Infection-related and lifestyle-related cancer burden in Kampala, Uganda: projection of the future cancer incidence up to 2030

Recent Patterns and Trends in Global Prostate Cancer Incidence and Mortality: An Update

BACKGROUND AND OBJECTIVE

Our aim was to examine worldwide patterns and trends for prostate cancer (PC) incidence and mortality using high-quality, up-to-date, population-based data.

METHODS

We analyzed age-standardized PC incidence and mortality rates by country and region from the 2022 GLOBOCAN estimates and temporal trends in incidence (50 countries/territories) and mortality (59 countries/territories) rates using data from the Cancer Incidence in Five Continents series and the World Health Organization mortality database.

KEY FINDINGS AND LIMITATIONS

Estimated PC rates across regions in 2022 varied 13-fold for incidence and 9.5-fold for mortality. The highest incidence rates were in Australia/New Zealand, North America, Northern Europe, and Latin America/Caribbean. The highest mortality rates were in sub-Saharan Africa and Latin America/Caribbean. During the most recent 5-yr period, incidence rates increased in 11 of the 50 countries included in the study and mortality rates increased in nine of 59 countries, mostly located in Africa, Asia, Latin America/Caribbean, and Central and Eastern Europe. Mortality rates decreased in 38 countries, largely located in Europe, Oceania, and Latin America/Caribbean. Limitations include the lack of data for low- and middle-income countries.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The increase in PC incidence and mortality rates in many countries in Africa, Asia, and Latin America/Caribbean may be because of increases in detection (incidence) and limited access to and availability of treatments (mortality only). The findings reinforce the importance of improving the health care infrastructure in these countries to mitigate the rising burden of PC.

Evolution and Recent Radiation Therapy Advancement in Uganda: A Precedent on How to Increase Access to Quality Radiotherapy Services in Low- and Middle-Income Countries

The evolution of radiation therapy in Uganda has been a journey marked by significant milestones and persistent challenges. Since the inception of radiotherapy services in 1988-1989, there has been a concerted effort to enhance cancer treatment services. The early years were characterized by foundational developments, such as the installation of the first teletherapy units, low-dose-rate brachytherapy units, and conventional simulators, and the recognition of radiation oncologists and medical physicist professionals laid the groundwork for radiotherapy treatment modalities. With more support from the International Atomic Energy Agency, the acquisition of dosimetry equipment, treatment planning systems, and additional professional training signaled a new era in the fight against cancer. As we entered the second decade of the millennium, the Uganda Cancer Institute (UCI) witnessed a progression in sophisticated radiotherapy services, including high-dose-rate brachytherapy, initiation of intensity modulated radiation therapy (IMRT)/volumetric modulated arc therapy (VMAT), and use of artificial intelligence. These advancements improved the efficiency/precision of treatments and the time patients spent undergoing therapy. Around the second decade of radiotherapy services, about 600 new patients with cancer were annually treated compared with about 2,600 in 2023. Currently, an average of 1,440 brachytherapy insertions are done annually compared with 300 insertions for the first 20 years. Despite the technological strides, the UCI faced numerous obstacles, including limited equipment, knowledge gaps in appropriate tumor/organs at risk segmentations, treatment planning, and protocols. However, international support and collaboration efforts have led to significant improvement in the precision and effectiveness of treatments. Currently, about 51% of all patients are treated with image-guided techniques-IMRT/VMAT (42%) and three-dimensional conformal radiation treatment (10%). The Government has commenced the decentralization of radiotherapy services to other regions. This review can be a learning lesson for the more than 25 countries in Africa and other low-middle-income countries globally that do not have access to radiotherapy and/or are in the process of starting such facilities.

Health-related quality of life among adult patients with cancer in Uganda - a cross-sectional study

OBJECTIVES

The study aimed to investigate the prevalence and factors associated with poor health-related quality of life in adults with cancer in Uganda.

METHODS

This cross-sectional study surveyed 385 adult patients (95% response rate) with various cancers at a specialised oncology facility in Uganda. Health-related quality of life was measured using the EORTC QLQ-C30 in the Luganda and English languages. Predetermined validated clinical thresholds were applied to the instrument in order to identify patients with poor health-related quality of life, that is, functional impairments or symptoms warranting concern. Multivariable logistic regression was used to identify factors associated with poor health-related quality of life in six subscales: Physical Function, Role Function, Emotional Function, Social Function, Pain and Fatigue.

