Is cancer a problem in Uganda?

Prevalence of cancer patients in Mulago Hospital (Uganda Cancer Institute) Uganda

By WAISWA AKUZE Joseph1 Department of Planning, Institute of Statistics and Applied Economics, Makerere University, P.O. Box 7062 Kampala, Uganda Email: joseph2.akuzewaiswa@live.uwe.ac.uk Abstract
Cancer is a disease where a population of cells in the body grow and divide without responding to the normal processes that limit their growth. They spread into and destroy nearby tissues, and may spread to other parts of the body through lymphatic system. Cancerous tumours are called malignant. It is among the cause of upcoming deaths in Uganda because of late diagnosis and inability to access treatment. This paper is based on secondary data analysis of the 2006-2008 research by The Fred Hutchison Cancer Research Center (FHCRC) and Uganda Cancer Institute (UCI) collaboration on infections and cancer comparing the prevalence of cancer among the children and adults according to the different types of cancer. Cancer is most prevalent among the women (58%) than men (42%) and the old age group (60+). HIV increases the risk of cancer by up to 20,000- fold, leading to epidemics of cancer in areas hard-hit by the HIV pandemic. UCI has only two oncologists and the only treatment facility in a country of about 32 million people. Nearly one in two Ugandans is infected with, human herpesvirus-8 (HHV-8), compared with only one in ten people in the US. Average number of annual new cancer cases seen at the UCI is 300 among children and 1, 500 in adults. Average number of annual follow-up visits (at least a single visit) at the UCI: 5,000 The chances of a person developing cancer up to the age of 75 will fall from more than one in four to one in five if communication about cancer is done through awareness campaigns to inform people about the risk factors for cancer, effective treatment will increase survival rates for all common cancers, with more than two-thirds of newly-diagnosed patients living for at least five years. Emphasis should be made for low income communities. Key words: Cancer, Awareness, Treatment, Uganda

1 Introduction Cancer a malignant tumour of potentially unlimited growth that expands locally by invasion and systemically by metastasis; a group of more than 100 distinct diseases are characterized by the uncontrolled growth of abnormal cells in the body. Cancer affects one in every three persons born in developed countries and is a major cause of sickness and death throughout the world. It has been known since antiquity, significant improvements in cancer treatment have been made since the middle of the 20th century. Treatment is mainly through a combination of timely and accurate diagnosis, selective surgery, radiation therapy, and chemotherapeutic drugs. Such advances actually have brought about a decrease in cancer deaths (at least in developed countries), and grounds for further optimism are seen in laboratory investigations into elucidating the causes and mechanisms of the disease. Owing to continuing advances in cell biology, genetics, and biotechnology, researchers now have a fundamental understanding of what goes wrong in a cancer cell and in an individual who develops cancer and these conceptual gains are steadily being converted into further progress in prevention, diagnosis, and treatment of this disease. [7]

On average there are 10.9 million new cases, 6.7 million deaths and 24.6 million persons alive with cancer (within three years of diagnosis). The most common causes of cancer deaths are lung cancer 1.8 million deaths, stomach cancer -700000 deaths and liver cancer 598000 deaths. [6] 2 Infections and Cancer in Uganda I was interested to read of the experiences of Tristan Lench and Yasmin Ismail (Nov 30, p 1789) [1] in the Mbarara teaching hospital in Uganda. The management of malignant tumours in Uganda also faces many challenges, not only in service provision (up to half of Uganda's population still do not have access to essential drugs [2]), but also in the multiplicity of illnesses, particularly infectious diseases, with which patients present. The management and study of cancer in Uganda has an impressive history. In Mulago hospital, Kampala, Denis Burkitt first reported on the jaw sarcomas later identified and labeled as Burkitt's lymphoma. [3] With the development of the Uganda Cancer Institute at Mulago in 1967, a wealth of research and subsequent publications was produced, including many studies on the cause, presentation, and treatment of Burkitt's lymphoma.

