1st KESHO-AORTIC-UICC-Regional Symposium

Prostate Screening – Controversies and Innovations- Carnjini Yogeswaran (Kenya)

Dr. Carnjini Yogeswaran a Consultant Urological Surgeon based in Nairobi, Kenya, focused on screening, the controversies surrounding it, and any new innovations in prostate cancer in Kenya. Dr. Carnjini explained that prostate cancer (Pca) is the second most common cancer in men after respiratory cancers in the world. It is the 5th cause of cancer mortality worldwide, but the mortality is greater in developing countries. The cancer is twice as common in black men, who are 2.5 times more likely to die of Pca compared to non-black men. According to globocan 2020 statistics, Pca is the most common cancer in men in Africa. Screening of Pca aims to detect cancer early to facilitate timely interventions, and reduce overall and disease-specific mortality, thus improving a person’s future quality of life. Screening increases the detection of Pca at any stage, where 18 cases were diagnosed per 1000 men, across all localized Pca diseases. Screening has been shown to reduce the detection of advanced Pca disease. This may have relevance in the African setup. However, lack of knowledge among uneducated patients of low socioeconomic status and lack of finances are major barriers to Pca screening in Africa. The benefits of Pca screening have to be weighed against the harms of diagnosis and treatment. However, evidence for prostate cancer screening is highly controversial. Two studies (The Cochrane Review 2013 and a systematic review and meta-analysis 2018) reported that increased cancer screening increased Pca diagnosis but did not reduce overall or disease-specific mortality. However, these studies have methodological limitations. The reason why Pca screening has not been recommended for routine clinical use is the fact that significant biopsy is required, in addition to treatment-related complications. In addition, for every 1000 men screened, 1 was hospitalized for sepsis, 3 required pads for urinary incontinence while 25 had erectile dysfunction. Although MRI has changed the Pca diagnosis, it has been reported to be non-inferior to the standard biopsy technique. Although this is finding is applicable in the developed countries, MRI may not be applicable in Africa because the scans are very expensive. Although PSA has been in use for a long time for prostate cancer screening, it is limited by giving inaccurate results. Other better scores for Pca screening include 4K Score, Prostate Health Index (PHI), urine-based PCA3, and Stockholm 3 model.  Although these methods give an accurate diagnosis, they are complex and require multiple tests. In spite of Pca affecting more African than non-African men, the under-representation of African men is dominant in the data. There is a need for clinical studies involving African men in order to generate Pca data.

Recommendations

Dr. Carnjini advocated for awareness campaigns to promote health, create awareness and educate the public on the disease, especially men in the risky age groups.

Although there is limited data showing the benefits of screening, increased opportunistic testing may help with the early detection of the disease.

Dr. Carnjini acknowledged that the health authorities provide funding for Pca treatment in Kenya, and urged them to fund PSA screening, which is a valid and cheap test.

She emphasized the need to demystify biopsy testing, in order to encourage more men to take the test.

The need to generate more data on prostate cancer screening to inform whether Pca screening would make a difference in reducing mortality was also emphasized.

Role of Pathology in UHC- Cesaltina Ferreira Lorenzoni (Mozambique)

Prof. Cesaltina Ferreira Lorenzoni is a Pathologist, Head of the National Cancer Control Program, Ministry of Health, Mozambique, and Director of Science and Pedagogy of Maputo Central Hospital. She explained that diagnostics play an important role in healthcare systems as a basic component of healthcare and part of resource stewardship. It is an integral part of healthcare systems, as well as in public health and epidemiology research. Pathology diagnostics should be an integral part of National plans to implement Universal Health Coverage (UHC). Pathology plays a critical role in cancer control, as it guides clinical decisions about patient diagnosis and treatment. It is an essential tool in screening and disease prevention programs. Prof. Lorenzoni observed that pathology diagnostics are often lacking or are of poor quality in most parts of the world. Additionally, they do not produce results in a timely manner and are unaffordable to large parts of populations, thus creating inequitable access. She suggested that national and international bodies should recognize the importance of diagnostics in health care systems, and seek to analyze the barriers to improving access to diagnostics.  Institutions should come up with solutions to solve those barriers. Inadequate pathology services lead to ineffective treatment programs due to delayed or inaccurate diagnoses. Consequently, lack of pathology in diagnosis leads to erroneous estimates of disease rates and compromised ability to plan for resource allocation for health care systems. Pathology is the backbone of treatment strategies and the success of cancer care. It provides evidence of cancer presence, a specific diagnosis that is necessary for effective treatment. It provides evidence of success/response/failure in cancer treatment in addition to population data on cancer incidence. Diagnosis involves surgical pathology biopsies, cytopathology, autopsies, immunohistochemistry, and other special tests. Although pathology is an important part of cancer care, other areas such as prevention and education, screening and early diagnosis, radiation therapy, surgery, systemic therapy, palliative and survival care, and social support should also be emphasized.

