PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of intorthopspringer.comThis journalToc AlertsOpen ChoiceSubmit Online
 
Int Orthop. 2009 February; 33(1): 211–213.
Published online 2007 December 7. doi:  10.1007/s00264-007-0475-x
PMCID: PMC2899239

Language: English | French

Challenges in the diagnosis and management of musculoskeletal tumours in Nigeria

Abstract

The management of musculoskeletal tumours is important because of the high mortality rates associated with the available treatment modalities. A 5-year prospective study of bone and soft-tissue tumours is presented, along with the difficulties encountered in diagnosis and treatment. There were 71 patients (male:female ratio of 1.7:1, age range 5–85 years, mean age 32 years) with an average duration of 24.7 weeks (range 1 day to 34 years) before presentation. No patient had computed tomography (CT) scanning or magnetic resonance imaging (MRI) due to financial constraints, 95% had biopsies and X-rays, 15% could afford chemotherapy/ror chemotherapy is a sad consequence. 50% agreed to amputation. In the soft-tissue sarcoma group, only one of three patients could pay for limb-sparing surgery. In the benign group, 65% had limb-sparing surgeries and 15% had amputation. Fifty percent (50%) of patients were lost to follow up within 3 months and 39% of the malignant group died within the same period. Musculoskeletal tumours are a reality in our environment and a significant portion of our population have financial limitations. Ignorance and cultural beliefs promote late presentation to our hospitals, which are poorly equipped to give optimal care, despite the presence of trained personnel.

Résumé

Le suivi des tumeurs musculo squelettiques est important du fait du haut taux de mortalité associé malgré les différentes modalités thérapeutiques possibles. Nous avons réalisé à cinq ans, une étude prospective des tumeurs osseuses et des tissus mous et de nos difficultés tant au niveau du diagnostic que du traitement. Cette étude comportait 71 patients avec un ratio homme femme de 1.7 sur 1, un âge moyen de 32 ans (de 5 à 85) et un retard au diagnostic moyen de 24.7 semaines (1 jour à 34 ans). Aucun patient n’a eu d’IRM du fait des contraintes financières, 95% ont eu une biopsie et une radio, 15% ont bénéficié d’une chimio thérapie et d’une radio thérapie et 50% ont accepté l’amputation. Dans le groupe des sarcomes des tissus mous, un patient sur trois a pu payer pour bénéficier d’une chirurgie conservatrice, dans le groupe des tumeurs bénignes 65% ont eu une chirurgie conservatrice, 15% une amputation, 50% ont été perdus de vue à trois mois, 39% de tumeurs malignes sont décédés durant cette même période. Les tumeurs musculo squelettiques sont une réalité dans notre environnement et une proportion significative de la population ont des limites financières. L’ignorance et l’inculture entraînent un retard au diagnostic et à l’hospitalisation dans notre établissement qui est pauvrement équipé en dépit d’un personnel entraîné pour donner des soins optimaux.

Introduction

The incidence of bone tumours is very low (1–1.5% of all malignancies) [4], with benign cases being 3–4 times more common than malignant cases. Tumour distribution varies with age, with most benign bone lesions as well as osteosarcomas and Ewing sarcomas occurring in the second and third decades of life. Giant cell tumours, chondrosarcomas, fibrosarcomas, myelomas, lymphomas and metastatic disease all have a predilection for the older age group [1].

The management of bone tumours, especially malignant cases, forms an important segment of orthopaedic practice, as they continue to cause high morbidity and mortality, despite varied treatment modalities. Accurate diagnosis is critical, as a missed diagnosis of a malignant bone tumour can result in unnecessary limb amputation or death [3]. The information used here is extracted from a 5-year prospective study of the distribution of bone and soft-tissue tumours confirmed by either fine needle aspiration cytology (FNAC) and/or incisional/excisional biopsies. Designed proforma invoices were filled for all patients.

In the tropics, where health-care delivery systems function sub-optimally, insufficient funds help limit patients’ access to appropriate early and effective care. We highlight some factors that were counterproductive in patients’ efficient management.

The high cost of management

In this era of neo-adjuvant and adjuvant therapy and when limb salvage is being considered, management costs as outlined below are beyond the reach of most patients

Diagnostic methods

The initial evaluation of most bone tumours involves a plain radiograph, which may be diagnostic (e.g. endochondroma of the hand or non-ossifying fibroma [1]). This costs about 1,000 NGN (Nigerian naira) (8 USD) and is generally affordable by most patients. With more malignant processes however, definitive diagnosis may not be possible without further evaluation with computed tomography (CT) scanning, magnetic resonance imaging (MRI) and radioisotope scans. These help in determining both the medullary and extracortical involvement needed to proceed with staging and the development of a treatment plan [2]. These are usually not affordable, even if they are available. Biopsy leading to histological diagnosis is also pivotal, as appropriate treatment cannot be initiated without such information [3]. Its average cost in our centre is 20,000 NGN (150 USD). With most of our patients living below the poverty line, the high combined cost of admission, investigation and surgery deters patients from receiving a timely tissue diagnosis. A risk of wrong diagnosis and incomplete care due to the lack of knowledge of the extent of the disease is then very real.

