Aug 20, 2020
Dr. Frederick Chite Asirwa, a medical oncologist and director of the International Cancer Institute in Kenya, discusses the impact of COVID-19 on cancer care in Kenya and highlights how virtual training platforms adopted during the pandemic will shape oncology education in Sub-Saharan Africa in the future.
Transcript
ASCO Daily News: Welcome to the ASCO Daily News podcast. I'm Geraldine Carroll, a reporter for the ASCO Daily News. I'm honored to welcome Dr. Frederick Chite Asirwa to the podcast today. Dr. Asirwa is a medical oncologist and director of the International Cancer Institute in Kenya. He leads global cancer control programs in Sub-Saharan Africa and joins us to discuss the impact of COVID-19 on patients with cancer and lessons learned from the pandemic that are likely to inform the future training of oncology clinicians in the region.
Dr. Asirwa has received grant funding from Novartis, Roche, and
Takeda. Full disclosures relating to all Daily News podcasts are
available on our episode pages. Dr. Asirwa, it's great to have you
on the podcast today.
Dr. Asirwa: Thank you so much for having me.
ASCO Daily News: Can you first tell us about the
prevalence of cancer in Kenya and the capacity for diagnostics and
treatment?
Dr. Asirwa: Very well. Thank you so much for this.
So as you may be aware, cancer care and control in Sub-Saharan
Africa and in Kenya is no exception. It hasn't really been focused
on as much as it should have. In Kenya, it's just been about the
last six, seven years that the government has put some concerted
efforts in improving cancer care.
And as we talk, the numbers we are seeing are making diagnosis of
about 40,000 cancer patients a year. And we are losing about 28,000
patients on an annual basis, pretty much due to late stage of
presentation.
Now one of the things is that in Kenya, there has been a lot of
focus and emphasis on HIV, on TB, malaria, and then all of these
communicable diseases to the expense of non-communicable diseases.
And when the focus started shifting a little bit, I could see a
little bit being done on hypertension and diabetes. But cancer has
largely been left in the dark for several reasons.
And part of it is the comprehensive nature in which cancer care is
given, the multidisciplinary nature of it, and all of the expertise
that is involved in quality cancer care. And so we didn't really
have in-country training for medical oncologist or gynecological
oncologists and these other specialists in cancer care up until
about six years ago when we developed our own national cancer
control program with strategic plans on cancer care, and even
developed the national policy guidelines in terms of cancer
management.
So we see that the burden for cancer care has generally already
been on the rise and has been increasing. And although we are now
producing quite a few subspecialists in Kenya in terms of cancer
management like gynecological oncologists and medical oncologists
and clinical oncologists, still the numbers are not enough for the
number of cancer patients that we've been seeing.
ASCO Daily News: So you have cancer control
programs underway in Kenya and population-based research programs,
and then COVID-19 happens. How has COVID-19 impacted your patients
and the oncology care community?
Dr. Asirwa: COVID-19 has really impacted
negatively cancer patients and pretty much patients also with
non-communicable diseases, but cancer in particular. And there are
various reasons for that. When COVID-19 hit Kenya, there was mixed
messaging in terms of what is causing it and what do we need to do;
how do people protect themselves. So with that mixed messaging and
also there were the stay-at-home orders and lockdown that went into
effect, especially from the counties that really had higher numbers
of COVID-19 patients when testing began.
And so what ended up happening is that when you look at our
infrastructure in cancer care, there are very few centers that have
radiotherapy for cancer patients. And most of these centers are
concentrated in Nairobi. And Nairobi was one of the counties.
Nairobi is the capital city of Kenya. And it's one of those
counties that were locked out from the rest of the country. So
patients and people could not really travel across the borders to
Nairobi to access care.
And for those patients who were undergoing their care at the time,
there was a lot of confusion about what to do. And with the
messaging of stay-at-home and don't travel to any place, most of
the patients were calling from their houses and asking, what do we
need to do now.
And at the time, most of our hospitals and clinics had actually
closed to any non-essential services. And cancer had been
considered at the time as a non-essential service. And they were
only taking care of people either with fevers or COVID-like
illnesses.