RESULTS

The mean age of the patients was 48 years. The majority self-reported poor functioning ranging between 61% (Emotional Function) to 79% (Physical Function) and symptoms (Fatigue 63%, Pain 80%) at clinically concerning levels. These patients were more likely to be older, without formal education and not currently working. Being an inpatient at the facility and being diagnosed with cervical cancer or leukaemia was a predictor of poor health-related quality of life.

CONCLUSION

Improvement of cancer care in East Africa requires a comprehensive and integrated approach that addresses various challenges specific to the region. Such strategies include investment in healthcare infrastructure, for example, clinical guidelines to improve pain management, and patient education and support services.

Prevalence of prostate cancer and its grade group stage at diagnosis in patients treated with prostatectomy in rural south western Uganda

BACKGROUND

Prostate cancer is the most frequently diagnosed cancer among men in the world. Uganda and Zimbabwe have been reported to have highest incidence rates of prostate cancer in sub-Saharan Africa. There are no urologists and no prostate cancer diagnostic facilities in rural communities in south western Uganda. Men with lower urinary tract symptoms are treated with prostatectomy by midlevel healthcare workers and general surgeons without prior prostate cancer screening. Histological diagnosis relies on the prostate tissue retrieved during surgery and the results may take several months. Prostate cancer care in southwestern Uganda remains uncoordinated and has not been documented before. This study aimed to establish and document the burden of prostate cancer in rural southwestern Uganda as a basis for further research.

METHODS

This was a retrospective study conducted in hospitals in rural southwestern Uganda. We used hospital records as primary source of data. Histology results of patients treated with prostatectomy during the five-year period (2019-2023) were retrieved and data extracted for analysis. 1013 patients were included in the study. Univariate data analysis was done with STATA version 17.0. The study received ethics clearance for Kabale university REC and Uganda National council of Science and Technology.

RESULTS

The average age of patients in this study was 70.6 year (range 54-102 years). Prostate cancer was present in 232 (22.9%) patients. Seventeen (7.3%) patients with prostate cancer were below sixty years. Most (75.4%) of the patients with prostate cancer in this study had low to intermediate risk disease. Perineural tumor infiltration was present in 28.9% of prostate cancer patients.

CONCLUSION

More than 1 in 5 men (22.9%) with lower urinary tract symptoms treated with prostatectomy in the study period in southwestern Uganda had prostate cancer. Majority of patients (75.4%) had low to intermediate risk disease. These findings highlight the urgent need for systematic improvements in prostate cancer care, including sensitization of both health workers and the general population, establishment of early screening and regional diagnostic and treatment facilities to enhance patient outcomes in resource -limited rural communities in Uganda.

CLINICAL TRIAL NUMBER

Not applicable.

Baseline knowledge on risk factors, symptoms and intended behavior of women and men towards screening and treatment of cervical cancer in rural Uganda: a cross-sectional study

BACKGROUND

Knowledge of risk factors and symptoms of cervical cancer has been found to promote uptake of screening of cervical cancer. Most interventions targeted women without much involvement of men (husbands/decision makers) who are often decision makers in many low- and middle-income countries. This study aimed at assessing baseline knowledge and intended behavior of both women and men to enable design specific targeted messages to increase uptake of cervical cancer screening and promote early detection of women with symptoms.

METHODS

This cross-sectional study was conducted in two districts in Western Uganda using the modified African Women Awareness of CANcer (AWACAN) questionnaire. Women aged 30-49 years and their husbands/decision makers were interviewed. Knowledge on risk factors and symptoms, intended behavior and barriers towards participation in cervical cancer screening and treatment were assessed. Descriptive and logistic regression analyses were done to establish the association between knowledge levels and other factors comparing women to men.

RESULTS

A total of 724 women and 692 men were enrolled. Of these, 71.0% women and 67.2% men had ever heard of cervical cancer and 8.8% women had ever been screened. Knowledge of risk factors and symptoms of cervical cancer was high and similar for both women and men. Lack of decision making by women was associated with low knowledge of risk factors (X2 = 14.542; p = 0.01), low education (X2 = 36.05, p < 0.01) and older age (X2 = 17.33, p < 0.01). Men had better help seeking behavior than women (X2 = 64.96, p < 0.01, OR = 0.39, 95% CI: 0.31-0.50) and were more confident and skilled in recognising a sign or symptom of cervical cancer (X2 = 27.28, p < 0.01, OR = 0.52, CI (0.40-0.67).

