Filling the gap

In Malawi’s capital city, one pathologist has played an important role in speeding cancer diagnoses and supporting cancer research.

Filling the gap click to enlarge Malawian pathologist George Liomba was recruited to work with UNC-Project Malawi in Lilongwe. [Photo Credit: Dirk Dittmer, PhD, a UNC Lineberger member and co-director of the UNC Lineberger Global Oncology Program]

When George Liomba arrived in Malawi’s capital of Lilongwe nearly four years ago, he was the only full-time pathologist in the city of nearly 1 million people.

Before then, tissue samples were sent to a lab in Blantyre, Malawi’s second largest city approximately 200 miles away, so a pathologist there could confirm diagnoses. Or, the tissue sample slides were read by volunteer pathologists visiting from overseas. That meant delays in cancer diagnosis and treatment.

“Patients’ cancer would advance before we could get the results back,” said Mina Hosseinipour, MD, scientific director of UNC-Project Malawi, a public health and research collaboration in Lilongwe with the Malawi Ministry of Health.

Liomba, MBBS, was recruited from a pathology laboratory in Blantyre that he was running to work with UNC-Project Malawi in Lilongwe in 2011. The goal was to speed diagnoses for cancer patients, as well as to support the launch of a cancer research effort with support from the UNC Lineberger Comprehensive Cancer Center Global Oncology Program and other partners. A volunteer Bhutanese pathologist joined him for about a year through April at Kamuzu Central Hospital, and other Malawians physicians are expected to return from training in South Africa. And now, Liomba is expected to retire in the spring. UNC-Project Malawi leaders say he has played an important role in patient care and cancer research in the city, and in the surrounding area.

“Dr. Liomba and the launch of the pathology lab in Lilongwe have had a huge impact on clinical care by making rapid clinical care diagnoses possible,” Hosseinipour said. “And from the research perspective, it has allowed us to pursue multiple cancer research projects.”

To launch pathology services in Lilongwe, program leaders built the pathology lab in Lilongwe from the ground up. They received grants from the National Institutes of Health Medical Education Partnership Initiative and other sources as well as support from the UNC Lineberger Global Oncology program for equipment, training and other tools. Liomba reviewed the majority of cases in the first months that the lab opened, and became full-time there in 2012. In three years since the pathology lab opened, the case load grew from 700 cases in 2011 to 3,539 histology cases and 2,002 cytology cases last year, Liomba said.

The lab has helped speed diagnosis of cancers including Kaposi sarcoma, lymphoma and cervical cancer. Those and other virally-linked cancers are more common in eastern and southern African countries such as Malawi, where HIV incidence is high. Having the right diagnosis helped patients get the right treatment faster, Hosseinipour said.

The lab has also supported cancer research, particularly of virally-linked cancers. Recently, the UNC-Project Malawi partnership received a $3.7-million grant from the National Cancer Institute, jointly led by Satish Gopal, MD, MPH, assistant professor of medicine at the UNC School of Medicine and director of the UNC Malawi Cancer Consortium, Blossom Damania, PhD, a Lineberger member, director of the UNC Lineberger Global Oncology Program, the Boshamer Distinguished Professor of Microbiology and Immunology and assistant dean for research in the UNC School of Medicine, and Samuel Phiri, MD, adjunct associate professor in the UNC School of Medicine and executive director of the Lighthouse Trust in Malawi. The grant will allow researchers to describe the incidence of HIV-linked cancers in Malawi and to investigate the molecular characteristics of virus-linked lymphoma and Kaposi sarcoma, the most common cancer in the country.

“Our research program will also help catalyze improvements in cancer care, and build capacity for cancer care in Malawi,” Gopal said. “We are helping to address an exploding cancer burden in a country with remarkably few resources to address it. This work can also help us understand the underlying biology and to develop management approaches for cancer types that occur much more frequently here than in North Carolina, but that also occur in North Carolina as well.”

And through an Internet-connected microscopy system, the pathology laboratory in Lilongwe has allowed for a real-time exchange of knowledge between Chapel Hill and Malawi. Liomba reviews cases weekly with Yuri Fedoriw, MD, associate professor in the UNC School of Medicine Department of Pathology and Laboratory Medicine and director of Hematopathology. They use this telepathology system to confirm diagnoses and share rare cases.

“It truly gives you an appreciation of how different the environments are, and those differences are reflected in the diseases that we encounter,” said Fedoriw, who has seen pathology cases through the collaboration that are foreign to most pathologists in the United States – including cases of leprosy and of Kaposi sarcoma.

For Liomba, he said the telepathology conferences have provided a “tremendous” source of support.

“While most cases are straightforward with experience, it is not possible to know everything about human disease; so a second opinion, even when you have made a correct diagnosis, is comforting,” he said.

He also said that the launch of the lab has had a great impact on patient care. To speed the diagnoses of some cancer cases, they started a weekly biopsy service for patients with larger tumors.

And Liomba, who was born in Malawi, hopes to see more Malawians benefit from the health services provided through the collaboration, and to see it boost training and development for local scientists.

When he returned to Malawi from medical school in Australia in 1974, there were no pathologists in the country. Samples were sent to a laboratory in London, he said, for diagnoses. It could take between six weeks and three months to get results back.

He was recruited to study pathology by a retired professor who had an interest in seeing African doctors train in the specialty. When he returned from training in the specialty in the United Kingdom in 1983, he became the first Malawian pathologist, he said.

As a former professor of pathology at the University of Malawi College of Medicine, he helped train other Malawian pathologists as well.

 And now, after helping to build the laboratory in Lilongwe, Liomba is looking forward to his own final retirement in May.

“Hopefully there will be young Malawians back from training to fill the gap,” he said.