Capacity building for the clinical investigation of AIDS malignancy in East Africa

Creating a charter of collaboration for international university partnerships: the Elmina Declaration for Human Resources for Health

The potential of international academic partnerships to build global capacity is critical in efforts to improve health in poorer countries. Academic collaborations, however, are challenged by distance, communication issues, cultural differences, and historical context. The Collaborative Health Alliance for Reshaping Training, Education, and Research project (funded by the Bill and Melinda Gates Foundation and implemented through academic medicine and public health and governmental institutions in Michigan and Ghana) took a prospective approach to address these issues. The project had four objectives: to create a "charter for collaboration" (CFC), to improve data-driven policy making, to enhance health care provider education, and to increase research capacity. The goal of the CFC was to establish principles to guide the course of the technical work. All participants participated at an initial conference in Elmina, Ghana. Nine months later, the CFC had been revised and adopted. A qualitative investigation of the CFC's effects identified three themes: the CFC's unique value, the influence of the process of creating the CFC on patterns of communication, and the creation of a context for research and collaboration. Creating the CFC established a context in which implementing technical interventions became an opportunity for dialogue and developing a mutually beneficial partnership. To increase the likelihood that research results would be translated into policy reforms, the CFC made explicit the opportunities, potential problems, and institutional barriers to be overcome. The process of creating a CFC and the resulting document define a new standard in academic and governmental partnerships.

Clinical trials to improve childhood cancer care and survival in sub-Saharan Africa

Over 80% of children with cancer live in low and middle-income countries where survival rates are much lower than high-income countries. Challenges to successful treatment of paediatric cancers in these countries include late presentation, malnutrition, failure to complete treatment and less-intense supportive care leading to increased treatment-related mortality and the need to reduce the intensity of treatment. Clinical trials can contribute to improved care and survival by providing objective information on the number of patients treated, accuracy of diagnosis, causes of treatment failure and the efficacy of specific interventions. Clinical trials can also help to build capacity (salary support and training), improve facilities (equipment) and fund treatment or essential associated costs (social support, nutritional support and follow-up care). In this article, we discuss our experience with clinical trials in Malawi and sub-Saharan Africa with emphasis on the treatment of children with Wilms tumour.

AIDS-Related Non-Hodgkin's Lymphoma in Sub-Saharan Africa: Current Status and Realities of Therapeutic Approach

Today AIDS-related non-Hodgkin's lymphoma (AR-NHL) is a significant cause of morbidity and mortality in HIV-infected patients the world over, and especially in sub-Saharan Africa. While the overall incidence of AR-NHL since the emergence of combination antiretroviral therapy (cART) era has declined, the occurrence of this disease appears to have stabilized. In regions of the world where access to cART is challenging, the impact on disease incidence is less clear. In the resource-rich environment it is clinically well recognized that it is no longer appropriate to consider AR-NHL as a single disease entity and rather treatment of AIDS lymphoma needs to be tailored to lymphoma subtype. While intensive therapeutic strategies in the resource-rich world are clearly improving outcome, in AIDS epicenters of the world and especially in sub-Saharan Africa there is a paucity of data on treatment and outcomes. In fact, only one prospective study of dose-modified oral chemotherapy and limited retrospective studies with sufficient details provide a window into the natural history and clinical management of this disease. The scarcities and challenges of treatment in this setting provide a backdrop to review the current status and realities of the therapeutic approach to AR-NHL in sub-Saharan Africa. More pragmatic and risk-adapted therapeutic approaches are needed.

Accuracy of Burkitt lymphoma diagnosis in constrained pathology settings: importance to epidemiology

CONTEXT

Burkitt lymphoma (BL) is endemic in Uganda and because of the high incidence, diagnosis is often presumed during clinical care and epidemiologic studies.

OBJECTIVES

To assess the accuracy of the clinical and the local pathology diagnosis of BL as assessed by an outside pathology review diagnosis and to understand the limitations on histopathology practice in a resource-constrained setting at 1 hospital in Uganda.

DESIGN

Clinically presumed pediatric (<15 years) BL cases with biopsies and pathology reports, from 1993 to 2007, were identified at St Mary's Hospital, Lacor (Gulu, Uganda). Local histopathology procedures, hematoxylin-eosin-stained tissue sections, and formalin-fixed paraffin-embedded blocks were reviewed onsite by an outside pathologist, followed by outside study that included tissue microarray immunohistochemistry and in situ hybridization.

RESULTS

Local pathology laboratory procedures were inconsistent and suboptimal, especially for tissue fixation. There were 88 clinically presumed BL cases. Sixty-three could be reviewed by outside pathology (25 cases of lost blocks or no remaining tumor) and showed a clinical diagnostic accuracy of 75% (47 confirmed of 63), with a possible range of 62% to 85%, depending on the actual diagnosis of the 25 nonevaluable cases. There were 64 BL cases diagnosed by local pathology. Forty-five could be reviewed by outside pathology (19 cases of lost blocks or no remaining tumor) and showed a local pathology diagnostic accuracy of 82% (37 confirmed of 45), with a possible range of 58% to 88%, depending on the actual diagnosis of the 19 nonevaluable cases. Non-BL diagnoses included other non-Hodgkin lymphomas, Hodgkin lymphoma, and benign infectious lymphadenopathy.

CONCLUSIONS

Accuracy of clinical diagnosis of BL was reduced by inclusion of other diseases with similar clinical presentations. Local pathology, using morphology alone, only marginally improved clinical accuracy and often could not support outside pathology review due to inadequate laboratory procedures. There is an urgent need to improve pathology services in Uganda before conducting high-quality clinical and epidemiologic studies.

