KESHO

1st KESHO-AORTIC-UICC SYMPOSIUM
2021-08-19 17:00 - 20:30 (Africa/Nairobi) | Virtual Event (Zoom), Kenya
Theme: Innovations and Strategies for Screening and Early Detection for LMICs

The Kenya Society for Haematology and Oncology (KESHO), in partnership with the African Organization for Research and Training in Cancer (AORTIC) and with support from the Union for International Cancer Control (UICC) held its 1st Regional Symposium on 19th August 2021 5PM – 8:30PM EAT.
Due to the ongoing COVID-19 restrictions the event was held virtually and attracted over 600 attendees from all over the globe. The Symposium brought together top regional multi-disciplinary professionals with expertise in screening and early detection to share their research and progress in the field. The speakers were drawn from Africa, Asia and North America. The attendees comprised of oncologists, radiologists, haematologists, medical officers, pharmacists, scientists, students, advocacy groups, cancer survivors and persons living with cancer
The theme of the Symposium was on Innovations and Strategies for Screening and Early Detection for LMICs. WHO projects that cancer will be the leading cause of death globally by the year 2030. A major component of any cancer early detection programme is education to promote early diagnosis and ensure compliance with screening programmes. The cancer epidemic represents a huge challenge to LMICs mainly due to lack of screening and early detection, education and costly infrastructure. This symposium sought to show how strategies for screening and early detection of cancer are essential to reduce the proportion of patients presenting advanced disease stages hence increasing survival rates. The symposium provided a platform to promote knowledge exchange especially with the wide variety of speakers from Africa and across the globe. It also highlighted key innovations and treatment approaches for screening and early detection.
The format included different speaker presentations on various topics, Q&A sessions and illustrative presentations by the sector players.
The interactive Q&A sessions provided attendees an opportunity to address issues raised in the presentations. Find below the programme:

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Medical Oncologists
Radiation Oncologists
Clinical and Radiation Oncologists
Paediatric Oncologists
Surgical oncologists
Gynaecological oncologists
Haematologists
Other Specialists with special interest in Oncology
Medical officers and general practitioners working in the Oncology field
Radiation therapists
Medical physicists
Oncology pharmacists

Clinical trial co-ordinators
Oncology nurses
Oncology Social workers
Nutrionists
Sponsoring & exhibiting companies
Registrars and fellows specialising in oncology field
Trainee radiation therapists, medical physicists and oncology nurses
Medical advisors and administration staff involved in authorisation process

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Themes in the Management of Sickle Cell Disease
2021-08-05 19:00 - 20:30 | Virtual Event (Zoom), Kenya
Moderator: Dr. Paresh Dave, Clinical Pathologist, and Haemato-Oncologist, Medirest/
Sponsor: Novartis
Presenters:

Prof. Walter Mwanda, professor of Hematology and blood transfusion, University of Nairobi

Sickle cell disease (SCD) results from glutamine to valine substitution in the beta-globin gene that produces hemoglobin S (HbS). Pathophysiology manifests a complex network of interdependent processes. The patients have a lower life expectancy, with the majority in Kenya being below 12 years old. Less than 5% of SCD patients in Kenya are older than 25 years. The disease is characterized by dense, rigid red blood cells that are easily trapped within organs and have a sluggish microcirculation. Haemolysis is a common manifestation in acute and chronic states. The HbS polymerizes when exposed to reduced oxygenation. This causes deformation and damage to the red blood cells (RBCs) membrane, resulting in intravascular and extravascular hemolysis. The sickle RBCs block blood flow in capillaries and small vessels, causing acute pain in the patients. The immediate effects of hemolysis include loss of RBC which causes anemia, increased levels of toxic heme from the released hemoglobin, which depletes plasma haptoglobin and hemopexin, and saturates scavenger heme-binding proteins. Heme within the vessel interacts with inflammatory cells and the endothelium, damaging it. Anemia is a common manifestation in SCD and may be acute or chronic. Patients with SCD are immune-compromised and should be protected from infections. For example, vaccination together with the use of prophylactic penicillin has greatly reduced mortality and improved life expectancy in children with SCD. Vaso-occlusion is common among patients seeking treatment and is associated with adhesion of the sickle cells, coagulation of platelets, and activation of inflammatory cells. Hypercoagulable state of sickle cell anaemia adds to vascular occlusion. Hypercoagulation results from increased levels of thrombin and fibrin, and a marked increase in circulating tissue factor in the endothelial cells. Blood transfusion is known to worsen coagulation. Acute and chronic forms of organ injury. may occur. The prompt identification of a sickle cell event and timely therapeutic intervention are important prognostic factors, and delays could be life-threatening. Acute complications include acute chest syndrome, cerebral acute events, priapisms, while chronic complications include pulmonary hypertension, hepatic damage, kidney disease, splenomegaly, bone joint diseases, eye disease, and leg ulcers. Treatment is by use of hydroxyurea, bone marrow transplantation, and blood transfusion. However, transfusion therapy results in long-term iron overload complications. This is managed by the use of iron chelator drugs, including deferoxamine and Asunra, especially for patients on long-term blood transfusion. Various clinical trials on lentiviral gene therapy in SCD are ongoing. Gene editing by CRISPR/Cas9 to correct the beta-globin gene in hematopoietic stem cells is also undertrials

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Lung Cancer Management
2021-07-29 19:00 - 20:30 | Virtual Event (Zoom), Kenya
Moderator: Dr. Kevin Makori, Consultant Clinical Oncologist Oasis Specialist Hospital Kisii, Kenya & Lecturer, Maseno University/ JOOTRH
Sponsor: Beacon
Presenters:

Prof. Fredrick Chite Aswira, Consultant Physician, Chief Medical Oncologist & Hematologist, Executive Director of International Cancer Institute (ICI)

Lung cancer is a common cancer globally according to globocan, 2020). However, there is no cancer registry in Kenya, hence the statistics given are approximations. The risk factors include increasing age, history of or current tobacco use, exposure to cancer-causing substances in secondhand smoke, occupational exposure, radiation exposure, air pollution, family history, infection with human immunodeficiency virus, and beta carotene supplements in heavy smokers. There is a need for a high index of suspicion of lung cancer among the caregivers, being the first point of contact, as previous findings have revealed that most patients make several hospital visits before diagnosis. Consequently, most patients are diagnosed at an advanced disease stage and have poor overall survival. The majority of the patients are aged between 60-80 years. Education and training are needed to improve diagnostics in lung cancer in Kenya. Bio-banking of tissues will improve research, to generate knowledge mutations and signaling pathways that may be useful to define mechanisms of drug sensitivity and potential molecular targets. Efforts are geared towards characterizing, optimally treating, and measuring outcomes of lung cancer in Kenya. Limited awareness in the community and among health care providers is a major barrier to lung cancer management. An innovative lung cancer community outreach program targeting high-risk groups including tuberculosis patients was initiated in Kenya. A total of 412 clients were screened for lung cancer where 79 individuals were found to have lung cancer. Lung cancers are heterogenous diseases, hence consideration of the patient’s molecular patterns should be made when initiating treatment. For immunotherapy treatment, PD-L1 expression remains the most important biomarker to personalize immunotherapy, where patients with high PD-L1 expression should be treated with checkpoint inhibitor monotherapy. The addition of chemotherapy may be considered depending on symptom burden, clinical course, and performance status. Immunotherapy improves outcomes for patients with advanced non-small-cell lung cancer. Further research and clinical trials should be done to identify more precise biomarkers and the optimal duration of immunotherapy. The high cost of drugs and the challenges with the importation of essential drugs further limits the effective management of lung cancer. Currently, there are no patient assistance programs hence patients bear the cost of treatment.

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Practical Aspects of Immunotherapy... is Kenya Ready?
2021-07-22 19:00 - 20:30 | Virtual Event (Zoom), Kenya
Moderator: Dr. Amina K Habib, Medical oncologist, Aga Khan University Hospital, Mombasa
Sponsor: Beacon
Presenters:

Dr. Andrew Odhiambo, Consultant Physician, and Medical Oncologist, Head, Thematic Unit of Medical oncology & Lecturer, University of Nairobi.

