Medical Oncology Workload in Europe: One Continent, Several Worlds.

AIMS: The workload pressure on medical oncologists will increase in the near future. There are no comprehensive data available about the current workload of medical oncologists in Europe. Here we report the European results of a global survey of the workload of medical oncologists. MATERIALS AND METHODS: An online survey was distributed through a snowball method via national oncology societies to chemotherapy-prescribing physicians in 21 European countries. We compared the workload of medical oncologists in Eastern European countries (EECs) and Western European countries (WECs). The primary measure of workload was the annual number of new cancer patient consults seen per oncologist. RESULTS: In total, 495 oncologists from 16 European countries completed our survey: 100 from seven EECs and 395 from nine WECs. The median number of annual consults per medical oncologist was 225 in EECs compared with 175 in WECs (P < 0.001). The proportion of medical oncologists seeing more than 300 consults/year was 35% (35/100) in EECs compared with 18% (68/395) in WECs. The median number of patients seen in a full day clinic was 25 in EECs and 15 in WECs (P < 0.001). Eastern European medical oncologists reported spending a median of 25 min per new consultation compared with 45 min in WECs (P < 0.001). The top two reported barriers in both EECs and WECs to patient care were high clinical volumes and insufficient time for reading. CONCLUSION: The clinical workload of medical oncologists in EECs was substantially higher than in WECs. European health policymakers and educators need to address existing disparities in the workload of medical oncologist, undertake plans for future workforce supply and consider alternative models of care.

Medical oncology workload in Canada: infrastructure, supports, and delivery of clinical care.

Background: In 2000, a Canadian task force recommended that medical oncologists (mos) meet a target of 160-175 new patient consultations per year. Here, we report the Canadian results of a global survey of mo workload compared with mo workload in other high-income countries (hics). Methods: Using a snowball method, an online survey was distributed by national oncology societies to chemotherapy-prescribing physicians in 22 hics (World Bank criteria). The survey was distributed within Canada to all members of the Canadian Association of Medical Oncologists. Workload was measured as the annual number of new cancer patient consults per oncologist. Results: The survey was completed by 782 oncologists from hics, including 58 from Canada. Median annual consults per mo were 175 in Canada compared with 125 in other hics. The proportions of mos having 100 or fewer consults or more than 300 consults per year were 3% (2/58) and 5% (3/58) in Canada compared with 31% (222/724) and 16% (116/724) in other hics (p < 0.001 and p = 0.023 respectively). The median number of patients seen in a full-day clinic was 15 in Canada and 25 in other hics (p = 0.220). Canadian mos reported spending a median of 55 minutes per new consultation; new consultations of 35 minutes were reported in other hics (p < 0.001). Median hours worked per week was 55 in Canada and 45 in other hics (p = 0.200). Conclusions: Although the median annual clinical volume for Canadian mos aligns with recommended targets, half the respondents exceeded that level of activity. Health policymakers and educators have to consider mo workforce supply and alternative models of care in preparation for the anticipated surge in cancer incidence in the coming decade.

Breast cancer in men

Breast cancer in males is a relatively rare entity. In the sub-region, several reports indicate a higher incidence rate compared to other regions in the world. For many years, management strategies were derived from evidence based protocols established for managing female breast cancer. There are however,differences in the epidemiology, presentation, molecular profiles and response to therapies including chemotherapy, hormonal and targeted therapies. Outcomes even though mirroring female breast cancer may actually exhibit differences dependent onstage, race, prognostic and economic variables. The lack of large randomized trials on this subject has resulted in ad hoc management practices across the globe. With new information from renewed interest in the subject, screening and diagnostic guidelines are being established for high-risk groups and we expect to see improvement in outcomes for patients with male breast cancer. This article attempts to bring to light a summary of the current interest, recommendations and controversies in the management of male breast cancer

An update on the management of breast cancer in Africa.

