Kesho Conference 2014

1. ONCOLOGY AT THE PERIPHERY
Matilda.K.Ongóndi
Physician: Kenyatta National Hospital

2.  300 bed capacity.
 Started giving chemo
2011 prior few cases
mostly paeds.

3. Demographics
 31 patients.
 M:F ratio…...1.2:1 (14 females, 17males)
gender
male
female

4. 14
12
10
8
6
4
2
0
Frequency per age group
0-10 11 to 20 21-30 31-40 41-50 51-60 61-70 >71yrs
No.
Age group
Mean age: 42.6yrs with range 4-89yrs

5. Diagnosis n stage
Kaposis Sarcoma 12 low=high
risk
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

6. 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

7. Time to diagnosis
350
300
250
200
150
100
50
0
Tx as
TB,default
Conflicting biopsy
reports
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 days
Mean time: 43 days with range 3 to 318 days.
(data from 26 patients)

8. 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).

9. Co-morbidities
1 KS all had HIV except 2 African
endemic KS
2 Diabetes Mellitus
3 Sputum +ve TB (HIV negative): HL*
4 Systolic hypertension
5 COPD
6 Hep B/HIV co-infection with BL

10. 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

12. Complication tx associated
1 Leucopenia
2 Tumour lysis syndrome (worsening
hypoxia)
3 Post chemo-port insertion: clot in SVC

13. 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)

14. 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

15. Compliance with chemotherapy in childhood leukaemia
in Africa.
Mac Dougall LG, Wilson TD, Cohn R, Shuenyane EN
S. Africa Medical journal 1989 May 20; 75 (10): 481-4
Compliance of chemotherapy in childhood leukaemia
good 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

16. HOW
One 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 chemo
Later pharm techs.

17. 3 copies:
1. file..paper
chart.
2. Patient.
3. File in
pharmacy

18. Interesting!!!!

19. 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.

20. 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.

21. 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

22. Asante Sana