Palliative care and catastrophic costs in Malawi after a diagnosis of advanced cancer: a prospective cohort study

BACKGROUND

Inclusive universal health coverage requires access to quality health care without financial barriers. Receipt of palliative care after advanced cancer diagnosis might reduce household poverty, but evidence from low-income and middle-income settings is sparse.

METHODS

In this prospective study, the primary objective was to investigate total household costs of cancer-related health care after a diagnosis of advanced cancer, with and without the receipt of palliative care. Households comprising patients and their unpaid family caregiver were recruited into a cohort study at Queen Elizabeth Central Hospital in Malawi, between Jan 16 and July 31, 2019. Costs of cancer-related health-care use (including palliative care) and health-related quality-of-life were recorded over 6 months. Regression analysis explored associations between receipt of palliative care and total household costs on health care as a proportion of household income. Catastrophic costs, defined as 20% or more of total household income, sale of assets and loans taken out (dissaving), and their association with palliative care were computed.

FINDINGS

We recruited 150 households. At 6 months, data from 89 (59%) of 150 households were available, comprising 89 patients (median age 50 years, 79% female) and 64 caregivers (median age 40 years, 73% female). Patients in 55 (37%) of the 150 households died and six (4%) were lost to follow-up. 19 (21%) of 89 households received palliative care. Catastrophic costs were experienced by nine (47%) of 19 households who received palliative care versus 48 (69%) of 70 households who did not (relative risk 0·69, 95% CI 0·42 to 1·14, p=0·109). Palliative care was associated with substantially reduced dissaving (median US$11, IQR 0 to 30 vs $34, 14 to 75; p=0·005). The mean difference in total household costs on cancer-related health care with receipt of palliative care was -36% (95% CI -94 to 594; p=0·707).

INTERPRETATION

Vulnerable households in low-income countries are subject to catastrophic health-related costs following a diagnosis of advanced cancer. Palliative care might result in reduced dissaving in these households. Further consideration of the economic benefits of palliative care is justified.

FUNDING

Wellcome Trust; National Institute for Health Research; and EMMS International.

Incidence of HIV-positive admission and inpatient mortality in Malawi (2012-2019)

OBJECTIVE

To investigate trends in population incidence of HIV-positive hospital admission and risk of in-hospital death among adults living with HIV between 2012 and 2019 in Blantyre, Malawi.

DESIGN

Population cohort study using an existing electronic health information system ('SPINE') at Queen Elizabeth Central Hospital and Blantyre census data.

METHODS

We used multiple imputation and negative binomial regression to estimate population age-specific and sex-specific admission rates over time. We used a log-binomial model to investigate trends in risk of in-hospital death.

RESULTS

Of 32 814 adult medical admissions during Q4 2012--Q3 2019, HIV status was recorded for 75.6%. HIV-positive admissions decreased substantially between 2012 and 2019. After imputation for missing data, HIV-positive admissions were highest in Q3 2013 (173 per 100 000 adult Blantyre residents) and lowest in Q3 2019 (53 per 100 000 residents). An estimated 10 818 fewer than expected people with HIV (PWH) [95% confidence interval (CI) 10 068-11 568] were admitted during 2012-2019 compared with the counterfactual situation where admission rates stayed the same throughout this period. Absolute reductions were greatest for women aged 25-34 years (2264 fewer HIV-positive admissions, 95% CI 2002-2526). In-hospital mortality for PWH was 23.5%, with no significant change over time in any age-sex group, and no association with antiretroviral therapy (ART) use at admission.

CONCLUSION

Rates of admission for adult PWH decreased substantially, likely because of large increases in community provision of HIV diagnosis, treatment and care. However, HIV-positive in-hospital deaths remain unacceptably high, despite improvements in ART coverage. A concerted research and implementation agenda is urgently needed to reduce inpatient deaths among PWH.

