Keywords

10.1 Mauritania Demographics

The Islamic Republic of Mauritania (RIM) is situated in northwestern Africa, bordering the Atlantic Ocean, and located between Senegal and Mali in the south, Algeria and Morocco in the north. It belongs to both the Sahel and the Maghreb regions. Apart from the coastal region, the climate is often hot and windy with an annual rainfall ranging from 150 mm (5.9 in) in the north to about 600 mm (23.6 in) in the South. The total area of the country is 1,030,000 km2 formed mainly of vast arid plains except the Senegal River valley where most of the country’s agricultural production is harvested. Livestock is raised primarily in the south east. Mineral’s export, produced in the north, is dominated by iron but includes copper, gold, gypsum, oil, and steel [1, 2].

The country is organized in thirteen regions or “wilaya” all depending on the central interior ministry. A former French colony, Mauritania became independent in 1960. Estimated then at 850,384 inhabitants, now the total population counts 4,649,658 people according to UN data with a male to female ratio of 1.03.03 for residents aged 0–24 years and a growth rate of 2.72% [3]. The urban population represents 56.9% with about 5000 migrants. Arabic is the official language with the French spoken as a foreign language and four ethnic minority languages Wolof, Pulaar, Soninke, and Bambara. The Gross Domestic Product (GDP) was worth 7.59 billion US dollars in 2019 [4, 5].

10.2 Cancer Statistics in Mauritania

Two studies carried out, respectively, between (2000–2009) on 3305 patients and (2009–2020) on 10,437 patients showed that breast cancer (BC) was the most common cancer in the screened population (16.19% and 7.2%, respectively) (Figs. 10.1 and 10.2) [6, 7]. Deaths from cancer and communicable diseases represent, respectively, 5% and 59% of the total loss toll. Data from the registry of the Center National d’oncologie (CNO) also revealed an increase in cancer incidence rate since 2009 with a median age of 55 years at diagnosis. Table 10.1 shows the distribution by cancer type in the global cohort and in both genders (men: 1403 cases, 42% and women: 1902 cases, 58%), the mean age at detection and age group affected [8]. Overall, breast (15%) followed by cervical (10.4%) and skin (10%) cancers are the most common cancers in our population. This same order was found in women with, respectively, (25.5%), (18.1%), and (6%). In men, skin cancer (15.5%), prostate cancer (14.5%), and lymphomas (10.8%) were the most prevalent. Although the average age at diagnosis varied with cancer type, most cancer patients were 40–50 years old except, understandably, prostate cancer where the mean age was above 70 years [8,9,10].

Fig. 10.1
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Incidence of common cancers in Mauritania in 2020 [6]

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Fig. 10.2
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Evolution of cancer incidence in Mauritania for the period of 2009–2020 [6]

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Table 10.1 Description of cases by site, male, and female [8]
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10.3 Healthcare System in Mauritania

The healthcare service is organized in central hospitals in Nouakchott, the capital city, and regional hospitals in the 13 regions of the country supported by few dispensaries, maternal and child care centers in the less populated urban and rural zones (Table 10.2). Private health clinics also exist. All these facilities remain suffering from a lack of equipment, supplies, and well-trained staff. The state insurance covers 500,000 people and less than 1% of residents have a private health cover. Government health expenditure per person is estimated at 22 USD against 29 USD out-of-pocket spending [11]. There are about 15 physicians per 100,000 inhabitants [12]. Communicable, maternal, prenatal, and nutrition associated diseases represent 53% of the population total deaths. Infant mortality is 60.42 deaths/1000 live births. Life expectancy at birth is 67 years for females and 63 years for male [11, 12].

Table 10.2 Main hospitals offering care in Mauritania
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10.4 Oncology Care in Mauritania

Overall, there are 22 main hospitals in Mauritania (9 in Nouakchott and 13 in the remaining regions of the country). Five of these hospitals are providing specialized care (Table 10.2). Of these hospitals, Centre National Oncology (CNO) is the main cancer care center. Oncology activity in Mauritania began only in 1990 at the internal medicine department of Nouakchott Central Hospital. Most patients were then transferred abroad for treatment until the creation of the Centre National Oncology (CNO) in 2008 (Fig. 10.3). Before the inauguration of the first radiotherapy accelerator in 2010, the only service provided to cancer patients by the CNO was medical oncology [13].

