Challenges associated with the roll-out of HCC surveillance in sub-Saharan Africa - the case of Uganda

Abstract

In sub-Saharan Africa, where HBV infections are the main cause of HCC, surveillance programs are mostly not available.2 Nonetheless, with an incidence rate of 8.9 cases per 100,000 inhabitants per year, which is likely to be an underestimate, HCC surveillance is a pressing medical need in this part of the world.2,3 The recent introduction of country-wide vaccination programs in these countries will likely result in a drop in HCC incidence a few decades from now, but this does not apply to patients that are currently infected.4 In a recent African cohort of 1,315 hepatocellular tumors, 84% of the tumors were diagnosed at a late, multifocal disease stage with a mean size of 8 ± 4 cm and a median survival of 2.5 months.2 Given the strong association between early detection and improved survival, these findings highlight the need to set up surveillance programs in sub-Saharan Africa, provided curative treatment options are available.1 We have recently launched such a program in Uganda, where HCC is one of the most common malignancies. Age-standardized incidence rates of 6.5/100,000 in men and 6.0/100,000 in women have been reported. Unfortunately, its mortality rate almost mirrors its incidence.2,5–7 Following a kick-off meeting in Kampala in August 2019 where representatives from the radiology and internal medicine departments of 5 Ugandan, tertiary care hospitals were present, a questionnaire was launched among the participants to identify gaps that needed bridging in order to set up an HCC surveillance program. