Cancer survival in Kampala, Uganda

Awareness of cervical cancer risk factors and preventive approaches, and perceived causes of cervical cancer among secondary school girls: a cross-sectional study in Northern Uganda

BACKGROUND

The majority of women in low- and middle-income countries have low awareness of cervical cancer. This study sought to establish awareness of cervical cancer risk factors and preventive approaches, as well as sources of information and perceived causes of cervical cancer among secondary school girls in northern Uganda.

METHODS

This was a cross-sectional study conducted in rural northern Uganda. We collected data using an investigator administered pre-tested questionnaire. Analysis was done with STATA version 14.0. Multivariate analyses with logistic regressions models were used to determine magnitudes of association between independent and outcome variables. Odds ratios and accompanying 95% confidence intervals are reported. Statistical significance was considered if the two sided p-value <.05.

RESULTS

Most participants (97%; n = 624) had heard of cervical cancer before this study. The most common source of information about cervical cancer was friends (31.1%; n = 194). More than half of the participants (59%; n = 380) had heard about a vaccine that prevents cervical cancer, but only a third (33%; n = 124) had ever received a dose of the vaccine. The majority of participants (89%; n = 550) reported that cervical cancer could be prevented; however only half (52%; n = 290) knew that vaccination of girls aged 9-13 years could prevent cervical cancer. The majority of participants did not recognize the risk factors for cervical cancer; for example, only 15% (n = 98), 7% (n = 45), and 1.4% (n = 9) recognized early onset of sexual intercourse, infection by the human papillomavirus (HPV), and smoking respectively. On adjusting for age, students' class, and religion, students in schools with school health programs were twice (aOR = 2.24: 95%CI; 1.24-4.06) more likely to know that cervical cancer is preventable.

CONCLUSION

Secondary school girls need information on cervical cancer risk factors and approaches to prevention so that they may avoid exposures to the risk factors and promptly seek and undertake preventive approaches including HPV vaccinations.

Usability of a smartphone-compatible, confocal micro-endoscope for cervical cancer screening in resource-limited settings

BACKGROUND

More efficient methods to detect and treat precancerous lesions of the cervix at a single visit, such as low-cost confocal microscopy, could improve early diagnosis and hence outcomes. We piloted a prototype smartphone-compatible confocal micro-endoscope (SCME) among women presenting to a public cervical cancer screening clinic in Kampala, Uganda. We describe the piloting of the SCME device at an urban clinic used by lower cadre staff.

METHODS

We screened women aged 18 and 60 years, who presented for cervical cancer screening at the Kawempe National Referral Hospital Kampala, and evaluated the experience of their providers (nurses). Nurses received a 2-day training by the study doctors on how to use the SCME, which was added to the standard Visual Inspection with Acetic acid (VIA)-based cervical cancer screening. The SCME was used to take colposcopy images before and after VIA at positions 12 and 6 O'clock if VIA negative, and on precancer-suspicious lesions if VIA positive. We used questionnaires to assess the women's experiences after screening, and the experience of the nurses who operated the SCME.

RESULTS

Between November 2021 and July 2022, we screened 291 women with a median age of 36 years and 65.7% were HIV positive. Of the women screened, 146 were eligible for VIA, 123 were screened with the SCME, and we obtained confocal images from 103 women. Of those screened with the SCME, 60% found it comfortable and 81% were willing to screen again with it. Confocal images from 79% of the women showed distinguishable cellular features, while images from the remaining 21% were challenging to analyze. Nurses reported a mean score of 85% regarding the SCME's usefulness to their work, 71% regarding their satisfaction and willingness to use it again, 63% in terms of ease of use, and 57% concerning the ease of learning how to operate the SCME.

CONCLUSION

Our findings demonstrate the feasibility of using the SCME by lower cadre staff in low-resource settings to aid diagnosis of precancerous lesions. However, more work is needed to make it easier for providers to learn how to operate the SCME and capture high-quality confocal images.

Effect of metabolic syndrome and its components on the risk and prognosis of cervical cancer: A literature review

Despite the global implementation of preventive strategies against Human Papilloma Virus (HPV) infection, the incidence of invasive cervical cancer rose by nearly 1.3-fold, from 471,000 annual cases in 2000 to 604,000 cases in 2020. With over 340,000 deaths annually, cervical cancer is the fourth leading cause of cancer mortality in women globally. There is a need to understand other factors besides HPV such as metabolic syndrome (MetS) that potentially influence the onset and progression of cervical cancer. In this narrative review, we describe evidence showing that Metabolic syndrome (MetS) increases the risk for cervical cancer and worsens its prognosis. Combined screening for MetS and cervical cancer has potential to significantly reduce morbidity and mortality in women with cervical cancer.

Late Stage at Diagnosis of Cervical Cancer and Its Correlates at a Large Regional Referral Hospital in Uganda: A Cross-Sectional Study

Background The stage of disease at diagnosis is one of the major determinants of survival in women with cervical cancer. Most women with cervical cancer in low- and middle-income countries (LMICs) present to hospitals with advanced stages, thus reducing their survivorship following the diagnosis. Factors correlated with late-stage disease at diagnosis are not completely explored. This study aimed to describe the association between sociodemographic, clinical, and metabolic characteristics with late-stage disease at diagnosis in women with cervical cancer attending the Mbarara Regional Referral Hospital in Southwestern Uganda. Methodology We conducted a cross-sectional study of women with histological diagnoses of invasive cervical cancer between November 2022 and August 2023. Women who presented to the hospital with the International Federation of Gynecology and Obstetrics stage IIb and above were considered to have late-stage cervical cancer while those with stage IIa and below were considered to have early-stage disease. We used modified Poisson regression to determine the factors independently associated with the outcome. Results We enrolled 157 women. The average age of the participants was 52.4 years. The majority of the participants (83.4%) had late-stage disease at diagnosis. Women with adenocarcinoma (adjusted prevalence ratio (aPR) = 1.18, 95% confidence interval (CI) = 1.10-1.38) and those with lymphovascular space involvement on histology (aPR = 1.30, 95% CI = 1.05-1.60) were more likely to have late-stage disease at diagnosis while women living with human immunodeficiency virus (aPR = 0.83, 95% CI = 0.71-0.97) were less likely to present with late-stage disease at diagnosis. None of the sociodemographic and metabolic characteristics were associated with late-stage disease at diagnosis. Conclusions The number of women presenting with late-stage cervical cancer is high. Efforts to increase the availability and uptake of cervical cancer screening services in LMICs should be reinforced. Cervical cancer treatment services should be decentralized to increase accessibility.

Assessment of secular trends of three major gynecologic cancers burden and attributable risk factors from 1990 to 2019: an age period cohort analysis

BACKGROUND

This study aims to assess the long-term trends in the burden of three major gynecologic cancers(GCs) stratified by social-demographic status across the world from 1990 to 2019. To assess the trends of risk factor attributed mortality, and to examine the specific effects of age, period, cohort behind them in different regions.

METHODS

We extracted data on the mortality, disability-adjusted life years(DALYs), and age-standardized rates(ASRs) of cervical cancer(CC), uterine cancer(UC), and ovarian cancer(OC) related to risks from 1990 to 2019, as GCs burden measures. Age-period-cohort analysis was used to analyze trends in attributable mortality rates.

RESULTS

The number of deaths and DALYs for CC, UC and OC increased since 1990 worldwide, while the ASDRs decreased. Regionally, the ASDR of CC was the highest in low SDI region at 15.05(11.92, 18.46) per 100,000 in 2019, while the ASDRs of UC and OC were highest in high SDI region at 2.52(2.32,2.64), and 5.67(5.16,6.09). The risk of CC death caused by unsafe sex increased with age and then gradually stabilized, with regional differences. The period effect of CC death attributed to smoking showed a downward trend. The cohort effect of UC death attributed to high BMI decreased in each region, especially in the early period in middle, low-middle and low SDI areas.

CONCLUSIONS

Global secular trends of attributed mortality for the three GCs and their age, period, and cohort effects may reflect the diagnosis and treatment progress, rapid socioeconomic transitions, concomitant changes in lifestyle and behavioral patterns in different developing regions. Prevention and controllable measures should be carried out according to the epidemic status in different countries, raising awareness of risk factors to reduce future burden.

Survival Patterns Among Patients With Breast Cancer in Sub-Saharan Africa: A Systematic Review and Meta-Analysis

Importance

Breast cancer is the most prevalent cancer globally with tremendous disparities both within specific regions and across different contexts. The survival pattern of patients with breast cancer remains poorly understood in sub-Saharan African (SSA) countries.

Objective

To investigate the survival patterns of patients with breast cancer in SSA countries and compare the variation across countries and over time.

Data Sources

Embase, PubMed, Web of Science, Scopus, and ProQuest were searched from inception to December 31, 2022, with a manual search of the references.

Study Selection

Cohort studies of human participants that reported 1-, 2-, 3-, 4-, 5-, and 10-year survival from diagnosis among men, women, or both with breast cancer in SSA were included.

Data Extraction and Synthesis

Independent extraction of study characteristics by multiple observers was performed using open-source software, then exported to a standard spreadsheet. A random-effects model using the generalized linear mixed-effects model was used to pool data. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guideline for reporting was followed.

Main Outcome and Measures

Survival time from diagnosis.

Results

Forty-nine studies were included in the review with a sample size ranging from 21 to 2311 (total, 14 459; 196 [1.35%] men, 13 556 [93.75%] women, and 707 [4.90%] unspecified; mean age range, 38 to 71 years), of which 40 were summarized using meta-analysis. The pooled 1-year survival rate of patients with breast cancer in SSA was 0.79 (95% CI, 0.67-0.88); 2-year survival rate, 0.70 (95% CI, 0.57-0.80); 3-year survival rate, 0.56 (95% CI, 0.45-0.67); 4-year survival rate, 0.54 (95% CI, 0.43-0.65); and 5-year survival rate, 0.40 (95% CI, 0.32-0.49). The subgroup analysis showed that the 5-year survival rate ranged from 0.26 (95% CI, 0.06-0.65) for studies conducted earlier than 2010 to 0.47 (95% CI, 0.32-0.64) for studies conducted later than 2020. Additionally, the 5-year survival rate was lower in countries with a low human development index (HDI) (0.36 [95% CI, 0.25-0.49) compared with a middle HDI (0.46 [95% CI, 0.33-0.60]) and a high HDI (0.54 [95% CI, 0.04-0.97]).

Conclusions and Relevance

In this systematic review and meta-analysis, the survival rates for patients with breast cancer in SSA were higher in countries with a high HDI compared with a low HDI. Enhancing patient survival necessitates a comprehensive approach that involves collaboration from all relevant stakeholders.

