Scholarly article on topic 'Joining forces to overcome cancer: The Kenya cancer research and control stakeholder program'

Joining forces to overcome cancer: The Kenya cancer research and control stakeholder program Academic research paper on "Economics and business"

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Abstract of research paper on Economics and business, author of scientific article — Hillary Topazian, Mishka Cira, Sanford M. Dawsey, Joseph Kibachio, Lillian Kocholla, et al.

Abstract Background Cancer is the third leading cause of mortality in Kenya, accounting for 7% of annual deaths. The Kenyan Ministry of Health (MOH) is committed to reducing cancer mortality, as evidenced by policies such as the National Cancer Control Strategy (2011–2016). There are many Kenyan and international organizations devoted to this task; however, coordination is lacking among stakeholders, resulting in inefficient and overlapping expenditure of resources. Methods The MOH and the NCI Center for Global Health collaboratively executed a two day workshop to improve coordination among government, NGO, and private organizations. Over 80 stakeholders participated from leading cancer research and control institutions in Kenya and the international sphere. Findings Actionable recommendations include: establishment of a nationally representative population-based cancer registry; enhanced training for community health workers, nurses, researchers, pathologists, and oncology specialists; a reconfigured referral process, including leveraging of existing resources to improve access to cancer care; and coordinated community outreach and education. The MOH is in the process of forming a Technical Working Group (TWG) and has elected a Board of Directors for the newly established Kenyan National Cancer Institute (KNCI), with both entities committed to advancing the cancer control work of the MOH. Interpretation This stakeholder meeting enhanced in-country networks, identified priority needs and developed actionable proposals for coordinated improvement of cancer research and control. Active, persistent follow-up by the TWG, KNCI, and other partners will be needed to turn proposals into reality and ensure that partners' investments are integrated into larger cancer control efforts prioritized by MOH.

Academic research paper on topic "Joining forces to overcome cancer: The Kenya cancer research and control stakeholder program"

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Journal of Cancer Policy

journal homepage www.elsevier.com/locate/jcpo

Joining forces to overcome cancer: The Kenya cancer research and control stakeholder program

Hillary Topazian3, Mishka Cirab, Sanford M. Dawseyc, Joseph Kibachioc, Lillian Kochollac, Mary Wangaic, Jack Welch3, Makeda J. Williams3, Kalina Duncan a, Annette Galassi3'*

a U.S. National Cancer Institute, Center for Global Health, United States b U.S. National Cancer Institute, Division of Cancer Epidemiology and Genetics, United States c Ministry of Health, Kenya

ABSTRACT

Background: Cancer is the third leading cause of mortality in Kenya, accounting for 7% of annual deaths. The Kenyan Ministry of Health (MOH) is committed to reducing cancer mortality, as evidenced by policies such as the National Cancer Control Strategy (2011-2016). There are many Kenyan and international organizations devoted to this task; however, coordination is lacking among stakeholders, resulting in inefficient and overlapping expenditure of resources.

Methods: The MOH and the NCI Center for Global Health collaboratively executed a two day workshop to improve coordination among government, NGO, and private organizations. Over 80 stakeholders participated from leading cancer research and control institutions in Kenya and the international sphere. Findings: Actionable recommendations include: establishment of a nationally representative population-based cancer registry; enhanced training for community health workers, nurses, researchers, pathologists, and oncology specialists; a reconfigured referral process, including leveraging of existing resources to improve access to cancer care; and coordinated community outreach and education. The MOH is in the process of forming a Technical Working Group (TWG) and has elected a Board of Directors for the newly established Kenyan National Cancer Institute (KNCI), with both entities committed to advancing the cancer control work of the MOH.

Interpretation: This stakeholder meeting enhanced in-country networks, identified priority needs and developed actionable proposals for coordinated improvement of cancer research and control. Active, persistent follow-up by the TWG, KNCI, and other partners will be needed to turn proposals into reality and ensure that partners' investments are integrated into larger cancer control efforts prioritized by MOH.

Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://

creativecommons.org/licenses/by-nc-nd/4.0/).

