Africa has one of the highest cancer death rates in the world, yet this could be markedly improved by better access to treatments already widely available in high-income countries for the continent’s biggest killers – breast, cervical, lung and prostate cancers and Kaposi sarcoma.

This is according to a recent study by the Botswana-Rutgers Partnership for Health, which researched which cancer treatments that are effective in other regions could have an impact in sub-Saharan Africa (SSA) – but are not available or hard to get.

Cancer is in the top three causes of premature death in the vast majority of countries in SSA. Without significant intervention, annual deaths are projected to nearly double between 2020 and 2030, reaching about one million by 2030.

In high-income countries “the rapid evolution of precision oncology therapies is increasingly transforming the length and quality of life for cancer patients”. But in SSA “basic levels of cancer care, treatment and palliation are limited”, the study notes.

As a result, Africa’s cancer patients have “poor survival outcomes across most malignancies”. In 2020, Africa’s cancer incidence made up 5.7% of global cases, but its cancer mortality was 7.2% of global deaths.

There is a 30% survival rate for children with cancer in low-income countries in comparison to over 90% for children in high-income countries, WHO Director-General Dr Tedros Adhanom Ghebreyesus noted recently.

Access to high-impact treatments

“Cancer is threatening sub-Saharan African populations to a degree that demands a large-scale response,” said Richard Marlink, the director of Rutgers Global Health Institute and a study author. 

“This guidance provides a framework for how to improve access to the life-saving and life-altering medications that are proven to work. The high-impact treatments available elsewhere are needed in this region of our world.”

While there is a dearth of accurate data about cancer in the region, the study used cancer registries and other studies to get a sketch of the cancer burden.

Cervical Cancer

Cervical cancer is the leading cause of cancer-related death in women in SSA. For patients with advanced cervical cancer, the standard of care is chemotherapy in conjunction with radiation therapy. 

But a study of 29 oncology treatment centres in 12 SSA countries found an inconsistent supply of cisplatin, a preferred chemotherapy drug as well as limited access to radiation therapy.

In addition, access to radiotherapy is limited access due to a lack of trained personnel and equipment and equipment maintenance.

Breast Cancer

Data from cancer registries show that breast cancer incidence is rising in nine countries in SSA. For example, in Harare (Zimbabwe) there has been a 4.9% average annual increase in the incidence of breast cancer and a 4.5% increase in Kampala (Uganda).

Mortality rates in southern Africa are “among the world’s highest due to late-stage presentation and lack of screening programs”, according to the study.

In a population-based registry study of 834 patients in 11 countries in SSA, only one-third received chemotherapy.

Breast cancer patients are also not routinely tested to determine their specific hormonal profiles, which means that “treatment may not include precision targeting, which is available in high-income countries where profiling capabilities are more accessible”.

“Treatment for breast cancer greatly differs based on hormonal status and human epidermal growth factor (HER2) expression status,” the study notes.

HER2-positive breast cancer is one that tests positive for the protein HER2, which promotes the growth of cancer cells. Treatments that specifically target HER2 are very effective.

Hormonal therapy with the drug tamoxifen is recommended for HER2 tumours. Tamoxifen is inexpensive or even free in some countries, so it may be prescribed even if the patient’s hormonal profiling has not taken place. This could harm the patient and provide no therapeutic advantage.

But even when hormonal profiling is available, the medications that have proven to be most effective “may be cost-prohibitive to obtain” – such as trastuzumab, which targets HER2. 

“Another barrier is that immunotherapy, using drugs such as atezolizumab and pembrolizumab, requires specialized monitoring and management protocols that usually aren’t available in this region,” the study notes.

Prostate Cancer

A leading cause of cancer death among men is prostate cancer, particularly in southern Africa where there are approximately 66 cases per 100,000 (more than double the rate recorded in West and East Africa).

Prostate cancer is also increasing. For example, in Kampala, Uganda, an average annual percentage increase of 5.2% was found between 1991–2010.

Treatment with surgical castration to remove the testicles is widespread in sub-Saharan Africa, yet “newer generation oral hormone therapy may have an expanded role in the region”.

Abiraterone with prednisone therapy is an oral hormone therapy that can improve outcomes. This is included on the World Health Organization’s Essential Medicines List, and is “expected to be available through multiple generic options and that reduced pricing is in the foreseeable future”. 

Molecular profiling, which isn’t readily accessible in the region, could also assist to identify patients with metastatic castration-resistant prostate cancer and develop treatments appropriate for them. Androgen deprivation therapy can provide symptom relief and improve survival.

Kaposi sarcoma

While Kaposi sarcoma (KS) is relatively rare worldwide, it is more common in people with weakened immune systems and has increased 20-fold in SSA since the 1980s alongside the HIV/AIDS epidemic.

Antiretroviral treatment has reduced the incidence of AIDS-associated KS, but there is still “ongoing significant morbidity and mortality from KS in the region”, according to the study.

This cancer, caused by infection with human herpesvirus-8, manifests in patches of abnormal tissue growing in the body, especially under the skin, in the lining of the mouth, nose and throat; and in lymph nodes. 

Since most cases of KS are associated with HIV, the study notes that “it is imperative for all patients living with HIV to receive antiretroviral therapy”. 

The medicine, Paclitaxel, can be used to treat advanced KS and is “much more affordable and readily available in SSA” than other medicines.

The World Health Organization’s (WHO) updated Essential Medicines List (EML) released last week includes a new KS treatment, liposomal doxorubicin.

The study also notes the lack of interest in studying new therapies for KS, despite the significant burden of disease in the region. The first large clinical trial in more than a decade that compared chemotherapy drugs used to treat Kaposi sarcoma in SSA took place in 2020. 

Lung Cancer

In high-income countries, molecular targeted therapies for lung cancer have achieved substantial survival benefits – but the equipment and trained personnel to do this are lacking in SSA.

Increased affordability and marketing of tobacco products in sub-Saharan Africa is expected to increase lung cancer. The researchers emphasised the need for more advanced pathology capabilities in the region to improve precision diagnostics and therapeutics. 

Improving access is a ‘moral need’

“We recognize that costs and cost-effectiveness concerns are important factors in realistically increasing availability of a broad range of oncology drug therapies in SSA,” the study notes.

“The moral need, however, to advance therapeutics and reduce the significantly high case-fatality rates from cancer in SSA remains an urgent global imperative.”

“High drug costs are a major challenge to bridging the stark inequities in access to cancer treatments,”  said lead author Kirthana Sharma.

“To optimize cancer treatment in this region, diagnostic and laboratory infrastructure also needs to be strengthened, and the oncology workforce needs to be further trained and developed.”

The Botswana-Rutgers Partnership for Health is a collaboration between Botswana’s Ministry of Health, the University of Botswana and Rutgers Global Health Institute. Botswana’s cancer mortality rate exceeds 63%, and the partnership is engaged in efforts to strengthen the country’s health systems and provide comprehensive, patient-centred oncology care.

Image Credits: Roche, Cecille Joan Avila / Partners In Health, Flickr: Marco Verch Professional Photographer and Speaker.