Final report of Breast Cancer Care Registry at the Kenyatta National Hospital, Nairobi

Retraction

The abstract by Othieno-Abinya et al entitled, “Final report of Breast Cancer Care Registry at the Kenyatta National Hospital, Nairobi,” published in the Journal of Clinical Oncology 39, no. 15 suppl (May 20, 2021) e12552-e12552, was retracted by the authors as it did not meet the study sponsor's prior scientific verification and approval.

This abstract was retracted on June 29, 2021.

e12552

Background: Breast cancer is the commonest cancer among women in Kenya. We wanted to examine breast cancer seen at the Kenyatta National Hospital in relation to local factors that influence prognosis and quality of life, local variations in treatment and outcomes; describe the clinical care patterns, monitor the safety of the therapies provided to patients in a routine clinic setting. Methods: A prospective study of patients with breast cancer between 11.08.2011 and 11.09.2014 inclusive. Data included demographic details, diagnostic and staging procedures, stage, treatment and outcome. Estimates of relative survival used period approach. hi-square tests and analysis of variance (ANOVA) were utilised to make comparisons. Cross sectional data are presented in proportions, means and medians. Results: Four hundred patients were included, age range 20 to 83, median 49 years. Out 312, 65 (20.8%) were obese. Eight of 397 (2%) were smokers and 22(5.5%) took alcohol. Early disease was diagnosed in 269 out of 354 (76%) and metastatic disease in 85(24%). Breast lump presented in 388 out of 400 (97%), breast pain in 104 out of 388 (26.8%). Fifteen of 394 (3.8%) had second breast cancer, 4 (1%) had had ovarian cancer and 9 (2.3%) had had had other malignancy. History of breast cancer in first and second-degree relative was elicited in 41 out of 394 (10.4%). Ductal carcinoma NOS was commonest in 343 (88.2%), lobular carcinoma in 9(2.5%). Cases by T stage were T1 - 25(7.2%), T2 -130(37.4%), T3 - 96(27.6%), T4 - 87(25%). Of 322 cases, 187(58.1%) were ER positive and 175 (54.4%) PR positive. Her2 positive cases were 78 out of 322 (24.2%). Neo adjuvant and adjuvant chemotherapy mainly consisted of combinations of cyclophosphamide and doxorubicin [AC] +/- a taxane[AC→T] ( mainly by medical oncologists) or AC+ 5-FU [CAF] (mainly by clinical oncologists). Of 305 cases 272 (89.2%) completed adjuvant therapy, 8(2.6%) died during treatment. Median overall survival was 57.1 months (95% CI; 55.6 to 59.5 months). For metastatic disease, median PFS was worse for patients < 40 years. Conclusions: Pathology and biology mirrored global situation, over 75% of patients had non metastatic disease. A significant proportion of early disease patients did not complete treatment.

Breast cancer as seen at the Nairobi Hospital

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Background: Breast cancer is the most common cancer and the second leading cause of death among women globally. The Nairobi Hospital has a comprehensive cancer centre, with various practitioners treating cancer patients individually. To document breast cancer diagnosis, treatment and outcome at the Nairobi Hospital. Methods: A retrospective cohort study involving records of breast cancer patients between Jan 2014 and Dec 2019 inclusive. Details included, demographic details, comorbidities, pathology, stage, treatment and outcome. The study was approved by the hospital’s Ethics and Research Committee. Results: 591 patients; 580 (98.1%) women and 11(1.9%) men. Age group 41-60 years had 330 patients(57.2%). Mean parity was 3. Fifteen (2.5%) were smokers, 73 (12.4%) took alcohol, 159 (12.4%) used hormonal contraceptives, 4(0.7%) had been exposed to iatrogenic radiation. Family history of cancer was present in 112 (19%), 25 (4.2%) had personal history of cancer, breast cancer in 8 (1.4%). Diagnosis was by core needle biopsy in 301 (50.9%), excision biopsy in 238 (40.3%), and fine needle aspiration cytology in 52 (8.8%). Pathology was invasive ductal carcinoma in 502(84.9%), invasive lobular in 12(2%). Oestrogen receptors were expressed in 329 (55.7%), progesterone receptors in 264 (44.7%), and Her2 in 129(21.8%). Triple negative were 86( 18%). T1 tumors were 84 (14.2%), T2 were 197 (33.3%), T3 were 126 (15.9%,) and T4 in 94 (15.9%), 126 (21.3%) had distant metastases. Neoadjuvant combination of doxorubicin and cyclophosphamide (AC) was in 109(18.4%) of patients, a taxane following AC (AC-T) in 79 (13.4), and 5-FU with doxorubicin and cyclophosphamide (CAF) in 105 (17.8%). Adjuvant AC was administered to 59 (10%), AC-T to 65 (11%), and CAF to 105 (17.8%), adjuvant tamoxifen to 160 (27.1%). Overall 93 patients (15.7%) received trastuzumab. Adjuvant radiotherapy was completed in 367 (62.1%). At a median follow-up of 36 months, patients 33 (5.6%) were recorded dead. The younger patients had worse survival. Conclusions: Ductal carcinoma constituted 85% of cases and metastatic disease was in 21.3 %. Triple negative cancer were 18%. Younger patients had higher risk of early death.

