A review of Kenya's cancer policies to improve access to cancer testing and treatment in the country.

BACKGROUND: Cancer is the third-leading cause of mortality in Kenya, resulting in unique challenges to the country's health system. An increase in the number of cancer cases in Kenya over the past decade resulted in legislative actions and policies to guide delivery of cancer services. Kenya's new national cancer control strategy and past policy efforts provide an opportunity to synergise information and enhance understanding to improve cancer diagnosis and treatment in the country. The objectives of this study are to (1) document policy-modifiable factors based on a review of policy documents and results of a key informant survey and (2) develop recommendations to improve policies affecting cancer testing and treatment services in Kenya. This study builds upon our previous study Improving Access to Cancer Testing and Treatment in Kenya (Makau Barasa et al. J Global Oncol 2(216), 2017). METHODS: The study applied an in-depth systematic review of Kenya's cancer policies and guidelines, a qualitative analysis of results from a section of a semi-structured key informant survey focused on the opinions of clinicians delivering cancer services as well as cancer support groups and advocacy leaders, and a stakeholder analysis identifying key policy-makers and implementers. Details of the complete key informant survey were published in our previous study. RESULTS: Kenya's cancer policies have guided progress made in providing the legal and implementation frameworks for the development and delivery of cancer services at the national and county levels. Some policy implementation gaps are noted. These include inadequate financing for cancer services, limited research and data to support policy formulation, and the concentration of cancer services in urban areas. The key informant survey identified policy-modifiable actions that can address some of the gaps and improve the delivery of and access to cancer testing and treatment services in the country. Some of these include addressing the financial barriers affecting cancer testing and treatment services; increasing stakeholder engagement in training health personnel to deliver cancer testing and treatment services; decentralising cancer services and improving cancer surveillance and research; and increasing education and awareness about cancer symptoms, screening procedures and treatment options. A set of priority policy actions were selected from the study findings and used to develop recommendations for Kenya's policy-makers and stakeholders. CONCLUSIONS: Revisions to Kenya's cancer policies are seeking to address gaps noted in past policies and to improve access to cancer testing and treatment in Kenya. However, based on study findings, additional actions can be taken to strengthen policy implementation. Considering the policy formulation and implementation process and costs, this study recommends focusing on three priority policy actions that can have significant impact on improving access to cancer testing and treatment services. These include addressing financing, insurance and human resources gaps; increasing stakeholder engagement; and decentralising health services for better surveillance and data to inform policies.

The GLIVEC international patient assistance programme: the Nairobi experience.

Glivec is a drug used in the treatment of chronic myeloid leukaemia (CML) and gastrointestinal stromal tumours (GISI). It is an expensive drug which would be out of reach for most patients in Kenya. Norvatis Pharmaceutical together with Axios International a healthcare management company and Max Foundation have made it possible for patients in developing countries to get access to the drug at no cost. Patients meet the cost of the confirmatory test and are recruited into the programme to receive the drug at no cost. A total of 201 patients are in the programme in Nairobi, mainly drawn from Kenyatta National Hospital the major referral hospital in Kenya. The age range is nine years to 75 years with a mean age of 39.5 years. Males make up 56.5% while females are 43.5%. CML are 173 (86%) while GIST patients are 28 (13.9%). Most of the CML cases are referred in the chronic stable phase (87.8%) and 85.7% have been on hydroxyurea as the initial treatment. Compliance rates are approximately 80%.

Chemotherapy induced myelosuppression.

OBJECTIVE: To evaluate chemotherapy induced myelosuppression, its management and outcome. DESIGN: Retrospective analysis of patients aged 13 years and above. SETTING: Hurlingham Oncology Clinic and the Nairobi Hospital during the period of June 1998 to June 2003. SUBJECTS: Two hundred and two solid tumour and lymphoma patients treated with pulsed chemotherapy at Hurlingham Oncology Clinic and those treated by the same service at the Nairobi Hospital. RESULTS: Two hundred patients were evaluable for nadir blood counts. World Health Organisation (WHO) grade 3 neutropaenia complicated 57 (26.1%), and grade 4 complicated 56 (25.7%) treatments. Grade 0 neutropaenia was seen in 40 (18.4%) treatments, 33 having included prophylactic Granulocyte-Colony Stimulating Factors (G-CSF). Neutropaenia was worst following the first and sixth courses, and repeated second line courses but the difference was not statistically significant (p = 0.154). Fever complicated 6 grade 3 and 21 grade 4 neutropenic episodes (23.1% of 117 evaluable). Twenty eight patients were hospitalised because of severe neutropaenia (23 febrile, and five afebrile initially but with absolute neutrophil counts < 0.01 x 10(9)/litre). Eight of them died, six attributable to infections (21.4% mortality) and two attributed to other causes. Median time to neutrophil recovery to 21.5 x 10(9)/litre was three days with a mean of 4.6 days. Anaemia and thrombocytopaenia were not commonly experienced. CONCLUSION: Prophylactic use of G-CSF may have prevented severe neutropaenia and its use in severe neutropaenia may have reduced the duration and severity of neutropaenia but the mortality rate for febrile neutropaenia remained high.

