Expanding Programs to Reduce Unnecessary Cancer Mortality in Africa
By: Tony Boova, Beckman Coulter Life Sciences
Cancer is serious wherever a patient resides, but in some parts of the world, even highly treatable cancers are fatal much of the time1. There are several reasons for the divide, but in some regions in east Africa, lack of diagnosis may be the main culprit. Pilot programs are being implemented to address the problem, but more work still needs to be done, both to understand the differences in risk across the globe and to roll out effective, affordable solutions.
Cancer in Africa represents about 70% of the global burden2. Part of this is due to the high prevalence of infection-based cancers—for instance, HIV itself is a risk factor for cancer3, since it compromises the immune system, and being on antiretroviral therapy over the long-term can make a person additionally susceptible to certain blood cancers, including leukemia and lymphoma. But it’s not all HIV/AIDS-related. One common, but highly treatable form of lymphoma, called Burkitt’s lymphoma4, is essentially a repercussion of malaria and Epstein-Barr virus5—and while it’s fatal in only 10% of the cases in the U.S., because of the discrepancy in diagnosis, the the disease is fatal in up to 70% of cases6 in certain parts of Africa.
And discrepancies exist in other, non-infection-related cancers in the developing vs. developed world. For instance, a particularly severe form of blood cancer, acute myeloid leukemia (AML), is much more common in in Africa and researchers are working hard to understand why7.
Leaving alone the issue of treatment, as mentioned, just getting diagnosed can be nearly impossible in some resource-poor areas. One reason is that there’s almost no infrastructure among public health labs to screen for cancer. In the case of blood cancers, some people who can afford it leave the country for care, but most people don’t have this luxury. Experts in hematological malignancies are few and far between: A country like Uganda may only have one or two blood cancer specialists for its 40 million citizens. Even training staff to run a diagnostics lab—which would require far less training than a hematologist or oncologist—can be difficult. Funding is of course a central limiting factor, since a large portion of health funding goes toward fighting infectious diseases (HIV, malaria, and others).
For the cancers that are not only easy, but also inexpensive, to treat—e.g., Burkitt’s lymphoma—the situation is especially heart-breaking and sorely needs to change.
To try to address some of these issues, several organizations (Fred Hutchinson Cancer Institute, Children’s Hospital of the University of Washington, Uganda Ministry of Health, Uganda Cancer Institute, AMPATH Laboratories at Moi Teaching and Referral Hospital, Beckman Coulter Life Sciences CARES Initiative, and Burkitt’s Lymphoma Fund for Africa) have partnered together to launch a pilot program in Uganda and Kenya. The goal has been to demonstrate the feasibility of using flow cytometry to improve diagnosis of blood cancers throughout the two countries. Previously, the main diagnostic method had been morphology—looking at cells under the microscope. But because of limited numbers of trained professionals, diagnostic accuracy can be challenging. So, there was a need to train technicians to diagnose blood cancers using flow cytometry with comparisons to morphology, which is much more accurate and does much of the diagnostic work for the technician. And as mentioned, because there are effective and affordable treatments for certain blood cancers, getting the diagnostic element in place is critical.
The cancer pilot program has tapped into an already-robust flow cytometry infrastructure in east Africa to diagnose and monitor HIV. The network is centralized, so patient’s blood is collected locally and transferred to a central testing facility (two additional flow cytometers were deployed to help support the cancer diagnosis initiative). The nice thing about the instruments used is that the required reagents are cold chain-independent, meaning that they don’t need to be refrigerated along the way. They also use preformulated components, so there’s less room for error and wasted expensive reagents.
Covid-19 has slowed down the program somewhat, but so far about 1,000 patients have been tested between the two countries. The initiative will likely be extended through the end of 2022 to ensure sufficient data and results.
Though the primary goal of the initiative is to expand testing capability into the two countries and develop a model that others can follow, there are also larger aims. Getting treatment to patients locally after diagnosis is critical. In the case of Burkitt’s lymphoma, the survival rate without treatment and supportive care is low4. It’s an aggressive and disfiguring form of cancer that can grow exponentially fast—but with proper treatment, which is generally affordable, it can subside just as quickly. Centers like the Uganda Cancer Institute has been very successful in this area, but more are needed.
Another aim is to understand the disease patterns of blood cancers, and the discrepancies that exist between regions. There may also be a benefit in transferring diagnostics out closer to patients—in other words, to decentralize the highly-centralized system and move to a regional or district level. This would mean faster turnaround times and better care for patients. Finally, the CARES Initiative (Beckman Coulter Life Sciences Global Health Initiative) data may one day help inform policy, and lead to the implementation of more effective testing strategies in WHO guidelines, for instance. These changes would filter down into the countries and inform their day-to-day healthcare practices for cancer control programs.
A close parallel to all this work is education on a local level. Some people may not seek care for themselves or their children either because of lack of knowledge about symptoms or because cancer is seen as fundamentally untreatable. The CARES Initiative pilot program may begin to help address these issues, but more work will be needed to inform residents of available options.
Despite expected ongoing challenges—deploying technical support for the instruments as needed and keeping the labs stocked with reagents—the researchers are optimistic about the CARES Initiative’s potential value. Through this work and, hopefully, additional partnerships from other organizations wishing to be involved, the hope is that the divide between cancer success rates in the U.S. and in Africa will shrink to nothing in the coming years.
References:
- Shad et al. (2013) PAEDIATRIC ONCOLOGY IN ETHIOPIA: AN INCTR-USA AND GEORGETOWN UNIVERSITY HOSPITAL TWINNING INITIATIVE WITH TIKUR ANBESSA SPECIALIZED HOSPITAL. Cancer Control 2013; 108-112
- World Health Organization. (2020). Assessing national capacity for the prevention and control of noncommunicable diseases: report of the 2019 global survey. World Health Organization.
- Palella FJ Jr, Baker RK, Moorman AC, Chmiel JS, Wood KC, Brooks JT, Holmberg SD; HIV Outpatient Study Investigators. Mortality in the highly active antiretroviral therapy era: changing causes of death and disease in the HIV outpatient study. J Acquir Immune Defic Syndr. 2006 Sep;43(1):27-34. doi: 10.1097/01.qai.0000233310.90484.16. PMID: 16878047.
- Molyneux, E., Scanlan, T., Chagaluka, G. and Renner, L. (2017), Haematological cancers in African children: progress and challenges. Br J Haematol, 177: 971-978. https://doi.org/10.1111/bjh.14617
- Rowe M, Fitzsimmons L, Bell AI. Epstein-Barr virus and Burkitt lymphoma. Chin J Cancer. 2014 Dec;33(12):609-19. doi: 10.5732/cjc.014.10190. Epub 2014 Nov 21. PMID: 25418195; PMCID: PMC4308657.
- World Health Organization. (2021). CureAll framework: WHO global initiative for childhood cancer: increasing access, advancing quality, saving lives. World Health Organization. https://apps.who.int/iris/handle/10665/347370
- Williams Christopher KO, Foroni Letitzia, Luzzatto Lucio, Saliu Idris, Levine Arthur, Greaves Mel F (2014) Childhood leukaemia and lymphoma: African experience supports a role for environmental factors in leukaemogenesis ecancer 8 478
