Cancer in Kenya: Building a System of Excellence in An Experiment in - PowerPoint PPT Presentation

Cancer in Kenya: Building a System of Excellence in An Experiment in Care Cancer Care in Kenya Patrick J. Loehrer Sr., MD Indiana University Melvin and Bren Simon Cancer Center

The$beginnings$of$a$sustained$ partnership…$ Development$of$a$HIV/AIDS$$ care$program$

A cademic$ M odel$ P roviding$ A ccess$ T o$ H ealthcare $ (formerly$Academic$Model$for$the$PrevenBon$and$Treatment$of$HIV/AIDS)$ $ Health Indicators and Outcomes • 40,000$pregnant$women$screened$for$HIV$ • 3,361$HIV$infected$pregnant$women$enrolled$into$pMTCT$ • >110,000$other$persons$screened$for$HIV$ • 30,000$$food$insecure$persons$fed$weekly$ • 10$tons$food$grown$weekly$on$AMPATH$farms$ • 4615$orphans$and$vulnerable$children$served$ • Home$counseling$and$tesBng$successfully$demonstrated$in$ Turbo$and$Kosirai$(pop$160,000)$ • Riley$Mother$and$Baby$Hospital$completed$ • IU$docs$provided$services$in$Medicine,Pediatrics,$Medical$ Oncology,$Anesthesia,$Surgery,$Orthopedics,$ENT,$Ob/Gyn,$ Pathology$

Development$of$a$Cancer$Care$ Program$

Barriers to Cancer Control in LMCs • Lack of infrastructure • Poorly trained and Limited workforce • Patient care costs • Insufficient palliative care • Education Deficits

OutpaBent$Rounds:$Day$2$$ • 25$yo$paBent$presents$with$pathologic$ fracture$of$the$right$distal$radius.$ • States$that$he$fell$on$arm$6$years$prior$and$ reinjured$it$a$year$later.$ • Biopsy$reveals$NHL.$$ • PaBent$treated$with$CAV$x$3$cycles$without$ significant$change$in$mass.$ • He$carries$his$own$x^ray$with$him.$$

Cancer$care$infrastructure$ Kenya$ No(Na*onal(Cancer(Registry( • No(Na*onal(Screening(for( • Breast,(Cervical,(or(other( Cancers( 2(Cobalt(60(Radia*on(Units(in( • Public(Sector( – Older,(in(need(of(frequent( repair( Oncologists( • – 3((or(4)(Oncologists( – 4((or(5)(Radia*on( Oncologists(

AMPATH^Oncology$ Capacity$Building$for$paBent$care$–$nursing$&$Pharmacy$

AMPATH^Oncology$ Capacity$Building$for$paBent$care$–$Pathology$infrastructure$ PreL2008( 2009L(present( • Pathologic$diagnosis$as$ • Visual$diagnosis$of$most$ accepted$standard$ cancers$ • Turn^around$Bme$for$ • Turn^around$Bme$for$ biopsies$2^4$weeks$ biopsies$of$6^8$weeks$ • Basic,$but$developing,$ • Morphologic$diagnosis$ immuno^staining$ only$ capabiliBes$ • Lack$of$a$funcBonal$ • Up^to^date$populaBon^ cancer$registry$ based$cancer$registry$

AMPATH^Oncology$ Increasing$PaBent$Volume$ • Rapid$rise$in$non^HIV$ Total$Visits$AMPATH^Oncology$ malignancy$referrals$ • Over$9000$visits$in$2012$ • Early$acempt$to$offer$ treatment$to$all^comers$ • Frequent$lack$of$biopsy^ proven$diagnosis$ • Lack$of$standardized$ protocols$ • PotenBal$for$ unsustainable$costs$

Development$of$AMPATH$$ Gyne^Oncology$Program$ • May$2008$–$Dr.$$Orango � $took$4$weeks$observership$at$ PMH.$ • 2009$^Through$Forgarty$Grant$(Pis:$Dr$Mabeya,$Susan$ Cu^Uvin)$a$study$was$iniBated$to$compare$VIA$to$Pap$ smear$in$HIV$+ve$women.$150$women$were$recruited$ in$the$study$and$we$found$VIA$to$be$as$sensiBve$as$PAP$ smear$and$but$the$specificity$was$lower$to$Pap$smears.$ • With$this$findings$MTRH$agreed$to$give$ongoing$ support$for$screening$at$AMPATH$for$HIV$paBents.$$

