Brain tumor problems in Ghana
By Dr.  Nii Bonney Andrews

Ghanadot, Sept 02, 2009

He was the acknowledged “Lion of the US Senate”, the scion of and later the patriarch of a distinguished American family with a large estate in the sea scented village of Hyannis Port, located 70 miles from Boston.

He had enough money of his own to afford the best medical care- and it was available and administered.

However, within 15 months after he had been diagnosed with a malignant brain tumor (brain cancer) Senator Ted Kennedy was dead. The news wires said he had lost his battle with brain cancer and millions mourned his passing. But do we have brain tumors in Ghana? If so who do they affect? What causes them? How do they affect people? How do doctors know when a patient has a brain tumor? What kinds of modern treatments are available- and are they available in Ghana- and where? What are the chances of survival with or without treatment and what are the complications of treatment?

In the 1940’s it was thought that brain tumors were rare in the African; this was because Africa lacked the facilities and specialists to detect them. With the increased presence of trained specialists and equipment we now know that brain tumors are not rare in the African.

In Ghana, in a hospital with a well equipped neurosurgical facility, one out of ten operations for cancer is for a brain tumor and one out of four operations done by a neurosurgeon is for brain tumor. Indeed by 2000, the number of brain tumors seen in Ghana had increased by at least 50% compared to Dr. Mustaffah’s (the first Ghanaian neurosurgeon) report in 1970.

Sadly, brain tumor is one of the commonest tumors in children - more common than in adults. The average age of affected children is 10 years and adults 41years. It is estimated that there are between 3 000 to 17 000 brain tumor patients in Ghana at any time. If the brain surgeons in Ghana worked on only brain tumors, then each would operate on between 600 to 3 400 cases per year. To date no one is sure as to what exactly causes a brain tumor.

When a patient has a brain tumor, they often complain of headaches, seizures (also called fits or convulsions) and weakness of an arm or a leg. A first time convulsion in an adult is always very suspicious. Gradual weakness of an arm or leg is also worrisome and so is a persistent headache usually worse on waking up in the morning (the latter in Ghana often leads to multiple treatments of malaria and typhoid!- after a Widal test?!, a most unsatisfactory state of affairs).

In children, persistent headache and an unsteady walk - as if drunk, are the usual problems pointing to a brain tumor, occasionally children also have twisting of the head to one side (so called “wry neck”). These early problems, if they do not ensure detection and treatment of the brain tumor, cause things to get much worse leading to blindness, inability to talk or walk - with confinement to bed and disturbance of consciousness.

Indeed, the success of treatment and the prospect of recovery rest on the condition of the patient at the time diagnosis is made and treatment commenced. Simply put, a patient who “can do everything by themselves” is more likely to have successful treatment than one who is bed-ridden or “cannot do anything”. Therefore, a high level of suspicion leading to prompt accurate diagnosis by doctors is important.

Sadly, most patients report very late.  It is an indictment of our health care system that 50% of our patients with midline deep brain tumors are totally blind before definitive treatment - when all of them have been complaining to healthcare professionals of persistent headaches and worsening vision for at least twelve months.

A Head CT scan quickly and accurately tells us if a patient has a brain tumor or not. It tells us the size of the tumor and its location. The situation of the tumor with respect to big blood vessels is important in planning surgery on the tumor; for example we may not be able to remove the whole tumor if it is wrapped around or attached to a major blood vessel- trying to remove it fully may lead to catastrophic bleeding.

The Head CT scan will also tell us if the tumor is causing a lot of pressure on the brain or brain shift. What the Head CT scan DOES NOT tell us is what kind or type of tumor it is. That is we CANNOT know from the CT scan if the tumor is a “good” tumor-that is benign, or a “bad/nasty” tumor- that is malignant or cancer.

In our part of the world, what looks like a brain tumor on the Head CT scan may turn out to be tuberculosis in the brain (yes, yes! you can get tuberculosis in the brain or spine and you will not be coughing!) or some other infection.

In more medically and technologically advanced third world countries such as Egypt, Morocco and South Africa, MRI scans of the brain and Cerebral angiograms (maps of all the blood vessels of the brain) are readily available to provide more information on the tumor and assist in surgery- here we have ONE MRI scanner for the twenty two million of us and more times than not it is out of order; as for cerebral angiograms….!