Immunotherapy is a form of cancer treatment that uses the power of the body’s own immune system to prevent, control, and eliminate cancer. William Coley is known as the “father of immunotherapy”, where he successfully used Coley’s toxin to treat cancer patients. Immune checkpoint inhibitors are the most common immunotherapies, including PD1/PDL1 and CTLA4. The demand for immunotherapy treatment is increasing and the expertise in Kenya is growing. This treatment has a minimum toxicity profile, where the colitis associated with immunotherapy is immune-mediated and not an infection. The high cost of treatment is a major challenge to the use of immunotherapy since the patients bear the cost of the drugs, hence the need for the Kenyan government to work with the manufacturers to bring the prices down. Additionally, the treatment is not available in public hospitals in Kenya, and there is a need to lobby for their availability in public referral hospitals. There are few clinical trials in oncology in Kenya. Oncologists need to do more research to generate data and to publish the outcomes, in addition to building capacity for clinical trials in Kenya. Aga Khan is undertaking a clinical trial that is studying biomarkers that can predict response to immunotherapies. This will guide the choice of patients who would benefit from immunotherapy treatment. Before using immunotherapy as the first line of treatment for non-small cell lung cancer, one has to check the presence of mutations that may give inferior benefits to the patients. Immunotherapy and chemotherapy combinations have no effects on neutropenia. Generic immunotherapy and biosimilars are also effective in the treatment of various forms of cancers. Chimeric Antigen Receptor engineered T cells (CAR T cells) are a form of immunotherapy used to treat aggressive relapsed and relapsed non-Hodgkin’s Lymphoma. Unfortunately, they are very expensive.

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Endometrial Cancer
2021-07-15 19:00 - 20:30 | Virtual Event (Zoom), Kenya
Moderator: Dr. Gregory Ganda, Gynaecology oncologist Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH Sponsor: AMRING Presenters:

Dr. Khadija Warfa, Gynecologic oncologist, Aga Khan University Hospital
Dr. Ahmed Komen, Clinical and Radiation Oncologist, Kenyatta National Hospital/AKUH.

To date, many cancers are affecting the uterus. Endometrial cancers (EC) affect the endometrial lining of the uterus and are more common in North America and parts of Russia and China. They are less common in sub-Saharan Africa, and mostly affect postmenopausal women with an average age of 64 years. Obesity is a major risk factor for EC oncogenesis. Hereditary risk factors for EC pathogenesis include Lynch and Cowden syndromes. Proper diet and regular exercise, use of hormonal contraception, multiple childbirths, and breastfeeding decrease the risk of EC. Clinical presentation of EC is mainly abnormal/postmenopausal bleeding, while advanced disease presents with pelvic and abdominal symptoms resembling ovarian cancer. Diagnosis is by office pipelle biopsy and hysteroscopy biopsy. Women with ET >4-5mm on transvaginal ultrasound and also post-menopausal women with endometrial fluid >11mm and are asymptomatic should get a biopsy. The gold standard for imaging is MRI. The primary treatment for uterine-confined endometrial carcinoma is TH/BSO and lymph node assessment, where sentinel node assessment has been shown to reduce complications related to complete lymphadenectomy. Molecular classification of EC is encouraged in all endometrial carcinomas, especially in high-grade tumors. In molecular dualistic classification, type I tumors are estrogen-dependent, and associated with endometrial hyperplasia, while Type II tumors are estrogen-independent and associated with endometrial atrophy with a poorer prognosis. The WHO histologic classification involves endometrial epithelial tumors and serous endometrial cancer. Clear cell carcinoma accounts for <10% of endometrial adenocarcinoma. They demonstrate molecular heterogeneity and can overlap with serous and endometrial carcinoma. Carcinosarcoma represents 5% of EC. The benefit of molecular classification is that the method is based on more objective variables and it identifies significantly more patients with favorable features that would otherwise be classified as a high intermediate risk with pathology review alone. Unlike other cancers, FIGO staging does not determine the patient outcome, because some of the prognostic characteristics of the disease have not been incorporated in the staging. Early presentation following post-menopausal bleeding results in a generally good prognosis but should be treated using an evidence-based protocol. Considerations for adjuvant treatment include the extent of surgery, adequacy of the pathology report, risk stratification, and molecular classification. Lymphadenectomy should be considered for high intermediate-risk patients for adequate staging and optimal tailoring of adjuvant treatment. Radiotherapy can be used for definitive treatment on patients not candidates for surgery, patients with recurrent disease, and also for palliation. In a rural setup where resources are constrained, an ultrasound can be done, followed by a referral to a facility with the necessary resources and personnel.

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Head and Neck Cancer
2021-07-08 19:00 - 20:30 | Virtual Event (Zoom), Kenya
Moderator: Dr. Primus Ochieng, Programme Director of MMed Radiation Oncology training at the University of Nairobi. He is both a Lecturer and a Consultant Clinical Oncologist at Kenyatta National Hospital
Sponsor: Merck
Presenters:

Dr. Njoki Njiraini, Consultant Clinical Oncologist at The Nairobi Hospital
Dr. Chege Macharia, Head and Neck Surgeon at AIC Kijabe Hospital

Head and neck cancers encompass a variety of cancers. The risk factors for their oncogenesis include lifestyle, environmental factors, age (over 45 years), and gender (which affects more males than females). To reduce the risk, health education should focus on proper feeding habits, human papillomavirus vaccination, use of appropriate personal protective equipment (PPE) at places of work, use of sunscreen by the population at risk, and good oral hygiene, in addition to annual dental check-ups. Local clinical examination of the tumor size is necessary. Tissue biopsy and imaging are necessary for correct staging and to select patients who would benefit from chemotherapy. Consequently, the choice of therapy should consider patient and disease factors and the functional outcomes. Clinical examination can give a lot of information about the patient. Proper management of head and neck (H and C) tumors is hindered by late-stage patient presentation, socioeconomic challenges, and resource strain on health care infrastructure. To overcome these challenges, multidisciplinary teams (MDT) and contextualized national management guidelines have been established to help in the management of H and C cancers. Dentists are an important part of the MDT as they help in diagnosis and patients follow-up after treatment, to check on their dental health. Surgery for H and C cancers should preserve organs. Although reconstruction surgery is necessary, it is more common in the west, but not available in our African setup due to scarcity of resources. Patients who develop mucositis after radiation must be well managed since they have challenges with feeding and drinking, hence are likely to become dehydrated and malnourished. The future of H and C management will involve training and fellowship programs and homegrown solutions. Merck is offering cetuximab (Erbitux), a monoclonal antibody that targets the epidermal growth factor receptor (EGFR) and is active in a variety of EGFR-expressing tumors.

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The Unmet Need In Previously Untreated Stage IV CD30+ Hodgkin's Lymphoma
2021-07-06 19:00 - 20:30 | Virtual Event (Zoom), Kenya
Moderator: Peter Oyiro, Medical Oncologist Kenyatta National Hospital Teaching and Referral Hospital
Sponsor: Takeda, a pharmaceutical company with a patient assistance program for Hodgkin’s lymphoma in Kenya.
Presenters:

Prof. N.A.O.Abinya, Medical Oncologist, the Nairobi Hospital Cancer Centre.
Prof. John Radford, Professor of medical oncology, University of Manchester, Director of Research at the Christie NHS Foundation Trust. Both partners in the Manchester Cancer Research Centre.

Hodgkin lymphoma (HL) is a germinal center B cell lymphocytic lymphoma with Reed-Sternberg cells and their variants. It is less frequent than non- Hodgkin lymphoma (NHL) and constitutes 10% of all lymphomas. It is more prevalent in black males all over the world. It has a single peak age of occurrence at 17 years and a bimodal incidence with a peak age between 15-30 years and 50-70 years. It is more frequent in cases with mixed cellular histology, males, children, and older adults and is more prevalent in developing countries. Although the etiology is unknown, immune depression, infectious agents, and environmental factors are associated with the disease. Up to 40% of HL cases are associated with infection with Epstein-Barr-Virus (EBV), an oncovirus whose oncogenes generate a particular phenotype of the Hodgkin Reed-Sternberg (HRS) cells. HRS attracts a supportive microenvironment of immune and stromal cells, suppressing local immune responsiveness. Furthermore, EBV induces epigenetic changes in the host genome, in addition to altering the composition and activity of the immune cells surrounding the HRS cells. The mechanisms of tumorigenesis involve dysregulation of several signaling networks and transcription factors including NFkB, possibly by CD30 receptor signaling, leading to genomic alterations affecting RS cell survival and immune evasion. Although there are no genetic defects to malignant HRS cells, a number of molecular defects have been demonstrated. HL presentation involves a single peripheral lymph node with a centrifugal distribution and a continuous spread. Splenomegaly occurs in 50% of cases during the course of the disease. HL staging is by history, physical examination, blood hematology and chemistry, bone marrow aspirate, and biopsy and imaging. About 95% of early HL is treated while for advanced disease, 70% of the cases are cured. Radiotherapy is now obsolete while chemotherapy is the common mode of treatment. Antibody therapies, immunotherapies, and immune checkpoint inhibitors mainly targeting programmed cell death 1 (PD-1) are available. However, when used on their own, they hardly induce a complete response; instead, they convert HL into a chronic disease. Newer combinations of drugs are in use. Unlike in NHL, CAR-T cells do not work in HL, due to the absence of the target, CD19. Brentuximab vedotin is an antibody-drug conjugate targeting CD30 and is effective as a single agent in relapsed/refractory Hodgkin lymphoma. Although EBV is associated with so many cancers, there is no vaccine targeting this oncogene. The cost of treatment is a major challenge to many patients in developing countries. Quality of cure is also a major concern in developing as well as developed countries.

