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Ngabonziza E, Ghebre R, DeBoer RJ, Ntasumbumuyange D, Magriples U, George J, Grover S, Bazzett-Matabele L. Outcomes of neoadjuvant chemotherapy and radical hysterectomy for locally advanced cervical cancer at Kigali University Teaching Hospital, Rwanda: a retrospective descriptive study. BMC Womens Health 2024; 24:204. [PMID: 38555423 PMCID: PMC10981286 DOI: 10.1186/s12905-024-03024-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 03/14/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Half of countries in Africa lack access to radiation (RT), which is essential for standard treatment of locally advanced cervical cancers. We evaluated outcomes for patients treated with neoadjuvant chemotherapy (NACT) followed by radical hysterectomy in settings where no RT is available. METHODS We performed a retrospective descriptive study of all patients with FIGO stage IB2-IIA2 and some exceptional stage IIB cases who received NACT and surgery at Kigali University Teaching Hospital in Rwanda. Patients were treated with NACT consisting of carboplatin and paclitaxel once every 3 weeks for 3-4 cycles before radical hysterectomy. We calculated recurrence rates and overall survival (OS) rate was determined by Kaplan-Meier estimates. RESULTS Between May 2016 and October 2018, 57 patients underwent NACT and 43 (75.4%) were candidates for radical hysterectomy after clinical response assessment. Among the 43 patients who received NACT and surgery, the median age was 56 years, 14% were HIV positive, and FIGO stage distribution was: IB2 (32.6%), IIA1 (7.0%), IIA2 (51.2%) and IIB (9.3%). Thirty-nine (96%) patients received 3 cycles and 4 (4%) received 4 cycles of NACT. Thirty-eight (88.4%) patients underwent radical hysterectomy as planned and 5 (11.6%) had surgery aborted due to grossly metastatic disease. Two patients were lost to follow up after surgery and excluded from survival analysis. For the remaining 41 patients with median follow-up time of 34.4 months, 32 (78%) were alive with no evidence of recurrence, and 8 (20%) were alive with recurrence. One patient died of an unrelated cancer. The 3-year OS rate for the 41 patients who underwent NACT and surgery was 80.8% with a recurrence rate of 20%. CONCLUSIONS Neoadjuvant chemotherapy with radical hysterectomy is a feasible treatment option for locally advanced cervical cancer in settings with limited access to RT. With an increase in gynecologic oncologists skilled at radical surgery, this approach may be a more widely available alternative treatment option in countries without radiation facilities.
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Affiliation(s)
| | - Rahel Ghebre
- University of Rwanda, Kigali, Rwanda
- University of Minnesota Medical School, Minneapolis, MN, USA
| | | | | | - Urania Magriples
- University of Rwanda, Kigali, Rwanda
- Yale School of Medicine, New Haven, CT, USA
| | | | | | - Lisa Bazzett-Matabele
- University of Rwanda, Kigali, Rwanda.
- Yale School of Medicine, New Haven, CT, USA.
- Department of OBGYN, University of Botswana, Sir Ketumile Masire Teaching Hospital, Pvt Bag, 00713, Gaborone, Botswana.