Surgery

Surgery is integral to bone tumour management. Depending on the extent of involvement, excision biopsy may be sufficient in benign cases. Compartmental excision or more radical limb amputation with prosthetic replacement are needed in malignant cases [3]. At a cost of about 100,000 NGN (800 USD) in most Nigerian centres, surgery is beyond the poor patient’s reach. This results in delayed surgery and attendant poor results, with low 5-year survival rates. Prostheses costs are also largely beyond the reach of these patients.

Radiotherapy

Radiotherapy is unavailable in most Nigerian centres and the cost where it is available is prohibitive at approximately 100,000 NGN (800 USD) per course. Inadequate maintenance results in non-functioning machines, so patients then do not receive adequate radiotherapeutic care. The required chemotherapeutic agents are also scarce and costly. Early recurrence following the excision of these tumours without appropriate ror chemotherapy is a sad consequence./or chemotherapy is a sad consequence.

Illiteracy, religious fanatism and competing traditional practices

Some religious groups refuse blood transfusions and limb amputation. Others believe that their tumours are spiritual/witchcraft-induced and can, therefore, only be solved spiritually. Belief in the efficacy of traditional care for orthopaedic conditions results in prolonged palliation with traditional bone setters, whose practices like tumour massaging can actually aid in tumour dissemination. Some patients are just genuinely ignorant of the need for urgent intervention. Illiteracy and the high cost of orthodox treatment dissuade patients from seeking timely medical intervention before metastatic complications ensue.

Institutional factors

It is important to note that this country of over 150 million population has only a few trained orthopaedic cytologists and medical oncologists and one orthopaedic oncologist. Some malignancies have been reported as benign following the faulty evaluation of biopsy results. Specialised palliative care for terminal cases is virtually non-existent. Some medical workers caring for these terminally ill patients are poorly motivated and, therefore, show reduced commitment and dedication towards their care. There is also little assistance for willing and able healthcare workers involved in treating these patients to embark on research aimed at improving the quality of care delivered to these patients. This results from the non-availability of research grants, creating a state of apathy for the medical staff involved. General practitioners may also inappropriately delay referral to specialists.

General infrastructural decay

Most medical records at our centre are still paper-based, making retrospective/prospective research, data collation and analysis quite cumbersome. In our study, we lost many patients during follow up. The lack of a base map and poor road networks in most cities makes it virtually impossible to keep track of patients when they default.

Lack of political commitment by the government

The government’s commitment to proper medical care of its citizens is questionable. There is a poorly organised healthcare delivery system, ineffective health insurance schemes, poor hospital funding, inadequate research grants and poor staff motivation. Government officials readily travel abroad for their medical care. The government’s suboptimal drive towards improved citizens’ socio-economic status leaves them too poor to take care of their medical bills.

Recommendations

Taking the above into consideration, the management of these patients could be improved by:

  • Improving the socio-economic status of the populace, thereby, empowering them to take charge of their healthcare needs. More importantly, they can buy into health insurance schemes.
  • Essential equipment in the form of CT and MRI scanners, chemotherapeutic agents and radiotherapy units should be provided and subsidised.
  • Awareness should be created with regards to the nature of the disease and the availability of equipment needed in the management of the disease.
  • The traditional healers should be supervised and educated on the need to limit their activities and curtailing the dangerous methods.
  • Patients’ fanatical religious belief should be addressed by detailed patient education and awareness programmes on bone tumours.
  • More qualified specialist personnel should be trained to render the needed requisite services.
  • Research grants would go a long way in motivating the caregivers to identify better treatment modalities, thereby, improving the general quality of care given to these patients.

References

1. Skinner HB. Current diagnosis and treatment in orthopedics. 2. New York: McGraw Hill; 2000.
2. Solomon L, Warwick DJ, Nayagam S. Apley’s system of orthopaedics and fractures, Chap 9. 8. London: Edward Arnold; 2001.
3. Mehlman CT (2005) Osteosarcoma. eMedicine article, available online at http://www.emedicine.com/orthoped/topic531.htm
4. Natarajan M, Mayilvahanan N (2004) Book of orthopedics and traumatology, Chap 9. MN Orthopaedic Hospital, Chennai, India

Articles from International Orthopaedics are provided here courtesy of Springer-Verlag