The outside medical evacuation for cancer from Madagascar

The outside medical evacuation for cancer from Madagascar

Refeno Valéry^1,&, Hasiniatsy Nomeharisoa Rodrigue Emile², Ramahandrisoa Andriatsihoarana Voahary Nasandratriniavo³, Rabarijaona Léontine Irène³, Rafaramino Florine³

 

¹Oncology Department of Professor Zafisaona Gabriel Teaching Hospital, Faculty of Medicine of Mahajanga, Mahajanga, Madagascar, ²Oncology and Palliative Care Department of Military Hospital, Faculty of Medicine of Antananarivo, Antananarivo, Madagascar, ³Oncology Department of Joseph Ravoahangy Andrianavalona Teaching Hospital, Faculty of Medicine of Antananarivo, Antananarivo, Madagascar

 

 

^&Corresponding author
Refeno Valéry, Oncology Department of Professor Zafisaona Gabriel Teaching Hospital, Faculty of Medicine of Mahajanga, Mahajanga, Madagascar

 

 

Medical evacuation (MEDEVAC) is the transfer of a patient from one health facility to another. This patient is suffering from a medical or surgical condition requiring investigation and/or care exceeding the limits of the capacity and technical competence of the health unit that transfers [1]. In developed countries, cancer care benefits from the availability and accessibility of different therapeutic resources [2]. In developing countries, particularly those in Africa, the management of cancer is hampered by the unavailability and inaccessibility of certain technical platforms including radiotherapy and scintigraphy [3]. Knowledge of the missing technical platforms could help prioritize investments in health infrastructure for the fight against cancer. Thus, our objective was to describe the requests for external medical evacuation for cancer in order to make an inventory of the technical platforms missing in Madagascar in terms of oncology.

 

We carried out a retrospective cross-sectional descriptive study, at the Department of the Hospital System of the Ministry of Public Health, Antananarivo, which is the only institution authorized to grant the outside medical evacuation in Madagascar, from 1^st January 2012 to 31^st December 2012. We have included all files of external medical evacuation request. After excluding records of non-oncology cases, we retained patient records requesting outside medical evacuation for cancer. Of the 91 external MEDEVAC application files, 25 were cancer cases (27.47%). The mean age of the patients was 45.12±18.11 years and the sex ratio was 0.47. Eighteen patients (72%) came from the capital of Madagascar. Metropolitan France was the most popular MEDEVAC site (44%). The most represented clinical situations were breast cancer waiting for adjuvant treatment (n=9 or 36%), lymphoma waiting for second-line treatment (n=2 or 8%) and brain tumors waiting for initial treatment (n=2 or 8%). The main technical platforms required were radiotherapy (n=13 or 52%), specialized paraclinical investigations (n=5 or 20%), specialized surgeries (n=4 or 16%) and specialized medical treatments (n=3 or 12%). Table 1 summarizes in detail the reasons for requesting outside medical evacuation for cancer. The most common clinical situations were breast cancer waiting for adjuvant treatment (36%), lymphoma waiting for second line treatment (8%) and brain tumors waiting for initial treatment (8%). Only one patient had requested outside MEDEVAC for adjuvant treatment of cervical cancer. This fact draws our attention because cervical cancer was, with breast cancer, among the most represented cancers in epidemiological studies conducted in the cancer centers of the capital [4-7]. According to GLOBOCAN 2012 estimates, cervical cancer is the most common cancer in Madagascar [8]. Otherwise, radiotherapy was an essential treatment in the management of cervical cancer in Madagascar when it was functional [2]. Therefore, in the absence of radiotherapy, it can be assumed that the majority of patients with cervical cancer did not receive optimal treatment.