CrossMark

ARTICLE INFO

Article history: Received 12 October 2015 Accepted 30 December 2015 Available online 4 January 2016

1. Introduction

Non-communicable diseases (NCDs) cause more deaths in low-and middle-income countries (LMIC) than all infectious causes, a reality that will be even more pronounced by 2030 [1]. In Kenya, an estimated 40,000 new cancer cases and 28,000 cancer deaths occur each year [2], making cancer the third leading cause of mortality and accounting for 7% of all annual deaths [3]. The Kenya Med-

* Corresponding author. E-mail addresses: htopazian@gmail.com (H. Topazian), mishka.cira@gmail.com (M. Cira), dawseys@mail.nih.gov (S.M. Dawsey), kibachiojoseph@gmail.com (J. Kibachio), Lilianak42@hotmail.com (L. Kocholla), mwangai@gmail.com (M. Wangai), Jack.Welch@nih.gov (J. Welch), willimak@mail.nih.gov (M.J. Williams), Kalina.Duncan@nih.gov (K. Duncan), agalassi57@gmail.com (A. Galassi).

ical Research Institute (KEMRI) documents that 80% of reported cases in the country are diagnosed at an advanced stage, leaving few options for remediation [3]. Late diagnosis, combined with the lack of and uneven distributions of cancer diagnosis and treatment facilities, personnel, and equipment, highlight the importance of a National Cancer Control Program as a fundamental next step for Kenyan policy.

The Kenyan Government has demonstrated commitment to reducing cancer mortality, as evidenced by policies such as the National Cancer Control Strategy (2011-2016) [3] and others [4-7]. Additionally, the Cancer Prevention and Control Act (2012) called for the establishment of a National Cancer Institute of Kenya (KNCI) to advise the Cabinet Secretary, collect and analyze research data, collaborate with partners, disseminate information, and support treatment facilities and training [8].

http://dx.doi.org/10.1016/jjcpo.2015.12.001

2213-5383/Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Table 1

Organizations represented at the Kenya Cancer Research and Control National Stakeholder Meeting.

Organization type

United States

Government

Kenya Ministry of Health Mombasa County government CDC KEMRI

US National Cancer Institute (NCI), NIH

Fogarty International Center, NIH

Centers for Disease Control and Prevention (CDC)

Research Institutions

Kenya Medical Research Institute (KEMRI) African Population and Health Research Center

The Epidemiology of Burkitt Lymphoma in East-African Children and Minors Project, NCI

Academia

Aga Khan University Moi University

Moi University School of Medicine University of Nairobi

Duke University

Indiana University School of Medicine

University of Alabama

University of Maryland

University of Massachusetts Medical School

University of North Carolina, Chapel Hill

University of Washington

Cancer care - Cancer Care Kenya - Denver Health

- The Nairobi Hospital

- Moi Teaching and Referral Hospital

- Aga Khan University Hospital

- Kenyatta National Hospital

- AIC Kijabe Hospital

- East Africa Public Health Laboratory Networking Project

NGO - Academic Model Providing Access to Healthcare (AMPATH)*

- Machakos Women

- Childhood Cancer Initiative

- Kenya Network ofCancer Organizations

- Kenya Cancer Association

- Kenya Hospices and Palliative Care Association

- Women 4 Cancer Early Detection and Treatment

- KEMRI-FACES (Family AIDS Care and Education Services)*

International - World Health Organization (WHO)

- International Atomic Energy Agency (IAEA)

- PATH

- University of Burundi*

* Partnership between US and Kenyan entities. t Burundi, East Africa.

Many other stakeholders are also involved in cancer work in Kenya. The US National Institutes of Health (NIH) and the US Centers for Disease Control and Prevention (CDC) collectively invested $160.1 M into Kenya's health sector from 2010 to 2012. Six US NCI-designated cancer centers are also partnering with research groups in Kenya, which include the Academic Model Providing Access to Healthcare (AMPATH), the Kenya Network of Cancer Organizations (KENCO), and KEMRI. The US President's Emergency Plan for AIDS Relief (PEPFAR) funding and the AMPATH Oncology and Hematology Institute have additionally provided support for cervical cancer screening and treatment program implementation.

