Uganda: Why Cancer Burden in Uganda Is Rising

Ms Hellen Owiny was diagnosed with breast cancer in 2015, forcing her to give up her teaching job in Lira Town to travel to Uganda Cancer Institute (UCI) for treatment.

She underwent mastectomy, which is the complete removal of the breast, and was later introduced to chemotherapy and radiotherapy to fight off any remaining cancer cells.

Ms Owiny later acquired a prosthesis (artificial breast slipped into a bra). The prosthesis is given at a free cost.

Currently, she prides herself to be one of the survivors of cancer and is a member of the Uganda Women Cancer Support Organisation. She attributes her recovery to strict adherence to medication.

But current statistics from UCI indicate that all cancers are on the rise, and deaths continue to occur.

According to referral guidelines for suspected cancer from UCI, the disease is on the rise and the cause of the trend is multi-factorial, ranging from environmental agents, lifestyle, infections and the HIV epidemic.

There are more than 60,000 cases of cancer per year in the country, of which 25,000 are incident cases.

Each year, about 22,000 deaths occur in the country due to cancer. In addition, the risk of cancer before the age of 65 years is 10 per cent, and in the next five years, it is estimated that there will be 80,000 cancer cases in the country at any one time.

The trends are also observed at the UCI, where almost 80 per cent of patients present the disease in advanced stages, hence limited interventions to prolong survival.

For all the common cancers, more than 50 per cent of patients present it with distant metastases.

This indicates the level of knowledge in the public and their perception of cancer, its symptoms, where to access treatment, and the care by the general practitioners is lacking.

Dr Noleb Mugisha, an oncologist at UCI, says different cancers are more common in different age groups and gender.

Dr Mugisha says the institute receives between 15 and 30 new cancer patients per day.

The 2018 Globocan statistics on cancer in Uganda, compiled by the World Health Organisation, indicate that 32,617 new cancer cases were recorded.

Of these, 18,068 were female while 14,569 were male. The number of cancer deaths stood at 21,829 of which 11,819 were among females and 10,010 in males.

Women

Cervical cancer is the commonest in women and among all the others in Uganda.

It is one of the preventable cancers because of the Human Papilloma Virus (HPV) vaccine. New cases of cervical cancer as of last year were 6,413, and the number of deaths stood at 4,301.

Dr Mugisha says the cancer is the most common because its risk factors are more prevalent.

He says the HPV is a strong risk factor among Ugandans. Its prevalence is about 34 per cent in women of reproductive age.

Dr Mugisha adds that cervical cancer is also highly associated with HIV, noting that once a woman has an infection, they are more likely to develop the disease than those who do not have HIV.

For a woman with suspected cancer of the cervix, the first symptom is an alteration in the menstrual cycle, intermenstrual bleeding, postcoital bleeding, postmenopausal bleeding or vaginal discharge.

Risk factors include persistent HPV infection, multiple sexual partners, high risk sexual partners, history of STDs (including genital warts), high parity, tobacco smoking, oral contraceptive use, chronic immunosuppression (for example HIV) and low socioeconomic status.

Breast cancer

Breast cancer is the second commonest cancer among women in Uganda.

However, Dr Mugisha says the cancer affects women and men of all ages, therefore, all women should be encouraged to undertake regular self breast exam and a clinical examination.

Often the first symptom is a lump palpable in the breast. However, not all patients referred with a breast lump are diagnosed with the disease.

Risk factors include personal history of breast cancer, increased breast density, increased age at birth of first child, treatment with hormone replacement therapy, family history of breast cancer, family history of ovarian cancer, tobacco smoking and alcohol consumption.

New breast cancer cases as of last year were at 2,318 and deaths stood at 1,076.

Other risks of cancer include obesity, high fat diet and the female sex hormone, which puts them at a higher risk developing the disease.

Breast cancer presents itself as a swelling in the breast, arm pits, nipple, bloody discharge, change of the breast skin, which has a resemblance of the orange peel.