 

In our study, the main technical platform requested was radiotherapy (52%). Outside MEDEVAC patterns seem to vary according to the technical platform available within the country. In the study by Amoussou-Guenou et al. in Benin, the main reasons for outside evacuation from 2006 to 2010 were radiotherapy and scintigraphy [3]. The scintigraphy was functional in Madagascar in 2012 and did not require outside MEDEVAC. Currently, this treatment is available based on the supply of radioactive material. In the Muteganya et al. study in Burundi from 1986 to 1993, radiotherapy-being unavailable-was the only reason for requesting outside MEDEVAC for cervical cancer patients who needed it [9]. According to Barbe et al. the specialties of onco-hematology, neurosurgery, cardiac surgery and radiotherapy did not exist in New Caledonia from 2008 to 2011 and required the outside medical evacuation of patients concerned by these diseases. In addition, New Caledonia received outside MEDEVAC from neighboring islands, particularly from the Wallis and Futuna Islands, for the management of certain serious medical and surgical conditions and all cancers since chemotherapy was not available in these areas [10]. Many chemotherapy molecules and neurosurgery were available in Madagascar and have not motivated outside MEDEVAC in our sample. The overwhelming demand of MEDEVAC for radiotherapy of our patients can be explained by the fact that radiotherapy was not available in Madagascar from 2009 to 2014 [2]. The existence of a private radiotherapy center that has been operational since April 2015 should reduce the number of outside medical evacuations for cancer and improve the management of patients who need it. In addition, a second radiotherapy center is currently under construction in a Teaching Hospital of the capital and should further improve access to this treatment. Nevertheless, a lot of authorities investment remains to be done because positron emission tomography, digestive echo-endoscopy, interventional radiology and hematopoietic stem cell transplantation which were unavailable in 2012 are still unavailable in 2018 and require the outside MEDEVAC of patients.

 

 

The authors declare no competing interests.

 

 

Table 1: summary of the reasons for requesting outside medical evacuation for cancer in Madagascar in 2012

 

 

1. King MA, Niven AS, Beninati W, Fang R, Einav S, Rubinson L et al. Evacuation of the ICU: Care of the critically ill and unjured during pandemics and disasters: CHEST Consensus Statement. CHEST. 2014 Oct;146(4 Suppl):e44S-60S. PubMed | Google Scholar


2. Hasiniatsy N, Ernestho-ghoud I, Ralamboson S, Rabarijaona LI, Rafaramino F. Prise en charge et suivi des cancers du col utérin: la réalité à Antananarivo, Madagascar. J Afr Cancer. 2014;6(1):40-46. Google Scholar


3. Amoussou-Guenou K, Fachinan O, Gbénon S, Komonguib DG, Houndétoungana GD. Place de la scintigraphie et de la Radiotherapy dans les évacuations sanitaires hors du Bénin de 2006 à 2010. Médecine Nucl. 2013;37(10-11):507-510. Google Scholar


4. Ranaivomanana A, Hasiniatsy N, Randriamalala N, Rafaramino F. R01 Les cancers vus au service d'oncologie CHUA-HUJRA de 2009 à 2010. Rev Méd Madag. 2012;3(2):S288-9.


5. Hasiniatsy N, Ramahandrisoa A, Refeno V, Rakoto FA, Rafaramino F. Epidémiologie des cancers pris en charge en Oncologie Médicale à l'Hôpital Militaire d'Antananarivo, Madagascar. Bull Can. 2017 Oct;104(10):902-904. PubMed


6. Rafaramino F, Rabarijaona L, Randriamampandry A et al. Cancérologie: brochure-guide à l'usage des médecins, Antananarivo, Trano Printy Fiangonana Loterana Malagasy. 2004.


7. Raharisolo Vololonantenaina C, Pecarrere J, Roux J. Le cancer à Madagascar, expérience de l'Institut Pasteur de Madagascar de début septembre 1992 à fin 1996. Bull Soc Pathol Exo. 1998;91(1):17-21. PubMed | Google Scholar


8. Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2012;136(5):E359-86. PubMed | Google Scholar


9. Muteganya D, Bigayi T, Bigirimana V, Sindayirwanya JB, Marerwa G. Les cancers du col utérin au CHU de Kamenge: à propos de 35 cas. Med Afr Noire. 1999;46(3):153-6. Google Scholar


10. Barbe C. Les évacuations sanitaires dans le Pacifique. Le cas de la Nouvelle-Calédonie. Hermès. 2013;1(65):144-8. Google Scholar