BACKGROUND: There is limited information about the challenges of cancer management and attempts at improving outcomes in Africa. Even though South and North Africa are better resourceds to tackle the burden of breast cancer, similar poor prognostic factors are common to all countries. The five-year overall Survival rate for breast cancer patients does not exceed 60% for any low and middle-income country (LMIC) in Africa. In spite of the gains achieved over the past decade, certain characteristics remain the same such as limited availability of breast conservation therapies, inadequate access to drugs, few oncology specialists and adherence to harmful socio-cultural practices. This review on managing breast cancer in Africa is authored by African oncologists who practice or collaborate in Africa and with hands-on experience with the realities. METHODS: A search was performed via electronic databases from 1999 to 2016. (PubMed/Medline, African Journals Online) for all literature in English or translated into English, covering the terms "breast cancer in Africa and developing countries". One hundred ninety were deemed appropriate. RESULTS: Breast tumors are diagnosed at earlier ages and later stages than in highincome countries. There is a higher prevalence of triple-negative cancers. The limitations of poor nursing care and surgery, inadequate access to radiotherapy, poor availability of basic and modern systemic therapies translate into lower survival rate. Positive strides in breast cancer management in Africa include increased adaptation of treatment guidelines, improved pathology services including immuno-histochemistry, expansion and upgrading of radiotherapy equipment across the continent in addition to more research opportunities. CONCLUSION: This review is an update of the management of breast cancer in Africa, taking a look at the epidemiology, pathology, management resources, outcomes, research and limitations in Africa from the perspective of oncologists with local experience.

MANAGEMENT OF PROSTATE CANCER IN ACCRA, GHANA.

INTRODUCTION: Africans living with prostate cancer in Africa face problems of early diagnosis and appropriate treatment. AIM: To study the clinical incidence of prostate cancer, risk factors, TNM stage, their management and outcomes. METHODS: A prospective study of Prostate Cancer cases managed at Korle Bu Teaching Hospital and hospitals in Accra, diagnosed by history, abnormal PSA/DRE, physical examination and histologically confirmed by biopsy from 2004 to 2013 was carried out. The cases were TNM staged and managed by approved protocol. RESULTS: There were 669 cases with a mean age 70±0.045SE years, median Gleason Score of 7, organ confined Prostate Cancer(PC) in 415(62%), locally advanced in 167(25%) and metastatic Prostate Cancer in 87(13%) cases. The cases were followed for median of 10 months to ≥ 84 months. Organ confined cases were managed by: Radical Prostatectomy (RP) 92 (13.8%) with a mortality of 0.3%; brachytherapy 70 (10.5%) with a mortality of 0.1% and External Beam Radiotherapy (EBRT) 155 (23%) with a mortality 0.7%. In all, 98 men constituting (14.1%) cases with a mean age of 75+0.25SE years, life expectancy <10 years were treated by hormonal therapy with a mortality of 1.7%. Twenty cases who were for active surveillance (GS6), PSA <10ng/ml, life expectancy <10 years later all opted for EBRT. Locally advanced cases 25% all had neoadjuvant hormonal therapy then Brachytherapy in 3 (0.4%) mortality 0.15% and EBRT in 64 (9.5%), mortality 0.59%. Hormonal therapy was given in 100 (15%) locally advanced cases, mortality 5%. Metastatic prostate cancer cases (13%) were managed by hormonal therapy, mortality 6%. CONCLUSION: Improved facilities and dedicated skilled teams led to a significant rise in proportion of organ confined Prostate Cancer from 15.3% to 62% curable by Radical Prostatectomy, brachytherapy or EBRT with longer disease free survival.

Patterns of practice in palliative radiotherapy in Africa - case revisited.