Another risk is old age. As men and women grow older, the risk for getting cancer increases.

The risk in developing prostate cancer is directly proportional to the increase in amount of alcohol consumed.

The risk of developing breast cancer is high in the second breast. Sometimes the mutation could have developed already in the breast. If the first one has developed cancer, the second is likely to be infected.

Men

Prostate cancer is the commonest cancer among men in Uganda, and the leading cause of cancer mortality among men.

In 2018, there were 2,086 new cases of prostate cancer and approximately 1,177 deaths.

Risk factors include increasing age, family history, high fat diet, especially dairy products. The cancer is associated with minimal physical activity.

Signs of prostate cancer include difficulty in passing urine because of an enlarged prostate.

Men above the age of 40 years are at high risk to get the disease.

Children

At least 500 children are diagnosed with cancer every year at the cancer institute.

However, Dr Mugisha says there is a projection of 5,000 children with cancer across the country, which is about 10 per cent of what they receive at the cancer institute.

The commonest cancers in children currently are brain tumors, leukemia and lymphoma.

Non-Hodgkin lymphoma had 1,888 new cases last year and 1,341 deaths.

It presents with itching, night sweats and fever. On the other side, Non-Hodgkin's lymphoma typically shows a more rapid progression of symptoms, and may present itself with breathlessness, lymph nodes are non-tender, fever or weight loss of the axillary nodes are involved (in the absence of local infection or dermatitis)

Leukemia had 711 new cases in 2018, and 599 deaths.

Its signs and symptoms include sustained fatigue, continuing unexplained irritability, fever, any infection that does not resolve as expected, persistent or unexplained bone pain, unexplained bruises.

Brain tumors presented 432 new cases and 387 deaths as of last year.

Symptoms and signs include persistent headache as the primary one in children.

This is followed by vomiting, drowsiness, posture-related headache, blackouts, change in personality or memory.

Dr Mugisha says cancers in children have no risk factors.

"We appeal to all parents to be keen when taking care of children so that they are able to be checked for cancer as well. Cancers in children do not present specific symptoms and signs for certain cancers.

Cancer screening is not done in children but it can be identified early.

Commonest cancer in women, men

Kaposi's Sarcoma is the second commonest cancer among people living with HIV, and it is the third commonest cancer in either men or women in the country.

Last year, registered new cases stood at 4,238 and 2,159 deaths.

Risk factors include HIV infection and low social economic status and its sign is mainly severe anaemia.

Rare cancers on the rise

Cancer of the ovary is one of the cancers that affect women. It is a silent killer because it is hard to detect at an early stage.

It does not present any early signs and symptoms until its late, notes Dr Mugisha.

Ovarian cancer is the second leading cause of death from gynaecological cancer.

The incidence increases with age and the median age at diagnosis is 45 years and more than 70 per cent of the patients present it with advanced stage at diagnosis.

Common signs and symptoms include pelvic or abdominal, persistent abdominal bloating, loss of appetite, increased urinary urgency and unexplained weight loss.

Penile cancer is also on the rise. It is relatively among HIV-infected patients. Commonly, the disease presents with a painless lump or an ulcer on the penis. Its risk factors include HIV and HPV infection.

The symptoms may require an urgent referral for suspected penile cancer and progressive wounds particularly the skin of the penile shaft.

Cancer treatment and diagnosis

Dr Mugisha says every cancer has a screening test. However, not all cancers are screened but can be identified early.

For anyone interested in screening for cancer, he says is advisable to go to the nearest health unit.

He says most cancers can be treated in the country as long as they are still at an early stage, but if a patient prefers treatment abroad, they need to seek approval from the cancer institute because different countries have different health systems and laws.

Cancer treatment has five modalities; namely surgery, chemotherapy, radiotherapy hormonal therapy and immunotherapy.

