The impact of in-house pathology services on downstaging cervical cancer in Tanzania over an 18-year period.

PURPOSE: Reducing time between cancer screening, diagnosis, and initiation of treatment is best achieved when services are available in the same hospital. Yet, comprehensive cancer centers are typically unavailable in low- and middle-income countries (LMICs), where resources are limited and services scattered. This study explored the impact of establishing an in-house pathology laboratory at the largest public cancer hospital in Tanzania on the downstaging of cervical cancer. METHODS: We examined clinical datasets of 8,322 cervical cancer patients treated at the Ocean Road Cancer Institute (ORCI). The first period included patients treated from 2002 to 2016, before establishment of the pathology laboratory at ORCI; the second period (post-pathology establishment) included data from 2017 to 2020. Logistic regression analysis evaluated the impact of the pathology laboratory on stage of cervical cancer diagnosis. RESULTS: Patients treated during the post-pathology period were more likely to be clinically diagnosed at earlier disease stages compared to patients in the pre-pathology period (pre-pathology population diagnosed at early disease stage: 44.08%; post-pathology population diagnosed at early disease stage: 59.38%, p < 0.001). After adjustment for age, region of residence, and place of biopsy, regression results showed patients diagnosed during the post-pathology period had higher odds of early stage cervical cancer diagnosis than patients in the pre-pathology period (OR 1.35, 95% CI (1.16, 1.57), p < 0.001). CONCLUSIONS: Integrated and comprehensive cancer centers can overcome challenges in delivering expedited cervical cancer diagnosis and treatment. In-house pathology laboratories play an important role in facilitating timely diagnosis and rapid treatment of cervical and possibly other cancers in LMICs.

Distance to Health Care Facilities, Lifestyle Risk Factors, and Stage at Diagnosis in relation to Geographic Pattern of Esophageal Cancer in Tanzania, 2006-2016.

Esophageal cancer is an aggressive, often deadly disease globally that represents a significant health problem in Tanzania. The WHO reported 604,100 new esophageal cancer cases worldwide during 2020 and 544,076 deaths (Sung, 2021; World Health Organization, 2020). In Eastern Africa, 16,137 cases and 15,188 deaths were related to this disease in 2020. Esophageal cancer is associated with various etiologic risk factors, and access to the disease treatment is a major barrier to survival. This study examined associations between the prevalence of four geographically stratified, population-level, etiologic risk factors (tobacco use, unprotected water use, solid fuel source use, and poverty), as well as two access-to-care predictors (persons per hospital and distance from residence to where esophageal cancer treatment occurs). Regional- and coarser-scale zonal incidence rates were calculated for 2006 through 2016 and evaluated for geographic differences in relation to risk factors and access to care predictors using Poisson regression. Differences in the geographic distribution of esophageal cancer were observed. Distance from the region of residence to the treatment center (Ocean Road Cancer Institute) was statistically associated with the geographic pattern of esophageal cancer incidence. Further research into etiologic risk factors, dietary practices, and nutrition is needed to better understand the associations with esophageal cancer in Tanzania and other parts of Eastern Africa.

Breast Cancer Screening in Low-Income Countries: A New Program for Downstaging Breast Cancer in Tanzania.

Background: Most breast cancer diagnoses in Tanzania are in advanced stages. The Ocean Road Cancer Institute (ORCI) established a new breast cancer screening program in 2014 to reduce advanced-stage diagnoses. This study is aimed at describing the screening program's referral process and at identifying patient and health system factors that contribute to patients completing diagnostic testing referrals. Methods: Six-hundred and forty patients were included in the study. Testing types, outcomes, and date of diagnostic results were abstracted from records at ORCI and Muhimbili National Hospital (MNH) to determine the proportion of testing completed and the duration between initial referrals and diagnostic tests. Prediction of completion of diagnostic testing was investigated in logistic regression. Results: Of the patients who received referrals for further testing, fifty-two percent completed the recommended ultrasound (USS), mammography (MMG), and fine-needle aspiration cytology (FNAC). Only 33.0% of patients completed the recommended MMG referrals compared to 55.0% for ultrasound and 68.7% for FNAC. The average number of days between initial screening and results was 42 days for MMG, 20 days for USS, and 18 days for FNAC. Significant predictors for completing referrals for USS, FNAC, and MMG included age < 44 and >55 years, presenting with symptoms at the initial appointment, and education. The odds of completing an USS was 3.03 (95% CI, 1.65-5.64) for patients 25-34, 2.27 (95% CI, 1.17-4.48) for patients 35-44, and 4.41 (95% CI, 1.66-10.11) for patients older than 55 years compared to the reference group (age 19-24). The presence of symptoms at the initial appointment was a significant predictor of FNAC. The odds of completing an FNAC was 1.55 (95% CI, 1.02-3.72) for symptomatic compared to nonsymptomatic patients. Education was a significant predictor of MMG. The odds of receiving MMG was 4.29 (95% CI, 1.05-21.00) for patients with tertiary education or higher compared to primary education or lower. Possession of health insurance for treatment and living in Dar es Salaam were not significant predictors. Discussion. Future research should focus on patients' understanding of recommended referrals and factors that influence decision-making. Investigating the cost effectiveness of scaling up screening programs and setting up a patient navigation program that follow patients as they complete the recommended treatment plan will be crucial for Tanzania and other developing countries as they seek to launch and strengthen screening programs.

