Colorectal Cancer Epidemiology in Tanzania: Patterns in Relation to Dietary and Lifestyle Factors

This research article was published by American Society of Clinical Oncology in 2018Background: Chronic noncommunicable diseases are increasingly captured as contributing to morbidity and mortality in low and middle income countries. Aim: This study aimed to investigate the epidemiology of colorectal cancer and the potential modifiable local risk factors in Tanzania. Methods: A cross sectional retrospective chart audit study was conducted to establish the pattern and distribution of colorectal cancer, The Food Frequency Questionnaire and the Step® survey tool were used to collect data. Descriptive statistics, χ2 tests, and regression analysis were used and augmented by data visualization to display risk variable differences. Results: Tanzania's colorectal cancer incidence has increased six times in the last decade in which major towns and cities of Dar es Salaam (20.2 per 100,000), Pwani (7.2 per 100,000), Kilimanjaro (4.4 per 100,000), Arusha (4.2 per 100,000), and Morogoro (3.6 per 100,000) had the highest percentage. This study reported that, almost 45% of the participants were hypertensive. Two major dietary patterns, namely “healthy” and “western”, existed among the study sample. Obesity was found in 25% of participants, whereas overweight was present in 28%; of note, the prevalence was higher in females (26.9%) than in males (23.6%) respectively. The prevalence of alcohol consumption was 21.5%, with a significantly lower rate of smoking (12.2%) noted within the study subjects. Both alcohol consumption and tobacco smoking were more common in men than women (22.7 vs. 20.6% and 24.5 vs. 3.2%, respectively). The prevalence of vigorous, moderate, and low physical activity for both sexes was 18.6%, 54.1% and 42.3%, respectively. Conclusion: Evidence from this study demonstrate that, like other NCDs CRC is increasing in Tanzania. Colon cancer is increasing at higher rate than rectal cancer seeming to align with change in lifestyle. Major towns and cities had the highest share of CRC patients. Diet, obesity, tobacco smoking, alcohol consumption, and sedentary behavior have potential role to play in the rising trend of CRC and other NCDs. We recommend a large longitudinal study with robust methodology which can establish cause and effect relationships between specific lifestyle behaviors and the incidence of colorectal cancer

The changing pattern of ano-rectal cancer, squamous cell carcinoma of the eye, and Hodgkin’s lymphoma as non-AIDS-defining cancers, by HIV status, in Tanzania over 11 years (2002-2012): a retrospective case-report study

Abstract Background In Tanzania, 5.1% of adults aged 15-49 are infected with HIV. While rates of HIV-related malignancies have declined globally with antiretroviral therapy (ART), including Tanzania, rates of non-AIDS-defining cancers (NADCs) are believed to have increased. Therefore, we determined trends of three NADCs in Tanzania: ano-rectal cancer, squamous cell carcinoma of the eye, and Hodgkin’s lymphoma. Methods This study was conducted at the Ocean Road Cancer Institute (ORCI) in Dar es Salaam. All medical records of patients diagnosed with ano-rectal cancer, squamous cell carcinoma of the eye, and Hodgkin’s lymphoma between 2002 and 2012 were reviewed regarding HIV status, cancer clinical characteristics and management. Analysis was conducted to determine trends and proportions in these three NADCs and patient characteristics. Results We identified 980 NADCs. The relative proportion of these three NADCs at ORCI out of all cancers treated increased from 2.37% in 2002 to a peak of 4.34% in 2009. The prevalence of HIV in patients diagnosed with these NADCs also increased—from 6.67% in 2002 to 20.87% in 2010—and 85% of squamous cell carcinoma of the eye cancer patients with a reported HIV status were HIV-positive. Conclusions The frequency and proportions of these three NADCs in Tanzania have increased over the past 11 years, as has the prevalence of HIV positivity amongst these NADC patients. The current and possibly increasing burden of NADCs in Tanzania and other low- and middle-income countries with high HIV rates should be a focus for future cancer prevention and control and HIV therapy programs.http://deepblue.lib.umich.edu/bitstream/2027.42/111050/1/13027_2014_Article_524.pd

Association between invasive cancer of the cervix and HIV-1 infection in Tanzania: the need for dual screening

