AFRICA TAKES THE FIGHT AGAINST CANCER HEAD ON ALTHOUGH CHALLENGES ABOUND

By BENJAMIN OPUKO

According to the World Health Organization (WHO) estimates, cancer is the world's second leading cause of death accounting for nearly 10 million deaths in 2020. In the same year, 70% of the nearly 10 million cancer-related deaths worldwide occurred in low-and-middleincome countries. The disparity is even more pronounced in the case of cervical cancer, with 90% of new cases and deaths occurring in low- and middle-income countries. Although not officially recognized as a pandemic, cancer poses a significant obstacle to increasing life expectancy in every country and experts globally have been working to find solutions to keep the disease at bay. In this article, we highlight the cancer burden and strategies being explored by experts, particularly in Africa, to contain the disease.

Global Cancer Incidence And Burden Outlook

There were an estimated 18.1 million cancer cases around the world in 2020, according to data from the Global Cancer Observatory. Of these, 9.3 million cases were in men and 8.8 million in women. The most common in 2020 in terms of new cases of cancer according to the WHO were: breast (2.26 million); lung (2.21 million); colon and rectum (1.93 million); prostate (1.41 million); skin (non-melanoma) (1.20 million cases); and stomach (1.09 million).

The global cancer burden continues to rise, putting enormous physical, emotional, and financial strain on individuals, families, communities, and healthcare systems. In 2022, the American Cancer Society estimates that will be an estimated 1.9 million new cancer cases diagnosed and 609,360 cancer deaths in the United States. By 2040, the global burden of cancer is expected to rise to 27.5 million new cases and 16.3 million cancer deaths. For SubSaharan Africa, cancer incidence is projected to double by 2040 to more than 1.4 million cases per year, if rapid interventions are not put in place, according to a new Lancet Oncology Commission report.

As cancer spreads like wildfire, it is the lowincome countries that are most affected. In 2020, 70% of the estimated 10 million cancer deaths occurred in low and middle-income countries (LMICs). If nothing is done, the number of premature deaths from cancer is expected to reach four million by 2040. Many LMICs lack the necessary healthcare infrastructure to adequately treat and care for cancer patients, owing to a lack of diagnostics, medicines, and other services for comprehensive cancer care. In fact, cancer treatment and care are available in less than 15% of LMICs compared to more than 90% in high-income countries, according to anecdotal evidence from Union for International Cancer Control (UICC) members around the world.

Aggregate Cancer Burden In Africa

According to Globocan data, the aggregate cancer burden in Africa showed 1.1 million new cases, and 711,429 deaths were estimated to have occurred on the continent in 2020. The most prevalent cancers in Africa are breast, cervical, prostate, gastrointestinal, and Kaposi sarcoma in regions with high HIV. Females bear the brunt of breast cancer in Africa, with nearly 186,598 new cases and 85,787 deaths reported in 2020. Cervix uteri (cervical cancer, henceforth) ranks second in Africa with an estimated incidence of 117,316. In males, prostate cancer is leading cancer in Africa with 93,173 cases and 47,249 deaths reported in 2020.

Egypt tops the ranking in terms of new cancer cases (134,632) and deaths (89,042), followed by Nigeria and South Africa with estimated incidences of 124,815, and 108,168 respectively. including infections, environmental exposures, aging populations, increasing adoption of westernized lifestyles, infrastructure challenges, scarcity of qualified staff, a critical shortage of diagnostics, treatment, and prevention facilities, patients who present with late-stage cancer, high treatment abandonment rates, and lack of awareness about cancer risk factors. Many of these existing challenges were further exacerbated during the COVID-19 pandemic, making an already dire situation worse.

The disease is one of the top three causes of premature death (aged 30-69 years) in almost all constituent countries, accounting for one in every seven premature deaths overall and one in every four non-communicable disease deaths.

Cancer's burden has the potential to rise further. With 2040 projections put at 1.4 million cases annually, Africa is forecast to have the world’s largest increase in cancer incidences and deaths in the next 2 decades.