Establishment of a high-dependency unit in Malawi

Adults admitted to hospital with critical illness are vulnerable and at high risk of morbidity and mortality, especially in sub-Saharan African settings where resources are severely limited. As life expectancy increases, patient demographics and healthcare needs are increasingly complex and require integrated approaches. Patient outcomes could be improved by increased critical care provision that standardises healthcare delivery, provides specialist staff and enhanced patient monitoring and facilitates some treatment modalities for organ support. In Malawi, we established a new high-dependency unit within Queen Elizabeth Central Hospital, a tertiary referral centre serving the country's Southern region. This unit was designed in partnership with managers, clinicians, nurses and patients to address their needs. In this practice piece, we describe a participatory approach to design and implement a sustainable high-dependency unit for a low-income sub-Saharan African setting. This included: prospective agreement on remit, alignment with existing services, refurbishment of a dedicated physical space, recruitment and training of specialist nurses, development of context-sensitive clinical standard operating procedures, purchase of appropriate and durable equipment and creation of digital clinical information systems. As the global COVID-19 pandemic unfolded, we accelerated unit opening in anticipation of increased clinical requirement and describe how the high-dependency unit responded to this demand.

Trends in cervical cancer incidence in sub-Saharan Africa

BACKGROUND

Cervical cancer is the second most common cancer and the leading cause of cancer death in women in sub-Saharan Africa (SSA).

METHODS

Trends in the incidence of cervical cancer are examined for a period of 10-25 years in 10 population-based cancer registries across eight SSA countries (Gambia, Kenya, Malawi, Mauritius, Seychelles, South Africa, Uganda and Zimbabwe). A total of 21,990 cases of cervical cancer were included in the analyses.

RESULTS

Incidence rates had increased in all registries for some or all of the periods studied, except for Mauritius with a constant annual 2.5% decline. Eastern Cape and Blantyre (Malawi) registries showed significant increases over time, with the most rapid being in Blantyre (7.9% annually). In Kampala (Uganda), a significant increase was noted (2.2%) until 2006, followed by a non-significant decline. In Eldoret, a decrease (1998-2002) was followed by a significant increase (9.5%) from 2002 to 2016.

CONCLUSION

Overall, cervical cancer incidence has been increasing in SSA. The current high-level advocacy to reduce the burden of cervical cancer in SSA needs to be translated into support for prevention (vaccination against human papillomavirus and population-wide screening), with careful monitoring of results through population-based registries.

Assessing and Addressing the Need for Cancer Patient Education in a Resource-Limited Setting in Haiti

PURPOSE

Misinformation and lack of information about cancer and its treatment pose significant challenges to delivering cancer care in resource-limited settings and may undermine patient engagement in care. We aimed to investigate patients' knowledge and attitudes toward cancer and its treatment and to adapt, implement, and evaluate a low-literacy cancer patient education booklet at the Hôpital Universitaire de Mirebalais (HUM) in rural Haiti.

MATERIALS AND METHODS

A low-literacy cancer patient education booklet was adapted into Haitian Creole in collaboration with clinicians at HUM. Patients were recruited for structured interviews (n = 20) and two focus groups (n = 13) designed to explore patients' attitudes toward cancer and its treatment and to assess whether the booklet increased patients' knowledge via an investigator-designed knowledge test.

RESULTS

Participants reported a subjective lack of knowledge about cancer and its treatments and described views of cancer as deadly or incurable. Patients of varying education levels valued receiving written materials that set expectations about cancer treatment and expressed a desire to share the booklet with caregivers and others in their community. Participants across all levels of education significantly increased their performance on a knowledge test after counseling using the booklet (p < .001).

CONCLUSION

We found that an educational booklet about cancer developed in collaboration with local providers was well received by patients with variable literacy levels and improved their knowledge of cancer and its treatment in a resource-limited setting. Such educational materials have the potential to serve as tools to engage patients with cancer and their families in care.

