Early Experience after Developing a Pathology Laboratory in Malawi, with Emphasis on Cancer Diagnoses

BackgroundDespite increasing cancer burden in Malawi, pathology services are limited. We describe operations during the first 20 months of a new pathology laboratory in Lilongwe, with emphasis on cancer diagnoses.Methods and FindingsWe performed a cross-sectional study of specimens from the Kamuzu Central Hospital pathology laboratory between July 1, 2011 and February 28, 2013. Patient and specimen characteristics, and final diagnoses are summarized. Diagnoses were categorized as malignant, premalignant, infectious, other pathology, normal or benign, or nondiagnostic. Patient characteristics associated with premalignancy and malignancy were assessed using logistic regression. Of 2772 specimens, 2758 (99%) with a recorded final diagnosis were included, drawn from 2639 unique patients. Mean age was 38 years and 63% were female. Of those with documented HIV status, 51% had unknown status, and 36% with known status were infected. Histologic specimens comprised 91% of cases, and cytologic specimens 9%. Malignant diagnoses were most common overall (n = 861, 31%). Among cancers, cervical cancer was most common (n = 117, 14%), followed by lymphoma (n = 91, 11%), esophageal cancer (n = 86, 10%), sarcoma excluding Kaposi sarcoma (n = 75, 9%), and breast cancer (n = 61, 7%). HIV status was known for 95 (11%) of malignancies, with HIV prevalence ranging from 9% for breast cancer to 81% for cervical cancer. Increasing age was consistently associated with malignancy [bivariable odds ratio 1.24 per decade increase (95% CI 1.19–1.29) among 2685 patients with known age; multivariable odds ratio 1.33 per decade increase (95% CI 1.14–1.56) among 317 patients with known age, gender, and HIV status], while HIV infection and gender were not.ConclusionsDespite selection and referral bias inherent in these data, a new pathology laboratory in Lilongwe has created a robust platform for cancer care and research. Strategies to effectively capture clinical information for pathologically confirmed cancers can allow these data to complement population-based registration

Early Experience after Developing a Pathology Laboratory in Malawi, with Emphasis on Cancer Diagnoses

Abstract Background: Despite increasing cancer burden in Malawi, pathology services are limited. We describe operations during the first 20 months of a new pathology laboratory in Lilongwe, with emphasis on cancer diagnoses

Informatics solutions for bridging the gap between clinical and laboratory services in a low-resource setting

Background: There has been little formal analysis of laboratory systems in resource-limited settings, despite widespread consensus around the importance of a strong laboratory infrastructure. Objectives: This study details the informational challenges faced by the laboratory at Kamuzu Central Hospital, a tertiary health facility in Malawi; and proposes ways in which informatics can bolster the efficiency and role of low-resource laboratory systems. Methods: We evaluated previously-collected data on three different aspects of laboratory use. A four-week quality audit of laboratory test orders quantified challenges associated with collecting viable specimens for testing. Data on tests run by the laboratory over a one yearperiod described the magnitude of the demand for laboratory services. Descriptive information about the laboratory workflow identified informational process breakdowns in the pre-analytical and post-analytical phases and was paired with a 24-hour sample of laboratory data on results reporting. Results: The laboratory conducted 242 242 tests over a 12-month period. The four-week quality audit identified 54% of samples as untestable. Prohibitive paperwork errors were identified in 16% of samples. Laboratory service workflows indicated a potential process breakdown in sample transport and results reporting resulting from the lack of assignment of these tasks to any specific employee cadre. The study of result reporting time showed a mean of almost six hours, with significant variation. Conclusions: This analysis identified challenges in each phase of laboratory testing. Informatics could improve the management of this information by streamlining test ordering and the communication of test orders to the laboratory and results back to the ordering physician

Timeline for development of pathology services at Kamuzu Central Hospital (KCH).

<p>Timeline for development of pathology services at Kamuzu Central Hospital (KCH).</p

Immunohistochemistry stains being implemented in the Kamuzu Central Hospital pathology laboratory.

<p>HPV = human papillomavirus. LANA = latency-associated nuclear antigen. ER = estrogen receptor. PR = progesterone receptor.</p

Comparison of patient characteristics for premalignant/malignant diagnosis versus other diagnosis in the Kamuzu Central Hospital pathology laboratory between July 1, 2011 and February 28, 2013.

<p>SD = standard deviation. *Includes only specimens with known patient age, gender, or HIV status.</p

Associations of patient characteristics with premalignant/malignant and malignant diagnosis in the Kamuzu Central Hospital pathology database between July 1, 2011 and February 28, 2013.

<p>OR = odds ratio. CI = confidence interval. *Bivariable analyses include only specimens with known patient age (n = 2685), gender (n = 2748), or HIV status (n = 328). **Multivariable analyses include only 317 specimens with known patient age, gender, and HIV status.</p

Specimens received in the Kamuzu Central Hospital pathology laboratory between July 1, 2011 and February 28, 2013.

<p>Specimens received in the Kamuzu Central Hospital pathology laboratory between July 1, 2011 and February 28, 2013.</p

Patient, specimen, and diagnosis characteristics in the Kamuzu Central Hospital pathology laboratory between July 1, 2011 and February 28, 2013.

<p>SD = standard deviation. *HIV status routinely collected beginning November 2012.</p