A Doctor’s Doctor

A member of INCTR’s advisory board, Dr Manzoor has long understood the importance of international collaboration. He was the principal investigator for a collaborative research project between the National Cancer Institute, Bethesda, and the AFIP on lymphoid neoplasia.

There are many powerful arms in the world’s cancer-fighting arsenal, but for Lt. General Manzoor Ahmed, his chosen field of pathology is an essential foundation to the understanding of cancer and thus to the forging of more effective weapons to use against it.

The former commandant at the Armed Forces Institute of Pathology and the retired Surgeon General and Director of General Medical Services for the Pakistan Armed Forces, General Ahmed has devoted his career to teaching, research and advancing the prospects of cancer treatment in the developing world.

Trained at King Edward Medical College in Lahore, Dr Manzoor completed his residency training at the University of Maryland in the USA and obtained American board certification in pathology. In 1960 he returned to Pakistan, where he became head of pathology at the Pakistan Naval Hospital. He later led the anatomic pathology department at the Armed Forces Institute of Pathology (AFIP), where he taught postgraduate students and conducted research with special emphasis in the areas of cancer epidemiology and lymphomas.

One of his first initiatives was AFIP’s cancer registry-a monograph he published which describes the frequency of various tumors in Pakistan. Certain lymphomas and leukemias are very common, in addition to breast, cervical, gall bladder and lung cancers. What was rather unexpected for a developing country, Manzoor says, is the high incidence of colon cancer. “More interestingly, these cancers do not begin as polyps as they do in western countries,” he says. “This needs to be further studied.”

Manzoor also has identified regional connections to some types of cancers: a high frequency of esophagal cancer around Caspian City; cancer of the mouth in the southern part of the country, attributable to chewing habits and tobacco use; lymphomas and leukemias in impoverished regions. Malnutrition, immune systems depressed by viral and bacterial infections, and lack of clean water are all factors contributing to the incidence of lymphomas and leukemias. The challenge, he says, is not only to address these contributing factors, but to devise treatments commensurate with the economic realities of the region.

“We have completed a lot of research, we have a lot of good medicine in Pakistan, but most people don’t have the resources to take advantage of this,” he says. “People cannot afford the treatment protocols we are supposed to be carrying out. More than half of those diagnosed with lymphoma receive insufficient treatment or no treatment at all. The end result is the same: the majority of people with cancer will die.”

To help ease the financial burden of cancer, Manzoor and his colleagues are streamlining their approach to diagnosis and treatment, and aiming for earlier detection. “We try to cut down on the number of investigations we make to distinguish between aggressive and less-aggressive cancers, which one has to pursue to prescribe the proper treatment. We also try to cut down on the number of biopsies performed by using the less-costly fine needle aspiration of the large lymph nodes for diagnosis. Tuberculosis is a very common disease in our country, and fine needle aspiration is the standard means of diagnosis. If something more time- and cost-efficient is applicable in our setting, then we really ought to use it.”

When Manzoor first started practicing medicine in Pakistan, medical interest in cancer was limited, and pathologists were few and far between. Forty years later, he is witnessing a gradual shift in perspective. The country’s medical attention is still largely focused on infectious diseases, and facilities for diagnosis and treatment of cancer are limited, but Manzoor and his colleagues are making strides to raise awareness that cancer could be Pakistan’s major health concern in the coming years. He advocates better organization, education and information as the keys to combating cancer in the developing world.