IMPLICATIONS FOR PRACTICE

Misinformation and lack of information pose significant challenges to delivering cancer care in resource-limited settings; however, there are often no culturally and literacy appropriate tools available to aid in patient education. This article shows that written educational materials are well received by patients of variable literacy levels and can be effective tools for increasing patients' knowledge of cancer and its treatment in a limited-resource setting. Furthermore, the authors have made their educational booklet, Cancer and You, freely available online and welcome the opportunity to connect with readers of The Oncologist interested in implementing this educational booklet in clinical care.

Evaluating the use of pathology in improving diagnosis in rural Malawi

Introduction

Limited data exists on histologically confirmed cancers and tuberculosis in rural Malawi, despite the high burden of both conditions. One of the main reasons for the limited data is the lack of access to pathology services for diagnosis. We reviewed histopathology results of patients in Neno District, one of the poorest rural districts in Malawi, from May 2011 to July 2017, with an emphasis on cancers and tuberculosis.

Methods

This is a retrospective descriptive study reviewing pathology results of samples collected at Neno health facilities and processed at Kamiza Pathology Laboratory. Data was entered into Microsoft Excel and cleaned and analysed using Stata 14.

Results

A total of 532 specimens were collected, of which 87% (465) were tissue biopsies (incision or core biopsies), and 13% (67) were cytology samples. Of all specimens, 7% (n=40) of the samples had non-diagnostic results. Among the results that were diagnostic (n=492), 37% (183) were malignancies, 33% (112) were infections and inflammatory conditions other than tuberculosis, 20% (97) were benign tumours, 7% (34) were tuberculosis, 4% (21) were pre-malignant lesions, 5% (23) were normal samples, and 4% (22) were other miscellaneous conditions. Among the malignancies (n=183), 62% (114) were from females and 38% (69) from males. Among females, almost half of the cancers were cervical (43%, n= 49), followed by Kaposi sarcoma (14%, n=16), skin cancers (9%, n=10), and breast cancer (8%, n=9). In males, Kaposi sarcoma was the most common cancer (35%, n=24), followed by skin cancers (17%, n=12). About 75% (n=137) of the cancers occurred in persons aged 15 to 60 years.

Conclusion

Histopathology services at a rural hospital in Malawi provides useful diagnostic information on malignancies, tuberculosis and other diagnoses, and can inform management at the district level.

Five-year single-centre experience of carcinoma of the oesophagus from Blantyre, Malawi

Background

Oesophageal squamous cell carcinoma (OSCC) is increasing worldwide and has an exceptionally high prevalence in certain distinct geographical locations such as the African oesophageal SCC corridor. Despite this, there is a paucity of evidence to characterise the disease particularly in the Malawian context.

Method

We retrospectively audited our endoscopy database over 5 years, including for patient demographics, endoscopy findings, therapeutic intervention and recommendations for treatment.

Results

1586 patients with oesophageal cancer were identified from a total of 5882 endoscopy records from 2013 to 2017. Our cohort showed a larger proportion of oesophageal cancers found higher in the oesophagus compared with other African studies and a female preponderance in this upper-oesophagus disease subset though a male preponderance overall. 39% of patients with oesophageal cancer underwent bougie dilatation and 11% underwent palliative stent placement, which likely reflects local availability of resources.

Conclusion

This study validates the observation that OSCC predominates in sub-Saharan Africa in Malawi over other forms of oesophageal carcinoma, though our cohort appears to have subtly distinct demographics and disease-specific data. This highlights the need to prioritise preventative and therapeutic strategies for OSCC in this and similar settings.

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.