Gastric cancer in Sub-Saharan Africa - a systematic review of primary data

Introduction

Gastric cancer (GC) is the third leading cause of global cancer-related mortality. Despite the shifting burden of GC to low-and middle-income countries, the data regarding incidence, treatment, and outcomes in these settings are sparse. The primary aim of this systematic review was to aggregate all available data on GC in sub-Saharan Africa (SSA) to describe the variability in incidence across the region.

Methods

Studies reporting population-based primary data on GC in SSA were considered. The inclusion was limited to primary studies published between January 1995 and March 2022 which comprised of adult patients in SSA with GC. Studies without accessible full text in either French or English language were excluded. Unadjusted GC incidence rates with their standard errors for each study were recalculated from the crude numerators and denominators provided in individual studies.

Results

A total of 5,626 articles were identified in the initial search, of which, 69 studies were retained. Reported incidence rates ranged from a high of 5.56 GC cases per 100,000 in Greater Meru Kenya to a low of 0.04 GC cases per 100,000 people in Benin City Nigeria. The overall crude pooled incidence was 1.20 GC cases per 100, 000 (95%CI 1.15-1.26) with a variability of 99.83% (I2 p < 0.001). From the 29 high-quality population-based registry studies the crude pooled incidence was 1.71 GC cases per 100,000 people (95%CI 1.56-21.88) with a variability of 99.60%.

Conclusion

This systemic review demonstrates that GC incidence is highly variable across SSA. The limited data on GC treatment, mortality, and survival presents a significant challenge to providing a complete epidemiologic description of the burden of GC in SSA. There is a need for further robust data collection, exploration, and research studies on cancer care in SSA, with continued assessment of primary data availability.

Diagnostic and pre-treatment intervals among patients with cervical cancer attending care at the Uganda Cancer Institute: a cross-sectional study

BACKGROUND

Majority of patients with cervical cancer in the low- and middle-income countries experience long diagnostic and pre-treatment intervals. This study sought to determine the factors associated with the diagnostic and pre-treatment intervals among patients with cervical cancer.

METHODS

This was a cross-sectional study conducted at the Uganda Cancer Institute (UCI) during October 2019 to January 2020. Patients aged ≥ 18 years with histological diagnosis of cervical cancer were consecutively sampled. Data were collected using a pre-tested semi-structured questionnaire and a data abstraction form. Diagnostic intervals, defined as the time between first visit of a patient to a primary healthcare provider to time of getting confirmed diagnosis, of ≤ 3 months was defined as early & >3 months as late. Pre-treatment intervals, which is the time from histological diagnosis to starting cancer chemo-radiotherapy of ≤ 1 month was defined as early and > 1 month as late. Data were analysed using STATA version 14.0. We used modified Poisson regression models with robust variance to determine socio-demographic and clinical factors associated with the intervals.

RESULTS

The mean age of the participants was 50.0 ± 11.7 years. The median diagnostic and pre-treatment intervals were 3.1 (IQR: 1.4-8.2) months and 2.4 (IQR: 1.2-4.1) months respectively. Half of the participants, 49.6% (200/403) were diagnosed early; one in 5 patients, 20.1% (81/403) promptly (within one month) initiated cancer chemo-radiotherapy. Participants more likely to be diagnosed early included those referred from district hospitals (level 5) (aPR = 2.29; 95%CI: 1.60-3.26) and with squamous cell carcinomas (aPR = 1.55; 95%CI: 1.07-2.23). Participants more likely to be diagnosed late included those who first discussed their symptoms with relatives, (aPR = 0.77; 95%CI: (0.60-0.98), had > 2 pre-referral visits (aPR = 0.75; 95%CI (0.61-0.92), and had advanced stage (stages 3 or 4) (aPR = 0.68; 95%CI: 0.55-0.85). Participants more likely to initiate cancer chemo-radiotherapy early included older patients (≥ 60 years) (aPR = 2.44; 95%CI: 1.18-5.03). Patients likely to start treatment late were those who had ≥2 pre-referral visits  (aPR = 0.63; 95%CI: 0.41-0.98) and those that took 3 - 6 months with symptoms before seeking healthcare (aPR = 0.52;95%CI: 0.29 - 0.95).

CONCLUSION

Interventions to promote prompt health-seeking and early diagnosis of cervical cancer need to target primary healthcare facilities and aim to enhance capacity of primary healthcare professionals to promptly initiate diagnostic investigations. Patients aged < 60 years require targeted interventions to promote prompt initiation of chemo-radiation therapy.

Survival of cervical cancer patients at Moi teaching and Referral Hospital, Eldoret in western Kenya

BACKGROUND

Cervical cancer is a major health burden and the second most common cancer after breast cancer among women in Kenya. Worldwide cervical cancer constitutes 3.1% of all cancer cases. Mortality rates are greatest among the low-income countries because of lack of awareness, screening and early-detection programs and adequate treatment facilities. The main aim was to estimate survival and determine survival predictors of women with cervical cancer and limited resources in western Kenya.

METHODS

Retrospective charts review of women diagnosed with cervical cancer and follow-up for two years from the date of the histologic diagnosis. The outcome of interest was death or survival at two years. Kaplan Meier estimates of survival, log-rank test and Cox proportional hazards regression were used in the survival analysis.

RESULTS

One hundred and sixty-two (162) participants were included in the review. The median duration was 0.8 (interquartile range (IQR) 0.3, 1.6) years. The mean age at diagnosis was 50.6 years (SD12.5). The mean parity was 5.9 (SD 2.6). Fifty percent (50%) did not have health insurance. Twenty six percent (26%) used hormonal contraceptives, 25.9% were HIV positive and 70% of them were on anti-retroviral treatment. The participants were followed up for 152.6 person years. Of the 162 women in the study, 70 (43.2%) died giving an overall incidence rate (IR) of 45.9 deaths per 100 person years of follow up. The hazard ratios were better for the patients who survived (0.44 vs 0.88, p-value < 0.001), those who had medical insurance (0.70 vs 0.48, p-value = 0.007) and those with early stage at diagnosis (0.88 vs 0.39, p-value < 0.001). Participants who were diagnosed at late stage of the disease according to the International Federation of Gynecology and Obstetrics staging for cervical cancer (FIGO stage 2B-4B) had more than eight times increased hazard of death compared to those who were diagnosed at early stage (1-2A): Hazard Ratio: 8.01 (95% CI 3.65, 17.57). Similarly, those who underwent surgical management had 84% reduced hazard of mortality compared to those who were referred for other modes of care: HR: 0.16 (95% CI: 0.07, 0.38).

CONCLUSION

Majority of the participants were diagnosed late after presenting with symptoms. The 1 and 2-year survival probability after diagnosis of cervical cancer was 57% AND 45% respectively. It is imperative that women present early since surgery gives better prognosis or better still screening of all women prioritized.

Clinicopathological profile and management of thyroid carcinoma: a Sub-Saharan country experience

BACKGROUND

In Sudan, there is limited knowledge on the epidemiology, clinical characteristics and pathological patterns of thyroid cancer. To address this shortcoming, we studied the clinical, pathological and treatment patterns of thyroid cancer at the National Cancer Institute ‒ University of Gezira (NCI-UG), Sudan.

METHODS

We performed a retrospective health facility-based study of patients with thyroid cancer who were treated at NCI-UG from January 2009 to December 2017.

RESULTS

A total of 139 patients with thyroid cancer were identified during the study period. Tumors were more common among women (69%). Goiter was the main presenting symptom (85%). The most common type of thyroid cancer was follicular carcinoma (41%), followed by papillary carcinoma (24%), then anaplastic carcinoma (20%). The mean age of the women was 56.3 years (SD ± 14.7), compared to 52.5 years (SD ± 16.6) for the men. The frequencies of stage I, II, III, and IV were 17%, 22%, 16%, and 45%, respectively. Different types of thyroidectomies were performed in 79% of the cases, lobectomy in 4%, and no surgery in 17%. Only 28% of the cases received radioactive iodine. Palliative chemotherapy and radiotherapy were prescribed to 17% and 37% of the cases, respectively.

CONCLUSION

Thyroid cancer is more prevalent among women and most patients present at later stages. The dominance of follicular type suggests that the majority of this population is iodine-deficient.

Understanding Fertility Attitudes and Outcomes Among Survivors of Adolescent and Young Adult Cancers in a Low-Resource Setting: A Registry-Based Computer-Assisted Telephone Interview Survey

Purpose: To establish the extent of self-reported reproductive failure associated with cancer treatment, and attitudes toward fertility among adolescent and young adult (AYA) cancer survivors in Uganda. Methods: A registry-based computer-assisted telephone interview survey was conducted in Uganda. The survey population were survivors of childhood, adolescent and early adulthood cancers diagnosed between 2007 and 2018. The survey explored fertility outcomes, experiences of oncofertility and fertility attitudes of AYA cancer survivors. Results: Thirty-four (female = 14 and male = 20) interviews were completed. Survivors were 18-35 years of age. The median age at cancer diagnosis was 23.5 for females and 17.5 for males. Kaposi's sarcoma contributed to 44% of primary cancer diagnoses. All the survivors had received chemotherapy alone or in combination with other modalities and 79% of survivors had not received satisfactory information about future fertility before cancer treatment. Twenty one percent of males and 46% females met the criteria for infertility and 60% of these had met this criterion after their cancer diagnosis. Eighty two percent wanted to raise a biologically related child. Forty seven percent would be dissatisfied with their lives if they were unable to have a child or additional children. Conclusion: AYA cancer survivors in this low-resource setting reported reproductive failure, despite a strong fertility desire. Information and counseling provided on therapy-related problems before cancer treatment was insufficient and reinforces the need to build capacity for oncofertility resources within the region.

Knowledge, perceptions and uptake of human papilloma virus vaccine among adolescent girls in Kampala, Uganda; a mixed-methods school-based study

BACKGROUND

Cervical cancer is a major public health challenge, accounting for substantial morbidity and mortality. Human Papilloma Virus (HPV) vaccination is the recommended primary public health intervention for HPV infection prevention. However, there's limited evidence on the level of knowledge, attitude, and practices of adolescent girls regarding HPV vaccination in Kampala city, Uganda. This study assessed the knowledge, perceptions, and practices of adolescent girls aged 10-14 years towards HPV vaccination program in Kampala, Uganda to generate evidence to guide programs targeted at improving uptake of the vaccine.

