It’s the deadliest cancer in the world, killing 1.8m people each year – more than any other cancer. But the official statistics suggest that isn’t the case in sub-Saharan Africa. In fact, based on mortality rates, it seems that lung cancer is only a problem in South Africa – the richest country in the region – and, in particular, the Western Cape, the province with the most efficient and well-resourced healthcare system.
Yet experts say these statistics hide the real story: how lung cancer is being grossly undercounted across sub-Saharan Africa, reports NPR.
While smoking is slightly higher in South Africa compared with its neighbours, that’s only half the story, according to Dr Coenie Koegelenberg, a pulmonologist at Tygerberg Hospital in Cape Town.
“We have the most accurate stats because we actually diagnose lung cancer,” he said.
Smokers and the reality
Eleanor Ceres found out she had lung cancer after the tumour spread from her chest and began protruding from her neck.
Born and raised in Cape Town, Ceres has been smoking for more than 30 years – and smoking causes nearly three-quarters of lung cancer deaths around the world.
Why wasn’t she diagnosed earlier? Before the tumour’s manifestation, her only symptom had been a sore arm, which the doctors chalked up to arthritis. By the time she was diagnosed in April 2024, the cancer had advanced to stage 4 and was terminal.
Doctors could only offer palliative care, easing her pain.
“I’ve got a child of 12-years-old. I want to see her grow up and get married and have her own children,” said Ceres, a single mother. “I cry a lot because I’m going to die and everybody’s going to stay alive.”
The story of Ceres holds clues to the puzzling issue involving lung cancer.
Africa’s hidden lung cancer epidemic, as Koegelenberg calls it, is part of a larger crisis in global health, as infectious diseases like TB and HIV have increasingly come under control and non-communicable diseases (NCDs) become an existential threat.
Africa’s cancer burden, for example, is expected to more than double by 2050, from 370 000 new cases a year to 940 000 cases.
However, only 1% of global health funding is allocated to preventing and treating NCDs in low- and middle-income countries, despite accounting for two-thirds of annual deaths.
Lung cancer offers a case study for how these countries can succeed or fail in addressing NCDs, given that this disease can usually be prevented through smoking cessation or even cured with regular screening and early treatment.
Instead, systemic undercounting and resource constraints have allowed the disease to grow unchecked across sub-Saharan Africa.
“If you don’t report things and put your head in the sand, that doesn’t mean it’s not there,” Koegelenberg said.
Why lung cancer goes undiagnosed
There are almost no nerve endings in the lungs, so in the early stages, the most common symptom of lung cancer is no symptom at all, said Dr Keertan Dheda, a pulmonologist at Groote Schuur Hospital.
And when symptoms do appear, they are often quite generic – chest pain, coughing up blood and difficulty breathing. So, doctors in sub-Saharan Africa often misdiagnose lung cancer patients as having TB, given the high burden in the region, Dheda said.
“Patients would go through the whole treatment regimen for TB and not really be investigated for lung cancer,” said Lorraine Govender, a nurse and the national manager of health promotion at the Cancer Association of South Africa (CANSA).
Those lost six to nine months of possible treatment can be deadly, since 55% of people with lung cancer die within a year, according to Cancer Research UK.
“The lack of training for healthcare providers to identify lung cancer is a big problem,” Govender added.
Tuberculosis may play an even more direct role, given that patients with this disease are twice as likely to get lung cancer than those without, probably due to this bacterial disease causing lung inflammation and DNA damage.
HIV is also implicated in lung cancer, as the virus weakens patients’ immune systems, leaving them less able to fend off respiratory diseases or kill budding cancer cells, according to Koegelenberg.
His own research shows that, among lung cancer patients, those with HIV tend to be younger and have more advanced cancer than those without HIV.
Misdiagnosed frequently
“Lung cancer is but one spoke in the wheel of colliding epidemics,” Koegelenberg said.
Given these challenges, many lung cancer patients die misdiagnosed, and their real cause of death is rarely known, given poor infrastructure to certify deaths and their causes.
“In Africa, where we don’t have the screening and diagnosis available, we may see deaths from cancer but not know what cancer the patient actually died from,” Govender said, “or maybe have deaths and not know it was cancer.”
Autopsies could help answer these questions but are rarely performed for religious and cultural reasons, said Dr Kelechi Okonta, a cardiothoracic surgeon at the University of Port Harcourt Teaching Hospital in Nigeria.
