THEME: CANCER SCREENING AND EARLY DETECTION FOR LMICS; INNOVATIONS AND STRATEGIES

DATE: 19th August 2021 5 PM – 8:30 PM EAT

Venue: Virtual

No. of Attendees: 697

Sponsors:

Beacon, AstraZeneca, AMRING, Janssen Oncology, INTAS, and the Nairobi  Radiotherapy and Cancer Center.

The 1st KESHO Cancer Screening Symposium, in partnership with AORTIC and with support from the UICC was an interactive, immersive, virtual event focused around Innovations and Strategies for Screening and Early Detection for LMICs. Using a mix of pre-recorded educational presentations and real-time expert discussions, as well as interactive live Q&A opportunities, the Symposium addressed topics relevant to an international audience. Faculty will provide anecdotal experience and reviewed current data to highlight successes and help remove barriers to increased adoption of more uniform and effective screening in Kenya and East Africa.

OUTCOMES:

  1. Promoting knowledge exchange and increasing understanding of the current evidence for early detection and screening, as well as international successes and challenges regarding the implementation of screening programs.
  2. Highlighting key innovations for screening and early detection that have been used in LMICs
  3. Interaction with experts and colleagues from around the globe via live Q&A periods and chat.
  4. Promoting multi-stakeholder involvement and collaborations amongst professionals and organisations keen on cancer screening and early detection.

CHAIRS:

Dr. Miriam Mutebi, Dr. Ntokozo Ndlovu, Dr. Hannah Ayettey, Dr. Shahin Sayed

Welcome address and opening remarks by:

1. Dr. Miriam Mutebi (KESHO)

2. Melanie Samson (UICC)

3. Dr. Abubakar M. Bello (AORTIC)

Introduction: Why screening and early detection matter…

Dr. Miriam Mutebi welcomed the president of AORTIC Dr. Bello Abubakar, the immediate past Head of Radiology and Oncology at the National Hospital in Abuja, Nigeria. He is also a Clinical Consultant and Radiation Oncologist. She also welcomed Dr. Melanie Samson, a Senior Manager in capacity building with the Union for International Cancer Control (UICC).

Dr. Bello Abubakar welcomed the attendees to the symposium and mentioned that the symposium was primarily organized by KESHO and supported by AORTIC and UICC. He noted that the topic of the day was guided by the clinical findings across sub-Saharan Africa, where most cancer patients present at the hospital late. About 86% of patients present at stages III and IV, hence the need for innovations that would facilitate early detection. This may be achieved through institutionalizing early cancer screening centers. Most countries in sub-Saharan Africa lack nationally institutionalized screening programs. Such countries should develop National Cancer Control Programs, with screening as an integral part. Dr. Abubakar expressed optimism that early cancer screening will make cancers a thing of the past. He thanked KESHO for collaborating with AORTIC and UICC to organize the virtual symposium and wished the attendees a fruitful deliberation.

Dr. Melanie Samson highlighted the need to have early screening and detection programs and called for global commitments on cancer control. She explained that innovations including digital health, molecular testing, tumor markers, and other innovative interventions have a great potential to achieve early detection, thus avoiding missed opportunities for patients.  

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.

Chaired by:

  1. Shahin Sayed
  2. Hannah Ayettey

Head and Neck Cancer Screening and Early Detection -Johan Fagan (SA)

Prof. Johan Fagan, Design of Otolaryngology, University of Cape Town, South Africa

Prof. Johan Fagan explained that cancer screening reduces the burden of morbidity and mortality from cancer. The common performance indicators of cancer screening include sensitivity, specificity, positive and negative predictive values. He observed that an effective cancer screening should reduce cancer-specific morbidity and mortality, by early detection of precancerous lesions. The benefits of screening must outweigh the harm, and the screening must be cost-effective to the individual and society. Targeted screening targets a higher-risk population, with an increased incidence of cancer of interest. The screening is cost-effective and the net benefits are high.  

Prof. Johan Fagan observed that Head and Neck Cancer (H& N) is an LMIC disease. He mentioned that although early detection help to reduce morbidity/mortality, there is no evidence to support the benefits and cost-effectiveness of screening the general population. However, for high-risk individuals, there is evidence that visual examination is effective in reducing the mortality rate of oral cancer.   

Recommendations for Head and Neck Cancer Screening 

There is a need to consider competing healthcare priorities

Screening should target high-risk groups

Screening should be part of a periodic health examination

Considering the challenges with recognizing premalignant and early malignant lesions, and also the acquisition of biopsies, education is key to community health care workers, nurses, clinical officers, general practitioners, and dentists to identify patients suspected of having cancer.

Breast Cancer Early Detection – Ibreast to assist early detection in Nigeria-Olalekan Olasehinde (Nigeria)

Dr. Olalekan Olasehinde, a faculty at Obafemi Awolowo University, and a consultant surgeon at Obafemi Awolowo University Hospital, Lagos, Nigeria. 

