Palliative care and catastrophic costs in Malawi after a diagnosis of advanced cancer: a prospective cohort study.

BACKGROUND: Inclusive universal health coverage requires access to quality health care without financial barriers. Receipt of palliative care after advanced cancer diagnosis might reduce household poverty, but evidence from low-income and middle-income settings is sparse. METHODS: In this prospective study, the primary objective was to investigate total household costs of cancer-related health care after a diagnosis of advanced cancer, with and without the receipt of palliative care. Households comprising patients and their unpaid family caregiver were recruited into a cohort study at Queen Elizabeth Central Hospital in Malawi, between Jan 16 and July 31, 2019. Costs of cancer-related health-care use (including palliative care) and health-related quality-of-life were recorded over 6 months. Regression analysis explored associations between receipt of palliative care and total household costs on health care as a proportion of household income. Catastrophic costs, defined as 20% or more of total household income, sale of assets and loans taken out (dissaving), and their association with palliative care were computed. FINDINGS: We recruited 150 households. At 6 months, data from 89 (59%) of 150 households were available, comprising 89 patients (median age 50 years, 79% female) and 64 caregivers (median age 40 years, 73% female). Patients in 55 (37%) of the 150 households died and six (4%) were lost to follow-up. 19 (21%) of 89 households received palliative care. Catastrophic costs were experienced by nine (47%) of 19 households who received palliative care versus 48 (69%) of 70 households who did not (relative risk 0·69, 95% CI 0·42 to 1·14, p=0·109). Palliative care was associated with substantially reduced dissaving (median US$11, IQR 0 to 30 vs $34, 14 to 75; p=0·005). The mean difference in total household costs on cancer-related health care with receipt of palliative care was -36% (95% CI -94 to 594; p=0·707). INTERPRETATION: Vulnerable households in low-income countries are subject to catastrophic health-related costs following a diagnosis of advanced cancer. Palliative care might result in reduced dissaving in these households. Further consideration of the economic benefits of palliative care is justified. FUNDING: Wellcome Trust; National Institute for Health Research; and EMMS International.

Incidence of HIV-positive admission and inpatient mortality in Malawi (2012-2019).

OBJECTIVE: To investigate trends in population incidence of HIV-positive hospital admission and risk of in-hospital death among adults living with HIV between 2012 and 2019 in Blantyre, Malawi. DESIGN: Population cohort study using an existing electronic health information system ('SPINE') at Queen Elizabeth Central Hospital and Blantyre census data. METHODS: We used multiple imputation and negative binomial regression to estimate population age-specific and sex-specific admission rates over time. We used a log-binomial model to investigate trends in risk of in-hospital death. RESULTS: Of 32 814 adult medical admissions during Q4 2012--Q3 2019, HIV status was recorded for 75.6%. HIV-positive admissions decreased substantially between 2012 and 2019. After imputation for missing data, HIV-positive admissions were highest in Q3 2013 (173 per 100 000 adult Blantyre residents) and lowest in Q3 2019 (53 per 100 000 residents). An estimated 10 818 fewer than expected people with HIV (PWH) [95% confidence interval (CI) 10 068-11 568] were admitted during 2012-2019 compared with the counterfactual situation where admission rates stayed the same throughout this period. Absolute reductions were greatest for women aged 25-34 years (2264 fewer HIV-positive admissions, 95% CI 2002-2526). In-hospital mortality for PWH was 23.5%, with no significant change over time in any age-sex group, and no association with antiretroviral therapy (ART) use at admission. CONCLUSION: Rates of admission for adult PWH decreased substantially, likely because of large increases in community provision of HIV diagnosis, treatment and care. However, HIV-positive in-hospital deaths remain unacceptably high, despite improvements in ART coverage. A concerted research and implementation agenda is urgently needed to reduce inpatient deaths among PWH.

Establishment of a high-dependency unit in Malawi.

