The Cancer Burden in Kenya

The Cancer burden has become a huge steadily emerging Public Health concern that at large continues to receive minimal priority in Africa especially in the Sub Sahara even though the incidence of cancer in the region has markedly increased.(Kimani et al, 2017). In 2012 alone according to Parkin et al, 2014), the incidence of cancer in Africa was 6% (847000 new cases) with a mortality of 591,000 cases of which 75% of the global burden was in the Sub Sahara Africa. Prostate cancer in men and Breast cancer in women are the commonest cancer in the region. Furthermore, it is estimated that in the next decade more than 20 million people will be diagnosed with cancer annually with over 70% of the global death to occur particularly in the Sub Sahara Africa and other low income countries in which 82% of the world population lives (Kimani et al., 2017). This increase will therefore necessitate a huge demand for professionals in the care and treatment of cancer more importantly in cancer induced pain. However many Sub-Sahara countries have not yet prepared to address this epidemic. Thus there is a huge unmet need to scale up the uptake of cancer screening, early diagnosis, treatment and palliative care services in the region(Zubairi et al., 2017) (Kimani et al., 2017).

Data from the Kenya Demographics and Health Survey of 2014 also shows that cancer is the second leading cause of death besides cardiovascular disease among the non communicable diseases with a national case mortality rate of about 7%. The Kenya National Palliative Guidelines 2013 also estimates that over 28000 new cancer cases are diagnosed annually and 22100 people die of cancer each year. More so, Kenyans below 75 years are at a 17% risk of getting cancer and a 12% risk of dying from it (Ali, 2016). At Moi teaching and Referral Hospital the second largest hospital in Kenya, data extracted from the Eldoret cancer registry at Moi University estimated that about 5336 patients were diagnosed with cancer from 1996 to 2006. On average about 671 cancer cases were diagnosed annually. Solid tumours being the commonest in the region and accounted for 79% of the cancer patients however a slight difference in the pattern of the diseases was noted. Unlike elsewhere Ca. esophagus was the commonest cancer in the region while Ca. Cervix and Ca. Prostate were the commonest in females and males respectively. Hence therefore like elsewhere in the globe, cancer still poses a huge significant Public Health burden at MTRH and Kenya as a whole.(Tenge, Kuremu, Buziba, Patel, & Were, 2009)

On the other hand however, the bone is the third most common site of metastatic disease after the liver and lungs with the axial skeleton i.e. spine being the most commonly affected. A joaquim 2015 kassamali 2010 These metastases to the bone still possess a huge challenging orthopedic oncology problem despite the advances and innovations in treatment modalities today. Kassamali 2010XX) It is estimated that over 60 to 84 % of all metastatic cancer patients will eventually develop bone metastases and more than 40% of these will get spine metastases. A joaquim 2015 lee 2011 Annually approximately 5% of the cancer patients get spine metastases. kassamali 2010 Spine metastases are commonly associated with numerous Skeletal Related Events that chiefly include axial or radicular pain, pathological fractures, spinal cord compression and hypercalcaemia. These associated Skeletal Related Events pose a significant burden of morbidities in patients with spine metastases that they can adversely reduce the patients” quality of life and consequently even shorten survival.lee 2011 With advances in cancer treatments, survival time has greatly improved even in patients with bone metastases which in return has lead to an increase in number of patients surviving with spine metastases and associated cancer induced bone pain. Curtin 2016 laredo 2017 a joaquim 2015

Spine metastases are most common in elderly patients. The age range for patients with spine metastases is between 40 to 60 years. Men aged above 60 are at a higher risk of getting spine metastases than women of the same age group.max 2003 These are usually patients with advanced cancers of the breast, prostate, lungs and or kidney that account for about 85% of all metastases cases. felice 2017 This stage usually marks the terminal stage of the disease where palliative care and pain control are the best holistic treatment approaches. (XXXXX) The role of palliative care here is not of a curative purpose but aims to improve the quality of life of the patient, assessment and treatment of pain and physical and spiritual problems. (WHO) Since pain is the most common and important morbidity in cancer patients with spine metastases xxxxxx, it is therefore important to adequately assess and manage pain in these patients because patient survival and improvement in quality of life have been greatly linked to optimal pain and symptoms control in cancer patients. (Milgrom 2017) Laredo 2017