Barriers to implementing pathology

• Financial, competition for resources
• Political instability
• Shortage of trained staff and health care providers
• Lack of equipment services, and maintenance

In the year 2020, there was an inadequate number of pathologists in the world. To date, there are still a large number of African countries in which diagnostic pathology services are often non-existent, or are run with a limited number of pathologists. In addition, there is inadequate infrastructure and severely restricted budgets from the government. Consequently, cancer is largely undiagnosed or untreated in these regions. For cancer diagnosis, most African countries use hematoxylin and eosin, and cytology while a few countries have histochemistry for diagnosis. Molecular testing is not available in most African health centers.

Challenges with diagnosis in Africa

• Inadequate infrastructure, equipment, and reagents
• Lack of funding for training programs and for reimbursement of services
• The inadequate volume of surgical pathology specimens
• Inadequate diagnostic tools and lack of required technology and raw materials.
• Delays in delivery of samples to the laboratory, timely processing, and fixation of samples to be analyzed
• Lack of prompt reporting on processed specimens
• Unreliable archiving and storage of samples and results
• The uninterrupted supply chain of reagents and equipment

To overcome these challenges, there is a need to:

• Advance the education and training of residents in laboratory medicine and facilitate continuous education for consultant trainers
• Provide incentives to retain trained pathologists.
• Foster cooperation between pathologists in the developed and the developing world,
• Foster lateral cooperation in the global south for training and research (South-South).

Universal health coverage (UHC) encompasses population, service, and costs coverage. Countries lacking pathology cannot make progress towards achieving UHC, especially in lowering cancer-related mortality. Therefore, governments must make strategic political and economic investments in training and equipping adequate numbers of pathologists to serve the health system and to support the facilities. They should invest in long-term initiatives and incentives to retain trained pathologists and adjunct staff.

Barriers to implementing pathology

• Financial, competition for resources
• Political instability
• Shortage of trained staff and health care providers
• Lack of equipment services, and maintenance

In the year 2020, there was an inadequate number of pathologists in the world. To date, there are still a large number of African countries in which diagnostic pathology services are often non-existent, or are run with a limited number of pathologists. In addition, there is inadequate infrastructure and severely restricted budgets from the government. Consequently, cancer is largely undiagnosed or untreated in these regions. For cancer diagnosis, most African countries use hematoxylin and eosin, and cytology while a few countries have histochemistry for diagnosis. Molecular testing is not available in most African health centers. 

Challenges with diagnosis in Africa 

• Inadequate infrastructure, equipment, and reagents
• Lack of funding for training programs and for reimbursement of services
• The inadequate volume of surgical pathology specimens
• Inadequate diagnostic tools, and lack of required technology and raw materials.
• Delays in delivery of samples to the laboratory, timely processing, and fixation of samples to be analyzed
• Lack of prompt reporting on processed specimens
• Unreliable archiving and storage of samples and results
• The uninterrupted supply chain of reagents and equipment

To overcome these challenges, there is a need to:

• Advance the education and training of residents in laboratory medicine and facilitate continuous education for consultant trainers
• Provide incentives to retain trained pathologists.
• Foster cooperation between pathologists in the developed and the developing world,
• Foster lateral cooperation in the global south for training and research (South-South).

Universal health coverage (UHC) encompasses population, service, and costs coverage. Countries lacking pathology cannot make progress towards achieving UHC, especially in lowering cancer-related mortality. Therefore, governments must make strategic political and economic investments in training and equipping adequate numbers of pathologists to serve the health system and to support the facilities. They should invest in long-term initiatives and incentives to retain trained pathologists and adjunct staff.   

