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

Cancer in Kenya: An Experiment in Care

Patrick J. Loehrer Sr., MD Indiana University Melvin and Bren Simon Cancer Center

Building a System of Excellence in Cancer Care in Kenya

The$beginnings$of$a$sustained$ partnership…$

Development$of$a$HIV/AIDS$$ care$program$

Academic$Model$Providing$Access$To$Healthcare$

(formerly$Academic$Model$for$the$PrevenBon$and$Treatment$of$HIV/AIDS)$

$

• 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$

Health Indicators and Outcomes

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.$$

• 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(

Cancer$care$infrastructure$

Kenya$

AMPATH^Oncology$

Capacity$Building$for$paBent$care$–$nursing$&$Pharmacy$

• Pathologic$diagnosis$as$

accepted$standard$

• Turn^around$Bme$for$

biopsies$2^4$weeks$

• Basic,$but$developing,$

immuno^staining$ capabiliBes$

• Up^to^date$populaBon^

based$cancer$registry$

• Visual$diagnosis$of$most$

cancers$

• Turn^around$Bme$for$

biopsies$of$6^8$weeks$

• Morphologic$diagnosis$
• nly$
• Lack$of$a$funcBonal$

cancer$registry$

AMPATH^Oncology$

Capacity$Building$for$paBent$care$–$Pathology$infrastructure$

PreL2008( 2009L(present(

• Rapid$rise$in$non^HIV$

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$costs$

AMPATH^Oncology$

Increasing$PaBent$Volume$ Total$Visits$AMPATH^Oncology$

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$2012$

• 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$intervals$

AMPATH^Oncology$

Capacity$Building$for$paBent$care$–$treatment$protocols$ Sikora, Annals of Oncology, 1999

AMPATH^Oncology:$PalliaBve$Care$$

• Started in late Sept, 2010
• Growing needs for palliative care (over 60-80%
• f 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$$

Premorbid$ CondiBon$ Cancer$ PrevenBon$ Screening$ and$Early$ DetecBon$ Treatment$ and$PalliaBve$ Care$ Survivorship$ Health$care$ Policy$

$A$Sustainable$Approach$for$Cancer$ Control$$

Premorbid$ CondiBon$ Cancer$ PrevenBon$ Screening$ and$Early$ DetecBon$ Treatment$ and$PalliaBve$ Care$ Survivorship$ Health$care$ Policy$

Pa*ent(Care( Educa*on( 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$

Referral$Hospital$

• Indiana$University$
• Brown$University$
• University$of$Toronto$
• Vrei$University$
• University$of$

Massachusecs$

 Pfizer  Eli Lilly  Levinson Family

Foundation