Survival of cervical cancer patients at Moi teaching and Referral Hospital, Eldoret in western Kenya

BACKGROUND

Cervical cancer is a major health burden and the second most common cancer after breast cancer among women in Kenya. Worldwide cervical cancer constitutes 3.1% of all cancer cases. Mortality rates are greatest among the low-income countries because of lack of awareness, screening and early-detection programs and adequate treatment facilities. The main aim was to estimate survival and determine survival predictors of women with cervical cancer and limited resources in western Kenya.

METHODS

Retrospective charts review of women diagnosed with cervical cancer and follow-up for two years from the date of the histologic diagnosis. The outcome of interest was death or survival at two years. Kaplan Meier estimates of survival, log-rank test and Cox proportional hazards regression were used in the survival analysis.

RESULTS

One hundred and sixty-two (162) participants were included in the review. The median duration was 0.8 (interquartile range (IQR) 0.3, 1.6) years. The mean age at diagnosis was 50.6 years (SD12.5). The mean parity was 5.9 (SD 2.6). Fifty percent (50%) did not have health insurance. Twenty six percent (26%) used hormonal contraceptives, 25.9% were HIV positive and 70% of them were on anti-retroviral treatment. The participants were followed up for 152.6 person years. Of the 162 women in the study, 70 (43.2%) died giving an overall incidence rate (IR) of 45.9 deaths per 100 person years of follow up. The hazard ratios were better for the patients who survived (0.44 vs 0.88, p-value < 0.001), those who had medical insurance (0.70 vs 0.48, p-value = 0.007) and those with early stage at diagnosis (0.88 vs 0.39, p-value < 0.001). Participants who were diagnosed at late stage of the disease according to the International Federation of Gynecology and Obstetrics staging for cervical cancer (FIGO stage 2B-4B) had more than eight times increased hazard of death compared to those who were diagnosed at early stage (1-2A): Hazard Ratio: 8.01 (95% CI 3.65, 17.57). Similarly, those who underwent surgical management had 84% reduced hazard of mortality compared to those who were referred for other modes of care: HR: 0.16 (95% CI: 0.07, 0.38).

CONCLUSION

Majority of the participants were diagnosed late after presenting with symptoms. The 1 and 2-year survival probability after diagnosis of cervical cancer was 57% AND 45% respectively. It is imperative that women present early since surgery gives better prognosis or better still screening of all women prioritized.

The East Africa Consortium for human papillomavirus and cervical cancer in women living with HIV/AIDS

The East Africa Consortium was formed to study the epidemiology of human papillomavirus (HPV) infections and cervical cancer and the influence of human immunodeficiency virus (HIV) infection on HPV and cervical cancer, and to encourage collaborations between researchers in North America and East African countries. To date, studies have led to a better understanding of the influence of HIV infection on the detection and persistence of oncogenic HPV, the effects of dietary aflatoxin on the persistence of HPV, the benefits of antiretroviral therapy on HPV persistence, and the differences in HPV detections among HIV-infected and HIV-uninfected women undergoing treatment for cervical dysplasia by either cryotherapy or LEEP. It will now be determined how HPV testing fits into cervical cancer screening programs in Kenya and Uganda, how aflatoxin influences immunological control of HIV, how HPV alters certain genes involved in the growth of tumours in HIV-infected women. Although there have been challenges in performing this research, with time, this work should help to reduce the burden of cervical cancer and other cancers related to HIV infection in people living in sub-Saharan Africa, as well as optimized processes to better facilitate research as well as patient autonomy and safety. KEY MESSAGESThe East Africa Consortium was formed to study the epidemiology of human papillomavirus (HPV) infections and cervical cancer and the influence of human immunodeficiency virus (HIV) infection on HPV and cervical cancer.Collaborations have been established between researchers in North America and East African countries for these studies.Studies have led to a better understanding of the influence of HIV infection on the detection and persistence of oncogenic HPV, the effects of dietary aflatoxin on HPV detection, the benefits of antiretroviral therapy on HPV persistence, and the differences in HPV detections among HIV-infected and HIV-uninfected women undergoing treatment for cervical dysplasia by either cryotherapy or LEEP.

