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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.



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 podcast, please take a moment to rate and review us on Apple podcasts.

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