The initiative is so noble and the need seems to be so obvious that no question has been raised about the urgency of undertaking the costly endeavour of building a state of the art cancer hospital in the country. But a deeper look into the problems of cancer treatment and realities on the ground raises some questions about establishing the proposed state of the art cancer hospital.

The country presently has one government funded National Institute of Cancer Research & Hospital at Mohakhali, Dhaka. Banghabandhu Sheikh Mujib Medical University Hospital and almost all medical college hospitals have arrangements for cancer treatment. All these facilities are far too little compared to the needs of the cancer patients of the country.

The first step in managing cancer is proper diagnosis. It means determining the exact type of cancer and the extent to which it has spread in the body. In most cases, throughout the world (and especially in a low income country like ours) cancer is usually diagnosed at a very late stage when the cancer had already spread widely throughout the body. Once the diagnosis is confirmed the single management issue is to decide whether there is any curative option available. In most cases the answer is negative. The next question is, do we have any management options in the vast majority of incurable cases? Here comes the role of cancer hospital. Although a great effort would be exerted to pursue cure, taking care of the incurable patients will constitute a cancer hospital's main responsibility.

The job of reducing the pain and sufferings of the incurable ones lies with a medical specialty called palliative care. This service is led by physicians but includes nurses, paramedics, social workers, etc. Though this specialty is not specific for cancer patients, rather any patient suffering from painful and incurable disease can be managed by palliative specialty, cancer patients are the largest beneficiary of palliative care . An incurable patient with cancer receives chemotherapy or radiation therapy from cancer physicians in close consultation and collaboration with palliative specialists for meaningful prolongation of life or for comfortable terminal life. When pain or depression engulfs a cancer victim, this palliative service attempts to treat or alleviate those symptoms.

In the context of Bangladesh, we have to consider other aspects of cancer treatment, as well. When a patient is made aware of the diagnosis of cancer, the patient or the patient's family becomes desperate to bring cure to this and gets ready to spend everything. Many a times the family sell their properties, interrupt the education of children but at the end the patient dies leaving the family destitute with a huge burden of debt. Addressing such issues needs careful assessment of several non-medical aspects of the patient in addition to the medical issues.

A coordinated multidisciplinary approach is essential to manage cancer patients both for curative or palliative purposes that can only be delivered by a well-organized institution born out of a carefully conceived plan. With money it will be easy to procure expensive new machines for investigation or to build fancy buildings. But we need more than money to utilize these facilities for the real benefit of the patients and their families. For instance, palliative medicine specialty is non-existent in any medical institute in Bangladesh. Medical oncology is still in infancy; whereas it is a well developed specialty in all developed and most developing countries. Cancer chemotherapy, which belongs to the field of medical oncology remains the dominion of radiation oncologists in our country.

Before venturing to build a cancer hospital by purchasing expensive machines and equipments, far greater priority should be devoted towards developing a team of personnel in all the crucial issues related to cancer management. Our doctors have immense potentialproven on several occasions in many countries of the world. If they are sent on scholarships for training from the budget of cancer hospital to training hospitals in the developed countries, it will be more useful for patients before importing the expensive machines. Similarly nurses and paramedics should also be sent for training.

Once we have the trained personnel, we need to address the issue of adequate remuneration so that these skilled people can devote their full energy for the service of cancer patients without having to worry about private practice or finding other ways to supplement their regular earnings. Adequate remuneration would also be essential for keeping the overseas trained and internationally competent personnel from taking up a job abroad and leaving the country. In my humble opinion once the issue of developing and then retaining a well-organized team of competent human resources is resolved, the noble initiative of building a dedicated cancer hospital with sophisticated machines will bring benefits to the people who are in dire need of such facility.

Manzur Morshed, FCPS,MRCP(UK) is Hematologist, King Faisal Cancer Center King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia.