Furaha Serventi MD
Specialist Radiation and clinical Oncologist
Head of KCMC Cancer Care Centre, Moshi
Introduction
Tanzania:
 Estimated population of 53 million people as of 2015
 A low income country according to 2015 World bank
report
 Though the poverty rate fell from 60% in 2007 to an
estimated 47% in 2016, based on the $1.90 per day
global poverty line, about 12 million Tanzanians still
live in extreme poverty earning less than US$ 0.60 per
day
Zones of Tanzania
Tanzania by Region
Cancer centers in Tanzania
Oncology centres in Tanzania
 ORCI – 1st and only Cancer centre since 1980
Providing oncology services countrywide
 Situated in Dar Es Salaam the commercial/industrial
city
 The only centre offering both medical and radiation
oncology services to date.
 Under ministry of health and is government funded to
a large proportion
Services offered
 Screening programs for cervix and breast cancer
 Medical oncology services - adults
 Radiation oncology services -paediatrics/adults
 Inpatient services
 Palliative care clinics
Patient Navigation to ORCI
 Patient is diagnosed at regional/ referral hospitals
 Basic staging invetigations ( Chest x-ray, abdominal
Ultrasonography) done
 Patient given a referral to ORCI for further
management
Patients perception having to go to
ORCI
 Despair
 Helplessness
 Confusion
 Loss of hope
Obstacles - Patient factors
 Most cannot afford
 Would have no one to accommodate them during the
treatment course
 Some are family pillars in who`s presence the family
relies. Their absence destabilises the already shaky
economic status
 Too sick to travel ( 80% are advanced at diagnosis)
ORCI adult female inpatient unit
Obstacles- Institutional
 One institute serving an entire nation- services are
stretched beyond capacity ( staff, drugs and medical
equipment)
 In 2015/2016 Ocean Road Cancer Institute received a
total of 33,563 patients
 Of these, commonest is cervical cancer with an
estimated more than 6000 and breast cancer
Obstacles-institutional
 In the year 2015/2016 – Government allocated 7.2
billion shillings( 3.3 million dollars) to ORCI for
running services
 Only 11 % of the funds was received
 This trickles down to adult patients having to buy their
own chemotherapy in private pharmacies
 This was a factor observed by our visit to ORCI in 2016
where more than 90% of patients planned for
chemotherapy had to purchase it privately
Establishing other centres to join
the fight
 Currently two other oncology centres being
established
 Bugando oncology centre – started services in 2009
and serves the Western Lake zones
 Kilimanjaro Christian medical centre cancer care
centre officially – officially opened in December 2016
and serves the Northern zones
KCMC experience
 Case 1: history & physical examination
 MKM, 35 year old Dx: left breast ca cT4c cN3cM1
ER/PR/Her2neu unknown
 Hx of Left breast mass for 3/12, rapid progression in size over
3/52 with associated DIB
 No commorbidities, Sobber habits
 ECOG PS 3
 Clinically: Vitals – sats: 95% on Oxygen
 dyspnoeic,left breast mass 8x6 cm with ulcer of 5x4 cm.
Tethered to chest wall, peau d`orange. Left axillar with fixed
and matted lymph nodes largest 2x2cm. Left supra-clavicular
Nodes.
KCMC experience
 Case 1: investigations
 Bx: Infiltrating high grade ductal carcinoma, Ki67? For
IHC to determine ER/PR/Her2neu status
 Chest xray: Left Pleural effusion 90%, Diffuse infiltrates
right lung
 Abd uss: Multiple infiltrates in liver
 Summ: Stage IV ca left breast with lung and liver
metastasis. ECOG PS3 with Significant Left pleural
effusion, Oxygen dependant.
KCMC experience
 Case 1: Management
 Consultation to surgeons: Chest tube for drainage
 Start morphine syrup for optimal pain and symptoms
control
 Counsel patient on prognosis and intent of treatment
 Systemic therapy: Capecitabine 1500mg BD PO D1-D14
every 3/52
KCMC experience
 Challenges encountered
 No Immunohistochemistry facilities for ER/PR/Her2neu
determination
 Would have to re- do Bx as first was too small in order to
consider sending a block to Muhimbili Hospital 500km
away and would take 3 weeks for results
KCMC experience
 Challenges encountered
 KCMC pharmacy does not stock chemo
 No private pharmacies in Moshi stocking chemotherapy
– Biggest pharmacy in town only has expired
Methotrexate and Vincristine
 KCMC dermatology program only has ABV for its KS
program and the program is not flexible for non KS
patients
 KCMC Gynae Department have Cyclophosphamide as
part of protocol for GTD and would be willing to release
one dose
KCMC experience
 Case 2: History and physical examination
 VM, 27 years old
 Dx: NHL DLBC stage IIIb clinically
HIV +ve stage IV on ART since 2012, baseline CD4
count 464, current CD4 unknown
 Hx : bilateral cervical lymph node enlargement 3/52
with associated B symptoms
 Clinically: ECOG PS 2, pale +, not dyspnoeic, stable
vitals, Huge matted cervical lymph nodes I-IV,
bilateral,15x12 cm.
KCMC experience
 Case 2: Investigations
 CBC: Hb 8.6g/dl, Electrolytes: uric acid 360
 BMAT: not possible. No needles available
 Imaging: CXR - Hilar and mediastinal widening
 Abd USS: multiple para-aortic LNs, spleen and liver free
of tumour
 ECHO- EF 66%
KCMC experience
 Case 2:
 Summary: 27 years, HIV +ve on ART, ? Current CD4
count, Stage IIIB NHL, Anaemia of 8.6 g/dl, high uric
acid but no TLS( K+,Ca2+,Creat normal)
 Management




Supportive: Transfuse 2 units of whole blood( no blood in
blood bank hence relatives donated for 1 unit)
Start cautious hydration with NS 2.5L/24 hours
Allopurinol 100mg PO 8 hrly
For CHOP regimen
KCMC experience
 Challenges encountered
 Agents not available at KCMC or Private pharmacies –
Relatives sent to Dar to buy
 Blood bank – Not enough blood in stock for adequate
transfusion
 Patients and family stretched financially – will only
afford 1 cycle (60 $) of chemo 1st then raise funds for the
other with time.