Adults admitted to hospital with critical illness are vulnerable and at high risk of morbidity and mortality, especially in sub-Saharan African settings where resources are severely limited. As life expectancy increases, patient demographics and healthcare needs are increasingly complex and require integrated approaches. Patient outcomes could be improved by increased critical care provision that standardises healthcare delivery, provides specialist staff and enhanced patient monitoring and facilitates some treatment modalities for organ support. In Malawi, we established a new high-dependency unit within Queen Elizabeth Central Hospital, a tertiary referral centre serving the country's Southern region. This unit was designed in partnership with managers, clinicians, nurses and patients to address their needs. In this practice piece, we describe a participatory approach to design and implement a sustainable high-dependency unit for a low-income sub-Saharan African setting. This included: prospective agreement on remit, alignment with existing services, refurbishment of a dedicated physical space, recruitment and training of specialist nurses, development of context-sensitive clinical standard operating procedures, purchase of appropriate and durable equipment and creation of digital clinical information systems. As the global COVID-19 pandemic unfolded, we accelerated unit opening in anticipation of increased clinical requirement and describe how the high-dependency unit responded to this demand.

Assessing and Addressing the Need for Cancer Patient Education in a Resource-Limited Setting in Haiti.

PURPOSE: Misinformation and lack of information about cancer and its treatment pose significant challenges to delivering cancer care in resource-limited settings and may undermine patient engagement in care. We aimed to investigate patients' knowledge and attitudes toward cancer and its treatment and to adapt, implement, and evaluate a low-literacy cancer patient education booklet at the Hôpital Universitaire de Mirebalais (HUM) in rural Haiti. MATERIALS AND METHODS: A low-literacy cancer patient education booklet was adapted into Haitian Creole in collaboration with clinicians at HUM. Patients were recruited for structured interviews (n = 20) and two focus groups (n = 13) designed to explore patients' attitudes toward cancer and its treatment and to assess whether the booklet increased patients' knowledge via an investigator-designed knowledge test. RESULTS: Participants reported a subjective lack of knowledge about cancer and its treatments and described views of cancer as deadly or incurable. Patients of varying education levels valued receiving written materials that set expectations about cancer treatment and expressed a desire to share the booklet with caregivers and others in their community. Participants across all levels of education significantly increased their performance on a knowledge test after counseling using the booklet (p < .001). CONCLUSION: We found that an educational booklet about cancer developed in collaboration with local providers was well received by patients with variable literacy levels and improved their knowledge of cancer and its treatment in a resource-limited setting. Such educational materials have the potential to serve as tools to engage patients with cancer and their families in care. IMPLICATIONS FOR PRACTICE: Misinformation and lack of information pose significant challenges to delivering cancer care in resource-limited settings; however, there are often no culturally and literacy appropriate tools available to aid in patient education. This article shows that written educational materials are well received by patients of variable literacy levels and can be effective tools for increasing patients' knowledge of cancer and its treatment in a limited-resource setting. Furthermore, the authors have made their educational booklet, Cancer and You, freely available online and welcome the opportunity to connect with readers of The Oncologist interested in implementing this educational booklet in clinical care.

Trends in cervical cancer incidence in sub-Saharan Africa.

BACKGROUND: Cervical cancer is the second most common cancer and the leading cause of cancer death in women in sub-Saharan Africa (SSA). METHODS: Trends in the incidence of cervical cancer are examined for a period of 10-25 years in 10 population-based cancer registries across eight SSA countries (Gambia, Kenya, Malawi, Mauritius, Seychelles, South Africa, Uganda and Zimbabwe). A total of 21,990 cases of cervical cancer were included in the analyses. RESULTS: Incidence rates had increased in all registries for some or all of the periods studied, except for Mauritius with a constant annual 2.5% decline. Eastern Cape and Blantyre (Malawi) registries showed significant increases over time, with the most rapid being in Blantyre (7.9% annually). In Kampala (Uganda), a significant increase was noted (2.2%) until 2006, followed by a non-significant decline. In Eldoret, a decrease (1998-2002) was followed by a significant increase (9.5%) from 2002 to 2016. CONCLUSION: Overall, cervical cancer incidence has been increasing in SSA. The current high-level advocacy to reduce the burden of cervical cancer in SSA needs to be translated into support for prevention (vaccination against human papillomavirus and population-wide screening), with careful monitoring of results through population-based registries.