Breast Cancer in Nigeria

Dr. Olalekan Olasehinde explained that the incidence of breast cancer is rising in Nigeria. He highlighted the major challenges of late presentation and limited access to care. Since the stage is an important determinant of outcomes, most patients have poor outcomes in Nigeria.  Dr. Olalekan explained that they had started an early breast cancer detection program in Ile-Ife, Nigeria. The program carried out community education through media and public awareness campaigns. They performed targeted screening of risky populations including the family members of breast cancer patients. In addition, they carried out an evaluation and navigation of symptomatic women. They have a project that uses low-cost technology iBreast Exam (iBE) for breast evaluation. iBE is an FDA-cleared, highly portable, hand-held device that utilizes piezoelectric finger tactile pressure sensors to electronically palpate the breast. The device was designed to be used by community health workers with minimal training, as it is easy to learn. It is used to assess tissue elasticity and to identify abnormal parts of the breast, which warrant further evaluation. The device is calibrated by placing it on a normal part of the breast, to obtain the baseline value for that particular breast. After breast examination, any value that will be different from the calibrated value in terms of tissue elasticity will be considered abnormal. The shortcoming of this device is that it cannot distinguish benign from malignant lesions. Dr. Olalekan’s team carried out a study to determine the performance of iBE compared to clinical breast examination (CBE) and to compare the imaging and pathology findings of lesions detected and missed on iBE, in addition to training staff (community health nurses) to utilize the iBE device. To achieve these objectives, they trained 4 nurses over a two weeks period, followed by recruitment of patients who had been educated on breast cancer and what the iBE device was about. Clinical breast examination was performed by clinicians, while iBE was performed by the trained nurses. In addition, each patient received a mammogram and a targeted ultrasound scan. The training was conducted within 2 weeks and involved 424 women, with 151 women at high risk and 273 women being symptomatic. The average reported time for the iBE exam was 6.2 minutes. A total of 30 women had a biopsy recommendation, and 15 of them had breast cancer; 1 from the high-risk screen group and 14 from the symptomatic group. The average size of the cancer lesion on imaging was 3.3 cm (range 1.3-7cm). The identified cancers were as shown in the table below

Cancer type Number of Cases
DCIS 1
Invasive ductal carcinoma 11
Invasive papillary 1
Metaplastic carcinoma 1
Others 1

Comparing the performance of CBE with iBE in detecting any breast finding, the sensitivity was 63.1% and 30.6% while the observed specificity was 59.2% and 94.2% for iBE and CBE respectively. For detecting suspicious breast finding, the sensitivity was 86.0% and 83.4% while the observed specificity was 49.9% and 86.5% for iBE and CBE respectively. Considering cancer detection, both CBE and iBE identified 13 out of 15 cancers. The two methods had a comparable ability to detect cancers as they both missed the same two cancers. Patients reported a good experience with the device and noted that it was painless. They observed that they will be willing to get iBE yearly and would recommend iBE to others.

Moving forward, the iBE device will be applied in a triple mobile assessment and patient navigation model, which will combine iBE and CBE for assessment. Patients with positive results will be recommended for an ultrasound scan and a mammogram.

An Integrated Model for Cancer Screening and Early Detection in Kenya- Frederick Chite (Kenya)

Prof. Chite explained that the International cancer institute (ICI) has opened EMPOWER clinics, which do awareness and education to enable the community to understand the need for screening. The institute trains oncologists on case-based approaches, for example, breast surgeons do training in breast surgery. The center has designed an integrated approach to include hypertension, diabetes screening, and linkages to care. They have virtual tumor boards that meet twice a week to discuss patient cases. In addition, they offer mentorship and partnership programs and work with the county leadership to bring cancer care services to the county level. This has facilitated the establishment of a fully functional histopathology lab in Meru County. The institute does survivorship care and supports groups. 

Recommendations

Advocacy must be linked to Health systems strengthening for screening and early detection. The strategic partnership is key; otherwise screening without linkage to care should not be done. 

There is a need to train HCWs, data abstractors, and patient navigators on essential skills to standardize practice.

Digital tools including telemedicine, digital pathology, virtual multi-disciplinary tumor boards, and electronic medical records can facilitate care. 

Patient/client navigation through the health care system is key to retention in the system and routine screening practices and programs.

Opportunistic screening is useful for early detection but should be paired with routine facility-based screening to optimize outcomes.

Insurance needs to cover screenings and diagnoses for cancers and other non-communicable diseases. 

Role of Tumor Markers -Fidel Rubagumya (Rwanda)

Dr. Fidel Rubagumya is a Clinical and Radiation Oncologist at Rwanda Military Hospital, a visiting Clinical Oncologist at King Faisal Hospital and a lecturer at the University of Global Health Equity Dr. Fidel discussed tumor markers as substances that are produced by the tumor or by the host as a response to the presence of the tumor.

Tumor markers provide information about the biological characteristics of the tumor. They can be measured qualitatively in serum or biological fluids or can be quantified through histopathological examination and tumor tissue biopsy.

An ideal tumor marker should be:

  • Highly specific of one pathology
  • Highly sensitive thus can help in early diagnosis.
  • Highly accurate, thus should not be present in other diseases or in healthy subjects
  • It should have a low cut-off value, which should correlate with the tumor mass and prognosis.
  • Have a short life which enables efficient follow-up.

