East Africa

Africa is facing an unprecedented growth in cancer burden. By 2030, 1.27 million new cancer cases per year are expected, with 0.97 million expected deaths. While there is no population-based cancer registry in Tanzania to provide reliable data on the country’s cancer burden, Tanzania estimates that it will see approximately 44,000 new cancer patients per year. Currently, demands for cancer care at the national referral center, Ocean Road Cancer Institute (ORCI), far exceed available services, and the number of new cases is steadily increasing, doubling between 2006 and 2013 alone.

UCSF’s partnership with Tanzania’s Muhimbili University of Health and Allied Sciences (MUHAS) began in 2005, with funding from the Bill & Melinda Gates Foundation, to support cultivation of a strong national health workforce in East Africa. During the following years, this partnership between UCSF and MUHAS expanded to include additional collaborative activities in the areas of emergency medicine, surgery, orthopaedics, and oncology. In the area of cancer research, Dr. Katherine Van Loon, Global Cancer Program Director, began working with Dr. Elia Mmbaga of MUHAS in 2011 to examine esophageal cancer in Tanzania, and their partnership has since expanded to include biostatistical, epidemiologic, genetic, genomic, virologic, and laboratory studies. In 2017, they cohosted a meeting of UCSF and MUHAS stakeholders in Dar es Salaam to formally launch the MUHAS-ORCI-UCSF Cancer Collaboration across multiple cancer disciplines. During this meeting, a collaborative needs assessment identified priorities for the collaboration across a variety of specialties, including pathology, radiology, oncology, nursing, and surgery, and participating Tanzanian faculty highlighted the critical need for cancer research training and mentorship. The MUHAS-ORCI-UCSF Cancer Collaboration has since initiated partnerships and projects across all of these specialties, and the teams are focusing significant effort on cancer research education and mentorship for trainees. 

The MUHAS-ORCI-UCSF Cancer Collaboration employs a full-time Tanzanian program manager and three full-time Tanzanian research coordinators to support all Collaboration projects and activities in Tanzania. 

Current Projects: 

Cancer Research Training Program in Tanzania

UCSF Investigator: Katherine Van Loon, MD, MPH

Tanzania Investigator: Elia Mmbaga, MD, PhD, Muhimbili University of Health and Allied Sciences (MUHAS)

The Cancer Research Training Program in Tanzania will be implemented at MUHAS in Dar es Salaam and leverages a longstanding relationship between MUHAS and UCSF. Dr. Elia Mmbaga, Associate Professor in the Department of Epidemiology and Biostatistics emphasizes, “This D43 could not have come at a better time than now when the newly established [non-communicable diseases] program at the Ministry of Health needs evidence to inform cancer control policies in Tanzania." This program will leverage existing training programs at MUHAS and will also build further institutional support by expanding the training activities and strengthening the pool of mentors at MUHAS. Read more. 


Determinants of Esophageal Cancer in Tanzania

UCSF Investigator: Katherine Van Loon, MD, MPH

Tanzania Investigator: Elia Mmbaga, MD, PhD, Muhimbili University of Health and Allied Sciences (MUHAS)

Eastern Africa faces a disproportionately high age-standardized rate of esophageal cancer. Together, Dr. Katherine Van Loon from UCSF and Dr. Elia Mmbaga from Muhimbili University of Health and Allied Sciences (MUHAS) lead a multi-disciplinary team of researchers from MUHAS, Muhimbili National Hospital (MNH), and Ocean Road Cancer Institute (ORCI) in Dar es Salaam focused on understanding the clinical burden and etiology of this high-incidence disease in Tanzania.


Evaluation of the GeneXpert Breast Cancer STRAT4 Assay for Point of Care Analysis of Breast Cancer Biomarker Status from Fine Needle Aspiration Biopsies in Tanzania (GX-BCB)

UCSF Investigator: Dianna Ng, MD

Tanzania Investigator: Edda Vuhahula, DDS, PhD, MUHAS

Breast cancer hormone receptor status is critical in determining patient prognosis and treatment. However, identification of breast cancer biomarkers in Tanzania is currently limited by reagent shortages, lack of trained staff, and long processing times. This project aims to validate the GeneXpert Breast Cancer STRAT4 assay as a tool for the evaluation of breast cancer biomarkers from fine needle aspiration specimens obtained from patients in Tanzania through assessing rates of misclassification and describing the impact of a rapid biomarker assay for determination of hormone receptor status on breast cancer care in a low-resource setting.