Though many domestic and international organizations are committed to reducing cancer mortality in Kenya, a lack of coordination exists among these stakeholders. As a result, inefficient and over-expenditure of resources leads to little progress made in implementation of national cancer policies. The Kenya Cancer Research and Control National Stakeholder Meeting provided an opportunity for these groups to interact and develop coordinated action plans toward their shared goal of improved cancer research and control in Kenya.

2. Methods

To improve coordination among stakeholders, the Kenyan Ministry of Health (MOH) and the US National Cancer Institute (NCI) Center for Global Health (CGH) collaboratively executed a two-day in-country workshop to address national cancer control and research priorities. NCI CGH chaired a planning committee of staff

from the MOH, 6 NCI-designated cancer centers, and the US CDC. Current challenges were consolidated into 4 central Track themes: clinical research priorities and capacity building; cancer registries and pathology; cancer awareness, community engagement and stigma; and national health delivery infrastructure and access to care. Each Track was co-chaired by a representative from Kenya and a US planning committee partner. Co-chairs met weekly or biweekly in the 4 months preceding the meeting to gather necessary cancer control status information and to plan workshop sessions.

The meeting was structured to bring all stakeholders face-to-face to draft a tangible, multi-year action plan. Over 80 entities were represented, including the Kenyan government, the US government, Kenyan and foreign academic and cancer research and control institutions, private and faith-based hospitals, and nongovernmental organizations (NGOs) in the health and research sectors (Table 1). Partners from the International Atomic Energy Agency (IAEA) and the World Health Organization (WHO) also participated.

Sessions were structured as follows: Day 1 included a plenary session in which hospitals and organizations described the state of cancer control and care services at their institutions. Then the 4 Track working groups began separate discussions on their specific topics and their related action plans. Day 2 continued action planning in Track groups and included rapid-fire presentations of these plans to all meeting attendees. The meeting concluded with sessions on the importance and facilitation of partnerships and concrete next steps presented by the MOH. Follow-up calls were planned for 3,6,9, and 12 months (Table 2).

Table 2

Kenya Cancer Research and Control National Stakeholder Meeting recommendations and follow-up.

Progress to date

Long term goals

Clinical research priorities and capacity building

Cancer registries and pathology

Cancer awareness, community engagement, and stigma

National health delivery infrastructure and access to care

June-September 2015: formation of a cancer research advisory board; formation of a dedicated training working group to set national cancer research and control training priorities and capacity building needs September 2015: first cancer research advisory board meeting

April 2015: quality and needs assessment of the current population based cancer registries (PBCRs), to be followed by support of PBCR development and capacity building

June 2015-2017: 2 year trial ofthe CAP electronic forms and reporting module for gross and microscopic description and synoptic reporting of cancer specimens May 2015-September 2017: pathology resident-driven training of local hospital personnel in FNA/BMA collection and processing in select level 5 hospitals

August 2014-present: community education working group

May 2015-present: engagement with the American Cancer Society (ACS) to commence the Knowledge, Attitude, and Practice (KAP) process with MOH guidance May 2015-present: desk review in partnership with ACS: existing Information, Education, and Communication materials in Kenya

April 2015-present: developing cancer management protocols: priority cancer selection and committee membership

May 2015-present: developing Guidelines for Establishing a Comprehensive Cancer Center June 2015-present: coordinating dialogue: patient financing, childhood cancer consortium

Communication channel amongst in and out-of-country researchers

Integrate research into the national agenda and establish a cancer research advisory board to liaise through KNCI Convene panels to assess current programs research gaps

Identify capacity building needs, centralize training information

Conduct grant writing workshops, instruction in research management

Strengthen Kenya's three PBCRs and establish a new PBCR on the eastern coast (Mombasa) Develop hospital-based cancer registries in level 5 hospitals

Establish a National Population-based Cancer Registry Central Data Center, merging data from regional PBCRs Upgrade pathology services to create Centers of Pathology Excellence in select level 5 hospitals Expand pathology training opportunities

Coordinate knowledge sharing about community education efforts

Engage community leaders and members to identify key

drivers of stigma through KAP studies

Develop culturally appropriate messages to address

perceptions and knowledge gaps

Raise public awareness about cancer prevention and

early detection; reach 60% of the population by 2018

Leverage HIV/AIDS infrastructure (referral, transportation networks) established through PEPFAR Develop curricula for referral systems and training Include essential cancer drugs in the KEMSA drug list Support MOH to establish radiotherapy units, cancer treatment and palliative centers MOH fund chemotherapy through the National Health Insurance Fund

3. Recommendations

3.1. Track 1: Clinical research priorities and capacity building

Co-chaired by Dr. Esther Arthur Ogara (MOH), Dr. Patrick Loehrer (Indiana University Cancer Center) and Dr. Jack Welch (NCI).

