An Approach to Comprehensive Cancer Control in Low- and Middle-Income Countries: The Ugandan Model

Mar 08, 2022

By Alfred Jatho, BScPH, MPH, PhD; Solomon Kibudde, MBChB, MMed; and Jackson Orem, MBChB, MMed, PhD

Cancer is a major public health problem in Uganda. According to Globocan, in 2020, there were 34,008 new cancer cases, 22,992 cancer deaths, and 62,548 adults living with cancer in the country. The top five causes of cancer morbidity are cancers of the cervix, Kaposi sarcoma (KS), breast, prostate, and non-Hodgkin lymphoma; the top five causes of cancer deaths are cancers of the cervix, KS, esophagus, liver, and non-Hodgkin lymphoma.1 Children age 14 and younger constitute 10% of patients with cancer in Uganda.2 In Uganda, the risk of developing cancer before age 75 is 15.1%, while that of dying before age 75 is 11.3%. 
The basic components of cancer control are inadequate in Uganda, similar to other sub-Saharan African countries, where survival remains lower than in all other low-income countries.3 The Uganda Cancer Institute (UCI) has been mandated by the government through an Act of Parliament, The UCI Act of 2016, to undertake and coordinate the management of cancer and cancer-related diseases in Uganda.4 This spans the entire continuum of cancer control: primary prevention, early detection, diagnosis and treatment, palliative care, survivorship, and surveillance. In serving equitably the entire population of Uganda, UCI is in the process of establishing and operationalizing four regional cancer centers. Given the unique model it has shown in this aspect, UCI has been designated East Africa Centre of Excellence in Oncology for the East African community member states. 