METHODS

A convergent parallel mixed methods study was conducted in Kampala, Uganda. A structured questionnaire was used to elicit data from 524 adolescent girls. In addition, 6 Focus group discussions, and 24 key informant interviews (teacher and parents) were conducted. Multistage and purposive sampling techniques were used to select quantitative and qualitative participants respectively. Quantitative data were entered using epidata, cleaned and analyzed using Stata v14 while qualitative data were analyzed using thematic content analysis in atlas ti version 8.

RESULTS

Overall, only 8.6% (45/524) of the girls had completed the HPV vaccine schedule of two dozes, 49.2% (258/524) of the girls had low knowledge about the HPV vaccine and teachers and parents affirmed this lack of knowledge among adolescent girls especially concerning the target age group, dosage, and vaccine interval. About 51.9% (272/524) of girls had negative perceptions towards HPV vaccination. Parents expressed negative perceptions, beliefs, superstitions, and safety concerns of the vaccine.Girls residing in rural areas (adjusted prevalence ratio, aPR = 0.35, C. I = 0.14-0.85) had lower knowledge levels compared to those in urban areas. Girls whose mothers were healthcare providers (aPR = 1.94, C. I = 1.10-3.41), girls with high knowledge levels (aPR = 1.79, C. I = 1.21-2.63) and positive perceptions (aPR = 2.87, C. I = 1.93-4.27) had a higher prevalence of being fully vaccinated.

CONCLUSION

Girls generally had low levels of knowledge, negative perceptions, and poor uptake of HPV vaccination. We recommend sensitization campaigns in schools and communities to improve awareness, perceptions, and practices of stakeholders towards HPV vaccination.

Operational Feasibility of Hospital-Based Cancer Registries in Low- and Middle-Income Countries: A Systematic Review

Cancer registration is crucial for any country's cancer surveillance and management program. However, there is a lack of systematic evidence on the operational feasibility of hospital-based cancer registries (HBCRs) in low- and middle-income countries (LMICs). We systematically reviewed and described the challenges and prospects of HBCRs in LMICs. We reported the study according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines. Electronic databases such as MEDLINE, EMBASE, Web of Science, ProQuest, and CINAHL were searched. Peer-reviewed studies published between January 1, 2000 and June 30, 2021 were included. We used thematic analysis to synthesize the findings discussing barriers and enablers of HBCRs. Thirteen studies were eligible for the analysis after eliminating duplicates, screening of title and abstract, and full-text review. The determinants, registry functionality, data management and abstraction, data security, data quality, organizational readiness, and perception of registry staff influence the implementation of HBCRs. In LMICs, many registries lacked functional documentation and data management systems due to a shortage of skilled professionals. However, in many instances, physicians and patients communicated via digital media, which helped obtain accurate data. The HBCR completeness rate was high in Ethiopia, China, Thailand, and Tanzania. Qualification and capacity building of the data managers was linked to the completeness and accuracy of the registry data, which led to sustainability. In addition, a few registries implemented new worksheets to enhance documentation. This review highlights the need for additional digitalization of the cancer registry to improve its functionality, completeness, follow-up, and output. Further, physicians and data managers require regular training to address cancer registry completeness and reduce errors.

Barriers to and facilitators of prostate cancer screening among men in Uganda prisons

Background

Studies have shown that prostate cancer (PCa) is increasing at a rate of 5.2% per annum in Uganda and as few as 5% of men have ever been screened for PCa in Uganda. The situation may be worse among male prisoners given their 'vulnerable status'. The goal of this study was to examine the perceptions, attitudes and beliefs of men in Ugandan prisons regarding barriers to and facilitators of PCa screening. This would enable the identification of potential interventional strategies to promote PCa screening among men in Ugandan prisons.

Methods

This study applied the explanatory sequential mixed methods study design. We first conducted 20 focus group discussions and 17 key informant interviews. The qualitative data were analysed to enrich a survey among 2,565 prisoners selected using a simple random sampling technique.

Results

Qualitatively, the belief that all cancers have no cure was a barrier against most participants considering screening to be of any value, coupled with the fear of screening positive for PCa and the associated stress. In addition, poor PCa knowledge and lack of PCa screening services in prisons were perceived as barriers to PCa screening in prison settings.The quantitative data from the survey of 2,565 participants with a mean age of 50.2 (9.8), indicated that the main barriers to PCa screening were mainly myths, beliefs, lack of screening facilities and technical capacity. The majority believed that creating PCa awareness, conducting screening outreach in prisons, and providing equipment for PCa screening in prisons health facilities will facilitate PCa screening, as well as working with the Uganda prison service to train the prison health staff to perform PCa screen to facilitate Prison Health Centres capacity to screen for PCa.

Conclusion

There is a need to develop interventions to increase awareness among the inmates in the prison health system, while ensuring that the prison health facilities are equipped with the required screening logistics, backed with outreaches from cancer-specialised hospitals/facilities.

The impact of HIV infection on clinical presentation and mortality among persons with hepatocellular carcinoma in Kampala, Uganda

BACKGROUND

HIV infection is associated with more rapid progression of some comorbidities. This study assessed the impact of HIV-infection on the presentation and outcome of HCC.

METHODS

HCC patients attending the Mulago National Referral Hospital in Uganda were enrolled into a natural history study of HCC between March 2015 and February 2019. Standardized methods were used to collect clinical, ultrasound and laboratory data at enrolment. HCC cases were confirmed and enrolled based on a combination of clinical, ultrasound, tumor marker and pathology data. Follow-up contact was made at one, three, six, and twelve months post-enrolment to determine vital status. Symptoms and signs at diagnosis and subsequent survival were compared by HIV status. Kaplan Meier curves were used to assess HCC survival.

RESULTS

Of 441 persons with HCC, 383 (87.0%) died within 12 months following HCC diagnosis. The median (IQR) survival was 42 (20, 106) days. HIV infection was present in 79 (18%) cases. After adjusting for baseline demographic and clinical characteristics, HIV infection was associated with increased mortality but only among those with severe HIV-associated immunosuppression (CD4 count < 200 cells per cubic milliliter), aHR (95% C) = 2.12 (1.23-3.53), p = 0.004, and not among PLWH with ≥ 200 CD4 cells per cubic milliliter, aHR (95% C) = 1.15 (0.82-1.60), p = 0.417.

CONCLUSION

Among relatively young Ugandans, HCC is a devastating disease with rapid mortality that is especially rapid among people living with HIV(PLWH). HIV was associated with slightly higher mortality, notably among PLWH with lower CD4 cell counts. As a substantial majority of PLWH diagnosed with HCC were engaged in HIV care, further investigation should determine the effectiveness of incorporating screening and early identification of HCC among high-risk individuals into existing HIV care programs. Concurrent with growing access to curative localized treatment for HCC in sub-Saharan Africa, leveraging HIV care infrastructure affords opportunities for earlier HCC intervention.

Survival pattern of colorectal cancer in Sub-Saharan Africa: A systematic review and meta-analysis

Cancer incidence is relatively low in sub-Saharan Africa (SSA), however, prognosis is expected to be poor in comparison with high-income countries. Comprehensive evidence is limited on the survival pattern of colorectal cancer patients in the region. We conducted a systematic review and meta-analysis to investigate the pattern of colorectal cancer survival in the region and to identify variation across countries and over time. We searched international databases MEDLINE, Scopus, Embase, Web of Science, ProQuest, CINAHL, and Google Scholar to retrieve studies that estimated survival from colorectal cancer in SSA countries from inception to December 31, 2021 without language restriction. Due to between-study heterogeneity, we performed a random-effects meta-analysis to pool survival rates. To identify study-level sources of variation, we performed subgroup analysis and meta-regression. Results are reported in line with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) 2020 guideline and the protocol was registered in PROSPERO database (CRD42021246935). 23 studies involving 10,031 patients were included in the review, of which, 20 were included in the meta-analysis. The meta-analysis results showed that the pooled 1-, 2-, 3-, 4-, and 5-year survival rates in SSA were 0.74 (95% CI, 0.66-0.81), 0.50 (95% CI, 0.41-0.58), 0.36 (95% CI, 0.27-0.47), 0.31 (95% CI, 0.22-0.42), and 0.28 (95% CI, 0.19-0.38) respectively. Subgroup analyses indicated that the survival rate varied according to year of study, in which those conducted in recent decades showed relatively better survival. The 5-year survival was higher in middle-income SSA countries (0.31; 95%CI: 0.17-0.49) than low-income countries (0.20; 95%CI: 0.11-0.35), however, the difference was not statistically significant. In conclusion, survival from colorectal cancer is low in sub-Saharan Africa compared to other regions. Thus, intervention strategies to improve screening, early diagnosis and treatment of colorectal cancer should be developed and implemented to improve survival in the region.

Cervical cancer survival times in Africa

Objective

Accessibility to quality healthcare, histopathology of tumor, tumor stage and geographical location influence survival rates. Comprehending the bases of these differences in cervical cancer survival rate, as well as the variables linked to poor prognosis, is critical to improving survival. We aimed to perform the first thorough meta-analysis and systematic review of cervical cancer survival times in Africa based on race, histopathology, geographical location and age.

Methods and materials

Major electronic databases were searched for articles published about cervical cancer survival rate in Africa. The eligible studies involved studies which reported 1-year, 3-year or 5-year overall survival (OS), disease-free survival (DFS) and/or locoregional recurrence (LRR) rate of cervical cancer patients living in Africa. Two reviewers independently chose the studies and evaluated the quality of the selected publications, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA-P). We used random effects analysis to pooled the survival rate across studies and heterogeneity was explored via sub-group and meta-regression analyses. A leave-one-out sensitivity analysis was undertaken, as well as the reporting bias assessment. Our findings were reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA-P).

Results

A total of 16,122 women with cervical cancer were covered in the 45 articles (59 studies), with research sample sizes ranging from 22 to 1,059 (median = 187.5). The five-year overall survival (OS) rate was 40.9% (95% CI: 35.5-46.5%). The five-year OS rate ranged from 3.9% (95% CI: 1.9-8.0%) in Malawi to as high as 76.1% (95% CI: 66.3-83.7%) in Ghana. The five-year disease-free survival rate was 66.2% (95% CI: 44.2-82.8%) while the five-year locoregional rate survival was 57.0% (95% CI: 41.4-88.7%).

Conclusion

To enhance cervical cancer survival, geographical and racial group health promotion measures, as well as prospective genetic investigations, are critically required.

