 Hello everyone and welcome to another edition of cancer with Dr. Denise Egeo, the CEO of Comode Cancer Foundation in partnership with Plus TV Africa. We'd like to thank you once again for joining us. I thank you. We really appreciate your time as you learn more about the journeys of cancer patients and how we navigate in our ecosystem. Today we're going to be talking about the role of the general practitioner in diagnosing cancer. It's very interesting because the general practitioner is a word I know used globally. And I think in Nigeria we call everybody a doctor. But anyway, we've got specialists in the house who's going to help us to firstly understand that word because it's very important to have clarity on what we're talking about. So today in the house I've got Dr. Ngozi Onoha. Hello, doc. How are you? I'm doing good. How are you? Nice to see you. Thank you for agreeing to join us this afternoon. Thank you for agreeing to be part of this conversation and to be able to educate us. Once again, as I said, this is Comode Cancer Foundation. You can find us on any of our social media platforms. What is this month? This month is July. July, what happens in July? It's actually the sarcoma awareness month. Sarcomas are unknown cancers that can affect any part of your body. A key symptom of sarcoma is a lump that gets bigger quickly. Most people get diagnosed when their sarcoma is about the size of a large tin of beans or whatever, any of the tin foods. Also, June, July hosts the World Neck and Header Neck Cancer Day, which is the end of July, the 27th. So I'm just bringing this to the forefront for us all to know what's going on in the month of July with every other thing that we're going to be talking about as the month goes through. Today, as I had mentioned, our guest is Dr. Ngozi Onoha. So Ngozi Onoha is a medical doctor, primary care physician. And she's the founder, CEO of Health for Niger. Thank you, doc, for joining us this time. So let's talk about the role of the GP. I call it the GP in the UK. I think that's what they're called in most countries. I think in Nigeria we're still called the GP, but all of us just refer to medical practitioners as doctors. I think that's what is very common for all of us that were born and brought up in Nigeria. But I'm going to ask you first to please explain this word GP. Please, just even for me myself, because I need to understand why it's different in different countries. OK. All right, great question. So GP stands for general practitioner. And when you look at the word general, so in the UK, GP is general, which means this is a doctor that takes care of both kids and adults. In Nigeria, GP is also used, general practitioner. In the United States, the terminology is a little different. It's called primary care. And it's primary care provider. For primary care physician, because in America, we have nurse practitioners who see patients, and we have physician assistants who see patients under primary care. So they are called physician extenders. So primary care is, I would say, the gateway to health, because if a person has health concerns, their first point of call is primary care or the GP. Now, primary care can be further divided into family medicine or internal medicine. So family practitioners can see adults and kids, and the, I'm sorry, I'm blanking out for a minute. So we have the family medicine, and we have internal medicine, and we have pediatricians. So the internal medicine providers would see adults, 18 and above, while the pediatricians will see kids who are under 18. So that's the structure. That's the breakdown. They, yeah, that's the breakdown, the details of it, the details, the, you know, meet up. The basics, the basics. Yeah, it's the basics. But as a general, as a general, GPs are the first point of call. When someone has a concern about their health, they would go to a general practitioner. As you have just explained, we all have different roles of GPs. Now, in America, you seem to have a wide explanation. But I mean, generally, if I look at it from low, middle-income countries, it's the common one-size-fits-all. So let's look at it from the one-size-fits-all, especially for Nigeria. What, therefore, would you describe as the role of the GP in cancer care? OK, so in the context of Nigeria, the GP who sees all ages, so kids, adults, is the first point of call for health, any health concerns. So the GPs play a very important role in cancer diagnosis. So when we look at cancer diagnosis, we can evaluate it from two perspectives. So the first perspective is screening. So screening is merely finding conditions that have not manifested yet. While diagnosis is finding cancer in someone who has symptoms, so has symptoms maybe weight loss or has a mass or has blood in stool or has blood in urine. So in that role, the GP acts as a detective because the GP now has to find what is causing those symptoms and to make sure that it is not cancer. So that is the role of the GP screening, diagnosing cancer and facilitating care and follow-up. OK, so based on what you're saying now, you have four things that you do as the GP for us. The first one was the screening. Screening is a very big thing when we talk about cancer anywhere in the world because screening with screening and with regular screening with regular checking, there is a better chance of us living. And statistically, one in two people will get