Head CT scan from Accra showing Giant Brain tumor

Clearly, once a brain tumor is seen on a Head CT scan, surgery must be performed to remove a small part of it in order to analyse it in the laboratory so as to find out precisely if it is “good” or “bad or nasty” or if it is an infection. When the tumor is small a modern computer guided “pin hole” approach can be used; this can be done with the patient awake. Happily, this treatment has been available in Ghana for over ten years.

Another important treatment is video surgery through a “key hole” called neuroendoscopy; it has also been available to patients in Ghana since 2000. When the tumor is large and causing pressure, then an open or “bigger” approach under general anesthesia with total or near total removal of the tumor is more appropriate. International best practice dictates that this is done by neurosurgeons competent in delicate deep brain surgery utilizing a sophisticated neurosurgical operating microscope and microinstruments- for where the brain is concerned, no tool can be too refined. Again, happily these resources have been available in Ghana for over fifteen years.

What is depressing is the lack of laboratory support in the operating room so that as soon as the tumor is removed, within 15 minutes, the surgeon can be told what kind of tumor it is from laboratory analyses for this information then to guide him as to the extent of further surgery.

Indeed, laboratory analysis of brain tumors in the public system often takes six weeks. What is again depressing is that sometimes patients with brain tumors are sent for radiation therapy without prior laboratory analysis of the tumor (that is the patient’s doctor has only guessed that the tumor on the Head CT scan is likely to respond to xray treatment!)

What is even more depressing is the limited or revisionist application of anachronistic laws on “medical advertising,” thus leaving brain tumor patients (and other patients for that matter) ignorant of important resources available in Ghana outside the public system that can benefit them.  Recently, a patient arrived in a moribund condition from a giant brain tumor diagnosed four months earlier in a public hospital where she had been waiting for treatment.

Senator Ted Kennedy traveled from his native Massachusetts and the famous Massachusetts General Hospital (where his diagnosis was first made by Brain MRI scan after he suffered a seizure or convulsion; it’s a “proper Teaching Hospital” and “center of excellence” not at all like.., but more like the Hospital Specialite in Rabat or the Nasser Institute in Cairo or Albert Luthuli in Durban) to Duke University in North Carolina.

The move was done after both the senator and his medical team had done extensive research on treatment programs and patient outcomes- information available to anyone on the world wide web- and a galaxy of experts had deliberated on treatment options….just like in Ghana!   However, the way we handle these problems in Ghana and their short comings clearly mark out our status as a non-third world country.  The same do not happen in the three countries mentioned hitherto above.

Unfortunately for us, the type of brain tumor suffered by the illustrious departed senator is the commonest brain tumor in Ghana where it is present in one out of 4 brain tumors. This tumor is “bad/nasty”- it is called malignant glioma and usually causes death within 12-15months when treated in the first world.

Some of the “good” tumors are Meningioma and Pituitary tumor; each of these occurs in one out of five tumor patients. Surgery for brain tumor can be relatively safe- a death rate of 8% (eight out of 100) during admission has been reported from well equipped centers in Ghana. The risk of complications such as infection, bleeding and stroke is also about 10% (one out of 10) in Ghana. This means that close to 90% of brain tumor patients can undergo surgery in Ghana without problems and sophisticated tools such as video surgery, computer-guidance and microneurosurgery are available.

Following surgery and analyses of the tumor, most patients may need to undergo further treatment in the form of xray treatment (radiation therapy) or specialized drug therapy (called chemotherapy). In order for the patient to realize the full benefits of these treatments, the tumor size must have be relatively small- again emphasizing the importance of early, accurate and safe surgery. Newer treatment methods utilizing the advances in molecular chemistry and nanoscience are in the works and are available in specialist centers in the first world.

The full array of treatments can ensure tumor free survival in patients with “good” or benign tumors. There are patients in Ghana who had brain surgery to remove tumors and have been tumor free and living normal lives for fifteen years. With “bad/nasty” or malignant tumors the outcome is not as good, but prompt treatment always provides hope for “Tumor Control”- where the patient can lead a pain free, and satisfying life while harboring a brain tumor which is not growing.

A more judicious use of the human and material resources currently available in Ghana, linked with the strategic upgrading of the existing infrastructure, will improve patient outcomes, save lives and advance knowledge.

For those of us who are dedicated to fighting serious diseases, in a “challenging” (oh no, not that word again! lol) environment - where practising modern neurosurgery is  like eating soup with a knife and not for not for the faint-hearted, “the work goes on, the cause endures, hope lives on, the dream will never die”.

The author is Chief of Neurosurgery and Vice-President of neuroGHANA.