Fig. 10.3
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Development of oncology in Mauritania [6]

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Currently, the CNO, an autonomous public institution, is the single institution in charge of cancer care in the country. There is no private cancer care in the country. The mission of CNO includes:

  • Offering and supervising cancer treatments. The CNO works with the anatomy and pathology departments of the various central and regional hospitals for cancer diagnosis.

  • Following-up treated patients.

  • Ensuring the full and free care of all nationals for radio-chemotherapy.

  • Coordination of patients’ evacuations abroad. This action is currently limited to bone marrow transplants and severe leukemias. Costs of all oncology care are largely covered by the state. People with relatively higher income seek treatment abroad at their expense.

  • The CNO undertakes and assists in campaigns to fight and raise awareness against the possible causes of cancer.

  • The CNO also provides statistics on cancer types and cancer patients in Mauritania.

10.5 Cancer Risk Factors

According to the Global Youth Tobacco Surveillance (GYTS) surveys conducted in Mauritania in 2000, 2006, and 2009, the prevalence of tobacco use is steadily increasing among adolescents aged 13–15 years. It was 41%, 59%, and 68%, respectively. Among adults (16–64 years), a study carried out by STEP-Wise NGO in 2006 showed a prevalence of 32% in men and 4.9% in women, respectively. Traditional tobacco called Meneiygeis very accessible and preferably used by rural aged women [14, 15].

Although female obesity is slightly decreasing, it is estimated that about 60% of Mauritanian women have a Body Mass Index (BMI) over 25 and therefore considered overweight [16,17,18]. The high rate of consanguinity and endogamy in the Mauritanian population (about 40–60%) particularly in some ethnic groups of sub-Saharan African origin (Sonikés) is also a risk factor for cancer and other disease with genetic trait such as heart diseases, hypertension, hearing deficit, and diabetes mellitus known to be more frequent in consanguineous marriages [19, 20].

Lifestyles such as high red meat consumption by many people in Mauritania particularly in the south may also contribute to various cancers like bowel (colorectal) cancer [21]. Hepatitis B (prevalence: 14%) and other infectious illnesses such as diarrhea, malaria, and tuberculosis remain endemic in the country [22, 23].

10.6 Cancer Screening Programs

There are no nationwide cancer screening programs in Mauritania because of funding priorities and lack of skilled healthcare workers to perform efficient screening plans. However, many promotional activities to raise public awareness on cancer risks (mainly smoking and obesity) are frequently undertaken by the state and Non-Governmental Organizations (NGOs) across the country such as “pink October,” a nationwide campaign organized every October to raise awareness on cervical and breast cancer and promote early diagnosis of these cancers. Screening mammograms are available in the country. The cost of the service is either covered by the state for patients with national insurance or by NGO for those with no medical insurance. For insured besides, irregular screening actions are also launched on the most common cancers like breast, cervical, and lung cancers. Counseling services remain scarce. The plans to introduce state screening programs and national registry for cancer are underway [24].

10.7 Cancer Prevention Programs

Few steps have been taken to prevent cancer in the country. For instance, a total ban on use of plastic bags has been effective since 2014 as a measure in the fight to reduce carcinogen items in consumers’ lifestyle although there is no clear evidence that people can get cancer from using plastic bags. High taxation on tobacco has been implemented. TV sketches on the risks of child and women obesity are regularly launched by the Ministry of Social Affairs [23]. Due to the high prevalence of hepatitis B in the country, vaccination against Virus of all newborn babies has been added since 2010 to the national program of child vaccination which already include (programme Elargie de Vaccination (PEV)). The screening for hepatitis B and the vaccine are also advised and freely available for all health workers but not yet mandatory. Vaccination for Human papillomavirus (HBV) is also recommended for girls when 12 years old [25].