cancer with effect from 2023. Statistically, 80% to 90% of people that have cancer in low-middle income countries like Nigeria will die of cancer as against the 80% who would survive in developed countries. So now looking at it from that perspective and with no screening is a key issue. How will the doctors get... How are they supposed to be able to walk around getting this message out that people have to do this screening? You see, I hope you understand what I'm coming from because it is still going to come back to being the doctor's responsibility. Or am I wrong? So I would say it's the dual responsibility. It's the responsibility of the person also because in our culture in Nigeria, we're not used to going to the doctor for a general checkup. So people wait until they get sick and then they go to the doctor for that acute illness. Now an acute illness evaluation is not the ideal setting for a screening type of visit. The screening type of visit is typically done when the person is well. So you go in, it's typically once a year for adults. You go in and screening means you feel well but you are just going for a screening. And I always say, if you drive, you always take your car in for oil change every three months. You take your car in for yearly car inspection to allow your car be on the road. So screening is more like a maintenance. Like a maintenance. You don't have any symptoms. You don't have any complaints. You're just going to the doctor. You're just going for a checkup. Now during that checkup, based on your age, your doctor might recommend certain tests based on your age, based on certain other risk factors like family history and your general lifestyle. If you smoke, if you smoke, for instance, your certain age above 50 and you've smoked a 20-pack year history, your doctor might recommend a cup scan of the lungs looking for lung cancer. This is screening because you don't have any symptoms. So when someone has symptoms, that's a whole different ballgame. Those tests are now called diagnostic tests but for screening, it means you don't have any symptoms. So the typical cancers we look for when someone comes in for a screening evaluation, just a general checkup, physical, they call it physical checkup, physical exam, annual exam, annual physical. It's all the same thing. It just means once a year you go in, just tell the doc, doc, I'm here for my screening test and cancer screening is one of the things offered. So for women, it would be mammograms after the age of 40 every year, pap smears from the age of 21. For men, it would be a prostate screening blood test after the age of 50 every year, colon cancer screening from the age of 45 and then the lung cancer screen that I mentioned earlier. So those are the top ones that are typically screened for. Does that answer your question? Yes, it does. Why I'm asking the way I'm asking is because you see, one of the very first things I learned when I started to do research because you know that I am not a medical doctor. I am an academic and having to be able to talk about cancer as a survivor, but create information, you have to also do your own homework. One thing that has always stood out is I've always been able to translate and I don't know if it's correct, but I always say to people, if you have a persistent illness and when I use persistent, I say persistent everyday illness, I'm very specific, everyday. So you have a persistent cold. You have a persistent, you have persistent diarrhea. You have nonstop always having constipation and you're always tired, you know? It's things that are just not going away, a persistent headache. I always say to people that those are points where you need to be looking to get yourself checked. But somehow it is the conversation now that needs to go from that point. If I'm right, if that is a correct statement, then how important is this conversation in navigating the cancer journey? Because automatically you've already gone through the process, you've had the screening, you've had the conversation, if your doctor has started your screening. Now a journey starts once you are diagnosed with cancer. So the journey starts and then what happens? So what's that about? People tend to neglect symptoms that occur and oh, to get better tomorrow and to get better tomorrow and they delay care. So if someone is having symptoms that are bothersome, they should get it checked out definitely and not delay. So you want a symptom depending on the severity, you know, you have access to emergency rooms. So the A&E, depending on how acute the problem is, how severe it is, if it is causing pain, if it is causing discomfort, the best thing is to have that symptom assessed. So there are various pathways to get the symptoms assessed. Like I said, quick evaluation would be the A&E, the emergency room or the urgent care centers or the doctor's office. So that person can call the doctor line and they'll have a nurse who will do triage and the nurse will talk to the person and determine how acute the problem is and how quickly the person needs to be evaluated. So I think being mindful to your health, being mindful to symptoms is important. If you don't feel good, you wanna get those things checked out. Now, if someone comes in and they're presenting with symptoms and in the course of the workup, the evaluation, cancer is detected. For instance, if someone is coming in and they have abdominal pain