OBJECTIVE ‘The State of Oncology in Africa’ (2015) Report was written about cancer in Africa by Africans working in Africa. Overall, it demonstrated that the situation of cancer in Africa is critical, requiring coordinated actions for prevention. The African Code against Cancer emerged as the needed framework for a common vision of cancer prevention. It aims to reduce the risk of cancer but will also impact favourably on other diseases that share the same risk factors. The objectives of the project are to: 1) increase the evidence-based knowledge about cancer; 2) increase cancer awareness and prevention; 3) support sound public health policy with evidence-based guidelines.
METHODS The African Code against Cancer was developed through round table discussions with African oncology professionals and international colleagues working closely with Africa. It was adapted for Africa from the early versions of the European Code against Cancer.
RESULTS The African Code against Cancer contains 11 items informing people about cancer risk factors they can avoid or protect against. They address infection driven cancers, avoiding consumption of known carcinogens, and active actions reducing cancer risk.
1.Vaccinate your baby against Hepatitis B;
2.Be screened for cervical cancer at least once in your life, or every three years;
3.Make sure young girls are vaccinated against Human Papilloma Virus (HPV);
4.Practice safe sex, particularly by limiting the number of sexual partners and using a condom during intercourse;
5.Do not smoke tobacco, avoid all other tobacco products and do not stay in the presence of others who smoke;
6.Limit your consumption of alcohol
7.Avoid eating mouldy or poorly stored foods;
8.Do not put on weight as an adult
9.Walk, jog, run or take part in sports for at least 30 minutes every day
10.Breast feed your children for at least two years;
11.Avoid handling chemicals and radioactive substances without adequate protective equipment
RECOMMENDATIONS Citizens of all African countries, AORTIC members, governments and their officials, health professionals, civil society, and media need to support, adopt and disseminate the African Code against Cancer in order to help save lives.
CONCLUSIONS Based on the impact of the European Code Against Cancer, we heartily encourage the wide adoption and support of the African Code against Cancer to reduce cancer mortality.

OBJECTIVE Cancer surveillance programmes in particular population-based cancer registries are essential in providing data on cancer burden in a defined population, therefore informing interventions. Breast and cervical cancer are the leading cancers among women in Meru county, informed by data generated by the Kenya national cancer registry. Our objective was to use innovative approaches to address the burden of cancer and other non-communicable diseases (NCDs) in Meru County and to optimize the care given to cancer patients through systematic implementation of evidenced-based interventions in prevention, early detection, prompt treatment, palliative and survivorship care.
METHODS A model that utilizes a multi-institutional, multidisciplinary approach was designed to address the burden of NCDs in Kenya. The programme labelled the Blueprint for success brings together a team of Kenyan oncologists, researchers, palliative care experts, community health facilitators to holistically address the burden of cancer, diabetes and hypertension in Meru County, Kenya. Primary Health Care (PHC) approach was used and programmes were designed focusing on screening, training of community health workers (CHWs), creating awareness, education of primary care physicians, establishing palliative care services and strengthening the cancer registries.
RESULTS The Meru blueprint for success programme leverages innovative models of service delivery by a multi-institutional, multidisciplinary team collaborating with the Meru County government, local and international partners to deliver holistic health for the community. Our anticipated targets include improvement in the screening and early detection of NCDs, improved community awareness and increase in the number of CHWs and nurses trained in the early detection of NCDs, improvement in infrastructure and knowledge among primary healthcare physicians, improved referral pathways, access to treatment and improved quality of life.
CONCLUSION Primary health care intervention is a key strategy to realizing Universal Health Coverage. This model if successful will be replicated in other parts of the country and is expected to dramatically reduce the burden of NCDs in Kenya.
ACKNOWLEDGEMENTS This programme is supported by Takeda Pharmaceutical.

OBJECTIVE Tobacco taxes are an effective tool to reduce smoking and improve public health, but the tobacco industry claims that increasing taxes increases illicit tobacco trade. From 2016-2019 we explored the relationship between tobacco taxes and illicit trade in four developing countries: South Africa, The Gambia, Mongolia and Georgia, to provide rigorous evidence on the relationship between illicit tobacco trade and tobacco taxes.
METHODS We used a mixed method approach to collect primary data in each country which included discarded pack collection and household surveys. In Mongolia, Georgia and South Africa baseline data were collected prior to the tax increase, and then the same areas or households revisited again after the tax increase to measure the associated impact on illicit trade. In the Gambia one household level survey was conducted, given the expected tax increase did not occur. Packs were examined for tax stamps and health warnings, and individuals were also asked to self-report on the prices they paid for their last pack. These prices were compared to the minimum possible price that would cover all tobacco taxes.
RESULTS In the Gambia, Mongolia and Georgia, despite historical increases to tobacco taxes in the years prior to our study, illicit tobacco trade was very small. In townships in South Africa, illicit tobacco trade represented a larger problem. No evidence of a statistically significant impact of an increase in illicit trade was found as a result of the tax increases in Mongolia or South Africa and we are awaiting final results for Georgia.
CONCLUSION Despite the tobacco industry refrain that tobacco taxes increase illicit trade, there is no evidence of this across a range of developing countries. As such, policymakers can continue to use tobacco taxes to reduce tobacco usage and improve public health, without concern of an associated increase in illicit activity.

