Incidence and treatment of hypercalcemia in cancer patients receiving radiotherapy: a retrospective review of practice at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) from 2012 to 2015

A research report submitted to the Faculty of Medicine in a partial fulfillment of the requirements for a degree of Master of Medicine in the specialty of Radiation Oncology (MMED Rad Onc) at the University of the Witwatersrand, Johannesburg October, 2017.Background: Cancer induced hypercalcemia (CIH) is the most frequent metabolic oncologic emergency and occurs in up to 44.1% of all cancer patients at some time in their disease course. It occurs in patients with both solid and hematologic malignancies. CIH occurs mostly in patients with advanced cancer and is an indicator of poor prognosis. Timely diagnosis and intervention is lifesaving and also may enhance patient compliance with primary and supportive treatment and quality of life. This study aimed to describe the incidence, clinical patterns and treatment outcomes of hypercalcemia in cancer patients receiving Radiation therapy in Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg. Materials and Methods: This was a retrospective descriptive study, 125 patients who were admitted at the Radiation oncology ward CMJAH for hypercalcemia management from January 2012 to December 2015, were analyzed. Demographic data, relevant clinical information such as Stage of the disease, type of cancer, level of hypercalcemia, toxicity and Response to the treatment were recorded. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS_version 23). The incidence of hypercalcemia, clinical patterns, treatment outcomes and toxicities were evaluated. The study was approved by the Human Research Ethics Committee medical (HRECM) of the University of Witwatersrand with Clearance certificate number M140546. Results: Of the 125 patients analysed, males to females ratio was 1:1. The most frequent site of primary cancer diagnosis in patients with hypercalcemia was gynaecological malignancies 31 (24.8%), followed by head and neck cancers 23 (18.4%), prostate 19 (15.2%), breast cancer 17 (13.6%), gastrointestinal malignancies 12 (9.6%), multiple myeloma 5 (4%), lung cancer 3 (2.4%) and other malignancies 15 (12%). Most patients had metastatic disease and uncontrolled primary disease 78 (62.4%) compared to primary controlled disease 47 (37.6%). Bone metastasis were present in 51 (41%) of patients. Clinical presentation of patients with hypercalcemia was mainly Neuromuscular 41 (32.8%), nausea/vomiting 37 (29.6%), Polyuria 20 (16%), mental 16 (12.8) and Polydipsia 9 (7.2%). Most of patients had severe hypercalcemia with pre-treatment corrected serum calcium level of > 2.9 mmol/L 77 (61.6%), 28 (22.4%) had Corrected serum Calcium between 2.71-2.89 mmol/L and 20 (16%) had corrected serum calcium between 2.56-2.70 mmol/L. One hundred and four patients (83.2%) received hydration + bisphosphonates and 21 (16.8%) of patients received hydration alone and non-received haemodialysis. One week post treatment majority of patients had ≤2.55 mmol/L Serum level of Calcium 81 (64.8%), 11 patients (8.8%) had serum level of calcium 2.56-2.71 mmol/L, 23 patients (18.4%) had serum calcium between 2.71-2.89 mmol/L and only 10 patients (8.0%) had serum level of calcium ≥2.9 mmol/L. The corrected serum calcium was 2.4770 ± 0.34512 mmol/L one week after treatment. One month post treatment majority of patients 99 (79.2%) remains to have normal serum level of calcium ≤2.55 mmol/L and only about 11 (8.8%) patients had ≥2.9 mmol/L. Forty four patients (35.2%) had relapse in 33 days (median) time and were subsequently treated with hydration and bisphosphonates. As the patients were enrolled from radiation oncology ward, most were treated with either radiation alone 72 (57.6%) or Concurrent chemo radiation 15 (12.0%) as treatment modalities for their primary cancer. Patients who received chemotherapy first and then radiotherapy for the treatment for their primary cancer were 37 (29.6%). Fourteen (58%) patients with pre-treatment calcium level of 2.56-2.70 mmol/L received hydration alone and 76 (98%) of patients with serum pre-treatment calcium of ≥2.9 mmol/L were treated with hydration + bisphosphonates (P=0.001). Side effects to bisphosphonates were mainly gastrointestinal: Nausea/vomiting 42 (33.6%) patients, Constipation 14 (11.2%), abdominal pain 13 (10.4), Diarrhoea 11 (8.8) and anorexia 1 (0.8) patients. Other toxicities reported were fever 12 (9.6%) patients and hypocalcaemia 14 (11.2%). Eighteen patients (14.4%) did not report any side effect to treatment. Conclusion: Hypercalcemia of malignancy is a common finding in patients with advanced stage cancers. Hypercalcemia of malignancy usually presents with markedly elevated calcium levels and patients are therefore usually symptomatic. For acute management of hypercalcemia, rehydration is the mainstay of treatment because all patients tend to have dehydration. Bisphosphonates are potent calcium lowering agents, but they require careful administration and are contraindicated in patients with declined renal function. Common bisphosphonates toxicities are mainly gastrointestinal: Nausea/vomiting, constipation, abdominal pain, diarrhoea and anorexia. Other toxicities reported were fever and hypocalcaemia.LG201

Colorectal cancer in Tanzania: the current status and future directions.

