Allama Iqbal Medical College, Jinnah Hospital, Lahore

The Allama Iqbal Medical College.

Pakistan is a developing country with a limited budget for health care - only 0.7 of the gross national product is allocated to health. The major focus of the government is on maternal and child health and infectious diseases. Health care is provided by the public (government-sponsored) hospitals to the poor and low middle class - approximately 30-40% of the population live below the poverty level - and private sector hospitals, which are expensive, cater to patients from the upper socioeconomic strata.

Allama Iqbal Medical College/Jinnah Hospital is a medical college for undergraduate and post-graduate students. It was created in 1975 in response to the rapidly expanding population in and around Lahore and a corresponding growing need for hospitals beyond the city centre. The clinical facilities of this large hospital (1,100 beds) include five surgical units, five medical units, two gynecology units, pediatrics and a range of other speciality units, including ophthalmology, ear, nose and throat, orthopedics, neurosurgery, urology, dermatology, plastic surgery and cardiology.

The Department of Medical Oncology was established in 1993 as a two-bedded day care unit on one of the hospital verandas. Twelve years later it has grown to a 40-bedded unit with 100% occupancy rate and is recognized as a major tertiary care referral center for oncology patients. Approximately 3,000 new cancer cases are seen each year, 80% from the province of Punjab and the remainder from all parts of Pakistan. Approximately 90% of the patient population of the Oncology Department live below the poverty level, but essentially all patients are provided with free medicine through zakat (a wealth tax paid by affluent Muslims). In addition, breakfast and lunch are provided free of charge and, through an outreach initiative, 100 of the children of our cancer patients are being educated, using funds provided by our donors. In lieu of a population-based registry in the region, which we are in the process of developing, we maintain our own institutional tumor registry.

As in other developing countries, most cancers in Pakistan are preventable, and are related to smoking, diet and infections. The most common cancer in women is breast cancer. The most common cancers in men are lymphomas, leukemias, lung and hepatocellular cancers.

Goals of the Department

The primary goals of the department are:

• To constantly improve patient care
• To teach medical students and residents, who rotate through the department
• To provide post-graduate teaching in medical oncology (resulting in a degree awarded by the College of Physicians & Surgeons)
• To conduct research, both at national and international levels
• To undertake public and professional education directed toward early diagnosis (75% of patients currently present with advanced disease and are incurable).

Breast Cancer

Breast cancer is a particular interest of the department, in part because it is numerically of great importance, and in part because there are potential approaches to both its early detection and treatment. Unfortunately, approximately 75% of all of our patients, as with all our cancer patients, present with advanced disease, where cure is not possible. The medical center is therefore conducting an intensive campaign aimed at early diagnosis.

Dr. Zeba Aziz, Professor of Oncology at AIMC, is Pakistan's first trained medical oncologist to practice in her native country. She has been instrumental in raising breast cancer awareness and conducting breast cancer research.

Factors predisposing to the development of breast cancer in the USA and Europe include pregnancies later in life, not breastfeeding, and having few children. However, these parameters are not particularly relevant in Pakistan, where 70% of patients have no identifiable risk factors. There is a need to collect better information pertaining to the epidemiology of breast cancer in Pakistan, since we believe the incidence of this disease is rising. Given recent advances in understanding the genetics of the disease, we have investigated the prevalence of mutations in the genes BRCA1 & BRCA2, which are known to predispose to breast cancer. We have also studied the frequency of breast cancer in women born of consanguineous marriages.

Recently, we examined the outcome of treatment in 286 women with breast cancer according to their socio-economic status. Data was collected on the size of the tumor, the time of diagnosis, the type of treatment given and survival rates. Early stage breast cancer was seen in nearly three-quarters of the women with high socio-economic status and 89% received adequate treatment. In contrast, nearly half the women from poorer, less educated backgrounds, did not seek medical help until the cancer had reached an advanced stage, and only 44% received adequate treatment. This resulted in an overall survival rate at 10 years of 73% of women in the high socio-economic status, 49%, in the middle tier and less than one quarter, 22%, in the lower group.

Clearly, poorer people do not seek help soon enough, and in any event have poor access to appropriate medical care. A significant component of the problem is that in their sector of society, breast cancer carries a stigma that greatly lowers self-esteem. Both sexes view women with breast cancer (or who have had a mastectomy because of breast cancer) as sexually unattractive. Thus women are afraid to bring attention to a lump because of fear of mastectomy and the resultant stigma. Emotional and physical abandonment is a common end result, and many women do not even complete their treatment. Gross ignorance also leads to breast cancer being considered contagious. We have seen women isolated to the point of not being allowed to touch their children or to use household utensils.

Educating people, including health professionals (many surgeons, for example, still perform mastectomy, even in circumstances where it may be avoided), is a vital tool in the fight against this cancer. In our public education programs we urge women to put the stigma aside and seek medical advice early in order to avoid surgery to remove their breast. It is important also for women to participate in clinical trials, for only then will we be able to determine the best approaches to therapy in our own situation, and to move towards a reduction in the fraction of women who require mastectomy.

	Resources at AIMC
	Total Beds	1,100
	Beds Devoted to Cancer patients	40
	Staff Physicians	85
	Nurses (approximately)	200
	Dedicated Oncology Nurses	8
	Pathologists	6
	Oncologists	2
	Equipment:
	CT Scanners	1
	Ultrasound Machines	4
	MRI Scanners *	0
	Cobalt Radiotherapy Units	1
	Linear Accelerator Units	1
	Brachytherapy Units	1
	Pathology Department - Routine Services:
	Histopathology
	Microbiology
	Haematology
	Biochemistry
Patients in 2003
	Total visits, entire hospital	347,547
	Total patients admitted	40,697
	New adult cancer patients	10,500
	Adult cancer patients admitted	2,670
	New pediatric cancer patients	115
	Total number of new cancer patients	3,120
* To be installed in the near future

Zeba Aziz, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan