BACKGROUND AND OBJECTIVE: Industry-led access programs make important contributions to improving access to new, life-saving cancer treatments for poor patients in low- and middle-income countries. As these countries’ gross domestic product and income ranking increase, certain patients may no longer be eligible for such free or subsidized treatments. Governments, most of which are working towards universal health coverage (UHC), are expected to provide access to new therapies.
Needs and expectations for cancer care increase in low- and middle income countries' health systems working toward UHC. However, a growing pipeline of highly-priced new cancer therapies may not be affordable and/or cause unacceptable trade-offs.
Exemplified by chronic myeloid leukemia (CML) treatments, we illustrate the dilemma between meeting individual patient care needs and population-level stewardship of resources.
METHODS: We estimate the budgets needed to provide targeted therapies for CML in selected African countries and compare estimated budget needs with current expenditures on health. We then estimate budget impacts of scenarios in which we vary the proportion of needed treatments covered, at different negotiated prices, for privately and publicly insured patients, and provided by company access programs at no cost to the system for the uninsured and the underinsured. We use data on the number of patients with CML from the Global Burden of Disease study and local sources and international treatment guidelines to estimate needed medication volumes. Medicines prices come from national and international sources.
RESULTS AND CONCLUSIONS: This study aims to inform a discussion on prices, equity and trade-offs caused by the entry of new, effective, highly-priced cancer medicines which challenge financial sustainability of low- and middle income country's health systems working toward UHC and threaten to widen inequities in access to and outcomes of health care, within and across countries.

OBJECTIVE To describe the discovery, development and preclinical evaluation of a novel class of anticancer therapies developed by L.E.A.F. Pharmaceuticals (USA) and L.E.A.F. Rwanda. The premise of LEAF’s pipeline is based on the observation that polyglutamates of the folate analog class of antimetabolites (e.g. pemetrexed and methotrexate) are much more potent than their respective monoglutamates. For example, pentaglutamate pemetrexed is ≥ 80 times more potent than pemetrexed in inhibiting thymidylate synthase. For polyglutamation, monoglutamates require intracellular conversion by endogenous Folyl-Poly-Glutamate Synthetase (FPGS). FPGS is often downregulated in resistant tumour settings. Direct treatment of cancers with polyglutamate forms would be ideal, however, for 70 years researchers could not deliver these large negatively charged molecules inside a cell, thus limiting their therapeutic potential. LEAF's new generation of drugs were designed to address this challenge by directly delivering the more active polyglutamates inside cancer cells and bypass the need for endogenous FPGS.
METHODS The active pharmaceutical ingredients (API) for LEAF-1401, LEAF-1701, LEAF-1702 and LEAF-1703 were synthesized de-novo and encapsulated into nanoliposomes. In-vitro testing in various cell lines and in-vivo testing in mice were performed in a variety of tumour types.
RESULTS In-vitro, all four molecules were more potent than pemetrexed in various cancer cell lines, while sparing normal liver cells, colon and neutrophils. In-vivo, treatment of H292 lung cancer xenografts with LEAF-1701 improved survival to 59 days compared to 39 days for pemetrexed. In A549 lung cancer orthotopic models, treatment with LEAF-1401 led to reduced metastatic tumour burden and prevention of new metastases compared to pemetrexed. In-vivo in mice, doses of 60-80 mg/kg IV weekly were well tolerated with minimal impact on blood counts and chemistries.
CONCLUSION LEAF-1401 and LEAF-1700 series show promising preclinical activity and safety profiles. Following initial review by US-FDA and Rwanda-FDA, these molecules are now advancing towards the clinic.

OBJECTIVE Compared to cytology, HPV DNA testing is highly sensitive but often lacks in specificity. Our objective was to investigate whether select combinations of HPV genotypes, ascertained by Linear Array (LA) and GeneXpert (GX), can optimize sensitivity/specificity trade-offs to detect CIN2+.
METHODS Seven hundred fourteen women aged 35 to 60 years were recruited in Cape Town, South Africa. Each woman underwent a pelvic exam to collect cervical samples (tested by LA and GX for 14 high-risk HPV genotypes) and biopsy, LEEP, or ECC (reviewed by a pathologist for CIN2+). Using multivariable logistic regression, we determined HPV genotypes 16, 18, 31, 33, 35, 52, and 58 were significantly associated with CIN2+ (P<0.05). We included these 7 types, along with HPV 45, in our sensitivity and specificity calculations of selected typing. Full typing included all 14 high-risk types.
RESULTS We found that sensitivity estimates for full typing were similar to that of selected typing: 89.2% (full) vs. 84.8% (selected) for LA and 91.6% (full) vs. 89.2% (selected) for GX. Specificity estimates improved for selected vs. full typing: 77.2% (full) vs. 82.4% (selected) for LA and 75.3% (full) vs. 80.2% (selected) for GX.
CONCLUSION To optimize the performance of GX and LA as tools for cervical cancer screening in high-burden, under-resourced settings like South Africa, only HPV 16, 18, 45, 31, 33, 35, 52, and 58 should be included to define screen-positive. We recommend inclusion of HPV 45 for its known link to adenocarcinoma. HPV 51, 59, 39, 56, 66, 68 could be considered for exclusion.

