Partnering for Answers to African Cancer

When Jackson Orem, MBChB, returned to Uganda in 2004 after oncology training in the United States, he faced a crisis. He was the new head of the 50-year-old Uganda Cancer Institute (UCI) in Kampala, the country's only cancer hospital, which was treating 10,000 patients a year.

As the only oncologist in Uganda, he was treating them all.

The lack of resources, Orem says simply, “was appalling.”

Over the years, Orem has recruited colleagues and gained significant government backing for the institute, which once again supplements patient treatment with training and research efforts. One key partnership came in an alliance with the Fred Hutchinson Cancer Research Center in Seattle, WA.

Orem was seeing patients in the UCI wards one day in 2005 when he got a visit from Corey Casper, MD, MPH, now an associate member of the Hutchinson Center's Vaccine and Infectious Disease Division.

A specialist in HIV-related and other infection-driven cancers, Casper was looking to gather patients for clinical trials as HIV diagnoses and HIV-related cancer subsided in the United States. Sub-Saharan Africa, where high numbers of cancers are driven by infection, was a logical place to look, and Uganda offered particular advantages for research.

“Uganda was 1 of 2 places in the billon people of sub-Saharan Africa that has a World Health Organization-certified cancer registry,” says Casper. “It actually takes quite an infrastructure to count cancer cases, and Uganda had been doing that successfully for over 50 years. The other unique thing was that in a country with the population the size of Canada, every single patient came to one place.”

On his trip, “we were all blown away by the magnitude of the problem of cancer in Africa,” Casper notes. “UCI had a single doctor, no cancer pharmacist, and one cancer nurse, who were treating 10,000 cancer patients a year in a facility that had intermittent electricity and no running water.”

“It was a place with a very high burden of disease, but it was also a place where even a very small intervention could make a huge difference and we could have very clear metrics,” he adds.

Today the UCI/Hutchinson Center Cancer Alliance, formed in 2008 and funded primarily by the U.S. National Cancer Institute, supports basic and clinical cancer research, medical and research staff training, and improved facilities.

“Research is the cornerstone of what we're doing,” says Casper. “That may seem strange, given the huge burden of cancer to patients there. In low- and medium-resource countries, we don't know how to deal with cancer effectively. We don't understand the biology of cancer in Africa, it doesn't respond the same way that treatments do here, and we don't have the same treatments available. We can't just take what we're doing here in the United States and stamp it on a plan in Africa and think it will make any difference.”

Some of the alliance's 25 current research programs study the natural history of infection-driven cancer, including how such infections are acquired and, in small subsets of people, how they develop into cancer. Other programs examine genetic variability among cancer patients and look at new models for care, such as combining viral treatments with chemotherapy.

Earlier patient diagnosis is key. “Throughout sub-Saharan Africa, one of the major limits in treating cancer is being able to diagnose it,” says Casper. It's not clear that this task can be done the same way in Africa as in the United States, he says; for one thing, health systems lack the screening and diagnostic infrastructure built up over decades in the United States. That calls for innovative approaches, such as seeing if the PCR facilities widely used in African cities for checking patients' HIV viral levels can be redeployed to diagnose leukemia as well.

For all of the alliance's projects, staff training is vital. “There are enormous research opportunities in Africa,” notes Orem. “To take advantage of the opportunities, western research institutions need to commit to training their colleagues here on the science so that we are all on the same page.”

Fred Hutchinson has done that in Uganda. “We have 40 people on the research team there, and every one of them had to be trained from the ground up,” Casper says. “That takes a lot of time, energy, and money.”

“No matter how many doctors and nurses you have, no matter how many medications you have, even if you have new strategies for dealing with cancer, the facilities in Africa have not been capable of dealing with cancer,” Casper comments. The alliance committed to building a new comprehensive cancer facility. Funded by the U.S. Agency for International Development and Fred Hutchinson, the $9-million, 3-story building will be fully set up for outpatient treatment, training, research, and pathology services.

Doing research in Africa brings plenty of difficulties, among them obtaining and maintaining basic requirements such as liquid nitrogen, Casper says.

Overall, however, “the research platform we've built in Uganda is equal or better than the platform we have in Seattle,” he declares. “There are incredible efficiencies in doing research in Uganda.” One huge plus is a 98% recruitment rate for patients in clinical trials; researchers can enroll more patients in Uganda in a single day than in a month in Seattle.

As the project develops new models of cancer care, the results may be applicable in low-resource settings around the world. “In Seattle, our city hospital just closed its only cancer treatment unit because it was too expensive,” Casper says. “We think there is an advantage in being able to study ways to treat cancer that are less expensive in places like Uganda and bring those back to the United States.”

UCI now sees 22,000 patients annually, and roughly 80–90% of them die within a year—a tragic level of mortality that is not uncommon in sub-Saharan Africa.

“The problem of cancer in Africa is so overwhelming, and you can easily get despondent about it, but you can look for the small victories and make sure you achieve them while you are looking for the longer victories,” Casper comments. In a joint program like the UCI/Hutchinson alliance, “you have to have a partnership in the true sense of the word, realizing what you are willing to bring and what you can expect from your partner.”

“Our collaboration prides itself on being bi-directional; each of us brings the best that we can offer,” says Orem. “The key ingredient is mutual respect.” –Eric Bender