Henry Wabinga

Mind the gaps: A qualitative study of perceptions of healthcare professionals on challenges and proposed remedies for cervical cancer help-seeking in post conflict Northern Uganda.

BackgroundThere are limited data on perceptions of health professionals on challenges faced by cervical cancer patients seeking healthcare in the developing countries. We explored the views of operational level health professionals on perceived barriers to cervical screening and early help–seeking for symptomatic cervical cancer and the proposed remedies to the challenges.MethodsFifteen key informant interviews were held with health professionals including medical directors, gynecologists, medical officers, nurses and midwives in the gynecology and obstetrics departments of two hospitals in northern Uganda during August 2012 to April 2013. We used content analysis techniques to analyze the data.ResultsHealth professionals’ perceived barriers to cervical cancer care included: (i) patients and community related barriers e.g. lack of awareness on cervical cancer and available services, discomfort with exposure of women’s genitals and perceived pain during pelvic examinations, and men’s lack of emotional support to women (ii) individual healthcare professional’s challenges e.g. inadequate knowledge and skills about cervical cancer management; (iii) health facility related barriers e.g. long distances and lack of transport to cervical cancer screening and care centers, few gynecologists and lack of pathologists, delayed histology results, lack of established palliative care services and inadequate pain control; and (iv) health policy challenges e.g. lack of specialized cancer treatment services, and lack of vaccination for human papilloma virus. Other challenges included increased number of cervical cancer patients and late stage of cervical cancer at presentations.ConclusionsOperational level healthcare professionals in northern Uganda reported several practical challenges facing cervical cancer care that influence their decisions, management goals and practices. The challenges and proposed remedies can inform targeted interventions for early detection, management, and control of cervical cancer in Uganda.

Awareness of cervical cancer risk factors and symptoms: Cross-sectional community survey in post-conflict northern Uganda.

Lack of awareness of risk factors and symptoms for cancer may lead to late diagnosis and poor prognosis.

Symptomatic presentation with cervical cancer in Uganda: a qualitative study assessing the pathways to diagnosis in a low-income country

BackgroundSymptomatic cervical cancer patients in low- and middle-income countries usually present with late stage disease and have poor survival. We explored the views of cervical cancer patients on their symptom appraisal and interpretations, and their help-seeking including lay consultations.MethodsWe conducted an in-depth interview study in two northern Ugandan hospitals. Theoretical models underpinned the study guide for data collection and analysis. We used thematic analysis techniques, informed by the theoretical concepts in the Model of Pathways to Treatment. Sub-themes and themes were identified through consensus among investigators.ResultsEighteen women aged 35–56 years, recently diagnosed with cervical cancer were interviewed. Their first symptoms included abnormal vaginal bleeding, offensive vaginal discharge and lower abdominal pain. Most participants did not perceive themselves to be at risk for cervical cancer and they usually attributed the initial symptoms to normal bodily changes or common illnesses such as sexually transmitted diseases. Lay consultations with husbands, relatives and friends were common and often influenced decisions and timing for seeking care. Prompt help-seeking was frequently triggered by perceived life threatening symptoms such as heavy vaginal bleeding or lower abdominal pain; symptom burden sufficient to interfere with patients’ work routines; and persistence of symptoms in spite of home-based treatments. Participants did not promptly seek care when they perceived symptoms as mild; interpreted symptoms as due to normal bodily changes e.g. menopause; and attributed symptoms to common illnesses they could self-manage. Their cancer diagnosis was often further delayed by long help-seeking processes including repeated consultations. Some healthcare professionals at private clinics and lower level health facilities failed to recognize symptoms of cervical cancer promptly therefore delayed referring women to the tertiary hospitals for diagnosis and treatment.ConclusionUgandan patients with symptomatic cervical cancer often misattribute their gynaecological symptoms, and experience long appraisal and help-seeking intervals. These findings can inform targeted interventions including community awareness campaigns about cervical cancer symptoms, and promote prompt help-seeking in Uganda and other low- and middle-income countries with high incidence and mortality from cervical cancer.

