The 39-year-old woman, vomiting and with severe abdominal pain, was admitted to the Emergency Room at a Botswana hospital. Prior to her arrival, she hadn’t been eating well and had lost a lot of weight. She had never been tested for HIV.
These facts were presented a few months later at the Botswana-Harvard Tumor Board meeting, held concurrently in a conference room at the Botswana Harvard AIDS Institute Partnership (BHP) in Gaborone, Botswana, and in the Department of Radiation Oncology at Massachusetts General Hospital (MGH) in Boston. It was a challenge to connect the audio-visual feed between rooms 7,000 miles apart, but soon both groups were looking at the same pathology images.
In Botswana, Dr. Memory Bvochora-Nsingo, a radiation oncologist, described the test results for her patient. The woman was HIV-positive with a low CD4 count, meaning her immune system was severely compromised. Dr. Joseph Makhema, C.E.O. of the BHP and one of the doctors in the crowded room in Botswana, had started the patient on antiretroviral drugs to treat her HIV.
From the pathology images, the woman had also been diagnosed with low-grade lymphoma, yet because of her symptoms and the severity of her illness, Memory thought that she was suffering from high-grade B cell lymphoma instead.
Memory, a native of Zimbabwe, is one of just a few oncologists working in Botswana. Until recently, most people diagnosed with cancer in Botswana were sent to South Africa for treatment. This was difficult for patients and expensive for the healthcare system. Today, Botswana is developing its own cancer treatment programs.
That’s where the white coats huddling around the microphone at MGH in Boston helped out. The Tumor Board holds monthly meetings to review cancer cases from Botswana and have experts weigh in on treatment decisions. Most of the cancer patients are also infected with HIV.
Dr. Jeremy Abramson, a lymphoma specialist whom another doctor described as “the go-to guy for all HIV-related lymphomas and Kaposi sarcoma,” offered reassuring words to Memory. “I was pleased to see your treatment plan,” said Jeremy. “That’s exactly what I would have done in this scenario.”
“I’m very happy you say that because I had to make a decision,” said Memory. “The clinical presentation was contrary to the pathology. The patient was very sick. We just decided to go on and treat it as a high-grade [lymphoma]. I thought that if we go for the pathology review and wait for things, she might, you know…”
“It’s a much greater sin to over-treat a low-grade lymphoma than to undertreat a high-grade lymphoma,” replied Jeremy. “This patient has a very good chance of being cured [of the lymphoma] with the therapy you initiated.”
In Boston, pathologist Dr. Aliyah Sohani confirmed that the cancer cells were characteristic of a high-grade lymphoma. She told Memory about a website where she can post pathology images. MGH pathologists will look at the images and offer an informal second opinion in a few days or less.
Dr. Jason Efstathiou, a radiation oncologist at MGH, gently guided the proceedings. The Tumor Board was his idea. “This is an opportunity to bring the experts in Botswana together in one room at the same time to facilitate discussion and communication,” said Jason. “It allows a forum for exchange, addressing individual patient care and broader system issues.” The Tumor Board is part of a larger collaboration, which also includes one-on-one mentorship and a two-way exchange of clinicians between Boston and Botswana.
Dr. Scott Dryden-Peterson, an infectious disease specialist in Boston, weighed in about chemotherapy and possible interactions with the antiretroviral drugs the patient was taking for her HIV infection. Scott works part of each year in Botswana and co-founded the Tumor Board at the BHP.
At the end of the call, Memory gave an update on her patient’s status. “She’s doing well.”
For very little money, doctors in Botswana’s nascent cancer program have the opportunity to confer with experts in several medical specialties. “Our main focus is not to be the ones who go there and give care,” said Jason. “The key is capacity building on the Botswana side. Ultimately, Botswana will be best served by retaining their best.”