IntroductionGlobally, colorectal cancer (CRC) is the third most common malignancy and the second most common cause of cancer death. By 2030, the incidence is expected to increase to reach 2.2 million cases and 1.1 million deaths. In Sub-Saharan Africa, accurate cancer incidence data is limited, but anecdotally, clinicians note a significant rise in the incidence of CRC in the past decade. To educate clinicians on the growing burden of CRC, the Tanzanian Surgical Association hosted a 4-day CRC symposium from 3rd to 6th October 2022. Following the meeting, a group of multidisciplinary stakeholders created a working group whose first task was to assess the epidemiology, presentation and available resources for CRC care in Tanzania. The findings of that assessment are described in this article.FindingsThe true incidence of CRC in Tanzania is currently unknown. However, individual high-volume centres have noted a dramatic rise in cases of colon and rectal cancer on their wards. A review of the published data on CRC in Tanzania showed that most patients present with CRC late and the limited availability of endoscopic and diagnostic services poses a challenge for accurately staging these patients prior to treatment. Multidisciplinary care, including surgery, chemotherapy and radiation, is available for the treatment of CRC in Tanzania, although the capacity and quality of these services vary throughout the country.ConclusionThere is a substantial burden of CRC in Tanzania that appears to be increasing. While there is capacity in the country to provide all aspects of multidisciplinary care, late presentation, limited access to diagnostic and treatment services and poor coordination continue to be significant barriers to providing optimal treatment to these patients

Highlights from the Second Choosing Wisely Africa conference: a roadmap to value-based cancer care in East Africa (9–10 February 2023, Dar es Salaam, Tanzania)

The ecancer Choosing Wisely conference was held for the second time in Africa in Dar es Salaam, Tanzania, from the 9th to 10th of February 2023. ecancer in collaboration with the Tanzania Oncology Society organised this conference which was attended by more than 150 local and international delegates. During the 2 days of the conference, more than ten speakers from different specialties in the field of oncology gave insights into Choosing Wisely in oncology. Topics from all fields linked to cancer care such as radiation oncology, medical oncology, prevention, oncological surgery, palliative care, patient advocacy, pathology, radiology, clinical trials, research and training were presented to share and bring awareness to professionals in oncology, on how to choose wisely in their approach to their daily practice, based on the available resources, while trying to offer the maximum benefit to the patient. This report, therefore, shares the highlights of this conference

Feasibility and Clinical Acceptability of Automation-Assisted 3D Conformal Radiotherapy Planning for Patients With Cervical Cancer in a Resource-Constrained Setting

Automation may enable high-quality cervical cancer radiation on shorter treatment planning timelines

Feasibility and Clinical Acceptability of Automation-Assisted 3D Conformal Radiotherapy Planning for Patients With Cervical Cancer in a Resource-Constrained Setting.

PURPOSE: The Ocean Road Cancer Institute (ORCI) in Tanzania began offering 3D conformal radiation therapy (3DCRT) in 2018. Steep learning curves, high patient volume, and a limited workforce resulted in long radiation therapy (RT) planning workflows. We aimed to establish the feasibility of implementing an automation-assisted cervical cancer 3DCRT planning system. MATERIALS AND METHODS: We performed chart abstractions on 30 patients with cervical cancer treated with 3DCRT at ORCI. The Radiation Planning Assistant (RPA) generated a new automated set of contours and plans on the basis of anonymized computed tomography images. Each were assessed for edit time requirements, dose-volume safety metrics, and clinical acceptability by two ORCI physician investigators. Dice similarity coefficient (DSC) agreement analysis was conducted between original and new contour sets. RESULTS: The average time to manually develop treatment plans was 7 days. Applying RPA, automated same-day contours and plans were developed for 29 of 30 patients (97%). Of the 29 evaluable contours, all were approved with <2 minutes of edit time. Agreement between clinical and RPA contours was highest for the rectum (median DSC, 0.72) and bladder (DSC, 0.90). Agreement was lower with the primary tumor clinical target volume (CTVp; DSC, 0.69) and elective nodal clinical target volume (CTVn; DSC, 0.63). All RPA plans were approved with <4 minutes of edit time. RPA target coverage was excellent, covering the CTVp with median V45 Gy 100% and CTVn with median V45 Gy 99.9%. CONCLUSION: Automation-assisted 3DCRT contouring yielded high levels of agreement for normal structures. The RPA met all planning safety metrics and sustained high levels of clinical acceptability with minimal edit times. This tool offers the potential to significantly decrease RT planning timelines while maintaining high-quality RT delivery in resource-constrained settings

Views from Multidisciplinary Oncology Clinicians on Strengthening Cancer Care Delivery Systems in Tanzania