10.8 Cancer Diagnosis

Evaluation of cancer in the country uses mainly patient history, physical examination, and basic laboratory testing such as tumor markers. Access to more reliable diagnostic tools such as imaging (X-ray), endoscopic exams, tumor biopsies is still limited and available only in few hospitals of the capital city such as the Institut National d’Hépatovirologie (INHV), Cheikh ZAYED hospital, and the Centre Hospitalier National (CHN). Advanced imaging facilities, Computed Tomography Scan (CT scan), and Mammograms are available in the CNO, at few public hospitals and some private clinics.

The main department of histopathology, located in the CNO, is supported by secondary services both in Nouakchott’s hospitals and in few private clinics. There is only one Nuclear Medicine Department, created at the CNO in June 2015 [26]. An Immunohistochemistry laboratory and oncogenetic unit (for genetic testing) have been recently added to the CNO diagnostic and follow-up facilities.

10.9 Treatment

10.9.1 Medical Oncology

The CNO is the major fully competent facility for cancer treatment in the country. The medical staff currently (2020) available consists of three medical oncologists and two hematologists all men, two pediatric oncologists both women, 10 nurses and technicians (4 women and 6 men). The CNO also uses clinical help from other medical departments based in different hospitals of Nouakchott like surgery, ophthalmology, etc. Oncologists in CNO are all former General Practitioners (GP) who then received their training in oncology largely abroad.

Cancer drugs, chemotherapy, and targeted therapy such as Trastuzumab/Pertuzumab for breast cancer, Rituximab for B lymphomas, and Bevacizumab used in broader applications like malignant solid tumors are only available in the CNO. Treatments are free at the CNO for indigent patients and offered at much reduced cost for patients with state insurance. Two private clinics Sahel and twvigh provide conventional chemotherapy for patients with insurance or self-pay.

Conventional-dose chemotherapy and targeted therapy are accessible only at the CNO. However, high dose chemotherapy, Bone Marrow Transplant (BMT), and immunotherapy are not yet available at the center due to their high cost, the associated equipment, and isolation rooms. Efforts are currently undertaken to introduce these therapies in the CNO [13].

10.9.2 Radiation Therapy

The single radiotherapy Linear Accelerator (LINAC) in the country, using Intensity-Volumetric Modulated Arc Therapy (VMAT), Modulated Radiation Therapy (IMRT), and 3D Conformal Radiation Therapy, is based at the CNO. It is operated by a Radiation therapist. The appropriate treatment volume and dosage prescribed to the patients by the radiation oncologist is then followed by the medical physicist and the dosimeters [27]. The radiotherapy staff currently (2020) available consists of four radiation oncologists and six physicists all men trained in Turkey, Morocco, and France.

10.9.3 Surgery

An oncological surgery has recently been set in the CNO. However, most organs and pieces removal procedures are still carried out within the surgery departments of the main hospitals of Nouakchott (Table 10.2) as part of their daily actions. There is no robotic or Hyperthermic Intraperitoneal Chemotherapy (HIPEC) surgery.

10.9.4 Pediatric Oncology

There is only one fully specialized pediatric oncology unit in the CNO since 2011. All hospitals refer young patients once diagnosed with cancer in their pediatric services to the CNO. The service is run by pediatric oncologists, all women and two juniors. It also includes two junior pediatric oncologists and four pediatric oncology nurses performing an integrated role of childhood cancer care and family support. Overall, 151 patients have been referred and followed at the CNO between 2017 and 2019 [6].

10.9.5 Survivorship Track

Data on cancer survival remain inaccurate in Mauritania as many patients do not complete their treatment or do not come back for checkup after completion of treatment. This group is termed “lost patients” by the CNO due to lack of possibility of tracking such patients. However, efforts are undertaken to minimize this loss and set an updated register of patient outcomes in the center. For instance, recent data have shown that 26% of women diagnosed with breast cancer in 2018 have died giving a 2–3-year survival rate 64% [6].