An Ethical Approach to Routine Tragic Choices: Radiotherapy Allocation in Rwanda

UCSF Investigator: Rebecca DeBoer, MD, MA

Nearly every radiotherapy machine in sub-Saharan Africa and in low- and middle-income countries (LMICs) worldwide is over-burdened with more patients in need than can possibly be treated. Patients are generally treated based on ability to pay rather than clinical need, so those who can benefit most—whose lives are likely to be saved by radiotherapy—routinely lack access. This project aims to describe the experience of radiotherapy allocation at Butaro Hospital in rural Rwanda using mixed methods, to develop and implement fair deliberative process for radiotherapy priority setting at Butaro Hospital, and to revise radiotherapy prioritization guidelines using rigorous application of ethical theories. The prioritization guidelines that will be developed through this project can be directly applied in LMICs with similar disease burdens and healthcare barriers. The new protocol for fair deliberative process may be used broadly in other resource-limited settings, to refine the radiotherapy prioritization guidelines for a specific context or to set priorities for other limited resources, such as chemotherapy and biologic drugs. This project’s examination of explicit rationing may also inform priority setting in high-income countries in context such as drug shortages, intensive care unit beds, and waiting lists in socialized healthcare systems.


Improving shared decision-making about palliative cancer therapy in Tanzania

UCSF Investigator: Rebecca DeBoer, MD, MA

At Ocean Road Cancer Institute (ORCI) in Dar es Salaam, Tanzania, physicians and nurses have identified decisions about palliative cancer therapy as among the most difficult clinical and ethical challenges they face on a day-to-day basis. The goal of this project is to explore this challenge and develop a context-appropriate decision tool to support oncology providers who treat cancer patients in low-resource settings.


Implementation of Tanzania's National Cancer Treatment Guidelines at Ocean Road Cancer Institute

UCSF Investigators: Katherine Van Loon, MD, MPH, Rebecca DeBoer, MD, MA, Geoffrey Buckle, MD, MPH, and Tracy Kuo Lin, PhD

Tanzania Investigators: Jerry Ndumbalo, MD, MBA, and Stephen Meena, MD, MMed, Ocean Road Cancer Institute (ORCI)

Adherence to standard treatment guidelines is key to addressing global disparities in cancer mortality: in low-income countries, the overall case fatality from cancer is estimated to be 75%, compared with 46% in high-income countries. In 2017, leaders from Ocean Road Cancer Institute (ORCI) participated in the joint effort with the National Comprehensive Cancer Network (NCCN) and African Cancer Coalition to develop cancer treatment guidelines six cancers and two supportive care categories for Sub-Saharan Africa. Contemporaneously, ORCI also  drafted Tanzania’s first edition of its National Treatment guidelines. In April 2018, leadership of the Committee for Tanzania’s National Cancer Treatment Guidelines visited UCSF to refine these guidelines with expert reviews by over 30 UCSF sub-specialist. This project supports the initial implementation phase of these guidelines at ORCI, with the overall objective of evaluating the feasibility and effectiveness of a theory-informed implementation strategy to facilitate adoption of guideline-based clinical practice at ORCI.


Management of esophageal cancer in East Africa: a prospective cohort study of treatment strategies and supportive care

UCSF Investigator: Geoffrey Buckle, MD, MPH

Despite emerging research on esophageal cancer in East Africa, limited data exists on optimal management strategies for advanced disease in this resource-limited setting. This prospective observational cohort study is at thee sites within the African Esophageal Cancer Consortium (AfrECC), including Ocean Road Cancer Institute (ORCI) and Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania and Tenwek Hospital in Bomet, Kenya. The project aims to describe the types of treatments administered for all patients diagnosed with esophageal cancer, evaluate the effect of different esophageal cancer treatment modalities on patients’ quality of life during and after completion of treatment, and measure the effect of different treatment modalities on overall survival at six months.