Pediatric, adolescent, and young adult cancer in an HIV-infected rural sub-Saharan African population

Youth living with HIV (YLWHIV) have an increased cancer risk. Our objective is to describe the prevalence of medical record (MR) reported suspected cancers in a contemporary cohort of YLWHIV in Uganda that was assembled through MR reviews of patients 10 to 24 years old across 35 Ugandan HIV care health facilities. Clinical data were abstracted to identify suspected cancer cases and information about HIV care. Among 3728 YLWHIV, we identified eight suspected cancer cases. The most common suspected types were Kaposi sarcoma (n=4) followed by lymphoma (n=3). Challenges encountered in data abstraction were missing data for several variables and confirmatory cancer diagnostic information. In follow-up of suspected cases referred for diagnosis at the Uganda Cancer Institute (UCI), none had diagnosis records in UCI files. In addition, ∼18% of patients (n=686) were lost-to-follow-up (LTF) defined as not having returned to the clinic in ≥183 days and three patients died from presumed Kaposi sarcoma. Although our results suggest that cancer is rare in YLWHIV, the possibility that the cancer burden is higher cannot be excluded due to incomplete information in MRs and high LTF rates. Further, our study raises concern that patients referred for diagnosis are not accessing potential life-saving care.

A 10-year retrospective study of lung cancer in Uganda

Background

Lung cancer is a leading cause of cancer-related deaths in Uganda. In this study, we aimed to describe the baseline characteristics and survival of patients with lung cancer at the Uganda Cancer Institute (UCI).

Methods

We retrospectively reviewed medical records of all patients with a histological diagnosis of lung cancer registered at UCI between January 2008 and August 2018. Data on demographic, clinical, and treatment characteristics, and vital status were abstracted and analyzed. Patients with undocumented vital status on the medical records were contacted through phone calls. We determined survival as time from histological diagnosis to death. The Kaplan-Meier survival analysis was performed to estimate the median survival time and the 5-year overall survival rate.

Results

Of the 207 patients enrolled, 56.5% (n = 117) were female, median age was 60 years (range: 20–94), 78.7% (n = 163) were never-smokers and 18 (8.7%) were living with HIV. Presumptive anti-tuberculosis treatment was given to 23.2% (n = 48). Majority had non-small cell lung cancer (96.6%, n = 200) with 74.5% (n = 149) adenocarcinoma and 19% (n = 38) squamous cell carcinoma. All had advanced (stage III or IV) disease with 96.1% (n = 199) in stage IV. Chemotherapy (44.9%, n = 93) and biological therapy (34.8%, n = 72) were the commonest treatments used. Overall survival at 6 months, 1-, 2- and 5-years was 41.7, 29.7, 11.8, and 1.7%, respectively. The median survival time of 4.4 months was not statistically significantly different between participants with NSCLC or SCLC (4.5 versus 3.9 months, p = .335).

Conclusion

In Uganda, adenocarcinoma is the predominant histologic subtype of lung cancer and patients are predominantly females, and non-smokers. Patients present late with advanced disease and poor overall survival. Public awareness should be heightened to facilitate early detection and improve outcomes.

Colorectal cancer survival in sub-Saharan Africa by age, stage at diagnosis and Human Development Index: A population-based registry study

There are limited population-based survival data for colorectal cancer (CRC) in sub-Saharan Africa. Here, 1707 persons diagnosed with CRC from 2005 to 2015 were randomly selected from 13 population-based cancer registries operating in 11 countries in sub-Saharan Africa. Vital status was ascertained from medical charts or through next of kin. 1-, 3- and 5-year overall and relative survival rates for all registries and for each registry were calculated using the Kaplan-Meier estimator. Multivariable analysis was used to examine the associations of 5-year relative survival with age at diagnosis, stage and country-level Human Development Index (HDI). Observed survival for 1448 patients with CRC across all registries combined was 72.0% (95% CI 69.5-74.4%) at 1 year, 50.4% (95% CI 47.6-53.2%) at 3 years and 43.5% (95% CI 40.6-46.3%) at 5 years. We estimate that relative survival at 5 years in these registry populations is 48.2%. Factors associated with poorer survival included living in a country with lower HDI, late stage at diagnosis and younger or older age at diagnosis (<50 or ≥70 years). For example, the risk of death was 1.6 (95% CI 1.2-2.1) times higher for patients residing in medium-HDI and 2.7 (95% CI 2.2-3.4) times higher for patients residing in low-HDI compared to those residing in high-HDI countries. Survival for CRC remains low in sub-Saharan African countries, though estimates vary considerably by HDI. Strengthening health systems to ensure access to prevention, early diagnosis and appropriate treatment is critical in improving outcomes of CRC in the region.

Global pattern and trends of colorectal cancer survival: a systematic review of population-based registration data

This review will describe the global patterns and trends of colorectal cancer survival, using data from the population-based studies or cancer registration. We performed a systematic search of China National Knowledge Infrastructure (CNKI), Wanfang Data, PubMed, Web of Science, EMBASE, and SEER and collected all population-based survival studies of colorectal cancer (up to June 2020). Estimates of observed and relative survival rates of colorectal cancer by sex, period, and country were extracted from original studies to describe the temporal patterns and trends from the late 1990s to the early 21st century. Globally, 5-year observed survival rates were higher in Seoul, Republic of Korea (1993-1997; 56.8% and 54.3% for colon and rectum cancers, respectively), Zhejiang province (2005-2010; 52.9% for colon cancer), Tianjin (1991-1999; 52.5% for colon cancer), Shanghai (2002-2006; 50.0% for rectum cancer) of China, and in Japan (1993-1996, 59.6% for colorectal cancer). Five-year relative survival rates of colorectal cancer in the Republic of Korea (2010-2014), Queensland, Australia (2005-2012), and the USA (2005-2009) ranked at relatively higher positions compared to other countries. In general, colorectal cancer survival rates are improving over time worldwide. Sex disparities in survival rates were also observed in the colon, rectum, and colorectal cancers in most countries or regions. The poorest age-specific 5-year relative survival rate was observed in patients > 75 years of age. In conclusion, over the past 3 decades, colorectal cancer survival has gradually improved. Geographic variations, sex differences, and age gradients were also observed globally in colorectal cancer survival. Further studies are therefore warranted to investigate the prognostic factors of colorectal cancer.

Prostate cancer survival in sub-Saharan Africa by age, stage at diagnosis, and human development index: a population-based registry study

OBJECTIVES

To estimate observed and relative survival of prostate cancer patients in sub-Saharan Africa (SSA) and to examine the influence of age, stage at diagnosis and the Human Development Index (HDI).

PATIENTS AND METHODS

In this comparative registry study, we selected a random sample of 1752 incident cases of malign prostatic neoplasm from 12 population-based cancer registries from 10 SSA countries, registered between 2005 and 2015. We analyzed the data using Kaplan-Meier and Ederer II methods to obtain outcome estimates and flexible Poisson regression modeling to calculate the excess hazards of death RESULTS: For the 1406 patients included in the survival analyses, 763 deaths occurred during 3614 person-years of observation. Of patients with known stage, 45.2% had stage IV disease, 31.2% stage III and only 23.6% stage I and II. The 1 and 5-year relative survival for the entire cohort was 78.0% (75.4-80.7) and 60.0% (55.7-64.6), while varying between the registries. Late presentation was associated with increased excess hazards and a 0.1 increase in the HDI was associated with a 20% lower excess hazard of death, while for age at diagnosis no association was found.

CONCLUSIONS

We found poor survival of SSA prostatic tumor patients, as well as high proportions of late stage presentation, which are associated with inferior outcome. This calls for investment in health-care systems and action regarding projects to raise awareness among the population to achieve earlier diagnosis and improve survival.

Histological characteristics, survival pattern and prognostic determinants among colorectal cancer patients in Ethiopia: A retrospective cohort study

Background

The incidence of colorectal cancer (CRC) and associated mortality are rising in low- and middle-income countries. In Ethiopia, colorectal cancer is among the leading causes of cancer morbidity and mortality in both sexes. Although some studies provided estimations on the national burden and regional distribution, the histological characteristics, survival pattern and determinants among colorectal cancer patients are not well-documented.

Aim

This study aimed to describe the histological characteristics, to determine the patterns of survival, and identify factors that determine mortality rate among CRC patients in Ethiopia.

Methods

A retrospective cohort study was conducted among CRC patients registered at cancer treatment center of Tikur Anbessa Specialized Hospital, from January 2012 to December 2016. Data were extracted from a total of 161 patient medical records using a pretested abstraction form and supplemented by phone calls with the patients/caregivers. To determine colorectal cancer specific survival overtime, we performed a Kaplan-Meier survival analysis and significance of variation in survival across covariates and treatment categories was tested using log-rank test. A multivariable Cox proportional-hazards model was performed to identify determinants of survival after diagnosis with colorectal cancer.

Results

Overall, the median survival time was 21 months [95%CI: 16-35], with two-, three- and five-year CRC-specific survival rates of 46.8%, 39.5% and 28.7% respectively. In the multivariable Cox regression model, the rate of death due to CRC is significantly higher for patients with elevated baseline carcinoembryonic antigen (CEA) level (Adjusted Hazard Ratio (AHR) = 2.31, 95%CI: 1.27-4.19), stage IV at diagnosis (AHR = 2.66, 95%CI: 1.44-4.91), and mucinous or signet-ring cell carcinoma histology type (AHR = 4.92, 95%CI: 1.75-13.80). Moreover, patients who underwent surgery showed a better survival than those who did not (AHR = 0.35, 95%CI: 0.14-0.88).

Conclusion

In Ethiopia, patients diagnosed with CRC showed a low rate of cancer-specific survival. Histology type, stage of cancer and CEA level at diagnosis, and the type of treatment a patient received significantly determine mortality rate. Hence, cancer screening programs could help to detect the disease at an earlier stage and to initiate available treatments timely so as to extend the lifespan of CRC patients.

Understanding health-seeking and adherence to treatment by patients with esophageal cancer at the Uganda cancer Institute: a qualitative study

BACKGROUND

In the low- and middle-income countries, most patients with esophageal cancer present with advanced stage disease and experience poor survival. There is inadequate understanding of the factors that influence decisions to and actual health-seeking, and adherence to treatment regimens among esophageal cancer patients in Uganda, yet this knowledge is critical in informing interventions to promote prompt health-seeking, diagnosis at early stage and access to appropriate cancer therapy to improve survival. We explored health-seeking experiences and adherence to treatment among esophageal cancer patients attending the Uganda Cancer Institute.

METHODS

We conducted an interview based qualitative study at the Uganda Cancer Institute (UCI). Participants included patients with established histology diagnosis of esophageal cancer and healthcare professionals involved in the care of these patients. We used purposive sampling approach to select study participants. In-depth and key informant interviews were used in data collection. Data collection was conducted till point of data saturation was reached. Thematic content analysis approach was used in data analyses and interpretations. Themes and subthemes were identified deductively.