Surgery

It involves medical personnel operating on the patients to remove the swelling or the part that has cancer.

Surgery is for early stages, but sometimes it is done late to improve the quality of life of a patient.

Chemotherapy

It involves administering drugs or injection to a patient to kill or arrest the growth of the cancer cells. The process treats cancers that have spread or late stage cancer.

Radiotherapy

This involves directing a high energy radiation beam to the body part affected to kill cancer cells in that area. It is not used to treat cancer that has spread.

Hormonal therapy

When some cancers progress or growth is mediated by hormones, such cancers are treated using hormonal drugs.

These may include tablets and injections. For instance, prostate cancer is treated using injections, while breast cancer is treated using hormonal tablets.

Immunotherapy

Dr Mugisha says some patients have cancers that respond better if their immunity is boosted.

For instance, Kaposi's Sarcoma is a cancer resulting mainly from HIV. When such patients are given ARV drugs, their immunity recovers and many cancers show regression. Some immune factors can be used in Lukemia.

Palliative care

It involves alleviating symptoms of a cancer patient to control the pain and other distressing symptoms. It also involves giving good care to a patient.

Dr Mugisha discourages patients from prescribing what treatment should be given. It is the medical personnel to determine which treatment options to give to the patient.

He also notes that every cancer drug has its side effects. Many cancer drugs cause hair loss, discolouring of nails, suppressing of the bone marrow, resulting into less blood in the body, vomiting, oral sores, diarrhoea, and fever.

Challenges in treatment

The Uganda Cancer Institute is currently faced with a challenge of inadequate diagnostic equipment, with most of the tests done in private facilities outside the hospital. This costs patients large amounts of money. For example, the institute's main radiotherapy machine currently performs below capacity, not withstanding breaking down on regular occasions.

The Cobalt 60 machine was installed in 1995 and has become less effective with its radioactive substance decaying off as a single patient takes long time while receiving treatment.

On a daily basis, the radiotherapy department receives about 100 cancer patients who need external exposure to radioactive waves to receive relief against cervical cancer, prostate cancer, breast cancer and other organ cancers.

Mastitis

How it happens. Mastitis is an inflammation of breast tissue that sometimes involves an infection. It occurs in women who are breastfeeding or have a crack on the skin around the nipple of the breast. The cracking into the breast results in inflammation and increased blood flow to the area. Sometimes mastitis may lead to an abscess, containing a collection of pus, which has to be surgically drained.

Common Cancers in Uganda

According to Referral Guidelines for Suspected Cancer, Uganda has different cancers clustered according to their groups below:

Cancer in HIV patients

Kaposi's sarcoma

Aids associated lymphomas

Children and young people

Burkitt's Lymphoma

Retinoblastoma

Leukemia

Lymphoma

Breast cancer

Upper Gastrointestinal cancer

Oesophageal cancer

Gastric cancer

Liver cancer

Pancreatic cancer

Gall bladder cancer

Lower Gastrointestinal cancer

Colorectal cancer

Anal cancer

Head and Neck cancer

Thyroid cancer

Gynaecological Cancer

Ovarian cancer

Endometrial cancer

Vulval cancer

Lung cancer

Genitourinary cancer

Prostate cancer

Renal cancer

Bladder cancer

Testicular cancer

Penile cancer

Skin cancer

Melanoma

Squamous cell carcinomas.

Basal cell carcinomas

Haematological cancer

Lymphomas

Plasma cell dyscrasias

Bone and soft tissue sarcomas

Bone sarcomas

Soft tissue sarcomas

Brain and CNS tumours

October free testing/ discounts

International Hospital Kampala: Prostate cancer at 30 per cent discount, HPV-V brush at Shs125,000, PAP smear (Cervical Cancer) 30 per cent, breast cancer physical examinations.

Alexander Medical Center: Free doctor's consultation and breast cancer screening, 50 per cent discount on cervical cancer screening (pap smear test) for two weeks.

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