Return on Investment of a Breast Cancer Screening Program in Tanzania: Opportunity for Patient and Public Education.

Breast cancer is the second incident and second cause of cancer mortality among women in Tanzania due to late-stage presentation. The screening clinic at the Ocean Road Cancer Institute (ORCI) can help detect cases early and reduce cost of treatment. We calculated the return on investment (ROI) of the ORCI breast screening clinic. Screening and treatment data of all newly diagnosed breast cancer patients seen at ORCI during 2016-2018 were abstracted from the medical records. Also, data on time, resources, and cost of screening and treatment were obtained. The cost of treating screened patients was compared with cost of treating unscreened patients, and differences in cost of treatment were compared with cost of operating the screening program. Of the 730 total patients, 58 were screened prior to treatment, and 672 were not. There was no significant difference between stage at diagnosis and treatments received by screened and unscreened patients (79.3% late- stage vs 72.2% late-stage diagnosis, respectively (p = .531), or cost of treatment between the two groups (cost, in Tanzanian Shillings, for screened (2,167,155.14 or $954.27) vs unscreened (1,918,592.28 or $844.52), (p = .355). There was also no significant difference in cost of treatment between the screened and unscreened groups and a slightly negative ROI (- 0.05%) from implementing the program. The breast screening clinic in Tanzania has not yet proven its cost-effectiveness in reducing stage with screening. The likelihood that patients have utilized the clinic for treatment rather than early detection is a possible reason for the lack of cost-effectiveness. Future studies should focus on educational initiatives to encourage screening at early disease stage. Public education should increase awareness about the clinic for early detection. The experience of this program is ideal for dissemination to other low-income countries that are initiating cancer early detection and cancer education programs.

Developing Research Education Groups in African Cancer Centers: The Experience in Tanzania.

Research productivity and outcomes of junior researchers are usually correlated with the degree and quality of mentorship they receive. A bottom-up approach was followed to develop a research group at the Ocean Road Cancer Institute (ORCI), the major cancer center in Tanzania, to build upon the existing clinical and research resources and institutional global collaborations. The ORCI is a clinical center focused on radio- and chemo-therapy treatment of cancer patients from all over Tanzania. In addition, ORCI has a long-standing early detection program for educating women and screening them for cervical cancer. The ORCI physicians have been exposed to cancer research for the past 20 years through non-degree and degree training in the USA and Europe. In addition, US and European groups have been conducting collaborative research and training of oncologists and graduate students at ORCI. The exposure to research through the above-listed venues motivated the clinicians at ORCI to develop their own Research Club (RC) to learn about research methods, seek independent funding, and outline a research agenda for cancer research in Tanzania. However, it seems that mentorship is needed to help the RC members apply the lessons learned from didactic teaching. Mentorship is also needed to enable the RC members to utilize the enormous clinical and epidemiologic data generated by the institutional programs for prevention, treatment, and follow up of patients. This manuscript describes the inception of the program and its achievements, limitations, and suggested opportunities for improvement as a possible model for other LMICs.

Field Research Experience of Medical Students: Learning and Translation from Global to Underserved US Settings.