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Cancer And COVID 19
2021-07-01 19:00 - 20:00 | Virtual Event (Zoom), Kenya
Moderator: Dr. Mohammed Ezzi
Sponsor: AstraZeneca, a global, science-led, patient-focused biopharmaceutical company
Presenters:

Dr. Mary Nyangasi, Head of Division, National Cancer Control Program, Ministry of Health, Kenya
Dr. Catherine Nyongesa, Clinical Oncologist, Texas Cancer Center, Nairobi and Kenyatta National Hospital.

Cancer is a major cause of morbidity/mortality, where 70% of all cancer mortality occurs in low and middle-income countries. COVID origin remains unknown, although the first case was reported in Wuhan, China in 2019, and the official name was declared in Feb 2020. The pandemic has greatly affected cancer patients, their families, and caregivers. Common symptoms of COVID 19 include fever, chills, cough, and shortness of breath or difficulty in breathing, fatigue, and body aches. Control measures include cleaning of frequently used surfaces, use of detergent or soaps and water, disinfection, maintaining social distance, and wearing masks in public places. If quarantined, stay home and monitor your health, check if you have symptoms, stay away from others, especially those at a high risk of COVID infection. There is no specific report of increased incidence of COVID-19 asymptomatic infections in cancer patients, although data from China, the USA, and Italy confirms a higher risk. Cancer cases are grouped into high-priority cases which are life-threatening conditions, clinically unstable, and require intervention. The medium-priority cases are non-critical but delayed intervention could impact the overall outcome. The low-priority cases have a stable condition; hence services can be delayed for the duration of the COVID-19 pandemic or is non-priority. COVID has drastically impacted the screening and diagnosis, treatment, palliative care, and follow-up of cancer patients. Additionally, adjustments have been made for logistics and supplies of cancer drugs and other essential commodities. To counter the effects of COVID on cancer patients, the ministry of health listed cancer as an essential service and recommended that cancer centers remain open and encouraged telemedicine and alternative treatment. Additionally, personal protective equipment and medicines were distributed to the regional cancer centers by use of courier services. Socioeconomic support for vulnerable cancer patients were provided through the Ministry of Labor and Social Services. The current policy guideline is for cancer programs to continue offering services following strict COVID-19 preventive measures, and for the cancer patients to observe all the control measures. In addition, doctors should consider scheduling treatment to avoid delays and rescheduling, minimize outpatient visits, and reduce hospital visits for patients on oral treatment by offering at least 3 courses. Patients can have some tests done near home, and then call the doctor to give a report. Follow-up visits can also be delayed or the patients can visit the nearest hospitals. Also, there is a need for increased surveillance while treating lung cancer patients and the elderly as they may have symptoms similar to those in COVID 19 patients. The caregivers and patients in cancer centers should be screened and positive cases should be referred to the relevant caregivers. Multidisciplinary tumor boards (MDTs) are encouraged in decision-making as they can discuss the benefits and risks of present therapies. Non-life threatening conditions may explore the possibilities of watchful waiting. Additionally, oral therapies may be alternatives to chemotherapies. Adjuvant therapies are highly recommended for patients with resected high-risk diseases who are set to benefit from treatment. Late presentation is a major challenge in cancer management in the country. Vaccination of cancer patients is generally safe, but the timing of vaccination depends on the treatment that the patient is receiving.

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Role of New Therapies in the Management of ITP and Other Haematological Disorders
2021-06-24 19:00 - 20:30 | Virtual Event (Zoom), Kenya
Moderator: Dr. Fatmah Abdallah, Haematologist and pediatric Oncologist
Sponsor: Beacon
Presenters:

Prof. Malkit Riyat, Associate professor of hematology and Consultant hematologist, Aga Khan University Hospital, Nairobi

Immune thrombocytopenia (ITP) is an acquired autoimmune hemorrhagic disorder characterized by low platelet count. This may be as a result of platelet destruction or impaired platelet production. A platelet count in peripheral blood less than or equal to 100×10^9/L is the most important criterion for the diagnosis of ITP. It has an incidence of 2to 5 per 100,000 persons and may be either primary or secondary. Pathogenetic mechanisms of ITP involve platelet autoantibodies, T lymphocytes, and impaired thrombopoiesis. Clinical presentation is the increased bleeding tendency, petechiae, and mucosal hemorrhages. Additional symptoms include exhaustion and fatigue, depressive disorders, anxiety, increased risk of infection, and iron deficiency anemia. Predictors of bleeding include severe thrombocytopenia, chronic ITP, history of major bleeding, older age (>60 years), patients on anticoagulants or antiplatelet agents. The goal of treatment is to achieve adequate hemostasis and not to achieve a normal platelet count. Initiation of treatment should put into consideration the age of the patient, upcoming surgery, comorbidities associated with the risk of bleeding, antiplatelet medications or anticoagulation, distance from the hospital and ability to follow up, and additional symptoms such as fatigue. Platelet count is the most important measure of disease activity and is inversely correlated with morbidity from bleeding. Management of newly diagnosed ITP maybe by observation for individuals with a platelet count greater than or equal to 30×10^9/L and asymptomatic or minor mucocutaneous bleeding or by use of corticosteroids for individuals with a platelet count less than 30×10^9/L and asymptomatic or minor mucocutaneous bleeding. This is dependent on factors that impact the risk of bleeding, including the degree of thrombocytopenia, patient comorbidities, medications, and age. Other factors to consider include the disease duration, access to care, quality of life implications, patient and provider preferences. Conventional first-line therapy includes corticosteroids, intravenous immunoglobulin, and watch-and-wait. Second-line treatments include immunosuppressive therapy and splenectomy.

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Cytoreductive Surgery (CRS) And Hyperthermic Intraperitoneal Perfusion (HIPEC)
2021-06-22 19:00 - 20:30 | Virtual Event (Zoom), Kenya
Moderator: Dr. Mohammed Ezzi
Sponsor: RAND
Presenters:

Prof Ignace De Hingh, MD, PhD, Catharina Cancer Institute, Eindhoven, The Netherlands
Umberto Carletti, Clinical perfusionist, Product Manager, RAND
Dr. Abdi Hakin Mohammed, Surgical Oncologist, and Consultant Laparoscopic Surgeon, Mombasa.

Peritoneal metastases (PM) affect hundreds of thousands of patients a year globally. The patients have a very poor prognosis, without adequate treatment. PM is not a systemic but a regional disease, initially regarded as untreatable, resistant to systemic chemotherapy, and refractory to surgery. Accumulating evidence suggests that PM can be treated by radical regional combination therapy. Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal perfusion (HIPEC) is associated with significantly improved recurrence-free and overall survival in ovarian and Pseudomyxoma peritonei (PMP low-grade rare clinical condition) patients, without increasing toxicity. CRS-HIPEC program can be safely implemented in high-volume dedicated centers, though currently, there is an unmet need for this technology since there is no center in Kenya offering the services. Rand Company in Italy is producing systems for HIPEC, which ideally should be effective, easy to use with automatic functions, traceable, safe, controlled, and supported by clinical experts. The cost of installing the machine is on average 3.4-4 million Kenya shillings and is cost-effective since each procedure requires one kit. The machine is easy to use and any nurse can use the machine without perfusion skills. The company offers training to individuals using the machine in their respective countries.

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Colon Cancer
2021-06-15 19:00 - 20:30 | Virtual Event (Zoom), Kenya
Moderator: Dr. Angela McLigeyo, Physician and medical Oncologist, JOOTRH, Kenya
Sponsor: Beacon
Presenters:

Dr. Caroline Tonio, Consultant Physician and Medical Oncologist, Muranga County Hospital, Kenya.
Dr. Abdi Hakin Mohamed, Surgical Oncologist, and Consultant Laparoscopic Surgeon, Mombasa.