AIMS: To investigate patterns of practice in palliative radiotherapy in Africa. MATERIALS AND METHODS: Fifteen centres in Africa provided detailed information about radiotherapy in both metastatic and locally advanced disease via a questionnaire. Information included general information (institution status, equipment, staff, patient number), radiotherapy and other treatment characteristics in bone metastasis, brain metastasis, metastatic spinal cord compression, lung and liver metastasis, as well as locally advanced tumours. RESULTS: The number of patients annually seen/treated ranged from 285 to 5000. Breast, cervix, head and neck, gastrointestinal and prostate cancer were the top five cancers overall. Eight (53%) institutions were without linear accelerators, four (27%) had a single one, whereas one institution each had two, three and four linear accelerators. The number of cobalt machines ranged from 0 to 2 (median 1). Most centres still prefer to use fractionated radiotherapy regimens over single-fraction regimens in bone metastasis, although most centres are now using single-fraction radiotherapy in retreatments. Radiotherapy in brain metastasis and metastatic spinal cord compression mostly conform to worldwide standards. Lung and liver metastases are rarely irradiated, largely as a consequence of the lack of modern radiotherapy technology. Locally advanced disease in various tumour sites was mostly palliated, in agreement with current evidence-based practices. CONCLUSIONS: African countries still lack adequate staffing and equipment to adequately address their clinical burden, being palliative in most cases. Emphasis should also be made on more rationally using existing capacities by using more of the single-fraction radiotherapy regimens, especially in bone metastasis.

Management of febrile neutropenia in patients receiving chemotherapy for solid tumors: a retrospective study of twenty cases from the radiotherapy centre, Accra, Ghana.

BACKGROUND: One in ten patients on anticancer medication will develop febrile neutropenia irrespective of tumour type. There is need to protect our patients from this fatal condition while optimising chemotherapy. This may be difficult for a poor country. OBJECTIVE: to assess the management of cancer patients with febrile neutropenia in a low resource setting. METHODS: records of 20 cancer patients with febrile neutropenia (fn) over a three-year period were retrospectively analysed. data retrieved included age, sex, type of cancer and number of cycles of chemotherapy taken. Other parameters included initial temperature, site of infection, absolute neutrophil count (ANC) at presentation and antibiotic choice. Use of antifungal drugs, duration of fever and overall treatment outcome were also assessed. RESULTS: the male : female ratio was 3:2 with a median age of 24 years (range: 15 - 68 years), and a mean temperature of 38.8 oC (range 38.0-39.8 0C). Mean absolute neutrophil count was 0.2 x 109 (range: 0.0 to 0.6 x 109). Thirteen (65%) received Cisplatin, five (25%) received Adriamycin, two (10%) received Paclitaxel or Cyclophosphomide-Methotrexate-5, Fluorouracil (CMF). Ten(50%) developed FN with the first cycle of chemotherapy, and six(30%) in the second cycle. Twelve (60%) had oral infection, four(20%) had gastroenteritis and single episodes of respiratory and urinary tract infections. Eleven (55%), received Ceftriaxone and Gentamycin, five (25%) cases received Levofloxacin or ciprofloxacin and Amoxicillin/clavunate + metronidazole; two cases(10%), Ceftazidime and Gentamycin; two cases(10%) received Meropenem. Twelve (60%) patients had antifungal therapy for oral candidiassis. Eight (40%) patients received growth factors. The mean fever duration was 4.5 days (range 1-10 days). Two (10%) of the patients died. CONCLUSION: febrile neutropenia in resource limited countries can be managed with good history and physical examination skills. Aminoglycosides are important components of empiric treatment in Ghana.

Palliative radiation therapy practice for advanced esophageal carcinoma in Africa.

While numerous surveys of pattern of practices of palliative radiotherapy (RT) in advanced esophageal cancers have been published in developed countries, there is no such survey in African countries. During and after a regional training course by the International Atomic Energy Agency (IAEA) in palliative cancer care, a questionnaire was distributed to African RT centers to gather information about infrastructure and human resources available, and the pattern of practice of palliative RT for esophageal cancers. Twenty-four of the 35 centers (60%) completed the questionnaire. Twenty out of 23 (87%) centers treat patients with esophageal cancer presenting with dysphagia using external beam RT (16 centers external beam RT alone and 4 centers also use brachytherapy as a boost). Twelve (60%) centers prescribe RT doses of 30 Gy in 10 fractions and 2 centers 20 Gy in 5 fractions. Eighteen centers (78%) have low dose rate (LDR) brachytherapy, and 9 (39%) centers have high dose rate (HDR) brachytherapy. One center only used HDR brachytherapy alone to a dose of 16 Gy in 2 fractions over 8 days. RT remains a major component of treatment of patients with esophageal cancers in African countries. Still, there is a great variety among centers in both indications for RT and its characteristics for a treatment indication.