High-Risk Adult Wilms' Tumour in Pregnancy: A Case Report.

Wilms' tumour is the most common renal neoplasm in children with an incidence of 10 cases per 1 million children and a median age at diagnosis of 3.5 years. In Western countries its occurrence in adults is 0.2 cases per million people in western countries and carries a poorer prognosis. The co-existence of Adult Wilms' tumour and pregnancy is extremely rare with less than 20 cases published in the English literature. We present a case of a Malawian woman who had progressive high-risk metastatic Adult Wilms' tumour in pregnancy after nephrectomy, radiotherapy and two lines of chemotherapy.

Five-year single-centre experience of carcinoma of the oesophagus from Blantyre, Malawi.

BACKGROUND: Oesophageal squamous cell carcinoma (OSCC) is increasing worldwide and has an exceptionally high prevalence in certain distinct geographical locations such as the African oesophageal SCC corridor. Despite this, there is a paucity of evidence to characterise the disease particularly in the Malawian context. METHOD: We retrospectively audited our endoscopy database over 5 years, including for patient demographics, endoscopy findings, therapeutic intervention and recommendations for treatment. RESULTS: 1586 patients with oesophageal cancer were identified from a total of 5882 endoscopy records from 2013 to 2017. Our cohort showed a larger proportion of oesophageal cancers found higher in the oesophagus compared with other African studies and a female preponderance in this upper-oesophagus disease subset though a male preponderance overall. 39% of patients with oesophageal cancer underwent bougie dilatation and 11% underwent palliative stent placement, which likely reflects local availability of resources. CONCLUSION: This study validates the observation that OSCC predominates in sub-Saharan Africa in Malawi over other forms of oesophageal carcinoma, though our cohort appears to have subtly distinct demographics and disease-specific data. This highlights the need to prioritise preventative and therapeutic strategies for OSCC in this and similar settings.

Evaluating the use of pathology in improving diagnosis in rural Malawi.

Introduction: Limited data exists on histologically confirmed cancers and tuberculosis in rural Malawi, despite the high burden of both conditions. One of the main reasons for the limited data is the lack of access to pathology services for diagnosis. We reviewed histopathology results of patients in Neno District, one of the poorest rural districts in Malawi, from May 2011 to July 2017, with an emphasis on cancers and tuberculosis. Methods: This is a retrospective descriptive study reviewing pathology results of samples collected at Neno health facilities and processed at Kamiza Pathology Laboratory. Data was entered into Microsoft Excel and cleaned and analysed using Stata 14. Results: A total of 532 specimens were collected, of which 87% (465) were tissue biopsies (incision or core biopsies), and 13% (67) were cytology samples. Of all specimens, 7% (n=40) of the samples had non-diagnostic results. Among the results that were diagnostic (n=492), 37% (183) were malignancies, 33% (112) were infections and inflammatory conditions other than tuberculosis, 20% (97) were benign tumours, 7% (34) were tuberculosis, 4% (21) were pre-malignant lesions, 5% (23) were normal samples, and 4% (22) were other miscellaneous conditions. Among the malignancies (n=183), 62% (114) were from females and 38% (69) from males. Among females, almost half of the cancers were cervical (43%, n= 49), followed by Kaposi sarcoma (14%, n=16), skin cancers (9%, n=10), and breast cancer (8%, n=9). In males, Kaposi sarcoma was the most common cancer (35%, n=24), followed by skin cancers (17%, n=12). About 75% (n=137) of the cancers occurred in persons aged 15 to 60 years. Conclusion: Histopathology services at a rural hospital in Malawi provides useful diagnostic information on malignancies, tuberculosis and other diagnoses, and can inform management at the district level.