Dose-modified oral chemotherapy in the treatment of AIDS-related non-Hodgkin's lymphoma in East Africa

PURPOSE Africa is burdened by the AIDS epidemic and attendant increase in HIV/AIDS-related malignancies. Pragmatic approaches to therapeutic intervention could be of great value. Dose-modified oral chemotherapy for AIDS-related non-Hodgkin's lymphoma is one such approach. PATIENTS AND METHODS The oral regimen consisted of lomustine 50 mg/m(2) on day 1 (cycle 1 only), etoposide 100 mg/m(2) on days 1 to 3, and cyclophosphamide/procarbazine 50 mg/m(2) each on days 22 to 26 at 6-week intervals (one cycle) for two total cycles in HIV-infected patients with biopsy-proven non-Hodgkin's lymphoma. Results Forty-nine patients (21 in Uganda and 28 in Kenya) were treated. The majority of patients were female (59%) and had a poor performance status (63%); 69% of patients had advanced-stage disease; and 18 patients (37%) had access to antiretroviral therapy. In total, 79.5 cycles of therapy were administered. The regimen was well tolerated, had modest effects (decline) on CD4(+) lymphocyte counts (P = .077), and had negligible effects on HIV-1 viral replication. Four febrile neutropenia episodes and three treatment-related deaths (6% mortality rate) occurred. The overall objective response rate was 78% (95% CI, 62% to 88%); median follow-up time was 8.2 months (range, 0.1 to 71 months); median event-free and overall survival times were 7.9 months (95% CI, 3.3 to 13.0 months) and 12.3 months (95% CI, 4.9 to 32.4 months), respectively; and 33% of patients survived 5 years. CONCLUSION Dose-modified oral chemotherapy is efficacious, has comparable outcome to that in the United States in the pre-highly active antiretroviral therapy setting, has an acceptable safety profile, and is pragmatic in sub-Saharan Africa. The international collaboration has been highly successful, and subsequent projects should focus on strategies to optimize combination antiretroviral therapy and chemotherapy and follow-up tissue correlative studies.

Targeted therapy for Kaposi's sarcoma and Kaposi's sarcoma-associated herpesvirus

PURPOSE OF REVIEW

To summarize major recent findings on the biology of human herpesvirus-8, i.e. Kaposi's sarcoma-associated herpesvirus, and the implications of these findings for Kaposi's sarcoma treatment.

RECENT FINDINGS

Although reduced in incidence in developed countries since the introduction of highly active antiretroviral therapy, Kaposi's sarcoma incidence is still markedly increased in HIV-infected patients in resource-rich areas of the world and is a major complication among HIV-infected individuals in sub-Saharan Africa. The Akt/mammalian target of rapamycin pathway has emerged as a major driving force in Kaposi's sarcoma. In addition, the roles of p53, the Kaposi's sarcoma-associated herpesvirus viral cyclin and nuclear factor-kappaB in the development and progression of Kaposi's sarcoma are being further clarified, and therapeutic agents are being developed that may target these pathogenetic mechanisms. New Kaposi's sarcoma treatments should be considered that target the molecular interface between virus and host.

SUMMARY

The growing knowledge of Kaposi's sarcoma biology provides multiple opportunities for rational targeted therapies. Further research is needed to better understand the mechanisms by which Kaposi's sarcoma develops and to develop therapeutic strategies that prevent resistance to treatment.

Cancer initiatives in developing countries

The coming decades will bring dramatic increases in morbidity and mortality from cancer in the developing world. The burden of cancer is increasing globally, with an expected 20 million new cases per year in 2020, half of which will be in low- and middle-income countries. Despite an already overwhelming burden of health problems, developing countries must somehow address this cancer pandemic and their alarming share of cancer illness. Many large-scale and innovative worldwide initiatives have been launched in the fight against cancer. These programs represent colossal efforts to expand resources for health education among people and healthcare workers in developing countries and to increase awareness of cancer prevention. Many novel evidence-based and culturally-relevant programs are being implemented for screening and early prevention of common cancers. Several key initiatives are supporting clinical research, guideline development, oncology training, and appropriate technology transfer, such as access to electronic medical literature. Treatment programs are expanding access and quality of radiologic and pharmacologic therapies for cancer. These initiatives represent an unprecedented level of and cooperation among international agencies, governmental and nongovernmental organizations, international foundations, scientific societies, local institutions, and industry. This review examines the scope of need in response to the increasing burden of cancer in the developing world and major initiatives that have been created to respond to these needs.

Challenges and opportunities for treatment and research of AIDS-related malignancies in Africa

PURPOSE OF REVIEW

Following our review of AIDS-associated cancer in developing nations in 2004, we sought to update recent publications and review data on the challenges and opportunities for the treatment and research of AIDS malignancies in Africa.

RECENT FINDINGS

It is apparent that the burden of AIDS-related malignancies and other virus-associated tumors is significant and increasing in Africa. Several recent studies report findings on conjunctival squamous cell carcinoma and there is a report that Hodgkin's disease, a non-AIDS-defining neoplasm, is increasing in incidence. International collaborative partnerships dedicated to AIDS malignancies in developing countries are feasible and invaluable for clinical strategies to address this aspect of the pandemic. A departure point is the ongoing work of the East Africa - Case Western Reserve University Collaboration in AIDS malignancies.

SUMMARY

The burden of neoplastic complications of HIV infection and endemic virus-associated tumors are assuming increasing significance in Africa. There is a need to develop nonmyelotoxic therapies and approaches that are hypothesis-driven and pathogenesis-based. The scarcity and shortages in this region demand that our scientific and therapeutic strategies are both suitable and pragmatic for testing in this setting. It is also imperative that African investigators lead us in this important endeavor.