The incidence of colorectal cancer in Africa is increasing. In Kenya, it ranks position 5, with the majority of patients being young (age group 41-50 years). The disease is most common in the rectum, with a proximal anatomical distribution. The 5-year survival rate for localized cancer is 90% while for distant disease, it’s almost 15%. Kenya has a relatively lower incidence of colorectal cancer compared to western countries with the incidence being higher in men. The major risk factors include environmental, diet, familial syndromes, and inflammatory bile diseases. Mortality is associated with the male gender, presence of comorbidity, recurrence, disease stage, and receipt of chemotherapy. 8-29% of patients with colorectal cancer present with an emergency obstruction of the bowel at the time of diagnosis. Acute obstruction is associated with high morbidity and mortality. High-risk patients require regular screening. Due to late presentation, and lack of screening capacity, it’s difficult to detect early lesions. Consequently, most patients end up with abdominoperineal resection with a poor prognosis. Treatment recommendation for invasive colon cancer is dependent on the pathological stage of the disease and is mainly guided by specific Biomarkers. Curative intent surgery depends on the location of the tumor and involves removing the tumor-containing a segment of the bowel with adequate margins, by en bloc excision of the mesentery containing the feeding vessels and regional lymph nodes. Removal of as many lymph nodes as possible increases the patient’s survival. Complete mesocolic excision and 3D lymphadenectomy are associated with higher complication rates, but no differences in post-operational mortality. They have positive effects on 5 years of overall survival and three years of disease-free survival. Additionally, they are associated with decreased local and distant recurrences. Surveillance for stage I disease requires colonoscopy 1 year after surgery, while stage II and III of the disease require more than just colonoscopy. Stage IV is generally incurable except in a small subset of patients with oligometastases, where curative intent may be considered. Primary tumor sidedness has prognostic and predictive significance, where right-sided tumors seem to be associated with inferior outcomes. Such tumors are associated with age and methylation phenotypes. Surgery in rectal cancer is very complicated because oncologists have to determine the probability of maintaining or restoring bowel functions versus anal continence and preserving genitourinary functions. Consideration is made as to whether the intention is curative or palliative. The risk of pelvic recurrence is higher in patients with rectal cancer compared to those with colon cancer, where locally recurrent rectal cancer is associated with a poor prognosis. Enhanced Recovery After Surgery (ERAS), involves multimodal perioperative pathways, which have successfully reduced in-hospital stay, medical complications, and costs. Laparoscopy is a minimally invasive procedure with better postoperative outcomes including reduced rates of surgical site infections, incisional hernias, and small bowel obstructions than ERAS. The ultimate goal of oncological surgery is an in toto resection of the primary tumor together with its entire lymphatic drainage territory to achieve low locoregional recurrence rates with long overall and disease-free survival rates. Adjuvant treatment declines with age. Currently, neoadjuvant therapy is under consideration with very promising results. Although there is the availability of molecular testing, high cost remains a major barrier for the patients to access the services.

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Immunotherapies In Gastrointestinal Cancers - Focus On Esophageal And Liver Cancer
2021-06-10 19:00 - 20:30 | Virtual Event (Zoom), Kenya
Moderator: Prof. Asim Jamal Shaikh, Associate professor of Medicine, Consultant Medical Oncologist, Aga Khan Hospital, Nairobi
Sponsor: Roche
Presenters: Dr. Sitna Mwanzi, Consultant Physician and Medical Oncologist, Aga Khan Hospital, Nairobi
Cancer immunotherapies involve harnessing cytokines, vaccines, cell therapy, and immune checkpoint inhibitors to fight cancer cells. The interaction of antigen processing and presenting cells (APC) with T cells requires two costimulatory signals to activate T cells. Cytotoxic T lymphocyte antigen 4 (CTLA4) competes with CD28 for B7 on dendritic cells to prevent T cell activation. Blocking CTLA4 binding to B7 removes the inhibition, resulting in T cell activation. Some immunotherapies target blocking PD1 from binding to PDL1, thus restoring T cell expansion and activation. There is a need for biomarkers study to generate more data on mechanisms of interaction of host immune and tumor cells. Gastrointestinal cancers (GI) constitute ¼ of cancers diagnosed globally with colon cancer leading among the GI cancers. There is increased incidence and mortality for GI cancers. For the management of stage II and III diseases, neoadjuvant and surgery improve survival. Additionally, adjuvant nivolumab for one year doubles disease-free survival. In metastatic disease, the addition of immunotherapy in the first and later lines of treatment to chemotherapy improves overall survival. Sequencing of treatments is highly recommended in the region. It is also important to consider the duration of the treatment and its accessibility by the patients. Additionally, it is important to consider whether we can handle the associated toxicities. Assessing patients’ response to treatment using IRECIST and biomarker testing by immunohistochemistry and next-generation sequencing is recommended. The high cost of immunotherapies prevents some patients from accessing treatment. There are challenges with timely diagnosis especially in resource-constrained countries since most health facilities in Kenya lack the necessary equipment for performing Fluorescent In situ hybridization (FISH) and have to send samples for diagnosis outside the country. This comes with additional costs that most patients cannot afford. Patient selection is very important when deciding on the correct treatment since those with advanced disease may not be initiated on treatment but will instead be referred for palliative care and support.

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Strategic Cancer Advocacy- Meaningful Engagement Of Cancer Survivors
2021-06-03 19:00 - 20:30 | Virtual Event (Zoom), Kenya
Moderator: Muthoni Mate, Founder Cancer Cafe
Sponsor: Takeda, a pharmaceutical company with a patient assistance program for Hodgkin’s lymphoma in Kenya.
Presenters:

Christine Mugo-Sitati, Executive director KENCO
Dr. Zipporah Ali, Palliative Care Specialist and advocate
Benda Kithaka, Executive director, Kilele health
Philip Odiyo, Psycho-oncologist, Faraja
Livingstone Simiyu, Lawyer and Secretary HENZO Kenya
Wanjiru Githuka, Chairlady CSAK

Kenya Network of Cancer Organization (KENCO) is an umbrella body for civil society groups involved in meaningful engagement with cancer survivors. KENCO groups provide information, education, and screening of cancer while some member groups are involved in patient navigation to access health services. They are also involved in palliative care and advocacy, influencing policy and representing cancer patients in government. They compliment the government in providing financial and psychosocial support to the patients, sensitize and build capacity for the health care workers, and provide basic information to cancer patients to ensure patient needs are met. The National Cancer Act 2012 provided a legal framework on how to deal with cancer patients. There are calls by various bodies to decentralize cancer services to the counties, in order to ease the financial burden and to enable patients to adhere to treatment. This would greatly improve cancer services delivery in the country. The unavailability of locally generated data on cancer survivorship demonstrates the need to focus on research and clinical trials, and to publish the research findings. Data generated from research will guide informed policy development. Public education on what services the Universal Health Care (UHC) has for cancer patients, is a step in providing financial support to the patients, especially since the National Hospital Insurance Funds (NHIF), do not comprehensively cover cancer treatment. In addition, private insurers and families are encouraged to supplement NHIF. Community and public engagement efforts about a healthy lifestyle and health-seeking behavior would help to reduce the number of cancer patients in the country. Additionally, public education will help to reduce stigmatization and discrimination of cancer patients. Early diagnosis is a major challenge for childhood cancers, due to late patient presentation. Since over 60% of children with cancer are cured with timely intervention, there is a need for parents to be on the lookout for any abnormal signs in children.

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HR+/HER2-Ve Advanced Breast Cancer
2021-05-27 19:00 - 20:30 | Virtual Event (Zoom), Kenya
Moderator: Prof Alice Musibi, Assistant Professor and Medical Oncologist, Kenyatta National Hospital
Sponsor: Novartis
Presenters:

Dr. James Mbogo, clinical oncologist working with Dr. Vj Oncology Associates based at the Nairobi West Hospital.

Treatment choice for advanced breast cancer should take into account hormone receptor and HER-2 status and germline BRCA status of the patient, in addition to PIK3CA in HR+ and PD-L1 in TNBC patients. It’s important to consider the accessibility of targeted therapies, previous therapies, and their toxicities. Other important factors to consider include tumor burden, biological age, comorbidities, menopausal status, need for rapid disease/ symptom control, socioeconomic and psychological factors, available therapies, and patients preference. Endocrine-based therapy is preferred for hormone receptor-positive disease in patients with visceral disease. The presence of visceral crisis as a result of severe organ dysfunction can be determined by signs and symptoms, laboratory studies, and rapid progression of the disease. Its presence implies important visceral compromise; a clinical indication for a more rapidly efficacious therapy, particularly because another treatment option at progression will probably not be possible. For pre-menopausal women for whom endocrine therapy was decided, ovarian suppression/ablation (through surgery and radiation) combined with additional endocrine-based therapy is the preferred choice. Primary and secondary endocrine resistance after endocrine therapy is associated with various mechanisms. A CDK4/6 inhibitor combined with endocrine therapy is the standard of care for patients with ER+/HER-2 negative advanced breast cancers. The body composition parameters may influence prognosis in patients receiving CDK4/6 inhibitors, whose side-effects include bone marrow toxicities, liver enzymes, fatigue, pain, skin toxicities (rashes), vomiting, and neutropenia.