The case mix of malignancies seen at the cancer institute has changed somewhat since Burkitt's time, with HIV/AIDS-related tumours now predominating. Infectious agents have a key role in the cause of many of the most prevalent cancers seen in Uganda, and in causing a range of intercurrent illnesses that can often compromise the optimum management of their malignancy. Kaposi's sarcoma, caused by human herpes virus 8, is now the number one malignancy in men and children in Uganda and the second most common in women after cervical cancer. [4] Many of the non-Hodgkin lymphomas, including Burkitt's lymphoma, that have an increased incidence in the HIV/AIDS population have been linked to Epstein-Barr virus infection,[5] and the association of human papillomavirus with cervical cancer is well documented. In addition to these oncogenic viruses, bacterial and protozoal infections frequently complicate the picture of a newly diagnosed cancer patient. Malaria and tuberculosis remain widespread, and with the other opportunistic infections seen in the HIV/AIDS setting, they can cause significant concurrent illness in cancer patients. A recent departmental review of routine stool analyses on patients at the cancer institute also revealed a high prevalence of intestinal infestations. From a total of 1771 stool samples analysed, the most prevalent infectious agent identified (13%) was hookworm. Strongyloides infection was seen in 3%, Giardia lamblia in 35%, and Ascaris lumbricoides in 15%. With iron deficiency anaemia, malabsorption, dysentery, and dehydration as potential sequelae to such infections, control of helminths and protozoa is one of the important early steps in the management of patients with tropical cancers. 3 Objectives of the study 3.1 Major object of the study The major objective of this study is establish the prevalence of cancer patients in Uganda 3.2 Specific object (i) To identify the types of cancer in Uganda. (ii) To establish the trend of cancer in Mulago hospital.

(iii)To establish the distribution of cancer according to the age and any other socioeconomic characteristics in Uganda. 4 Methodology 4.1 Source of data The source of data for this paper is based on the 2006-2008 research by The Fred Hutchison Cancer Research Center (FHCRC) and Uganda Cancer Institute (UCI) collaboration on infections and cancer comparing the prevalence of cancer among the children and adults according to the different types of cancer. The FHCRC-UCI collaboration carried out the research to answer; how are infections that cause cancer acquired? What factors govern the progression from chronic infection to cancer? Can molecular diagnostics predict persons at high risk for development of cancer from chronic infection? Can therapies be developed or employed to prevent viral-associated cancers? 4.2 Data analysis

The data was compared according to the cancer types and their prevalence among the adults (18+) and the children (<18), it compares the average new cases of the cancer patients who report to UCI annually. In order to give more details related to variations in the distributions of the cancer type among the adults and children, a comparison was also done with other factor/ variables (socioeconomic). 4.3 Limitation of the data The sample was relatively small and was not representative of the whole desirable characteristics such as; the trends of cancer, the distribution of cancer according to the sex of the patients and the age categories. 5. Findings of the study Table 1(a) shows some of the most common cancers in adults, these are; Kaposis sarcoma (KS), Non Hodgkins lymphoma, Breast cancer, soft tissue sarcoma, Liver cancer, Hodgkins lymphoma, Colon cancer, Lung cancer and Others (Tumors). Table 2(a) shows that KS, nonHodgkins lymphoma, breast cancer and Soft tissue sarcoma are the types suffered by about four out of five cancer patients (adults) in Uganda, this implies that each of these cancers are more

frequent, and often more severe, in persons with HIV infection; consequently, due to the high prevalence of HIV, rates of viral-associated cancers in Uganda which are among the highest in the world. On the other hand others, lung cancer, colon cancer and Hodgkins lymphoma are suffered by about 11% of the cancer patients.

Results form table 1(b) shows the common types of cancer that are suffered by the children which include; Burkitts lymphoma, Kaposis sarcoma, Lymphomas, Leukemia, Osteosarcoma, Nephroblastoma, Rhabdomyosarcoma, Other tumors, Neuroblastoma, Hepatoblastoma and Retinoblastoma, from the results that were obtained after the analysis in table 2(b) Burkitt's lymphoma, Kaposi's sarcoma, Lymphomas, Leukemia and Osteosarcoma are suffered most among the children contributing about 90% of cancer patients (children). The other extreme cases are the types of cancer that are suffered by very few patients below the age of 18, these include Neuroblastom, Hepatoblastoma, Retinoblastoma, Rhabdomyosarcoma and Other tumors which covers about 10% of all the children who suffer from cancer in uganda.

Table 1(a): Types of cancer in Adults, Number of new Annual cases, Percentages type of cancer in adults number of new cases percentage annually Kaposi's sarcoma 9 Non Hodgkin's lymphoma 10 Breast cancer 90 oft tissue sarcoma 90 Liver cancer Hodgkin's lymphoma colon cancer 0 2 Lung cancer 0 2 Others 0 2

Table 1(b): Types of cancer in children, Number of new Annual cases, Percentages Cancer Type: Childhood Number of new cases Percent annually Burkitts lymphoma 150 50 Kaposis sarcoma 42 14 Lymphomas 36 12 Leukemia 21 7 Osteosarcoma 18 6 Nephroblastoma 12 4 Rhabdomyosarcoma 6 2 Other tumors 6 2 Neuroblastoma 3 1 Hepatoblastoma 3 1 Retinoblastoma 3 1

