ONCOLOGY AT THE PERIPHERY

Matilda.K.OngóndiPhysician: Kenyatta National Hospital

300 bed capacity.

Started giving chemo

2011 prior few cases

mostly paeds.

Demographics 31 patients.

M:F ratio…...1.2:1 (14 females, 17males)

gender

male

female

0

2

4

6

8

10

12

14

0-10 11 to 20 21-30 31-40 41-50 51-60 61-70 >71yrs

No

.

Age group

Frequency per age group

Mean age: 42.6yrs with range 4-89yrs

Diagnosis n stage

Kaposis Sarcoma 12 low=highrisk

Non-hodgkins lymphoma(DLBCL 3, Burkitts 4, Follicular lymphoma1, T cell lymphoblastic lymphoma 1)

10

*suspected

Stage I-1,II-2, IV-7

Hodgkins Lymphoma 3 IV-2, II-1

Multiple myeloma 2 III

Esophageal cancer 1 IV

CLL 1 II

Breast Cancer 1 II

Requirement to make a diagnosis

Lymph node biopsy 8

Punch biopsy 6

Interventional radiologist 1

BMA 2

Sx intervention 14

Core needle biopsy (axillary mass biopsy, liver mass), nasal

mass, supraglottic mass, tonsillar mass, gingival mass, uvula

mass, laparatomy-intra-abdominal biopsy, endoscopy, foot bx,

colonoscopy, laminectomy

Time to diagnosis

0

50

100

150

200

250

300

350

a b c d e f g h i j k l m n o p q r s t u v w x y

No

. of

day

s

Mean time: 43 days with range 3 to 318 days.(data from 26 patients)

Tx as TB,default

Conflicting biopsy reports

Time to initiation of chemo: 20days

(range: 2- 70days)

23 patients..data available.

Pt. counselled on diagnosis and chemotherapy as

well as cost; reduced time.

Team work…multi-disciplinary consult (direct

communication).

Co-morbidities

1 KS all had HIV except 2 Africanendemic KS

2 Diabetes Mellitus

3 Sputum +ve TB (HIV negative): HL*

4 Systolic hypertension

5 COPD

6 Hep B/HIV co-infection with BL

Complications @ presentation

1 Superior Vena Cava syndrome** chylothorax

2 Upper airway obstruction with dysphagia

3 Paraplegia

4 Post-obstructive pneumonia

5 Dry gangrene and cryoglobulinaemia

6 DVT

Complication tx associated

1 Leucopenia

2 Tumour lysis syndrome (worsening hypoxia)

3 Post chemo-port insertion: clot in SVC

Mortality: 25% (7 patients)

Reason for mortality:

1) sepsis (2)

2) treatment failure (2)

3) Extensive d’se (1..primary respiratory failure,

?castelman)

4) Uncertain (1-prior chemo)

Lost to follow up: 7 (financial reasons)

Evaluation of patients adherence to chemotherapy for breast cancer.

Adewale O Adisa, Omkayede O, et al

African Journal of health sciences Vol 15, no 1-2, Jan –March 20007;p22-27

10yr period (Jan 1993 to Dec 2002), 225 females and 6 males.

56% stage 4 at presentation, non-adherence was 80.9% (73% not

seen again)

Reasons: financial, thought well enough, fearful of sx, unable to

bear side effect.

1

Compliance with chemotherapy in childhood leukaemiain Africa.Mac Dougall LG, Wilson TD, Cohn R, Shuenyane ENS. Africa Medical journal 1989 May 20; 75 (10): 481-4

Compliance of chemotherapy in childhood leukaemiagood due to parental fear of disease.

15 blacks, 30 white children

53% blacks attended clinic on appointment day.

<50% understood nature of child’s illness.

White parents reported toxic effects more frequently.

3

HOWOne man /woman show: identify patients, not sustainable.

Interested colleagues: nurse…assist give drugs

More Interested colleagues:nurses: Mix drugs: VB…KS, review by CO no issue, give drug. Be informed.Other chemo: mix then they would fix it after fluids: inform me when chemo was done.Pharmacist (Dr) trained in KNH : mix chemoLater pharm techs.

3 copies:1. file..paper

chart.2. Patient.3. File in

pharmacy

Interesting!!!!

Lessons learnt

Challenges: late presentation pt and clinician factors,

working up patients and financial constraints

influencing time lines, cost of meds.

Cannot work alone (success due to team

support…institution and colleagues).

Support from hemato-oncologists (phone

consultation).

Pt understanding condition and need f/u.

Conclusion

Reality- increasing number of patients, more

advanced dse, misdiagnosis/late diagnosis in the

face of financial constraints limiting accessibility.

Cannot have oncologist everywhere!

Presentation shows its possible to give simple

chemo regimens in periphery facilities with good

support.

Acknowledgement

• Tenwek Hospital: mx and staff

Nurses: Dennis, Caroline ,Linner Rotich, Phylis Siele

Pharmacy: Dr Langat,Isaiah, Wesley

MO: Dr Masese and Sirera

• Dr Sylvester. Kimutai …data collection and review

• Dr MD Maina, Dr Ann Waweru: phone consults

• KESHO secretariat/ Novartis (sponsorship)

• Colleagues in Hemato-Oncology at KNH/UON

Asante Sana