OBJECTIVE We explain the development and uses of CanGeo, a tool for measuring time to cancer care, accompanied by results from a three-phase decentralization case study in Tanzania.
METHODS CanGeo uses geospatial data for health facilities and administrative boundaries. Administrative boundaries are approximated as being located at the geometric centroid of the boundary and assigned a population based on census data. These centroids and health facilities are connected by shortest path to a multi-tiered transportation network in which roads are assigned travel speeds based on road level. Times between all administrative boundaries and health facilities are then calculated using Dijkstra’s shortest path algorithm. A three-phase case study on cancer care decentralization in Tanzania is presented using population-weighted wards (n=3,614). In phase one, three treatment facilities were available nationally. Phase two, the current situation, includes seven facilities, and phase three, a projected decentralization using maximum coverage location problem (MCLP) criteria, includes 31 facilities.
RESULTS From the produced time matrix numerous calculations can be made including average population time to cancer care, percent population within a specified catchment time, and average population served per facility. In phase one, population-weighted average time to nearest cancer facility was 5.25 hours (median 4.75 hours). The average for phase two was 3.68 hours (median 3.55 hours) and would be 1.74 hours (median 1.56 hours) for phase three. The percent of population within four-hours of care increases from 41.5% to 57.8% to 95.7% for the three phases, respectively.
CONCLUSIONS CanGeo is an open source tool that can be used in low-resource settings to help quantify access to cancer care and develop optimized decentralization strategies. The tool also provides a standardized way of measuring patient time to care using patient addresses, which can help determine if time to care significantly impacts patient outcomes such as survival or abandonment.

OBJECTIVE Africa is facing a staggering non-communicable disease (NCD) burden that is only expected to increase dramatically in the coming decades. Several implementing partners came together under the “Blueprint for Success – Meru County Project” to deliver a collaborative, focused and county-led Project. The objective is to identify and create a sustainable model, where all stakeholders collaboratively address NCDs in a low and middle-income country (LMIC). This program seeks to improve access to screening, diagnostics, treatment and patient support services for breast, cervical and prostate cancers as well as diabetes and hypertension in Meru County.
METHODOLOGY Through a collaborative public-private partnership (PPP) health systems approach - led by the Meru County’s Ministry of Health (MoH). The partners are Academic Model Providing Access to Healthcare (AMPATH) - Oncology & International Cancer Centre (ICI), Amref Health Africa, Kenya Palliative Care Association of Kenya (KEHPCA), Kenya Medical Research Institute (KEMRI) and National Cancer Institute (NCI) – Kenya. The project is embedded in national and county health structures and policies, including the MoH community health strategy. Health care professionals at different tiers of the health system and CHWs at the household level are being trained on the National Oncology “Integrated Cancer Care and Management Curriculum”. In addition, AMPATH Oncology/ ICI has availed their established, Faculty, Pathology services, Telemedicine, and Telepathology services as well as mentorship support to Meru County teams. KEMRI/ NCR will spearhead cancer registry training and mentorship. KEHPCA will handle palliative care.
RESULTS To provide about 20,000 women with breast and cervical cancer screening services and navigation of care and at least 1,000 men with prostate cancer screening services and care. All those diagnosed with breast, cervical and prostate cancers will be accessing optimal treatment and follow-up care at AMPATH Oncology/ ICI. The project is also deploying training content of diabetes, hypertension, palliative care, and the CHW integrated cancer care curriculum to CHW across Meru county as well as training of primary health care physicians. KEHPCA is taking the lead on the training of primary health caregivers on patients support and palliative care
CONCLUSION This multisectoral approach to addressing the burden of NCD in Meru County – Kenya, is essential in addressing the gaps in NCD care and control.