With advances and innovations in the comprehensive cancer care and cancer treatment modalities (that is to say palliative radiotherapy, surgery, chemotherapy) in the globe, there has been enormous improvement in the ability to decrease tumor recurrence rates, quality of care and life, improve pain control and reduce the need of pain medications. Actually many cancer patients with spinal metastatic bone disease are now able to survive for long. The median survival for a patient with a solitary spine metastasis is more than 24 months compared to 3 months in liver metastases. Curtin 2016 felice 2017 However cancer induced pain remains the major symptom and cause of morbidity in these patients kassamali 2017 who often receive inadequate management for their pain which can be devastating to their quality of life. The breast 2013 Spine metastases are the commonest causes of this pain and worse still up to 85% of patients with spine metastases are estimated to be having varying degrees of pain. (Milgrom 2017) In 2017 K.N Kimani et al reported that one study conducted in Kenya found many cancer patients suffered with unrelieved pain which became increasingly intolerable as the disease advanced and as patients approached their end of life. And despite the fact that there has been increased globe awareness for cancer pain, little progress has been made in cancer pain treatment. vision

Numerous studies have broadly shown the effectiveness of these modalities in controlling and treating metastatic spine pain and their indications, benefits and limitations discussed in details. However few publications have tried to compare the superiority of these modalities over the others in controlling metastatic spine pain of cancer patients. Therefore it is significantly important that such a study be carried out to in order optimize pain management in cancer patients in a resource limited centre like MTRH as it is looking forward to establishing a comprehensive cancer care centre. Since at this stage of the disease the overall goal is usually to assess and treat pain, and restoring function during the remaining life span of the patient even though cure is usually not a realistic treatment outcome for spine metastatic disease. Nonetheless I am very confident that such a study will have a huge positive impact on the quality of life of patients surviving with spine metastases at MTRH.

With such limited resources at MTRH there is always a prior need to prioritize when choosing an optimal treatment modality for managing cancer induced pain hence for this reason it is always justifiable why such a study need to be carried out. This is solely because these treatment modalities still remain scarce and not readily available in the Sub Sahara. For instance K.N Kimani et al in 2017 reported that Africa has the lowest global coverage of radiotherapy with two thirds of its 277 radiotherapy machines located in only South Africa and Egypt. That only 5% of the cancer patients in the Sub Sahara have access to Chemotherapy and the region still has the lowest global consumption of opiods analgesics. Morphine consumption stands at 0.39mg per capita below the world average of 6.24mg. We can therefore note that a huge percentage of cancer patients in the region receive inadequate pain management even when cancer induced pain is a huge cause of morbidity and death. Therefore in order to give a general scope of this problem, evaluate the heath service for cancer patients at MTRH and be able to involve influence policy that will see the development of an integrated cancer care system in Kenya, I believe it is important that such a study evaluating the effectiveness of these modalities in pain management of patients with spine metastases at MTRH. I truly believe that this study will not only improve patient care but it will also provide a basis for future research in orthopedic oncology and pain control at Moi University and Kenya. It will also be of a very huge public significance which can attract further funding.

I must precisely state that even though the measure of pain in cancer patients is complex as in context it does not only entail the sensory component but rather also the psychosocial aspect of pain evaluation. (Willamson et al 2014). It is important to note therefore that for the purpose of this study I will only assess the clinical physical pain dimension alone and will exclude pain due to psychosocial factors such as fear, anxiety and depression. The effectiveness of a given cancer treatment modality will be evaluated and assessed basing on the patient’s response to pain which will be determined using the international consensus on bone metastases standards that account for changes in pain scores and analgesics use. ( GW. Paulien et al 2017, E Chow et al 2012)