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Akinwande AM, Ugwuanyi DC, Chiegwu HU, Idigo F, Ogolodom MP, Anakwenze CP, Abi R, Odukoya O. Radiotherapy services in low resource settings: The situation in Nigeria. SAGE Open Med 2023; 11:20503121231153758. [PMID: 36778199 PMCID: PMC9909043 DOI: 10.1177/20503121231153758] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 01/12/2023] [Indexed: 02/10/2023] Open
Abstract
Objective About 50%-60% of all cancer cases will require radiotherapy during their treatment. Nonetheless, radiotherapy facilities are limited in low- and middle-income countries and despite high cancer burden in these regions of the world, only 5% have access to radiation therapy. This study identified the location of radiotherapy centers, the types of radiotherapy machines available and the personnel available in each radiotherapy center in Nigeria. Methods A cross-sectional questionnaire-based study conducted across the six geopolitical zones of Nigeria from May 2020 to April 2021. A questionnaire having sections on facility profile, status of facility, and human resources, was used to elucidate information for the study. Descriptive statistics (frequency and proportion) were used to describe facilities' characteristics, status, and human resources available. Results Out of nine radiotherapy centers evaluated, the majority 33.3% (n = 3) were found in the southwest geopolitical zone of Nigeria. Out of 10 equipment and accessories evaluated for availability, Ahmadu Bello University Teaching Hospital and University of Benin Teaching Hospital had the highest number of available equipment and accessories 90% (n = 9) each respectively. Out of the nine centers evaluated, only four centers had at least one functional equipment. The highest number 64.3% (n = 9) out of the 14 required number of staff in each center was found at University College Hospital. Out of 31 medical physicists identified, the majority 22.6% (n = 7) was found at University of Nigeria Teaching Hospital. Conclusion A high percentage of radiotherapy centers in Nigeria lacks the equipment and manpower to function optimally and is located within the southwest geopolitical zone of Nigeria. Therefore, proper investment in the radiotherapy service through private-public partnership, staff training, and equipment upgrade and maintenance could substantially improve the state of cancer care.
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Affiliation(s)
- Abidoye Matthew Akinwande
- Department of Radiography and Radiological Sciences, Faculty of Health Sciences and Technology, College of Health Sciences, Nnamdi Azikiwe University, Awka, Nigeria,Department of Radiation Oncology, College of Medicine, University of Ibadan, Ibadan, Nigeria,Department of Radiography and Radiation Science, Lead City University, Ibadan, Nigeria,Abidoye Matthew Akinwande, Department of Radiation Oncology, University College Hospital, Queen Elizabeth Road, P.M.B. 5116, Ibadan, Oyo state 200211, Nigeria.
| | - Daniel Chimuanya Ugwuanyi
- Department of Radiography and Radiological Sciences, Faculty of Health Sciences and Technology, College of Health Sciences, Nnamdi Azikiwe University, Awka, Nigeria
| | - Hyacienth Uche Chiegwu
- Department of Radiography and Radiological Sciences, Faculty of Health Sciences and Technology, College of Health Sciences, Nnamdi Azikiwe University, Awka, Nigeria
| | - Felicitas Idigo
- Department of Radiography and Radiological Sciences, Faculty of Health Sciences and Technology, College of Health Sciences, Nnamdi Azikiwe University, Awka, Nigeria,Department of Medical Radiography and Radiological Sciences, University of Nigeria Nsukka, Nsukka, Nigeria
| | - Michael Promise Ogolodom
- Department of Radiography and Radiological Sciences, Faculty of Health Sciences and Technology, College of Health Sciences, Nnamdi Azikiwe University, Awka, Nigeria
| | | | - Roland Abi
- Department of Epidemiology and Medical Statistics, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Oluwaponmile Odukoya
- Department of Radiation Oncology, College of Medicine, University of Ibadan, Ibadan, Nigeria
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Beltrán Ponce SE, Abunike SA, Bikomeye JC, Sieracki R, Niyonzima N, Mulamira P, Kibudde S, Ortiz de Choudens S, Siker M, Small C, Beyer KMM. Access to Radiation Therapy and Related Clinical Outcomes in Patients With Cervical and Breast Cancer Across Sub-Saharan Africa: A Systematic Review. JCO Glob Oncol 2023; 9:e2200218. [PMID: 36795990 PMCID: PMC10166435 DOI: 10.1200/go.22.00218] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
Abstract
PURPOSE To better understand the barriers to accessing standard-of-care radiation therapy (RT) for breast and cervical cancer in sub-Saharan Africa and their impact on outcomes. METHODS A comprehensive literature search was completed with a medical librarian. Articles were screened by title, abstract, and full text. Included publications were analyzed for data describing barriers to RT access, available technology, and disease-related outcomes, and further grouped into subcategories and graded according to predefined criteria. RESULTS A total of 96 articles were included: 37 discussed breast cancer, 51 discussed cervical cancer, and eight discussed both. Financial access was affected by health care system payment models and combined burdens of treatment-related costs and lost wages. Staffing and technology shortages limit the ability to expand service locations and/or increase capacity within existing centers. Patient factors including use of traditional healers, fear of stigma, and low health literacy decrease the likelihood of early presentation and completion of therapies. Survival outcomes are worse than most high- and middle-income countries and are affected by many factors. Side effects are similar to other regions, but these findings are limited by poor documentation capabilities. Access to palliative RT is more expeditious than definitive management. RT was noted to lead to feelings of burden, lower self-esteem, and worsened quality of life. CONCLUSION Sub-Saharan Africa represents a diverse region with barriers to RT that differ on the basis of funding, available technology and staff, and community populations. Although long-term solutions must focus on building capacity by increasing the number of treatment machines and providers, short-term improvements should be implemented, such as interim housing for traveling patients, increased community education to reduce late-stage diagnoses, and use of virtual visits to avoid travel.