OBJECTIVES Ethiopia faces a high burden of breast cancer, a lack of accessible cancer treatment centers outside of Addis Ababa, and a large cancer patient backlog at Tikur Anbessa Specialized Hospital (TASH) in Addis Ababa, the main cancer treatment center in the country. To address these challenges, the FMOH began expanding cancer treatment services to six regional hospitals in 2016 by training general medical practitioners to provide basic breast cancer treatment, and training nurses to administer chemotherapy. The study objective was to measure the number of new patients initiating breast cancer treatment in regional hospitals and the average waiting period (AWP) for patients to initiate breast cancer chemotherapy after prescription.
METHODS Study outcomes were measured by collecting patient registration data from January to December 2018 from hospital registers, and by collecting average waiting period (AWP) estimates by asking oncology unit staff. We then compared results from the 6 regional hospitals with TASH.
RESULTS 515 patients initiated breast cancer treatment across the six regional hospitals in 2018, with a median number of 99.5 patients per hospital in comparison to the 2,676 patients at TASH. Median AWP was estimated to be 1 week at the regional hospitals vs. 4 months at TASH. Median of patients initiating treatment across the six hospitals rose from 31.5 patients over January-June 2018 to 65.5 patients over July-December 2018.
CONCLUSIONS The program was successful at initiating diagnosed breast cancer patients on treatment at regional hospitals. This should reduce financial and geographic barriers to treatment, since regional patients no longer need to travel to Addis Ababa for treatment. In addition, these patients are receiving quicker access to the treatment they need, since travel times for treatment are significantly lower and average waiting periods to begin chemotherapy in regional hospitals are much lower than at TASH in Addis Ababa.

INTRODUCTION Outpatient chemotherapy is a core treatment for malignancies; however, its toxicities frequently lead to distressing side-effects ranging from mild to severe. Early detection of these side effects is vital to improved patient outcomes, decrease loss to follow-ups, decrease morbidity and improve quality of life.
OBJECTIVE AMPATH Oncology Institute proposes to implement a post chemotherapy administration follow up system using Unstructured Supplementary Service Data (USSD).
METHODOLOGY This is a communication service which is a critical piece of infrastructure used to provide mobile based information on any phone, and at low cost, hence all patient can access this service from the most basic phone without need of internet. USSD enables patients to send their post chemotherapy conditions to AMPATH Oncology care center along with their patient identification number for authentication, while enabling clinician to send responses to patients and confirm their conditions. We will start with a pre-project assessment questionnaire to both patients and Health Care Professionals, Implement the project between May 2019 and Oct 2019 and do a post-project questionnaire and have the results ready to be presented at the November 2019 AORTIC Conference.
RESULTS USSD service is almost seven times faster than SMS, and there is minimal delay between sending a query and receiving a response. This is evident by use of USSD as a mobile-based intervention to improve screening and adherence rates for TB and other medical conditions in other similar settings.
CONCLUSION Through use of USSD gateway, the system will enable clinicians to classify patients post chemotherapy conditions from the data collected as either high, moderate or low risk; which will guide in providing necessary intervention in management of adverse chemotherapy side effect. It is hoped this will increase the compliance and on-schedule chemotherapy administration as well as patient outcomes and satisfaction with responsiveness of HCP.

INTRODUCTION Testicular cancer is a rare malignancy worldwide, particularly in Africa and black population of another continent. Its aetiology is largely unknown but can be associated with maldescended testis. Five factors may feature prominently in the increase frequency of testicular tumours. These include abnormal germ cell, elevated temperature, and interference with blood supply, endocrine disturbances and gonadal dysgenesis.
OBJECTIVES To highlight the pattern of malignant testicular tumours based on age of patient and histological types in Sokoto, North-western, Nigeria.
METHOD This was a retrospective study of all patients histologically confirmed to have malignant testicular tumour at the Usmanu Danfodiyo University Teaching Hospital, Sokoto from January 2006 to December 2015. Information was obtained from database of Department of Histopathology. The data were validated using Microsoft Excel and exported to SPSS for analysis. The data was analysed for age, sex and histological types using SPSS version 20 software. The results are presented in form of simple frequency, percentages and tables.
RESULTS A total of 12 patients were seen with histologically confirmed malignant testicular tumours out of the 3933 patients with malignancies between the years 2006 and 2015, accounting for 0.3% of all malignancies diagnosed in the same period. Their mean age was 34.67 with SD ± 30.6, and age range of 3-77 years. The two common malignant testicular tumour were yolk sac tumour 4 (33.3%) and metastatic carcinoma 4 (33.3%). Others were rhabdomyosarcoma 2(16.7%), Burkitts Lymphoma 1 (8.3%) and seminoma 1(8.3%).
CONCLUSION Malignant testicular tumours are rare in our environment. Yolk sac tumour and metastatic carcinoma are the predominant histological types. Late presentation, poverty, paucity of resources and the high cost of newer imaging and treatment modalities are major challenges suffered by these patients.

