Background: Colonel Dr Muhammad Ali Azad is a Head and Neck Oncosurgeon and Head of Department at the Combined Military Hospital, Chattogram, Bangladesh. He is a recipient of the prestigious Sena Parodorshita Padak Award for “Outstanding Performance in Head and Neck Cancer Management in the Armed Forces” and has completed fellowships at TATA Memorial Hospital, Mumbai & MD Anderson, Texas. He is passionate about teaching and training and has held international faculty positions on numerous live surgery workshops. He has performed over 65 laryngectomies and has a special interest in surgical and quality of life outcomes after total laryngectomy in advanced laryngeal cancer in Bangladesh.
Pathology What is the scale of head and neck cancer in Bangladesh and what are the main causes? Head and Neck Cancer in Bangladesh is rising and it is now the 2nd most common cause of cancer related death in the country. The major risk factors are smoking, alcohol consumption and recreational tobacco chewing. Like elsewhere, outcomes are favorable if detected early. Unfortunately, patients are often diagnosed late, and there is a high prevalence of recurrent cancers which often have poor mortality rates compared to more developed countries. In my practice I commonly treat squamous cell carcinoma of the larynx and oral cavity but have noted a recent increase in papillary thyroid cancer.
Current Facilities and Health Care Structure How do patient’ access head and neck cancer care in the public sector (in Bangladesh)? In Bangladesh, 85% of the population lives in ‘villages’/rural settings where their first point of care is community clinics. From here, they can be sent to primary health care centers and then again referred to district hospitals for secondary care. Finally, patients are referred to large tertiary health care facilities, often in cities far away from their homes, for specialized care. This process is time-consuming and requires timely referral at each step. Furthermore, diagnostics such as endoscopies or biopsies are only performed at tertiary centers causing further delay and increasing the likelihood of late-stage presentation. Additionally, due to lack of awareness of the causes and presentation of head and neck cancer, many rural patients may first present to indigenous community healers or ‘medicine shops’ instead of seeking out appropriate care. These practices further delay presentation. Conversely, there are a few patients who have the resources and ability to go directly to the large tertiary centers.
What facilities do you have in Bangladesh for managing Head and Neck Cancer??
There are 5 hospitals where patients can receive specialized head and neck cancer care in Bangladesh:
1) Bagnabandhu Sheikh Mujib Medical University
2) Combined Military Hospital, Dhaka
3) National Institute of ENT, Dhaka
4) Dhaka Medical Collage And Hospital
5) National Institute of Cancer Research And Hospital
All 5 of these hospitals are in public sector. Currently there are 12 trained and dedicated head and neck onco-surgeons in the country. Whilst the majority of us work in the public sector, some additionally work in smaller private facilities. However these smaller private facilities cannot provide all necessary facets of treatment needed for head and neck cancer patients.
How do patients pay for treatment? The cost of care in the public sector is fully covered by the government, however due to large patient volumes there are often long delays in appointments and treatments. Furthermore, these public facilities may at times lack the necessary instruments or equipment needed and so on rare occasions, patients may need to pay out of pocket for external items or services and many struggle to fund travel to tertiary hospitals. In private facilities, patients have to pay out of pocket or use private insurance for care.
Challenges for Head and Neck patients in Bangladesh: What are the current challenges faced in treating head and neck patients in Bangladesh?
1) Awareness - As mentioned, there is a significant lack of awareness of the causes and symptomatology of head and neck pathology among the population. This often leads to delayed presentation and treatment and in turn poor outcomes. Additionally, there is a high volume of recurrent disease. When diseases recur, patients are often hesitant to repeat surgery, and as surgeons we also have limited experience in managing complex recurrent disease and the complications that can occur during and after surgery.
2) Trained staff - Not only are there a limited number of dedicated head and neck surgeons, there are also limited numbers of allied health professionals such as speech and language pathologists, dieticians, radiologists, histopathologists, or radio-oncologists who have specialized training in head and neck pathology.
3) Facilities - whilst we have adequate access to chemotherapy and radiation therapy we have a lack of histopathology and radiology facilities further contributing to delays in diagnosis and treatment. Lastly, we currently do not have any robotic surgery which would be particularly useful for early stage disease.
ENT Training and Research in Bangladesh
Can you tell us about the current training pathway for ENT/head and neck surgeons in Bangladesh? Following an MBBS degree, you complete a 1 year of internship before starting a 5 year otolaryngology residency programme. Two years ago we started to offer head and neck fellowships in Bangladesh. Before this, doctors would have to travel outside of Bangladesh for fellowship in order to become a head and neck surgeon.
Describe the importance of international collaboration In ENT? We frequently collaborate with nearby countries such as India and Singapore.
Unfortunately, there are not many opportunities for collaboration with western countries or countries that are further away.
I think collaboration would be mutually beneficial to individuals from both countries. Although treatment protocols are the same, each individual has a unique approach to it and each country has their own unique mix of pathology. Collaboration across borders allows both countries to expand their arsenal of skills as well as widen their knowledge. Governments and hospitals need to develop agreements with various countries in order to increase access to opportunities for collaboration among students, residents, fellows and practitioners.
How big is the focus on research within the Bangladeshi ENT community? Compared to many countries, research is not a big focus in the ENT community. We lack research opportunities, facilities and resources especially when it comes to genomic or molecular research.
Future for ENT in Bangladesh: What do you see as the main priorities in ENT/head and neck surgery in Bangladesh?
Disease awareness - among patients and healthcare providers in primary and secondary care.
Cancer Registry - improved documentation, ability to monitor and track patients, improve continuity of care
Sub-specialty development in dedicated head and neck facilities - for all providers of head and neck care (surgeons, oncologists, pathologists, radiologists, allied health professionals)
Develop research capacity
Opportunities for international collaboration - fellowships, observerships
How do you see your scope of practice changing over the next 10 years? Without a doubt, there will be more and more patients presenting with head and neck pathologies. Hopefully, due to increasing awareness and interest from trainees, we will also have more dedicated head and neck surgeons and health care providers. We are aiming to increase cross-collaboration with foreign countries, which would include inviting foreign faculty members to visit our own institutions. Hopefully with greater resources we will aim for earlier detection and treatment of patients as well as increase our research output.
Do you have any advice for aspiring surgeons in your country? Seek out opportunities to get specialized training and exposure and focus on research!
How do you think a relationship with the Global OHNS could benefit you, your colleagues and your patients?
I hope that this will create increased opportunities for international collaboration as well as a venue for sharing knowledge.
Interviewers:
Joshua Wright MBBS
Department of Pediatric Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, USA
Department of Head and Neck Surgery, The International Centre for Recurrent Head and Neck Cancer (IReC), The Royal Marsden Hospital, London, UK