Three-year cancer incidence in Blantyre, Malawi (2008-2010)

In this paper, we present incidence rates of different cancers calculated for the population of Blantyre, Malawi for the period 2008-2010, using data from the Malawi Cancer Registry. Active methods were used for case finding, with standard checks for accuracy and validity performed in CanReg 4. During this 3-year period, a total of 3,711 cases were registered comprising 1,643 men (an estimated age-standardized incidence rate (ASR) of 169.8 per 100,000) and 2,068 women (ASR 238.7 per 105 ). Kaposi sarcoma (KS) was the most common cancer in men (40.5% of all cancers in men; ASR 54.0 per 105 ) while cervical cancer was the commonest in women (33.3%; ASR 88.6 per 105 ). The incidence rates for esophageal cancer remain one of the highest in the world (ASR 30.9 per 100,000 in men, 22.1 per 100,000 in women). Incidence of cancer of the prostate is relatively low in Blantyre (5.1%; ASR 16.4 per 105 ), compared with elsewhere in Africa. In childhood, the cancer spectrum is dominated by Burkitt lymphoma (32.5% ASR 90.9 per 106 ) followed by Wilms tumor (11.3%; ASR 35.9 per 106 ) and pediatric KS (11.0%; ASR 31.1 per 106 ). The overall percentage of cases with histological verification was 47.5%, a slight improvement from 42.4% in late 1990s also indicating successful case finding outside laboratories.

Development of multi-disciplinary breast cancer care in Southern Malawi

The Edinburgh Malawi Breast Cancer Project, a collaborative partnership project between the Queen Elizabeth Central Hospital (QECH) Oncology Unit, Blantyre, Malawi and the Edinburgh Cancer Centre, UK, was established in 2015. The principal objective of the project is to help to develop high quality multi-disciplinary breast cancer care in Malawi. A needs assessment identified three priority areas for further improvement of breast cancer services: multi-disciplinary working, development of oestrogen receptor (ER) testing and management of clinical data. A 3-year project plan was implemented which has been conducted through a series of reciprocal training visits. Key achievements to date have been: (1) Development of a new specialist breast care nursing role; (2) Development of multi-disciplinary meetings; (3) Completion of a programme of oncology nursing education; (4) Development of a clinical database that enables prospective collection of data of all new patients with breast cancer; (5) Training of local staff in molecular and conventional approaches to ER testing. The Edinburgh Malawi Breast Cancer Project is supporting nursing education, data use and cross-specialty collaboration that we are confident will improve cancer care in Malawi. Future work will include the development of a breast cancer diagnostic clinic and a breast cancer registry.

Leveraging HIV Research and Implementation for Cancer and Noncommunicable Diseases in Malawi

Abstract 33

Background:

Enabled by collaboration and political stability, Malawi is a global leader for HIV research and implementation. We undertook this work to identify ways to leverage successes in HIV treatment and research for cancer and noncommunicable diseases (NCDs).

Methods:

Over more than two decades, investment from the National Institutes of Health (NIH) and other funders has allowed Malawi participation in international HIV networks. As these sought to address HIV-positive cancer, investment occurred to increase pathology, improve cancer registration, scale up cervical cancer screening, and improve nursing and pharmacy skills for chemotherapy administration. This allowed Malawi to participate in multinational clinical trials for HIV-positive Kaposi sarcoma treatment and cervical cancer prevention. Building on this, Malawi was one of six countries in 2014 to receive an NIH U54 consortium award for HIV-positive malignancies and was one of six countries added to the National Cancer Institute (NCI) AIDS Malignancy Consortium. In 2016, expanding beyond HIV-positive cancer, Malawi was one of three countries invited to join a new NCI–International Agency for Research on Cancer esophageal cancer consortium, one of five recipients of a new NCI Burkitt lymphoma award, and one of six recipients of a new NCI P20 grant for a regional center of research excellence for NCDs. Malawi is also one of 11 countries to convene a Lancet noncommunicable diseases and injury poverty commission for NCDs and injury. Finally, partners have improved surveillance and treatment for hypertension, diabetes, injury, and sickle cell anemia, in part, through a national Knowledge Translation Platform for HIV-NCD integration. With this support and funding, career development opportunities are embedded for Malawian NCD researchers.