and they undergo a workup and they have a CAT scan, for instance, and the CAT scan shows liver cancer. So that person is then referred to a secondary center facility for secondary care. So that person will be referred to an oncologist and ideally that referral should take place within two weeks. So that referral, that person should be seen by the oncologist or cancer doctor within two weeks. So someone with cancer needs to be seen fairly quickly. So it would be considered an urgent referral. If a person comes in and we had a person who came in with abdominal pain and on the CAT scan, we found liver cancer. So an urgent referral was made to the oncologist and the oncologist saw the person within two weeks, which is the standard. So two weeks from diagnosis, that person should be seen by the cancer specialist. Now that person goes to the cancer specialist. The cancer specialist evaluates has to confirm the diagnosis to a biopsy tissue diagnosis and then staging, you have to determine staging. How far has this cancer gone? Has it spread, where is it? What kind of cancer is it? And then a treatment plan is then formulated for that person. Now the treatment ideally should happen within two months of diagnosis of that cancer. So that is sort of where, you know, the UK system guidelines want cancer care to be at. Within two months, the treatment should be up and running. Now based on the diagnosis, so one of the things I want to clear and I think it's important we clarify, is a lot of the time patients do not understand in low-medium countries, let's focus on Nigeria, knowing that there is a cancer doctor. In Nigeria, as of 2021, and I know it's lower now, but I haven't got exact figures, so I don't want to use figures anyhow. But as of 2021, there were about 80 oncologists serving a country as big as Nigeria. I know it's less, and I know its word is about 50. Now that is a serious concern because that is automatically pushing cancer patients to GPs who are then becoming oncologists and prescribing as oncologists and doing the surgeries where necessary as the surgeons. The surgeons, exactly. And then when, even though we're getting the biopsies in some parts, it's still not the right team that are looking and we need to get the message out that it is the oncology team. However, the medical team still have a role in the care of the cancer patients. So please, can you help me to separate these two roles, please, especially when you look at it from Nigeria, because we need to get the right message out. There are two different roles and we've got to find the right people to help us through the journey. If not, we're going to continue to have more death rates rather than more survival rates. I think what you're looking at, cancer care in Nigeria, it has limitations, number one. You have the financial limitations. If a person cannot afford to see a specialist, there will be delayed care. And then you also have the training needs, the fact that you don't have enough oncologists in Nigeria. Because of that, general surgeons might be taking the role of cancer surgeons, for instance, doing the surgeries to remove the tumors. And yeah, if you look at the teaching hospitals, the teaching hospitals have cancer specialties. So traditionally, the role of radiation therapy and chemotherapy has been in the realm of the specialists, the oncologists. You're not going to find a general practitioner giving chemo, we just don't do that. That's not our training. I think that a lot of the times, what you find is the limitation to access care because of financial cost implications. It's not that the patients don't want to get care, but they just cannot afford it. And secondly, they don't know where to go. So they don't know where to go for care. They don't know which hospitals to trust. And this is often true when someone has not established care with a GP. They don't have a regular clinic that they go to for their care. So when they get sick, they're going to all different hospitals all over the place. And they don't have a doctor who's familiar with them, who's familiar with the history. So with their history, and they haven't had the opportunity to build the relationships, to build the trust with a GP. Because that is so important. If you have not built trust with a GP and you need healthcare, not only are you dealing with the issue of the sickness, you're also dealing of the issue of, do I trust this provider? Do I trust this provider? And that is why people are falling victims to quacks. Quacks are coming to the homes and give all kinds of cocktails of concoctions without any proper diagnosis. So and this causes adverse health outcomes. It causes delayed care. So I think this is just, I don't know what to call it. It's the failure of the healthcare systems in low and middle income countries on a whole. So that's a whole nother topic. And I don't think, Doc, you can solve it. We cannot solve these challenges. You see, one of the things I recognize is that there's a lot of things we can't solve. But being an advocate means you have to bring those hard conversations to the forefront. And the fact is that because of this disease, I've not been able to work again. But at least, since I can't work, at least I can do something that makes a difference and stops people from dying and at least helps to guide. And that's what I want to come out of this, that if we know what to do, we will