Validation of Estrogen Receptor Immunohistochemistry of Breast Cancer on Cell Block at Muhimbili National Hospital

Tanzania Investigator: Asteria H. Kimambo, MD, MUHAS

In Tanzania, breast cancer is the second leading cause of cancer mortality among women. The clinical management and prognosis of breast cancer depend critically on the hormone receptor status, including estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). At Muhimbili National Hospital (MNH), breast cancer biomarkers are determined by immunohistochemistry but are performed only on surgical specimens, requiring invasive and expensive procedures that are subject to suboptimal handling and long turnaround times. Fine needle aspiration biopsy is a minimally invasive and cost-effective procedure that can be performed at the bedside and can be used to collect material for cell block for ancillary studies, such as breast cancer biomarkers. Several past studies have shown comparable immunohistochemistry results for ER, PR, and HER2 between cell blocks and surgical specimens. In addition, performing immunohistochemistry on cell block can decrease turnaround time for breast cancer biomarker results, thus reducing delays in treatment and allowing patients to be eligible for life-prolonging and accessible hormone therapies more rapidly. This study hypothesizes that concordance for ER expression evaluated on cell block compared with corresponding histologic specimen will be greater than 90%.


Accelerating Radiation Oncology at Ocean Road Cancer Institute using Machine learning-based Assistance - Cervix (AROMA-C)

UCSF Investigator: Melody Xu, MD


Evaluation of Factors Related to Delay in Imaging Presentation of Women with Breast Cancer in Tanzania

Tanzania Investigator: Lulu L. Sakafu, MD, MMed RAD, MUHAS

Breast cancer is the second leading cause of cancer death in women worldwide. While breast cancer is widely prevalent in both developed and developing regions, the prognosis is far worse in low- and middle-income countries, where women are typically diagnpsed at more advanced stages. In Tanzania, approximately 80% of women are diagnosed at stage III or IV, when treatments are much less effective and mortality is high. In wealthy countries, like the United States, the standard of care is to immediately refer patients for diagnistic breast imaging evaluations as soon as signs and symptoms of breast cancer, such as a palpable lump, are recognized. It is well know that delay between onset of breast symptoms and the diagnosis and treatment of breast cancer is detrimental to survival. The aim of this study is to evaluate the extent and factors involved in the delay between symptom onset and diagnostic imaging evaluation of breast cancer in Tanzania. Specifically, this study will: 1) Assess the psychosocial factors associated with late presentation of imaging services in Tanzania; 2) Determin how breast cancer information and perception contributes to late imaging; 3) Assess how health seeking behavior, preference for alternative treatment, culture, and norms contribute to late breast cancer imaging; and 4) Assess knowledge and skills in breast cancer imaging among medical doctors attending breast cancer patients. 

African Esophageal Cancer Consortium (AfrECC)

UCSF Investigators: Katherine Van Loon, MD, MPH, and Geoffrey Buckle, MD, MPH

Esophageal cancer is the sixth most common cause of worldwide cancer death, with very high incidence of esophageal squamous cell carcinoma (ESCC) occurring throughout the eastern corridor of Africa, from Ethiopia to South Africa. During the past several years, several groups have initiated studies of ESCC at sites in sub-Saharan Africa. In 2017, these groups recently joined together to form the African Esophageal Cancer Consortium (AfrECC) to share expertise, infrastructure, and resources. MUHAS, ORCI, and UCSF lead AfrECC activities in Tanzania.


Efficacy of an Intensive, Ultrasound-Guided Fine-Needle Aspiration Biopsy Training Workshop in Tanzania

UCSF Investigator: Dianna Ng, MD

Tanzania Investigator: Edda Vuhahula, DDS, PhD, MUHAS

In January 2019, faculty from the UCSF and Muhimbili University of Health and Allied Sciences (MUHAS) Departments of Pathology and Radiology collaboratively organized and led an ultrasound-guided fine-needle aspiration biopsy (FNAB) short course at MUHAS. This workshop was the second FNAB short course facilitated by UCSF at MUHAS, and it was designed for pathologists, radiologists, and residents in Tanzania to improve their technical skills in ultrasound-guided FNAB . The course consisted of case-based presentations and hands-on practice, focusing on sampling technique and basic ultrasounds skills. Course attendees included many individuals who had taken part in the previous course, held in Fall 2017, as well as many new attendees.