CONCLUSION

The baseline knowledge for cervical cancer was high in majority of participants and similar in both women and men. Their intended behavior towards screening was also positive but screening uptake was very low. This study suggests developing messages on multiple interventions to promote screening behavior in addition to education, consisting of male involvement, women empowerment and making services available, accessible and women friendly.

Cancer patterns in Arua district, Uganda: a hospital-based retrospective study

Introduction

Cancer is the second leading cause of mortality with over 19 million cases and 10 million deaths worldwide. Available data on cancer patterns in Uganda are through modelling of data from two population-based cancer registries (PBCRs) representing only about 10% of the cancer situation in Uganda. This study sought to determine the common types of cancer among adults and children in Arua District over a 5-year period (2017-2021).

Methods

Retrospective cohort chart review and 'catchment population approach' were employed. All newly diagnosed cancer patients from Arua between 2017 and 2021 were included in this study. Data were collected using Redcap whereas management and analysis were conducted using Stata 17. Cancer patterns were computed as frequencies and percentages and the interest was in finding out the common cancers among adults (above 19 years) and children (0-19 years).

Results

Over the 5-year study period, a total of 1,118 new cancer cases were registered, with slightly more females (52.1%). The top five common cancers irrespective of sex and age were: liver cancer (13.7%), cervical (11.8%), breast (10.7%), oesophagus (10.5%) and Burkitt's lymphoma (BL) (6.4%). In this study, 15.3% (n = 171) of the study participants were children. The top five common childhood cancers included BL (42%), leukemia (10.5%), other lymphomas (9.4%), osteosarcoma (4.7%) and nephroblastoma (3%).

Conclusion

There is a high incidence of liver cancer in Arua district. The high levels of cervical, breast and oesophagus cancer were consistent with what is reported by the two PBCRs in Uganda. However, BL could be due to the presence of a BL treatment centre at Kuluva hospital in Arua. Cancer interventions in Arua should therefore be targeted towards liver, cervix, breast, and oesophagus cancer and furthering research on the reason for the high incidence of liver cancer.

Spectrum and Trends of Cancer in Southwestern Uganda from 2012 to 2021

Background

Cancer has become a global public health challenge and the number one cause of premature death. The incidence is increasing globally and more rapidly in low and middle-income countries despite the gross under-registration and challenges in diagnosis. Data about Uganda is mostly from the Mulago cancer registry which may not entirely represent other parts of the country. This study presents the trends of cancer incidence for Southwestern Uganda in a decade (2012 to 2021).

Method

We did a review of records at the Mbarara University histopathology laboratory and Mbarara Regional Referral Oncology Clinics from January 2012 to December 2021 for cancer diagnoses. Records missing patients' age or sex were excluded.

Results

We registered 4197 incident cancers, 51.8% were among males, and 10.7% were among children (0-18 years). The median age was 52 years and the interquartile range was 35-67 years. The most commonly diagnosed cancers were prostate cancer (13.46%), ocular surface carcinoma (11.03%), cervical cancer (10.55%), head and neck cancers (7.31%), esophageal carcinoma (6.79%), lymphomas (5.36%), retinoblastoma (5.31%), and breast cancer (5.00%) in descending order. Retinoblastoma was the most common cancer among children.

Conclusion

The cancer pattern in Southwestern Uganda has changed and the numbers diagnosed each year are increasing. Prostate cancer is the most common diagnosed cancer overall, and the commonest cancer among men. Among women, cervical cancer is the most common cancer, followed by ocular surface carcinoma, and breast cancer. Retinoblastoma is the most common cancer among children. The trend of Kaposi sarcoma has plummeted together with ocular surface carcinomas. The cancer trends seem to be influenced by the presence of diagnostic and treatment expertise in the region.