<p>Abstract</p> <p>Background</p> <p>Cancer of the cervix is the second commonest malignancy in females worldwide and is the leading malignancy among women in Tanzania. Cancer of the cervix has been strongly associated with Human Papilloma Virus (HPV) which is a sexually transmitted disease. However, the role of HIV-1 in the aetiology of cancer of the cervix is less clear. Studies suggest that HPV and HIV-1 infection are synergistic and therefore their dual occurrence may fuel increased incidence of cancer of the cervix and AIDS. We therefore conducted a study to determine the association between cancer of the cervix and HIV-1.</p> <p>Methods</p> <p>The study was carried out in Ocean Road Cancer Institute, Dar-es-salaam, Tanzania between January and March 2007. A hospital-based case control design was used to study 138 cases and 138 controls. The cases were consenting women 18 years and above with histologically confirmed squamous cell carcinoma of the cervix, while the controls were consenting non-cancer adult women attendants or visitors. The participants were counselled and tested for HIV-1 and interviewed to assess risk factors for cancer of the cervix and HIV-1. Estimation of risk was done by computing odds ratios and confidence intervals. Confounding and interaction between the factors were assessed using logistic regression.</p> <p>Results</p> <p>HIV-1 prevalence was much higher among the cases (21.0%) than among the controls (11.6%). In logistic regression, HIV-1 was associated with cancer of the cervix (OR = 2.9, 95% CI = 1.4–5.9). Among the cases the mean age was lower for HIV-1 infected (44.3 years) than HIV-1 uninfected women (54 years, p = 0.0001).</p> <p>Conclusion</p> <p>HIV-1 infection is associated with invasive cancer of the cervix. Resource-constrained countries with a high burden of HIV-1 and cervical cancer should adopt a high-risk approach that targets HIV-1 positive women for screening of cervical cancer initially by utilizing HIV/AIDS resources.</p

Promoters of and barriers to cervical cancer screening in a rural setting in Tanzania

ObjectiveTo investigate promoters and barriers for cervical cancer screening in rural Tanzania.MethodsWe interviewed 300 women of reproductive age living in Kiwangwa village, Tanzania. The odds of attending a free, 2‐day screening service were compared with sociodemographic variables, lifestyle factors, and knowledge and attitudes surrounding cervical cancer using multivariable logistic regression.ResultsCompared with women who did not attend the screening service (n = 195), women who attended (n = 105) were older (OR 4.29; 95% CI, 1.61–11.48, age 40–49 years versus 20–29 years), listened regularly to the radio (OR 24.76; 95% CI, 11.49–53.33, listened to radio 1–3 times per week versus not at all), had a poorer quality of life (OR 4.91; CI, 1.96–12.32, lowest versus highest score), had faced cost barriers to obtaining health care in the preceding year (OR 2.24; 95% CI, 1.11–4.53, yes versus no), and held a more positive attitude toward cervical cancer screening (OR 4.64; 95% CI, 1.39–15.55, least versus most averse).ConclusionEfforts aimed at improving screening rates in rural Tanzania need to address both structural and individual‐level barriers, including knowledge and awareness of cervical cancer prevention, cost barriers to care, and access to health information.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135344/1/ijgo221.pd

Most women diagnosed with cervical cancer by a visual screening program in Tanzania completed treatment: evidence from a retrospective cohort study

Abstract Background Visual inspection with acetic acid (VIA) to identify and treat pre-cancerous lesions is effective for cervical cancer prevention. Screening programs also facilitate screening and diagnosis of invasive cancers that must be referred for radiation therapy or chemotherapy. This study compared characteristics of women diagnosed with invasive cervical cancer by a VIA screening program who did and did not follow up for treatment and who did and did not complete treatment at the Ocean Road Cancer Institute (ORCI), Dar es Salaam, Tanzania. Methods We conducted a retrospective cohort study of ORCI screening referrals from the period November 2002 to June 2011. Women referred for treatment of invasive disease (n = 980) were identified from an existing database of all women attending the screening clinic during this period (n = 20,131) and matched to a dataset of all cervical cancer patients attending ORCI in this period (n = 8,240). Treatment information was abstracted from patient records of women who followed up. Records of a random sample (n = 333) of unscreened patients were reviewed for disease stage. Results Of the 980 women referred women, 829 (84.6%) sought treatment. Most of those women (82.8%) completed their prescribed radiation. Lower disease stage, having a skilled occupation, residence in Dar es Salaam, and younger age were independently associated with loss to follow-up. Higher disease stage, residence in Dar es Salaam, older age, and later year of first treatment appointment were independently associated with incomplete treatment among those who followed up. Significantly more screened women had stage 1 disease (14.0%) than unscreened women (7.8%). Conclusions Most women referred from the screening clinic completed treatment for their cancer at ORCI. Some of those lost to follow-up may have sought treatment elsewhere. In most cases, the screening clinic appears to facilitate diagnosis and treatment, rather than screening, for women with invasive cervical cancer.http://deepblue.lib.umich.edu/bitstream/2027.42/109468/1/12889_2013_Article_7027.pd