Results:

Building on successes in HIV treatment and research, Malawi has become a global leader for cancer and NCD research and implementation.

Conclusion:

Continue developing a multilateral national platform for NCD research and implementation that is globally impactful and can lead to measurable outputs for individual cancer and NCD focus areas. Funding: National Institutes of Health.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

No COIs from the authors.

The Edinburgh Malawi Cancer Partnership: helping to establish multidisciplinary cancer care in Blantyre, Malawi

In response to the growing incidence of cancer in Malawi, a new oncology unit was established at the Queen Elizabeth Central Hospital, Blantyre. The unit opened in 2010, the first in the country, and is led by a single consultant oncologist. In 2012, a healthcare partnership was formed between the oncology and palliative care unit at Queen Elizabeth Central Hospital and the Edinburgh Cancer Centre, UK. The principal objective of the partnership is to help develop high quality multidisciplinary cancer care in Malawi. Methods A needs assessment identified three priority areas for further improvement of cancer services: nurse-led treatment delivery; management of clinical data; and multidisciplinary working. The partnership received grant funding from the Scottish Government Malawi Development Programme in 2013 and a three year project plan was implemented. This has been conducted through a series of reciprocal training visits. Results Key achievements have been completion of a programme of oncology nursing education attended by 32 oncology nurses and other healthcare professionals, which has resulted in increased experience in cancer practice and standardisation of chemotherapy delivery procedures; development of a clinical database that enables prospective collection of data of all new patients with cancer and which links to the Malawi Cancer Registry; development of weekly multidisciplinary meetings involving oncology, gynaecology and surgery that has enabled a cross-specialty approach to patient care. Conclusion The Edinburgh Malawi Cancer Partnership is supporting nursing education, data use and cross-specialty collaboration that we are confident will improve cancer care in Malawi. Future work will focus on the further development of multidisciplinary breast cancer care and the development of a radiotherapy service for patients in Malawi.

The Malawi Cancer Consortium – Catalyzing Cancer Care and Research in Southern Africa

Abstract 68

Background:

Cancer burden is increasing in Malawi, particularly for HIV-associated malignancies.

Methods:

With support from the National Cancer Institute, the Malawi Cancer Consortium (MCC) was initiated in September 2014. Partners include the UNC Lineberger Comprehensive Cancer Center, Malawi Ministry of Health, University of Malawi College of Medicine, and Lighthouse Trust. Spanning Malawi’s two major cities, Lilongwe and Blantyre, MCC includes three support cores (administration, analysis, mentoring) and three multi-institution research projects: (1) a national HIV-cancer match study to assess cancer incidence in the ART era; (2) a longitudinal cohort to identify clinical and molecular correlates of KS chemotherapy response; and (3) a longitudinal cohort to elucidate lymphoma biology and develop better treatments for HIV-associated lymphoma.

Results:

For project 1, 65,500 records from the Malawi National Cancer Registry and Malawi HIV cohorts have been abstracted, and initial data harmonization completed. Record linkage is planned for February 2016, will be updated at regular intervals, and will contribute to regional analyses through the IeDEA- Southern Africa network. For project 2, KS studies through MCC have led to descriptions of KS biologic subtypes defined by viral gene expression profiling, and detailed characterization of multicentric Castleman disease. Malawi has also led enrollment into multinational phase III KS clinical trials implemented by the AIDS Clinical Trials Group and AIDS Malignancy Consortium. For project 3, more than 300 adults and children with lymphoma have been enrolled since June 2014, with approximately 2/3 of adults being HIV-infected. Patients receive standardized treatment and supportive care, and standardized clinical and laboratory evaluations. Specimen-based correlative studies (virologic, genomic, biomarker studies) are ongoing. Finally, the consortium provides a platform for pilot studies in breast and esophageal cancer, and facilitates career development for Malawian cancer investigators.