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Affiliation(s)
| | - Sarah Adamma Abunike
- Division of Epidemiology & Social Sciences, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | - Jean C Bikomeye
- Division of Epidemiology & Social Sciences, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | - Rita Sieracki
- Medical College of Wisconsin Libraries, Milwaukee, WI
| | | | | | | | | | - Malika Siker
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Christina Small
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Kirsten M M Beyer
- Division of Epidemiology & Social Sciences, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
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4
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DeBoer RJ, Umutoni V, Bazzett-Matabele L, Katznelson E, Nguyen C, Umwizerwa A, Bigirimana JB, Paciorek A, Nsabimana N, Ruhangaza D, Ntasumbumuyange D, Shulman LN, Triedman SA, Shyirambere C. Cervical cancer treatment in Rwanda: Resource-driven adaptations, quality indicators, and patient outcomes. Gynecol Oncol 2021; 164:370-378. [PMID: 34916066 DOI: 10.1016/j.ygyno.2021.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 11/20/2021] [Accepted: 12/01/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Most cervical cancer cases and deaths occur in low- and middle-income countries, yet clinical research from these contexts is significantly underrepresented. We aimed to describe the treatment quality, resource-driven adaptations, and outcomes of cervical cancer patients in Rwanda. METHODS A retrospective cohort study was conducted of all patients with newly diagnosed cervical cancer enrolled between April 2016 and June 2018. Data were abstracted from medical records and analyzed using descriptive statistics, Kaplan Meier methods, and Cox proportional hazards regression. RESULTS A total of 379 patients were included; median age 54 years, 21% HIV-infected. A majority (55%) had stage III or IV disease. Thirty-four early-stage patients underwent radical hysterectomy. Of 254 patients added to a waiting list for chemoradiation, 114 ultimately received chemoradiation. Of these, 30 (26%) received upfront chemoradiation after median 126 days from diagnosis, and 83 (73%) received carboplatin/paclitaxel while waiting, with a median 56 days from diagnosis to chemotherapy and 207 days to chemoradiation. There was no survival difference between the upfront chemoradiation and prior chemotherapy subgroups. Most chemotherapy recipients (77%) reported improvement in symptoms. Three-year event-free survival was 90% with radical hysterectomy (95% CI 72-97%), 66% with chemoradiation (95% CI 55-75%), and 12% with chemotherapy only (95% CI 6-20%). CONCLUSIONS Multi-modality treatment of cervical cancer is effective in low resource settings through coordinated care and pragmatic approaches. Our data support a role for temporizing chemotherapy if delays to chemoradiation are anticipated. Sustainable access to gynecologic oncology surgery and expanded access to radiotherapy are urgently needed.