Oncology Drug Production in Sub-Saharan Africa: The Challenge and Opportunity, with Evidence from India

This chapter focuses on the scope for local production in East Africa of essential oncology medication, drawing on evidence of local clinical need; on Indian data on markets for generic oncology medication; and on industrial and regulatory experience. Import-dependence in oncology is almost complete across Sub-Saharan Africa, while India is a key exporter. The chapter documents competition failures in generic oncology markets and demonstrates the huge affordability impact of effective procurement of these medicines within India. Challenges for local oncology manufacturing are identified. The chapter argues that active health-industrial research linkages can build a local African oncology industry

Beyond “Late Presentation”: Explaining Delayed Cancer Diagnosis in East Africa

[Diagnosis] is like the basis of everything. If I am diagnosed early, I have a chance to survive. (Survivor, Kenya) In Tanzania and Kenya, as in many other low- and middle-income countries (LMICs), the majority of cancer patients are diagnosed when their cancer is at a late stage, with negative implications for treatment options and efficacy, the cost of care, and rates of survival (Lehmann et al., 2020; Makau-Barasa et al., 2018; Mlange et al., 2016; Ngoma et al., 2015). Reducing delays to diagnosis, and increasing the number of patients diagnosed, is a policy priority in both countries (Ministry of Health, 2017; Ministry of Health and Social Services, 2013) and internationally (WHO, 2020). Enabling earlier diagnosis is critical not only for patient outcomes but also for its potential to reduce the cost of care for patients and healthcare providers (Espina et al., 2017, Moodley et al., 2018). However, research regarding factors influencing the timeliness of diagnosis of cancers in LMICs remains limited (Nnaji et al., 2022). Delayed diagnosis is often framed as a challenge of “late presentation” by patients at health facilities, to be explained by patient behaviour and characteristics, and prompting calls for public education about cancer symptoms and treatment and the importance of prompt facility attendance (Kassaman et al., 2022; Mlange et al., 2016, Mwaka et al., 2021). Indeed, interventions aimed at addressing barriers to timely diagnosis in LMICs tend to emphasise improving patient, community, and to a lesser extent health provider knowledge, rather than addressing structural issues such as the financial costs associated with care (Qu et al., 2020). It is certainly the case, as explored in Chapter 3, that limited knowledge and understanding of cancer and cancer treatment among patients, caregivers, and their communities contribute to fear and experiences of stigma, influencing whether and how patients seek care. However, this chapter builds on Chapter 4’s demonstration, from the accounts of patients, caregivers, and survivors, of the limitations of “late presentation” in explaining delays to diagnosis. We shift here to a more “professional” health system perspective, drawing largely on interviews with health professionals and policymakers in Kenya and Tanzania. These interviews identified key challenges, including access to screening, weak referral systems, the very limited availability of diagnostic pathology, and the direct and indirect costs of obtaining a cancer diagnosis, to which feasible responses could speed diagnosis. We argue that policy aimed at increasing early diagnosis must go well beyond improving population knowledge to address wider health system issues such as referral procedures, availability and accessibility of diagnostic tests, and the affordability of care

Innovation and Policy in Cancer Pain Management: Systemic Interactions in Tanzania

In contrast to India, Tanzania imports all its opiate medication, yet there too, need is unmet. This chapter reports findings from a sustained collaborative effort in Tanzania to understand the roots of undertreatment of severe cancer pain. It analyses the complex sources of this cancer care failure, contrasting the Tanzanian situation to the Ugandan experience of providing more widespread access to opiate medication for severe pain. The chapter describes findings from multi-sectoral and multi-disciplinary workshops in Tanzania, documenting critical causal feedback loops that generate sustained undertreatment of severe pain, and identifies innovations that could turn this outcome around

Pattern and Distribution of Colorectal Cancer in Tanzania: A Retrospective Chart Audit at Two National Hospitals