Management of Febrile Neutropenia in Patients Receiving Chemotherapy for Solid Tumors: a Retrospective Study of Twenty Cases from the Radiotherapy Centre; Accra; Ghana

BACKGROUND: One in ten patients on anticancer medication will develop febrile neutropenia irrespective of tumour type. There is need to protect our patients from this fatal condition while optimising chemotherapy. This may be difficult for a poor country. OBJECTIVE: To assess the management of cancer patients with febrile neutropenia in a low resource setting. METHODS: Records of 20 cancer patients with febrile neutropenia (FN) over a three-year period were retrospectively analysed. Data retrieved included age; sex; type of cancer and number of cycles of chemotherapy taken. Other parameters included initial temperature; site of infection; absolute neutrophil count (ANC) at presentation and antibiotic choice. Use of antifungal drugs; duration of fever and overall treatment outcome were also assessed. RESULTS: The male : female ratio was 3:2 with a median age of 24 years (range: 15 - 68 years); and a mean temperature of 38.8 oC (range 38.0-39.8 0C). Mean absolute neutrophil count was 0.2 x 109 (range: 0.0 to 0.6 x 109). Thirteen (65) received Cisplatin; five (25) received Adriamycin; two (10) received Paclitaxel or Cyclophosphomide-Methotrexate-5; Fluorouracil (CMF). Ten(50) developed FN with the first cycle of chemotherapy; and six(30) in the second cycle. Twelve (60) had oral infection; four(20) had gastroenteritis and single episodes of respiratory and urinary tract infections. Eleven (55); received Ceftriaxone and Gentamycin; five (25) cases received Levofloxacin or ciprofloxacin and Amoxicillin/clavunate + metronidazole; two cases(10); Ceftazidime and Gentamycin; two cases(10) received Meropenem. Twelve (60) patients had antifungal therapy for oral candidiassis. Eight (40) patients received growth factors. The mean fever duration was 4.5 days (range 1-10 days). Two (10) of the patients died. CONCLUSION: Febrile neutropenia in resource limited countries can be managed with good history and physical examination skills. Aminoglycosides are important components of empiric treatment in Ghana

Profile of breast diseases at a self-referral clinic in Ghana.

BACKGROUND: Breast cancer is a common malignancy in Ghana, and many patients are referred with advanced disease and long duration of symptoms. OBJECTIVE: To determine the spectrum of breast disease diagnosed through patient self-referral in Ghana. METHODS: A breast clinic, where patients could walk in without referral, was started in the Korle Bu Teaching Hospital in 2001. A team of surgeons, radiation oncologists, oncology nurses, a clinical psychologist and a clinical pharmacist sat in conference once a week to see and discuss self-referred patients. RESULTS: Seven hundred and forty eight patients, mean age 38.6 (range 8-85) years, were seen during a four-year period. There were 741 females and seven males. The main complaints were pain 450 (50.2%), lump 257 (28.7%) and nipple discharge 62 (8.3%). Fifty (5.6%) came for check-up; 139 (18.6%) had more than one complaint. The mean (S.D.) duration of symptoms was; for nipple discharge 14.1 (10.5) months, lump 11.9 (7.7) months, and pain 11.3 (8.9) months. The main diagnoses were: Normal breasts 192 (27.7%), mastalgia 135 (18.1%), fibroadenosis 114 (15.2%), fibroadenomas 84 (11.2%), breast cancer 58 (7.8%), suspected breast cancer 25 (3.3%), galactorrhea 9 (1.2%), mastitis 8 (1.1%), musculoskeletal pain 8 (1.1%), duct ectasia 8 (1.1%), mondor's disease 7 (0.94%) and recurrent breast cancer 6 (0.8%). In patients with breast cancer, 42 (66%) had advanced disease, 6 (9.4%) had recurrent disease and 4 (63%) had metastatic disease. CONCLUSION: The number of self-referrals, detected breast cancers and duration of symptoms justify the need for self-referral clinics in Ghana.