And so we have a lot of patients that ended up missing several
clinic visits for their cancer care. There are patients who, even
now, have not returned back to the hospitals to continue with the
care that they had started. There are patients who are in between
getting their ideal therapy sessions that they had to discontinue
that.
And so, I don't really know so far how much impact in terms of
mortality we will end up having from this. However, my team at
International Cancer Institute are calling each and every patient,
especially those who missed at least one or two clinic visits, to
find out first if they're still alive and what is going on and how
can we assist them to access the care.
ASCO Daily News: Right. And can you tell me about
the stigma associated with COVID-19 in Kenya and how this is
impacting health care workers?
Dr. Asirwa: Oh, this is a huge problem. And part
of it, initially, was due to the fact that there were quite a
number of Kenyans who were afraid of going to the hospitals and
interacting with health care workers for fear of getting COVID-19
from the health care workers.
And then there was the issue of the stigma itself from health care
workers. It's very unfortunate that there are some health care
workers who would see a patient coming to the emergency room and
the moment they are tested and they have a fever, it could actually
be a neutropenic fever or a fever from any other cause, they would
actually leave the patient and run away.
And so we had a lot of confusion both from the health care workers'
side as well as the patient side. And that stigma really drove a
lot of the problems that we noticed in terms of lack of follow up
of clinic visits or even diagnostics and follow up of the cancer
patients that were being seen in clinics.
And I think that is improving a little bit. But I think we are
doing now more messaging that just practically says that we have a
little bit of a handle on what COVID-19 is and what we need to do
to protect ourselves. And we have centers that have now opened up.
We can continue seeing patients with cancer. However, patients with
other conditions that are thought to likely have COVID-19 are being
seen in different centers.
So there are all those things that are now being put in place. But
initially, we did not really have such kind of procedures that
could really help us in taking good care of this patient. And I
really think that that is part of the reason that we had a lot of
loss to follow up during this period.
ASCO Daily News: Right. And it's my understanding
that patients with cancer have been prevented from going for
treatment in some cases by security forces who will not let them
pass checkpoints, even though they have letters from their cancer
centers. What's that all about?
Dr. Asirwa: Yes. So that's a very good question.
So when we had the lockdown and restrictions of movement, sometimes
we would actually have a patient who you see in clinic and you
write a note (for them), hoping that the security forces will allow
the patient to move from one county to another where they are
crossing the county borders to get to the county that has either
radiation or imaging or where they can get proper care.
But most of these patients were being turned away because the
security forces were not honoring some of the notes that we had
written for these patients. There are few that we had to write; we
have a doctor who was receiving the patient call, and write a note.
And then the doctor who was referring, would write another note.
And the patient has a summary of the cancer diagnosis and
treatments. But still, they would be turned away. So that actually
ended up just compounding the issue of giving proper patient care
during this period.
And so we would call patients and ask them, have you actually gone
for your various diagnostics or treatments like we had recommended.
And they would say that even when we recommended this care and even
when they wanted to go for those treatments, they were still turned
away by the security forces on the roads because they had been
told, 'we don't want anybody to cross the borders from one county
to another.' And so they were just following that strictly.
ASCO Daily News: Well, the International Cancer
Institute has done great work to finesse the messaging to patients
about COVID-19. And the pandemic has paved the way for increased
collaboration in cancer care, thanks to telemedicine, virtual
meetings, tumor boards, and trainings. What has been your
experience with this?
Dr. Asirwa: So I would say that I've actually been
pleasantly surprised by the uptake of these virtual meetings, the
virtual tumor boards, and telemedicine in our setting. When this
pandemic started, International Cancer Institute was holding one
virtual tumor board a week during that time and have been doing
this for the last one.
However, we started holding multiple meetings and started doing
preceptorships in terms of cancer care where we have breast
preceptorships. These courses are usually six weeks to eight weeks.
And some of them, 10 weeks long. And it was very surprising,
actually, the uptick. And we have a lot of health care
professionals even from Nigeria, Ghana, South Africa, Kenya,
Ethiopia, Rwanda, Burundi that have been logging onto this online
platform and being part of not only the faculty for these courses,
but also being part of the participants in the courses.
