16 I KENYA NATIONAL CANCER SCREENING GUIDELINES
GLOBAL CANCER BURDEN
Cancer incidence and mortality rates continue to rise globally, with an estimated 18.1
million new cases and 9.6 million deaths in 2018.The detailed cancer patterns in different
world regions, however, are complex. Majority of cancers occur in low-and middle-in-
come countries (GLOBOCAN 2018; WHO, 2017). The number of new cases is expected
to rise by about 70% over the next two decades, with significant and rising economic
effects. The direct and indirect economic costs related to the prevention and treatment
of the cancer globally were approximately $1.16 trillion in 2010 (WHO, 2017).
Lung cancer is the most commonly diagnosed cancer (11.6% of the total cases) and the leading cause of cancer death (18.4% of the total cancer deaths) among both sex- es combined. This is closely followed by female breast cancer (11.6%), prostate cancer (7.1%), and colorectal cancer (6.1%) for incidence and colorectal cancer (9.2%), stomach cancer (8.2%), and liver cancer (8.2%) for mortality. Globally, among males, lung cancer is leading in incidence and mortality, followed by prostate and colorectal cancer (for incidence) and liver and stomach cancer (for mortality). Among females, breast cancer is the leading type of cancer in incidence and mortality, followed by colorectal and lung cancer (for incidence), and vice versa (for mortality); cervical cancer ranks fourth for both incidence and mortality (GLOBOCAN 2018).
The incidence and mortality for various types of cancer, however, substantially vary across countries and within each country. This depends on the degree of economic de- velopment and advancement of healthcare, associated environmental, sociocultural factors, and lifestyle factors, among others.
Global Incidence & Mortality rates (Age-standardized) for top 10 cancers
It is noteworthy that high-quality cancer registry data which would form the basis for planning and implementing evidence-based cancer control programs, are not available in most low- and middle-income countries (LMICs). Even then, the scanty data is enough to trigger action to prevent and control cancer.
In Kenya, cancer is the 3rd leading cause of death after infectious and cardiovascular
diseases. The annual incidence of cancer was estimated at 47,887 new cancer cases,
with an annual mortality 32,987 in 2018. Among men, prostate, oesophageal and col-
orectal are the leading cancers, while among women, breast, cervical and oesophageal
cancers are most common. The leading cause of cancer death in Kenya is oesophageal
cancer contributing 13.2 % (4,351 deaths) of cancer mortality. Cervical cancer is the sec-
ond leading cause of cancer death contributing 10% (3,266 deaths) while breast cancer
comes in third at 7.7% (2,553 deaths) (GLOBOCAN, 2018).
Estimated number of new cancers in Kenya among all ages, both males & females, GLOBOCAN 2078
Estimated number of cancer deaths in Kenya among all ages, both males & females, GLOBOCAN 2078
Late-stage presentation when cure is difficult to achieve is a common problem here in Kenya as is the case in many LMICs (WHO, 201Bb), where diagnostic and treatment services are inadequate or non-existent (WHO, 2017). Data from Kenyatta national Hospital shows that between 2014 and 2016, approximately 64% of cancer patients were diagnosed at stage III or IV, when treatment for cure is difficult to achieve. Cancer registration and surveillance in Kenya has been suboptimal. Currently, there are two (2) established regional population-based cancer registries in Eldoret and Nairobi covering an estimated 10% of the Kenya population. For childhood cancers, low awareness and stigma amongst parents/guardians and caregivers leads to late presentation of patients to cancer treatment centres (Njuguna, 2016). Amongst oth- er factors that contribute to poor outcomes are limited diagnostic facilities with in- sufficient equipment, personnel and consumables.
While about a third to half of cancers can be prevented, the cancer burden can be significantly reduced through early detection and management of precancerous con- ditions. However, there is low uptake of screening services in Kenya. For example, uptake of cervical cancer screening is 16% among women aged 30-49 years, which is disproportionate to the awareness on availability of the screening services which is 47% among women (STEPS survey, 2015; Ng’ang’a et al., 201B). This is unfortunate since some of the leading cancers can be detected early through screening.