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Affiliation(s)
- Rebecca J DeBoer
- University of California San Francisco, San Francisco, CA, United States.
| | - Victoria Umutoni
- Vanderbilt University Medical Center, Nashville, TN, United States
| | - Lisa Bazzett-Matabele
- University of Botswana, Gaborone, Botswana; Yale University, New Haven, CT, United States
| | | | - Cam Nguyen
- University of Colorado Cancer Center, Aurora, CO, United States
| | | | | | - Alan Paciorek
- University of California San Francisco, San Francisco, CA, United States
| | | | | | | | - Lawrence N Shulman
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, United States
| | - Scott A Triedman
- Warren Alpert Medical School of Brown University, Providence, RI, United States; Dana Farber Cancer Institute, Boston, MA, United States
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Barcellini A, Dal Mas F, Paoloni P, Loap P, Cobianchi L, Locati L, Rodríguez-Luna MR, Orlandi E. Please mind the gap-about equity and access to care in oncology. ESMO Open 2021; 6:100335. [PMID: 34902710 PMCID: PMC8671867 DOI: 10.1016/j.esmoop.2021.100335] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/26/2021] [Accepted: 11/11/2021] [Indexed: 12/25/2022] Open
Affiliation(s)
- A Barcellini
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - F Dal Mas
- Department of Management, Lincoln International Business School, University of Lincoln, Lincoln, UK; Ipazia Observatory on Gender Research, Rome, Italy; Interdepartmental Research Center "Organization and Governance of the Public Administration", University of Pavia, Pavia, Italy
| | - P Paoloni
- Ipazia Observatory on Gender Research, Rome, Italy; Department of Law and Economics of Productive Activities, Sapienza University of Rome, Rome, Italy
| | - P Loap
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy; Department of Radiation Oncology, Institut Curie, Paris, France
| | - L Cobianchi
- Department of General Surgery, IRCCS Policlinico San Matteo Foundation, Pavia, Italy; Department of Clinical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - L Locati
- Unit of Translational Oncology, IRCCS ICS Maugeri, University of Pavia, Pavia, Italy
| | - M R Rodríguez-Luna
- Institute for Research against Digestive Cancer (IRCAD), Strasbourg, France
| | - E Orlandi
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy.
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Vanderpuye V, Dadzie MA, Huo D, Olopade OI. Assessment of Breast Cancer Management in Sub-Saharan Africa. JCO Glob Oncol 2021; 7:1593-1601. [PMID: 34843373 PMCID: PMC8624034 DOI: 10.1200/go.21.00282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To document progress and bottlenecks in breast cancer management in sub-Saharan Africa, subsequent to a 2013 pilot survey conducted through the African Organization for Research and Treatment in Cancer (AORTIC) network. METHODS An anonymous survey of breast cancer management was conducted in 2018 among AORTIC members. Results concerning respondent specialty, access to tumor boards, treatment accessibility, diagnostic services, and factors influencing treatment outcomes were compared with the 2013 findings. RESULTS Thirty-seven respondents from 30 facilities in 21 sub-Saharan Africa countries responded. The majority (92%) were clinical oncologists. Radiotherapy facilities were available in 70% of facilities. Seventy-eight percent of these had linear accelerators, and 42% had cobalt60 machines. Eighty percent of facilities had multidisciplinary tumor boards. Immunohistochemistry was routinely performed in 74% of facilities, computed tomography scan in 90%, bone scan in 16%, and positron emission tomography scans in 5%. Anthracyclines, taxanes, tamoxifen, letrozole, anastrozole, and zoledronic acid were available in the majority; trastuzumab, fertility, and genetic counseling were available in 66%, 58%, and 16%, respectively. There were a 50% increase in oncologist respondents over 2013 and a > 50% increase in radiotherapy facilities, particularly linear accelerators. Availability of trastuzumab, aromatase inhibitors, and taxanes increased. Immunohistochemistry capacity remained the same, whereas facilities harvesting at least 10 axillary lymph nodes increased. Bone scan facilities decreased. Responses suggested improved diagnostic services, systemic therapies, and radiotherapy. Sociocultural and economic barriers, system delays, and advanced stage at presentation remain. CONCLUSION Clinicians in sub-Saharan Africa have basic tools to improve breast cancer outcomes, recording positive strides in domains such as radiotherapy and systemic therapy. Socioeconomic and cultural barriers and system delays persist. Workforce expansion must be prioritized to improve quality of care to improve outcomes. This study highlights the current state of breast cancer management in Sub Saharan Africa, documenting key advancements , challenges and bottlenecks encountered in the sub region. Aside the major aspects of management, pertinent areas such as multidisciplinary tumour board engagements, fertility , genetic counselling and factors affecting outcome were explored. Majority of institutions manage breast cancer patients within a multidisciplinary setting using standard treatment guidelines. The high out of pocket cost of cancer treatment and advanced stage at presentation transcends in many sub Saharan countries negatively impacting outcomes. These results should serve as a benchmark to stakeholders , to guide urgent interventions required to further improve outcomes.