RESULTS

Sixteen patients and 17 healthcare professionals were included in the study. Delayed health-seeking and poor adherence to treatment were related to (i) emotional and psychosocial factors including stress of cancer diagnosis, stigma related to esophageal cancer symptoms, and fear of loss of jobs and livelihood, (ii) limited knowledge and recognition of esophageal cancer symptoms by both patients and primary healthcare professionals, and (iii) limited access to specialized cancer care, mainly because of long distance to the facility and associated high transport cost. Patients were generally enthused with patient - provider relationships at the UCI. While inadequate communication and some degree of incivility were reported, majority of patients thought the healthcare professionals were empathetic and supportive.

CONCLUSION

Health system and individual patient factors influence health-seeking for symptoms of esophageal cancer and adherence to treatment schedule for the disease. Interventions to improve access to and acceptability of esophageal cancer services, as well as increase public awareness of esophageal cancer risk factors and symptoms could lead to earlier diagnosis and potentially better survival from the disease in Uganda.

Symptom appraisal, help-seeking and perceived barriers to healthcare seeking in Uganda: an exploratory study among women with potential symptoms of breast and cervical cancer

OBJECTIVE

We assessed the process of recognising abnormal bodily changes, interpretations and attributions, and help-seeking behaviour among community-based Ugandan women with possible symptoms of breast and cervical cancer, in order to inform health interventions aiming to promote timely detection and diagnosis of cancer.

DESIGN

Qualitative in-depth interviews.

SETTING

Rural and urban communities in Uganda.

PARTICIPANTS

Women who participated in the African Women Awareness of CANcer cross-sectional survey who disclosed potential breast and cervical cancer symptoms were eligible; recruitment was purposive. Interviews were conducted in women's homes, lasted between 40 and 90 min, were audio-recorded, transcribed verbatim and translated to English. Thematic analysis was used to identify themes and subthemes, underpinned by the conceptual framework of the Model of Pathways to Treatment.

RESULTS

23 women were interviewed: 10 had potential symptoms of breast cancer and 13 of cervical cancer. Themes regarding symptom appraisal and help-seeking included the: (1) detection and interpretation of abnormal bodily sensations; (2) lay consultations regarding bodily changes; (3) iterative process of inferring and attributing illnesses to the bodily changes; (4) restricted disclosure of symptoms to lay people due to concerns about privacy and fear of stigmatisation; (5) help-seeking from multiple sources including both traditional and biomedical health practitioners, and (6) multiple perceived barriers to help-seeking including long waiting times, lack of medicines, absenteeism of healthcare professionals, and lack of money for transport and medical bills.

CONCLUSION

Women with potential symptoms of breast and cervical cancer undergo complex processes of symptom interpretation, attributing symptoms or inferring illness, and lay consultations before undertaking help-seeking and management. Increasing community understanding of breast and cervical cancer symptoms, and tackling perceived barriers to health-seeking, could lead to prompt and appropriate symptom appraisal and help-seeking, and contribute to improving cancer outcomes.

Capacity building for cancer prevention and early detection in the Ugandan primary healthcare facilities: Working toward reducing the unmet needs of cancer control services

Background

In 2018, approximately 60,000 Ugandans were estimated to be suffering from cancer. It was also reported that only 5% of cancer patients access cancer care and 77% present with late‐stage cancer coupled with low level of cancer health literacy in the population despite a wide coverage of primary healthcare facilities in Uganda. We aimed to contribute to reducing the unmet needs of cancer prevention and early detection services in Uganda through capacity building.

Methods

In 2017, we conducted two national and six regional cancer control stakeholders’ consultative meetings. In 2017 and 2018, we trained district primary healthcare teams on cancer prevention and early detection. We also developed cancer information materials for health workers and communities and conducted a follow‐up after the training.

Results

A total of 488 primary healthcare workers from 118 districts were trained. Forty‐six health workers in the pilot East‐central subregion were further trained in cervical, breast, and prostate cancer early detection (screening and early diagnosis) techniques. A total of 32,800 cancer information, education and communication materials; breast, cervical, prostate childhood and general cancer information booklets; health education guide, community cancer information flipcharts for village health teams and referral guidelines for suspected cancer were developed and distributed to 122 districts. Also, 16 public and private‐not‐for‐profit regional hospitals, and one training institution received these materials. Audiovisual clips on breast, cervical, and prostate cancer were developed for mass and social media dissemination. A follow‐up after six months to one year indicated that 75% of the districts had implemented at least one of the agreed actions proposed during the training.

Conclusions

In Uganda, the unmet needs for cancer control services are enormous. However, building the capacity of primary healthcare workers to integrate prevention and early detection of cancer into primary health care based on low‐cost options for low‐income countries could contribute to reducing the unmet needs of cancer prevention and early detection in Uganda.

In Uganda, the unmet needs for cancer control services are enormous. We engaged district leaders and healthcare managers, developed cancer information materials, and trained the district PHC workers to integrate prevention and early detection of cancer into the primary healthcare system. This could contribute to reducing the unmet needs of cancer control services in Uganda.

Surgical candidacy and treatment initiation among women with cervical cancer at public referral hospitals in Kampala, Uganda: a descriptive cohort study

OBJECTIVES

This study aimed to report the proportion of women with a new diagnosis of cervical cancer recommended for curative hysterectomy as well as associated factors. We also report recommended treatments by stage and patterns of treatment initiation.

DESIGN

This was an observational cohort study. Inperson surveys were followed by a phone call.

SETTING

Participants were recruited at the two public tertiary care referral hospitals in Kampala, Uganda.

PARTICIPANTS

Adult women with a new diagnosis of cervical cancer were eligible: 332 were invited to participate, 268 met the criteria and enrolled, and 255 completed both surveys.

PRIMARY AND SECONDARY OUTCOMES MEASURES

The primary outcome of interest was surgical candidacy; a secondary outcome was treatment initiation. Descriptive and multivariate statistical analyses examined the associations between predictors and outcomes. Sensitivity analyses were performed to examine outcomes in subgroups, including stage and availability of radiation.

RESULTS

Among 268 participants, 76% were diagnosed at an advanced stage (IIB-IVB). In total, 12% were recommended for hysterectomy. In adjusted analysis, living within 15 km of Kampala (OR 3.10, 95% CI 1.20 to 8.03) and prior screening (OR 2.89, 95% CI 1.22 to 6.83) were significantly associated with surgical candidacy. Radiotherapy availability was not significantly associated with treatment recommendations for early-stage disease (IA-IIA), but was associated with recommended treatment modality (chemoradiation vs primary chemotherapy) for locally advanced stage (IIB-IIIB). Most (67%) had started treatment. No demographic or health factor, treatment recommendation, or radiation availability was associated with treatment initiation. Among those recommended for hysterectomy, 55% underwent surgery. Among those who had initiated treatment, 82% started the modality that was recommended.

CONCLUSION

Women presented to public referral centres in Kampala with mostly advanced-stage cervical cancer and few were recommended for surgery. Most were able to initiate treatment. Lack of access to radiation did not significantly increase the proportion of early-stage cancers recommended for hysterectomy.

Knowledge of cervical cancer risk factors and symptoms among women in a refugee settlement: a cross-sectional study in northern Uganda

BACKGROUND

There are limited data on awareness of cervical cancer risk factors and symptoms among refugee populations living in Uganda. In this study, we sought to determine the awareness and knowledge of cervical cancer risk factors and symptoms among women in Palabek refugee settlement, northern Uganda.

METHODS

We conducted a cross-sectional study. 815 women (aged 18-60 years) were randomly selected using multistage sampling in Palabek refugee settlement. Data were collected using pre-tested, structured questionnaires. Logistic regression models were used to determine magnitudes of association between socio-demographic and health system factors, and knowledge on cervical cancer risk factors and symptoms.

RESULTS

The majority of participants (53%, n = 433) were young (18-29 years), married (68%, n = 553), and did not have formal employment (93%, n = 759). Less than half (40%, n = 325) had heard of cervical cancer. Of those who had heard, most recognized multiple male sexual partners, early onset of sexual intercourse and HPV infections as risk factors for cervical cancer (93%, n = 295; 89%, n = 283; and 86%, n = 271 respectively). Median knowledge score for risk factor recognition = 7 (IQR: 3-9). Median knowledge score for symptoms recognition = 7 (IQR: 1-10). Half of women (50%, n = 409) correctly recognized 7 to 11 symptoms of cervical cancer, with vaginal bleeding between menstrual periods, pelvic pain, and vaginal bleeding during/after sexual intercourse recognized by 58, 52 and 54% respectively. Single women (OR = 0.59 (95%CI: 0.38-0.94), and women that lived farther than 1 kilo meter from nearest health facility in South Sudan (OR = 0.36-0.49 (95%CI: 0.26-0.84) were less likely to be knowledgeable of symptoms of cervical cancer.

CONCLUSION

A significant proportion of women in Palabek refugee settlement had not heard about cervical cancer. Refugee health services providers could increase awareness of cervical cancer risk factors and symptoms through health education in order to promote risk reduction behaviours and guide women during symptoms appraisal. Single women and those who lived more than one kilo metre from nearest health facility in home country could be a priority group for awareness intervention in the settlement.

Cervical cancer survival in sub-Saharan Africa by age, stage at diagnosis and Human Development Index: A population-based registry study

Cervical cancer is the leading cause of cancer death in African women. We sought to estimate population-based survival and evaluate excess hazards for mortality in African women with cervical cancer, examining the effects of country-level Human Development Index (HDI), age and stage at diagnosis. We selected a random sample of 2760 incident cervical cancer cases, diagnosed in 2005 to 2015 from 13 population-based cancer registries in 11 countries (Benin, Cote d'Ivoire, Ethiopia, Kenya, Mauritius, Mozambique, Namibia, Seychelles, South Africa, Uganda and Zimbabwe) through the African Cancer Registry Network. Of these, 2735 were included for survival analyses. The 1-, 3- and 5-year observed and relative survival were estimated by registry, stage and country-level HDI. We used flexible Poisson regression models to estimate the excess hazards for death adjusting for age, stage and HDI. Among patients with known stage, 65.8% were diagnosed with Stage III-IV disease. The 5-year relative survival for Stage I-II cervical cancer in high HDI registry areas was 67.5% (42.1-83.6) while it was much lower (42.2% [30.6-53.2]) for low HDI registry areas. Independent predictors of mortality were Stage III-IV disease, medium to low country-level HDI and age >65 years at cervical cancer diagnosis. The average relative survival from cervix cancer in the 11 countries was 69.8%, 44.5% and 33.1% at 1, 3 and 5 years, respectively. Factors contributing to the HDI (such as education and a country's financial resources) are critical for cervical cancer control in SSA and there is need to strengthen health systems with timely and appropriate prevention and treatment programmes.