So with this, we've noticed a lot of networking and collaboration
between various centers. And most importantly, we also have
established tele-clinics. And one of the things we've noticed is
that there are many innovative ways of getting around. Because our
patients still need to hear our voice. They still need to see their
doctors that have been taking care of them.
However, showing them that because of the travel restrictions,
perhaps, or the fact that we think it's safer, we don't really have
a lot of people at the clinic due to COVID-19 that we can link up
to the regional doctors. But then they can reach us through a
tele-clinic. It seems like they are really enjoying this and
thinking this is really a good idea. And I think these are some of
the things that should continue even past this COVID.
And the other thing is that now with increased virtual tumor
boards, we used to have 10 centers logged onto this virtual tumor
boards every week. Now we have more than 40 centers. And some
centers, it's a whole classroom that is part of the tumor
board.
I think there is a need for a lot more sites because then there are
so many presentations to be done. And we've expanded this to be
done twice a week on Mondays and Thursdays. However, every day we
have at least 8 to 9 virtual classes that we are holding with more
than 1,000 people logging on to our electronic learning platform at
any given time. I think this is mainly driven due to COVID-19. and
obviously the necessity to keep updated on knowledge and skills.
But most importantly, COVID-19 has made this to become more
functional.
ASCO Daily News: Absolutely. And scaling up this
kind of collaboration, especially the training, in a low resource
region is especially impactful and important.
I totally agree with that. And I couldn't agree more. When we are
looking at some of this technology related activities in terms of
increasing skills and training, we have always been thinking that
most of these centers are so poor. They do not have good internet
connection. The internet is so low. And we may not be able to do
this.
I think during this COVID-19 period, it has shown us that we can
actually be able to do this. And so this is really a positive
learning experience for us.
ASCO Daily News: Absolutely. Now COVID-19
has impacted your research as well. You are leading several key
research programs. Tell us how this has been impacted and how you
see the way forward?
Dr. Asirwa: So thank you for that question. Yes,
it has really impacted a lot of our work. So I'll just preface this
by saying that in our settings, we do a lot of population based
research where we are doing a lot of-- a lot to do with cervical
cancer screening. We have HPV or chemotherapy, radiotherapy,
teaching colposcopy in various centers so that we can collect data
about what is the best method of screening on a large scale.
So one of our programs, which is the Shining Tower Project, a
partnership with Roche and another program called Blueprint for
Innovative Access to Health Care Program, where we are partnering
with Takedo on the ground, is the fact that now we've had to change
our method of doing this work on the ground.
So initially, my team and I would go to a center and do community
screening. We do a lot of the health advocacy, working very closely
with community health workers and volunteers and the county
governments of those various counties. And we do a large event
where we'd have as many as 2,000 women show up for cervical cancer
screening and some for breast screening.
And so, one of the things we've changed with this is because of the
regulations and rules around congregating together and the social
distancing, it's very hard for us to do such a community event.
However, there are two things that are the reasons for that. One is
the ability that we can now start implementing the self collection
techniques for HPV screening for cervical cancer.
But we've also worked with various regional hospitals and we've
created in-facility screening services where patients are called by
patients navigators. And people who are participants for the
screening events are called and given specific times for
appointments to come for screening. We've noticed this, 2 of our 10
centers have had very good uptake of this service. And we are
thinking that we will do a lot of training and education in this
other sites so that we can work to increase to those sites as
well.
And then with the travel restrictions, we have multinational lung
cancer control program that I'm also the overall PI for. And this
involves five countries around the world and we cannot travel. So
we've been doing a lot of things on virtual platforms. Some
of the studies accrual has stopped a little bit. And now that we
are really getting a handle on how well to manage COVID-19 in spite
of the restrictions that are there in travel and congregating, we
are looking at better methods of implementing some of these
studies.
ASCO Daily News: Well, in the best of times, you
wear a lot of hats. You're an administrator, researcher, and an
oncologist. You're a thought leader in the region. And now you're a
crisis manager. How do you cope? It has been nonstop.
And it's my understanding, you have the names and numbers of 6,000
patients on your smartphone. Is that true?