Screening and Early Detection for Esophageal Cancers In Africa- Dr. Michael Mwachiro (Kenya)

Dr. Michael Mwachiro is a Consultant General Surgeon, and Director of the Endoscopy Unit, at Tenwek Hospital, Bomet. Esophageal cancer is common cancer in Kenya and in the world, he stated. Poor survival is associated with late diagnosis, due to late symptoms. There is a need for early detection and treatment. Esophageal balloon cytology is insufficient for primary screening, due to sampling error, blind sampling of small lesions, and morphologic evaluation of a small % of the cell sample. The gold standard for endoscopic localization of dysplasia involves the use of Lugol’s iodine solution, while treatment involves excisional and ablative methods. Kenya lacks the infrastructure for endoscopic screening. The method is also very costly in Kenya. To identify a minimally invasive screening method, esophageal sponge cytology is currently under investigation. 

Who should be screened for Esophageal Cancers?

The National Cancer Screening Guidelines recommend that individuals with first-degree relatives with biopsy-proven esophageal cancer should have screening endoscopy 10 years prior to index age of diagnosis of the first-degree relative or at age 40 whichever is earlier. 

Asymptomatic individuals living in high-risk areas should get a one-time screening endoscopy at age 40 years. 

Patients treated for head and neck cancer squamous cell carcinoma should be screened annually for 10 years. 

Patients who have had caustic acid ingestion should be screened 10 years from the injury via endoscopy. 

Challenges with endoscopy screening in Kenya 

Few public facilities are able to offer endoscopic services, mainly due to a lack of functioning equipment. Other patients end up with incomplete endoscopy procedures.  

Dr. Mwachiro emphasized the need for public education and community engagement to fight the stigma associated with cancer and to create awareness of the risk factors, in addition to reducing fear of the unknown. The community should receive feedback on the findings after the screening, to enhance the acceptance of endoscopy procedures. He called out the stakeholders to facilitate endoscopy training for capacity building, fund cancer care programs, and strengthen referral systems.  

Cervical Cancer Screening – Hpv – Use Of M-Health In Malaysia – Prof. Woo Yin Ling- University of Malaysia

Professor Woo Yin Ling is a Professor of Obstetrics and Gynecology at the University of Malaya and a consultant gynecological oncologist at the University of Malaya Medical Centre.  Prof. Yin Ling explained that to achieve the 2030 cervical cancer elimination vision, innovations around screening are necessary. She emphasized the need to use new technologies and innovations to empower women. She observed that most developed countries have the ability and the tools to shift cervical cancer screening from tertiary centers and hospitals to the public. One such innovative technology is currently being applied by women in Malaysia to collect lower vagina samples (self-sampling). The samples are tested for Human Papilloma Virus-Deoxyribonucleic acid (HPV-DNA) by polymerase chain reaction (PCR) at the point of care or are shipped to a centralized laboratory. The samples are stable at room temperature for two weeks, thus allowing time for sample shipment. This method is cost-effective and would enhance uptake of cervical cancer screening in the community. For example, what was previously an uncomfortable pap smear done by a male physician can now be easily achieved through self-sampling.

Prof. Yin Ling discusses mobile medicine, where she explained that with appropriate apps, this technology can help to minimize hospital visits, especially in the elderly population where blood pressure, heart rate, and oxygen levels can be monitored at home. Several mobile apps can be designed to ensure the provision of medical services, without necessarily going to see a health professional. She quoted a phrase from Melinda Gates that mobile phones are most powerful in the hands of the poorest women. Since health systems are different between developing and the developed countries, poor countries should adopt a new set of approaches to health services and systems depending on their social setup. Such countries ought to identify within their social setup, the challenges and infrastructural barriers that prevent women from coming for screening. She called for co-development and mutual learning where developing countries should seek to introduce the ideas and practices from richer countries. However, it is not possible to copy and paste the methods between the countries, hence the need for some innovative modifications of these methods. For example, organized cytology screening in high-resourced settings has not been reproducible in LMIC, thus the global elimination strategy of cervical cancer is an opportunity to innovate. Prof. Yin Ling observed that while systems make things work, isolated technology does not. However, sometimes a technology comes along that “encourages” a system to be built around it, since it solves many unique problems.