Abstract PO-031: Fostering a multisectoral and multidisciplinary approach in the fight against cancer: The Blueprint for Success program in Meru County, Kenya

Introduction Blueprint for Success initiative utilizes a multi-institutional and multidisciplinary approach that brings together team of Kenyan oncologists, researchers, palliative care experts, community health facilitators to holistically address the burden of cancer as well as address barriers across the entire cancer continuum of care, including awareness, advocacy, screening, diagnostics, treatment, and optimum aftercare to improve care outcomes. Methods Blueprint for Success initiative brings together multidisciplinary industries, governments, Non- Governmental Organisations (NGOs), healthcare professionals and communities to collaboratively identify and develop roadmaps to bridge access gaps for patients living with cancer in Meru County. Primary Health Care (PHC) approach is used and programmes are designed focusing on screening, training of community health workers (CHWs), creating awareness in the community, education of primary care physicians, establishing palliative care services and strengthening the cancer registries. Results The strategic partnerships formed through the Blueprint for Success initiative has enabled us to not only implement global best practice but also ensure that our initiatives are providing high-quality, culturally competent patient support for the longer term. We have established an oncology Centre, trained 100 Health Care Workers and 500 Community Health Volunteers (CHV’s), established community health reporting tool – Mobile Jamii Afya Link (M-Jali), established a Cancer Registry, strengthened palliative care services as well as improve access to cancer screening and promote public awareness of cancer with an emphasis on breast, cervical and prostate cancers. Conclusion The program continues to work closely with local communities, governments and healthcare workers and if successful will be replicated in other parts of the country and is expected to dramatically reduce the burden of cancer in Kenya and Sub-Saharan region.

Citation Format: Denis Munene, Chite Asirwa, Zipporah Ali, Beatrice Okumu, Ann Korir, Alice Musibi, Helena Musau, Edwin Odoyo. Fostering a multisectoral and multidisciplinary approach in the fight against cancer: The Blueprint for Success program in Meru County, Kenya [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-031.

Randomized control trial of advanced cancer patients at a private hospital in Kenya and the impact of dignity therapy on quality of life

Background

Palliative care is a modality of treatment that addresses physical, psychological and spiritual symptoms. Dignity therapy, a form of psychotherapy, was developed by Professor Harvey Chochinov, MD in 2005.The aim of the study was to assess the effect of one session of dignity therapy on quality of life in advanced cancer patients.

Methods

This was a randomized control trial of 144 patients (72 in each arm) randomized into group 1 (intervention arm) and group 2 (control arm). Baseline ESAS scores were determined in both arms following which group 1 received Dignity therapy while Group 2 received usual care only. Data collected was presented as printed (Legacy) documents to group 1 participants. These documents were a summary of previous discussions held. Post intervention ESAS scores were obtained in both groups after 6 weeks. Analysis was based on the intention to treat principle and descriptive statistics computed. The main outcome was symptom distress scores on the ESAS (summated out of 100 and symptom specific scores out of 10). The student T-test was used to test for difference in ESAS scores at follow up and graphs were computed for common cancers and comorbidities.

Results

Of the 144 (72 patients in each arm) patients randomized, 70%were female while 30% were male with a mean age of 50 years. At 6 weeks, 11 patients were lost to follow up, seven died and 126 completed the study. The commonly encountered cancers were gastrointestinal cancers (43%, p = 0.29), breast cancer (27.27% p = 0.71) and gynaecologic cancers (23% p = 0.35). Majority of the patients i.e. 64.3% had no comorbidities.

The primary analysis results showed higher scores for the DT group (change in mean = 1.57) compared to the UC group (change in mean = − 0.74) yielding a non-statistically significant difference in change scores of 1.44 (p = 0.670; 95% CI − 5.20 to 8.06). After adjusting for baseline scores, the mean (summated) symptom distress score was not significant (GLM p = 0.78). Dignity therapy group showed a trend towards statistical improvement in anxiety (p = 0.059). The largest effects seen were in improvement of appetite, lower anxiety and improved wellbeing (Cohen effect size 0.3, 0.5 and 0.31 respectively).

Conclusion

Dignity therapy showed no statistical improvement in overall quality of life. Symptom improvement was seen in anxiety and this was a trend towards statistical significance (p = 0.059).

Trial registration

Trial registration number PACTR201604001447244 retrospectively registered with Pan African Clinical trials on 28th January 2016.