Dr. Asirwa: It is actually. Thanks for this
question. It actually happened by mistake, initially. Because
regularly when patients come to my clinic and ask for my number, I
give them my number and not necessarily the clinic number. So I'll
tell them, here is the clinic number but also this is my personal
number. You can WhatsApp me, text me whenever there's any
question.
But then there was also a time I was having an interview on
national television. And I was asked what my phone number was and I
happened to give it when on TV. And so I have 6,000 plus numbers on
my phone.
And the question you ask is very true. One of the things that we're
experiencing the most in our setting is, first of all, we have very
few health care professionals dealing with cancer care even in good
times. And now we have to actually manage not only the cancer care
itself but all of this disruption that has been brought around by
COVID-19.
And in addition to that, the fact that you have patients that need
care but are really looking for that care and they want to come but
they can't come because of one reason on the other. And so we are
also having to manage the emotional states of the patients, not
only the ones who are getting diagnosed but also in treatment.
But there is always one thing that has always given me a positive
spin in terms of my work in global oncology. And that is always
when I see the gratitude of the patients when they come and say
that the care that you are giving them and even they know how much
your team and yourself are working hard to improve the quality of
life and of their families as well. That is always something that
drives me.
So the days we are low and we are huddled together as a team of
International Cancer Institute and our partners, and we will talk
about various things. And we have these meetings every Friday where
we talk about experiences during the week so that we can just
debrief. And if something has happened during the week that we need
to support our colleagues so that we can talk about this, we've
been doing this and mostly virtually now.
So I think, if anything, I think I'm lucky to work with the nicest
group of people, cancer patients, cancer survivors. I just find
them, they are very inspirational. And their outlook on life is
really illuminating. And for me, just the fact that you can be down
and one texts you and says, 'thank you so much for taking care of
my dad, or my dad was in pain last week but my dad is doing fine
now, or it's been 11 years since my dad was diagnosed with cancer,'
you know, those are some of the things that really keep us going.
So I think it's both ways. We derive so much of strength from the
patients that we take care of, I think, just as much as they derive
from us.
ASCO Daily News: Well, that is amazing. Dr.
Asirwa, is there anything else you'd like to add before we wrap up
the podcast today?
Dr. Asirwa: I'd just like to say that in our
settings, we are thinking about the physical needs of the cancer
patients that we see. But I also would like us to shine a light on
the mental and emotional needs that are not only for the cancer
patients and survivors, but also for the health care professionals
taking care of them.
And it's my hope that we could actually focus on this and really
improve that aspect of care as well. Because as much as we care for
our patients, also our caregivers, we've seen some of them having
burnout during this period. And because COVID-19 is with us and is
going to live with us for a very long time, we need to support each
other, network more, and figure out more innovative ways of
actually bringing the quality of care to the patients that need it
the most.
And for those communities or places in Sub-Saharan Africa or low
and middle income countries that think cancer care is not an
emergency during this time of COVID-19, I beg to differ. Because
for my patients, cancer care, whether it is early detection or the
screening components of it or the diagnostics, the work up, the
optimal therapies they are getting, the frequency of it, ensuring
of standards of care for me, and including palliative care, this
is something that we consider an emergency even in this
(pandemic) setting. The main goal for us is to share experiences
and see how well can we continue to optimally give this care to our
patients even through this COVID-19 pandemic.
ASCO Daily News: That's great. And I'll just
repeat, the research programs that you're working on include the
Blueprint For Innovative Access to Health Care Program and the
Shining Tower Project, a collaboration with Roche to personalize
care for patients with cancer. Thank you, Dr. Asirwa for sharing
your incredible insight with us today.
Dr. Asirwa: Thank you so much.
ASCO Daily News: And thank you to our listeners
for joining us today. If you're enjoying the content on the
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Disclaimer: The purpose of this podcast is to educate and to
inform. This is not a substitute for professional medical care and
is not intended for use in the diagnosis or treatment of individual
conditions. Guests on this podcast express their own opinions,
experience, and conclusions. The mention of any product, service,
organization, activity, or therapy should not be construed as an
ASCO endorsement.
COI Disclosure: Dr. Asirwa has received grant funding from Novartis, Roche, and Takeda