Conclusions:

MCC has initiated a national coalition to address cancer in Malawi, and continued progress is anticipated.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST:

Sam Phiri No relationship to disclose Joe Gumulira No relationship to disclose Hannock Tweya No relationship to disclose Lameck Chinula No relationship to disclose Agnes Moses No relationship to disclose Bongani Kaimila No relationship to disclose Christopher Stanley No relationship to disclose Edwards Kasonkanji No relationship to disclose Steady Chasimpha No relationship to disclose Richard Nyasosela No relationship to disclose Leo Masamba No relationship to disclose Tamiwe Tomoka No relationship to disclose Steve Kamiza No relationship to disclose Mina Hosseinipour No relationship to disclose Nora Rosenberg Research Funding: NIH/NCI Ron Mataya No relationship to disclose Charles Dzamalala No relationship to disclose George Liomba No relationship to disclose Irving Hoffman No relationship to disclose Dirk Dittmer No relationship to disclose Yuri Fedoriw Honoraria: Alexion Pharmaceuticals Blossom Damania No relationship to disclose Satish Gopal No relationship to disclose

Neoadjuvant chemotherapy in Albinos with locally advanced skin cancer at a Blantyre Hospital: - Case Series

Albinism in Africa remains a public health concern with increasing numbers of advanced skin cancer in this population at presentation. There are challenges with availability of Radiotherapy (RT) units in Africa which is an important modality for controlling loco-regional disease alone or in combination with surgery. Proposed chemotherapy regimens have not been well validated through Randomized Controlled Trials thus posing difficulties for standard of care for units that do not have access to functional RT facilities. Malawi is one such country without radiotherapy.

CASE SUMMARY

Seven patients with locally advanced skin cancer were seen in the adult oncology unit at Queen Elizabeth Central Hospital in Blantyre (QECH), Malawi between 2010 and 2013. QECH is one of the teaching hospitals in the country. All were subjected to neo-adjuvant chemotherapy. The primary treatment aim was cyto-reduction followed by surgery whilst the secondary outcome was general symptom control. Three patients achieved complete responses of which two underwent resection and a pectoralis major myocutaneous flap. One had a near complete response and three showed partial responses.

CONCLUSION

Neo-adjuvant chemotherapy may be a possible.

Biopsy case mix and diagnostic yield at a Malawian central hospital

Cancer is a major disease burden worldwide resulting in high morbidity and mortality. It is the leading cause of mortality in developed countries and is one of the three leading causes of death for adults in developing countries. Pathological examination of tissue biopsies with histological confirmation of a correct cancer diagnosis is central to cancer care. Without an accurate and specific pathologic diagnosis, effective treatment cannot be planned or delivered. In addition, there are marked geographical variations in incidence of cancer overall, and of the specific cancers seen. Much of the published literature on cancer incidence in developing countries reflects gross estimates and may not reflect reality. Performing baseline studies to understand these distributions lays the groundwork for further research in this area of cancer epidemiology. Our current study surveys and ranks cancer diagnoses by individual anatomical site at Queen Elizabeth Central Hospital (QECH) which is the largest teaching and referral hospital in Malawi. A retrospective study was conducted reviewing available pathology reports over a period of one full year from January 2010 to December 2010 for biopsies from patients suspected clinically of having cancer. There were 544 biopsies of suspected cancer, taken from 96 anatomical sites. The oesophagus was the most common biopsied site followed by breast, bladder, bone, prostate, bowel, and cervical lymph node. Malignancies were found in biopsies of the oesophagus biopsies (squamous cell carcinoma, 65.1%; adenocarcinoma, 11.6%), breast (57.5%), bladder (squamous cell carcinoma, 53.1%) and stomach (37.6%). Our study demonstrates that the yield of biopsy for clinically suspected malignancy was greater than 50% for the 11 most common sites and provides a current survey of cancer types by site present in the population reporting to our hospital.