By Nina Niu, HMS ’13
Dr. Sulma Mohammed, DVM, MS, PhD is an Associate Professor of Cancer Biology at the Purdue University College of Veterinary Medicine and Purdue University Center for Cancer Research. She and her medical colleagues in Sudan recently published a January 2013 article in the Lancet Oncology titled “Breast cancer screening with trained volunteers in a rural area of Sudan: a pilot study.” This study involved training local women volunteers in one county (Keremet) in rural Sudan, who then performed breast cancer screening on 10,309 woman > 18 years of age in that county. The study proved that this program was successful in increasing early detection rates of breast cancer and potentially decreasing breast cancer-specific mortality. Specifically, women in Keremet with breast abnormalities were referred to the district hospital for medical diagnosis. The majority of these women were diagnosed with early stage disease that was successfully treated and cured. In contrast, in the “control” county (Abugota) in which no screening took place, women with breast cancer presented to the hospital with late-stage disease and had a significantly worse prognosis.
How did you become interested in global oncology?
As a cancer researcher from Africa, global oncology has always been one of my interests. However, I became more interested in global oncology when I joined expatriate colleagues from Africa during the 2000 American Association for Cancer Research meeting in San Francisco in discussions about cancer in Africa. We discussed reactivating the African Organization for Research and Training in Cancer (AORTIC – www.aortic.org) which was established in 1982 but remained inactive. I joined the organization and contributed to its reactivation, which later was relocated to Africa, and conducted several successful conferences. In addition, my research collaboration with colleagues in Sudan, and my sabbatical with the National Cancer Institute solidified my interest in global oncology and health disparities issues.
What made you choose Sudan as the country for your pilot project?
Besides being my country of origin, I am deeply touched by the desperate cancer situation in Sudan. Women are dying young and leaving their orphan children. Despite the fact that Sudanese people are not the only people affected by cancer in the world, Sudanese people usually do not take care of their cancer early and they do not talk about it because of the myth surrounding it. For example, my husband’s best friend, an educated physician, died from prostate cancer without telling his wife, daughter, or his best friend (my husband). This fact of hiding the disease applies to all educated and non-educated Sudanese people. Patients usually hide the disease or seek alternative treatment until the disease and the pain become unbearable, but then they seek professional help when it is too late!
What were some of the major challenges you faced in implementing this project? Were there any political challenges?
The challenges, we faced included:
- Lack of funds to cover the costs of transportation and living expenses of the volunteers and staff for the one-week training period.
- Convincing the village leaders to let their girls spend one week away in the university, away from their highly religious and conservative families.
- Motivating some of the young girls to finish their screening jobs
- Having all screened women to come for further medical diagnosis and treatment (lack of fund contributed to this fact too)
- Some of the screened women that were referred and came to the cancer center refused to undergo treatment.
What types of traditional treatments for cancer are common in this culture and what are the dynamics between traditional healers and evidence-based medicine in the Sudanese villages? How are local village health providers ordinarily trained? Is it possible to have traditional healers collaborate in the screening process?
People in the rural areas of the Sudan believe in traditional healers and herbal medicine and faith healing. In most instances the patient exhausts all these possibilities before they make an attempt to go to the hospital. Unfortunately, the traditional healers and the MDs do not talk to each other and vaguely know what each other are doing. Often, there are uncomfortable feelings shared by the two sides. Since in the patients’ minds cancer equal death and that is associated with hospital, patients do not go the hospital until is too late and when they forced to go by the excruciating pain. It is an interesting thought to have the traditional healers collaborate in the screening process. I think this may be possible when they feel the researchers are not trespassing on their territories or threatening their influence.
Some counties of Gezira were reluctant to participate in your study – what do you think is the major source of this reluctance, and how might it be overcome?
These are very conservative communities
1. They do not trust professional medicine and do not specifically want to talk about cancer
2. The fact that girls have spent a week away without a guardian in a university setting in a big city.
The reluctance might be overcome when the community sees the fruits of the work and how many lives are saved in other counties.
Why do you think people in certain villages hesitant to work with those from other villages?
Village people have their own traditions and beliefs. Villages are formed based on tribal affiliation. For a woman to expose her breast to a strange person is not acceptable even if that person is another woman from a different village. They want to keep these “cancer secrets” within the family so as not to tarnish their reputation among other villages
You emphasized the importance of using local volunteers who are trusted within the community and share similar cultural beliefs as the women screened. Why don’t you think this type of strategy is used more frequently?
This work needs some leadership. Most physicians in these areas are overworked. They are either working in the hospital seeing patients or teaching, in addition to running private clinics to make ends meet. Physicians and health workers are not really paid well. As an example a senior consultant salary may be around $200/month. So physicians do not have enough time to be in the clinic and conduct research at the same time. This research was made possible because of the relentless encouragement from this end.
Do you think Sudan has the resources to provide comprehensive cancer care, including surgery, chemotherapy, and radiation, if significantly larger number of patients are diagnosed with cancer?
The Sudan health system does not have enough resources to provide comprehensive cancer care and we hope this study can shed the light on this need. Investment in health care ranked 17 in the list of the government priories. Most of the funding goes to the military to quell the unrest in Darfur, Nuba Mountains and Blur Nile districts. The private sector is investing in the health care, but these kinds of services are beyond the reach of the poor in rural communities.
Do you think this screening approach is limited to only visible and/or palpable cancer types, or can you envision ways of adapting this approach to screen for other cancer types?
The screening approach proved to be useful in breast cancer, but we are planning to not limit it to only this type of cancer. We actually are in the process of adopting this screening program to cervical cancer. Our plan is to use visual inspection using vinegar and cellular phones to train volunteers within the same villages to do the screening and communicate the results (photos) by phone. In addition to communicating the results, cell phones will be used as rewards to the volunteers to continue their engagement in these efforts, and help them learn more about cancer using the Internet.
Do you envision expanding this program to other parts of Sudan? Other African countries? Any thoughts on integrate such services with healthcare workers serving other diseases (e.g. HIV/AIDS?)
Yes that is the idea behind this pilot study. We have already started implementing this work in other states in the Sudan. In addition, a couple of African countries have contacted me to help them start similar breast cancer screening program. Once the concept of using volunteers for screening for breast cancer gains traction, and the logistics are worked out, we plan to integrate these services to help with the diagnosis and treatment of diseases such as cervical cancer, HIV/AIDS and others. Our ultimate goal is to use these services to foster early detection and prevention.