Knowledge of Cervical Cancer and Acceptability of Prevention Strategies Among HPV-Vaccinated and Nonvaccinated Adolescents in Eldoret, Kenya

Background: Primary prevention of cervical cancer with the introduction of the human papilloma virus (HPV) vaccines is the next generation means to reduction of the disease burden in developing countries. Sexually active adolescents have the highest rates of prevalent and incident HPV infection rates with over 50%–80% having infections within 12 months of initiating intercourse. From May 2012 to March 2013, through the Gardasil Access Program, Eldoret received 9600 vaccine doses and vaccinated over 3000 girls aged 9-14. Despite this, there is little information on the knowledge of cervical cancer among adolescents and their amenability to accepting cervical cancer prevention strategies. Aim: To compare the knowledge of cervical cancer and acceptability of prevention strategies among vaccinated and nonvaccinated adolescents after an HPV vaccination initiative in Eldoret, Kenya. Methods: A cross-sectional comparative study carried out in 6 public schools which were clustered into 2 groups of 2. 60 vaccinated and 120 nonvaccinated adolescents were randomly selected from each of the schools by proportionate allocation. IREC approval obtained and signed consent got from the parents. Data collection was then carried out using interviewer-administered questionnaires. Results: The median age of the participants was 14.0 (IQR: 13.0-15.0). Of 60 vaccinated adolescents, 56 (93.3%) had heard of the HPV vaccine compared with 6 (5%) of unvaccinated participants ( P < 0.001). Fifty-eight (96.7%) of vaccinated participants heard of cervical cancer compared with 61 (50.8%) unvaccinated participants ( P < 0.001). The participants were not different in their knowledge of risk factors for developing cervical cancer or its symptoms but overall, the vaccinated participants had a significantly higher knowledge score compared with the unvaccinated participants 14.4 (95% CI: 12.2-16.7). Both cohorts identified the school as the commonest source of information for health matters as compared with social media or hospitals. The 2 groups also showed similarity in their selection of cervical cancer prevention strategies acceptable to them like delaying sexual debut until after the teenage years and frequency of using barrier method for protection against sexually transmitted infections. Similar proportions of participants from both cohorts showed high acceptability of screening modalities for cervical cancer (85% vs 86.7%, P = 0.940). Of the unvaccinated participants, 63.7% expressed willingness to be vaccinated. Conclusion: Exposure to the HPV vaccine was associated with a higher knowledge of cervical cancer. The adolescents predominantly rely on the school for their information. They show remarkable acceptability for cervical cancer prevention strategies but are limited by the dearth of information they have.

Loss to Follow-Up in a Cervical Cancer Screening and Treatment Program in Western Kenya

Background: Increasingly, evidence is emerging from developing countries like Kenya on the burden of loss to follow-up care after a positive cervical cancer screening/diagnosis, which impacts negatively on cervical cancer prevention and control. Unfortunately little or no information exists on the subject in the western region of Kenya. This study is designed to determine the proportion of and predictors and reasons for defaulting from follow-up care after positive cervical cancer screen. Aim: To determine the rates and factors associated with loss to follow-up in a multivisit cervical cancer screening and treatment program in western Kenya. Methods: We conducted a prospective study of women, who presented for cervical cancer screening at Chulaimbo and Webuye subcounty hospitals, and screened positive by VIA. A 2-3 weeks appointment was then set for review by a gynae-oncologist. A total of 100 women, scheduled for review, were recruited in the study and followed between August 2016 and May 2017. LTFU was defined as failure to keep a second rescheduled appointment or being unreachable for 3 consecutive months and failure to confirm that a woman sought for care in another health facility. Descriptive statistics was used for summary and the Cox regression model was used to estimate the risk of LTFU for different covariates. Results: The age range was 21-77 years, with a mean of 44.45 years. 39% of the women defaulted from scheduled follow-up appointment of which 25 (64%) were LTFU. Univariate Cox regression was conducted for HIV cases (HR=2.7, P value=0.021), clinic revisits (HR=2.6, P value=0.026), married (HR=0.63, P value=0.237) and previously screened women (HR=1.67, P value=0.198). Increased risk of LTFU was observed for HIV cases (HR=2.4, P value=0.04) and revisits (HR=7.5, P value=0.014) in an adjusted model. Conclusion: LTFU affects cervical cancer management due to several factors some of which are beyond the control of the women. We recommend a larger study be replicated for ease of generalizability of results; awareness and strategies are required to retain them to obey the treatment appointment since they are the highly vulnerable.