Kenya is already a leader among African countries in publishing internationally recognized quality research in areas such as immunology [9]. Meeting participants recognized that the country also has the opportunity to excel in cancer research, given strong existing research institutions and willingness for collaboration.

The first step towards development of a domestic cancer research program is to establish a communication channel amongst in and out-of-country researchers. A Kenyan cancer research web portal will be a central resource to track all ongoing efforts, provide a repository for shared data, locate research gaps, function as a medium for scientific discussion, and coordinate future activities.

To make research results relevant to policy makers, a cancer research advisory board will be established, comprised of leaders from cancer-related constituencies such as researchers and patient advocates. This board will integrate research into the national agenda and will issue advisory statements every six months to the Board of Directors of the KNCI, which interfaces directly with the MOH to guide national cancer policy.

Stakeholders identified 4 common and actionable priority cancers for clinical research: cervical, breast, prostate, and pediatric. To

address these cancers, panels will convene to assess current screening, prevention and treatment programs, identify research gaps, and coordinate national research efforts. The resulting evidence will be published and disease-specific recommendations made to the cancer research advisory board.

To adequately fund cancer research in Kenya, stakeholders will perform and publish a costing analysis to inform policy makers about the cost of each desired program, fuel advocacy efforts to engage external funders to complement Kenyan funded initiatives, and potentially allow lawmakers to codify cancer funding into the national budget.

As the pool of Kenyan researchers is limited, nationally and externally sourced grants will be offered to encourage early career development and retain young researchers in Kenya. Grant writing workshops and instruction in research management will ensure that investigators have the resources to perform their work and to limit loss due to frustration over inadequate funding. These efforts will link with programs that will increase oncology content in medical and post-graduate training, and increase training for oncology sub-specialties and for specialties that support cancer research (e.g. radiotechnology and epidemiology). A number of international partner institutions currently offer research training programs in Kenya including the CDC Field Epidemiology Training Programs (FETP), the Integra Initiative, and several programs offered through the Fogarty International Center (FIC) of the NIH.

3.2. Track 2: Cancer registries and pathology

Co-chaired by Dr. Shahin Sayad (AKU), Ms. Ann Korir (KEMRI), Dr. Sanford Dawsey (NCI) and Ms. Annette Galassi (NCI).

Cancer registry and pathology stakeholders prioritized the strengthening and expansion of Kenya's three existing population-based cancer registries (PBCRs) located in Eldoret, Nairobi, and Kisumu. To achieve this goal, case ascertainment in the current catchment areas must expand and data quality improve to the 80-90% competence level defined as a minimum by the International Agency for Research on Cancer (IARC) [10].

As registries are currently staffed by volunteers or part-time employees, full-time workers will be hired to thoroughly collect case information. Health facility staff will undergo cancer and cancer registry training in order to increase awareness among hospital decision makers and those who will be referring cases to the registries.

As current records only capture populations in western Kenya and urban Nairobi, Stakeholders also prioritized the establishment of a new PBCRin the city of Mombasa on Kenya's eastern coast. The new registry will collect data on some of Kenya's eastern population groups, expanding the range and diversity of data available to researchers and policy makers. MOH will also encourage the development of hospital-based cancer registries (HBCRs) in Level 5 hospitals, with the goal of eventually upgrading these to PBCRs.

Finally, stakeholders recommended the establishment of a National Population-Based Cancer Registry Central Data Center to provide researchers and policy makers a more accurate picture of the true rates and trends of cancer incidence in Kenya. Funded and sustained by the MOH through the KNCI, this center will oversee the merging of data from the three existing and any future PBCRs.