A ‘giant’ intraluminal lipoma presenting with intussusception in an adult: a case report

IntroductionIntussusception is an uncommon cause of intestinal obstruction in adults. It usually presents with typical features of intestinal obstruction, and is associated with the presence of a ‘lead point’ for the invaginated portion. This ‘lead point’ is rarely an intraluminal, submucosal lipoma.Case presentationWe describe the case of a 64-year-old African-Ugandan woman of Bantu ethnicity who presented with features of intestinal obstruction secondary to intussusception. She was treated operatively. A left colocolonic invagination was found with the interssusceptum having a giant polyp. A left hemicolectomy was performed. A histopathological examination revealed a polypoid, submucosal lipoma.ConclusionsIn resource-rich countries, most cases of colonic intraluminal polyps are detected through colonoscopy during routine medical check-ups. With limited resources in our region, many tumors present as intestinal obstructions secondary to intussusception. Even then, most are associated with adenomas and malignancies. Rarely are polypoid, submucosal lipomas found. In our patient’s case a polyp of 9.5cm at its widest dimension is of particular interest. A lesson to learn is that the differential diagnosis for intussusceptions in resource-poor countries should be broadened to include submucosal lipomas.

Social, demographic and healthcare factors associated with stage at diagnosis of cervical cancer: cross-sectional study in a tertiary hospital in Northern Uganda.

Objective To examine patient and primary healthcare factors and stage at diagnosis in women with cervical cancer in Northern Uganda with the intention to identify factors that are associated with advanced stages in order to inform policies to improve survival from cervical cancer in low income and middle income countries. Design Cross-sectional hospital-based study. Setting Tertiary, not-for-profit private hospital in postconflict region. Participants Consecutive tissue-diagnosed symptomatic patients with cervical attending care. Of 166 patients, 149 were enrolled and analysed. Primary outcome Cervical cancer stage at diagnosis. Results Most women were diagnosed at stages III (45%) or IV (21%). After controlling for age, marital status, educational attainment and number of biological children, there was evidence for association between advanced stage at diagnosis and pre-referral diagnosis of cancer by primary healthcare professionals (adjusted OR (AOR)=13.04:95% CI 3.59 to 47.3), and financial difficulties precluding prompt help seeking (AOR=5.5:95% CI 1.58 to 20.64). After adjusting for age, marital status and educational attainment, women with 5–9 biological children (AOR=0.27:95% CI 0.08 to 0.96) were less likely to be diagnosed with advanced stage (defined as stages III/IV) cancer. In this pilot study, there was no statistical evidence for associations between stage at diagnosis, and factors such as age at diagnosis and marital status. Conclusions This study is a first attempt to understand the descriptive epidemiology of cervical cancer in rural Ugandan settings. Understanding individual patient factors, patients’ behavioural characteristics and healthcare factors associated with advanced stage at diagnosis is essential for targeted effective public health interventions to promote prompt health seeking, diagnosis at early stage and improved survival from cervical cancer.

A case-control study of cancer of the uterine cervix in Uganda.

As part of an epidemiological study of cancer in Uganda, we investigated social, sexual and reproductive factors in relation to the risk of cancer of the uterine cervix. Patients with all cancer types or with benign tumours were recruited from hospitals in Kampala, Uganda, interviewed about various demographic and lifestyle factors and tested for antibodies against the human immunodeficiency virus-1 (HIV). The case–control study reported here involves 702 HIV-seronegative women, 343 of whom were diagnosed with cancer of the uterine cervix. Key findings were that the risk of cervical cancer increased linearly with the number of pregnancies [χ2(1)=44.7; P<0.0001]; a woman reporting having had 10 or more children had a roughly seven-fold increase in risk of the tumour as compared with women reporting fewer than four pregnancies (odds ratio=7.1; 95% confidence interval 3.8–13.2). The risk also varied inversely with age at first reported sexual intercourse [χ2(1)=8.4; P=0.004], perhaps reflecting an earlier age of infection with human papillomavirus, the main causal agent. These results are in line with those reported from studies in other countries.