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Updates in the Management of Neuroendocrine Tumors
2021-05-20 19:00 - 20:30 | Virtual Event (Zoom), Kenya
Moderator: Dr. Njoki Njiraini, Resident Clinical and Radiation Oncologist at The Nairobi Hospital. Sponsor: Novartis Presenters:

Dr. Primus Ochieng, Programme Director of MMed Radiation Oncology training at the University of Nairobi. He is both a Lecturer and a Consultant Clinical Oncologist at Kenyatta National Hospital

Neuroendocrine tumors (NET) are a common malignant transformation of cells in the diffuse neuroendocrine system that regulates motility and secretion. The tumors are heterogeneous with a wide variety of clinical presentations and are difficult to diagnose. Neuroendocrine carcinomas are poorly differentiated with increased expression of Ki67. Most patients present with advanced disease and have a median survival of 33 months. NETs are distributed all over the body. Over 95% of NET is sporadic, with only a small percentage being genetic-related. Currently, there are no preventive strategies and no screening guidelines. Initially, the classification of NET was based on the tissue of origin. To date, WHO classification is based on grading and staging. Classification can also be based on functioning versus Non-functioning NET. Presentation is by tumor growth with pain, obstruction hepatomegaly, and early satiety. Diagnosis is by a systematic approach including history and physical examination, biochemical markers, and imaging, although conventional imaging has a limited role in diagnosis. Chromogranin A (CgA) is a valuable diagnostic and prognostic tool that can be used to monitor treatment response. It is more sensitive than radiology for measuring progression. The major challenge with this testing method is that other conditions can cause elevated CgA and also the CgA values vary considerably between different types of NETs. The test kits are also not universally standardized. Therapies for NETs apply three principles: surgical therapy, (best treatment option), symptomatic therapy, and anti-proliferative therapy. The current focus is shifting from symptom management to targeting tumors. Chemotherapy including temozolomide and capecitabine has been shown to improve overall survival benefits, better response, and progression-free survival. Considering immunotherapies, Pemblolizumab has benefits in NET tumors. Radiotherapies have palliative use. Although NETs are well managed with targeted therapy, the technology is not currently available in Kenya. Considering limited available data, there is a need to work in groups and generate local data on NETs.

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Chronic Myeloid Leukemia (CML) Treatment In Kenya
2021-05-13 19:00 - 20:30 | Virtual Event (Zoom), Kenya
Moderator: Prof. N. A. O. Abinya, Medical Oncologist, the Nairobi Hospital and GIPAP Physician
Sponsor: Novartis
Presenters:

Dr. Peter Oyiro, Medical Oncologist Kenyatta National Hospital Teaching and Referral Hospital

Chronic Myeloid leukemia is a cancer of bone marrow stem cells. The only known risk factors are radiation from nuclear reactors, with no evidence of heredity risk factors. It is characterized by a translocation between chromosomes 9 and 22, which results in an abnormal juxtaposition of two genes, bcr, and abl. It accounts for 15% of all leukemia cases and has an annual incidence of 1.5 cases per 100000 individuals. The median age at diagnosis is 55-65 years, with a median survival of 3-7 years. The clinical presentation is usually massive splenomegaly, where the disease has three phases: chronic, accelerated, and blast. Most patients are diagnosed in the chronic phase, often without symptoms. If untreated, all patients progress to the accelerated/blast phase within 3-5 years. Diagnosis is by physical examination of the spleen and liver size, complete blood cell count, bone marrow aspirate for cytological examination and cytogenetic, fluorescence in-situ hybridization, reverse transcriptase-polymerase chain reaction (RT-qPCR). Late referrals, inadequate infrastructure, and trained physicians are major challenges to diagnosis. The life expectancy of newly diagnosed patients with CML in the chronic phase is now very close to age-matched individuals in the general population of Western countries. In resource-constrained countries e.g. Kenya, the goal of treatment remains survival. The Glivec International Patient Assistance Program (GIPAP) is an international drug donation program established by Novartis Pharma AG and implemented in partnership with the Max Foundation. It has provided imatinib to eligible patients in Kenya since 2002, at the Nairobi and the Aga Khan Hospitals for free. Patients with CML diagnosis can be referred to the GIPAP. Before imatinib was approved (FDA 2001), most patients were being treated with supportive care, hydroxyurea, interferon, and allogeneic hematopoietic cell transplantation (“bone marrow transplant”). Today, CML management in Kenya is mainly based on imatinib. Those failing therapies are put on second and third-generation TKIs. It’s important to check on kinase mutations that confer resistance to kinase inhibitors. Patients resistant or intolerant to imatinib can be treated with nilotinib. The main goal of treatment is to reduce the leukemic burden and the risk of progression to AP or BC. However, if the warning signs are not recognized early, treatment can be either a success or a failure. Molecular responses such as MMR are associated with improved survival outcomes. The major challenge with treatment is the unavailability of some drugs and high prices. Due to the COVID-19 pandemic, there is a switch from physical to virtual review of files. The pandemic has greatly affected adherence and compliance to treatment.

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Optimizing Cancer Research in Kenya
2021-05-06 19:00 - 20:30
Moderator: Dr. Veronica Manduku, Radiologist at Kenya Medical Research Institute
Sponsor: Roche
Presenters:

Prof. Mansour Saleh, Chair, Department of hematology and oncology and consultant medical oncologist, Aga Khan University Hospital, Nairobi.
Prof. Fredrick Chite, CEO/Executive Director of International Cancer Institute (ICI)
Prof. N.A.O. Abinya, Medical Oncologist, the Nairobi Hospital and GIPAP Physician
Dr. Robai Gakunga, Independent Research Scientist, USIU-Africa

Cancer research in Kenya is mainly in the universities and is more of epidemiological studies with limited clinical research. Considering the increasing demand for cancer research in Kenya, there is a need to develop a curriculum, build capacity and create infrastructures to support quality research. Many drugs used in Africa are not tested in Africa, despite research showing variations in transcriptomics for example in triple-negative breast cancer for different races. Cancer research requires a multidisciplinary approach (MDT). Funding is a major challenge in cancer research. Additionally, managing clinical practice and research becomes difficult in Kenya where clinicians are expected to spend 100% of the time in practice, unlike in the USA, where there is the flexibility of working hours. In the USA, a clinician can spend 50% of the time in clinical practice and 50% in research. In Kenya, the workloads for doctors, clinicians, and lecturers are overwhelming, with no protected time for research from the institutions. In-Africa collaborations, as opposed to Africa-America, and networks between clinicians, consultants, academic institutions, and government agencies, would greatly help to generate local data. Data sharing and Trust is needed and the ability to work together to accomplish a goal. The University of Nairobi has an oncology training fellowship that is helping to build capacity in the region. Commitment in science for clinicians as well as developing and reviewing protocols collectively is necessary. Considering the high cost of cancer drugs, cancer clinical trials should seek collaborations with pharmaceutical companies. Community and patient engagement are important in clinical trials. There is a need for a data repository and registries. There is an epidemiological registry in breast cancer collected at Kenya National Hospital in collaboration with Roche. Collaborations will facilitate sharing of human resources, infrastructure, and samples. The literature review is equally important. The exchange program for fellows helps with gaining experience to see what other researchers are doing. Scientists are encouraged to apply for research grants, however small. There is a need for seed funds for young investigators. Government-government collaborations are also encouraged. Research governance is necessary. in lobbying government funding, in priority areas including the most prevalent cancers (breast cancer in women, prostate cancer in men).
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Testicular Cancer
2021-04-29 19:00 - 20:30
Moderator: Peter Oyiro, Medical Oncologist Kenyatta National Hospital Teaching and Referral Hospital
Sponsor: Glenmark
Presenters:

Dr. Amina H. Kidee, Medical Oncologist Aga Khan University Hospital
Dr. Carnjini Yogeswaran, Consultant Urological Surgeon, Aga Khan University Hospital

Testicular cancer (TC) accounts for less than 1% of adult neoplasms and 5% of urological tumors. It’s the most commonly diagnosed cancer in young men (20-34 years), and the incidence is increasing in industrialized countries., but there is a need for local data to determine incidence in Africa. It is predicted that the survival rate in Kenya is low since the disease is not diagnosed early. The risk factors for TC oncogenesis include cryptorchidism, history of subfertility, contralateral history of testicular cancer, history of germ cell neoplasm in situ, family history of TC, race, age, and HIV. Individuals at high risk should be informed about the importance of physical self-examination. WHO classification of TC is based on the tumor origin, and the presentation may be localized or disseminated. Diagnosis is by history, examination, imaging, and serum tumor markers used for prognosis and staging. Transcrotal ultrasound with Doppler is performed to confirm a testicular mass, to determine whether a mass is intra or extra testicular, and to explore the contralateral testis. Transscrotal biopsies of the testes should not be performed because of the risk of tumor cells seeding of the inguinal and pelvic lymphatic drainage. The biopsy is also of limited value because testicular germ cell tumors are heterogeneous. Management of the disease requires an integrated multidisciplinary team (MDT). Removal of the entire organ is necessary to properly identify the histologic type(s) present and to select the appropriate therapy. Radical inguinal Orchidectomy is the standard of care and involves the division of the spermatic cord at the internal inguinal ring. The scrotal approach should be avoided. Chemotherapy should be initiated prior to orchidectomy where applicable, to control the disease and stabilize the patient. Testis sparing surgery aims to preserve fertility and hormonal functions. Patients should be counseled and be informed of the risk of local recurrence which is 8%. The testicular prosthesis should be offered to all patients undergoing unilateral or bilateral orchidectomy. It can be inserted at orchidectomy or subsequently. Contralateral testicular biopsy should be offered to high-risk patients. Semen abnormalities occur in 24-50% of TC patients even prior to orchidectomy. Additionally, chemotherapy and radiotherapy can impair fertility. Semen preservation by sperm banking (cryopreservation) should be offered to all patients.

