Implementation of Brachytherapy for Patients With Cervical Cancer in Ethiopia: A 3-Year Practice Report

PURPOSE

Although cervical cancer is the second most commonly diagnosed cancer in Ethiopia, brachytherapy (BT) was not a component in patient treatment until 2015. The purpose of this study was to identify the patterns of utilization as well as to describe the practice of BT in Ethiopia.

MATERIALS AND METHODS

A retrospective descriptive data analysis of 138 patients with cervical cancer treated with a curative potential using BT from 2015 to 2018 at Tikur Anbassa Specialized Hospital, which housed the only BT facility in Ethiopia during the study period.

RESULTS

During the first 3-year period of BT service commencement, each year n = 37, n = 36, and n = 65 patients with cervical cancer were treated, respectively, with curative intention treatment. The median age of these 138 patients was 50 years (range, 22-75). All the patients were in International Federation of Gynecology and Obstetrics stage Ib-IIIb group, and stage IIb (66.4%) was the predominant. Majority (79%) of the patients were treated primarily with radiotherapy (RT), while 21% received RT after surgery. More than half of these patients (62%) received a total RT dose of 82 Gy in equivalent dose in 2 Gy fractions (EQD2), while the rest received a dose ranging from 76 to 86 Gy. Concurrent cisplatin with RT was given only for 36% of the patients for undocumented reasons. The overall treatment time including both external-beam RT and BT was greater than 8 weeks in 21% of the patients.

CONCLUSION

The utilization of BT service increased gradually and BT enabled the delivery of a higher RT dose to patients with cervical cancer (mostly stage IIB). However, there was protracted treatment duration and low concurrent chemotherapy utilization.

Patterns of cancer in Wolaita Sodo University Hospital: South Ethiopia

BACKGROUND

Variations in cancer occurrence between populations in different places are expected because of many factors. In Ethiopia there is no national cancer registry and here we are reporting the pattern of cancer in Wolaita Sodo University hospital located in Southern region of Ethiopia with catchment area of over ten million peoples.

METHODOLOGY

A retrospective record analysis of all pathologically confirmed malignancies from January 2021 up to June 2021. Data was filtered and descriptive analysis was done using IBM SPSS version 22 (Chicago IL USA).

RESULT

In the Wolaita Sodo University Teaching Referral Hospital during the first six months of 2021, out of 1,810 histopathologically tested samples 19.5% (354) were confirmed malignant cases. Among 354 patient samples, most of them (62.4%) were in females and the rest (37%) found to be in males. The age pattern shows occurrence of 336 (95%) cases in adults and 18 (5%) cases in children. Breast cancer, soft tissue sarcomas, cancer of uteri cervix, non melanomatous skin cancer, and non hodgkin lymphomas were the five top common cancers of all age groups. In adult population, breast cancer, soft tissue sarcomas, and cancer of uteri cervix are the most common. In children of age less than 14 years non hodgkin lymphomas, soft tissue sarcomas and bone sarcomas were the three top cancers. Breast cancer, cancer of uteri cervix and soft tissue sarcomas are found to be the commonest cancers in females. On the other hand, soft tissue sarcomas, non melanomatous skin cancers and Non Hodgkin lymphomas, are the three top commonest cancers in males.

CONCLUSION

Based on our current study cancer is one of the common finding from histopathology samples analyzed at the hospital and the pattern of cancer was similar to those reported in other regions of the country as well as neighboring countries. However, Comprehensive demographic and clinical data using population or facility-based cancer registry is required to get better information. Additionally, our finding of higher proportion of soft tissue sarcomas both in males and females of all age groups in this region is disparate and requires further investigation.

Magnitude and factors associated with anxiety and depression among patients with breast cancer in central Ethiopia: A cross-sectional study

BACKGROUND

Patients with breast cancer are assumed to be susceptible to anxiety and depression, while there is a lack of evidence about the epidemiology and underlying factors in Ethiopia. Hence, we aimed to assess the prevalence and predictors of anxiety and depression among patients with breast cancer in Ethiopia.

METHOD

An institutional-based cross-sectional study was conducted among patients with breast cancer who were attending treatment at the Oncology Center of the Tikur Anbessa Specialized Hospital, the largest referral teaching hospital in Ethiopia. The Hospital Anxiety and Depression Scale (HDAS) was used to evaluate the anxiety and depression status of the participants, and a structured questionnaire was used to collect sociodemographic, socioeconomic, and clinical data from the participants. Medical records of the participants were reviewed to collect and correlate information about the grade and stage of cancer. An analysis was done using STATA 15.1.

