialysis. The

laboratory has also analyzed tumour markers and hormone profiles. There is

one pathology laboratory that conducts routine pathology studies (including

blood studies). Six staff members work in the laboratory.

Regarding radiotherapy, the centre is equipped with one Co-60 machine operating

daily from 8:00 a.m. to 6:00 p.m. which treats sixty patients daily. The waiting


list is one week for patients beginning radiation therapy. Treatment and dose

schedules are radical and curative for fifty per cent of patients and palliative for

the remaining half. The centre does not have a brachytherapy machine and a

request to the IAEA has been put forth for a high-dose rate brachytherapy

machine. An old LDR machine has not been functional for the past ten years.

According to 2011 data, the centre treats an estimated 1 300 patients per year with

radiation.

Much like RICK, staff at NCI noted difficulties in keeping equipment up and

running on a consistent basis. There are no budgets or maintenance contracts in

place for the majority of equipment at NCI. There are no trained service

engineers on staff at NCI who are able to repair any out of service equipment

and obtaining maintenance from abroad under the present circumstances remains a

challenge. A quality assurance programme for radiotherapy is established at NCI.

The centre is equipped with 15 dedicated chemotherapy beds. Chemotherapy is

provided at no cost to the patient and an average of 25 patients is seen daily. NCI

presently has 47 inpatient beds for males and females. The centre has two

paediatric oncologists who are treating one hundred patients annually.

For male and female patients receiving treatment at NCI, a 50-bed boarding

house is made available for longer-term stays and is located in the vicinity of the

hospital. The house hosts a kitchen for patients and families staying at the

facility, and offers patients (who sometimes travel from neighbouring countries) a

chance to finish treatment while remaining on site.

Shandi Cancer Centre

Shandi Cancer Centre is a university based center. Shandi University Hospital has


one clinic, the ‘older’ Shandi Centre, which treats an estimated 375 new

cancer cases per year (an estimated 75 of these cases are referred from RICK).

Diagnosis services (except for nuclear medicine) are located in the hospital

campus. Hematology, parasitology, microbiology and histopathology laboratories

(no immunohistochemistry) are well equipped and staffed.

Radiology services include conventional X-ray, ultrasound and CT scan; a

radiologist and three technologists make up the staff. There is neither a

mammography unit in the hospital nor a colposcopy unit.

The nuclear medicine service is located in the cancer unit. The facility is

equipped with a gamma camera and staffed by two technologists, one medical

physicist and one nuclear medicine physician (currently training in Egypt). A

very small number of cases are seen, since only one Technetium99

generator per

month is procured from Turkey.

Surgery is mostly performed at the surgical departments of the hospital or in

Khartoum and then sent for chemotherapy and follow up in Shandi. The center

has a chemotherapy service that is run by one clinical oncologist who travels

from Khartoum once per week, typically examining 30 patients per visit. The

service is a day care service with 15 beds and a centralized area for

chemotherapy preparation (with a laminar flux cabin). One clinical pharmacist

and three nurses treat 10-12 patients per day. There is currently no radiotherapy

service at the center. Two oncologists are currently in training.

Though not yet ready to receive cancer patients, the Shandi Cancer Center has a

new campus under construction. Consisting of five buildings, the new centre is


about to open. In the new facility (located outside of the university hospital

campus), the main building will host radiotherapy and chemotherapy services.

Radiotherapy equipment has already been procured and consists of one

“Equinox” cobalt therapy unit, one conventional simulator, a 2D treatment

planning system (TPS) and a brachytherapy unit (with cobalt sources). Staff for

this service will be available when the centre opens, and will be comprised

of two clinical oncologists, two medical physicists, and two RTTs. A nuclear

medicine service will also be added to the treatment facility. The new center will

have two inpatient wards, a day care unit for oncology ambulatory treatment and

radiology department.

Additional Sites

Khartoum Teaching Dental Hospital is a government hospital that treats

250 patients annually with head and neck cancers. Most head and neck cancers

that present at the hospital are late-stage cancers among men aged 31-40 and are

referred to RICK for radiation and chemotherapy. Cases requiring surgery are

seen by three head and neck surgeons who perform complex resections and

reconstructions at the hospital. The hospital has four operating rooms and 50

beds. In 2006, 155 cancer patients were seen at the hospital. Two- hundred and

fifty were seen in 2011, and raise of awareness among the population about ‘the

bad disease’ (as cancers is sometimes referred to among the general population) is

seen as the cause.

Rabat University has an ambitious plan to construct a US $14 million cancer

center in Khartoum. To date, land has been secured for the project though lack of

funding has delayed the project.


Khartoum Breast Center is a privately owned, state of the art breast centre that

commenced operations last year. Staff from the centre claimed that they suffer

from currency fluctuations and few patients, since many nationals who can afford

treatment prefer travelling abroad.