OBJECTIVE Breast cancer (BC) is the most frequently diagnosed malignancy and most common cause of cancer-related death in women in Ghana, Kenya, and Nigeria. We evaluated healthcare resource use and financial burden for patients treated at tertiary cancer centers in these countries.
METHODS Records of BC patients treated at the following tertiary institutions were included: Korle-Bu Teaching Hospital and Sweden Ghana Medical Centre (Ghana), Kenyatta National Hospital and Aga Khan University Hospital (Kenya), and National Hospital Abuja and Lakeshore Cancer Center (Nigeria). Patients presenting within a prespecified 2-year period were followed.
RESULTS The study included 299 patient records from Ghana, 314 from Kenya, and 249 from Nigeria. Use of common screening modalities (eg, mammogram, breast ultrasound) was <45% in all 3 countries. Use of core needle biopsy was 76% in Kenya and Nigeria, but only 50% in Ghana. Across the 3 countries, 91-98% of patients completed blood count/chemistry; only 78-88% completed tests for hormone receptor and HER2. Most patients underwent mastectomy (64-67%) or breast-conserving surgery (15-26%). A lower than expected proportion received HER2-targeted therapy (5-8%), suggestive of poor/absent insurance coverage. In Ghana and Nigeria, most patients (87-93%) paid for their diagnostic tests entirely out of pocket (OOP) versus 30-32% in Kenya. Similarly, the proportion of patients paying OOP only for treatments was high: 45-79% in Ghana, 8-20% in Kenya, and 72-89% in Nigeria. Among those receiving HER2-targeted therapy, average number of cycles was 5 for patients paying OOP only versus 14 for those with some insurance coverage.
CONCLUSIONS Patients treated in tertiary facilities in Sub-Saharan Africa lack access to common imaging modalities and systemic therapies. Most patients in Ghana and Nigeria bore the full cost of their BC care, suggestive of privileged financial status. Access to screening/diagnosis and appropriate care is likely to be substantively lower for the general population.

OBJECTIVE A barrier to HPV vaccination uptake and adherence globally has been a focus on sexual transmission rather than cancer prevention. The purpose of this study is two-fold: 1. to design, prototype, and field-test messages and interventions to increase the uptake of the HPV vaccine for cervical cancer prevention using human-centre approach and behavioural science, and 2. to build an innovative cross-sectoral partnership led by a local cancer organization to develop strategies for implementation and scale-up.
METHODS The study uses a mixed method design. A literature review and qualitative research fleshes out a robust barrier map for the uptake of the vaccine in Kenya. This is followed by a quantitative survey to understand and test themes and behaviours arising from qualitative research. The results from quantitative research are utilized to conduct rigorous cluster analysis, which will inform the development of specific audience profiles. Brainstorming sessions and feedback loops with a sample audience group are used to finalize the message and intervention prototypes. A mobile lab will test the prototypes to finalize effective interventions and recommend for scale up.
RESULTS Messages and interventions proven effective will form a social and behavioural change communications interventions package to inform and enhance the uptake of HPV vaccination during and post national rollout. These will form the basis of efforts to address current behavioural barriers and normalize HPV vaccine as cancer prevention.
CONCLUSIONS Public health programs often attempt to motivate action through information and education, but behaviour is not always rational. Research from behavioural science has shown that people significantly under-value or ignore life-changing benefits of preventive health like vaccination due to biased beliefs, mental models, and procrastination. This research will address targeted behavioral barriers in Kenya, ensure high uptake, and serve as a best practice for Kenya and like countries.

OBJECTIVE Cancer patients are at risk of developing severe infections. Empiric management of infections is complicated by emerging antimicrobial resistance and changing local epidemiology of organisms. We sought to determine predominant species causing bacteraemia, their antimicrobial resistance profiles, and their contribution to mortality among hematologic cancer patients with febrile neutropenia at the Uganda Cancer Institute.
METHODS Blood drawn from participants during a febrile neutropenic episode (FNE; fever ≥ 37.5˚C and neutrophil count ≤ 1000 cells/µL) was cultured in the BACTEC 9120 blood culture system. Bacteria from positive cultures were identified biochemically. Antimicrobial susceptibility testing was performed with the disc diffusion method. Logistic regression and proportional hazards regression were applied to estimate associations between participant characteristics and FNE, bacteraemia, and mortality.
RESULTS Of 246 participants, 74 (30%) had an FNE. During the first FNE, 6/21 (29%) participants with acute lymphocytic leukaemia (ALL) developed bacteremia compared to 16/31 (52%) with acute myeloid leukaemia (AML) (OR 2.22 (0.65, 7.4)). AML patients were specifically at higher risk of Gram-negative bacteraemia (OR 4.59 (1.09, 19.3). Of the 41 aerobic bacteria isolated, 32 (78%) were Gram-negative, the most common being Klebsiella pneumoniae (11; 34%). Seventeen (53%) of the Gram-negative bacteria displayed the extended spectrum beta lactamase phenotype and 5 (16%) were resistant to carbapenems. One of the eight Enterococcus species was vancomycin resistant. Overall survival among patients with FNE was 54% at 30 days and 19% at 100 days. Bacteraemia was associated with higher mortality within 30 days (HR 2.1 (0.99, 4.45)) and 100 days (31% v 10%; HR 2.23 (1.09, 4.59)).
CONCLUSIONS Multidrug resistant bacteria are the main cause of bacteraemia and increase mortality in febrile neutropenic hematologic cancer patients at the UCI. Enhanced microbial surveillance, infection control and antimicrobial stewardship programs are needed to guide therapy and address emerging antimicrobial resistance at our institution.