Anticancer activities of natural antimicrobial peptides from animals

Cancer is the most common cause of human death worldwide, posing a serious threat to human health and having a negative impact on the economy. In the past few decades, significant progress has been made in anticancer therapies, but traditional anticancer therapies, including radiation therapy, surgery, chemotherapy, molecular targeted therapy, immunotherapy and antibody-drug conjugates (ADCs), have serious side effects, low specificity, and the emergence of drug resistance. Therefore, there is an urgent need to develop new treatment methods to improve efficacy and reduce side effects. Antimicrobial peptides (AMPs) exist in the innate immune system of various organisms. As the most promising alternatives to traditional drugs for treating cancers, some AMPs also have been proven to possess anticancer activities, which are defined as anticancer peptides (ACPs). These peptides have the advantages of being able to specifically target cancer cells and have less toxicity to normal tissues. More and more studies have found that marine and terrestrial animals contain a large amount of ACPs. In this article, we introduced the animal derived AMPs with anti-cancer activity, and summarized the types of tumor cells inhibited by ACPs, the mechanisms by which they exert anti-tumor effects and clinical applications of ACPs.

Medicinal plants used in the management of cancers by residents in the Elgon Sub-Region, Uganda

BACKGROUND

In Uganda, medicinal plants have been utilized to treat a variety of ailments, including cancer. However, there is little information available about the medicinal plants used to treat cancer in the Elgon subregion. As a result, the current study documented the plant species used in the management of cancer in the Elgon sub-region.

METHODS

Data were gathered by observation, self-administered questionnaires, interview guides, and guided field trips. Analyzing descriptive statistics and creating graphs were done using SPSS (version 21.0) and GraphPad Prism® version 9.0.0, respectively. Well-established formulae were used to calculate quantitative indices. The narratives were interpreted using major theories and hypotheses in ethnobotany.

RESULTS

A total of 50 plant species from 36 families were documented, and herbal knowledge was mainly acquired through inheritance. Fabaceae and Asteraceae comprised more plant species used in herbal preparation. Most plants were collected from forest reserves (63%); herbal therapies were made from herbs (45%); and leaves were primarily decocted (43%). The most frequently used plants were Tylosema fassoglensis, Hydnora abyssinica, Azidarachata indica, Prunus Africana, Kigelia africana, Syzygium cumini, Hydnora africana, Rhoicissus tridentata, Albizia coriaria, and Plectranthus cuanneus. All the most commonly used plants exhibited a high preference ranking (60-86%) and reliability level (74.1-93.9%). Generally, the ICF for all the cancers treated by medicinal plants was close to 1 (0.84-0.95).

CONCLUSIONS

The ten most commonly utilized plants were favored, dependable, and most important for treating all known cancers. As a result, more investigation is required to determine their phytochemistry, toxicity, and effectiveness in both in vivo and in vitro studies. This could be a cornerstone for the pharmaceutical sector to develop new anticancer medications.

Treatment compliance among adult cervical cancer patients receiving care at Uganda cancer institute, Uganda: a retrospective data review

BACKGROUND

Cervical cancer is one of the most common cancers and a major cause of morbidity among women globally. Chemoradiation therapy is the preferred standard treatment for women with stage IB to IVA. However, the benefits of this treatment can only be achieved if patients adhere to the treatment guidelines. In this study, the proportion of compliance or adherence to chemo-radiation treatment among cervical cancer patients at Uganda Cancer Institute (UCI) was determined.

METHODS

This was a cross-sectional study that reviewed data retrospectively for 196 cervical cancer patients who were prescribed to chemo-radiation therapy at UCI between November 2020 to May 2021, having been diagnosed with disease stage IB to IVA. Patient data and information on treatment uptake was obtained by review of the patient's medical records. Treatment compliance was determined by calculating the number of participants who completed the prescribed treatment (definitive pelvic concurrent chemoradiation to 50 Gy external beam radiotherapy with weekly concurrent cisplatin followed by intracavitary brachytherapy 24 Gy in 3 fractions at 8 Gy once a week over 3 weeks). Associations between patient factors and treatment adherence were determined using logistic regression analysis. In all statistical tests, a P- value of < 0.05 was considered as significant.

RESULTS

The proportion of patients who were administered with external beam radiation (EBRT), chemotherapy and brachytherapy were 82.6%, 52.04% and 66.2% respectively. However, only 23 of 196 patients (11.7%) were found to have adhered to the treatment plan by completion of all definitive pelvic concurrent chemoradiation to 50 Gy external beam radiotherapy (5 weeks) with weekly concurrent cisplatin (5 cycles) followed by intracavitary brachytherapy 24 Gy in 3 fractions at 8 Gy once a week over 3 weeks (3 sessions). There were no significant associations between patient factors and treatment adherence after multivariable analysis.