Cancer Pathology Turnaround Time at Queen Elizabeth Central Hospital, the Largest Referral Center in Malawi for Oncology Patients.

Purpose In all settings, a need exists for expedited pathology processing for patients with a suspected cancer diagnosis. In low- and middle-income countries (LMICs) with limited resources, processing pathology samples is particularly challenging, so the measurement of turnaround times (TATs) for pathology results is an important quality metric. We explored the pathology TAT for suspected cancer patients at Queen Elizabeth Central Hospital in Malawi to determine whether a difference exists when patients paid an out-of-pocket fee (paid for [PF] v nonpaid for [NPF]) to facilitate sample processing. Methods and Population This retrospective descriptive study included all patients with suspected cancer (N = 544) who underwent incisional and excisional biopsy in 2010 at Queen Elizabeth Central Hospital, a teaching hospital in Malawi. Data were abstracted from patient charts and administrative forms to build a database and determine the TAT for PF and NPF samples. Results The median TAT for the 544 patients was 71 days (interquartile range [IQR], 31 to 118 days). The median pathology processing time was 31 days (IQR, 15 to 52 days) and was shorter for PF versus NPF samples. The median TAT was 43 days for PF samples (IQR, 27 to 69 days) versus 101 days for NPF samples (IQR, 31 to 118 days), which was significantly different by the Wilcoxon rank sum test ( P < .01). Conclusion The TAT for pathology samples among patients with suspected cancer was longer than reported for other African countries during the study period, was longer than considered acceptable in high-income countries, and differed between PF and NPF samples.

Cervical cancer in southern Malawi: A prospective analysis of presentation, management, and outcomes.

BACKGROUND: Malawi has the highest age standardised rate of cervical cancer in the world. This study describes the presentation, management and short-term outcomes of patients with newly diagnosed cervical cancer at Queen Elizabeth Central Hospital (QECH), in Southern Malawi. METHODS: All patients with a new diagnosis of cervical cancer presenting to QECH between 1st January-1st July 2015 had demographic data, referral pathway, stage, histology and management prospectively recorded at presentation, and at two months after initial presentation. RESULTS: 310 women presented with cervical cancer to QECH and 300 were included (mean age 44.9 years; HIV 47%), representing 8% of the estimated annual number of new presentations in Malawi. Mean age of patients with HIV was 6.9 years younger compared to those without HIV (p<0.05). 132 (44%) patients had stage 1 cervical cancer and 168 (56%) presented with more advanced disease (stage II-IV). There was a mean delay of 23.1 weeks between onset of symptoms and being seen by a clinician and a further 19 weeks before attending QECH. Most common management plans at initial consultation were: same day biopsy (n=112, 37.3%);, booking for curative surgery (n=76, 25.3%);, and referral to palliative care (n=93, 31%). At 2 months, 64 (57%) biopsies were reported, 31 (40.8%) operations were completed and 27 (29%) patients had attended the palliative clinic. CONCLUSIONS: Patients presenting with cervical cancer to QECH were young, with a high prevalence of HIV, and late stage disease. The lack of pathological and surgical capacity and the absence of radiotherapy severely limited the possibility of curative treatment. Access to quality palliative care remains an important component of management in low resource settings. Improving awareness of cervical cancer in the community, and better recognition and management within the health service, are important in reducing the cancer burden for women in Malawi.

Three-year cancer incidence in Blantyre, Malawi (2008-2010).