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Rectal Cancer – Multidisciplinary Approach
2021-03-18 19:00 - 20:30
Moderator: Dr. Njoki Njiraini
Sponsor: Roche
Presenters:

Dr. Anthony Ndiritu, Consultant Clinical Oncologist, Kenyatta National Hospital (KNH)
Dr. Alex Muturi, Consultant General Surgeon & Endoscopist, Kenyatta University Teaching Referral and Research Hospital (KUTRRH)

Management of colorectal cancer requires staging and risk assessment by a multidisciplinary team (MDT) to help in decision making and to audit and review the outcomes. Nutrition therapists are part of the MDT as the patients need to be nutritionally optimal before chemoradiotherapy and surgery for them to tolerate the effects of the treatment. Colorectal cancer is preventable and treatable if detected early. Early screening using immunochemical testing would help to pick the lesions when they are precancerous, thus reducing cancer-related death by between 40-60%. A low index of suspicion of colorectal cancer among the caregivers is a major hindrance to timely diagnosis. For example, patients with bloody stool may be treated for hemorrhage or other infections, due to low suspicion of colorectal cancer. An accurate diagnosis would require a colonoscopy. Traditional, extensive lymph node dissection with limited use of neoadjuvant radio is falling out of favor, due to high functional genitourinary impairments and the need for experienced individuals to perform adequate dissection for outcomes. There is evidence that the dissection has similar recurrent rates as with neoadjuvant. Surgical site infections are a major challenge to surgery and require management. The cost of screening in Kenya is Ksh. 1000-2500. Management of colorectal cancer is by chemoradiation followed by surgery. The decision to take short-course radiotherapy (within a week) as opposed to the long course (5 to 6 weeks) should be guided by MDT. Patients with complete clinical response to chemoradiotherapy but who refuse to take surgery are at higher risk of local failure.

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Renal Cell Carcinoma
2021-03-11 19:00 - 20:30
Moderator: Dr. Caroline Tonio, Consultant Physician, and Medical Oncologist, Muranga County Hospital, Kenya. Sponsor: Roche Presenters:

Dr. David K. Kimani, Consultant Surgeon, and Urologist, Kenyatta National Hospital
Dr. Manel Haj Mansour, Consultant Physician, and Medical Oncologist, Aga Khan University Hospital

Kidney cancers account for 5% and 3% of all adult malignancies in men and women. It’s the 7th most common cancer in men and the 10th most common cancer in women. Renal cell carcinomas (RCC) account for 80% of kidney cancers with a median age of 64 years. The risk factors include lifestyle, comorbidities, environmental exposures, and genetic factors. Protective factors include the use of alcohol and coffee. Renal masses are primary or secondary, the majority of which are RCC while a few are transitional cell carcinomas. RCC is mainly asymptomatic, but the advanced disease has a range of symptoms. Mortality rates from RCC have remained stable or have decreased slightly in developed countries, mainly due to timely screening and early diagnosis. The current imaging modalities cannot reliably distinguish benign and malignant tumors or between indolent and aggressive tumor biology. Consequently, renal mass biopsy (RMB) should be considered when a mass is suspected to be hematologic, metastatic, inflammatory, or infectious, as they have a high sensitivity, specificity, and positive predictive value. The non-diagnostic rate of RMB can be reduced by a repeat biopsy. There is no specific molecular marker recommended for clinical prognostic use. Management of small renal masses is by active surveillance, nephron-sparing surgeries, ablative and radical therapies. Partial nephrectomy prioritizes the preservation of renal functions through optimum salvage of nephrons. Priority should be to maintain negative surgical margins and to avoid the possibility of positive surgical margins with a probability of local recurrence. For complex tumors where partial nephrectomy is challenging, radical nephrectomy is recommended. This involves the removal of the entire kidney with or without the adrenal gland and the lymph nodes. To remove the adrenal gland or not depends on findings of metastasis or direct invasion of the adrenal gland. The involvement of the adrenal gland is associated with a poor prognosis. In patients undergoing surgical excision of a renal mass, a minimally invasive approach should be considered when it would not compromise oncologic, functional, and perioperative outcomes. Since RCC is radioresistant, radiotherapy can only be used for palliative treatment. Systemic therapy should be prioritized over cytoreductive nephrectomy for patients with metastatic RCC. First-line treatment is different for the good or intermediate and the poor-risk groups. Currently, there is a paradigm shift to the use of immunotherapy treatment and immune checkpoint inhibitors. However, the high cost of drugs and the fact that the National Hospital Insurance Fund (NHIF) may not cover the entire costs, complicates effective treatment.

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Management of Advanced Prostate Cancer
2021-02-23 19:00 - 20:30
Moderator: Dr. Ahmed Komen
Sponsor: Beacon
Presenters:

Prof. Asim Jamal Shaikh, Associate professor of Medicine, Consultant Medical Oncologist, Aga Khan Hospital, Nairobi

Prostate cancer is the most common cancer in Kenyan men, where 80% of patients present with advanced disease, encompassing a broad spectrum of diseases. The disease can be metastatic or non-metastatic. Metastatic hormone-sensitive prostate cancer is diagnosed by serum total PSA, a biopsy, conventional imaging (not readily available in Kenya), and Next-Generation Imaging (NGI). NGI is useful in grouping the patients as high/low risk/volume, depending on the disease burden. The Kenya national cancer screening guidelines guide the screening process, which should be individualized with consultations between the physician and the patient. Management of Metastatic hormone-sensitive prostate cancer is by androgen deprivation therapy (ADT), achieved through surgical or medical castration. ADT should be started within 3 months of diagnosis. Advanced prostate cancer in patients who are hormone-sensitive or with high risk/volume requires a combination of ADT and chemotherapy treatment for a better outcome, where disease volume or aggressiveness may help tailor treatment selection. The addition of surgery and /or radiotherapy to systemic treatment may have a role in the treatment of newly diagnosed metastatic disease. Radiation therapy has a significant role in palliative treatment settings. Management of other histological subtypes of prostate cancer requires a histology review since the different subtypes are treated differently. Some patients transform from adenocarcinoma to neuroendocrine subtype hence may require ADT. However, the degree of differentiation should be put into consideration. Prognosis is relatively poor, hence it’s important to perform a pathology review in case the patient is not responding well to treatment. Prostate treatment affects a patient’s sexuality, but ADT and vacuum-assisted devices help to restore sexual function. Considering the high cost of treatment, chemotherapy and the use of generic forms of the drugs may be quite affordable.

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Molecular Testing For Breast Cancer and Implications For Treatment
2021-02-18 19:00 - 20:30
Moderator: Peter Oyiro, Medical Oncologist Kenyatta National Hospital Teaching and Referral Hospital
Sponsor: Beacon
Presenters:

Dr. Sitna Mwanzi, Consultant Physician and Medical Oncologist, Aga Khan Hospital, Nairobi

Breast cancer is the most common type of cancer with 6799 new cases and 3107 death in Kenya in 2020. The mean age is 45-51 years. Molecular signature by microarray and immunohistochemistry has classified four molecular subtypes of breast cancer as including luminal A, luminal B, HER2+, triple-negative breast cancer (TNBC), where luminal A and B are the most common molecular signatures The molecular profiles are important prognostic and predictive factors in breast cancer. Luminal A has a better prognosis followed by luminal B, hence patients with these subtypes are likely to be treated with surgery with or without adjuvant radiation therapy. HER2+ has a worse prognosis followed by TNBC, hence patients with these subtypes will require chemotherapy and neoadjuvant. Genetic testing can be recommended in a case where a family member has a known pathogenic variant, or in case of a personal history of breast cancer under the age of 45 years or within 45-60 years. Additionally, genetic testing is recommended in a new diagnosis of metastatic breast cancer, and for young patients TNBC. Management for patients with BRCA pathogenic variant involves continued screening using mammography with tomosynthesis (digital mammography) and discussion on the risk reduction mastectomy and salpingo-oophorectomy. Relatives of such patients should be counseled on screening for pathogenic variants and if possible, they should receive breast cancer screening at the age of 24-29 years, and the screening should be done annually. The major challenges of genetic testing in Kenya include a lack of technical expertise and a shortage of genetic counselors, to address the ethical concerns surrounding genetic counseling. The tests are unavailable in many health care facilities. Furthermore, the tests are not affordable, since the samples have to be shipped to the USA for analysis. Traditionally, the choice of adjuvant therapy was dependent on tumor size, nodal status, receptor status, tumor grade, age of the patient (younger patients were more likely to receive adjuvant chemotherapy). However, more recent understanding has revealed that not all node-negative hormone receptor-positive patients benefit from chemotherapy. Newer gene expression assays are helpful in tailoring treatment to avoid over and under-treatment.