Background. Colorectal cancer (CRC) is a growing public health concern with increasing rates in countries with previously known low incidence. This study determined pattern and distribution of CRC in Tanzania and identified hot spots in case distribution. Methods. A retrospective chart audit reviewed hospital registers and patient files from two national institutions. Descriptive statistics, Chi square ( 2 ) tests, and regression analyses were employed and augmented by data visualization to display risk variable differences. Results. CRC cases increased sixfold in the last decade in Tanzania. There was a 1.5% decrease in incidences levels of rectal cancer and 2% increase for colon cancer every year from 2005 to 2015. Nearly half of patients listed Dar es Salaam as their primary residence. CRC was equally distributed between males (50.06%) and females (49.94%), although gender likelihood of diagnosis type (i.e., rectal or colon) was significantly different ( = 0.027). More than 60% of patients were between 40 and 69 years. Conclusions. Age ( = 0.0183) and time ( = 0.004) but not gender ( = 0.0864) were significantly associated with rectal cancer in a retrospective study in Tanzania. Gender ( = 0.0405), age ( = 0.0015), and time ( = 0.0075) were all significantly associated with colon cancer in this study. This retrospective study found that colon cancer is more prevalent among males at a relatively younger age than rectal cancer. Further, our study showed that although more patients were diagnosed with rectal cancer, the trend has shown that colon cancer is increasing at a faster rate

Cancer patients’ pathways: evidence and implications for policy

This Discussion Paper presents findings from a patients' pathways survey conducted in 2019 with 62 Tanzanian participants suffering from cancer or survivors of cancer. The paper looks at facilitators and barriers to accessing cancer care in Tanzania. A number of identified challenges that hinder patients from accessing care in a timely manner relate to costs, diagnosis and referrals. The paper highlights the social and economic burden faced by patients on the path to treatment. The research forms part of a larger collaborative project, Innovation for Cancer Care in Africa (ICCA). The survey included an innovative methodology, tracing in detail patients’ pathways through their experience of cancer from first symptoms to diagnosis to treatment and after. Key findings in this paper include the following. * Late-stage presentation of cancer is acknowledged to be a serious impediment to effective treatment in Tanzania. The average delay for these patients between first going to a health facility with symptoms that were those of cancer, to diagnosis, was 2.13years. This delay is a central cause of late stage presentation for treatment. * In their search for a diagnosis, many patients have moved repeatedly between formal facilities as their (often severe) symptoms worsened. While most public sector patients had to move “up” the system, from district to zonal or national level hospitals to obtain a diagnosis, only 15% of all these movements between facilities were the result of a referral. Most were patients’ (and their families’) search for diagnosis. * Regional hospitals, to which many patients moved from district level, did not do well in terms of diagnosis; only 8 people were eventually diagnosed at regional level including none who began their pathways at that level. * Several patients had been well served by dispensaries and district hospitals: two directly diagnosed there, and several moving directly to the facility where diagnosed: there is thus some good practice at district level to be shared. * Two patients were diagnosed through screening, both after several moves between formal health facilities, evidencing both the importance of screening and the lack of effective investigation of symptoms within the system. * Out-of-pocket costs were high for patients in the period when they were seeking treatment, an average of over TZS 400,000. For those on lower household incomes in particular, this had imposed a major burden and source of impoverishment. This effect was worsened by the addition of transport costs of moving between facilities. * Patients starting in the private sector, generally with NHIF or private insurance, experienced shorter and more direct trajectories to diagnosis. Insurance was only partially financially protective before diagnosis, reducing on average but not eliminating out of pocket (OOP) spending. * Delays between diagnosis and treatment were much shorter: average 16 weeks to start of treatment. A cancer diagnosis triggered, on average, burdensome continuing costs: while half of respondents made no OOP payments after diagnosis, the average payments for all respondents were over TZS 1.6 million. Of those who made these payments, 80% had no insurance. * Over half of respondents said they had used a complementary or alternative form of care. For many this was prayer and faith healing, sometime associated with other forms of mosque or church support. Those who went to alternative healers and gave cost details had spent an average of nearly TZS half a million. * Free treatment at Ocean Road Cancer Institute (ORCI) is effective in protecting many lower income patients, who made up the majority of respondents interviewed at ORCI, from prohibitive costs of treatment, and is hugely appreciated by patients