BACKGROUND Chemotherapy-induced neutropenia (CIN) increases the risk for infection, sepsis, disruption of chemotherapy and poor prognosis. Knowledge of risk factors for CIN helps to determine patients at risk before starting chemotherapy. Breast cancer is the most common malignancy for which chemotherapy is given at Ocean Road Cancer institute (ORCI), however, the prevalence of CIN in these patients is not known.
OBJECTIVES To determine the prevalence and associated factors of CIN in breast cancer patients receiving chemotherapy at ORCI, Tanzania.
MATERIAL AND METHODS A retrospective cohort study of 100 breast cancer patients who have received chemotherapy from 12/1/2018 -1/31/2019 was conducted at ORCI. Demographics, nutrition status, haematological data, chemotherapy drugs, dose and number of cycles were collected before starting chemotherapy and for three consecutive cycles. SPSS version 20 was used for data analysis, relationship between clinical data and severe neutropenia was assessed.
RESULTS 100 patients were identified (median age of 41 years, range 26-81 years, all females). Advanced disease (clinical stage III and IV) was noted in 35 patients (45%). Low haemoglobin (<7g/dl) and hypoalbuminemia (<3.5g/dl) were seen in 70% and 62% respectively. Severe neutropenia (<500 cells /microliter) was noted in 35 (45%45% p less than 0.005). All patients received curative low dose regimen due to poor performance status. A statistically significant association was noted between severe neutropenia and advanced stage of the disease, low haemoglobin, low albumin, Taxanes and cyclosphamide drugs. Neutropenia increased with the number of chemotherapy cycles 2 and 3.
CONCLUSION Severe CIN is common in breast cancer patients treated at ORCI. More attention should be given for patients with advanced breast cancer, patient with lower haemoglobin and hypoproteinaemia, and patient receiving taxanes and cyclophosphamide.

OBJECTIVE In spite of the increasing cancer burden, the available cancer specialists remain limited. This has led to the exploration of ways of improving access to quality cancer care within the available resources. Combination chemotherapy requires the consideration of several factors including the tissue diagnosis, immunohistochemistry, clinical stage, the treatment intent, patient clinical status, the preferred regimen and number of cycles, in addition to the functional status of the hematopoietic, hepatic and renal systems. This project aimed to design, implement and evaluate the appropriateness and effectiveness of a spreadsheet-based clinical decision support (CDS) system for cancer chemotherapy, designed for the busy resource-limited clinic setting, and especially those with limited numbers of specialists.
METHODS The current spreadsheet was designed from scratch using MS Excel elements including lists, formulas and VBA macros to automatically calculate relevant intermediate variables, which in turn result in adjustments of chemotherapy drug doses, accounting for patients’ body habitus (body weight or surface area) and the functional state of the bone marrow, liver and kidneys. Adjustments are done in real time to achieve a personalized final regimen, without compromising patient safety and drug efficacy.
RESULTS The spreadsheet was used for training and later piloted among a group of 25 specialists, medical officers and oncology nurses in our chemotherapy clinic in Gaborone. Upon full implementation, the spreadsheet is expected to lead to a more efficient decision-making process, reduced patient waiting times, while ensuring stringent quality control measures.
CONCLUSION We conclude that cancer chemotherapy can be better implemented in busy oncology practices using appropriately designed CDS systems to improved patient care and safety, as well as improve efficiency, especially in settings with human resource constraints.