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Shifting Paradigms In Triple-Negative Breast Cancer (TNBC) With Cancer Immunotherapy
2020-12-09 19:00 - 21:00
Moderator: Dr.Njoki Njiraini Sponsor: Roche Presenters:

Prof. Asim Jamal Shaikh, Associate professor of Medicine, Consultant Medical Oncologist, Aga Khan Hospital, Nairobi.
Prof. Peter Schmid, Lead, Centre for Experimental Cancer Medicine, Barts Cancer Institute, St Bartholomew’s Hospital the Queen Mary University of London.
Prof. Nadia Harbeck, MD LMU Breast Center.

Triple-negative breast cancer (TNBC) is a heterogeneous disease with differential gene expression profiles. The morphological subtypes of TNBC include ER, PR, and Her 2 Neu Negative cancers. Hormone receptor-negative patients are usually young (mean age 48.8-34%) and are diagnosed with grade III tumors. The biomarkers are different for African, African American, and caucasian women The differences have clinical and biological implications which could be targeted for the development of personalized therapeutics. Testing for immunohistochemistry and participation in clinical trials may improve disease management, which is a global challenge as well as in Kenya. Poor handling of collected samples, challenges with sample analysis, quality control, and data registry affect data collection in Kenya. There are challenges with the correct pathologic diagnosis, as a result of differences in diagnostic methods. Testing for immunohistochemistry and participation in clinical trials may improve disease management. Data generated by molecular and genomic profiling is promising to open new therapeutic options. Today, neoadjuvant therapy is the standard for early TNBC management. Immunotherapies targeting single-agent anti-PD-L1/PD-1 in combination with chemotherapy are effectively treating TNBC, with good tolerability. Sacituzumab is a new antibody-conjugate in the treatment of TNBC. Other treatment options involve offering multiple lines of treatment, where standard chemotherapy contains anthracyclines and taxanes. However, the cost of treatment and diagnostics is still a big challenge in Kenya.

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The 6th Kenya International Cancer Conference
2020-11-21 08:00 - 17:00 | Virtual Event (Zoom), Kenya
Theme: Making Strides Towards Quality Cancer Care

EXECUTIVE SUMMARYThere is need for patient-centered, high-quality, and value-based care in the management of cancers in general. This includes the whole continuum from prevention, timely access to screening, diagnosis, treatment and palliative care services; and improving rehabilitation and support activities.
Practicing Oncologists are invariably asking questions around value-based care in oncology. For the first time, KESHO held a virtual forum looking critically at the value of cancer care in Kenya and Africa. The 2020 Kenya International Cancer Conference looked at Value as a measure of a patients’ expectations of care and how this can be translated into cost effectiveness, and how these two factors can be combined in a low-resource setting.
The conference had an impressive line-up of presenters from across the globe sharing their experiences on how HCPs can continue to deliver quality care as well as the considerations for providing the quality of care in the Covid environment. The virtual event incorporated several breakout sessions including site-specific discussions around delivering care as well as the related challenges, actual management of cancer patients, policy and advocacy, palliative care, nursing care in oncology, haematological conditions Click here to view agenda
The event also highlighted some of the challenges around delivering care and how to restructure and build systems that deliver effective care. Also, part of the Agenda was a collaborative session with AORTIC where presenters shared anecdotal experiences around research, education, training and building regional networks.
There is an increasing consciousness around how we as a continental community can generate our own evidence and look at what our best practice is, and a critical component to this is setting up our own clinical trials in Africa. Some of these issues were discussed by the conference keynote speakers who gave their experiences on clinical trials in Africa and offered practical tips that HCPs can use to build up our continental collaborations and gather robust clinical data for improved patient outcomes.
The conference also included a session looking at media and the oncologist which touched on effective communication with patients, effective communication with media and how to effectively package key messages for maximum impact.
The 2020 Kenya International Cancer (Virtual) Conference attracted over 400 attendees from various countries around the world including Kenya, Nigeria, Ghana, Rwanda, Ethiopia, Egypt, UK, USA, China, SA, Netherlands, Sudan, India, Tanzania, Libya, Zimbabwe, Germany, Argentina, Switzerland and many others. The 2020 KICC programme featured talks from leading specialists as well as primary care professionals from across Africa and the world.

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The 6th Kenya International Cancer Conference attracted 13 exhibitors including sponsors.

The 2020 Kenya International Cancer (Virtual) Conference attracted over 400 attendees. These included haematologists, oncologists, pathologists, nurses, radiotherapists, surgeons, patient advocates and medical students. The Conference brought together top multi-disciplinary professionals from across Africa and the globe. They shared how they were making strides towards quality cancer care especially under the shadow of the pandemic.

Find below the programme for the 6th Kenya International Cancer Conference.

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Management Of Sickle Cell Disease: A Multidisciplinary Approach
2020-10-29 19:00 - 20:30
Moderator: Dr. Gladwell Gatheca Sponsor: Novartis Presenters:

Dr. Fredrick Okinyi, Lecturer, hematologist, University of Nairobi, Kenya
Dr. Esther Nafula, Palliative Care Specialist and Head of Department, KNH Palliative Care Unit

Sickle cell disease (SCD) is a neglected genetic disease in sub-Saharan Africa that is responsible for 5-16% of mortality in children under 5 years. Approximately 75% of children die before 5 years of age. SCD has a mortality rate of 58/1000 cases per year. The goals of clinical assessment in to give an impression and confirm the diagnosis in new patients, to determine the symptomatology, acute or chronic complications, stable or unstable in known cases, to classify the type of crisis and precipitating factors in acutely sick patients, to decide on the level of care as outpatient/inpatient or referral. Diagnosis for new patients is based on clinical presentation, family history, clinical features (signs and symptoms), and laboratory testing which can be considered as neonatal screening. Preliminary laboratory tests include full blood counts, reticulocyte counts, blood film morphology. Sickling tests can be easily performed in the laboratory of lower-level facilities. Since the test is positive for individuals with sickle cell disease as well as in sickle cell trait, a Hb separation technique is necessary for a positive test. Confirmatory tests include hemoglobin electrophoresis (HE), High-performance Liquid Chromatography (HPLC), and Isoelectric Focusing (IEF). The point of care rapid tests has high specificity and sensitivity when compared with the HPLC. They are useful in lower-level facilities. Although rapid tests can identify the hemoglobins Hb A, Hb S, and Hb C, they cannot quantify the different hemoglobins or accurately identify some of the other forms of SCD such as Hb S beta-thalassemia. SCD patients should attend clinics as an outpatient management practice. Acute complications should be managed. Fluid management is an important aspect since SCD patients are at risk of dehydration due to impaired renal concentrating power and poor fluid intake. Simple transfusion may use packed red blood cells, where the donor hematocrit should be about 0.6. Exchange transfusion may be undertaken to rapidly reduce the percentage of sickle cells in circulation, especially in severe sickle chest syndrome. The complications of the sickle cell disease range from mild to severe and vary among individuals. Counseling is very important in pre-marital, early childhood, Adolescence/ adulthood, and end of life. Pain management involves the use of strong opioids for severe pain, weak opioids for moderate pain, and regular paracetamols. SCD is incurable often leading to premature death. The patients should be helped to achieve a good death, mainly through control of pain and other physical symptoms, accepting death is inevitable, forgiving others, reconciling with self, family, and God, and being in control of the dying process.