Characteristics, Treatment Modalities and Survival of Colorectal Cnacer Cases Presenting at Muhimbili National Hospital and Ocean Road Cancer Institute in Tanzania. 

UCSF Investigators: Katherine Van Loon, MD, MPH, and Geoffrey Buckle, MD, MPH

Tanzania Investigator: Beatrice Mushi, MD, MPH 

Colorectal cancer (CRC) is the third most commonly diagnosed malignancy and the fourth leading cause of cancer death in the world, accounting for approximately 1.4 million new cases and almost 700,000 deaths in 2012. Enormous disparities in colorectal cancer exist globally, including access to screening, early diagnosis and treatment services. The 5-year survival rate for people with colorectal cnacer stands at 65% in the US. The characteristics and survival rate of CRC in Tanzania, where the majority of cases present at an advanced stage, have not been previously studied. 

Efforts to improve and reduce CRC burden begins with knowledge of the disease and precise estimation of its magnitude and survival rate. This study will ensure information is captured in its entirety, leading to results that will reflect the true picture of the magnitude, characteristics, treatment modalities and survival of CRC in Tanzania. 

Implementing and Evaluating a Palliative Wound Care and Palliative Care Nursing Educational Program at Ocean Road Cancer Institute 

UCSF Investigators: Stella Bialous, Stephanie Kennell-Heiling, Kim Baltzel, Linda Abramovitz

Tanzania Investigators: Nazima Dharsee, MD PhD; Mary Haule, CN

Nurses at Ocean Road Cancer Institute (ORCI) manage primarily malignant fungating and post-surgical wounds, caring for 30-45 wounds daily. With 270 inpatient beds and multiple outpatient departments, palliative wound management is a large component of the daily nurses’ activities at ORCI. Similarly, many patients arrive at ORCI in advanced stages and require a palliative care plan.

This nursing capacity building project has a two-fold purpose: 1) to deliver a 2-module training (one in palliative wound care and one in palliative care) to 40 nurses caring for cancer patients in Dar es Salaam, Tanzania; and 2) to support the development of local oncology nurse mentors at ORCI to sustain practices learned in the training, including implementation of a palliative wound management nursing assessment & management tools.

The education will be sustained through the implementation and evaluation of a nursing protocol on palliative wound care and palliative care that will be supported by the identification of local nurse mentors, who will become a local resource in the long term. With support from the UCSF team, nurse mentors will be responsible for implementation, monitoring and evaluation of the program impact, using two key indicators: 1) wound care charting, using the wound assessment and management tools developed by ORCI nurses in partnership with UCSF nurses; and 2) medication administration to assess pain management in palliative wound care and palliative care. 

Understanding the Burden of Human Papilloma Virus-Associated Oropharyngeal Head and Neck Cancer in Tanzania

UCSF Investigator: Mary Jue Xu

Tanzania Investigator: Aslam Nkya

Worldwide, head and neck cancers are the 7th most common malignancy accounting for 20,000 deaths yearly. Among head and neck cancers, head and neck squamous cell carcinoma (HNSCC) accounts of 90% of head and neck cancer. HNSCC have been traditionally associated with tobacco and alcohol abuse, however is a rising prevalence of HNSCC associated with human papilloma virus (HPV) in Western countries. While epidemiologic studies of the prevalence of HIV and HPV in HNSCC patients have been well described in Western populations, the majority of the existing burden of HIV-associated malignancies continues to be in low and middle-income countries (LMICs). Although the use of highly active anti-retroviral therapy (HAART) in HIV-infected populations has decreased incidences of cancers such as cervical cancer, lymphomas, and Kaposi sarcoma, there have been little data to support its impact on the incidences and risk reduction in HPV-related HNSCC. This study will assess the overall rates and subtypes of high-risk human papilloma virus oropharyngeal squamous cell carcinomas in Tanzania. This study will also identify the risk for HPV infection among head and neck squamous cell carcinomas in relation to HIV-status, tobacco use, alcohol use, sexual practices, and oral health in Tanzania.