By Alice M. Musibi, MBChB, MMed (Internal Medicine)
Medical Oncology Research Officer, Kenya Medical Research Institute (KEMRI); Medical Oncologist, Kenyatta National Hospital (KNH); Acting Head, Biotechnology and Non-communicable Disease Programme, KEMRI
Cancer treatment is improving in the developed world. Metastatic testicular cancer—virtually lethal a few decades ago—can now be cured. Similar though less dramatic advances have also been made in the treatment of various hematologic malignancies, and the therapeutic promise of specific small molecule inhibitors and antibodies is becoming realized in the clinic. In Kenya, unfortunately, these advances are yet to be realized, owing to an underlying deficiency of resources, infrastructure, and trained personnel; the entire lack or prohibitive cost of chemotherapy drugs; and the advanced stage of the majority of cancers at the time of presentation.
There are more cancer cases being reported in Kenya now than 10 years ago, but studies to determine the reasons for the increased prevalence and incidence are not being conducted. Sadly, most of the reported cancers are diagnosed at late stages, when very little can be achieved with therapeutic intervention. Increasingly, younger Kenyans seem to be more affected by cancer, unlike in the past, when it was considered a disease of the old.
Reliable cancer data are wanting, as there is currently no national cancer registry. The only available data are from Nairobi and its environs through the Nairobi Cancer Registry (NCR), and even this scant information only dates back to 2000. The registry was established at the Kenya Medical Research Institute (KEMRI) with the sponsorship of the International Agency for Research on Cancer, the National Cancer Institute of the United States, and the World Health Organization, among other stakeholders. Data are collected from the city’s main hospitals (public and private), laboratories, and hospices. The figures are taken to be representative of the country, considering that the majority of cancer management services are available at Kenyatta National Hospital (KNH) and the main private hospitals in Nairobi.
Data from the NCR and verbal reports from practicing physicians indicate that cancer incidence is increasing in Kenya; it now numbers among the top 10 causes of mortality. The three most common cancers in men are those of the esophagus and prostate and Kaposi’s sarcoma; in women, breast cancer is the most commonly diagnosed form of the disease, followed by cervical and esophageal cancers, respectively. The majority of patients present in advanced disease stages, leading to untold morbidity and mortality. This occurs despite the known facts of reduced morbidity and mortality from primary prevention and early detection.
The clinical management of cancer requires a multidisciplinary team consisting of medical oncologists, surgeons and surgical oncologists, radiotherapists, pathologists, radiologists, oncology nurses, counselors, and palliative care specialists, among others.
Undergraduate cancer education programs in Kenya are very short in duration and are held primarily in outpatient clinics that specialize in diagnosis and treatment of cancer. Further specialization in any other field of oncology has to be conducted abroad. Thus, there are very few oncologists in the country. (Currently, there are three medical oncologists, four radiation oncologists, two surgical oncologists, and two gynecologic oncologists for the whole population.) Continuing medical education is available through the Kenya Society of Haematology and Oncology (KESHO), but these services are offered mainly in Nairobi. An integrated, problembased, multidisciplinary clinical cancer management course must be emphasized to enable medical officers to diagnose, manage, or refer the earliest possible cancers seen in the peripheral hospitals.
All of the oncology specialists in Kenya are located in Nairobi, making it almost impossible for the largest number of the population to access their services. Basic radiologic services are generally available; however, computed tomography scans and magnetic resonance imaging scans are few and, again, mainly in Nairobi. Molecular diagnostic facilities are very rare and quite expensive to the majority of patients. The only functional radiotherapy services are also in Nairobi, one in the referral hospital (KNH) and the other in a major private hospital. This leads to a very long waiting period—especially in the public hospital—of up to three months, causing even previously curable tumors to progress before patients can access treatment.
Surgical services are available, but are generally conducted by surgeons whose primary clinical practice is not oncology. Pathology services are poor in the public institutions, with delays in diagnostic reports sometimes stretching to months. The scope of these services is also poor, considering that there are too few pathologists for the population.
Although chemotherapy drugs are available, high cost prevents the majority of patients from even beginning treatment. Others are unable to afford the most current regimes. Chemotherapy is administered by general physicians and surgeons as much as 80% of the time, often exposing patients with cancer to preventable risks, side effects, and resistances from use of substandard regimens, and eventually leading to poor response rates. Awareness and availability of palliative services in the country are increasing. These exist mainly as joint services with HIV/AIDS management programs and in private hospices across the country.
Cancer research in Kenya is virtually nonexistent, as most of the funding is directed toward malaria, HIV/AIDS, and tuberculosis research. Politicians in this country do not recognize cancer as a priority. There are also no well-equipped laboratories to undertake the relevant research, especially in cancer, and the few that have the capacity are donor-driven to focus on infectious diseases.
Cancer control, prevention, and screening programs have not yet taken root in Kenya, considering the heavier burden imposed on the Ministry of Health by infectious diseases. However, there are a few non-governmental organizations, the World Health Organization, and private hospitals that run regular screening programs, especially for breast and cervical cancers. The present cancer management infrastructure in the Ministry of Health is not able to handle all the newly diagnosed cases, which negates the potential benefits yielded by early screening. Health promotion talks are given regularly by medical professionals through media outlets, but not every region of the country receives these broadcasts.
KEMRI now has a department dedicated to non-communicable diseases, including cancer, and the Kenyan government is in the process of developing National Cancer Control guidelines. We are hopeful that these will lead to the development of policies that address cancer as an entity in the health budget and enable many patients to afford cancer management services as early as possible. The formation of the East African Community, with the associated infrastructure for common bargaining in health issues, will push the implementation of the relevant policies on cancer control, prevention, and also training.
The entry of ASCO into Kenya’s oncology field could not have been more timely to enable multidisciplinary training, empowering the primary physicians and medical officers to manage cancers early and correctly. This will greatly improve our outcomes in survival and reduce the morbidity and mortality associated with late diagnosis.
ASCO will hold a Multidisciplinary Cancer Management Course in conjunction with the Kenya Society of Haematology and Oncology (KESHO) on March 6-7, 2008. For more information and to register to participate, send an e-mail to
mcmc@asco.org.