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Breast Cancer Management: A Comprehensive Approach Part 3
2020-10-27 19:00 - 20:30
Moderator: Sponsor: AstraZeneca Presenters:

Dr. Daniel Ojuka, Consultant General & Breast Surgeon & Lecturer, University of Nairobi
Dr. Andrew Odhiambo, Consultant Medical Oncologist & Lecturer, University of Nairobi

Breast cancer is the most common cancer in women globally. Although the surgery was previously the most successful form of treatment; it was associated with mortality (approximately 15%) and increased morbidity, hence was abandoned in the 1960s. Consequently, advances in general anesthesia and antiseptic techniques facilitated more extensive procedures. In Kenya, the current changes in breast cancer management are driven by early detection and diagnosis and timely referrals, resulting in better outcomes. Unfortunately, late diagnosis is still frequent. The current breast cancer management approach is multidisciplinary, consisting of a multidisciplinary team (MDT), of highly qualified specialists and a coordinator. The MDTs are economical and result in service improvement and better outcomes. To date, breast surgery involves MRM-Auchoncloss, skin, and nipple-sparing mastectomy techniques, which are selected depending on patient morphology, breast ptosis, and type of reconstruction planned. Since the female breast is a symbol of beauty, fertility, and femininity, and surgery causes disfigurement, mastectomy for younger women requires proper communication and engagement with the patient, especially on the use of an aesthetic approach to breast conservation and rehabilitation therapy. Alternative approaches to surgery include hormonal therapy, targeted therapy, and chemotherapy, where the choice depends on the stage, setting, disease biology, patient characteristics, and the genomic patterns of the patients. A combination of approaches such as the use of neoadjuvant chemotherapy before surgery has proven to be beneficial especially in ulcerated patients. Considering the anatomical and molecular staging, the stage-based treatment survival rate is dependent on the subtypes of breast cancer. The national cancer treatment protocols and training programs for capacity building have been availed to all the counties by the Ministry of Health, Kenya, to support the treatment of cancer patients, especially in the counties.

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Breast Cancer Early Diagnosis and Screening Part 2
2020-10-21 19:00 - 20:30
Moderator: Dr. Vera Manduku Presenters:

Dr. Mary Nyangasi, Head of Division, National Cancer Control Program, Ministry of Health, Kenya
Dr. Miriam Mutebi, Consultant, Breast Surgical Oncologist, Aga Khan University Hospital

The ministry of health is commemorating the annual national breast cancer awareness month 2020 by giving hope and saving the lives of breast cancer patients. Globally, cancer is a major cause of death, accounting for 1 out of 6 deaths annually. Over 70% of deaths occur in low and middle-income countries, where breast cancer accounts for 6.6% of all cancer deaths. In Kenya, cancer is the second leading cause of death from non-communicable diseases, accounting for 7% of overall mortality. Breast cancer is the third leading cause of death after esophageal and cervical cancers. Good prognosis is associated with timely screening and early detection, followed by timely treatment. Unfortunately, awareness and uptake of screening services remain low in Kenya. Consequently, 70% of breast cancer cases are diagnosed in advanced stages. Since survival of breast cancer patients is highly dependent on the stage of diagnosis, a low survival rate is observed in stage IV patients. To support the management of breast cancer, the ministry of health, Kenya has put infrastructure for screening mammography in all the 47 County Referral Hospitals. In addition, the ministry has provided national cancer screening guidelines (2018) to guide an organized and unified approach for screening priority cancers including cervix, breast, colorectal, prostate, and retinoblastoma. Mammography is the recommended method of screening for women in the average-risk population, and the only screening modality shown to reduce breast cancer mortality. Previous studies have shown that screening mammography helps with the early detection of cancer and greatly reduces breast cancer deaths for women aged 40-74 years as well as those above 74 years. However, mammography is very costly and is only recommended for countries with good health infrastructure that can afford long-term programs. Other early detection techniques include a clinical breast examination, ultrasound, monthly breast self-examination, and breast self-awareness. Breast cancer management in low and middle-income countries is complicated by poor health systems, poverty, and retrogressive cultural practices. In these countries, awareness of early signs and symptoms and screening by clinical breast examinations are recommended for the early detection of breast cancer. In Kenya, screening is mainly opportunistic, mainly due to challenges associated with lack of equipment, radiologists, and radiology personnel. The risk of breast cancer is stratified into two: the average-risk population, accounting for 80%, while the high-risk population (20%). While there is a need for risk reduction strategies, the risks involved in mammography are non-lethal; hence screening benefits outweigh the risks involved. Some of the risks include recall for additional imaging, needle biopsy, false positives, anxiety, and over-diagnosis. Lifestyle and environmental factors can have an impact on breast cancer risk. Some of the risk reduction measures include maintaining a healthy weight, exercising regularly, and limiting the amount of alcohol.

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Childhood Cancers and Early Detection
2020-10-13 19:00 - 20:30
Moderator: Dr. Sitna Mwanzi
Presenters:

Dr. Valerian Mwenda, Medical epidemiologist, Lead Cancer registration, Monitoring, Evaluation and Research, Division of National Cancer Control Program, Ministry of Health.
Dr. Doreen Karimi Mutua, Paediatric, hematologist/ oncologist, Gertrude’s Children’s Hospital, Childhood Cancer Initiative

Childhood cancer is becoming a public health crisis in the developing world. In high-income countries, the childhood cancer prevalence is only 20%, with up to 80% cure rates. Low and middle-income countries account for 80% of all new cancer cases and less than 20% survival rates. In 2018, 3000 new cases of childhood cancers were reported in Kenya, where the survival rate is less than 19-30%. The low survival rate is attributed to the late presentation of patients, lack of knowledge and awareness of symptoms and signs among health care workers, weak referral systems, few cancer diagnostic and treatment centers, cultural beliefs and myths, and financial constraints. To overcome these challenges, there is a need to raise awareness among caregivers and health care workers on early warning signs, encourage health-seeking behavior among Kenyans, strengthen referral systems to avoid time wastage, equip and train staff to diagnose and treat, adopt evidence-based protocols for the treatment of cancer patients, maintain data on the outcomes, and use it for treatment and resource planning. The global initiative for childhood cancer target for 2030 is to realize a double cure rate, ensuring at least 60% survival for children with cancer globally, and reducing suffering for all. To achieve this, efforts are being put in place to increase the capacity of countries to provide quality services for children with cancer, and to increase the prioritization of childhood cancer at the global, regional, and national levels. According to Kenya National Cancer Registry, the most common childhood cancers are Leukemia, Retinoblastoma, Renal, Lymphoma, and Central Nervous System. The risk factors are majorly unknown, though exposure to ionizing radiation and infectious agents has been associated with some cancers. The goal of the Kenya Cancer Policy is to provide a multi-sectoral framework to comprehensively address the cancer burden in the country. The national cancer control strategy (2017-2022) aims to optimize treatment and palliative care for childhood cancers. The national cancer screening guidelines guide early diagnosis while the national cancer treatment protocols guide treatment. Barriers to effective childhood cancer control include a low level of awareness, low index of suspicion among the caregivers, poor referral systems, and inadequate access to palliative care. Other system challenges include poor access to health care, lack of finances, and inadequate surveillance and tracking systems. To counter these challenges the ministry of health Kenya is increasing advocacy, training among the health care providers, and universal health coverage. Early detection of childhood cancer is key to improved survivorship and health outcomes, timely access to treatment and care, lower intensity of treatment, cost-saving for families and health systems, and a lower burden of short and long-term toxicity.

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The Role of Immunotherapy in Cancer Management
2020-10-08 19:15 - 20:30
Moderator: Dr. Miriam Mutebi
Sponsor: Beacon
Presenters:

Prof. Asim Jamal Shaikh, Associate professor of Medicine, Consultant Medical Oncologist, Aga Khan Hospital, Nairobi.

Immunotherapy is a type of cancer treatment that boosts the body’s natural defenses to fight cancer cells. It uses substances made by the body or in a laboratory to improve how your immune system works to find and destroy cancer cells. Traditional therapies such as surgery, radiation, and cytotoxic/targeted therapy target tumor cells, while immunotherapy harnesses the body’s immune system to fight diseases. Anti-tumor immunotherapy includes cancer vaccines that educate T cells to better recognize and kill the pre-existing tumor. Adoptive immunotherapy activates and increases T cell numbers to better kill tumor cells. Immunomodulation uses drugs or antibodies to either increase stimulation or to overcome immune inhibition. Many tumors escape the immune response by creating an immunosuppressive microenvironment that prevents an effective anti-tumor response, mainly through the involvement of the immune checkpoints located in the central or peripheral regions. The immune checkpoints PD-L1 binds to PD-1 and inhibits T cell killing of tumor cell, therefore, blocking PD-L1 or PD-1 allows T cell killing of tumor cells, while CTLA4 regulate the early phase of activation of naïve and memory T cells in response to T cell receptor (TCR) stimulation by peptides presented by MHC ligands expressed by antigen-presenting and processing cells. Its upregulation prevents normal T cell activation. Several checkpoint inhibitors with FDA approval are in clinical use and have proven to be highly effective in the treatment of relapsed, progressive solid cancers, with relatively mild but distinct safety profiles. Some immune checkpoint inhibitors available in Kenya, are quite costly, and hence National Hospital Insurance Fund (NHIF) is too little to cover for this treatment. Aga Khan is building capacity for PD-L1 analysis, an immunohistochemistry test, in addition to next-generation sequencing. More data is required on the safety of immunotherapy and its use on immunocompromised individuals e.g. HIV, and those with autoimmune diseases, Since several clinical trials, are in progress; more new indications are likely to emerge.

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Management of Hormone Receptor Positive Breast Cancer
2020-09-29 19:00 - 20:30 | Virtual Event (Zoom), Kenya
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