Dr. Fidel explained that tumor markers are of different origins, including hormones, enzymes, cancer antigens proteins and glycoproteins, metabolites, normal proteins, oncofetal antigens, receptors, genetic changes, etc. He explained that the markers are used for screening, diagnosis, prognosis, and monitoring.

Tumor markers can determine the risk, screen for early cancer, diagnose a type of cancer, estimate prognosis, predict response to therapy, monitor for disease or progression, and also for therapeutic selection.

Interpretation of tumor markers should consider pre-analytical, analytical, and post-analytical factors. For consistency of results, tumor markers should be done in the same laboratory and with the same assay.

Dr. Fidel gave an example of CEA that is used to diagnose colorectal cancer and has a specificity of 95% and a sensitivity of 70%. This marker is also found in 30-50% of other cancers and is elevated in smokers and in other conditions. Therefore, one cannot rely on CEA alone for the diagnosis of colorectal cancers. Other confirmatory investigations are required.

He concluded by highlighting other potential new markers that are currently being explored.

Point of Care Testing- Sulma Mohammed (USA)

Prof. Sulma Ibrahim Mohammed is a Professor of Cancer Biology at Purdue University, Center for Cancer Research, and a Professor of Immunology and Microbiology at Indiana University School of medicine, USA.

Prof. Sulma explained that the goal of cancer screening tests is to find cancer at its earliest stage before the onset of symptoms since this is when treatment is most successful. She mentioned examples of screening tests including mammography for early detection of breast cancer, pap smears, VIA, and HPV for early detection of cervical cancer and colonoscopy, and sigmoidoscopy for early detection of colorectal cancer. 

She observed that the current cancer detection methods are lab-based, invasive, time-consuming, expensive, prone to error, lack health care infrastructure, and require highly trained laboratory personnel. To overcome these barriers, Prof. Sulma advocated for point-of-care (POC) testing. This is laboratory testing (qualitative or quantitative) performed outside the laboratory by non-laboratory personnel or conducted close to the site of patient care, often by individuals with little or no training. It requires specific biomarkers and methods for their detection. However, tumor heterogeneity limits the development of a biomarker. 

She discussed that their lab is working to develop an accurate, easy-to-use, and inexpensive POC test for cervical cancer. They use lateral flow immunoassay-based techniques, which use an antibody to detect the presence of an antigen in a sample, forming a band. The absence of a band implies a lack of antigen. 

She mentioned other innovative POC imaging technology including liquid biopsy, miniaturization of PCR solar-powered, and use of implantable biosensors especially to monitor treatment. 

Interactive Question & Answer Session

A participant asked about how expensive the iBE is and whether over diagnosis is a concern. The participant further sought clarification on the possibility of collaborations to have multiple centers? 

Dr. Olalekan Olasehinde acknowledged that over diagnosis is real, but the device has been modified over time thus reducing over diagnosis. The device has not been commercialized yet, so there is no price on it yet.  He further noted that the device will be commercially available in the coming months. 

Dr. Hannah asked how cost-effective the device is as compared to training more community health care providers to perform clinical based-exams (CBE). Dr. Olalekan explained that the device is not a substitute for CBE but should be used in combination with the clinical-based examination. He noted that iBE does not differentiate benign from malignant lesions but only tells that there is an abnormality. 

A participant raised concerns that because of the low specify of iBE, it is not a cost-effective device. Dr. Olalekan explained that the device can be used to exclude the women without lesions so that only women with lesions will proceed for a biopsy. 

A participant asked to know the differences between breasti and iBreast. Dr. Olalekan explained that Breasti is a device that uses a laser beam to shine on the breast and utilizes differences in tissue vascularity to detect abnormalities in the breast. IBE device utilizes tissue elasticity since the presence of lesion changes tissue elasticity. 

A participant asked Prof Chite about the barriers that they are experiencing in the community, where the professor explained about cultural barriers. To overcome these barriers, they start with a baseline survey, and work with survivors to ensure uptake of intervention measures. Prof Chite emphasized the need for partnership between all the players like financiers, advocacy groups, and all stakeholders to look at financing especially for cancer diagnosis which is not covered by the national hospital insurance fund (NHIF). 

Dr. Fidel explained that since the sensitivity of CEA is low, it cannot be used as a screening modality. He mentioned new tumor markers including circulating DNA and other plasma tumor markers that are under investigation. However, these markers are currently not in use in Rwanda due to cost implications but may be applicable in the future.   

A participant asked about the validation of testing since there are briefcase testing devices, especially the devices that do not require a laboratory, how about the temperature regulation. Prof. Sulma explained that just like the pregnancy test is very stable and can be used in different regions, the point of care test for cervical cancer is equally stable at room temperature for two days. 

Closing Remarks

Dr. Angela McLigeyo thanked KESHO, AORTIC, and UICC for organizing the symposium

She thanked the panelists for their excellent presentations

Special thanks to the KESHO secretariat and the IT team.

She thanked the sponsors and the attendees.

Attendees left at leisure.

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