While most medical schools in the USA provide opportunities for global health experiences, global health education is not included consistently or emphasized adequately in many medical school curricula. The City University of New York Medical School (CSOM) has a mission to educate and train students who are traditionally underrepresented in medicine to practice primary care in medically underserved communities in New York. This manuscript documents the experience of the CSOM in expanding global health education by introducing a new global health cancer training program, partnering with clinicians at the Ocean Road Cancer Institute (ORCI) in Tanzania. This manuscript illustrates the following points: (1) the CSOM curriculum that focuses on community health and social medicine; (2) the process by which students learn by developing research proposals for global cancer; (3) the field research experience and lessons learned; (4) learning about cancer and medicine in a developing country; and (5) lessons learned for translation from global to domestic underserved populations. We also suggest a checklist for future students interested in pursuing global cancer education and research, and recommendations for maximizing learning and career development of students interested in global cancer research and its application to underserved populations in the USA.

Using Key Informants to Evaluate Barriers to Education and Acceptability of the HPV Vaccine in Tanzania: Implications for Cancer Education.

Cervical cancer is the third most common cancer globally, with high mortality when left untreated. In sub-Saharan Africa, Tanzania shows higher incidence rates of cervical cancer at 59.1 per 100,000 compared with the global average of 13.1 per 100,000. The HPV vaccine has been shown to successfully reduce HPV infection and is recommended for school-age girls and boys in the USA. Understanding the acceptability of the HPV vaccine and the barriers to vaccination is important for ensuring that HPV vaccination programs are successful. In 2016, Tanzania began school-based HPV vaccination programs in cities and towns surrounding Dar es Salaam, the largest city in Tanzania. Successful implementation of HPV vaccination programs in Dar es Salaam relies on overcoming barriers to vaccination. This study focused on primary school teachers as key informants to assess these barriers. Participants were given a short survey and then asked to participate in focus group sessions. Overall, knowledge of HPV was low, with only 37% of participants having heard of the HPV and only 28.6% having heard of the HPV vaccine. Teachers had a very positive response to the HPV educational sessions. Of the teachers who completed the questionnaires, 100% of them were willing to speak with their school parents about the HPV vaccine and 99% would recommend this vaccine to parents. This study has significant implications for national cancer prevention vaccination programs, not only in Tanzania, but also in other countries starting HPV vaccination as teachers are potentially important advocates for immunization and other childhood health initiatives.

Factors related to completion of referral among women with suspected cervical cancer and dysplasia in Tanzania.

OBJECTIVE: To investigate completion of referral among women with suspected cervical cancer in Tanzania. METHODS: Retrospective cohort study of 196 women referred from two healthcare clinics to Ocean Road Cancer Institute, Dar es Salaam, between March 2016 and June 2018. Women with precancerous lesions or suspected cancer were interviewed about their knowledge and perception of cervical cancer and referred for follow-up. RESULTS: Most participants were unable to name symptoms (55.1%), prevention methods (88.3%), or treatments (59.0%), although 79.1% rated the disease as severe. Women who came for routine early detection were less likely to complete referral than those who did not (odds ratio [OR], 0.18; 95% confidence interval [CI], 0.05-0.70). Women who knew someone who died from cervical cancer were 5.40 times more likely to complete referral than those who did not. Knowing someone with cervical cancer was a predictor of referral completion in three multivariate models: OR, 5.62 (95% CI, 2.20-14.38); 4.34 (1.64-11.47); and 4.61 (1.72-12.36). Having severe symptoms was a predictor of non-completion in two models: 0.30 (0.12-0.75) and 0.35 (0.14-0.87). CONCLUSION: Patient-directed interventions should include education involving survivors of cancer and dysplasia, whereas system-directed interventions should utilize reminders to increase referral completion.

Patterns and patient factors associated with loss to follow-up in the Muhimbili sickle cell cohort, Tanzania.