Approach to Components of Cancer Control in Uganda

Health promotion and cancer prevention services 
The main risk factor driving the cancer burden in Uganda is infections such as HPV, human herpesvirus 8, HIV, hepatitis B virus, Epstein Barr virus, and H. pylori. Vaccination against HPV was rolled out in 2015, targeting girls at age 10. Vaccination against hepatitis B was introduced in 2010 and is fully integrated in the routine Uganda National Expanded Program on Immunization (UNEPI). 
Tobacco consumption is still relatively low in the country, but the habit is growing, hence Uganda enacted the Tobacco Control Act in 2015. Uganda is also a signatory to the World Health Organization Framework Convention on Tobacco Control. According to a national survey in 2014, tobacco use prevalence among the Ugandan population was 11%. Another risk factor being targeted is alcohol, with an adult alcohol consumption rate of 26.8%. There is active promotion of physical activity through schools and to the general public, with July 8 being designated a national day of physical activity. 
UCI monitors the impact of these measures through its Department of Comprehensive Community Cancer Programme (CCCP). Since 2009, CCCP has been conducting public cancer awareness and early detection services at UCI and in the community, at workplaces and places of worships such as churches and mosques. As part of a mass media cancer awareness drive, CCCP conducts radio and TV talk show interviews, as well as print media pieces. This is done in partnership with civil society organizations such as the Uganda Cancer Society (UCS) and its member organizations. One such organization, the Uganda Child Cancer Foundation (UCCF), reaches out to young people in schools to provide cancer health education and encourage the formation of cancer clubs, named Children Caring about Cancer (3Cs) clubs. 
The strategies that are being implemented to increase access to cancer awareness and early detection services in Uganda include integrating the cancer prevention services in existing regional and primary health care services, establishing regional and community cancer centers, and developing a comprehensive National Cancer Control Plan (NCCP). The NCCP addresses seven pillars and two key population-specific interventions: health promotion and cancer prevention, early detection, diagnosis and treatment, palliative care, cancer survivorship, cancer surveillance and research, policy and advocacy, cancer control in children, and cancer control in special interest groups (which includes people living with HIV/AIDS, people with albinism, people with disabilities, and refugees).
Early detection services 
Early detection of cancer comprises screening in asymptomatic populations and early diagnosis in symptomatic individuals. In Uganda, due to various patient- and health system-related factors, about 80% of patients with cancer present at a late stage for diagnosis. To increase access to screening services, in 2017 and 2018 UCI trained at least four district primary health care workers in 118 districts (out of the targeted 122 total districts in Uganda in 2017), starting with east-central districts, followed by other districts of Uganda.5 
Cancer management services (diagnosis, treatment, and palliative care) 
Elements of all modalities for cancer management are available at UCI (surgery, radiotherapy, chemotherapy, and palliation). There is a strong culture of multidisciplinary approach to cancer treatment. 
The oncology services provided in Uganda include medical oncology, gynecologic oncology, surgical oncology, pediatric oncology, radiation oncology, cancer therapeutics, palliative care, diagnostics (laboratory and radiology), research, and training. Historically, a tissue diagnosis is the entry point into cancer care at UCI; however, through the community cancer program, patients with suspected cancer are accepted for workup and subsequent treatment. The new patient care pathway comprises a sequence of five steps: (1) registration, triage, and first evaluation; (2) completing all cancer staging investigations; (3) review by oncologist and/or multidisciplinary team evaluation and treatment prescription; (4) cancer treatment administration; and (5) post-treatment response evaluation and follow-up.
Currently, nearly all staging workup is readily available, including complete blood count, blood chemistries, tumor markers, pathology review and immunohistochemistry, endoscopy services, and conventional imaging with CT. UCI plans to upscale imaging services with the installation of a modern MRI, and establish a Nuclear Medicine Center equipped with a single photon-emission CT (SPECT) and a PET/CT.
Increasingly, more patients are evaluated in the setting of a multidisciplinary team before initiation of oncologic treatment. Although there is a limited number of cancer specialists in the country, we are able to staff six multidisciplinary tumor boards (on breast, gastrointestinal, urologic, pediatric, gynecologic, and head and neck oncology) that meet weekly to discuss and make treatment recommendations.
Treatment services include adult hematology and oncology, pediatric hematology and oncology, surgical oncology, gynecologic oncology, and radiation oncology. Palliative care services are integrated throughout all the main disciplines.
The main challenge to the provision of palliative care is lack of access to cancer diagnosis, and eventually timely curative treatment services. However, as recommended by the Lancet Commission on Global Access to Palliative Care and Pain Relief, nearly all patients with cancer who reach hospitals in Uganda have ready access to an essential package of palliative care and pain relief services.6 Particularly, pain relief medicines are readily available and are prescribed by several cadres with training in palliative care as provided for by the government of Uganda.
To increase access to cancer care, UCI is decentralizing cancer care services by establishing Regional Cancer Centres in the western, northwestern (West Nile), northern, and eastern regions of the country.
Cancer survivorship services 
Support to cancer survivors is crucial in terms of rehabilitation to regain functionality, rebuild body image, and heal from psychological effects. In Uganda, there is a growing number of cancer survivors supported by civil society organizations (CSOs) under the umbrella of UCS. CSOs like the Uganda Women’s Cancer Support Organization (UWOCASO) have been supporting cancer survivors in different ways, including access to assistive devices, prostheses, and psychosocial health. In partnership with UCS, UCI involves cancer survivors in cancer control activities, and provides opportunities for cancer survivors who are willing to share their success stories to counsel and inspire others to adhere to preventive measures, early diagnosis, and to complete treatment, thereby leading to more survivors. 
Cancer surveillance and research 
Uganda has three population-based cancer registries: the Kampala Cancer Registry (KCR), Gulu Cancer Registry, and Mayuge Cancer Registry. These cover about 15% of Uganda’s population, or 5,484,353 people. KCR is the oldest population-based cancer registry in Africa, established in 1954. The registry has provided internationally published high-quality cancer data on the population of Kyadondo County. The Gulu and Mayuge registries were established in 2013 and 2015, respectively. The Mayuge Community Cancer Registry was fully operationalized in 2017 to capture, analyze, and report on information about patients with cancer in Uganda’s east-central region. These registries collect integrated data on cancer incidence for both adults and children. Two additional cancer registries are being established—the Arua and Mbarara Cancer Registries—to have five population-based cancer registries that will feed into the National Cancer Registry.
Training the Next Generation of Cancer Care Specialists in Uganda
To address the human resource constraints in cancer control in Uganda, and in the East African region overall, UCI, in collaboration with the Fred Hutchinson Cancer Research Center in Seattle and Makerere University and Mulago Hospital in Kampala, provides fellowships in adult hematology and oncology, pediatric hematology and oncology, and gynecologic oncology. This dynamic environment provides a rich educational resource for fellows trained through this program.
UCI has an ongoing plan to expand this training program to include other specialty areas such as radiation oncology and oncology nursing. UCI, as the East Africa Centre of Excellence in Oncology, has positioned itself as a training hub for cancer specialists across the continuum of cancer control.
Dr. Jatho is a community cancer health educator at the Uganda Cancer Institute, Kampala, Uganda.
Dr. Kibudde is a clinical and radiation oncologist at the Uganda Cancer Institute, Kampala, Uganda.
Dr. Orem is the executive director of the Uganda Cancer Institute, Kampala, Uganda. He is a member of the ASCO International Affairs Committee. Follow Dr. Orem on Twitter @JacksonOrem.
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  2. Sharma R. A Systematic Examination of Burden of Childhood Cancers in 183 Countries: Estimates from GLOBOCAN 2018. Eur J Cancer Care (Engl). 2021;30:e13438.
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  4. Uganda Cancer Institute Act. 2016. Available at: Accessed Dec 23, 2021.
  5. Jatho A, Mugisha NM, Kafeero J, et al. Capacity building for cancer prevention and early detection in the Ugandan primary healthcare facilities: Working toward reducing the unmet needs of cancer control services. Cancer Med. 2021;10:745-56.
  6. Knaul FM, Farmer PE, Krakauer EL, et al. Alleviating the access abyss in palliative care and pain relief-an imperative of universal health coverage: the Lancet Commission report. Lancet. 2018;391:1391-454.
  7. Merriman A, Mwebesa E, Zirimenya L. Improving access to palliative care for patients with cancer in Africa: 25 years of Hospice Africa. Ecancermedicalscience. 2019;13:946.
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