The first pillar of the Kenya National Cancer Control Strategy (NCCS) 2017-2022 focus- es on Prevention, Early Detection and Cancer Screening. Early detection can result in better treatment outcomes, less morbidity and even lower costs of treatment. It can be achieved through early diagnosis and through screening. For certain types of can- cer, screening increases the chances of early detection. Screening programmes can be effective for certain cancers when suitable tests are utilized competently with quality assurance incorporated followed by linkage to diagnosis and treatment.
EARLY DETECTION OF CANCER
Early detection of cancer greatly improves the possibility of treatment being success-
ful and cure being achieved. Early detection implies detection of disease at an early,
pre-symptomatic stage when a client would have no reason to seek medical care – an
intervention referred to as secondary prevention.
There are two major components of early detection of cancer:
1. Early diagnosis
This is an important public health strategy that can have great impact in Kenya where
most patients present at advanced disease stages. It focuses on detection of symptom-
atic patients as early as possible through the recognition of possible warning signs of
cancer in order to take prompt action. It can be achieved by increasing awareness of
possible warning signs of cancer, among health care providers and among the general
public through education. The aim is to improve treatment outcomes by providing care
at the earliest possible stage.
Early diagnosis of cancer involves 3 steps:
1. Improving awareness and access to care
2. Building diagnostic capacity and improving referral mechanisms
3. Improving access to timely cancer treatment by addressing
the relevant barriers
The following table shows some signs and symptoms associated with certain cancers that can aid in early diagnosis of these cancers. Health care providers should recognize these as possible warning signs of cancer and take prompt action to diagnose these cancers early.
|CANCER||SIGNS & SYMPTOMS|
|Cervix||Post-coital bleeding, excessive vaginal discharge|
|Breast||Lump in the breast, asymmetry, skin retraction, recent nipple retraction, blood-stained nipple discharge, eczematous changes in areola|
|Colorectal||Change in bowel habits, unexplained weight loss, anaemia, blood in the stool|
|Stomach||Upper abdominal pain, recent onset of indigestion, weight loss|
|Urinary bladder||Pain, frequent and uneasy urination, blood in urine|
|Prostate||Difficulty in urination, frequent nocturnal urination|
|Head & neck cancers||Lump in nose, throat, or neck (with or without pain), persistent sore throat, difficulty swallowing (dysphagia), persistent cough, hoarseness or change in voice, ear pain or hearing loss, persistent headaches, persistent bad breath not explained by hygiene, nasal obstruction or persistent congestion, difficulty breathing, frequent nose bleeding or unusual discharge,|
|Oral cavity||White lesions (leukoplakia) or red lesions (erythroplakia), growth or ulceration in mouth|
|Retinoblastoma||White spot in the pupil, convergent strabismus (in a child)|
Cancer screening involves applying simple tests or procedures across a healthy popula-
tion in order to identify unrecognized cancer disease in individuals before they develop
any symptoms of the cancer. The goal of screening is to find asymptomatic individuals
who have abnormalities that indicate that they could be having a pre-cancerous condi-
tion or a specific cancer and then link them promptly with the appropriate diagnostic
care and treatment. Successful screening requires having adequate human resource to
perform the screening tests and availability of facilities that can undertake subsequent
diagnosis, treatment, and follow-up.
Principles for screening
The following are some of the recommended prerequisites that must be in place before establishing screening programmes:
• The disease prevalence must be high enough to justify the
expenditure on screening
• The screening programmes must have been proven to be effective
• Availability of adequate resources such as equipment and human re
sources to cater for most of the entire target population group should
• Availability of confirmatory diagnostic facilities and treatment facilities
for those who screen positive.
It is unlikely that the country will realize the full economic benefit potential of screening
through encouraging individuals to seek specific tests regularly or through maintaining
cancer detection as part of routine medical practice (WHOa, 2018). Screening, by itself,
has no actual preventive value and must be linked to treatment. If such a link can-
not be implemented, then the screening programme is likely to have no impact on
the incidence of cancer. All the activities along the continuum of patient care must
be implemented in a coordinated manner. These include community mobilization,
screening, diagnosis, referral, treatment and follow up. In addition, functioning of
other key components must be assured, including awareness creation, health educa-
tion, effective collaboration and networking between providers and different levels
of the health care system, a well-functioning quality control and quality assurance
programme; monitoring and evaluation, advocacy and resource mobilization.