Afro Middle East Asian symposium on cancer cooperation

This manuscript captures the discussion and recommendations that came out of a special Afro Asian symposium involving 13 countries. Unmet needs and cost-effective solutions with special emphasis on training form the backbone of practical next steps.

Geographical variation in the response of visceral leishmaniasis to paromomycin in East Africa: a multicentre, open-label, randomized trial

Background

Visceral leishmaniasis (VL) is a major health problem in developing countries. The untreated disease is fatal, available treatment is expensive and often toxic, and drug resistance is increasing. Improved treatment options are needed. Paromomycin was shown to be an efficacious first-line treatment with low toxicity in India.

Methods

This was a 3-arm multicentre, open-label, randomized, controlled clinical trial to compare three treatment regimens for VL in East Africa: paromomycin sulphate (PM) at 15 mg/kg/day for 21 days versus sodium stibogluconate (SSG) at 20 mg/kg/day for 30 days; and the combination of both dose regimens for 17 days. The primary efficacy endpoint was cure based on parasite-free tissue aspirates taken 6 months after treatment.

Findings

Overall, 135 patients per arm were enrolled at five centres in Sudan (2 sites), Kenya (1) and Ethiopia (2), when the PM arm had to be discontinued due to poor efficacy. The trial has continued with the higher dose of PM as well as the combination of PM and SSG arms. These results will be reported later. Baseline patient characteristics were similar among treatment arms. The overall cure with PM was significantly inferior to that with SSG (63.8% versus 92.2%; difference 28.5%, 95%CI 18.8% to 38.8%, p<0.001). The efficacy of PM varied among centres and was significantly lower in Sudan (14.3% and 46.7%) than in Kenya (80.0%) and Ethiopia (75.0% and 96.6%). No major safety issues with PM were identified.

Conclusion

The efficacy of PM at 15 mg/kg/day for 21 days was inadequate, particularly in Sudan. The efficacy of higher doses and the combination treatment warrant further studies.

Visceral leishmaniasis (VL) is a fatal parasitic disease with 500,000 new cases each year according to WHO estimates. New and better treatment options are urgently needed in disease endemic areas due to the long courses, toxicity and development of resistance to current treatments. Recently, the antibiotic paromomycin was tested and registered in India to treat this disease. The current study describes a clinical trial to test the effectiveness of injectable paromomycin, either alone or in combination with the standard drug sodium stibogluconate in three East African countries—Sudan, Kenya and Ethiopia. The study showed that at the same paromomycin dose that was successfully used and registered in India, a far poorer outcome was obtained, particularly in Sudan, suggesting that there are either differences in the patients ability to respond to the drug or in the susceptibility of parasites in East Africa compared with those in India. However, no major safety concerns were noted with the treatment. Further research was initiated to see if a higher dose of paromomycin would perform better, especially in Sudan. The results of this and the performance of the combination arm will be reported later. Our study highlights the importance of considering geographical differences to treatment responses.

Non-Hodgkin's lymphomas at Kenyatta the National Hospital Nairobi in the 1990's

OBJECTIVES

To determine the clinico-pathologic and prognostic factors, treatment and outcome of non-Hodgkin's lymphomas as seen at the Kenyatta National Hospital in the 1990s.

DESIGN

Retrospective study of patients with non-Hodgkin's Iymphoma.

SETTING

Kenyatta National Hospital, Nairobi, Kenya, between January 1990 and January 2000 inclusive.

SUBJECTS

Patients aged 13 years and above, with non-Hodgkin's Iymphomas.

RESULTS

Case records were available for 207 patients, 146 males and 60 females, with one having had gender not clarified. Fifty two per cent of the patients were aged less than 40 years and 18.4% over 60 years. Forty one per cent were not properly classified histologically, seventy patients out of 190 evaluable (36.8%) had stages IVA and IVB disease at diagnosis. Twenty five out of 77(32.5%) tested positive for HIV infection, none of them being of the indolent variety. Up to 57.1% of cases of Burkitt's lymphoma tested positive for HIV infection. Cyclophosphamide, doxorubicin, vincristine and prednisone, (CHOP) chemotherapy was given to 68.7% of the patients with complete remission rates of 55.6% for those who got a minimum of six courses of chemotherapy. Only 15.3% of 105 patients evaluable were followed up for 36 months and above, the majority of patients having been lost to follow-up. Poor performance status at diagnosis correlated with shorter follow-up durations (p<0.05).

CONCLUSION

A good percentage of the patients were not comprehensively characterized pathologically. Standard treatment was offered to the majority of patients, and those who could afford to purchase the medicines stood good chance of achieving complete remission. Poor performance status at diagnosis correlated with shorter follow-up durations and early stage disease correlated with longer follow-up durations. Overall, the outlook for NHLs treated at KNH in the 1990s appears to have improved tremendously.