BACKGROUND: Monitoring patient's clinical attendance is a crucial means of improving retention in care and treatment programmes. Sickle cell patients' outcomes are improved by participation in comprehensive care programmes, but these benefits cannot be achieved when patients are lost from clinical care. In this study, patients are defined as loss to follow-up when they did not attend clinic for more than 9 months. Precise information on the retention rate and characteristics of those who are not following their clinic appointments is needed to enable the implementation of interventions that will be effective in increasing the retention to care. METHOD: This was a retrospective study involving sickle cell patients registered in the Muhimbili Sickle Cohort in Tanzania. Descriptive and survival analysis techniques both non-parametric methods (Kaplan-Meier estimator and Log-rank test) and semi-parametric method (Cox's proportional hazard model), were used. A p-value of 0.05 was considered significant to make an inference from the analysis. RESULTS: A total of 5476 patients were registered in the cohort from 2004 to 2016. Of these, 3350 (58.13%) were actively participating in clinics, while 2126 (41.87%) were inactive, of which 1927 (35.19%) were loss to follow-up. We used data from 2004 to 2014 because between 2015 and 2016, patients were referred to other government hospitals. From the survival analysis results, pediatric (HR: 14.29,95% CI: 11.0071-18.5768, p <  0.001) and children between 5 and 17 years [HR:2.61,95% CI:2.2324-3.0705, p <  0.001] patients were more likely to be loss to follow-up than the adult (18 and above years) patients. It was found that patients with above averages for hematocrit (HR: 2.38, 95% CI: 1.0076-1.0404, p = 0.0039) or mean cell volume (HR: 4.28, (95% CI: 1.0260-1.0598, p < 0.001) were more likely to be loss to follow-up than their counterparts. CONCLUSION: Loss to follow-up is evident in the cohort of patients in long term comprehensive care. It is, therefore, necessary to design interventions that improve patients' retention. Suggested solutions include refresher training for health care workers and those responsible for patient follow-up on techniques for retaining patients and comprehensive transition programs to prepare patients who are moving from pediatric to adult clinics.

Correction to: Educational Opportunities for Down-Staging Breast Cancer in Low-Income Countries: an Example from Tanzania.

The original version of this article unfortunately contained errors.

Educational Opportunities for Down-Staging Breast Cancer in Low-Income Countries: an Example from Tanzania.

While more than 90% of breast cancer patients in western countries survive for at least 5 years, the survival rate in Tanzania is less than 45% because of late stage at presentation. The aim of this study was to identify patient and health system factors related to early or late stages of a breast cancer diagnosis. The study was conducted at the Ocean Road Cancer Institute (ORCI) in Dar es Salaam, Tanzania, and included interviews with 196 breast cancer patients diagnosed with early (stage I/II, n = 44) or late (stage III/IV, n = 152) stage who were referred to ORCI from January 2016 to August 2018. The questionnaire elicited information regarding disease history, sociodemographics, barriers to navigating the health system, and patient attitudes towards breast cancer. More early-stage patients (54.5%) stated history of previous breast examinations before their initial diagnosis compared to late-stage patients (19.7%) (p = < 0.001). Financial restraints were cited more often as barriers to diagnosis among late-stage presentation patients (55.7%) compared to early-stage patients (35.5%) (p = 0.047). Patients who were diagnosed at late-stage (47.5%) were also more likely to state time restraints as significant barriers to their diagnosis than early-stage patients (25.8%) (p = 0.041). Although the late diagnosis of breast cancer will take immense efforts of policy workers to resolve, this study offers significant opportunities for making immediate health system changes through patient and physician education that can aid in reducing diagnosis delay in Tanzania other low-income developing countries, and low-income communities within the USA.

Impact of Initiating Screening Programs on Referral and Management of Cervical Cancer in Tanzania.

PURPOSE: We investigated the impact of screening rural patients on referral and management of cervical cancer in Tanzania. METHODS: After reviewing more than 10,000 medical records of patients with cervical cancer who visited Ocean Road Cancer Institute (ORCI) from 2005 to 2014, 108 patients were from the rural communities of Bagamoyo and Chalinze. We abstracted demographic, clinical, and lifestyle factors and linked the data set to databases of all 1,151 patients who visited the Bagamoyo screening clinic from 2011 to 2014 and 1,273 patients who visited the Chalinze screening clinic from 2012 to 2014. RESULTS: After initiation of the rural screening clinics, difference in duration from diagnosis to prescribed treatment increased from 50.5 to 88 days (P = .030), and duration from referral to treatment increased from 38.6 to 101.3 days (P = .041). Proportion of patients who received combination chemoradiotherapy increased from 34.3% to 69% (P = .001) and completion of treatment decreased from 94.4% to 72.41% (P = .002) after initiation of the ORCI screening clinic. Patients who visited Muhimbili National Hospital had significantly shorter periods between referral and prescribed treatment than patients who did not use the Muhimbili National Hospital (mean ± standard deviation, 49.4 ± 128.8 and 112.1 ± 195.31 days, respectively; P = .010). Patients who were treated at ORCI had significantly shorter periods between diagnosis and referral to treatment (mean ± standard deviation, 31.4 ± 62.35 and 36.4 ± 121.79 days, respectively; P = .005). CONCLUSION: Future research should focus on investigating barriers to seeking cancer care, benefits of chemoradiotherapy in this population considering the change in prescribed treatment, and time until diagnosis and treatment. Prescription of complex treatments that require more visits to treatment centers may also contribute to decline in completion of treatment.

