NIHR Global Health Research Group for Improving Oesophageal Cancer Survival in Kenya: The Hub and Spoke Model 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. There remain key outstanding questions for our joint research programme: How can local engagement be optimised to refer individuals with symptoms to local endoscopy units within their counties? What is the feasibility of setting up and running early diagnostic centres associated with health centres in 5 pilot counties? 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? What is the feasibility of developing an integrated clinical outcomes platform between KUTRRH and the 5 counties for patients with OSCC? What can mutational signatures tell us about the aetiology of Kenyan versus Western OSCC and inform future detection-interception studies? 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: AIM 1: Co-develop enhanced community engagement strategies to establish equipollent partnerships and improve county-level access to cancer early detection services for OSCC. 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. 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. 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. AIM 1: Co-develop enhanced community engagement strategies to establish equipollent partnerships and improve county-level access to cancer early detection services for OSCC.
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. 
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.

AIM 1 outputs include:
1. Established advocacy roles: steering group to oversee community advisory board and field workers in each county (spokes)
2. Community sensitisation through workshops and education in advance of clinical interventions
3. Social media presence and increased Fafanuka subscription service for cancer information
4. Priorities document informed by county level data capture (randomised questionnaire deployment)
5. Powerful case studies for advocacy, awareness raising and reassurance-based interventions (videos,
blogs and infographics)
6. Attendance to events and meetings (CAB) by county members
7. Attendance to primary care facility by patients with early stage disease
8. New resources co-developed to improve communication, dissemination and risk awareness
9. Attendance to new mobile endoscopy units
10. Training staff in engagement strategies/ inclusive language/ clinical skills
11. Attendance of follow up appointment to demonstrate awareness and understanding importance
12. Consent to provide samples for further research (biobank/genetic data)

AIM 2 outputs include:
1. Show signal for increased numbers of new cases of OSCC from rural counties using best early detection and proposed engagement strategy from AIM 1 and compare this to historical data.
2. Show signal for OSCC stage distribution shift to lower stages based on best early detection and AIM
1 engagement and compare with historical data
3. Show signal for better clinical outcome of OSCC compared with historical data (c.f. 1 year survival)
4. Create endoscopic and histopathology pathways (latter for biopsies adjudicated in AIM 3 objectives)
5. Align MDT (tumour board) dates and treatment criteria between centres and Manchester
6. Collect and standardise structured clinical and demographic data for integration in AIM 3 WGS
aetiologic studies
7. Training of more than 30 clinical endoscopists in Kenya
8. Digital alignment of structured data between counties and KUTRRH
9. Sustained knowledge transfer and education in Kenya

AIM 3 outcomes include:
1. Training of 4 molecular pathologists
2. Sustained knowledge transfer and education in histopathology and molecular pathology within Kenya
3. Development and use of digital pathology and high-throughput histopathology lab infrastructure
4. Core and practical training in molecular pathology using state of the art techniques
5. Mutation spectra for 100 OSCC-the first in the world from Kenya and knowledge transfer of this back
to communities (collaboration with AIM 3)
6. Linkages between OSCC mutations and database from AIM 2 to infer signals towards OSCC
aetiology Communities within the five counties: Meru, Kiambu, Nyeri, Kisii and Nakuru. Locals within these communities that are experiencing signs or symptoms of Oesophageal Cancer. Oesophageal Cancer patients.