Title: NIHR Global Health Research Group for Improving Oesophageal Cancer Survival in Kenya: The Hub and Spoke Model
Funder: Department of Health and Social Care

Abstract: The Kenyan Ministry of Health is committed to reducing the incidence of cancer with a systematic and coordinated approach. Early diagnosis and accurate staging are key for optimising treatment and outcomes. Successful breast and cervical cancer screening programmes have been launched within a new National Cancer Control Strategy. To further improve cancer outcomes in Kenya and East Africa, the Ministry of Health, Kenya have reached out to and signed Memoranda of Understanding with The Christie NHS Trust and University of Manchester in January 2020. At the direction of President Kenyatta, a long-term partnership was subsequently established with Kenyatta University Teaching, Referral and Research Hospital (KUTRRH).In Kenya, oesophageal squamous cell carcinoma (OSCC) is the third most common cancer with the highest mortality of all cancers at 4400 deaths per year and a case fatality rate of 99.3%. This is thought to be due to late recognition of symptoms by the patient and general practitioner, with consequential delays in diagnosis and inevitable presentation as incurable, advanced disease. Kenyan healthcare researchers tasked Manchester researchers to understand the unique needs of the Kenyan oncology ecosystem and effectively partner with them to decrease OSCC mortality. This NIHR Research Group application supports this joint partnership using early detection of OSCC as a research exemplar._x000D_ There remain key outstanding questions for our joint research programme:_x000D_ How can local engagement be optimised to refer individuals with symptoms to local endoscopy units within their counties?_x000D_ What is the feasibility of setting up and running early diagnostic centres associated with health centres in 5 pilot counties?_x000D_ What is the feasibility of developing an integrated cancer network for diagnosis and treatment of OSCC via telemedicine between the 5 counties, KUTRRH and the Manchester Oesophageal Cancer Centre?_x000D_ What is the feasibility of developing an integrated clinical outcomes platform between KUTRRH and the 5 counties for patients with OSCC?_x000D_ What can mutational signatures tell us about the aetiology of Kenyan versus Western OSCC and inform future detection-interception studies?_x000D_ In addressing these questions, we hypothesise that improved engagement and pipelines towards OSCC early detection and increased OSCC biological knowledge will lead to a step change in OSCC prevention, interception and treatment; all these will be bespoke to Kenyan and East African populations. Our new NIHR GACD Group will drive 3 AIMs to address this hypothesis and will be delivered over a 3 year grant period with a unique paired expert approach to both scientific co-creation and NIHR Group Governance:_x000D_ AIM 1: Co-develop enhanced community engagement strategies to establish equipollent partnerships and improve county-level access to cancer early detection services for OSCC._x000D_ AIM 2: Co-create a research-based digital ‘hub and spoke outcomes unit’ with inward OSCC clinical data from counties to KUTRRH hub and outward harmonised OSCC care protocols to distant spoke counties._x000D_ AIM 3: Co-build a pathologist and pathology capacity to support early detection programmes and inform on bespoke Kenyan cancer biology relevant to future prevention studies._x000D_ Success in these AIMs will be evaluated using a Rapid Cycle Evaluation Framework (Plan>Do>Study>Act), which will allow the use of mixed methodologies to inform in real time and capture the nuances of the evolving project.

Lay abstract: As the 3rd leading cause of death in Kenya, cancer places an increasing burden on the country’s healthcare resources. In 2020, The Christie NHS Foundation Trust and The University of Manchester signed Memoranda of Understanding with Kenyatta University Teaching, Referral and Research Hospital (KUTRRH) and Ministry of Health, Kenya to develop a long-term equitable partnership that seeks to improve cancer outcomes within Kenya and East Africa._x000D_ _x000D_ This government interest and backing provides the perfect backdrop for initiating our NIHR Group between Kenya and Manchester. This partnership brings together researchers from a variety of scientific and clinical backgrounds to focus on the early detection of lethal squamous cell carcinoma of the oesophagus (OSCC). It is the third most common cancer and the most lethal (99% of patients die from their disease within 5 years) due to patients being diagnosed too late when they have advanced, incurable disease._x000D_ _x000D_ OSCC needs better early detection strategies to diagnose cancers at a much earlier stage whereby 40-50% of Kenyan patients could potentially be cured with surgery. However, there are obstacles to quickly introduce this early detection programme. The majority of Kenyans (~75%) live in rural areas with very low incomes, many of which are cut off from cancer care. There are also marked differences in the number of OSCC cases between different Kenyan counties, and even between East, West and South Africa. We do not know all the factors that lead to these different rates of OSCC presentation, but they could include late recognition of symptoms by the patient and general practitioner, social stigma of a cancer diagnosis, different access to healthcare, lifestyle and genetic factors or other environmental and exposure factors. We will overcome these research obstructions and develop interventions to improve OSCC early detection._x000D_ _x000D_ By pairing expertise within our joint NIHR GACD Group, we seek to address the problem of OSCC early detection through the following AIMs:_x000D_ • AIM 1: Co-develop best engagement and research practices for OSCC detection amongst local health leads and their communities;_x000D_ • AIM 2: Co-create a KUTRRH “Hub and Spoke” model whereby mobile units address cancer detection directly within rural communities and sends back clinical and imaging digital data and biological specimens to KUTRRH. It uses telemedicine to communicate regularly to rural settings and to Manchester collaborating clinicians;_x000D_ • AIM 3: Increase the capability for pathology high-throughput analysis of the extra specimens associated with increased early detection. Also to partner with world leading genetics experts to discover mutations in the OSCC tumour DNA that might explain why a cancer came to be in certain Kenyans - to describe how best to detect them or one day, to prevent them entirely._x000D_ We will work with local community partners and the Kenyan Network of Cancer Organisations (KENCO) to optimise a national Cancer Early Detection network to support research on OSCC and all cancers. Success in this first 3-year project could lead to further success in long-term goals in which we can show improved survival and quality of life in patients with OSCC, which will in turn decrease family separation or fragmentation due to treatment or worse, death. We see this as a way to improve Kenyan and East African healthcare for all cancers and success in this grant would lead to future larger applications.

Research activity codes: 2.1 BIOLOGICAL AND ENDOGENOUS FACTORS;4.5 RESOURCES AND INFRASTRUCTURE (DETECTION);7.4 RESOURCES AND INFRASTRUCTURE (DISEASE MANAGEMENT);8.5 RESOURCES AND INFRASTRUCTURE (HEALTH SERVICES)
Health categories: CANCER AND NEOPLASMS