Table 2(a): Extreme Values c

Cases Number cancer type: Value adult 1 Kaposi's 975.00 sarcoma 2 Non Hodgkin's 105.00 lymphoma 3 Breast cancer 90.00 4 Soft tissue 90.00 sarcoma 9 Others 30.00 8 Lung cancer 30.00 7 Colon cancer 30.00 6 Hodgkin's 75.00a lymphoma 1 Kaposi's 65.00 sarcoma 2 Non Hodgkin's 7.00 lymphoma 3 Breast cancer 6.00 4 Soft tissue 6.00 sarcoma 9 Others 2.00 8 Lung cancer 2.00 7 Colon cancer 2.00 6 Hodgkin's lymphoma 5.00b

number of new Higest cases annually

1 2 3 4

Lowest

1 2 3 4

Percentages

Higest

1 2 3 4

Lowest

1 2 3 4

a. Only a partial list of cases with the value 75.0 are shown in the table of lower extremes. b. Only a partial list of cases with the value 5.00 are shown in the table of lower extremes. c. The requested number of extreme values exceeds the number of data points. A smaller number of extremes is displayed. Table 2b: Extreme values
ase number of new cases annually i hest umber ancer type hildhood ur itt s lymphoma aposi s sarcoma ymphomas eu emia O steosarcoma etinoblastoma epatoblastoma euroblastoma O ther tumors habdomyosarcoma ur itt s lymphoma aposi s sarcoma ymphomas eu emia O steosarcoma etinoblastoma epatoblastoma euroblastoma O ther tumors habdomyosarcoma alue 50.00 .00 .00 7.00 .00 .00 .00 .00 .00 .00 50.00 .00 .00 7.00 .00 .00 .00 .00 .00 .00

5 owest

5 0

5 Percenta e i hest

5 owest

5 0

Figure 1(a): Cancer types in percentages for all adult cancer cases 2% 2% 2% 5% 5% 6% 6% 7% Kaposis sarcoma Non Hodgkins lymphoma Breast cancer Soft tissue sarcoma Liver cancer Hodgkins lymphoma 65% Colon cancer Lung cancer Others

Figure 1(b): Cancer types in percentages for all childhood cancer cases 1% 1% 1% 2% 2% Burkitts lymphoma 4% 6% 7% 50% 12% Kaposis sarcoma Lymphomas Leukemia Osteosarcoma Nephroblastoma Rhabdomyosarcoma Other tumors Neuroblastoma Hepatoblastoma 14% Retinoblastoma

6. Discussion of results Uganda is home to 33 million people. In this developing country, where 40 percent of the people live on less than one US-Dollar (1$) a day, cancer education and screening are rare, diagnoses come late, and treatments are often not available, or not obtain in time thus cancer patients survive five years after diagnosis on average. The UCI is also the only referral place for cancer patients in Uganda with two oncologists that cannot possibly handle all cases with much efficiency. The preference of cancer is still high in Uganda because not much has been done compared to how significant resources have been allocated and combated to curb Malaria, Tuberculosis, malnutrition and poverty. The research carried out has enormous potential to reduce the cancer cases in Uganda since it will lead to discovery more options that can possibly help reduce the numbers, however since the UCI facility receives about 1800 patients a year, with limited funding and a lot of bureaucratic process access any funding and services available at the facility, this still makes cancer common. Since Uganda is a peaceful country for over 20 years now, except the northern region the government in collaboration with the UCI, Ministry of Health and other interested parties should finance and lay down strategies that should rescue the country from the cancer scourge. Some of the strategies may include training more oncologists, financing further research, purchasing of more and better equipment at the UCI facility, and carrying out campaigns that will sensitive the people about healthy leaving to prevent cancer or how to leave longer with cancer.
(a) Has been used to represent the adult cancer patients (b) Has been used to represent the children with cancer

7. References [1] Lench T, Ismail Y. Update from Mbarara University Teaching Hospital. Lancet 2002; 360: 1789-1790. [2] UND . Human Development Report 2002. New York: Oxford University Press, 2002.

[3] Burkitt D. A sarcoma involving the jaws in African children. Br J Surgery 1959; 46: 218223. [4] arkin DM, Wabinga H, Nambooze S, et al. AIDS-related cancers in Africa: maturation of the epidemic in Uganda. AIDS 1999; 13: 2563-2570. [5] Newton R, Beral V, Weiss R. Human immunodeficiency virus infection and cancer. In: Newton R, Beral V, Weiss R, eds. Cancer survey volume 33: infections and human cancer. Cold Spring: Cold Spring Harbor Laboratory Press, 1999: 237-262.
[6]. Coren, M (2005) Cancer no longer rare in poorest countries. A study report. Washington: CNN [7]. World health organization (1997) the world health report