In this paper, we present incidence rates of different cancers calculated for the population of Blantyre, Malawi for the period 2008-2010, using data from the Malawi Cancer Registry. Active methods were used for case finding, with standard checks for accuracy and validity performed in CanReg 4. During this 3-year period, a total of 3,711 cases were registered comprising 1,643 men (an estimated age-standardized incidence rate (ASR) of 169.8 per 100,000) and 2,068 women (ASR 238.7 per 105 ). Kaposi sarcoma (KS) was the most common cancer in men (40.5% of all cancers in men; ASR 54.0 per 105 ) while cervical cancer was the commonest in women (33.3%; ASR 88.6 per 105 ). The incidence rates for esophageal cancer remain one of the highest in the world (ASR 30.9 per 100,000 in men, 22.1 per 100,000 in women). Incidence of cancer of the prostate is relatively low in Blantyre (5.1%; ASR 16.4 per 105 ), compared with elsewhere in Africa. In childhood, the cancer spectrum is dominated by Burkitt lymphoma (32.5% ASR 90.9 per 106 ) followed by Wilms tumor (11.3%; ASR 35.9 per 106 ) and pediatric KS (11.0%; ASR 31.1 per 106 ). The overall percentage of cases with histological verification was 47.5%, a slight improvement from 42.4% in late 1990s also indicating successful case finding outside laboratories.

Tuberculosis Diagnosis Delaying Treatment of Cancer: Experience From a New Oncology Unit in Blantyre, Malawi.

PURPOSE: Malawi is a low-income country in sub-Saharan Africa with limited health care infrastructure and high prevalance of HIV and tuberculosis. This study aims to determine the characteristics of patients presenting to Queen Elizabeth Central Hospital Oncology Unit, Blantyre, Malawi, who had been treated for tuberculosis before they were diagnosed with cancer. METHODS: Clinical data on all patients presenting to the oncology unit at Queen Elizabeth Central Hospital from 2010 to 2014 after a prior diagnosis of tuberculosis were prospectively recorded, and a descriptive analysis was undertaken. RESULTS: Thirty-four patients who had been treated for tuberculosis before being diagnosed with cancer were identified between 2010 and 2014, which represents approximately 1% of new referrals to the oncology unit. Forty-one percent of patients were HIV positive. Mean duration of tuberculosis treatment before presentation to the oncology unit was 3.6 months. The most common clinical presentation was a neck mass or generalized lymphadenopathy. Lymphoma was the most common malignancy that was subsequently diagnosed in 23 patients. CONCLUSION: Misdiagnosis of cancer as tuberculosis is a significant clinical problem in Malawi. This study underlines the importance of closely monitoring the response to tuberculosis treatment, being aware of the possibility of a cancer diagnosis, and seeking a biopsy early if cancer is suspected.

Targetable subsets of non-Hodgkin lymphoma in Malawi define therapeutic opportunities.

Diagnostics and supportive care for patients with non-Hodgkin lymphoma (NHL) in lower- and middle-income countries (LMICs) are lacking. We hypothesized that high-throughput transcription-based diagnostics could classify NHL specimens from Malawi amenable to targeted therapeutics. We established tissue microarrays and classified 328 cases diagnosed by hematoxylin and eosin as NHL at University of Malawi College of Medicine using immunohistochemistry (IHC) for conventional markers and therapeutic targets. A subset was analyzed using NanoString-based expression profiling with parsimonious transcriptional classifiers. Overall, 72% of lymphomas were high-grade B-cell tumors, subsets of which were enriched for expression of MYC, BCL2, and/or PD-L1. A 21-gene transcriptional classifier, previously validated in Western cohorts, divided 96% of diffuse large B-cell lymphomas (DLBCLs) with 100% of B-cell lymphomas, unclassifiable, into 1 cluster and 88% of Burkitt lymphomas into a separate cluster. Cell-of-origin categorization of 36 DLBCLs by NanoString lymphoma subtyping test (LST) revealed 69% concordance with IHC. All discordant cases were classified as germinal center B cell-like (GCB) by LST but non-GCB by IHC. In summary, utilization of advanced diagnostics facilitates objective assessment and segregation of biologically defined subsets of NHL from an LMIC without expert review, thereby establishing a basis for the implementation of effective and less toxic targeted agents.