A new Lancet Oncology Commission for sub-Saharan Africa estimates more than one million cancer deaths will occur per year in those countries by 2030 at current trends. Furthermore, the prevalence of childhood cancer in the region is currently at 56.3 cases per million, and it is projected that half of all global childhood cancer cases in 2050 will occur in Africa.

AFRICA’S NEW STRATEGIES TO COMBAT CANCER

Although the situation seems bleak by all metrics, Africa has greatly improved in its metrics on cancer management.

By 2017, 71% of African countries had operational national cancer control programs, up from 46% in 2013, and the oncology workforce has steadily increased, but not at par with the rate of new incidences and prevalence in the continent. For instance, the African Cancer Coalition has brought together more than 100 cancer experts from 13 countries to adopt dozens of cancer treatment guidelines from the United States for use in Sub-Saharan Africa, resulting in practical clinical standards that are harmonized across the region.

Furthermore, recently announced pricing agreements with international suppliers are

A combination of factors can be attributed to Sub-Saharan Africa's growing cancer crisis bringing high-quality cancer treatments to the African market at less than half of what they were previously.

African governments are increasing their cancer investments. Most have established national cancer programs, and the region now has more than 30 cancer centers. However, large investments in cancer treatment programs are not the best use of resources because treatment is often too late to save lives and cannot meet the ever-increasing demand for cancer treatment. According to the World Health Organization, reducing known risk factors can prevent nearly half of all cancers. Investing in prevention rather than treating late-stage cancer thus makes more sense.

Notably, Botswana, Kenya, and Rwanda have started to provide cancer care in their national efforts to achieve universal coverage of health services. Access to palliative care is expanding in some countries. Rwanda became one of the first African countries to pass a palliative care law in 2011. The law empowered nurses to prescribe morphine to advanced cancer patients. Additionally, the Rwandan law enabled the establishment of a new cadre of home-based care practitioners to provide palliative care and assist patients in managing other NCDs at home. Rwanda is also focusing on cancer prevention, such as cervical cancer, which accounts for approximately 22% of cancers affecting women in the WHO's African region, by expanding HPV vaccination. Further to that, Rwanda has instituted a health insurance scheme known as the Mutuelle de Santé that covers approximately 90% of the country's 11.6 million people, allowing access to cancer treatment as it moves toward universal health coverage.

Kenya is one of several African countries attempting to make cancer services more accessible through publicly-funded health insurance schemes as the country moves toward universal health coverage. For instance, Kenya's national insurance system took the bold step in 2016 of covering radiation therapy and surgery, as well as four courses of chemotherapy per year, at hospitals across the country, making these services free at the point of care for the 18% of Kenyans covered by the fund.

Further to that, the Kenyan government has managed to set up 10 cancer centers across the country to manage the cancer burden. Four of these are already operational to supplement the existing ones at Kenyatta National and Moi Referral Hospitals. Many in East Africa seek treatment in Kenya, which boasts the largest economy in the region with improved infrastructure and modern equipment. Kenya has about 16 radiation oncologists, but there is an ongoing training program at Agha Khan, Nairobi, and Moi Universities to expand the existing numbers.

The most recent development in Kenya’s fight against cancer was the opening of the Integrated Molecular Imaging Center and Hospitality Center, a cancer treatment facility with a 100-person hostel domiciled at Kenyatta University Teaching

Research and Referral Hospital (KUTTRH). The facility is expected to save Kenyans over US$89 million in cancer treatment costs outside the country each year.

The high and rising cost of cancer treatment is a worldwide issue. Cancer medicines were added to the WHO Model List of Essential Medicines in 2015 in order to encourage countries to prioritize effective cancer treatments, but not all countries can afford them. Botswana, for example, incorporated 80% of 2015 WHO list into its national essential medicines list.