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Affiliation(s)
- Verna Vanderpuye
- National Centre for Radiotherapy, Oncology and Nuclear Medicine, Korle Bu Teaching Hospital, Accra, Ghana
| | - Mary-Ann Dadzie
- National Centre for Radiotherapy, Oncology and Nuclear Medicine, Korle Bu Teaching Hospital, Accra, Ghana
| | - Dezheng Huo
- Department of Public Health Sciences, University of Chicago, Chicago, IL
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7
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Dereje N, Addissie A, Worku A, Gebremariam A, Kantelhardt EJ, Assefa M, Jemal A. Association between waiting time for radiotherapy initiation and disease progression among women with cervical cancer in Addis Ababa, Ethiopia. Int J Cancer 2021; 149:1284-1289. [PMID: 33997978 DOI: 10.1002/ijc.33689] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 04/19/2021] [Accepted: 04/29/2021] [Indexed: 12/24/2022]
Abstract
There is shortage of radiotherapy machines in low-income countries, including Ethiopia. Data on adverse effects of this on cancer outcomes are limited, however. Herein, we examined the extent of waiting time for radiotherapy and its association with disease progression based on a prospective cohort study of women diagnosed with stage IA-IVA cervical cancer in Addis Ababa and who were scheduled to receive radiotherapy at Tikur Anbessa Specialized Hospital, the only hospital that provides radiotherapy services in the country. Association was examined using Multivariable mixed effects logistic regression model. Among the 178 women with cervical cancer scheduled for receipt of radiotherapy and with vital status information, 16 deceased (9.0%) while waiting for radiotherapy. For the remaining 162 women who initiated radiotherapy, the median treatment waiting period was 137 days (IQR = 60-234 days), with 74.1% of women waiting for >60 days. Tumor progressed to higher stage for 44.4% of these women. Compared to those women who initiated radiotherapy ≤60 days after diagnostic confirmation, the odds of tumor progression to higher stage was three times higher in those women who initiated radiotherapy between 120-179 days (aOR =3.30, 95%CI: 1.18-9.27) and ≥180 days (aOR =3.06, 95%CI: 1.24-7.52). Waiting period for receipt of radiotherapy among women with cervical cancer is exceedingly long in Addis Ababa, and it is associated with disease progression to higher stages. These findings reinforce the need to expand radiotherapy infrastructure in order to mitigate the undue high burden of the disease in Ethiopia and other parts of Africa.
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Affiliation(s)
- Nebiyu Dereje
- Department of Public Health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia.,Department of Preventive Medicine, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Adamu Addissie
- Department of Preventive Medicine, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alemayehu Worku
- Department of Preventive Medicine, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alem Gebremariam
- Department of Preventive Medicine, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia.,Department of Public Health, College of Medicine and Health Sciences, Adigrat University, Adigrat, Ethiopia
| | - Eva Johanna Kantelhardt
- Department of Gynecology, Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University Halle, Halle, Germany
| | - Mathewos Assefa
- Department of Oncology, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ahmedin Jemal
- Surveillance & Health Equity Science, American Cancer Society, Atlanta, Georgia, USA
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