Implementation of a prevention and screening programme can have positive outcomes in terms of the quality of the health-care facilities and services, including improved in- frastructure, updated training of health-care providers, increased health awareness, and establishment of a quality control and quality assurance programme (WHOa, 2018).
GUIDELINE OBJECTIVES AND TARGET GROUP
These guidelines are meant to standardize cancer screening, provide operational
protocols and improve the outcome of cancer screening and treatment by stream-
ing referral along the levels of care in Kenya. They are to serve as a general guide
for health care providers in selecting the appropriate tests for their patients and
should be applied through an individualized patient-centered approach. They are
not intended to be a basis upon which patients seeking screening services are denied
their right to be screened.
They are designed for use by all cadres of health care providers (doctors, nurses and clinical officers -among others) across the KEPH levels of the health care system. Strengthening of the referral systems is important to ensure optimal services to the clients.
PANEL SELECTION AND COMPOSITION
The guideline development panel was constituted by the Ministry of Health – National
Cancer Control Program (NCCP) and comprised program officers from NCCP and sub-
ject-matter expert teams from academic institutions, health research organizations,
relevant civil society organizations as well as cancer specialists from various cancer
treatment centers and representatives from the county departments of health. The
panel held several consultative meetings and workshops that culminated in the de-
velopment of the working draft, which subsequently underwent external review and
validation, before publication of this final version of the guidelines.
The process started with a desktop review to identify available cancer screening guide-
lines, both locally and globally and especially in contexts similar to Kenya. Relevant re-
search publications, existing international guidelines and guidance statements from
several cancer care organizations globally were also obtained and reviewed in order
to formulate these guidelines. Local context was considered and expert opinion em-
ployed where there was paucity of evidence. The information is stated in clear, concise
statements that can guide cancer screening activities at all levels of healthcare provision
SCOPE OF THE GUIDELINES
These guidelines cover cancer types that are major contributors to cancer morbidity and
mortality in Kenya and are amenable to screening as per currently available evidence.
These include cervical, breast, colorectal, prostate, oral, childhood and esophageal can-
cers. They address the early detection of these cancers, including aspects of early diag-
nosis where relevant.
GLOBOCAN, 2018: Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics
2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA
Cancer J Clin [Internet]. 2018 Sep 12 [cited 2018 Sep 24]; Available from: http://doi.wiley.com/10.3322/
Ministry of Health K. Kenya STEPwise Survey for Non Communicable Diseases Risk Factors 2015 Report;
2015. p. 8-210. Available from: http://aphrc.org/wp-content/uploads/2016/04/Steps-Report-NCD-2015.
Ng’ang’a, A., Nyangasi, M., Nkonge, N., Gathitu, E., Kibachio, J., & Gichangi, P. et al. (2018). Predictors of cervical cancer screening among Kenyan women: results of a nested case-control study in a nationally representative survey. BMC Public Health, 18(S3). doi: 10.1186/s12889-018-6054-9
Njuguna F., Martijn H., Langat S. et al. Factors Influencing Time to Diagnosis and Treatment among Pedi- atric Oncology Patients in Kenya. Pediatric Hematology and Oncology 2016; 33:186-99
World Health Organization (2018a): Cancer Screening for various cancers. Retrieved from https://www. who.int/cancer/detection/variouscancer/en/
World Health Organization (2018b): Early Diagnosis and Screening. Retrieved from https://www.who. int/cancer/prevention/diagnosis-screening/en/
World Health Organization 2017: Cancer Factsheet. World Health Organization: Cancer. (2018). Retrieved from http://www.who.int/mediacentre/factsheets/fs297/en/
World Health Organization 2017: Cancer Control Knowledge into Action-WHO Guide for Effective
Programmes :Module 3