10.9.6 Palliative Care Track

Palliative care was successfully integrated in Mauritania in 2015. The country has about 50 nurses and a dozen of doctors specialized in medical care for people living with serious illnesses, mainly those with terminal cancers. Their task includes, besides improving the quality of life and outcome for patients of advanced diseases, the moral and spiritual support for stressed families, mainly those looking after their patients at home. There are no wards or hospice dedicated for palliative care in the country. However, in the plan for 2021, the CNO has approved a Department of Palliative Care to start in the first quarter of the year. Few Non-Governmental Organizations (NGO) charities such as Cairdeas Medical are also active in this field [28,29,30].

10.10 Research and Education

Oncology teaching program is part of the medical studies at the Faculty of Medicine but specialization in cancer practice remains largely carried out abroad. A program in oncology nursing is offered to nurses freshly joining the CNO but no national diploma in oncology nursing is yet available. Staff training in oncology remains very limited in local hospitals. They are provided mainly through exchange programs largely funded by the International Atomic Energy Agency (IAEA) allowing local staff to go for observation and skills learning in North African and European states.

Basic research on cancer is almost nonexistent. Few studies on the epidemiology of cancers such as breast and colorectal cancers in the Mauritanian population have been published [31,32,33]. A joint epidemiological study on breast cancer is underway between a team of the CNO and groups from the institut Pasteur of Tunis (Tunisia) and the institut Pasteur of Casablanca (Morocco). A Next Generation Sequencing (NGS) study aimed to identify gene mutations in a cohort of 135 breast cancer Mauritanian patients, being carried out by the oncogenetic unit of the CNO. The finding of this study may be useful in adapting standard treatment protocols to local patients if specific mutations were identified. There is a society of medical oncology.

10.11 Cost-Effective Cancer Care

Statistics are showing that cancer is rapidly being a public health problem in Mauritania. Due to the state’s limited infrastructure in the field and patient low income, cancers are often diagnosed at an advanced stage. As in most African states, the high cost of oncological care and the scarcity of medical oncologists (pathologists, radiation oncologists, and other healthcare workers) are key factors in the poor prognosis and low survival rate. Patients with private insurance or sufficient income often seek treatment in countries such as Turkey, Tunisia, Morocco, and western countries [6].

10.12 Challenges and Advantages

Numerous factors are still decreasing the chance of good prognosis and the probability of recovery from cancer in the country. Among these different challenges in the fight against cancer we may cite, for instance:

  • Absence of nationwide screening programs.

  • Cost of the infrastructure needed for an advanced and adapted care. As a result, most cancers are identified at a late stage. Access to immunohistochemistry to quickly assess cancer proliferation is still very difficult. Drugs targeting specific cancer cells are often not available.

  • Shortage of skilled oncology staff as training or recruiting specialized doctors and nurses is expensive for the state.

  • Migration of trained workers seeking better opportunities offered in western countries.

However, the current stability of the political climate, the high percentage of a young population combined with the increasing awareness and priority given to education and health in the state economy programs are relatively reassuring on a better prospect of disease care in Mauritania.

10.13 The Future of Cancer Care in Mauritania

The government has recently implemented a new national policy making the cancer entirely supported by the state for needy patients and at reduced price to individuals with state insurance. To ease the burden on the CNO, being the only cancer care facility in the country, regional secondary oncology centers providing basic care before referring to the CNO are to be planned. Advanced equipment for treatments like radiotherapy, imaging, etc., should also be purchased. Another key element needed is the training of skilled cancer workers: specialized physicians and nurses.

10.14 Conclusion

As in most third world countries, lack of prioritization in funding, shortage of infrastructure, and qualified oncology workers remain a barrier for efficient care of cancer patients. Training programs in demanding specialized fields such as nursing and medical oncology ought to be developed. A national program for palliative care needs to be implemented. Efforts are made by the government to overcome these obstacles through more financial support and training through regional and international collaboration.