Clinical oncology in resource-limited settings

Infectious Agents and Cancer is introducing a new section of Clinical Oncology with the main objective of stimulating debate through articles published in the section. Infectious diseases have been the major causes of morbidity and mortality in human populations, and have dominated the medical approach to clinical and public health. Successful efforts to control mortality from acute infections have paved the way for chronic, mostly indolent, infections to become major causes of morbidity. Cancer, hitherto thought to be rare in resource-limited settings, is becoming a major contributor. The changes in mortality patterns are due, in part, to diseases linked to rapid changes in lifestyle, urbanization, and pollution. These diseases include many of the non-infection associated cancers. However, there is a dearth of information about the burden, pathogenesis, and therapeutic approaches about cancer in resource-limited countries. There are also substantial other challenges, including economic, infrastructure, technology, and personnel. The Journal advocates for interactive local–global (lo-bal) efforts to generate relevant knowledge about cancer burden, pathogenesis, and therapeutic approaches using a bottom-up approach to sharpen the focus on local and global relevance of research and clinical and public practice, particularly in resource-limited countries. The section on Clinical Oncology in Infectious Agents and Cancer will harness these “lo-bal” strategies to reduce substantially the time from concept, discovery, and development and implementation of locally and globally applicable diagnostic and therapeutic technologies.

Pyomyositis in Nodding Syndrome (NS) patient - A case report

We report a case of Pyomyositis in a 13-year-old boy diagnosed using WHO surveillance definition of Probable Nodding syndrome. Complete blood count showed Leukocytosis with immature granulocytes and atypical lymphocytes. Except for the liver enzymes which were high the renal functions and serum electrolytes were within normal range values. Culture of a pus-swab grew Staphylococcus aureus. Abdominal ultrasound scan showed a focal mass on the internal and external oblique muscles of the right abdominal wall. Incision and drainage was performed. Histology of the muscle showed non-specific inflammation of the external and internal oblique muscles. This finding may highlight some of the other tropical diseases that occur in children with Nodding syndrome.

Survival from childhood cancers in Eastern Africa: A population-based registry study: Survival from childhood cancers in Eastern Africa

Cancers occurring in children in Africa are often underdiagnosed, or at best diagnosed late. As a result, survival is poor, even for cancers considered ‘curable’. With limited population‐level data, understanding the actual burden and survival from childhood cancers in Africa is difficult. In this study, we aimed at providing survival estimates for the most common types of cancers affecting children aged 0–14 years, in three population‐based Eastern African registries; Harare, Zimbabwe (Kaposi sarcoma, Wilms tumour (WT), non‐Hodgkin lymphoma (NHL), retinoblastoma, and acute lymphocytic leukaemia (ALL)), Kampala, Uganda (Burkitt lymphoma, Kaposi sarcoma, WT, and retinoblastoma), and Nairobi, Kenya (ALL, retinoblastoma, WT, Burkitt lymphoma, and Hodgkin lymphoma). We included cases diagnosed within the years 1998–2009 and followed up till the end of 2011. We estimated the observed and relative survival at 1, 3, and 5 years after diagnosis. We studied 627 individual patient records. Median follow‐up ranged from 2.2 months for children with Kaposi sarcoma in Harare to 30.2 months for children with ALL in Nairobi. The proportion of children lost to follow‐up was highest in the first year after diagnosis. In Harare and Kampala, the 5‐year relative survival was <46% for all cancer types. The 5‐year relative survival was best for children in Nairobi, though with wider confidence intervals. Survival from childhood cancers in Africa is still poor, even for cancers with good prognosis and potential for cure. Supporting cancer detection, treatment, and registration activities could help improve survival chances for children with cancers in Africa.

Esophageal cancer male to female incidence ratios in Africa: A systematic review and meta-analysis of geographic, time and age trends

Highlights • We conducted a review and meta-analysis of esophageal cancer sex ratios in mainland Africa using data from 197 populations in 36 countries.• We observed a consistent male excess in incidence rates overall and in the high-risk Eastern and Southern African regions.• A male excess was evident in 30–39 year olds in high-risk Eastern and Southern African regions.• Our findings suggest that a substantial fraction of the African EC burden could be avoided by targeting gender-specific exposures.