To improve pathology services in Kenya, stakeholders recommended the upgrading of pathology practice in selected Level 5 hospitals outside of Nairobi, creating regional Centers of Pathology Excellence. As 50 of Kenya's 60 pathologists are based in Nairobi, most counties retain only a sole pathologist or none at all. As a first step towards improvement, quality and needs assessments will be performed at targeted Level 5 hospitals and individual pathology improvement plans developed for each of these centers. In addition, evidence-based standard operating procedures and tools will be developed and implemented to achieve standardized specimen handling, processing, and reporting of major cancers in the selected hospitals.

At these Centers of Excellence pathology residents will lead training of medical officers, surgeons, nurses, and technicians in proper collection and processing of fine needle aspirate and bone marrow aspirate specimens, to allow more accurate diagnosis and better patient care. Stakeholders also planned for the installation of telepathology systems to link these Centers of Excellence with the clusters of pathologists working at the University of Nairobi and Aga Khan University. This will widen the experience of pathology resident trainees and will give the Level 5 hospital pathologists access to consultations and continuing medical education (CME).

3.3. Track 3: Cancer awareness, community engagement, and stigma

Co-chaired by Dr. Mary Wangai (MOH), Dr. Natasha Buchanan (CDC), Ms. Mishka Cira and Dr. Makeda Williams (NCI).

A significant barrier to cancer control derives from misconceptions and stigma surrounding cancer etiology, prevention, screening and treatment. Stakeholders prioritized engaging key community leaders, developing and testing education tools, and carrying out additional Knowledge, Attitudes, and Practices (KAP) studies to identify existing cultural beliefs, drivers of stigma, and existing knowledge of cancer prevention. The KAP study

report will be adapted to target groups including women, men, community leaders, schools, religious leaders, underserved populations, providers, and community health workers. To address community education on cancer prevention and early detection, culturally-appropriate Information, Education and Communication (IEC) materials such as fliers, brochures, advertising messages, and posters will be developed, translated into local languages, and disseminated through appropriate channels identified through KAP study findings.

On a larger scale, a health education action plan will be created and health education mapped in various settings such as barazas, religious gatherings, women's groups, peer groups, and social mobilization campaigns through engagement of county health teams and community-based champions. The number of activities performed and number of people reached will be assessed on a quarterly basis and evaluated using a follow-up KAP survey. Stakeholders aim to raise public awareness about cancer prevention and early detection, with the goal of reaching 60% of the population by 2018. These efforts will reduce late presentation of cancer cases which leave Kenyans with palliative care as a sole option.

3.4. Track 4: National health delivery infrastructure and access to care

Co-chaired by Prof. Nicholas Othieno-Abinya (UoN), Dr. Linda Kupfer (FIC) and Ms. Kalina Duncan (NCI).

Radical devolution has placed the responsibility of healthcare on the county governments which struggle with a lack of clear referral systems, treatment protocols, financing, and expertise to diagnose and treat cancers at the county level. For example, Nairobi is the only place in the country with radiotherapy resources, with public services centralized at one hospital: Kenyatta National Hospital (KNH). To improve access to care, stakeholders prioritized greater leveraging of resources and HIV/AIDS infrastructure. Replicating the AMPATH-Oncology model, patients will utilize existing HIV/AIDS referral and transportation networks to obtain cancer treatment [11]. Access to care will further improve through standardization of protocols, curriculum development for referral systems, and incorporation of cancers into the current referral policy.

Stakeholders identified high treatment costs as a barrier to healthcare delivery. Patients admitted to KNH currently pay 1,500 Kenya shillings (Ksh) per week per bed, while private hospitals can charge up to 80,000 Ksh per week. CT scans and MRIs are priced at 10,000-30,000 Ksh, and chemotherapy treatment can require 30,000 Ksh per course [12]. Stakeholders will negotiate and lobby for the National Health Insurance Fund (NHIF) to cover chemotherapy and for the creation of a national cancer fund, to direct resources towards research that prevents and treats cancer.

To ensure that providers are able to appropriately screen and refer patients, an assessment of nurses and clinical officers will identify those groups in need of supplemental training. The National Guidelines for Cancer Management (2013) [7] and developed cancer treatment protocols will be disseminated to district hospitals to ensure standardization of procedures. To further improve treatment quality, essential cancer drugs must also be included in the Kenya Medical Supplies Agency (KEMSA) drug list as per the National Guidelines for Cancer Management (2013) [7]. It is also recommended that KEMSA source cervical cancer screen-and-treat supplies such as compressed gas-based cryosurgical equipment for the outpatient treatment of precancerous cervical lesions. These interventions and others will improve access to cancer care for patients for whom the healthcare system is currently inaccessible.