RESULTS

The study included 333 randomly selected participants, of which 35.4% were on stage III and 33% on stage II, and 67.9% were on chemotherapy and surgery. The prevalence of anxiety and depression were 60.7 and 58.6%, respectively. Poor patient-provider interaction (adjusted odds ratio [AOR] = 4.5, 95% CI: 2.49, 8.12) and having no financial support (AOR = 2.83, 95% CI: 1.63, 4.91) were the significant predictors of anxiety. Age >49 years (AOR = 0.48, 95% CI: 0.25, 0.90), poor patient-provider interactions (AOR = 3.36, 95% CI: 1.87, 6.02), and having no financial support (AOR = 3.36, 95% CI: 1.95, 5.79) were the significant predictors of depression.

CONCLUSION

In this study, the prevalence of anxiety and depression was high among patients with breast cancer, and the lack of financial support and poor patient-provider interactions were significant predictors of anxiety and depression among these groups of patients. Patients with cancer need regular screening for mental health and better emotional support from their healthcare providers and families to prevent and treat anxiety and depression.

The effect of interpersonal psychotherapy on quality of life among breast cancer patients with common mental health disorder: a randomized control trial at Tikur Anbessa Specialized Hospital

PURPOSE

To determine the effect of interpersonal psychotherapy on anxiety, depression, and quality of life among breast cancer patients with mental health disorders at Tikur Anbessa Specialized Hospital, Ethiopia.

METHODS

A two-arm parallel randomized controlled trial study was conducted among 114 (n = 57 intervention, and n = 57 control group) breast cancer patients with common mental health disorder at the oncology center of Tikur Anbessa Specialized Hospital. The hospital anxiety and depression measurement scale was used to assess depression and anxiety disorder and a 30-item quality of life questionnaire was used to assess the quality of life. General linear model analysis was done, confounding factors were controlled, and p < 0.05 was used to declare statistical significance.

RESULTS

Patients in the intervention group showed a significant improvement in the anxiety (coefficient - 3.68; 95% CI - 5.67, - 1.69; p < 0.001), depression (coefficient - 3.22; 95% CI - 4.7, - 1.69; p < 0.001), physical functioning (coefficient 10.55; 95% CI 3.13, 17.98; p = 0.006), health-related quality of life (coefficient 21.85; 95% CI 14.1, 29.59; p < 0.001), insomnia (coefficient - 19.56; 95% CI - 31.87, - 7.25; p = 0.002), and fatigue (coefficient - 11.37; 95% CI - 21.49, - 1.24; p = 0.028) respectively.

CONCLUSIONS

The adapted Ethiopian version of interpersonal psychotherapy had improved anxiety, depression, and some domains of health-related quality of life. Hence, health programmers should consider incorporating it as a treatment option in oncology centers.

TRIAL REGISTRATION NUMBER

PACTR202011629348967 granted on 20 November 2020 which was retrospectively registered.

Cervix Cancer in Sub-Saharan Africa: An Assessment of Cervical Cancer Management

PURPOSE

Underdeveloped nations carry the burden of most cervical cancer, yet access to adequate treatment can be challenging. This report assesses the current management of cervical cancer in sub-Saharan Africa to better understand the needs of underdeveloped nations in managing cervical cancer.

METHODS

A pre- and postsurvey was sent to all centers participating in the Cervical Cancer Research Network's 4th annual symposium. The pre- and postsurvey evaluated human papillomavirus and HIV screening, resources available for workup and/or treatment, treatment logistics, outcomes, and enrollment on clinical trials. Descriptive analyses were performed on survey responses.

RESULTS

Twenty-nine centers from 12 sub-Saharan countries saw approximately 300 new cases of cervical cancer yearly. Of the countries surveyed, 55% of countries had a human papillomavirus vaccination program and 30% (range, 0%-65%) of women in each region were estimated to have participated in a cervical cancer screening program. In the workup of patients, 43% of centers had the ability to obtain a positron emission tomography and computed tomography scan and 79% had magnetic resonance imaging capabilities. When performing surgery, 88% of those centers had a surgeon with an expertise in performing oncological surgeries. Radiation therapy was available at 96% of the centers surveyed, and chemotherapy was available in 86% of centers. Clinical trials were open at 4% of centers.

CONCLUSION

There have been significant advancements being made in screening, workup, and management of patients with cervical cancer in sub-Saharan Africa; yet, improvement is still needed. Enrollment in clinical trials remains a struggle. Participants would like to enroll patients on clinical trials with Cervical Cancer Research Network's continuous support.

Extent and Predictors of Delays in Diagnosis of Cervical Cancer in Addis Ababa, Ethiopia: A Population-Based Prospective Study

PURPOSE

A substantial proportion of cervical cancers are diagnosed at advanced stage in Ethiopia. Therefore, the aim of this study was to determine the extent and predictors of delays in cervical cancer diagnosis in Addis Ababa.