Recognizing that the high cost of chemotherapy and radiotherapy is a source of financial hardship and catastrophic spending for low-income populations, the Tanzanian government has exempted cancer patients from paying for treatment since charging (cost sharing) was introduced into the public health sector in 1993. However, cancer patients continue to pay for other inpatient treatment, such as surgery and transfusions, and for diagnostic investigations and other medication.

Partnerships Increase Access To Lifesaving Cancer Treatment In Subsaharan Africa

A strong coalition between governments, experts, communities, and donor agencies has played a key role in enhancing access to lifesaving cancer therapies in Africa. In 2020, the American Cancer Society (ACS) and the Clinton Health Access Initiative (CHAI) entered into agreements with pharmaceutical companies Pfizer, Novartis, and Mylan to increase access to 20 life-saving cancer treatments in 26 countries across Sub-Saharan Africa and Asia. Purchasers of medicines obtained through the agreements are expected to reduce costs by an average of 59 percent.

The medications covered by the agreements cover recommended regimens for 27 types of cancer and allow for complete chemotherapy regimens for the three cancers that kill most people in Africa—breast, cervical, and prostate cancer. The new agreements cover both chemotherapies and endocrine therapies that are aligned with evidence-based guidelines for Sub-Saharan Africa, and they expand access to additional formulations, including those critical for treating childhood cancer. The market access agreements guaranteed competitive prices, allowing governments to save money while improving the quality and quantity of treatment available.

Given the growing burden of cancer in LMICs driving high demand for care, private investment could fill the gap in public and donor funding. Private capital has poured into markets such as India and Kenya, establishing sophisticated hubs for high-quality cancer care.

In this breath, the Apollo Proton Cancer Center was recently launched in Kenya, becoming the first and only Proton center in South Asia, the Middle East, and Africa. However, it is not available to everyone due to high-cost implications. Proton therapy is more expensive than traditional radiation, with costs ranging from US$50,000 to US$60,000, and not all insurance companies can cover the cost of the treatment. Additionally, public–private partnerships have, for example, donated radiation machines for cancer centers in the continent. The International Atomic Energy Agency (IAEA) is a key player in the advancement of radiation therapy on the continent.

Investments In Cancer Research Projects To Address A Range Of Cancer

Scientific developments in the field of cancer research have undergone a fascinating journey during the second half of the 20th century and Africa has not been left behind. African countries have worked with developed countries to implement world-class research projects. Burkitt's lymphoma, the relationship between aflatoxin and hepatocellular carcinoma, and HIV and AIDS are all examples of success.

The Beginning Investigator Grant for Catalytic Research (BIG Cat) initiative was launched in 2010 by the US National Cancer Institute in collaboration with the African Organization for Research and Training in Cancer to support cancer research projects conducted by earlycareer African investigators. BIG Cat has awarded 18 grants of up to US$50,000 to support two-year cancer research projects that have generated locally relevant findings that address a range of cancer sites and multiple areas of scientific interest.

In terms of research partnerships, recently Kenya’s Ministry of Health and international research partners launched a hub for advancing cancer registration to accelerate cancer registration in Sub-Saharan Africa by leveraging training and innovative financing. The facility, which will be housed at the Kenya Medical Research Institute (KEMRI), will serve as a nerve center for collaborative research aimed at promoting the collection and dissemination of data on the continent's cancer burden.

The center will provide critical data on cancer incidence, mortality, and survival rates, as well as improve cancer surveillance, treatment, and long-term management. Kenya is one of three African countries, along with South Africa and

Côte d'Ivoire centers

WHO-affiliated

Agency

Research

Cancer as part of continental efforts to revitalize the fight against non-communicable diseases. The East African country hopes to become a continental hub for cancer data collection through collaboration with the Africa Cancer Registries Network and the Global Initiative for Cancer Registry.