The breast center in Khartoum Hospital opened in 2005 which has four

surgeons and four medical oncologists as staff. Most cases are advanced and

require mastectomy and/orchemotherapy. Reconstruction has been recently

introduced. There is currently a five months delay for treatment, and treatment is

not free for patients. There is no MRI capability. They refer mammography to

private centers.

Royal Care Private Centre is a private multi-specialization hospital. The

surgical department is made up of three general surgeons, one vascular

surgeon and one neurosurgeon. There is one clinical oncologist on staff

taking care of chemotherapy for referred cancer patients. Royal Care has a

clinical p harmacy department. The hospital demonstrated interest in acquiring

radiation oncology facilities. The oncologist informed the team that Royal Care’s

plan was for one linear accelerator, one planning system and one CT simulator.

Bunkers for two machines have been designated in the basement.

Alneelin Diagnostic Clinic is a private facility with nuclear medicine and radio

diagnostic capabilities. The centre has a SPECT Single Head Gamma camera,

one MRI scan, one CT Scanner, one Mammography machine, one ultrasound

(alone), one ultrasound with Doppler facility, one conventional x-ray, in

addition to endoscopy facilities (Including Gastroenterology, cystoscopy,

echo cardiography, EEG, ECG, lithotripsy and blood studies). The centre works

in two shifts and some services are available for 24 hours per day, seven day per


week. The staff included seven doctors on permanent staff and seven working on

a Shift basis.

Khartoum Maternity Hospital is the oldest and largest women’s hospital in

Sudan. The hospital has one gynecologist oncologist on staff. The hospital gives

special attention to the early detection of cervical cancer.

3.7 Assessing Sudan’s Radiotherapy Needs

When devising a radiotherapy plan, it is advised that the plan be designed in

phases based on the quantity and complexity of the equipment and the human

resources needed. The plan specific for radiotherapy should be integrated within

the larger National Cancer Control Plan. According to GLOBOCAN 2008 data,

there are 21 860 new cancer cases in Sudan per year. As it is recognized that

60% of patients will require radiotherapy during the course of treatment,

approximately 13 116 cancer patients will need treatment annually.

Sudan presently has two linear accelerators and three Co-60 machines in working

order for a population of 30 million. However, these machines are present in

only two centres in two adjacent states (Khartoum and Gezira) and do not cover

the whole population. The impact team endorses the government’s plan to develop

five new centres with additional machines to meet the radiotherapy needs of

Sudan.

Since one radiotherapy machine can treat an estimated 500 patients per year, it

is foreseen that 26 radiotherapy units would be required to serve the needs of


cancer patients in Sudan. However, the requirement of 26 teletherapy units is

made on the assumption that all patients with cancer in Sudan would seek

treatment. At present, the number of patients in Sudan seeking treatment with

radiotherapy (and other interventions) is expected to be less than those expressed

by GLOBOCAN estimates due to the following reasons:

• Access, whether geographic or economic. Given the large distances that

patients must travel across Sudan to seek treatment, many patients may not have

the financial means to support transportation costs. Further, patients and families

must have sufficient financial resources to arrange for accommodation and

other requirements for the duration of treatment in Khartoum or Wad Madani;

• Sub–prescription of treatment, often attributable to the lack of specialized

knowledge by doctors in charge a patient’s treatment; and

• Overcapacity of radiotherapy treatment centres. Often, overloaded

radiotherapy centres cannot accommodate a large influx of patient demand, or

must delay treatment for patients who present at late stages of disease. As per

IAEA staffing recommendations (one radiation oncologist per 250-300 new

patients), radiation oncologist staff is adequate in both RICK and NCI (25

radiation oncologists for 7000+ patients at RICK and three oncologists at NCI for

1300 patients), though a continuous professional development program needs to

be instituted so that trained staff can be retained. The number of radiation therapy

technologists is adequate as per IAEA recommendations. Given the IAEA

guidance on medical physicist staffing (one medical physicist per 400

patients), the current 15 working in Sudan would need to be coplemented to

meet a recommended 21. Staffing requirements would need to be reassessed

given the planned expansion of radiotherapy services in the country.

With respect to training and human resource development, a training programme

for radiation Oncologists was started in 2002 and is under the Medical Council.

Currently, 34 radiations Oncology registrars are under training; of those, nine

are in their final year. Fifteen such Students have graduated from the programme

in the last five years. Medical physicists also receive training and obtain a Master’s

of Science Degree. The radiation therapy technologist course is offered and is of

four years duration. Under the programme, training is conducted in both radio-

diagnosis and therapy.

The IAEA provides guidance on the assessment of radiotherapy needs and further

recommendations on setting up a radiotherapy programme1.

1 Setting Up a Radiotherapy Programme: Clinical, Medical Physics, Radiation

Protection and Safety Aspects:http://cancer.iaea.org/documents/Ref5-

TecDoc_1040_Design_RT_proj.pdf Planning National Radiotherapy Services: A

Practical Tool: http://www-

pub.iaea.org/MTCD/publications/PDF/Pub1462_web.pdf

1

Health & Medicine

Oncology services in sudan