Introduction
Welcome to the 2023 edition of the South African Health Review, which delves into the critical topic of cancer systems in South Africa. Cancer care requires a multifaceted approach, encompassing prevention, early detection and treatment, as well as seamless coordination among multidisciplinary teams. Unfortunately, the South African public healthcare system, which serves the majority of South Africans, faces numerous challenges in delivering comprehensive cancer care.
These challenges stem from significant inequalities in healthcare access and financial and human resource constraints. Geographic disparities worsen the situation, particularly in rural areas, where access to diagnostic and treatment facilities is limited. High costs for advanced treatments and the scarcity of cutting-edge technology further hinder the delivery of effective care, leading to delayed diagnoses, suboptimal treatment, and ultimately poorer outcomes for patients.
Looking forward, projections suggest a significant rise in cancer cases by 2030. This makes it imperative to address the systemic issues affecting cancer care delivery in the country. The 2023 Review focuses on these challenges, examining the importance of early recognition, definitive treatment, and integrated care. In addition, innovative cancer management strategies, the economics of prevention, and systems monitoring are explored.
We have divided the Review into four sections. The section on health systems explores the various challenges in providing cancer and oncology services in South Africa. Despite well-intentioned guidelines and policies aimed at facilitating and expediting screening, early diagnosis and treatment, significant delays prevail due to logistical and resource constraints. Articles illustrate the necessity of re-evaluating implementation strategies to better align practice with government policy and highlight gaps in policy regarding the needs of vulnerable populations, inequities in access to timely oncology diagnostic and treatment services and particularly medication, service fragmentation, and communication breakdowns.
Section two addresses issues related to prevention, screening, and early diagnosis, highlighting both efforts and challenges in early cancer recognition. The critical importance of increasing public awareness and equipping primary healthcare providers with better tools for symptom assessment and referrals is emphasised to enable timely diagnosis and intervention. The importance of standardised histopathology reporting and national surveillance systems is also discussed. This section underscores the significance of prioritising early recognition and management of people with symptomatic cancers as part of a comprehensive cancer control plan and service.
Featuring articles on genetic counselling, methods to improve perioperative care, and a futurist approach to identifying and influencing factors affecting access to radiology and radiotherapy services, section three focuses on definitive treatment and supportive care. Key themes emerging from this section highlight the importance of integrated approaches to patient care and the need for innovative strategies to enhance treatment outcomes and support for cancer patients.
The final section on health economics and surveillance centres on the rationale for adopting a more focused approach to addressing the commercial determinants of healthcare and cancer prevention in South Africa and provides information from various sources on healthcare and related indicators, revealing the limited availability of relevant, quality data related to cancer. This section advocates for improved data collection and analysis to inform policy and practice, ultimately aiming to strengthen cancer prevention and control measures.
Section 1: Health Systems
In their research article ‘Breast cancer: do the current policies mean anything?’, Botha, Ledibane and Dreosti critically examine the adequacy of policies related to malignancies, especially breast cancer, in ensuring timely diagnosis and treatment. Through a cross-sectional study at the University of Pretoria/Steve Biko Pretoria Academic Hospital, the authors highlight significant delays in diagnosing newly identified breast cancer patients, particularly from initial consultation to diagnostic biopsy. Although the National Department of Health Breast Cancer Prevention and Control Policy (2018) aims for referrals to advanced facilities within 21-60 days, the study found an average delay of four months, with some patients waiting over a year due to non-representative biopsies and other technical deficiencies. Many patients also visited multiple medical facilities before being diagnosed. Botha et al. conclude that, despite policy provisions, logistical issues, resource limitations, and gaps in knowledge and referral practices cause prolonged diagnostic intervals, affecting timely treatment and potentially patient outcomes.
In article two, Joosse and co-authors critically evaluate the 2017-2022 National Cancer Strategic Framework (NCSF), focusing on its adequacy in addressing childhood cancer treatment, especially with regards to paediatric oncology medicines. Insights from a triangulation study, including in-depth interviews with 29 stakeholders from South Africa’s public and private healthcare sectors, revealed three main gaps: the neglect of childhood cancers in policy and healthcare organisation compared to adult cancers, the need for targeted interventions due to the rarity of childhood cancer diagnosis, and the social and financial burdens on families requiring caregiver presence during treatment. The authors call for a strategic cancer plan that addresses these specific needs, recognising the differences between childhood and adult cancers, and implementing targeted interventions in an updated NCSF.
In article three, Lubuzo, Hlongwana and Ginindza discuss the complexities of coordinating lung cancer care in South Africa, which often becomes fragmented due to the involvement of multiple health professionals and services over extended periods. The study examines healthcare professionals’ perspectives on this coordination, highlighting challenges such as service fragmentation, staff shortages, and communication issues. Key themes identified include interoperability and communication challenges. The study proposes enhanced communication, better interoperability, and improved care transitions to address these issues. The findings emphasise the need for fundamental changes to make the KwaZulu-Natal public healthcare system more responsive, patient-centred, and coordinated. Empowering primary healthcare service providers to play a significant role in care coordination is suggested as a potential solution.