PATIENTS AND METHODS

We prospectively recruited 231 patients with cervical cancer diagnosed from January 1, 2017, to June 30, 2018, in 7 health facilities in Addis Ababa, representing 99% of all cervical cancers recorded in the Addis Ababa population-based cancer registry. A structured questionnaire on patients’ experience was administered face to face by trained interviewers. Health-seeking intervals > 90 days (date from recognition of symptoms to medical consultation) and diagnostic intervals > 30 days (dates from medical consultation to diagnostic confirmation) were categorized as delayed. Factors associated with these delays were assessed using multivariable binary logistic regression models.

RESULTS

The median health-seeking and diagnostic intervals for patients with cervical cancer in Addis Ababa were 10 and 97 days, respectively. Approximately one quarter of the patients were delayed in seeking medical consultation, and three fourths of the patients had delayed diagnostic confirmation. Factors associated with health-seeking delays included poor cervical cancer awareness, practicing of religious rituals, and waiting for additional symptoms before visiting a health facility. Factors associated with diagnostic delays included first contact with primary health care units and visits to ≥ 4 different health facilities before diagnosis.

CONCLUSION

A considerable proportion of patients with cervical cancer in Addis Ababa have delays in seeking medical care and diagnostic conformation. These findings reinforce the need for programs to enhance awareness about cervical cancer signs and symptoms and the importance of early diagnosis in the community and among health care providers.

Delayed initiation of adjuvant chemotherapy among women with breast cancer in Addis Ababa, Ethiopia

PURPOSE

Chemotherapy within 90 days following surgery for non-metastatic breast cancer is the standard of care. There are no data, however, on the extent of time to initiation of chemotherapy (TTC) in Africa settings, including Ethiopia.

METHODS

A total of 223 women with stage I-III breast cancer treated with surgery and adjuvant chemotherapy during 2017-2019 in Addis Ababa, Ethiopia, were included in the analysis. Based on information from medical records, we calculated TTC from date of surgery and completion of planned chemotherapy, with TTC > 90 days considered delayed and receipt of 85% of planned therapy as complete. Multivariable Poisson regression with robust variance was used to assess whether TTC > 90 days was associated with sociodemographic or clinical factors.

RESULTS

The median TTC was 63 days. Chemotherapy initiation was delayed in 30% (95% CI 24.4-36.6%) of patients, with the risk significantly higher in low-income women. For example, the risk of delay in women with lowest quartile family monthly income group (US$ < 61) was 3.98 (95% CI 1.67-9.46) higher than in those women with highest quartile family income group (US$ > 194). Remarkably, adjuvant chemotherapy was completed in 95% of patients.

CONCLUSIONS

A staggering one-in-three women with breast cancer in Addis Ababa, Ethiopia, delay to initiation of adjuvant chemotherapy, with the delay more common in low-income women and yet with remarkably high degree of treatment adherence. These findings underscore the need for public policy to expand health care to low-income population to improve breast cancer care and other health outcomes in the country.

Factors associated with advanced stage at diagnosis of cervical cancer in Addis Ababa, Ethiopia: a population-based study

OBJECTIVE

To describe the patterns and factors associated with advanced stage at diagnosis of cervical cancer among Addis Ababa residents, Ethiopia.

DESIGN

A population-based cross-sectional study.

SETTING

Seven major hospitals or diagnostic facilities in Addis Ababa, Ethiopia.

PARTICIPANTS

All histopathology-confirmed patients with incident cervical cancer diagnosed from 1 January 2017 to 30 June 2018 among Addis Ababa residents.

OUTCOME MEASURES

The proportion of patients with cervical cancer diagnosed at early stage (stage I/II) and advanced stage (stage III/IV) of the disease according to International Federation of Gynaecology and Obstetrics staging criteria, and adjusted prevalence ratio (APR) for factors associated with advanced-stage diagnosis using a Poisson regression with robust variance model.

RESULTS

The mean age of the study participants was 52.9 (±13.3) years. Nearly two-thirds (60.4%, 95% CI: 53.8% to 66.5%) of patients with cervical cancer were diagnosed at an advanced stage. Advanced stage at diagnosis was significantly associated with paying medical bill out of pocket (APR=1.44, 95% CI: 1.08 to 1.91), diagnostic interval >90 days (APR=1.31, 95% CI: 1.04 to 1.71), practicing religion as a remedy or not taking immediate action following symptom recognition (APR=1.25, 95% CI: 1.08 to 1.91) and visiting more than three different health facilities prior to diagnostic confirmation (APR=1.24, 95% CI: 1.07 to 1.51).

CONCLUSIONS

Our findings of the high proportion of advanced-stage diagnosis of cervical cancer in Addis Ababa and its strong associations with out-of-pocket medical bill, seeking care out of conventional medicine settings and multiple visits to healthcare facilities before diagnostic confirmations underscore the need for public policies to improve the affordability of cancer care and enhance community awareness about the severity of the disease and referral system, in addition to expanding cervical cancer screening.