Few Losses to Follow-up in a Sub-Saharan African Cancer Cohort via Active Mobile Health Follow-up

Accurate survival estimates are needed for guiding cancer control efforts in sub-Saharan Africa, but previous studies have been hampered by unknown biases due to excessive loss to follow-up (LTFU). In the African Breast Cancer-Disparities in Outcomes Study, a prospective breast cancer cohort study, we implemented active mobile health follow-up, telephoning each woman or her next-of-kin (NOK) trimonthly on her mobile phone to update information on her vital status. Dates of every contact with women/NOK were analyzed from diagnosis in 2014-2017 to the earliest of September 1, 2018, death, or 3 years postdiagnosis. The cumulative incidence of being LTFU was calculated considering deaths as competing events. In all, 1,490 women were followed for a median of 24.2 (interquartile range (IQR), 14.2-34.5) months, corresponding to 8,529 successful contacts (77% of total contacts) with the women/NOK. Median time between successful contacts was 3.0 (IQR, 3.0-3.7) months. In all, 71 women (5.3%) were LTFU at 3 years: 0.8% in Nigeria, 2.2% in Namibia, and 5.6% in Uganda. Because of temporary discontinuity of active follow-up, 20.3% of women were LTFU after 2 years in Zambia. The median time to study notification of a death was 9.1 (IQR, 3.9-14.0) weeks. Although the present study was not a randomized controlled trial, in this cancer cohort with active mobile health follow-up, LTFU was much lower than in previous studies and enabled estimation of up-to-date and reliable cancer survival.

Clinicopathological spectrum of colorectal cancer among the population of the KwaZulu-Natal Province in South Africa

Introduction

the burden of colorectal carcinoma (CRC), once considered rare in Africa, may be changing with the disease being increasingly diagnosed and there is a suggestion that age and race influence tumour behaviour. We sought to describe the clinicopathological spectrum of CRC among the different race and age groups in a South African setting.

Methods

analysis of prospectively collected data from an on-going colorectal cancer database, including demographics, clinical presentation, site, staging and grading on all patients enrolled over an 18-year period.

Results

a total of 2232 patients with CRC were accrued over the study period (Africans, 798; Indians, 890; Coloureds, 104; and Whites, 440). Mean age was 57.7 (SD 14.4) but varied considerably by race (p < 0.001) with Africans being significantly younger. Young adults (aged < 40 years) totalled 305 and older patients (aged > 40 years) totalled 1927. The proportion of young patients (< 40 years old) was 28%, 7%, 9% and 3% among Africans, Indian, Coloured and White patients respectively. There were minimal variations in anatomical sub-site distribution. There was no difference in tumour stage between the various races and between older and young adults. Mucinous differentiation was more common in Africans and in young patients and poor differentiation was more common in African patients. Africans had a significantly lower resection rate compared to the other race groups (p < 0.001). Younger patients had a significantly lower resection rate compared to the older age group (p < 0.001).

Conclusion

African patients were the youngest compared to the other race groups. Mucinous differentiation predominated in Africans and young adults. Poor differentiation predominated in Africans. Resection rate was lower for African patients and in young patients.

Perceptions of key informants on the provision of cervical cancer prevention and control programme in Uganda: implication for cervical cancer policy

Background

Uganda has one of the highest burdens of cervical cancer globally. In 2010 the Ugandan Ministry of Health launched the Strategic Plan for Cervical Cancer Prevention and Control with the hope of developing cervical cancer policy in Uganda. This study explored the beliefs of senior key informants in Uganda about cervical cancer prevention, the control programme, and the relevance of cervical cancer policy.

Methods

We conducted 15 key informant interviews with participants from six organisations across Northern and Central Uganda. Participants were drawn from district local government health departments, St. Mary’s Hospital Lacor, Uganda Nurses and Midwifery Council, non-governmental organisations (NGOs) and Ministry of Health in Kampala, Uganda. The interview recordings were transcribed and analysed using thematic analysis.

Results

Seven themes emerged relating to the cervical cancer prevention and control programmes in Uganda: (1) policy frameworks for cervical cancer, (2) operationalising cervical cancer prevention and control, (3) financial allocation and alignment, (4) human resources and capability, (5) essential supplies and vaccines, (6) administrative data and resource distribution, and (7) cervical cancer services.

Conclusions

The key informants perceive that the lack of a cervical cancer policy in Uganda is hindering cervical cancer prevention and control programmes. Therefore, the Ministry of Health and stakeholders need to work together in coming up with an effective policy framework that will accelerate efforts towards cervical cancer prevention and control in Uganda.

Ethnobotanical study of selected medicinal plants traditionally used in the rural Greater Mpigi region of Uganda

ETHNOPHARMACOLOGICAL RELEVANCE

This study provides the first report on selected traditional medicinal plant use, including parts used and methods of preparation, in the Greater Mpigi region of Uganda. This data supports the conservation of local traditional ecological knowledge and will facilitate future drug discovery research.

AIM OF THE STUDY

Our study aimed to conserve culturally and scientifically-valuable medical knowledge of 16 plant species traditionally used in the Greater Mpigi region in Uganda, namely Albizia coriaria, Cassine buchananii, Combretum molle, Erythrina abyssinica, Ficus saussureana, Harungana madagascariensis, Leucas calostachys, Microgramma lycopodioides, Morella kandtiana, Plectranthus hadiensis, Securidaca longipedunculata, Sesamum calycinum subsp. angustifolium, Solanum aculeastrum, Toddalia asiatica, Warburgia ugandensis and Zanthoxylum chalybeum. An additional objective of the study was an ethnological investigation of the socio-cultural background and medical understanding of diseases treated by traditional healers in the study area.

MATERIALS AND METHODS

A pilot survey in the study area revealed that 16 plant species were frequently used in treatment of a variety of medical disorders. In order to obtain more complete information, we conducted a broader ethnobotanical survey using structured interviews with 39 traditional healers from 29 villages, specifically asking about the traditional uses of these 16 medicinal species.

RESULTS

Results of the survey confirmed a high level of traditional use of these species in the Greater Mpigi region. In addition, various other traditional uses and methods of preparation were recorded, most of them for the first time. In total, 75 different medical disorders treated with the plants were documented.

CONCLUSIONS

Conservation of traditional knowledge for future generations is vital, as loss has already been recorded due to multiple causes. The need for novel and more effective drugs derived from natural products is more important than ever, making future studies on herbal remedies both justified and urgently required. The traditional healers surveyed in this project also have expectations of the research - they would like to be updated about any resulting studies into the pharmacological efficacy of medicinal plants so that the research findings can inform their confidence in each herbal remedy.

Traditional and Complementary Medicine Use Among Adult Cancer Patients Undergoing Conventional Treatment in Sub-Saharan Africa: A Scoping Review on the Use, Safety and Risks

Background

Use of traditional and complementary medicine (T&CM) is very common among patients in sub-Saharan Africa (SSA). However, there are limited data on concurrent use of T&CM with conventional cancer therapies. In this scoping review, we sought to describe the (i) prevalence of use, (ii) types of medicine, (iii) reasons for taking T&CM, (iv) current knowledge on safety and risks, (v) characteristics of adult cancer patients who use T&CM, and (vi) perceived treatment outcomes among cancer patients undergoing conventional cancer treatment in SSA.

Methods

We conducted a systematic literature search for articles published in the English language in three scientific databases (PubMed, Embase and Web of Science). We used a scoping review approach to map relevant literature on T&CM use among cancer patients undergoing conventional cancer treatments. We assessed 96 articles based on titles and abstracts, and 23 articles based on full text. Twelve articles fulfilled preset eligibility criteria.

Results

More than half of the included articles were from only two countries in SSA: Nigeria and Uganda. Median prevalence of use of T&CM was 60.0% (range: 14.1-79.0%). Median percent disclosure of use of T&CM to attending healthcare professionals was low at 32% (range: 15.3-85.7%). The most common reasons for non-disclosure were: the doctor did not ask, the doctor would rebuke them for using T&CM, and the doctors do not know much about T&CM and so there is no need to share the issue of use with them. T&CM used by cancer patients included herbs, healing prayers and massage. Reported reasons for use of T&CM in 8 of 12 articles included the wish to get rid of cancer symptoms, especially pain, cure cancer, improve physical and psychological well-being, treat toxicity of conventional cancer therapies and improve immunity. There were limited data on safety and risk profiles of T&CM among cancer patients in SSA.

Conclusion

Use of traditional and complementary medicines is common among cancer patients undergoing conventional cancer treatments. Healthcare professionals caring for cancer patients ought to inquire and communicate effectively regarding the use of T&CM in order to minimize the risks of side effects from concurrent use of T&CM and biomedicines.

Medicinal Plants Used in Traditional Management of Cancer in Uganda: A Review of Ethnobotanical Surveys, Phytochemistry, and Anticancer Studies

The burden of neoplastic diseases is a significant global health challenge accounting for thousands of deaths. In Uganda, about 32,617 cancer cases were reported in 2018, accompanied by 21,829 deaths. In a view to identify some potential anticancer plant candidates for possible drug development, the current study was designed to compile the inventory of plants with reported anticancer activity used in rural Uganda and the evidences supporting their use in cancer therapy. An electronic survey in multidisciplinary databases revealed that 29 plant species belonging to 28 genera distributed among 24 families have been reported to be used in the management of cancer in Uganda. Anticancer plants were majorly from the families Bignoniaceae (7%), Caricaceae (7%), Fabaceae (7%), Moraceae (7%), and Rutaceae (7%). Most species occur in the wild (52%), though some are cultivated (48%). The growth habit of the plants is as trees (55%) or herbs (45%). Anticancer extracts are usually prepared from leaves (29%), bark (24%), roots (21%), and fruits (13%) through decoctions (53%), as food spices (23%) or pounded to produce ointments that are applied topically (10%). Prunus africana (Hook.f.) Kalkman, Opuntia species, Albizia coriaria (Welw. ex Oliver), Daucus carota L., Cyperus alatus (Nees) F. Muell., Markhamia lutea (Benth.) K. Schum., and Oxalis corniculata L. were the most frequently encountered species. As per global reports, Allium sativum L., Annona muricata L., Carica papaya L., Moringa oleifera Lam., Opuntia species, Prunus africana (Hook.f.) Kalkman, and Catharanthus roseus (L.) G. Don. are the most studied species, with the latter having vincristine and vinblastine anticancer drugs developed from it. Prostate, cervical, breast, and skin cancers are the top traditionally treated malignancies. There is a need to isolate and evaluate the anticancer potential of the bioactive compounds in the unstudied claimed plants, such as Cyperus alatus (Nees) F. Muell., Ficus dawei Hutch., Ficus natalensis Hochst., and Lovoa trichilioides Harms, and elucidate their mechanism of anticancer activity.