Achievements:$Gyne^Oncology$ $ • In$2009,$study$iniBated$with$150$paBents$$ • Prior$to$2009,$there$was$no$screening$at$Moi$ • Results:$ – To$date$have$screened$more$than$12,000$women$ – Treated$with$Cryotherapy$324$ – Treated$with$LEEP$250$ • Now$detecBng$early$stage$cervix$cancers$at$ higher$frequency$which$can$be$cured$surgically$ • A$Gyne^Oncology$Curriculum$approved$2012$

AMPATH^Oncology$ Capacity$Building$for$paBent$care$–$treatment$protocols$ • WHO$List$of$ EssenBal$Drugs$ • Research$protocols$that$ use$these$drugs$ • Minimize$toxicity$ • Importance$of$creaBng$a$ standard,$recording$data,$ and$re^assessing$at$ regular$intervals$ Sikora, Annals of Oncology, 1999

AMPATH^Oncology:$PalliaBve$Care$$ • Started in late Sept, 2010 - Growing needs for palliative care (over 60-80% of cancer patients) - IU Palliative Care Physicians, Drs Greg Gramelspacher and Colleen Brown visited MTRH and AMPATH • Recommendations: Kenyan champions, accurate prognostication & good communication • Patient volumes: 783 (2005) ! 5953 (2011)

AMPATH^Oncology$ Capacity$Building$for$paBent$care$–$treatment$protocols$ Similari*es(and(Differences(in(Approach( • Is$it$cancer?$ – Is$there$a$biopsy,$can$we$biopsy,$do$we$need$a$biopsy$ (does$it$really$change$treatment?)$ • Is$it$staged?$ – Can$we$stage,$can$we$afford$to$stage,$will$staging$really$ make$a$difference$in$treatment?$ • Can$we$treat?$ – Is$there$a$surgeon$able$to$do$the$operaBon,$do$we$have$ the$drugs,$can$the$paBent$get$to$radiaBon?$ • Can$the$paBent$and/or$the$system$afford$any$of$this?$$$$$$

AMPATH^Oncology$ MEASURING$SUCCESS$–$LONDON$DECLARATION$ESSENTIAL$STEPS$ " Cancer$Surveillance$and$NaBonal$Cancer$ Plans$ " PrevenBon$Programs$ " Early$Diagnosis$and$Screening$Programs$ " Treatment$ " PalliaBve$Care$$ " Training$and$Research$

$A$Sustainable$Approach$for$Cancer$ Control$$ Screening$ Treatment$ Premorbid$ Cancer$ Health$care$ and$Early$ and$PalliaBve$ Survivorship$ CondiBon$ PrevenBon$ Policy$ DetecBon$ Care$

$A$Sustainable$Approach$for$Cancer$ Control$$ Screening$ Treatment$ Premorbid$ Cancer$ Health$care$ and$Early$ and$PalliaBve$ Survivorship$ CondiBon$ PrevenBon$ Policy$ DetecBon$ Care$ Educa*on( Pa*ent(Care( Research(

Final$reflecBons$on$global$health $ • Care$must$lead$the$way$ • Strategic$partnerships$ • High^income$Countries$need$to$listen,$really$listen $ • LMCs$can$teach$high^income$counBes$how$to$ deliver$more$cost$effecBve$cancer$care ! • The$Academic$triparBte$missions$(service,$ educaBon$and$research)$work$ • AMPATH^Oncology$is$one$such$model !

Acknowledgements$ • Moi$University$ • Moi$Teaching$and$  Pfizer Referral$Hospital$ • Indiana$University$  Eli Lilly • Brown$University$  Levinson Family • University$of$Toronto$ Foundation • Vrei$University$ • University$of$ Massachusecs$