Factors associated with late-stage diagnosis of breast cancer among women in Addis Ababa, Ethiopia

PURPOSE

Stage at diagnosis is a key determinant of breast cancer prognosis. In this study, we characterize stage at diagnosis and determine factors associated with advanced stage at diagnosis among women diagnosed with invasive breast cancer in Addis Ababa, capital city of Ethiopia.

METHODS

Stage information was collected from medical records of 441 women with invasive breast cancer seen in seven major health facilities in Addis Ababa, from January 2017 to June 2018; these seven facilities capture 90% of all incident breast cancer cases in the city. We used multivariable Poisson regression model with robust variance to determine factors associated with advanced stage at diagnosis.

RESULTS

The predominant tumor histology was ductal carcinoma (83.7%). More than half of the tumors' grade was moderately or poorly differentiated. The median tumor size at presentation was 4 cm. Sixty-four percent of the patients were diagnosed at advanced stage of the disease (44% stage III and 20% stage IV), with 36% of the patients diagnosed at early-stage (5% stage I and 31% stage II). The prevalence of advanced stage disease was significantly higher among women who used traditional medicine before diagnostic confirmation (adjusted prevalence ratio [aPR] = 1.31; p = 0.001), had patient delay of >  3 months (aPR = 1.16; p = 0.042) and diagnosis delay of > 2 months (aPR = 1.24; p = 0.004). But it was lower among women who had history of breast self-examination (aPR = 0.77; p = 0.021).

CONCLUSIONS

Advanced stage at diagnosis of breast cancer among women in Addis Ababa is strongly associated with use of traditional medicine and with prolonged time interval between symptom recognition and disease confirmation. Community- and health systems-level interventions are needed to enhance knowledge about breast cancer and facilitate timely diagnoses.

Short-Course 2-Dimensional Radiation Therapy in the Palliative Treatment of Esophageal Cancer in a Developing Country: A Phase II Study (Sharon Project)

PURPOSE

Patients with locally advanced and metastatic esophageal cancer are usually affected by cancer-related symptoms, which worsen their performance status and quality of life. The aim of this study was to determine the efficacy of short-course accelerated radiation therapy for symptomatic palliation in a low resourced setting where only a 2-dimensional radiation therapy (RT) technique was available.

METHODS AND MATERIALS

A phase II trial based on Simon's 2-stage design was planned. A total dose of 12 Gy in 4 fractions, twice per day, over 2 days, ≥8 hours apart, using a 2-dimensional conventional RT technique was delivered with a Cobalt 60 unit (Equinox, Best Theratronics, Ottawa, Ontario). Symptoms were graded using the International Atomic Energy Agency scoring system.

RESULTS

A total of 17 patients were treated (male/female = 10/7; median age, 50.0 years; range, 27-78 years; histology: 6 adenocarcinomas and 11 squamous cell carcinomas; tumor site: 4 gastresophageal junction and 13 esophagus). The most frequent baseline symptoms were dysphagia or regurgitation (100%), odynophagia (76%), and chest or back pain (53%). At 1 month after RT, all patients were alive with palliative response rates (complete plus partial) for dysphagia, regurgitation, odynophagia, and chest or back pain of 76%, 82%, 69%, and 56%, respectively. No patients presented acute ≥G3 toxicity.

CONCLUSIONS

Short-course accelerated radiation therapy treatment, planned and delivered using a conventional 2-dimensional RT technique, was effective and well tolerated for the symptomatic palliation of locally advanced or metastatic esophageal cancer. This schedule may be useful for RT centers in developing countries to reduce treatment times, costs, and patient waiting times before treatment.

Palliative Short-course Radiotherapy in Advanced Pelvic Cancer: A Phase II Study (SHARON Project)

AIM

To define safety and efficacy of a palliative, short-course accelerated radiation therapy for symptomatic locally advanced primary pelvic cancer.

MATERIALS AND METHODS

A phase II trial was planned based on the minimax Simon's two-stage design. A total of 18 Gy in 4.5 Gy/fraction administered twice a day was delivered (SHARON). Pain and quality of life were recorded according to the Visual Analogue self-assessment and the cancer linear analog scales (CLAS), respectively.

RESULTS

Twenty-five patients were enrolled in the study. The most frequent baseline symptoms were pain (48%), bleeding (40%), bleeding/pain (8%), and intestinal sub-occlusion (4%). The overall palliative response rate was 96.0%, with a median palliative duration of 6 months. An improvement of quality-of-life indices (well-being, fatigue, and ability to perform daily activities) was noted in 64.0%, 36.0%, and 48.0% of patients, respectively.

CONCLUSION

The SHARON regimen was well tolerated and effective in the palliative treatment of patients with locally advanced pelvic cancer. Based on these results, a multicentric prospective phase III trial is ongoing to compare this regimen with traditional 2-week radiotherapy treatment.