Uganda Cancer Institute (UCI) has partnered with Fred Hutchinson Cancer Center to launch “Cancer Genomics and Genomic Data Science for East Africa,” and additional programs to train East African researchers in cancer genomics and foster future researchers. This program is funded at a cost of US$1.25 million over five years and builds upon research that explores the genomics of breast cancer, lung cancer, non-Hodgkin lymphoma, and Kaposi sarcoma.

Further West, Moffitt Cancer Center together with the University of Ghana have struck a fiveyear deal to work to strengthen and expand the capacity to conduct cancer research in Ghana.

Shortage Of Oncologists And Palliative Facilities Hinders Adequate Care Delivery

A study titled “Global Survey of Clinical Oncology Workforce” revealed that Oncologists in Africa range from zero in Lesotho, Benin, Gambia, South Sudan, and Sierra Leone to single digits in Malawi, Burkina Faso, Rwanda, and Togo, and up to 1500 in Egypt. This results in a very high caseload per physician. Data from a 2018 review of 21 countries in Africa showed a high burden of incident cases per oncologist while also highlighting the large numbers of oncologists in Africa who practice both radiation and medical oncology (i.e. clinical oncologists) further compounding the workload.

With the scarcity of medical oncologists (MOs) in Africa and other low-middle-income regions, a large proportion of cancer patients lack the opportunity to see a medical oncologist in consultation. As a result, patients do not have access to early interventions that could alleviate their suffering and improve their outcomes. Pediatric cancers are perhaps the best example of this unfortunate situation, with survival rates of more than 80% in high-income countries and less than 10% in East and West Africa. Inadequate cancer services mean a continued increase in premature deaths.

Although a comprehensive list of all cancer treatment facilities in Africa remains to be compiled, a valuable step in the right direction has been made by the African Organization for Research and Training in Cancer. As per African Cancer Network Project, the continent has 102 cancer treatment facilities, including general oncology centers, gynecologic oncology or other single-organ malignancy units, pediatric oncology, and palliative care facilities.

South Africa is home to 38 of these institutions. Although the list is not yet complete, it suggests that there is a significant shortage of cancer care services on the continent. Closer home, Kenya is yet to achieve the aspirations of the Cancer Control Strategy 2017-2022 which was to build four regional cancer treatment centers in Kisii, Nakuru, Mombasa, and Nyeri. Besides that, Kenya has only 35 oncologists in both public and private hospitals.

The low number of oncology centers and practitioners has given rise to medical tourism, which is chiefly defined as when people from lessdeveloped nations travel abroad for treatments they need and which are not yet available in their own country. India is the prime medical tourism destination for Africans who seek affordable high-quality critical care for cancer and other medical conditions.

Way Forward For Cancer Prevention And Control

Even with much to celebrate, the perennial failure of governments to prioritize health and allocate adequate resources is partly the reason why Africa fairs poorly compared to the rest of the world. Currently, African countries spend US$8 to US$129 per capita on health compared to highincome countries that spend above US$4,000. The Abuja Declaration sought to address this by committing at least 15% of the national budget to the health sector. However, many countries have struggled to meet this goal, and two decades later, only two countries, Rwanda and South Africa have met the 15% target. Even worse, most countries move far too slowly to meet the goal of allocating adequate resources for healthcare. Low government spending primarily harms citizens, resulting in high out-of-pocket spending and an inequitable healthcare system that only guarantees access to those who can pay for the high cost of cancer treatment.

Opportunities for reducing suffering and death from cancer however exist across all stages of the cancer control spectrum, from prevention to early detection, treatment, and palliative care. To combat this lifestyle epidemic, global, national, and individual commitments are required. WHO is mobilizing countries worldwide for collective action, particularly African countries, many of which have insufficient non-communicable disease (NCD) interventions.

Some of the options that WHO is promoting to reduce lifestyle diseases are raising taxes and prices on tobacco products, implementing plain packaging or comprehensive bans on tobacco packaging designed to attract consumers, increasing taxation on alcoholic beverages, and enforcing bans on alcohol advertising.