4. Discussion

4.1. Partnerships in cancer control and cancer research

Organizations often work independently from one another because of geographic separation, sector isolation (government, private, NGO, faith-based groups), and objective differentiation (research, training, screening, treatment). The Stakeholders' Meeting offered cancer organizations the unprecedented opportunity to coalesce and develop country-level action plans, moving towards shared goals of cancer control. The Meeting laid the foundation for the development of effective public-private partnerships to reduce cancer burden and improve cancer research and care in Kenya.

The partnerships engendered in this meeting can facilitate many policy initiatives, including the referral of patients between private and public sectors to increase access to cancer treatments. Utilizing the linear accelerator machine at a private hospital to provide radiotherapy to patients at the overburdened public hospital would reduce treatment delays and potentially improve outcomes. Collaborating on research studies between private and public organizations could increase sample sizes, reduce time for study completion, and construct a stronger base for analysis. For instance, in the months since the meeting, a Kenyan study of triple negative breast cancer was greatly enhanced through the use of specimens provided by private, public and faith-based hospitals [13].

These enormous benefits from partnerships also carry challenges in communication and cooperation. Stakeholder discussions highlighted distrust and cultural differences as obstacles to effective communication between North American and Kenyan partners. However, the biggest and most difficult barrier is likely financial, as many of the initiatives identified in the Track action plans are beyond the means of a single sponsor. This makes the formation of public-private partnerships critical to moving the cancer control agenda forward. Such partnerships leverage the strengths and financial assets of each organization and avoid wasteful duplication of efforts.

4.2. Human resources for health

While adequate human resources and infrastructure are necessary for the success of any cancer control initiative, Kenya lacks the manpower to support quality cancer research, prevention, early detection, treatment, and end of life care interventions for the entire population. Furthermore, oncology-specialization is rare: in 2012, Kenya had 6 medical oncologists, 4 radiation oncologists, and 3 oncology nurses for a population of 45 million. Relative to proposed numbers [7], a minimum deficit of 19, 11, and 47 staff remain, respectively. Despite this large gap, training programs are developing to meet this need. Moi University (Eldoret, Kenya) and the University of Toronto (Canada) are collaborating to develop an oncology nursing curriculum. The Higher National Diploma program in Medical Oncology at Moi University welcomed its inaugural class of clinical officers in the fall of 2013. Moi University, Aga Khan University Hospital and the University of Nairobi are also developing fellowships for medical oncology, incorporating research into the training program.

The need for additional cancer specialty training for clinicians and researchers was a pervasive theme amongst stakeholders. Priorities include medical oncology, radiotherapy, surgical oncology, oncology nursing, and pathology. Kenyan university coursework content should also include IRB and human subject protection, epidemiology, biostatistics, and prevention, diagnosis, and management of common cancers at community in-service and pre-service levels. Stakeholders suggested that academic institutions lead curricula review and mount training programs for medical specialists. The KNCI and MOH will assist by updating pre-service

curricula to include research methodology and epidemiology, with the option of an intercalated degree in research. In-service health workers will also receive training with the new curricula developed through this partnership. Increasing the workforce of cancer specialists and the cancer knowledge of other health system staff and community health workers will allow a greater number of ordinary people to access education about the basics of cancer and its prevention and treatment.

4.3. Kenya ministry of health initiatives

MOH is currently establishing mechanisms to ensure that the National Cancer Control Strategy (2011-2016) [3], the outcomes of the Stakeholder Meeting, and governmental and nongovernmental activities are pursued in coordination to minimize duplication of work and to maximize effectiveness toward achieving cancer control targets.

Aligning with the Cancer Prevention and Control Act (No. 15 of 2012) [8], MOH inaugurated the first Board of Trustees for the KNCI in February 2015. The Board is comprised of professionals from the fields of medicine, cancer advocacy, cancer research, philanthropy, law, finance, private sector development, and the media. The KNCI is mandated to advise the Cabinet Secretary on matters concerning cancer awareness, diagnosis, treatment and rehabilitation. This includes provision for increased public awareness about cancer, adequate access to cancer diagnosis and treatment, establishment of vocational training, coordination of cancer registration and research, and action on environmental and socioeconomic factors that contribute to cancer prevalence [8].