Article four, authored by Moodley and colleagues, is anchored in the findings from the African Women Awareness of Cancer (AWACAN) project and a review of studies on cancer diagnosis in South Africa over the past decade. The article reports on cancer awareness measurement tools, community-level symptom awareness and beliefs, factors affecting the journey to diagnosis, challenges faced by PHC providers, and interventions to support assessment and help-seeking.
The authors note that there is a need for more information on cancer risk, symptoms, and pathways to care for the general public, and a need to provide PHC providers with more support for symptom assessment and referral systems. The requirement for further work on developing and evaluating interventions to improve timely cancer diagnosis is also highlighted.
The challenges of accessing oncology medicines in both the public and private sectors of South Africa are the subject of article five, where Suleman and colleagues present a case study on a series of multi-stakeholder dialogues addressing this issue.
Key issues raised during these discussions included inequities between public and private sector access, non-transparency in the pricing of unregistered medicines accessed under section 21 of the Medicines and Related Substances Act, commercial decisions influenced by the small market for oncology medicines in South Africa, potential alternative price negotiation methods in the private sector, and restrictions imposed by the single exit price model.
The dialogues revealed a clear need for a dedicated forum where all stakeholders can engage in discussions to find solutions to the oncology medicines access conundrum, including the development of necessary legislative amendments. This collaborative approach is essential to improve access to life-saving cancer treatments in South Africa.
Section 2: Prevention, Screening and Early Diagnosis
In article six, Chen and team report on the efforts and advancements to reduce colorectal cancer made by the South African National Cancer Prevention Services (SANCaPS) which was established to implement national systems for identifying individuals with inherited cancers, especially in families with Lynch syndrome.
One of the key initiatives of SANCaPS is the standardisation of national pathology reporting for colorectal cancers. Currently, a minimum core pathology dataset collection is being piloted in the National Health Laboratory Service’s TrakCare system. Future efforts aim to expand adoption through stakeholder engagement, enhance the identification of patients with mismatch repair-deficient (MMR-D) colorectal cancers, support research, and improve reporting.
This consultative process and framework will be replicated to introduce standardised management workflows for other prevalent cancers such as breast, prostate, and uterine cancers, among others, to enhance patient outcomes. By addressing these challenges and implementing targeted interventions, SANCaPS strives to reduce the burden of colorectal cancer and improve the overall quality of cancer care in South Africa.
Cervical cancer is the second most common cancer and the leading cause of cancer-related deaths among women in South Africa. Despite evidence-based interventions for secondary prevention, the incidence remains high due to implementation failures. In article seven, Kawonga advocates for using implementation science frameworks to enhance cervical screening, early diagnosis and treatment programmes. She argues that these frameworks can improve the effectiveness of interventions by identifying barriers and selecting appropriate strategies. Through two case studies, Kawonga demonstrates how these frameworks can address implementation failures in South Africa. She concludes by calling for increased application of and capacity building in implementation science to strengthen cervical cancer prevention efforts, ultimately reducing its incidence and mortality.
Primary care clinicians play a crucial role in cancer care by educating patients, facilitating screening, ensuring early diagnosis, and making efficient referrals, which can significantly impact cancer outcomes in South Africa. In article eight, Ras, Adeleke and Moodley explore the role of primary care practitioners (PCPs) in cancer control, emphasising the shift from oncology specialists to a more inclusive approach involving PCPs in comprehensive cancer management. This includes health promotion, screening, early diagnosis, referral, and ongoing care coordination, including survivorship and palliative care.
The authors suggest that PCPs in community-based facilities are well positioned to address the psychosociocultural dimensions of care, making efficient care pathways essential and emphasise the importance of equipping PCPs with necessary skills and resources. These include PCPs to be trained in screening and diagnostic techniques, risk identification, counselling, clinical examination, basic x-ray interpretation, minor surgical skills, blood test interpretation, and point-of-care ultrasound. Given the overburdened primary care system and increasing co-morbidities, understanding these complexities is vital for a holistic cancer control programme in South Africa.
Article nine, authored by Peresu and colleagues, explores the factors influencing breast cancer (BC) screening uptake among women and highlights a concerning trend of a significant number of women within the recommended age range for BC screening reporting not to undergo the procedure. Their study also found that marital status, employment status, and perceived benefits of BC screening significantly impacted screening uptake. Married women were twice as likely to report undergoing BC screening compared to unmarried women, while employed women were nearly three times more likely than their unemployed counterparts. These findings underscore the importance of addressing socioeconomic, cultural, and individual perceptions to improve BC screening rates and promote early detection.
Article ten highlights the benefits of offering clinical genetics services through outreach clinics, focusing on the genetic counselling service at the Breast Clinic at Potchefstroom Hospital, North West Province from 2019 to November 2022. During this period, 52 patients attended consultations. Araujo et al. note that this service benefits both the affected individuals and their at-risk relatives, showcasing how limited resources can be effectively extended to benefit patients.