Attitudes and Barriers to Research Among Oncology Trainees in East Africa.

BACKGROUND: East Africa is one of the fastest growing regions in the world and faces a rising burden of cancer; however, few people are equipped to effectively conduct research in this area. MATERIALS AND METHODS: A 31-item questionnaire was distributed to current trainees and recent graduates of the Master in Medicine in Clinical Oncology Program at Muhimbili University of Health and Allied Sciences in Tanzania. Areas that were assessed included (a) demographic information, (b) prior research training, (c) prior and current research activities, (d) attitudes toward the importance of research, and (e) supports and barriers to inclusion of research in an oncology career path. RESULTS: A total of 30 individuals responded to the survey, of whom 53% (n = 16) were male and 70% (n = 21) identified as current trainees. Among the majority of respondents, attitudes toward research were strongly favorable. Although only 37% (n = 11) reported receiving any formal training in research methodology, 87% (n = 26) reported intentions to incorporate research into their careers. The absence of protected time for research and lack of access to research funding opportunities were identified by a majority of respondents as critical barriers. CONCLUSION: A majority of current or recent oncology trainees in Tanzania desire to incorporate research into their careers, but most also lack adequate training in research methodology and longitudinal mentorship. Our future collaboration will focus on creation of appropriate research training curriculums and fostering an environment that catalyzes interprofessional development and transforms and extends context-specific cancer research in East Africa. IMPLICATIONS FOR PRACTICE: Current and recent oncology trainees in East Africa expressed a high enthusiasm for research, driven by a sense of urgency related to the burden from cancer that the region faces. This highlights the need for cancer research training and mentorship in this setting. This work hypothesizes that African principal investigators can operate effectively if proper attention is given to selection and provision of high-quality foundational didactic training to learn the theory and implementation of research as well as to the development of an environment conducive to mentoring.

Evaluating a Newly Developed System for Electronic Medical Records in Tanzania: An Example of the Experience in Low-Income Countries.

The introduction of electronic medical records (EMRs) in health systems in high-income countries has streamlined access to care and quality of patient information. However, in low-income countries such as Tanzania, EMR remains in its initial stages. The aim of this study was to compare completeness of patient information in the paper medical records (PMRs) with that of the newly implemented EMRs. Using hospital records of newly diagnosed breast cancer patients treated at the Ocean Road Cancer Institute, demographic, diagnostic, and treatment data of 328 patients between January 2017 and April 2018 were abstracted and compared between PMRs and EMRs. The results showed that demographic information variables were documented significantly more in EMRs (occupation, 98.5%) compared to PMRs (occupation, 43.3%) (P < .001). However, diagnostic and treatment information variables were much less likely to be reported in EMRs (full blood panel, 8.2%) than PMRs (full blood panel:=, 93%) (P < .001.) The results showed that EMR utilization corresponded with a marked decrease in the overall documentation rate of patient information compared to the standard PMRs. Multiple barriers affected EMR use. A major one was the lack of EMR connectivity across health systems in the country. Future studies should focus on uncovering the barriers and facilitators to EMR utilization, health care workers perception of available EMR systems, and better ways to improve lifetime sustainability of EMR systems in Tanzania and similar low-income countries.

Bacteraemia in sickle cell anaemia is associated with low haemoglobin: a report of 890 admissions to a tertiary hospital in Tanzania.

Bacteraemia is a leading cause of morbidity in sickle cell anaemia (SCA), but information from studies in Africa is limited. We evaluated 890 admissions from 648 SCA patients at a tertiary hospital in Tanzania. Bacteraemia was present in 43 admissions (4·8%); isolates included Staphylococcus aureus (12/43; 28%), non-Typhi Salmonella (9/43; 21%), Streptococcus pneumoniae (3/43; 7%) and Salmonella Typhi (2/43; 5%). Compared to SCA patients without bacteraemia, SCA patients with bacteraemia had significantly lower haemoglobin [71 g/l vs. 62 g/l, odds ratio 0·72 (95% confidence interval 0·56-0·91), P < 0·01]. Further exploration is needed of the relationship between anaemia and bacterial infections in SCA in Africa.