BackgroundIn response to the increasing burden of cancer in Tanzania, the Ministry of Health, Community Development, Gender, Elderly and Children launched National Cancer Treatment Guidelines (TNCTG) in February 2020. The guidelines aimed to improve and standardize oncology care in the country. At Ocean Road Cancer Institute (ORCI), we developed a theory-informed implementation strategy to promote guideline-concordant care. As part of the situation analysis for implementation strategy development, we conducted focus group discussions to evaluate clinical systems and contextual factors that influence guideline-based practice prior to the launch of the TNCTG.Materials and methodsIn June 2019, three focus group discussions were conducted with a total of 21 oncology clinicians at ORCI, stratified by profession. A discussion guide was used to stimulate dialogue about facilitators and barriers to delivery of guideline-concordant care. Discussions were audio recorded, transcribed, translated, and analyzed using thematic framework analysis.ResultsParticipants identified factors both within the inner context of ORCI clinical systems and outside of ORCI. Themes within the clinical systems included capacity and infrastructure, information technology, communication, efficiency, and quality of services provided. Contextual factors external to ORCI included interinstitutional coordination, oncology capacity in peripheral hospitals, public awareness and beliefs, and financial barriers. Participants provided pragmatic suggestions for strengthening cancer care delivery in Tanzania.ConclusionOur results highlight several barriers and facilitators within and outside of the clinical systems at ORCI that may affect uptake of the TNCTG. Our findings were used to inform a broader guideline implementation strategy, in an effort to improve uptake of the TNCTGs at ORCI.Implications for practiceThis study provides an assessment of cancer care delivery systems in a low resource setting from the unique perspectives of local multidisciplinary oncology clinicians. Situational analysis of contextual factors that are likely to influence guideline implementation outcomes is the first step of developing an implementation strategy for cancer treatment guidelines. Many of the barriers identified in this study represent actionable targets that will inform the next phases of our implementation strategy for guideline-concordant cancer care in Tanzania and comparable settings

Addressing the Global Expertise Gap in Radiation Oncology: The Radiation Planning Assistant

PURPOSEAutomation, including the use of artificial intelligence, has been identified as a possible opportunity to help reduce the gap in access and quality for radiotherapy and other aspects of cancer care. The Radiation Planning Assistant (RPA) project was conceived in 2015 (and funded in 2016) to use automated contouring and treatment planning algorithms to support the efforts of oncologists in low- and middle-income countries, allowing them to scale their efforts and treat more patients safely and efficiently (to increase access).DESIGNIn this review, we discuss the development of the RPA, with a particular focus on clinical acceptability and safety/risk across jurisdictions as these are important indicators for the successful future deployment of the RPA to increase radiotherapy availability and ameliorate global disparities in access to radiation oncology.RESULTSRPA tools will be offered through a webpage, where users can upload computed tomography data sets and download automatically generated contours and treatment plans. All interfaces have been designed to maximize ease of use and minimize risk. The current version of the RPA includes automated contouring and planning for head and neck cancer, cervical cancer, breast cancer, and metastases to the brain.CONCLUSIONThe RPA has been designed to bring high-quality treatment planning to more patients across the world, and it may encourage greater investment in treatment devices and other aspects of cancer treatment

Treatment outcomes of esophageal cancer in Eastern Africa: protocol of a multi-center, prospective, observational, open cohort study.

BackgroundEsophageal squamous cell carcinoma (ESCC) is a major cause of cancer morbidity and mortality in Eastern Africa. The majority of patients with ESCC in Eastern Africa present with advanced disease at the time of diagnosis. Several palliative interventions for ESCC are currently in use within the region, including chemotherapy, radiation therapy with and without chemotherapy, and esophageal stenting with self-expandable metallic stents; however, the comparative effectiveness of these interventions in a low resource setting has yet to be examined.MethodsThis prospective, observational, multi-center, open cohort study aims to describe the therapeutic landscape of ESCC in Eastern Africa and investigate the outcomes of different treatment strategies within the region. The 4.5-year study will recruit at a total of six sites in Kenya, Malawi and Tanzania (Ocean Road Cancer Institute and Muhimbili National Hospital in Dar es Salaam, Tanzania; Kilimanjaro Christian Medical Center in Moshi, Tanzania; Tenwek Hospital in Bomet, Kenya; Moi Teaching and Referral Hospital in Eldoret, Kenya; and Kamuzu Central Hospital in Lilongwe, Malawi). Treatment outcomes that will be evaluated include overall survival, quality of life (QOL) and safety. All patients (≥18 years old) who present to participating sites with a histopathologically-confirmed or presumptive clinical diagnosis of ESCC based on endoscopy or barium swallow will be recruited to participate. Key clinical and treatment-related data including standardized QOL metrics will be collected at study enrollment, 1 month following treatment, 3 months following treatment, and thereafter at 3-month intervals until death. Vital status and QOL data will be collected through mobile phone outreach.DiscussionThis study will be the first study to prospectively compare ESCC treatment strategies in Eastern Africa, and the first to investigate QOL benefits associated with different treatments in sub-Saharan Africa. Findings from this study will help define optimal management strategies for ESCC in Eastern Africa and other resource-limited settings and will serve as a benchmark for future research.Trial registrationThis study was retrospectively registered with the ClinicalTrials.gov database on December 15, 2021,  NCT05177393