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

Utilizing quantitative dried blood spot analysis to objectively assess adherence to cardiovascular pharmacotherapy among patients at Kenyatta National Hospital, Nairobi, Kenya

The burden of cardiovascular disease (CVD) is rising in Kenya and non-adherence to cardiovascular pharmacotherapy is a growing global public health issue that leads to treatment failure, an increased risk of cardiac events and poor clinical outcomes. This study assessed adherence to selected cardiovascular therapy medications among CVD patients attending outpatient clinics at Kenyatta National Hospital, Kenya by determining drug concentration(s) in patient dried blood spot (DBS) samples. Patients who had been taking one or more of the five commonly prescribed CVD medications (amlodipine, atenolol, atorvastatin, losartan, and valsartan) for at least six months were enrolled. Each patient completed a short questionnaire about their medication history and then provided a finger-prick blood spot sample from which drug concentrations were determined by liquid chromatography-high resolution mass spectrometry analysis. Two hundred and thirty-nine patients (62.3% female) participated in the study. The median number of medications used by patients was 2 (IQR 75%-25% is 3-1). Less than half (117; 49.0%) of patients were adherent to their prescribed CVD pharmacotherapy. Binary regression analysis revealed a significant correlation between non-adherence and the number of medications in the treatment regimen (Odds Ratio (OR) 1.583; 95%CI: 0.949-2.639; P-value = 0.039) and that gender was not an independent predictor of medication adherence (OR 1.233; 95%CI: 0.730-2.083; P-value = 0.216). Valuable information about adherence to each medication in the patient’s treatment regimen was obtained using quantitative DBS analysis showing that adherence to CVD medications was not uniform. DBS sampling, due its minimally invasive nature, convenience and ease of transport is a useful alternative matrix to monitor adherence to pharmacotherapies objectively, when combined with hyphenated mass spectrometry analytical techniques. This information can provide physicians with an evidence-based novel approach towards personalization and optimization of CVD pharmacotherapy and implementing interventions in the Kenyan population, thereby improving clinical 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

Cost and affordability of non-communicable disease screening, diagnosis and treatment in Kenya: Patient payments in the private and public sectors.

The prevalence of non-communicable diseases (NCDs) is rising in low- and middle-income countries, including Kenya, disproportionately to the rest of the world. Our objective was to quantify patient payments to obtain NCD screening, diagnosis, and treatment services in the public and private sector in Kenya and evaluate patients' ability to pay for the services.We collected payment data on cardiovascular diseases, diabetes, breast and cervical cancer, and respiratory diseases from Kenyatta National Hospital, the main tertiary public hospital, and the Kibera South Health Center-a public outpatient facility, and private sector practitioners and hospitals. We developed detailed treatment frameworks for each NCD and used an itemization cost approach to estimate payments. Patient affordability metrics were derived from Kenyan government surveys and national datasets. Results compare public and private costs in U.S. dollars. NCD screening costs ranged from $4 to$36, while diagnostic procedures, particularly for breast and cervical cancer, were substantially more expensive. Annual hypertension medication costs ranged from $26 to$234 and $418 to$987 in public and private facilities, respectively. Stroke admissions ($1,874 versus$16,711) and dialysis for chronic kidney disease ($5,338 versus$11,024) were among the most expensive treatments. Cervical and breast cancer treatment cost for stage III (curative approach) was about $1,500 in public facilities and more than$7,500 in the private facilities. A large proportion of Kenyans aged 15 to 49 years do not have health insurance, which makes NCD services unaffordable for most people given the overall high cost of services relative to income (average household expenditure per adult is $413 per annum).There is substantial variation in patient costs between the public and private sectors. Most NCD diagnosis and treatment costs, even in the public sector, represent a substantial economic burden that can result in catastrophic expenditures

The genetic prehistory of southern Africa.

Southern and eastern African populations that speak non-Bantu languages with click consonants are known to harbour some of the most ancient genetic lineages in humans, but their relationships are poorly understood. Here, we report data from 23 populations analysed at over half a million single-nucleotide polymorphisms, using a genome-wide array designed for studying human history. The southern African Khoisan fall into two genetic groups, loosely corresponding to the northwestern and southeastern Kalahari, which we show separated within the last 30,000 years. We find that all individuals derive at least a few percent of their genomes from admixture with non-Khoisan populations that began ∼1,200 years ago. In addition, the East African Hadza and Sandawe derive a fraction of their ancestry from admixture with a population related to the Khoisan, supporting the hypothesis of an ancient link between southern and eastern Africa

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