CONCLUSIONS

Treatment compliance was found in only 12% of the cohort participants. No association of patient factors with treatment compliance was found. Additional studies on treatment adherence with larger sample sizes are needed to confirm the associations.

Prevalence, trends and distribution of lifestyle cancer risk factors in Uganda: a 20-year systematic review

BACKGROUND

Cancer is becoming an important public health problem in Uganda. Cancer control requires surveillance of lifestyle risk factors to inform targeted interventions. However, only one national Non-Communicable Disease (NCD) risk factor survey has been conducted in Uganda. This review assessed the prevalence, trends and distribution of lifestyle risk factors in Uganda.

METHODS

The review identified studies up to January 2019 by searching Medline, Embase, CINAL and Cochrane databases. Further literature was identified from relevant websites and journals; scanning reference lists of relevant articles; and citation searching using Google Scholar. To be eligible, studies had to have been conducted in Uganda, and report prevalence estimates for at least one lifestyle cancer risk factor. Narrative and systematic synthesis was used to analyse the data.

RESULTS

Twenty-four studies were included in the review. Overall, unhealthy diet (88%) was the most prevalent lifestyle risk factor for both males and females. This was followed by harmful use of alcohol (range of 14.3% to 26%) for men, and being overweight (range of 9% to 24%) for women. Tobacco use (range of 0.8% to 10.1%) and physical inactivity (range of 3.7% to 4.9%) were shown to be relatively less prevalent in Uganda. Tobacco use and harmful use of alcohol were more common in males and more prevalent in Northern region, while being overweight (BMI > 25 kg/m2) and physical inactivity were more common in females and more prevalent in Central region. Tobacco use was more prevalent among the rural populations compared to urban, while physical inactivity and being overweight were more common in urban than in rural settings. Tobacco use has decreased overtime, while being overweight increased in all regions and for both sexes.

CONCLUSION

There is limited data about lifestyle risk factors in Uganda. Apart from tobacco use, other lifestyle risk factors seem to be increasing and there is variation in the prevalence of lifestyle risk factors among the different populations in Uganda. Prevention of lifestyle cancer risk factors requires targeted interventions and a multi-sectoral approach. Most importantly, improving the availability, measurement and comparability of cancer risk factor data should be a top priority for future research in Uganda and other low-resource settings.

Malignancy and viral infections in Sub-Saharan Africa: A review

The burden of malignancy related to viral infection is increasing in Sub-Saharan Africa (SSA). In 2018, approximately 2 million new cancer cases worldwide were attributable to infection. Prevention or treatment of these infections could reduce cancer cases by 23% in less developed regions and about 7% in developed regions. Contemporaneous increases in longevity and changes in lifestyle have contributed to the cancer burden in SSA. African hospitals are reporting more cases of cancer related to infection (e.g., cervical cancer in women and stomach and liver cancer in men). SSA populations also have elevated underlying prevalence of viral infections compared to other regions. Of 10 infectious agents identified as carcinogenic by the International Agency for Research on Cancer, six are viruses: hepatitis B and C viruses (HBV and HCV, respectively), Epstein-Barr virus (EBV), high-risk types of human papillomavirus (HPV), Human T-cell lymphotropic virus type 1 (HTLV-1), and Kaposi's sarcoma herpesvirus (KSHV, also known as human herpesvirus type 8, HHV-8). Human immunodeficiency virus type 1 (HIV) also facilitates oncogenesis. EBV is associated with lymphomas and nasopharyngeal carcinoma; HBV and HCV are associated with hepatocellular carcinoma; KSHV causes Kaposi's sarcoma; HTLV-1 causes T-cell leukemia and lymphoma; HPV causes carcinoma of the oropharynx and anogenital squamous cell cancer. HIV-1, for which SSA has the greatest global burden, has been linked to increasing risk of malignancy through immunologic dysregulation and clonal hematopoiesis. Public health approaches to prevent infection, such as vaccination, safer injection techniques, screening of blood products, antimicrobial treatments and safer sexual practices could reduce the burden of cancer in Africa. In SSA, inequalities in access to cancer screening and treatment are exacerbated by the perception of cancer as taboo. National level cancer registries, new screening strategies for detection of viral infection and public health messaging should be prioritized in SSA's battle against malignancy. In this review, we discuss the impact of carcinogenic viruses in SSA with a focus on regional epidemiology.