Breast cancer survival in sub-Saharan Africa by age, stage at diagnosis and human development index: A population-based registry study

Breast cancer is the leading cancer diagnosis and second most common cause of cancer deaths in sub-Saharan Africa (SSA). Yet, there are few population-level survival data from Africa and none on the survival differences by stage at diagnosis. Here, we estimate breast cancer survival within SSA by area, stage and country-level human development index (HDI). We obtained data on a random sample of 2,588 breast cancer incident cases, diagnosed in 2008-2015 from 14 population-based cancer registries in 12 countries (Benin, Cote d'Ivoire, Ethiopia, Kenya, Mali, Mauritius, Mozambique, Namibia, Seychelles, South Africa, Uganda and Zimbabwe) through the African Cancer Registry Network. Of these, 2,311 were included for survival analyses. The 1-, 3- and 5-year observed and relative survival (RS) were estimated by registry, stage and country-level HDI. We equally estimated the excess hazards adjusting for potential confounders. Among patients with known stage, 64.9% were diagnosed in late stages, with 18.4% being metastatic at diagnosis. The RS varied by registry, ranging from 21.6%(8.2-39.8) at Year 3 in Bulawayo to 84.5% (70.6-93.5) in Namibia. Patients diagnosed at early stages had a 3-year RS of 78% (71.6-83.3) in contrast to 40.3% (34.9-45.7) at advanced stages (III and IV). The overall RS at Year 1 was 86.1% (84.4-87.6), 65.8% (63.5-68.1) at Year 3 and 59.0% (56.3-61.6) at Year 5. Age at diagnosis was not independently associated with increased mortality risk after adjusting for the effect of stage and country-level HDI. In conclusion, downstaging breast cancer at diagnosis and improving access to quality care could be pivotal in improving breast cancer survival outcomes in Africa.

Prognostic Factors for Overall Survival of Patients with Prostate Cancer in Kyadondo County, Uganda

Background

Prostate cancer is the second most common cancer among men globally. A few studies that have been done in Uganda on survival of patients with prostate cancer indicate that, the overall survival of patients with prostate cancer in Uganda is poor. The aim of this study was to determine the 3-year overall survival rate of a cohort of patients with prostate cancer residing in Kyadondo County who were diagnosed from 2012 to 2014. The secondary objective was to correlate the overall survival with the clinicopathological prognostic factors.

Materials and Methods

This was a retrospective cohort study which involved 136 patients who were diagnosed histologically with prostate cancer at the department of pathology between 2012 and 2014. The cases were registered at the Kampala cancer registry and followed up to 31^st December 2017. Data analysis was done using STATA version 12.0. The Kaplan-Meir curves were used for analysis of the 3-year overall survival rate. Hazard ratio (HR) and Log-rank test at 95% confidence interval under Cox-regression model were used to evaluate the effect of the covariates on the 3-year overall survival rate. p < 0.05 was considered statistically significant.

Results

More than half of the cases, 55.9% (n = 76) had Gleason score >8. Most of the patients, 67.7% (n = 92) had advanced disease at diagnosis. The 3-year overall survival rate was 67.6% with median survival of 36.5 months and range of 0-65 months. Clinical stage of the patients (HR = 1.65, p = 0.039), Gleason score (HR = 1.88, p = 0.008), and lymphovascular invasion (HR = 0.37, p = 0.002) were the independent predictors of the 3-year overall survival rate in this study. Conclusion. The 3-year overall survival of prostate cancer patients in Uganda is poor. Most of the patients with are diagnosed with advanced clinical stages (stage III and IV). The Gleason score, clinical stage and lymphovascular invasion can powerfully predict independently the overall survival of patients with prostate cancer. This implies that the Gleason score, clinical stage and lymphovascular invasion may be used to predict the overall survival of patients with prostate cancer even prior prostatectomy.

Use of traditional and complementary medicines by cancer patients at a national cancer referral facility in a low-income country

OBJECTIVE

The aim of this study was to describe use of traditional and complementary medicines (T&CM) and associated factors among patients with cancer.

METHODS

We conducted a cross-sectional study at the Uganda Cancer Institute (UCI) involving patients with selected solid tumours. Independent variables included age, sex, marital status, cancer site and stage. Main outcome variables were use and disclosure of use of T&CM.

RESULTS

The majority of participants were women (n = 352; 81.9%). Breast cancer (n = 312; 71.9%) was the predominant cancer type. 55.4% of participants (n = 240) self-reported use of T&CM. Among them, 68.3% (140/205) reported using them to treat/cure cancer, 35.6% (72/202) for strengthening the immune system and 31.2% (63/202) for management of pain. Patients with advanced stage cancers were more likely to be users compared with those in stage one. The majority (81.9%, 195/238) of T&CM users did not disclose use to their healthcare professionals. The main reasons for nondisclosure included lack of inquiry by clinicians (79.6%, 117/147) and fear of disapproval and/or rebuke (11.6%, 17/147).

CONCLUSION

Use of T&CM by patients with cancer under biomedical care is common but often undisclosed to the healthcare professionals.

Systematic review and meta-analysis of esophageal cancer in Africa: Epidemiology, risk factors, management and outcomes

BACKGROUND

Esophageal cancer (EC) is associated with a poor prognosis, particularly so in Africa where an alarmingly high mortality to incidence ratio prevails for this disease.

AIM

To provide further understanding of EC in the context of the unique cultural and genetic diversity, and socio-economic challenges faced on the African continent.

METHODS

We performed a systematic review of studies from Africa to obtain data on epidemiology, risk factors, management and outcomes of EC. A non-systematic review was used to obtain incidence data from the International Agency for Research on Cancer, and the Cancer in Sub-Saharan reports. We searched EMBASE, PubMed, Web of Science, and Cochrane Central from inception to March 2019 and reviewed the list of articles retrieved. Random effects meta-analyses were used to assess heterogeneity between studies and to obtain odds ratio (OR) of the associations between EC and risk factors; and incidence rate ratios for EC between sexes with their respective 95% confidence intervals (CI).

RESULTS

The incidence of EC is higher in males than females, except in North Africa where it is similar for both sexes. The highest age-standardized rate is from Malawi (30.3 and 19.4 cases/year/100000 population for males and females, respectively) followed by Kenya (28.7 cases/year/100000 population for both sexes). The incidence of EC rises sharply after the age of 40 years and reaches a peak at 75 years old. Meta-analysis shows a strong association with tobacco (OR 3.15, 95%CI: 2.83-3.50). There was significant heterogeneity between studies on alcohol consumption (OR 2.28, 95%CI: 1.94-2.65) and on low socioeconomic status (OR 139, 95%CI: 1.25-1.54) as risk factors, but these could also contribute to increasing the incidence of EC. The best treatment outcomes were with esophagectomy with survival rates of 76.6% at 3 years, and chemo-radiotherapy with an overall combined survival time of 267.50 d.

CONCLUSION

Africa has high incidence and mortality rates of EC, with preventable and non-modifiable risk factors. Men in this setting are at increased risk due to their higher prevalence of tobacco and alcohol consumption. Management requires a multidisciplinary approach, and survival is significantly improved in the setting of esophagectomy and chemoradiation therapy.

Prevalence and Pattern of Thyroid Disorders among Patients Attending University of Nigeria Teaching Hospital, Enugu, Southeastern Nigeria

INTRODUCTION

Thyroid disorders (TDs) remain the second-most common endocrine disease after diabetes worldwide. Recently, there has been increased interest in the prevalence and pattern of TD based on the fact that it accelerates cardiovascular complications. However, there are limited data on the prevalence and pattern of TDs in the University of Nigeria Teaching Hospital (UNTH) Enugu, Southeast Nigeria.

OBJECTIVES

We studied prevalence and pattern of TDs as seen in patients attending UNTH, Enugu, Nigeria.

METHODS

This study was conducted in the Outpatient Department of UNTH Enugu from January 2016 to January 2019. Demographic and clinical data collected include age, gender, anthropometrics, clinical features, and associated complications of TDs. The patients were grouped as hyperthyroidism, hypothyroidism, and euthyroid sick syndrome (ESS) according to symptoms, signs, thyroid function test, liver function test, fasting blood sugar, and cholesterol.

RESULTS

A total of 260 patients (210 females and 50 males) with a mean age of 49.22 ± 9.79 years reflected overall prevalence rate of 2.4%. The prevalence of hyperthyroidism 150 (58%), hypothyroidism 100 (39%), and (ESS) 10 (3.9%) was 1.4%, 0.9%, and 0.09%, respectively. Hypertension 34.3%, heart failure 26.7%, and atrial fibrillation 20% seen in Grave's disease were the most common cause of hospitalization and death.

CONCLUSION

Grave's disease is the most common cause of TDs and occurs more in females than males in this study. We observed that hypertension, heart failure, and atrial fibrillation are promoters of complication in TDs. Health system facilities need to be strengthened in this area to improve the detection and management of TDs.

Impact of HIV Infection on the Clinical Presentation and Survival of Non-Hodgkin Lymphoma: A Prospective Observational Study From Botswana

PURPOSE

Botswana has a high prevalence of HIV infection. Currently, there are few data regarding the sociodemographic factors, clinical characteristics, and outcomes of non-Hodgkin lymphoma (NHL)-an AIDS-defining cancer-in the country.

PATIENTS AND METHODS

This study used a prospective cancer registry to identify patients with a new diagnosis of NHL reporting for specialty cancer care at three hospitals in Botswana between October 2010 and August 2016. Treatment patterns and clinical outcomes were analyzed.

RESULTS

One hundred four patients with a new diagnosis of NHL were enrolled in this study, 72% of whom had HIV infection. Compared with patients not infected with HIV, patients infected with HIV were younger (median age, 53.9 v 39.1 years; P = .001) and more likely to present with an aggressive subtype of NHL (65.5% v 84.0%; P = .008). All patients infected with HIV received combined antiretroviral therapy throughout the course of the study, and similar chemotherapeutic regimens were recommended for all patients, regardless of subtype or HIV status (six to eight cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone; or cyclophosphamide, doxorubicin, vincristine, and prednisone plus rituximab). There was no difference in 1-year mortality among patients not infected with HIV and patients infected with HIV (unadjusted analysis, 52.9% v 37.1%; hazard ratio [HR], 0.73; P = .33; adjusted analysis, HR, 0.57; P = .14). However, when compared with a cohort of patients in the United States matched by subtype, stage, age, sex, and race, patients in Botswana fared worse (1-year mortality, 22.8% v 46.3%; HR, 1.89; P = .001).