KCMC experience
 Case 2: follow up
 20/7/2016( 1 day post chemo) - K+/Ca2+/Creat all
normal, Uric acid down to 302.03. Continued fevers
39˚C (?B symptoms)
 21/7/2016 Blood transfusion 2nd unit. Control CBC
ordered
 22/7/2016 Bloods: hb 8.6g/dl, lymphocytes 0.65, Neutro
0.23/k+ 4.97/creat 123/phosphate 3.24/calcium 1.70 (TLS
and grade 3-4 neutropenia)
KCMC experience
 Case 2: follow up
 22/7/2016



IV fluids 3L, encourage oral fluids, cont allopurinol, calcium
phosphate, 3rd unit WB transfused,
Filgrastim prescibed- Not available in Moshi, Relatives sent to
Dar to buy.
Blood culture taken, started on IV Ceftiaxone 2g 12 hrly.
 25/7/2016 Fever down to 35˚C, patient clinically better.
 26/7/2016 Patient died at 6pm. Stopped breathing.
Death certified
KCMC experience
 Learning points and action points
 Essential to establish protocols and Drug list based on
the best evidence based medicine available fit to local
setting
 Effort made to rationalize treatment based on balancing
limited budgets, limited availability of drugs against the
need to optimize clinical benefits.
 Prioritized allocation of chemotherapy to curative than
palliative ( in palliative, those with longer progression
free survival favoured).
Protocols based on WHO essential list of
cytotoxics maximising on cheaper regimens and
non Biologicals
Start cautiously- build on it
After prednisone for 5 days
Training/diagnostics/supportive
Care efforts
 With limited Specialists: Started with one Oncologist
and a Cancer care Coordinator having to:
1.
2.
3.
4.
Review consultations
Do Trucut Bx for some of the patients to reduce cost of
invasive surgery
Plan treatment as well as administer chemotherapies
Take care of non clinical aspects
Efforts were made to increase number of trained and
non trained staff
Training programs
 Expanded on existing sectioned programs – involving
local experts teaming up with North American and
German experts to train local clinicians/pharmacists
and nurses
 New programs using existing established oncology
sites in the country
 Short term, crash programs favoured
 Involve multiple disciplines
Staff
 2 Oncologists on site: managing adult oncology
patients – medical and haematological cases
 4 oncology nurses: General registered nurses with
experience in safe cytotoxic medication handling and
administration
 1 general pharmacist with experience in safe
chemotherapy mixing and handling
Support Staff
 1 cancer care coordinator – coordinates the centres
activities especially local fund raising and campaigns.
 Case registry reports: 1 public health specialist and
one volunteer statistician
Improving on diagnostics
 Tumour imaging
 Image guided biopsies: reduces cost and
invasiveness of procedures - done by radiologists. This
has freed oncologists to review more clinic cases and
offer expert services
 BMAT: Received BMAT needles through donations by
Fairview oncology nurses and Difaem mission
(German). This is now a regular service offered by
CCC.
Chemotherapeutics/ supportive
medication
 Established chemotherapy supply: This has saved
patients both money and shortened time to treatment
 Established supportive medication such as anti
emetics/ GCSF/ and now appropriate IVF bags for safe
chemo mixing as well as morphine for palliative care
Multi disciplinary rounds
With all the improved availability of cancer treatment at
the Cancer Care Centre, other challenges surfaced:
 Poor coordination of patient flow between
departments
 Patients having to queue long hours to get a file/
register
Multidisciplinary rounds
 Currently have established regular consultation rounds
with surgeons for surgical cases as well as doing
palliative care rounds
Multidisciplinary consultations have
helped us practice evidence based
medicine with what is available
First- neo adjuvant systemic
therapy before surgery
Multidisciplinary services
 Establishing multidisciplinary clinics has been a
challenge – staff shortage from various departments
 Efforts are ongoing however as this is the only way to
ensure protocols are adhered to and management
plans are shared – improves patient flow
 To reduce time from diagnosis to treatment- Cancer
cases requiring RT/CCRT still referred directly to ORCI
Current Data and Discussion
 We have seen 546 registered cancer cases to date.
 Most of the initial cases were undocumented in the
beginning
 200 well documented cases
Common cancers seen at CCC
4.90%
5.40%
19.70%
6.90%
8.40%
14.30%
10.30%
Breast Cancer
Oesophagus Cancer
Non-Hodgkin-Lymphoma
Kaposi Sarcoma
Prostate Cancer
Colorectal Carcinoma
Hepatocellular Carcinoma
Patients with NHIF
BIMA
k.A.
4%
yes
47%
no
49%
Age distribution of CCC patients
age
Series1
48
46
34
26
16
9
10
10
7
1
1 - 10 years
11 - 20 years
21- 30 years
31- 40 years
41- 50 years
51- 60 years
61- 70 years
71- 80 years
81- 90 years
91- 100 years
Conclusion
 Much success in access to cancer therapy in such a
short time
 This is a result of combined, well collaborated efforts
between FCCT/Supportive groups and KCMC
 This has shifted cancer management and is setting
standards to treatment and care of cancer patients in
resource constrained environment
Thank you for caring.
Thank you for joining hands with us. Together
we are making a difference.