In their laboratory, Prof. Woo Yin Ling’s program – Removing Obstacles to Cervical Screening (ROSE) applies the principles of design thinking to cervical cancer screening, with 3 components namely: self-sampling, HPV testing, and linkage to care through digital technology. It is a human-centered approach to developing innovative solutions, not only for testing but also to ensure women are navigated through the screening process. This helps to ensure that the program suits everyone. The program is also about stringent monitoring and surveillance of its performance, in order to continually improve it to suit the current environment. ROSE is evolving and agile, having been designed in 2017 before corona virus disease (COVID 19), but has gradually evolved to overcome the challenges posed by the disease.  Prof. Ling emphasized that since innovations in cancer screening must be women-centered, accessible, and acceptable, community engagement before the screening is important. She mentioned the need to teach women how to do the swab and the possible outcome of the screening. Since screening should have the intention to treat, individuals testing positive for HPV have to be referred for treatment. Prof. Ling noted that perfection can be a barrier to innovations and advised people to take small steps for innovation and then evolve it. The program ROSE started as a patient-centered pathway conceptualized on a paper in 2017, and involved thinking through the patient journey (the logistics, childcare, moving from the community to the hospital). It had several collaborative partners including representatives from the ministry of health and expertise from Australia who figured out how they could put the various elements and tools into a program that could benefit Malaysian women. Funding is a major challenge with most health programs. The program ROSE brought in resources and funds by working with industries, private corporations, and consultants to build a national goal. They improvised areas where the swabs are taken using plywood, with some instructions on how to do the swabs. This helped to minimize cost.

Their mobile technology is supported by personalized communication. They have a call center to monitor, guide and help and counsel those who test positive. Due to the restrictions posed by COVID 19 disease, the community screen in small groups, in open well-ventilated rooms while observing the COVID rules. Consequently, ROSE has successfully screened over 7000 women across 9 states, and most of them received follow-up. The program now targets new innovations such as using the zoom platform for teaching. In conclusion, Prof. Ling explained that mobile health care empowers self-care strategy, especially in the COVID 19        era. It decentralizes healthcare from hospitals and enables the linkage of care. It permits health surveillance, monitoring, and ensures the program translates to desired health outcomes, in this case, cervical cancer prevention towards elimination. Technology is built around humanity and the people using it.

Interactive Question & Answer Session:

During the interactive question and answer session, a participant sought clarification on how to collect the cervical swab, since the women may not be familiar with the anatomy of the cervix. Prof Ling explained that self-sampling involves the collection of lower vaginal samples with a soft small swab. They have posters teaching community leaders and women recruited in the program how to do the swab. She emphasized the importance of community and public engagement as the only way that self-testing for cervical cancer can be accepted by the public. However, uptake of screening depends on the social context which must be put into consideration. For example, Malaysia has a decade-old school vaccination program for HPV. Initially, there were a lot of anti-vaccine campaigns and resistance from the public. The government engaged the religious leaders and that saw vaccine acceptance by the public. She observed that stigma is a major barrier to screening and advised caregivers to look into their own community and explain the method of screening using a language that is acceptable in that particular population.

Dr. Mwachiro emphasized the need to engage the public so as to facilitate uptake of procedures including endoscopy. He observed that various African countries have begun training for capacity building on endoscopy. 

A participant sought clarification with the cost-effectiveness of telepathology, where Prof Lorenzoni acknowledged that telepathology is effective in improving diagnosis, accuracy, and reducing time for diagnosis. She however highlighted that it requires a laboratory with a technician, and a stable internet, which might be a challenge in African countries. Prof Lorenzoni called for collaborations with other partners that may help improve telepathology.  

A participant observed that the injections associated with screening for prostate cancer call for patient counseling before testing. Dr. Carnjini explained the need to demystify prostate cancer screening through psycho-social counseling before taking a biopsy. Dr. Carnjini quoted the lack of data as a major challenge to prostate cancer management since the available data is mainly from African-American men. She called for more research recruiting African men to generate applicable data in the African setup. She encouraged African men aged 45 years to take opportunistic tests.

Dr. Bello explained that there is a harmonized guideline for prostate cancer screening in sub-Africa, which has been reviewed to have men aged between 40-75years and those with family history screened for prostate cancer.  He reported that most clinical trials that have validated treatment for prostate cancer do not recruit men of African descent; hence there is a need to collect clinical data through clinical trials with inclusivity of African men. He called for intra-groups collaboration to perfect the guidelines.