Treatment outcome of locally advanced nasopharyngeal cancer with concurrent chemoradiotherapy.

BACKGROUND: Treatment options for locally advanced Nasopharyngeal lancer include radiation alone or cisplatin based concurrent chemoradiotherapy. Concurrent chemoradiotherapy is associated with higher morbidity but has been shown to yield better survival. OBJECTIVE: This study was aimed at determining the outcome of treatment of Nasopharyngeal Cancer with concurrent chemoradiotherapy in our setup. METHODS: Twenty-six patients with biopsy proven disease who had undergone staging procedures were studied according to age, sex, WHO histological type and stage of disease. Treatment consisted of 70 Gy to the primary site and 60 Gy to the neck with disease. Chemotherapy was given as follows: three cycles of three weekly cisplatin at 80 mg/m2 during radiation followed by three cycles of three weekly cisplatin at 60 mg/m2 on day 1 and 5-fluorouracil at 1000 mg/m2 on days 1 to 5 in the adjuvant setting. Side effects of treatment, pattern of failure and survival were determined. RESULTS: The male to female ratio was 2:1, age range was 10-68 years. WHO type 3 was predominant at 50%. Stage IVB disease was present in 73.1% of patients. Average number of chemotherapy cycles received was three. Median follow up period was 30 months (8-56 months), 42.3% survived beyond 24 months. Twelve patients developed recurrence of disease, of which eight had local regional recurrence only. CONCLUSION: Concurrent chemoradiotherapy is possible in our setting with acceptable morbidity at the prescribed doses. Survival beyond two years is possible in our environment with this regime. Local failure is the predominant cause of death.

Ovarian cancer: an analysis of forty-four patients at the National Radiotherapy Centre, Accra--Ghana.

BACKGROUND: The median age for ovarian cancer is 60-65 years. Greater than 70% present with advanced disease but recent treatment advances have resulted in modest improvement in treatment outcome over the past decade. OBJECTIVE: To evaluate the median age, time of presentation, histology and treatment outcome of 44 cases referred to us for management. METHODS: We studied 44 cases of ovarian cancer. Chemotherapy consisted of 3 weekly cycles of Cisplatin at 75mg/m2 and Cyclophosphamide at 750mg/m2 or Paclitaxel at 175mg/m2. Parameters documented included age, histology, time of presentation stage and treatment response. These were obtained from clinical examination, operation notes, pathology reports, radiological exams and Cancer Antigen 125 tumor marker levels. RESULTS: Age range was 12-64 years with a median of 45 years. Thirty-seven (82%) had stage 3 or 4 disease. Thirty-seven (82%) presented after four months of which two-thirds presented more than one year after initial symptoms. Thirty-seven (82%) had epithelial ovarian cancer, four (9%) had germ cell tumours and three (7%) stromal tumors. Only twenty five patients could be assessed for treatment response. Twenty (80%) out of these 25 patients received Cyclophosphamide and Cisplatin chemotherapy. Total clinical response rate was 52%, with only four patients (16%) achieving complete clinical response and nine patients (36%), a partial response. CONCLUSION: Our patients presented with a median age of 45 years which is lower than what is reported for most countries. A large majority present with advanced disease and presented more than four months after initial symptoms. The response rate of cyclophosphamide/Platinum chemotherapy in this group with epithelial cell type was relatively low.

Osteoradionecrosis of the mandible.

Osteoradionecrosis is a major complication of surgery or trauma in previously irradiated bone in the absence of tumor persistence. Radiation-induced vascular insufficiency rather than infection causes bone death. It occurs most commonly in the mandible after head and neck irradiation. Risk factors include the total radiation dose, modality of treatment, fraction size and dose rate, oral hygiene, timing of tooth extractions as well as the continued use of tobacco and alcohol. This condition is often painful, debilitating, and may result in significant bone loss. The recommended treatment guidelines are irrigation, antibiotics, hyperbaric oxygen therapy, and surgical techniques, including hemimandibulectomy and graft placements.