Among the patients, 83.7% were diagnosed with invasive ductal carcinoma, 57.7% had a family history of cancer, and 62.8% had a histological grade 3 tumour. Additionally, 25.5% tested positive for a pathogenic variant in BRCA1 (41.7%) or BRCA2 (58.3%), identifying 45 at-risk first-degree relatives for predictive testing.
Araujo et al. conclude that integrating genetic counselling in under-resourced areas of South Africa enhances patient management and identifies at-risk relatives, demonstrating effective resource extension through inter-departmental collaboration and outreach clinics.
Section 3: Treatment and Supportive Care
In article eleven, Oodit and colleagues report on the implementation of the Enhanced Recovery After Surgery (ERAS) programme which has been shown to enhance perioperative care. Four hospitals (one public and three private sector) implemented the ERAS evidence-based colorectal guidelines, adapted to local contexts and led by multidisciplinary teams. The study collected demographic variables, treatment details, and clinical outcomes using an electronic audit system. Primary outcomes measured included length of stay (LOS) and complication rates, with a focus on the relationship between these outcomes and year-by-year compliance with ERAS guidelines.
The results were encouraging: the overall LOS was six days in the public sector and four days in the private sector, with complication rates of 39.9% and 43.7%, respectively; both sectors achieved over 70% compliance with ERAS guidelines, and there was a clear association between higher compliance with ERAS protocols and reduced LOS and complication rates.
The authors argue that the findings provide a solid foundation for a large-scale national strategy to implement ERAS for perioperative cancer care across all surgical disciplines and that the programme demonstrates that high compliance, reduced LOS, and fewer complications are achievable in South Africa.
In article twelve, Soomaro and Ramiah suggest that futurist causal layered analysis offers a comprehensive approach to exploring the multifaceted factors that influence access to radiation oncology services and for identifying strategies for strengthening services, improving access, and reducing delays to oncology services in South Africa.
In article thirteen, Naidu and colleagues report on a promising initiative to improve childhood cancer care in South Africa in thirteen public sector hospitals using the Paediatric Oncology Facility Integrated Local Evaluation (PrOFILE) tool. The authors report on the process followed to utilise multi-level evidence-based assessments to obtain objective data to inform stakeholder prioritisation exercises for childhood cancer control, to identify priorities, review potential barriers to implementation, and design and develop action plans to inform childhood cancer care activities.
In article fourteen, Nagdee and de Andrade emphasise the importance of including audiological services, such as ototoxicity monitoring and management, in cancer care to reduce the morbidity associated with ototoxicity. The paper reviews current practices in South Africa, offering practical, evidence-based solutions for improvement. The authors note that resource and logistical constraints limit the effectiveness of ototoxicity monitoring and management. Challenges include oncology nurses’ lack of awareness about ototoxic effects and unclear roles within the multidisciplinary cancer team. The authors recommend the expansion of the NSCF 2017-2022 to include ototoxicity monitoring and management in cancer care, establishing a national, standardised protocol that incorporates tele-audiology, and task-shifting to enhance the effectiveness of ototoxicity management.
Section 4: Health Economics and Surveillance
Article fifteen examines the impact of smoking, alcohol consumption, obesity, and ultra-processed foods on cancer incidence in South Africa, highlighting the significant influence of these commercial determinants of health. Authors Goldstein and Mahomedy stress the need to address these factors, which are often driven by powerful commercial interests. Despite the clear links between these elements and various cancers, effective mitigation strategies face substantial barriers.
The paper advocates for a paradigm shift in cancer prevention policies, recommending comprehensive measures such as increased taxation on harmful products, strict marketing restrictions, enhanced product labelling, and the removal of conflicts of interest in health research and policies.
The final article, by Ndlovu et al., provides a repository of data that describes the broad status of the South African health system and the health status of the population. The focus is predominantly on the national and provincial levels, including socio-demographic indicators, determinants of health and health status indicators, as well as health service indicators. Data were sourced primarily from national routine data sources, but also incorporate results from major surveys and global reports. Aligned with the theme of this Review, particular attention has been paid to indicators of the burden of cancers in South Africa, access to cancer-related services, and to some extent, patient outcomes.
To conclude, this edition of the Review underscores the urgent need to address the persistent gaps and challenges in cancer care within South Africa. The insights and evidence presented throughout these articles highlight the necessity of rethinking current policies and practices, and the importance of fostering a more integrated and patient-centred approach to cancer prevention, diagnosis, treatment, and support that encompasses all the different levels of the health service, including improvement of community awareness and knowledge. As we move forward, it is crucial that stakeholders across the health system collaborate to implement the recommendations provided, ensuring that every person receives timely and equitable care.
We trust that this publication will serve as a catalyst for meaningful change, driving progress towards a stronger, more resilient healthcare system that meets the needs of all South Africans.
Themba Moeti, Ashnie Padarath, Jeannette Parkes, Sandhya Singh, Paul Ruff
Editors