January 21 - Public and Private Pathology

If you don't have the time to read through the blog today, please consider scrolling down to a summarized bullet-point version under 'TLDR;' at the bottom of the post!

Public Labs - Dr. Sam Kalungi, Mulago Hospital

We started our Saturday in search of the Mulago pathology lab, which Dr. Kalungi shared was ‘above the mortuary’ at Mulago. That is definitely not a place an average person wants to be on a Saturday - but for one of few pathologists like Dr. Sam Kalungi, and us who are looking for answers, that was where we were meant to be.

The pathology lab lies in New Mulago, a patch of newer buildings which stood away from the older buildings on Mulago Hill. In Old Mulago, most of the buildings were built in the 1950s whereas New Mulago boasts some modern building structure.

On our way to the pathology lab - many cranes circle the sky

When Dr. Kalungi found time to sit with us after his autopsy, he started sharing about the current state of pathology in Uganda. Around 10-15 pathologists in his department processes samples coming in from the public health system nationwide. He shares that there is no real limit to the number of slides a pathologist reads, but that they stop when they are tired. An average pathologist reads up to 20-30 cases each day, where each case can have multiple slides (~6 for breast cytology). Given the large number of cases each pathologist has to deal with, Dr. Kalungi shares that it would be helpful if the negative cases are caught at a lower tier health center (think high specificity), and have pathologists process the more difficult cases at a regional level.

“There is a need for policy improvements in task-shifting IHC and general diagnosis to regional hospital”

“If you move diagnosis down to lower HCs, you can reduce late presentation.”

Quotes from Dr. Sam Kalungi

From a technical standpoint, Dr. Kalungi warns us to be aware of fixation artifacts, and that whatever technology we are considering adopting should take that into account.

Private Lab - Dr. Dan Wamala, Path Diagnostics

Path Diagnostics Logo from https://pathdiagnosticslab.com/

It is easy to presume that anything private is heavily aimed at profits. This was the mentality that Teja and I (Kim Hwang) had when walking into Path Diagnostics. However, that changed when we spoke with Dr. Dan Wamala, who welcomed us into his small office, a microscope sitting on the table in between us. His office sits in a corner with a window view of the open field behind the Silver Arcade Mall, behind false doors which separated us from some of his waiting customers.

He shared that patients coming into private labs often do so because they trust the quality and customer service that is provided to each patient. In a government system, considerations are made ‘as a whole’. Considerations made include: “Does this boda contain enough samples for this trip to the hub to be worth it?”. In other cases, nurses may not have the same level of motivation to get the samples to the labs after a biopsy - in some cases, the samples sit and rot in the operating room. On the other hand, in a private setting each patient and their sample are treated as an individual case. Samples are shipped by courier as soon as they are received to the privately-practising pathologist, and processed as soon as possible.

Results that come late are almost always useless

Path Diagnostics sign outside the office at Silver Arcade Mall

We asked about the rate of receiving ER+ breast cancer cases, since there is a potential for those instances to be treated with oral drugs (Tamoxifen) - a real game changer in terms of time, cost, and access to treatment in the Ugandan context. Dr. Wamala shared that there are more ER+ than ER- cases. However, the proportion is lower than in western countries. This may partly be due to the low quality of fixation of samples, which is a huge problem to the quality and turnaround time of diagnosis.

He further shares that doctors have lost confidence in the pathology system. New services or interventions will have to garner the awareness and support of surgeons and clinicians who deal with breast cancer and get them to know that pathology is accessible even to the poorest.

Having studied in Sweden, he shares that FNA and immunocytochemistry (ICC) are done routinely in cases of suspected breast cancer. Tissue sampling on the other hand can worsen cancer - leading to changes in phenotype and spread of the malignancy. Physical trauma can cause cancer progression.

On closing, Dr. Dan Wamala shares his passion and support for accessible pathology - especially to the poor and rural communities who need it most. He probes us to consider that a truly successful intervention requires a concerted effort across different initiatives, and that it would be constructive to have a forum where well-meaning groups coordinate efforts to improve the state of breast cancer diagnosis.

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TLDR;

• 10-15 pathologists in Mulago process and read Uganda’s pathology samples from across the nation’s public health system

• it would be helpful if the negative cases are caught at a lower tier health center (think high specificity), and have pathologists process the more difficult cases at a regional level.

• Fixation artifacts should be accounted for in designing technology

• It is important to understand the root cause behind preference for private pathology, and how that may play into implementation of a new technology to encourage health-seeking behavior from patients and diagnosis being done by doctors on suspected cases.

• “Results that come late are almost always useless.” - Dr. Dan Wamala

• There may be a higher ER+ population in sub saharan africa (SSA) than meets the eye due to the poor fixation in many samples to preserve the biomarkers.

• Doctors have lost confidence in the pathology system. New services or interventions will have to garner the awareness and support of surgeons and clinicians who deal with breast cancer

• FNA and ICC is used routinely and successfully in Sweden. It has benefits over tissue sampling including trauma to cancer which can lead to further spread.

• Efforts aimed at tackling breast cancer diagnosis should be concerted.