Furthermore, proven measures, such as HPV vaccination, can prevent nearly all cases of cervical cancer, which kills many women in Africa each year and in other developing economies. Access to prevention, early detection, treatment, and palliative care services must be expanded if the cancer menace is to be eliminated.

Kenya Hosts Inaugural National Cancer Summit In Nairobi

The government of Kenya is set to host the first-ever National Cancer Summit 2023, scheduled for 2-4 February 2023, culminating with the commemoration of World Cancer Day.

This is in recognition of the need for a more coordinated and multisectoral response to the growing cancer burden in Kenya.

Under the theme – uniting our voices and taking action – the summit is the premier convention for all cancer stakeholders locally and internationally.

The top five cancers in Kenya are those of the breast, cervix, prostate, oesophageal, and non – Hodgkin’s lymphoma. accounting for nearly half (48 percent) of the cancer burden in the country.

According to the government, nine women die every day due to cervical cancer; nine in every 10 persons with oesophageal cancer will succumb to the disease.

The National Cancer Summit 2023 will provide an appropriate platform for stakeholders from across all sectors to, among other discussions, deliberate on the recommendations arising from the Cancer Taskforce Report, review the progress made over the last 10 years in addressing the cancer burden, identify areas of learning from successful strategies and together, formulate solutions for collective action.

VENUE: Safari Park Hotel, Nairobi, Kenya DATE: February 2-4, 2023

Cancer Numbers In Kenya

•

Third leading cause of death

• Second leading cause of Non-communicable deaths

• 47,887 new cases every year

• 32,500 cancer deaths every year

• 2 out of 3 persons diagnosed with cancer succumb

• 70% of cases diagnosed in advanced stages

• 23% of cancer patients access cancer management services they need

The simplest and cheapest means of preventing and controlling cancer is for individuals to make good lifestyle choices by opting for healthy diets (lots of vegetables and fruits and less sugar, salt, and fats), avoiding tobacco and alcohol, and exercising.

Overall, a rising cancer epidemic will necessitate increased resources for strengthening and adapting healthcare systems. Given that the African region's rates of social and economic growth are unlikely to keep pace with the rapid rise of cancer, taking immediate preventive action now will be far less daunting than waiting to address a full-blown epidemic later.

Kenya

Source: Globocan 2020

Number of new cases in 2020, both sexes, all ages

Breast 6 799 (16.1%) cancers

971

Colorectum 2 724 (6.5%)

Cervix uteri 5 236 (12.4%)

Prostate 3 412 (8.1%)

Oesophagus 2 974 (7.1%)

Total: 42 116

Summary

Population 26 718 527 27 052 773 53 771 300

Number of new cancer cases 15 566 26 550 42 116

Age-standardized incidence rate (World) 133.2 168.2 149.2

Risk of developing cancer before the age of 75 years (%) 14.3 18.0 16.2

Number of cancer deaths 10 466 16 626 27 092

Age-standardized mortality rate (World) 96.5 112.6 103.2

Risk of dying from cancer before the age of 75 years (%) 10.3 12.7 11.6 5-year prevalent cases 28 464 54 156 82 620

Top 5 most frequent cancers excluding non-melanoma skin cancer (ranked by cases) Prostate Oesophagus Colorectum Non-Hodgkin lymphoma Stomach

Breast Cervix uteri Oesophagus Colorectum Ovary

Incidence

Country-specific data source: Eldoret Cancer Registry, Nairobi Cancer Registry Method: Weighted/simple average of the most recent local rates applied to 2020 population

Mortality

Country-specific data source: No data Method: Estimated from national incidence estimates by modelling, using incidence:mortality ratios derived from cancer registry data in neighbouring countries

Prevalence

Computed using sex-; site- and age-specific incidence to 1-;3- and 5-year prevalence ratios from Nordic countries for the period (2006-2015), and scaled using Human Development Index (HDI) ratios.

Breast Cervix uteri Prostate Oesophagus Colorectum