know how to manage ourselves. That's the truth. And we'll at least have a bit of an idea of the type of questions we have because I'm going to categorically announce that in Nigeria, we have oncologists and a lot of doctors are on the federal, on the, what do you call it? In federal hospitals, you can get them, the university teaching hospitals, you can get specialists there. We've got the NSIA, which is one of the government private funded organ cancer centers in Nigeria. We've got private cancer centers, but those will be for more financially. Boyant. Yeah, people have financial. I wonder about those private ventures still have charity funding. Yes, so they still raise funds to help people who are locals, who require and can benefit from treatment. So we don't want to write off that, not things are not happening, things are happening. It's just the fact that it has to be continually brought to the forefront to make people understand that we are here and these things have to go on. What should a patient in a low-medium income country like Nigeria expect from its government? For me, what do I expect from the government? I expect the government to fund screening. For me, if the basic screenings and the highest cancers we have in Nigeria, for instance, cervical cancer, prostate cancer, liver cancer, I think it's liver, yeah. There are six that we actually, and we do have what they call the cancer health fund. The name has changed, it's no longer called the cancer health fund, right? If we have those spaces, then my own take or my own request is that funding is opened out in collaboration with private sector and NGOs to increase number of people that we screen. But there must be a recording system. That's my take. Because we are saying we're screening, how many are we screening? Where have they been screened? Are we putting all this in a central database? So we can see progress. Not one of, you get screened for breast cancer this year, you never get screened for 10 years. That's not what we're talking about. It's screening that is consistent and you have a map, you know, like we all have vaccination cards. Even in Nigeria, we grew up with vaccination cards. So if screening is going to be a key thing, then we should grow up with, we should all as adults from the age of 18, every child should have a vaccination card. But now that we're screening for the one that is starting in September and cervical cancer, we're starting cervical cancer vaccine, then we should, if we're going to be starting cervical cancer in September in Nigeria, then that means that we should have screening cards. That is my own, that's my take. So I would really like the government to introduce screening cards that provide the vaccine part. So you can see where you're screened and on the card you've got somewhere else where it's showing the vaccine. That's my take. What would be yours? Well, I think that there's a lot the government can do pertaining to cancer care, infrastructure answering very important. I think without the infrastructure, you can't grow, you can't grow a lot of systems. When I look at what happens in the States, you see hospitals that they are constantly building. The hospitals are constantly building infrastructure and they are constantly expanding. So you will see dedicated cancer hospitals just for cancer alone. So a hospital might decide to build a cancer center offsite. What this does, it provides avenues for training. So more medical staff, more doctors can be trained and it also creates visibility. So the patients know, or people know, oh yes, there's a big cancer hospital in this place. So it's also good for branding. The private sector has done very well with regards to cancer care in Nigeria. There's a cancer center in Lekos that has done really well. And the only thing, like I said, the cost and when it comes to accessing healthcare and the teaching hospitals, you have the issue of the wait list, the wait list, the lack of beds. You have someone, no bed and it's who you know, you can't get a bed. So I think infrastructure is very important. Building the infrastructure would be number one for me because as individuals, we can do all the talking but we cannot build, you and I, we cannot build a cancer hospital, right? Yeah, we can. I don't think we can put up a hospital, not to talk of a hospital. So I think if government really wanted to do something about cancer care, I would focus on infrastructure number one. The infrastructure and training is central to what I was going to say would be in a conversation that will come up again somewhere along the way. So really, really, and it's very key for us in Nigeria. We've got to be very honest. We're talking about our own country and we're going to talk about, we're talking about our needs. So yes, I'd like to anchor on this and say yes. Thank you very, very much, Dr. Angoti for joining me to discuss the role of the GP and the cancer diagnosis, yeah. So our viewers want to thank you for sticking with us. I want to thank you for joining us again and follow us on all our social media handles at Commonwealth Cancer Foundation. I want to thank you all for joining us and you can follow all our work anywhere and our work as well. Thank you, Doc, for joining us this afternoon. You're welcome, my pleasure. For joining us today. Always a pleasure. It was really great chatting with you. Thank you. Good seeing you. Thank you.