OBJECTIVE In Ethiopia, cervical cancer is the second common cancer and accounts for 17% of malignancies in females. There is unmet health care service need for cervical cancer in Ethiopia. Gynecologic Oncology Fellowship Training Program was launched in 2016 at two teaching hospitals in Addis Ababa, Ethiopia. At St. Paul’s Hospital Millennium Medical college (SPHMMC) the program works in collaboration with the University of Minnesota, University of Michigan and German Society of Gynaecological Oncology (AGO). In 2017, the program joined the global oncology fellowship training under the International Gynecologic Cancer Society (IGCS). This study is presented to show the impact of global partnership on surgical care delivery for patients with cervical cancer managed at SPHMMC.
METHODS A hospital-based retrospective cross-sectional study was conducted. A five-year period, 9/ 2008- 9/2013, was selected as a pre-fellowship period for baseline data. Starting at fellowship implementation 1/2016 was selected to determine the impact of fellowship training on service delivery. Data was collected from medical charts. We could retrieve 86 charts from the record office making the retrieval rate 84.3%.
RESULTS A total of 211 patients with cervical cancer were evaluated in our Gynecology Oncology clinic from 1/ 2016 to 8/2018 and 102 (48%) were eligible for radical hysterectomy and pelvic lymphadenectomy (RHPL). The average number of patients operated per year increased eight times from the pre-fellowship period. Patients with advanced disease were referred to chemo-radiation. The mean age was 48 ± 11 years with range of 28 - 88 years. Fourteen patients (16%) were HIV positive. Clinical stage included stage IB1 48 (46.5%), IB2 14 (16.3%) and IIA 25 (30%). Eighteen patients (20.9%) received neoadjuvant chemotherapy. There were 2 bladder injuries and 4 ureteric injuries, and no death reported during the hospital stay. The bivariate analyses showed taking neoadjuvant chemotherapy significantly decreases the rate of pelvic lymph node metastasis with a P value of 0.01.
CONCLUSION Implementation of gynaecologic oncology fellowship training increased surgical management of cervical cancer in Ethiopia. Quality improvement projects and cancer registry are needed to advance cervical cancer service delivery.

OBJECTIVE The phenotype of colorectal cancer (CRC) in Nigeria is distinct from that seen in the U.S. In South Africa (SA), there appears to be a similar trend between individuals of African and European descent. This study compares clinicopathologic variables between CRC patients in Nigeria and SA.
METHODS From Nigeria, 380 consecutive patients (09/2013-03/2019) from the African Research Group for Oncology (ARGO) CRC database were compared to 534 consecutive patients (01/ 2016-01/2019) from the Colorectal Cancer in South Africa (CRCSA) database. Patients with histologically confirmed adenocarcinoma were included. Patients were excluded if they had in-situ disease, no histological diagnosis or were unable to give written, informed consent.
RESULTS The median age at presentation was identical between Nigerian and black SAs (bSA) (55) with CRC. This was significantly lower than the median age among white SAs (wSA) (55 vs. 63, p<0.001). The Nigerian cohort had a higher proportion of cases in individuals younger than 30 years of age (8.2% vs. 4.0%, p=0.003). There was significantly more right-sided colon cancer in black and mixed-race patients in both cohorts compared to wSA (p=0.014). Nigerian patients were more likely to present with stage IV disease (50%) compared to both black (30%) and wSAs (23.5%, p<0.001). They were also more likely to have tumours with a mucinous component (38.4% vs. 9.9% bSAs vs. 11.7% wSAs, p<0.001). There was a significant difference in the median overall survival between cohorts and by ethnicity (p<0.001).
CONCLUSION There is significant variability in the phenotype of CRC between Nigeria and South Africa. In patients of African origin, CRC appears to share characteristics that are different than those of non-African origin – despite a similar environment. Larger series with tissue banking and next-generation sequencing are needed to better delineate these observed differences.

PURPOSE The CYP1A1 gene is highly polymorphic in human populations and ethnic differences in the distribution of these polymorphisms have been reported in various populations. The aim of the study to evaluate the association of three polymorphic variants in the CYP1A1 gene with breast cancer susceptibility in Sudanese women.
PATIENTS AND METHODS 100 patients and 100 controls were studied after written consent. A questionnaire extracted sociodemographic data, family history of breast cancer and gynecological history. Clinical examination was performed including weight and heights. Blood was drawn for PCR and RFLP analysis for CYP1A1 genotyping.
RESULTS Premenopausal age and later age at menopause, education levels, family history of breast cancer and BMI had significant associations with breast cancer risk in Sudanese women. The CYP1A1 M1 genotype was not associated with the risk of breast cancer in pre-post-menopausal ages neither were the CYP1A1 M3 genotypes in this respect. There were no homozygous CYP1A1 M1 (C/C) and the CYP1A1 M3 (C/C) genotypes in our study subjects. The homozygous CYP1A1 M2 (A/A) genotype had a significant association with risk reduction of breast cancer in premenopausal women. The heterozygous CYP1A1 M2 (A/G) and the homozygous (G/G) were associated with a significant increased risk of breast cancer.
CONCLUSION This study has shown that the CYP1A1 M2 polymorphism has an association with the risk of developing breast cancer among Sudanese patients. Illiteracy and family history of breast cancer have a highly significant association with breast cancer risk.