Hodgkin's lymphoma in the 1990s: a Kenyatta National Hospital experience.

OBJECTIVE: To re-evaluate clinico-pathologic categorisation of patients with Hodgkin's lymphoma, treatments offered and their appropriateness, and outcome of this disease at Kenyatta National Hospital in the 1990s. DESIGN: Retrospective survey of Hodgkin's lymphoma patients aged 13 years and above at the Kenyatta National Hospital. SETTING: Kenyatta National Hospital, Nairobi, Kenya. SUBJECTS: Patients aged 13 years and above, with diagnosis of Hodgkin's lymphoma. RESULTS: There were 75 males and 36 females. One case had no clear gender details. 14.2% of the cases were of lymphocyte predominant histologic subtype, 23.6% nodular sclerosis, 26.4% mixed cellularity and 17% Lymphocyte depletion (Rye Modification of Lukes and Butler Classification). Disease stages IIIB, IVA and IVB (Ann Arbor) were found in 24.5% of the cases. The majority of the patients (60.3%) were treated with the COPP protocol and 17% with ABVD. Complete remission was realised in 56% of the cases and most cases were lost to follow-up, making it difficult to correlate survival with known prognostic parameters, apart from early stage disease and attainment of complete remission which correlated with prolonged durations of follow-up. CONCLUSION: The patients had earlier stage diseases than in earlier studies locally, the histologic classification is still wanting, and the COPP protocol appeared still popular instead of being abandoned. Response rates were lower than expected and losses to follow-up made it difficult to properly evaluate prognostic parameters. Early disease stage and attainment of complete remission appeared to correlate with longer follow-up duration.

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.

Postsurgical management of patients with breast cancer at Kenyatta National Hospital.

OBJECTIVE: To assess post-surgical management of patients with breast cancer at the Kenyatta National Hospital. DESIGN: Retrospective analysis of patients treated for breast carcinoma at Kenyatta National Hospital between January 1989 and January 2000. SETTING: Kenyatta National Hospital. SUBJECTS: Three hundred and seventy-four patients who had surgery or biopsy for breast cancer at the Kenyatta National Hospital. INTERVENTION: Chemo-hormonal therapy and/or radiotherapy for adjuvant, metastatic, or palliative purposes. RESULTS: Twenty-two patients received adjuvant chemotherapy, and 21 patients received chemotherapy for metastatic disease. Forty-six patients received adjuvant radiotherapy and 53 had radiotherapy for palliative purposes. One hundred and twenty-six patients were given tamoxifen for adjuvant and metastatic purposes. The median duration of follow-up was 20 months. CONCLUSION: Chemotherapy is grossly underutilized in the treatment of breast cancer at the Kenyatta National Hospital, and radiotherapy is also underutilized. Follow-up durations are dismal and if this is used as a surrogate measure for survival then survival durations for breast cancer patients are also dismal at the Kenyatta National Hospital.

Chronic myeloid leukaemia at the Kenyatta National Hospital, Nairobi.

OBJECTIVE: To determine the clinical and haematological factors associated with treatment and outcome of chronic myeloid leukaemia (CML) at Kenyatta National Hospital. DESIGN: Retrospective survey of patients treated for chronic myeloid leukaemia. SETTING: Kenyatta National hospital, Nairobi, Kenya, between April 1990 and August 2000. SUBJECTS: Patients with chronic myeloid leukaemia. RESULTS: One hundred and four patients, 55 males and 49 females, age range 10-72 years with a median age of 35 years. Treatment with busulphan getting less popular in favour of hydroxyurea. Median follow-up 20 months with none of the clinical and haematological parameters impacting significantly on duration of follow-up. CONCLUSION: CML occurs at a younger age-group in Kenya, and none of the clinical or haematological parameters appears to impact on follow-up duration.

Nadir neutrophil counts in patients treated for breast cancer with doxorubicin and cyclophosphamide.

OBJECTIVE: To determine the impact on neutrophils if adriamycin is administered at 60 mg/m2 and cyclophosphamide at 600/m2 (AC 60/600); and at 50 mg/m2 and 500 mg/m2 (50/500) in the treatment of breast cancer. DESIGN: Restrospective analysis of nadir neutrophil counts in female mammary carcinoma patients treated with adriamycin/cyclophosphamide combination. SETTING: Hurlingham Oncology Clinic, Nairobi and The Nairobi Hospital between March 1995 and August 1999. SUBJECTS: Eighteen patients with breast cancer were treated either for adjuvant purposes or for metastatic disease. INTERVENTION: Chemotherapy with adriamycin and cyclophosphamide at 60/600 or 50/500. Patients were advised to avoid crowded places and given prophylactic broadspectrum antibiotics whenever grade 4 neutropenia occurred at nadir. RESULTS: Grade 3-4 neutropenia occurred in 75.5% of treatments at 60/600 and in 56.8% of the treatments at 50/500. Febrile neutropenia followed only one treatment and did not result in death. CONCLUSION: Neutropenia is frequent and severe at A/C 60/600 and need to be watched out for. Sepsis on the other hand is prevented if meticulous attention is given and corrective measures taken. A/C 50/500 was associated with less occurrences of neutropenia though still very high. Neutropenia should therefore be checked and steps be taken to prevent sepsis even at this dosage.

