Gynecologic Cancer Care: Collaboration With Resource-Challenged Ethiopia

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Eva J. Kantelhardt, MD

Forming a collaborative team is the only way forward to tackle a complex issue like oncologic care in these resource-challenged areas.

—Eva J. Kantelhardt, MD

Over the past 40 years, largely because of universal Pap screening, cervical cancer deaths have been drastically reduced in the United States and other wealthy industrialized countries. However, cervical cancer is still a leading cause of cancer death among women in resource-challenged areas of the developing world, such as sub-Saharan Africa. The ASCO Post recently spoke with Eva J. Kantelhardt, MD, a gynecologist at Martin Luther University of Halle-Wittenberg, Halle (Saale), Germany, whose clinical research focus is on gynecologic oncology and breast cancer. Among other things, she spoke about her ongoing research in cervical cancer in Ethiopia.

Rewarding Beginnings

Please tell the readers a bit about yourself, where you were born and raised.

I was born in Mount Kisco, New York. My parents are both German, but my father, a physicist, was in the United States doing a 1-year postdoctoral program at the IBM research laboratories in New York State. My early schooling was mainly in the western part of Germany in the small town of Schwerte, as well as high school in Göttingen.

Since my father had sabbatical leaves every 4 years, we spent 6-month periods in different parts of the United States as a family. This was a great experience as a child, as I discovered the cultural differences and learned English. It is a rewarding situation to begin school as the new foreigner in class and to then be welcomed and make new friends.

Path to a Medical Career

Please describe your early education and college, as well as any influences on your decision to pursue a career in medicine. 

My grandmother studied medicine in the 1920s in Germany and Austria, one of the first women to do so. Having Jewish family members and given the growing political turmoil in Germany, in 1938 she applied to work as a doctor in Latin America. Her request was denied, however, since the organization coordinating this effort thought women were unable do this type of work.

Fortunately, the family found another opportunity to emigrate from Germany to Brazil, where my grandmother practiced obstetrics. I still have her notes and some of her instruments. Even though I never met her personally, her example encouraged me to go into medicine. My mother was born in Brazil, and parts of the family still live there. My cousin is a plastic surgeon in São Paulo.

When I was 16, I saw a report from a pediatrician who was a missionary in South Africa and worked there during the Apartheid era. This impressed me very much. I asked her, if I study medicine, might I go and spend half a year working with her. She said yes, but not to come before the fourth year of studies.

From the Lab to the Clinic

Please describe medical school and what influences led you to specialize in gynecologic oncology.

The medical school at Georg-August University in Göttingen is known for very good natural sciences and preclinical education. I decided to spend time in the biochemistry laboratory of Kurt von Figura, MD, who later became the University President. Our group worked with one of the first transgenic mice, which I had to take care of even on weekends. Seeing accurate lab research and vigorous collaboration was very memorable.

After finishing the thesis before my internship, I decided not to stay in the lab full-time, but rather to work with patients and do clinical research as well. I did my residency at a university hospital to make sure research would be included. It’s worth noting that doing a residency in Germany is also possible in smaller regional hospitals, without a research background.

When I had finally finished my first 4 years of medicine, I went to the South African North West province, for an extended 6-month elective. The pediatrician, Angelika Krug, MD, arranged for me to start my elective where life starts: in the obstetrics ward of a small rural hospital. This was a very positive experience, but I also saw three maternal deaths in only 2 months. I realized that the accumulation of small mistakes can lead to catastrophes and that medicine does have its limitations.

Altogether, the experience there encouraged me to become a gynecologist and to focus on improving health care for women in settings with limited resources. I learned that this could only be done by analyzing the situation, generating evidence, and finding ways to improve the situation as a team.

Ethiopian Experience

Please tell us about your current career and your epidemiologic research in cervical cancer in Ethiopia.

In 2007, a very good Ethiopian nurse friend of mine was diagnosed with breast cancer during her pregnancy. This led me to Solomon Bogale, MD, the only oncologist in Addis Ababa at the only oncologic center (with one cobalt radiotherapy machine) in the country at that time. In the end, we treated my friend in Germany because there was less of a wait there. However, I started visiting Dr. Bogale and collaborating with him.

He was very open to collaboration, since few people were interested in his work in cancer. As we discovered, research funding was available mainly for HIV, tuberculosis, and malaria. We started with three German students in Addis Ababa in 2010. They documented pathology reports and patients’ disease course, and did interviews in the countryside.

One by one, colleagues from pathology, public health, surgery, and gynecology at Addis Ababa University joined the group to collect data on female cancer in Ethiopia. More students from Germany and Ethiopia worked together. Visiting conferences like the AORTIC (African Organization for Research and Treatment in Cancer) raised spirits on the interdisciplinary team.

We somehow convinced the German Ministry for Research and Education to provide a grant for our activities, including the start of a population-based cancer registry in Addis Ababa in 2011. Now there are three radiation oncologists working there, and Mathewos Assefa, MD, is our main collaborator.

We often faced bureaucratic challenges, technical problems, lack of essentials like water or Internet access, and many other unexpected events. But after working together for some time, I can quote my colleague Adamu
Addissie, MD, MPH, MA
, from the public health sector: “This is part of the experience!” And it truly is a wonderful experience and a privilege to work with my colleagues from Ethiopia and Germany to improve female cancer care.

No Quick-Win Strategies

As an oncologic specialist and global researcher, what is your outlook for reducing the cancer burden in developing nations?

The World Health Organization says: “Do not drink, do not smoke, participate in sports, and maintain a normal weight.” These recommendations are of course essential, but there are difficulties in promoting them even in countries with highly educated people. For female cancer in Africa, we need more evidence-based strategies.

Much progress has been made in surveillance, with 20 African countries currently submitting data to the International Agency for Research in Cancer, for example, in the GLOBOCAN Project (led by Donald Maxwell Parkin, MD). Prevention measures, such as HPV vaccination and optimization of early-detection strategies for cervical cancer, have been started nationwide now in Rwanda, with other countries following suit.

Downstaging breast cancer through awareness campaigns is on the way. Hospital-based care must be expanded as well, since there is no option for preventing breast cancer, for example. Oncology centers must become available throughout these countries. The fact that about half the countries in Africa do not offer radiotherapy represents a serious health-care gap.

For noncommunicable diseases like cancer, there will be no quick-win strategies. A multidisciplinary approach requiring tertiary-level institutions needs, first of all, political commitment with careful and wise planning. When governments start thinking about buying linear accelerators, they also have to think about stable electrical current and radiotherapy technicians who can handle the machines.

Looking Ahead

Any last thoughts about your future direction?

My future direction is to continue in clinical work and research, with a focus on Africa, striving to realize benefits for patients from translational medicine and transnational collaborative efforts. I am sure that high-quality research can be done in resource-challenged countries like Ethiopia. Having joint projects at an eye-to-eye level with colleagues in Africa is the basis for progress in the laboratory and the clinic.

I am aiming to continue surveillance and epidemiologic studies, look at best practices, do operational research, and in the long term, set up capacities for conducting clinical trials in Africa. Several international collaborations for improving oncologic care in Ethiopia are working together with the Addis Ababa University and the Ethiopian Ministry of Health.

Forming a collaborative team is the only way forward to tackle a complex issue like oncologic care in these resource-challenged areas. This will be to the benefit of colleagues in Africa who are the ones facing such a magnitude of patients, and who will ultimately change patients’ lives for the better. ■

Disclosure: Dr. Kantelhardt reported no potential conflicts of interest.