Gynecologic Cancers

Background

Woman cervical cancer survivor

This woman presented with late-stage cervical cancer was treated with chemotherapy. Her treatment was successful and she received surgical treatment.

By 2020, there will be 16 million new cases of cancer worldwide. 70% of them are expected to occur in the developing world. In Africa, many of these cancers will be gynecologic in origin with cervical cancer being the most predominant. In contrast to Canada where cervical cancer is only the 11th most common and where cure rates are high (>90%), in Kenya cervical cancer is almost never cured and kills more women than any other type of cancer.

Many Western countries have substantially decreased cervical cancer mortality rates with the implementation of screening programs (i.e. Pap smears), which identify abnormalities before they become cancerous. Patients who present with abnormalities receive early treatment and are frequently cured. Later stages of cervical cancer are treated aggressively with radiation and chemotherapy.

Such prevention and treatment programs are rare in Sub-Saharan Africa. Due to a lack of screening programs in Kenya, most women present cervical cancer that is already matured to its later stages and is difficult to treat, even with high quality medical care. Radiation and chemotherapy are common treatments for these stages of cancer yet there is only one radiation machine in all of Kenya.

Cervical cancer kills women in the prime of their lives, devastating the families and communities that are left behind.

cervix-map

Estimated global age-standardized incidence rates of cervical cancer in 2012 per 100 000 1

The substantial number of cancer cases in Sub-Saharan Africa is largely due to a lack of cancer awareness, knowledge of prevention, and diagnostic and treatment expertise. The Gynaecological Oncology representatives of AMPATH-UofT are working in partnership with Moi University representatives and other representatives of the AMPATH Consortium to address inequalities in gynecologic cancer care and improve the health of women in western Kenya.

The team is lead by Dr. Barry Rosen, Section Lead of Gynecologic Oncology at Beaumont Health System.

Care: Prevention through treatment

Cervical Cancer Screening
Prior to 2009 there were no prevention or treatment services for cervical cancer in western Kenya. AMPATH initiated cervical cancer screening in 2009. In the first year 150 women were screened at MTRH and since over 14,000 women have been screened at 7 clinics in western Kenya.

Number of women screened each year

Number of women screened each year

As awareness increases and demand for the screening program grows, AMPATH is training more health care professionals to provide the needed services.

Cryotherapy (SEE AND TREAT)
The screening program has a multidisciplinary team to treat abnormalities found using the VIA technique. Nurses perform cryotherapy (removal by freezing of the abnormal cells). The programs uses a “See and Treat” approach meaning they are treated the same visit the VIA shows abnormal cells, reducing travel costs.

Colposcopy and LEEP
For patients with abnormal lesions, trained gynecologists view using colposcopy and excise using a technique called LEEP (Loop Electrosurgical Excision Procedure).

Radical Hysterectomy
For patients with early stage cervical cancer, a surgical procedure called a radical hysterectomy (removal of uterus and upper vagina) can be curative. AMPATH-UofT representative, Dr. Barry Rosen, developed a protocol collaboratively with gynecologic oncologists from across Canada through the Gynaecological Oncology of Canada Society to train Kenyan gynaecologists to perform this life-saving surgery. To date over 50 radical hysterectomies have been performed successfully.

Education

Fellowship in Gynecologic Oncology
Building on the success of the Cervical Cancer Screening Program and enthusiasm for change, the next advancement was to train Kenyan gynecologists to be local leaders and experts in the treatment Gynecologic cancers so that the program can be sustained locally.

Drs. Rosen & Omenge leading rounds

Dr. Rosen and Dr. Omenge lead rounds at Moi Teaching and Referral Hospital.

AMPATH-UofT is supporting Moi University School of Medicine in establishing a Master’s Program in Gynecologic Oncology. It is the first program of its type in all of Kenya, and is training practicing physicians in the care of gynecologic cancers. The goal of the program is to develop local expertise in all aspects of cancer care including counseling, screening, diagnosis, radiotherapy, surgical and chemotherapy treatment and end-of-life care. Educating physicians to be experts in the field of gynecologic oncology promotes sustainability of the AMPATH-RH Oncology program with the goal that the current students will be the teachers of the future.

The teaching faculty is made up of top professionals in gynecologic oncology from Canada, led by Dr. Rosen, and in the oncology field from Kenya. The fellowship program incorporates principles of student-centered learning, evidence-based clinical decisions and community-oriented practice.

Research

The strength of the AMPATH-UofT Oncology program relies on a solid foundation of research to identify the health care needs of the community. Each project involves a principal investigator from North America and Kenya and focuses on projects relevant to Gynecologic Oncology in western Kenya.

Patient Data Collection
Data collection for patients at the Moi Teaching and Referral Hospital exists in the form of relational databases. These databases capture relevant patient information, at point of care, for clinical use and research purposes. Disease specific databases have been established for Cervical Cancer, Ovarian Cancer, Vaginal Cancer, Vulvar Cancer and Gestational Trophoblastic Neoplasia (GTN). Through a strong data management system, patients are tracked so that the quality of service and education programs are continuously evaluated and improved upon and to fuel potential research questions and projects within the area.

Other research areas:
Cost of cervical cancer screening program in low resource setting (accepted abstract)
Teaching Radical Hysterectomy in a low resource setting (accepted abstract)
Cervical cancer treatment for operable lesions in a low-resource contemporary setting.


1. GLOBOCAN. (2015). Estimated cervical cancer incidence worldwide in 2012.