In order to further advance stakeholder objectives, a Cancer Control Technical Working Group (CCTWG) has been established since the Meeting, made up of technical experts working in cancer prevention and control. The CCTWG will serve as the coordinating body for cancer prevention and control activities and will report to the non-communicable disease inter-agency coordinating committee of the MOH and the technical arm of the KNCI. The MOH is in the process of finalizing the terms of reference and membership of the CCTWG.

4.4. NCI-supported post-meeting activities

NCI has also contributed to stakeholder coordination efforts through a short-term in-country consultant to MOH. This consultant supports policy development and coordinates communication mechanisms to minimize duplication of activities amongst partners. This includes the development of specific cancer treatment protocols for selected cancers in Kenya through the efforts of a multi-sectorial technical working group; the finalization of cancer management guidelines; and the establishment of a review and revision plan for the National Cancer Control Strategy (2011-2016) [3].

The College of American Pathologists (CAP) has partnered with a combination of stakeholders to provide a 2-year trial of the electronic Forms and Reporting Module (eFRM) for standardized gross and microscopic description, and synoptic reporting of cancer specimens. Training and implementation of the electronic system will commence at Aga Khan University and the University of Nairobi in the fall of 2015. In addition, these universities have collaborated to develop the Cytology Improvement Project, acquiring experts to train pathology residents in fine needle aspirate, bone marrow aspirate, and bone marrow trephine biopsy acquisition and processing. These residents will in turn conduct workshops at targeted Level 5 hospitals to train medical officers, surgeons, clinical officers, nurses, and technicians, continuing to support these programs for up to 5 years.

Multiple stakeholders have additionally formed a community education working group, comprised of representatives from the US NCI, US CDC, MOH and civil society. The group has engaged with the American Cancer Society (ACS) to commence KAP study development through MOH guidance and leadership. The working group has supported an ACS desk review of existing Information, Education and Communication (IEC) materials in Kenya, in order to better understand the current health messages being shared, and to assist in integrating the results of the planned KAP studies into dissemination efforts. Local and international cancer advocacy groups, such as the Kenya Network of Cancer Organizations (KENCO) and the Women's Empowerment Cancer Advocacy Network (WE CAN) will also be key partners for raising public awareness and cancer advocacy at the community level. To that end, the working group will develop a database of local and international cancer advocacy partners active in Kenya, to serve as a resource for networking, information sharing, and collaboration.

5. Conclusion

The Kenya Cancer Research and Control National Stakeholder Meeting enhanced in-country networks, identified priority needs and developed actionable proposals for coordinated improvement of cancer research and control that align with the priorities set by the Kenyan MOH [3]. Active, persistent follow-up by the TWG, KNCI, and both Kenyan and international partners will be needed to turn developed proposals into reality and achieve the goals of involved stakeholders. It is the hope that this meeting has served as a catalyst to accelerate cancer efforts in Kenya, and will serve as a model for future country stakeholder meetings, guiding partners towards a more unified approach to cancer research and control.

Acknowledgement

The U.S. National Cancer Institute Center for Global Health thanks our colleagues from the U.S. Centers for Disease Control and Prevention who provided invaluable assistance in the

planning and implementation of the workshop: Dr. Wences Arvelo, Dr. Natasha Buchanan, Dr. Mona Saraiya and Dr. Kevin DeCock, CDC Kenya Country Director. We also thank the many partners and organizations in Kenya and internationally, listed in Table 1, who helped direct and implement this workshop. Specifically, we thank the track co-chairs, Dr. Esther Arthur Ogara (MOH), Dr. Patrick Loehrer (IUCC), Dr. Shahin Sayad (AKU), Ms. Ann Korir (KEMRI), Dr. Natasha Buchanan (CDC), Prof. Nicholas Othieno-Abinya (UoN), and Dr. Linda Kupfer (FIC) who provided guidance and content to the agenda and leadership at the workshop and in the months beyond.

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