The World Health Organisation thus assessed that two-thirds of countries in Africa don’t have reliable data on births, deaths and cause of deaths.
Okonta thinks sub-Saharan Africa is in a catch-22 on lung cancer, where systemic undercounting leads to limited data and limited data allow governments to ignore this disease and the need for better record-keeping.
“There is no intentional activity by any government at any level. There is no lung cancer registry, there is no lung cancer group, there is no lung research grant, there is no lung cancer unit, even in the hospitals,” Okonta said. “They think it’s not a problem.”
The other side of the problem is timely diagnosis. While the Western Cape and South Africa lead the region in spotting lung cancer, for most patients, it comes too late. Data from the largest hospital in the Western Cape showed that, in 2019, 94% of patients with lung cancer had advanced, incurable disease at the time of diagnosis.
There’s always an ethical dilemma around asking someone with advanced lung cancer to stop smoking, said Dr Ayanda Trevor Mnguni, head of the Department of Internal Medicine at Khayelitsha District Hospital, and a pulmonologist. “Once you are actually so far gone, there’s really no point.”
Skyrocketing smoking rates across sub-Saharan Africa mean the lung cancer problem is likely to get worse, as tobacco companies target the region to replace falling sales in the West.
Especially at risk are communities and townships like Khayelitsha, as tobacco companies often flood poor areas with cheap cigarettes and aggressive marketing.
“We obviously diagnose lung cancer a lot better than the rest of the country and the rest of the continent,” Mnguni said, given that the Western Cape has the strongest healthcare system in South Africa and perhaps all of sub-Saharan Africa.
“But that doesn’t mean much if smoking rates continue to rise,” he added, “and if disease is almost always so advanced that the only option is palliative care”.
Why screening isn't an easy solution
One way to find tumours and treat them early is with lung cancer screening, especially as pharmaceutical companies like AstraZeneca and Chinese firm BGI Genomics see Africa as a key region for innovation and investment.
So in 2019, Koegelenberg and Dheda created the first first lung cancer screening guidelines in sub-Saharan Africa, and Discovery, the largest private health-insurance provider in the country, started covering screening several months ago, Koegelenberg said.
That, however, would only serve the private healthcare system, and Dheda acknowledged that lung cancer screening isn’t practical for the 84% of South Africans in the public system, or even most other countries in sub-Saharan Africa, “although we should be screening and we know we should be screening”, he said.
Even if there were enough CT scanners to screen high-risk individuals, there wouldn’t be capacity to biopsy nodules and treat all of these cases, considering the budget shortfalls and rapidly growing waitlists.
“It’s unethical to do the scan if there’s an abnormality, and you actually can’t do anything about it,” said Dr Sameera Dalvie, an oncologist at Groote Schuur Hospital.
The only option, as Mnguni sees it, is public health awareness with comprehensive anti-smoking campaigns and regulations. He points out that most people in Khayelitsha don’t know that smoking can lead to lung cancer, so governments shouldn’t take awareness for granted. “For most limited resource countries, the best bet is to prevent people from getting the disease.”
This too is easier said than done, with the pressure from tobacco companies and the need for greater social support to help people manage addiction.
Change may be on the way
South African lawmakers are considering a new smoking law that would ban all tobacco and e-cigarette advertising, as well as raise penalties to 15 years of jail time for businesses that sell tobacco to children or at cut-rate low prices.
Furthermore, recent research from Vietnam suggests that lung cancer screening might be feasible with chest x-rays and artificial intelligence, which is a more realistic, scalable option for sub-Saharan Africa, Koegelenberg said.
Ultimately, change hinges on better data collection, from comprehensive cancer registries to a universal death registration system, Okonta said. And that might have to be proactively driven by the healthcare system instead of the government – to break the catch-22.
“With adequate record keeping and follow-up of patients, we can solve this,” Okonta added. “Maybe the government will start paying attention to lung cancer.”
NPR article – Why lung cancer is a 'hidden epidemic' in this part of the world (Open access)
See more from MedicalBrief archives:
Cancer ‘the new HIV in South Africa’
SA cancer cases climb as unequal treatment causes ‘needless deaths’
Cancer statistics in SA skewed by incomplete data, under-reporting
Cancer Alliance: R50bn needed for cancer over next decade