Uptake of prostate cancer screening and associated factors among men aged 50 years and above in Lira city, Uganda: a cross-sectional study

BACKGROUND

Prostate cancer is the most common cancer among men globally, with over 1.2 million cases reported in 2018. About 90% of men with prostate cancer are diagnosed when the disease is in an advanced stage. We assessed the factors associated with the uptake of prostate cancer screening among men aged ≥ 50 years in Lira city.

METHODS

This was a cross-sectional study involving 400 men aged ≥ 50 years in Lira city who were sampled using multistage cluster sampling method. Uptake of prostate cancer screening was defined as the proportion of men who received prostate cancer screening in the past one year prior to the interview. Multivariable logistic regression analyses were performed to assess the factors associated with the uptake of prostate cancer screening. Data were analyzed using Stata version 14.0 statistical software.

RESULTS

Of the 400 participants, only 18.5% (74/400) had ever been screened for prostate cancer. However, 70.7% (283/400) were willing to screen/rescreen if provided with the opportunity. Majority of the study participants, 70.5% (282/400) had ever heard about prostate cancer, mostly from a health worker (40.8% (115/282)). Less than half of the participants had high knowledge of prostate cancer. The factors that were significantly associated with prostate cancer screening were age ≥ 70 years, Adjusted Odds Ratio (AOR) 3.29: 95% Confidence Interval (CI): 1.20-9.00) and having a family history of prostate cancer, AOR 2.48 (95%CI: 1.32-4.65).

CONCLUSION

There was low uptake of prostate cancer screening among men in Lira City, but majority of men were willing to screen. We encourage policymakers in Uganda to ensure prostate cancer screening services are readily available and accessible by men so as to improve on early identification and treatment of the disease.

Ethnobotanical Survey of Medicinal Plants Used in Breast Cancer Treatment by Traditional Health Practitioners in Central Uganda

Purpose

The study aimed to document the existing knowledge and practices related to breast cancer recognition and treatment using medicinal plants by traditional health practitioners in Central Uganda.

Methods

This cross-sectional exploratory survey, conducted between February and August 2020, applied a mixed methods research approach. A semi-structured questionnaire was administered to 119 traditional health practitioners (THPs) in Kampala, Wakiso and Mukono. Content analysis of qualitative data was done. Quantitative ethnobotanical survey indices, namely user reports (Nur), percentage of respondents with knowledge (PRK), informant consensus factor (Fic), fidelity level (FL), preference ranks (PR) and direct matrix ranking (DMR) were determined.

Results

Most THPs recognized breast cancer by breast swelling (n=74, 62.2%) and breast pain (n=29, 24.4%). They cited 30 plants from 30 genera in 23 families (Fic 0.75 on breast cancer). Asteraceae, Apocynaceae, Euphorbiaceae, Fabaceae, Lamiaceae and Rutaceae were the predominant families. The ten most cited plants were Annona muricata L. (Nur=24), Rhoicissus tridentata (L.f.) Wild & R.B.Drumm (Nur =19), Erythrococca bongensis Pax (Nur=11), Ficus sp. (Nur=10), Cannabis sativa L. (Nur=8), Ipomoea wightii (Wall.) Choisy (Nur=7), Erythrina abyssinica DC. (Nur=5), Leucas martinicensis (Jacq.) R.Br. (Nur=4), Abelmoschus esculentus (L.) Moench (Nur=4) and Zanthoxylum chalybeum Engl. (Nur=3). Annona muricata L. was highly preferred by THPs (PR 1), Ficus sp. had highest fidelity level (FL=77%) and Zanthoxylum chalybeum Engl. ranked as the highest multipurpose plant (DMR 1). Herbs (n=14, 47%) were the most commonly used life forms besides trees (n=11, 37%) and shrubs (n=5, 16%). THPs mostly used leaves (46%), prepared decoctions (82%) and applied residues on the breast.

Conclusion

THPs in Central Uganda recognized breast cancer by symptoms. Medicinal plants applied in its folk treatment have been documented and the claims of cure by THPs merit further investigation.