OBJECTIVE This research study explored the social burden that families experience in the process of providing care to their family members who are living with cancer. It provides different perspectives into cancer care from the family caregiver point of view and a platform for family caregivers (FCs) to share their care giving experiences.
METHODS This study was conducted through qualitative methods and was rooted in the interpretivist paradigm to understand the cancer care giving experience by interpreting the subjective perspectives of the FCs. 20 FCs who were actively involved in caring for or previously had the experience of caring for a family member with cancer participated in the study. A semi-structured interview guide was used to conduct in-depth interviews where participants were asked questions that focused on the social burden of caring for a family member with cancer.
FINDINGS Three themes emerged concerning the social burden of cancer care giving among FCs; impact on the relationship with the patient, a change in life and social support.
CONCLUSIONS The results of this study demonstrated that cancer care giving is a difficult and time-consuming task for FCs and becomes even tougher for FCs who lack social support from others. Social support is what FCs long for the most as this can lighten the caregiver burden that they face. This study has pointed out that there is a need for a family centred approach to care giving and a collaborative partnership between patients, healthcare providers and FCs. There is a need for FCs to be recognized in the healthcare system with the development of policies and interventions that will support the needs of FCs and lighten the caregiver burden that they are faced with.

OBJECTIVE Provide prospective data for rituximab for diffuse large B-cell lymphoma (DLBCL) in Malawi.
METHODS We are conducting a phase 2 trial of rituximab + CHOP using the Indian biosimilar (NCT02660710). Eligible patients are 18-60 years with performance status (PS) ≤2, and new DLBCL diagnosis rendered locally using immunohistochemistry and telepathology. Adequate bone marrow, renal, and hepatic function are required, and CD4 ≥100 cells/µL if HIV+. Interim amendment allowed hepatitis B surface antigen-positivity (HBsAg+) if HIV+ on tenofovir-lamivudine antiretroviral therapy (ART).
RESULTS From 8/1/2016 to 4/30/2019, we screened 69 patients, enrolled 35 (51%), and excluded 34 [non-DLBCL (16), CD4 <100 cells/µL (9), PS >2 (3), HBsAg+ (2), died during screening (2), absconded during screening (1), platelets <100x103/µL (1)]. 1 patient was revised to Burkitt lymphoma after US review, leaving 34 DLBCL patients who received RCHOP. Median age was 44 years (range 22-58), 17 (50%) were female, and 26 (76%) were HIV+. 20 (59%) were stage III/IV, median lactate dehydrogenase was 510 IU/L (range 27-2480, laboratory upper limit 250), median PS 1 (range 0-2), and median age-adjusted international prognostic index (aaIPI) 2 (range 0-3). Among 26 HIV+ patients, 21 (81%) were on ART for a median 39 months (range 5-107) with median CD4 209 cells/µL (range 102-1551) and 19 (73%) with suppressed HIV. As of 4/30/2019, 27 patients completed treatment after a median 6 cycles (range 2-6), of whom 18 (67%) achieved complete response, 19 (70%) developed grade 3/4 neutropenia, 4 (15%) grade 3/4 anaemia, 4 (15%) grade 3/4 infection, and 3 other grade 3/4 toxicities (1 thrombocytopenia, 1 hypersensitivity, 1 bowel obstruction). 8 deaths occurred [DLBCL progression (5), RCHOP complication (1), diabetic complications (2)], and 1-year overall survival was 71% (95% confidence interval 47-85%).
CONCLUSIONS In early experience, rituximab appears safe, feasible, and effective for selected DLBCL patients in Malawi.