CONCLUSION

Among patients with NHL reporting for specialty cancer care in Botswana, there is no association between HIV status and 1-year survival.

Evidence-based improvisation: Facing the challenges of cervical cancer care in Uganda

There is significant disparity in the prevalence of cervical cancer globally, with low- and middle-income countries (LMICs) shouldering a disproportionate share of disease incidence and an even greater proportion of morbidity and mortality. Available resources for diagnosis, treatment and palliation of cervical cancer are inversely related to per capita income. While prevention and screening remain public health priorities, given the large number of women affected by cervical cancer, expanding treatment capacity should be included in any evidence-based intervention plan. Uganda, a country with a high incidence of cervical cancer, serves as a representative case study in terms of the challenges of diagnosis and access to treatment in sub-Saharan Africa. Providers and patients in Uganda are challenged by late presentation to care, limited training opportunities, cost-prohibitive diagnostic studies, insufficient access to gold-standard treatment, and under-utilized palliative care services. This review highlights the ways in which Uganda's experience is typical of the continent at large, as well as areas where Uganda is unique. We describe the ways in which a small but dedicated group of gynecologists carefully use limited evidence and available resources creatively to provide the best possible care for their patients. We show that improvisation, albeit evidence-based, is central to the nature and success of oncology care in Africa (Livingston, 2012). We argue that a "recalibrated global response" (Farmer et al., 2010), particularly stressing the expansion of radiotherapy capabilities, could dramatically improve cancer care and outcomes for women in Uganda as well as in LMICs globally.

Factors Contributing to the Low Survival Among Women With a Diagnosis of Invasive Cervical Cancer in Ghana

: Cervical cancer is one of the most common cancers among women worldwide, and more than 85% of the disease occurs in low- and middle-income countries. Although it ranks as the most common cancer in Ghanaian women, there are no data available on cervical cancer survival.

METHODS

Information on women with a diagnosis of cervical cancer from 2010 to 2013 was collected from the Komfo Anokye and Korle-Bu Teaching Hospitals through review of paper-based and electronic medical records (including pathology records) at the oncology units and the departments of obstetrics and gynecology. Telephone interviews were conducted with patients and relatives to gather further information. Data were recorded using a standardized questionnaire and analyzed using summary statistics.

RESULTS

Information for 821 women was available for the survival analysis. Of these, 497 (60.5%) died during follow-up. At 3 years after diagnosis, survival was 39%. Survival was lowest in women with stage IV disease. Women with squamous cell carcinoma had a survival advantage over those with adenocarcinoma. Furthermore, women who received surgery, radiotherapy, and chemotherapy had better survival than did women with other forms of treatment.

CONCLUSIONS

In conclusion, cervical cancer survival is low in Ghana and is likely to be improved if a greater proportion of the disease is detected early. Improving knowledge of the disease for early diagnosis, reducing financial barriers, and greater organization of health care delivery are likely to improve survival from cervical cancer in Ghana.

Cervical cancer in southern Malawi: A prospective analysis of presentation, management, and outcomes

Background

Malawi has the highest age standardised rate of cervical cancer in the world. This study describes the presentation, management and short-term outcomes of patients with newly diagnosed cervical cancer at Queen Elizabeth Central Hospital (QECH), in Southern Malawi.

Methods

All patients with a new diagnosis of cervical cancer presenting to QECH between 1st January-1st July 2015 had demographic data, referral pathway, stage, histology and management prospectively recorded at presentation, and at two months after initial presentation.

Results

310 women presented with cervical cancer to QECH and 300 were included (mean age 44.9 years; HIV 47%), representing 8% of the estimated annual number of new presentations in Malawi. Mean age of patients with HIV was 6.9 years younger compared to those without HIV (p<0.05). 132 (44%) patients had stage 1 cervical cancer and 168 (56%) presented with more advanced disease (stage II-IV). There was a mean delay of 23.1 weeks between onset of symptoms and being seen by a clinician and a further 19 weeks before attending QECH. Most common management plans at initial consultation were: same day biopsy (n=112, 37.3%);, booking for curative surgery (n=76, 25.3%);, and referral to palliative care (n=93, 31%). At 2 months, 64 (57%) biopsies were reported, 31 (40.8%) operations were completed and 27 (29%) patients had attended the palliative clinic.

Conclusions

Patients presenting with cervical cancer to QECH were young, with a high prevalence of HIV, and late stage disease. The lack of pathological and surgical capacity and the absence of radiotherapy severely limited the possibility of curative treatment. Access to quality palliative care remains an important component of management in low resource settings. Improving awareness of cervical cancer in the community, and better recognition and management within the health service, are important in reducing the cancer burden for women in Malawi.

Updating vital status by tracking in the community among patients with epidemic Kaposi sarcoma who are lost to follow-up in sub-Saharan Africa

BACKGROUND

Throughout most of sub-Saharan Africa (and, indeed, most resource-limited areas), lack of death registries prohibits linkage of cancer diagnoses and precludes the most expeditious approach to determining cancer survival. Instead, estimation of cancer survival often uses clinical records, which have some mortality data but are replete with patients who are lost to follow-up (LTFU), some of which may be caused by undocumented death. The end result is that accurate estimation of cancer survival is rarely performed. A prominent example of a common cancer in Africa for which survival data are needed but for which frequent LTFU has precluded accurate estimation is Kaposi sarcoma (KS).

METHODS

Using electronic records, we identified all newly diagnosed KS among HIV-infected adults at 33 primary care clinics in Kenya, Uganda, Nigeria, and Malawi from 2009 to 2012. We determined those patients who were apparently LTFU, defined as absent from clinic for ≥90 days at database closure and unknown to be dead or transferred. Using standardized protocols which included manual chart review, telephone calls, and physical tracking in the community, we attempted to update vital status amongst patients who were LTFU.

RESULTS

We identified 1222 patients with KS, of whom 440 were LTFU according to electronic records. Manual chart review revealed that 18 (4.1%) were classified as LFTU due to clerical error, leaving 422 as truly LTFU. Of these 422, we updated vital status in 78%; manual chart review was responsible for updating in 5.7%, telephone calls in 26%, and physical tracking in 46%. Among 378 patients who consented at clinic enrollment to be tracked if they became LTFU and who had sufficient geographic contact/locator information, we updated vital status in 88%. Duration of LTFU was not associated with success of tracking, but tracking success was better in Kenya than the other sites.

CONCLUSION

It is feasible to update vital status in a large fraction of patients with HIV-associated KS in sub-Saharan Africa who have become LTFU from clinical care. This finding likely applies to other cancers as well. Updating vital status amongst lost patients paves the way towards accurate determination of cancer survival.

Prevalence and correlates of anxiety and depression among family carers of cancer patients in a cancer care and treatment facility in Uganda: a cross-sectional study

Background

The process of caregiving may cause emotional distress in form of anxiety and depression among family carers of cancer patients. Little is known about the prevalence of anxiety and depression among family carers of cancer patients in Uganda.

Objectives

To determine the prevalence of anxiety and depression and related factors associated with abnormal levels of anxiety and depression among family carers of cancer patients in a cancer care and treatment facility in Uganda.

Methods

After obtaining ethical approval, we recruited family carers of cancer patients to this cross-sectional study. Data was collected with the use of the Hospital Anxiety and Depression Scale(HADS) standardized tool.

Results

A total of 119 family carers were recruited from the Uganda Cancer Institute. The prevalence of anxiety and depression among family carers was high (45% V. 26 %); Abnormal levels of anxiety (ALA)(OR 0.27, 95% CI, p= 0.01) and depression (ALD)(OR 0.37, 95% CI, p=0.05) were significantly associated with being a relative carer.

Conclusion

Anxiety and depression is prevalent among family carers of cancer patients. Being a relative carer predisposes you to increased risk of developing anxiety and depression. Incorporating evidence based psychological therapies into usual care and targeting family carers is imperative.

Evaluation of a Predictive Staging Model for HIV-Associated Kaposi Sarcoma in Uganda

BACKGROUND

HIV-associated Kaposi sarcoma (KS) is commonly staged using the AIDS Clinical Trials Group criteria, which classify 3 variables- tumor extent (T), immune status (I), and systemic symptoms (S)-into good risk (0) and poor risk (1). Although validated in the United States and Europe, these criteria have not been systematically evaluated in sub-Saharan Africa, where the burden of KS is greatest.

METHODS

We reviewed medical charts of adult patients with HIV-associated KS seen at the Uganda Cancer Institute from 1992 to 2007. Vital status at 2 years after KS diagnosis was determined from the medical chart, or by contacting the patient or next of kin. Survival estimates used Kaplan-Meier methods. Predictors were evaluated for 2 periods: 0-4 months and 4-24 months after diagnosis.

RESULTS

At 2 years after diagnosis, 167 (41%) patients were alive, 156 (39%) had died, and 81 (20%) were lost to follow-up. The Kaplan-Meier estimate of 2-year survival was 57%. S1 was associated with death in months 0-4 [hazard ratio: 6.4, 95% confidence interval: 1.9-21.1], whereas T1 was associated with death in months 4-24 [hazard ratio: 4.0, 95% confidence interval: 1.4 to 11.5]. Immune status was not associated with survival.

CONCLUSIONS

Systemic symptoms were strongly associated with death in the early period after KS diagnosis, whereas tumor status was most predictive of death in the 4- to 24-month period. These findings suggest that different processes may influence outcomes in early and late periods following KS diagnosis. Further studies are needed to confirm these observations and to identify better predictors of KS survival in sub-Saharan Africa.

Quantifying bias in survival estimates resulting from loss to follow-up among children with lymphoma in Malawi

Pediatric lymphoma is common in sub-Saharan Africa, where survival estimates are often based on limited follow-up with incomplete retention, introducing potential for bias. We compared follow-up and overall survival (OS) between passive and active tracing within a prospective cohort of children with lymphoma in Malawi. Median follow-up times were 4.4 months (interquartile range [IQR] 2.0-9.4) and 10.8 months (IQR 6.2-20.6) in passive and active follow-up, respectively. Twelve-month overall survival (OS) was 69% (95% confidence interval [CI] 54-80) in passive and 44% (95% CI 34-54) in active follow-up. Passive follow-up significantly overestimated the OS and underestimated the mortality. Efforts to improve retention in regional studies are needed.