Update on Gyne Malignancies in AMPATH/MTRH

Dr Elkanah Omenge Orang’o Lecturer Moi University School of Medicine

Impact of Cancer in Africa

• WHO predicts 16 million new

cancer cases per year in 2020 – 70% of these will be in the

developing world

• In the developing world: – 1/3 cancers potentially can

be prevented – Another 1/3 are treatable if

detected early

Why be concerned about Gynecology Cancers in Kenya?

• Cancer rates are growing in Africa faster than they are in North America

• Infrastructure to deal with growing cancer rates is lacking

• 30% of cancers worldwide have access to 90% of resources whereas 70% have <10% of resources

• Resources to prevent, diagnose and treat cancers are lacking

• Public awareness of cancer is low

Worldwide Cancer Burden*

*New cases in 2000 Parkin DM. Lancet Oncol 2001; 2(9):533-543.

471 379

154

193 142

101 75

132 117

55 65

39

0 100 200 300 400 500 600

579 91

292 125

175 91

114 34 16

66 47 61

100 200 300 400 500 600

Breast Cervix uteri

Colon/Rectum Stomach

Lung Ovary

Corpus uteri Liver

Oesophagus Non-Hodgkin lymphoma

Leukaemia Pancreas

More developed Less developed

2,176,000 2,562,000 Thousands

Total

Women

Cancer rates in Kenya: IARC

6

Years of life lost (YLL) • The leading cause of cancer-

related YLL in South Central Asia, Latin America, Sub-Saharan Africa

• A more important cause of YLL than AIDS, tuberculosis (TB) and maternal conditions in Latin America, Europe, Japan, and Australia and New Zealand

• 4.8 times as common and causes 7 times as many YLL in developing countries than in developed countries

Yang BH et al. Int J Cancer 2004; 109: 418–24.

0

0.5

1

1.5

2

2.5

YLL

Number of YLL among women, aged 25-64 years (millions)

Developed countriesDeveloping countries

What is the Gap? 2016

• Gynecologic cancers are the biggest cancer

killer in Kenya • Cervix cancer is individual biggest killer • No organized approach to cancer prevention,

treatment, or palliation • Virtually no access to radiation • Limited access to chemotherapy and limited

number of drugs

What has been done at Moi University

Dr Omenge Orangó Moi University School of Medicine

• 2009 - Through Forgarty Grant( PI Dr Mabeya and Susan Cu-Uvin) a study was initiated to compare VIA to Pap smear in HIV +ve women. 150 women were recruited in the study and we found VIA to be as sensitive as PAP smear and but the specificity was lower to Pap smears.

• With this findings MTRH agreed to give ongoing support for screening at AMPATH for HIV patients.

VIA Screening

Treating Cervix Cancer

• April 2010- 2 Gynecologists at Moi were trained to perform radical hysterectomy + pelvic lymphadenectomy for early cervical cancer. This module was delivered by a Gynecologic oncologist from PMH. To date about 161 radical hysterectomies have been completed.

GYNE ONC DATABASE SINCE 2010

Cervical cancer 718

Ovarian Cancer 177

Gestational Trophoblastic Neoplasia 58

Vulva 16

Treating Cervix Cancer

• Protocol was developed to use neo-adjuvant chemotherapy for down sizing of cacx and for palliation

• Treatment protocols for ovarian and GTN

malignancies.

Low Stage Cervical Cancer (1B1) Treatment

< 4 cm 1B1

Radical Hysterectomy + Pelvic Lymphadenectomy

Fertility Sparing Surgery (Chemotherapy + Cone Biopsy + PLND)

Refer to Post-Definitive

Treatment Follow-Up

Low Stage Cervical Cancer (1B2) Treatment

> 4 cm 1B2

Radiation (if Feasible)

Refer back to Gynecology Oncology

Should indicate if External Beam +/-

Intracavitary

Radiation Not

Feasible Chemotherapy Stable

Disease

Progressive Disease

Partial Response

Maximum 6 cycles

Maximum 3 cycles

Residual Disease < 4 cm

Residual Disease > 4 cm

Refer to 1B1 Flow

Refer to Hospice

Post-Palliative Treatment Follow-Up

Refer to Post-Definitive Treatment Follow-Up

Gyn Oncology Fellowship • Concept was developed to start a gyn oncology fellowship in Kenya

so that they could get the expertise needed to manage all gyn oncology patients, to administer a program in gyn oncology and to continue to train others

• Subspecialty training initially was not widely accepted in a country where there is a significant shortage of doctors and general specialists

• Dept of RH at Moi University and MTRH supported the concept after a great deal of discussion

• Support to proceed was obtained from KOGS, Kenyan Medical and Dental Board, Stakeholders, AMPATH Oncology, Dept of Ob Gyn at both U of and Indiana University

• First subspecialty training program at Moi University

Curriculum

• 2 year curriculum • Comprehensive with the following courses

– Introduction to Gyn Oncology 4 wks – Clinical Gyn Oncology 48 wks – Medical Oncology 12 wks – Radiation Oncology 8 wks – Pathology 5 wks – Palliative Care 6 wks – Epidemiology 4 wks – Communication 2 wks – Research project

On Campus faculty

• Omenge Orang’o • Peter Itsura • Philliph Tonui

Travelling Faculty

• Barry Rosen • Giuseppe del Priore • Allan Covens • Peter Bryson • Chris Giede

Progress

• There are 3 fellows in training • Two in second year and one in first year • One of the fellows is from Uganda. • Next intake in September.

Certification

• Completion of research project • Satisfactory evaluation of each rotation • Exam after first year • Final exam: Exam that will include evaluation

of clinical activity and an oral exam • MSc will be issued by Moi University

Research

• Vision: – Leadership in Gyn Oncology in Kenya will come

through recognized training and ongoing research – There is a need to develop a more comprehensive

approach to data collection – Research needs to be a pillar of the fellowship

training

Papers and Presentations • 4 papers published

– Rad hyst training – Chemotherapy treatment for ovarian cancer in low resource country

• GOC – Two poster presentations 2011 and 2012

• IGCS – Oral presentation, poster 2010

• APOG – Oral presentation

• SGO – poster

• KOGS – Two oral presentation by Kenyans

• UICC – 3 papers accepted 2012

• ASCO – Poster 2012

• Pelvic surgeons – Oral presentation

• Bethune surgical roundtable – Oral presentation

• IGCS 2012 – 5 abstracts accepted for poster presentation

THANK YOU