Establishing Cohorts to Generate the Evidence Base to Reduce the Burden of Breast Cancer in Sub-Saharan Africa: Results From a Feasibility Study in Kenya

Purpose: By 2025, Kenya is estimated to experience a two-thirds increase in the incidence of breast cancer. Local research is necessary to generate evidence to inform policy, public health, and medical practice. There have been no longitudinal cohort studies in sub-Saharan Africa of women with and without breast cancer. Our aim is to assess the feasibility of conducting cohort studies in Kenya that consider clinical characteristics, socioeconomic factors, and self-care behaviors. Methods: We initiated a short-term follow-up cohort study of women with and without a diagnosis of breast cancer with baseline face-to-face data collection and one follow-up interview (at approximately 3 months by telephone). We developed tailored instruments to capture demographics, socioeconomic factors, breast cancer risk, ability to identify breast cancer symptoms, treatments received for breast cancer, and quality of life of survivors. Results: We recruited 800 women between the ages of 20 and 60 years and successfully collected baseline data. Completeness of the data was high for demographic variables, but there was a larger proportion of missing information for specific variables required for assessing breast cancer risk. Respondents were able to complete standardized instruments to assess breast cancer knowledge among those without breast cancer and identification of symptoms among survivors. We were able to successfully contact approximately 80% of the participants for follow-up. Conclusion: This short-term follow-up study provides evidence that women can be successfully tracked and contacted for follow-up in the Kenyan setting and offers lessons to establish future longitudinal cohorts to identify approaches to improve breast cancer outcomes

Predictors of Breast Cancer Treatment Outcomes in Kenyan Women

Background: Breast cancer is the most prevalent cancer among Kenyan women.  Worldwide data show that diverse factors including socio-economic status, co-morbidities, and expression of hormonal receptors, have effect on disease recurrence or metastasis following treatment. Most studies on breast cancer treatment outcomes have been undertaken in developed countries, and there is scarcity of data on predictive indicators of breast cancer treatment outcomes in Africa. Objective: This study was designed to determine the factors that predict the treatment outcomes in breast cancer patients in a Kenyan teaching and referral hospital. Methods: This hospital based retrospective descriptive study was designed to evaluate the effect of the occurrence of estrogen receptor, progesterone receptor, human epidermal growth factor and cancer stage among other factors on the outcome of breast cancer treatment. Patients diagnosed with breast cancer and who had their first visit at the KNH in the period 2007-2008 were identified. Quantitative variables were described with medians or means. Association effects were determined by use of Chi-square test. Categorical variables were summarized using proportions. The time to event analysis was estimated using the Kaplan–Meier product limit method. Results: The mean age of the 219 participants was 46.5 years (range 23 to 92 years), majority (36.1%) of whom were aged between 41 to 50 years. Most study participants had stage 2B (21.9%) cancer type, and the histological grade 3 breast cancer was predominant type (50.2%). Nearly half of the patients (46.1%) developed metastases. In bivariate analyses, cancer stage 2A (OR 0.29, 95% CI 0.12 to 0.77) and stage 2B (OR 0.41, 95% CI 0.21- 0.77), presence of estrogen receptors (OR 0.24, 95% CI 0.12 to 0.77), presence of progesterone receptor (OR 0.26, 95% CI 0.09 to 0.72), human epidermal growth factors (OR 0.05, 95% CI 0.003 to 0.84), and those on hormonal treatment (OR 0.34, 95% CI 0.19 to 0.62) were factors less likely to be associated with development of metastasis after treatment. In multivariate analysis, HIV positive status (OR 0.004, 95% CI 0.002 to 0.75), presence of estrogen (OR 0.23, 95% CI 0.08 to 0.64) and human epidermal growth factors (OR 2.53, 95% CI 1.64 to 3.91) receptors and obesity (OR 2.53, 95% CI 1.64 to 3.91) were independent factors influencing development of metastasis after treatment. Conclusion: This study showed that development of metastasis after breast cancer therapy has associations with the expression of estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor -2 (HER-2) as well as the stage of diagnosis.  This study demonstrates the need for enhanced screening for breast cancer to improve early diagnosis and the testing of ER, PR and HER-2 are crucial as they predict outcomes of therapy. Key words: Breast cancer, breast cancer treatment, cancer treatment outcomes, cancer treatment predictors

Proactive risk assessment of vincristine use process in a teaching and referral hospital in Kenya and the implications

Introduction: The chemotherapy use process is potentially risky for cancer patients. Vincristine, a “High Alert” medicine, has been associated with fatal but preventable medication errors. Consequently, there is a need to improve the use of vincristine especially in lower- and middle-income countries where there are constraints with resources and often a lack of trained personnel to administer cancer medicines. However, where there is a rising prevalence of cancer cases. These concerns can be addressed by performing proactive risk assessments using Healthcare Failure Mode Effect Analysis (HFMEA) and implementing the findings. Methods: A multidisciplinary health team driven by pharmacists identified and evaluated potential failure modes based on a vincristine use process flow diagram using a hazard scoring matrix in a leading referral hospital in Kenya. Results: The processes evaluated were: prescribing, preparation and dispensing, transportation and storage, administration and monitoring of the use of vincristine. Seventy-seven failure modes were identified over the three-month study period, of which 25 were classified as high risk. Thirteen were adequately covered by existing control measures while 12 including one combined mode required new strategies. Two of the failure modes were single-point weaknesses. Recommendations were subsequently made for improving the administration of vincristine. Conclusions: HFMEA is a useful tool to identify improvements to medication safety and reduction of patient harm. The HFMEA process brings together the multidisciplinary team involved in patient care in actively identifying potential failure modes and owning the recommendations made, which are now being actively followed up in this hospital. Pharmacists are a key part of this process

Patient costs of managing complications of hypertension and diabetes (2017 US dollars).

<p>Patient costs of managing complications of hypertension and diabetes (2017 US dollars).</p

Unmapped exome reads implicate a role for Anelloviridae in childhood HIV-1 long-term non-progression

Human immunodeficiency virus (HIV) infection remains a significant public health burden globally. The role of viral co-infection in the rate of progression of HIV infection has been suggested but not empirically tested, particularly among children. We extracted and classified 42 viral species from whole-exome sequencing (WES) data of 813 HIV-infected children in Botswana and Uganda categorised as either long-term non-progressors (LTNPs) or rapid progressors (RPs). The Ugandan participants had a higher viral community diversity index compared to Batswana (p = 4.6 × 10−13), and viral sequences were more frequently detected among LTNPs than RPs (24% vs 16%; p = 0.008; OR, 1.9; 95% CI, 1.6–2.3), with Anelloviridae showing strong association with LTNP status (p = 3 × 10−4; q = 0.004, OR, 3.99; 95% CI, 1.74–10.25). This trend was still evident when stratified by country, sex, and sequencing platform, and after a logistic regression analysis adjusting for age, sex, country, and the sequencing platform (p = 0.02; q = 0.03; OR, 7.3; 95% CI, 1.6–40.5). Torque teno virus (TTV), which made up 95% of the Anelloviridae reads, has been associated with reduced immune activation. We identify an association between viral co-infection and prolonged AIDs-free survival status that may have utility as a biomarker of LTNP and could provide mechanistic insights to HIV progression in children, demonstrating the added value of interrogating off-target WES reads in cohort studies

Catastrophic health expenditure: Out-of-pocket spending ≥ 40% of household non-food expenditure.

<p>Source: 2013 Kenya Household Health Expenditure and Utilization Survey [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0190113#pone.0190113.ref031" target="_blank">31</a>].</p