Experience with vincristine--associated neurotoxicity.

OBJECTIVES: To evaluate the frequency and severity of occurrence of vincristine-associated neurotoxicity. DESIGN: A retrospective case series study. SETTING: Hurlingham Oncology Clinic, Nairobi. SUBJECTS: Thirty-eight patients treated for various neoplasms with vincristine containing chemotherapeutic regimens. MAIN OUTCOME MEASURES: The frequency and degree of neurotoxicity when vincristine was given at the standard dose of 1.4 mg/m2. RESULTS: Five patients (13.2%) developed peripheral neuropathy, one having had it even before vincristine was started. Therefore only four (10.5%) had it attributed to vincristine. Four of the patients who developed neuropathy (80%) were HIV-positive. Neuropathy grade 2 (severe) occurred in only two patients leading to discontinuation of the drug. All the neurotoxicity resolved after discontinuation of vincristine. CONCLUSION: Vincristine induced neuropathy occurred but was rarely severe at a dose of 1.4 mg/m2. It appeared to be more frequent in HIV infected individuals, but controlled studies with bigger sample sizes are required to determine whether this may warrant routine capping of the dose at a maximum of 2 mg.

Cutaneous basal cell carcinoma in Kenya.

BACKGROUND: Primary basal cell carcinoma(BCC) of the skin is the commonest tumour in Caucasians. Its incidence and mode of presentation in Kenyan Africans are unknown. OBJECTIVE: To study the incidence and mode of presentation of BCC in Kenya. DESIGN: A thirty year retrospective study (1968-1997) of all BCCs documented in the Kenya Cancer Registry (KCR), and a case report of one patient seen at Kenyatta National Hospital (KNH), Nairobi. RESULTS: Seventy four BCCs were recorded in thirty five Caucasians and thirty nine Africans. The race-specific mean annual incidence rates per million population were 58.5 and 0.065 for Caucasians and Africans, respectively. Clinical presentation in both racial groups was similar. CONCLUSION: BCC is a rare malignant tumour in Kenyan Africans but its mode of clinical presentation is similar to that in Caucasians.

Relapse of Hodgkin's disease after 10 years of complete remission: case report.

A 17 year old male patient with nodular sclerosis Hodgkin's disease had a relapse of lymphocyte depleted type ten years after entering complete remission with chemotherapy and radiotherapy. This is the first documented case in our experience of relapse after very long disease free interval. A review of the literature of late relapses in Hodgkin's disease is also presented. Relapses have been recorded from three years to twenty years, although few very late forms are registered. Long term follow up will be necessary to document the role of the different therapeutic regimen.

Ageing and cancer.

The process of carcinogenesis is complicated and in most cases requires several steps of cellular transformation resulting from various molecular signals brought about by interactions between carcinogens and the cellular genome. Cancers in which cellular transformation does not require numerous processes tend to occur in younger age groups while cancers of the advancing age tend to be those in which the process of cellular transformation occurs through complex molecular processes that require ample time for induction.

The consistent association between Epstein-Barr virus and Hodgkin's disease in children in Kenya.

Recent studies have suggested that Epstein-Barr virus (EBV) may play a role in the etiology of Hodgkin's disease (HD). In a previous study, we used a latent membrane protein 1 (LMP1)-specific antibodies to examine archival material from 74 British children with HD and found 50% of cases to be positive. It is known that there are geographic and ethnic variations in the incidence of HD. We have investigated LMP1 status in formalin-fixed, paraffin wax-embedded lymph nodes with HD involvement from 53 children and 48 adults from Kenya using immunohistochemical staining. We also developed sensitive and specific in vitro gene amplification protocols for examining the EBV strain type in such material using several combinations of primers derived from the EBNA 2 and EBNA 3 coding regions. LMP1 positivity was present in 100% of the pediatric cases (two lymphocyte-predominant, 25 nodular sclerosis, 16 mixed cellularity, 5 lymphocyte depletion, and 5 unclassified) and in 66% of the adult cases (two of three lymphocyte-predominant, 26 of 39 nodular, sclerosis, two of two mixed cellularity, and two of four lymphocyte depletion). Tests to type the EBV strain were undertaken in 25 EBV-positive pediatric cases. A combination of type-specific polymerase chain reactions for EBNA 2 and EBNA 3C genes indicated that seven patients had type 1, eight had type 2, and 10 had dual infections with both types. Five cases with dual infections were further investigated using a sensitive in situ hybridization for the EBV-encoded, small nuclear nonpolyadenylated RNAs (EBERs). EBER transcripts were detected in Reed-Sternberg and Hodgkin cells and in occasional infiltrating lymphocytes. These observations indicate that in Kenya EBV is consistently associated with pediatric cases of HD, and that biopsies from a number of such cases appear to carry both type 1 and type 2 viral sequences.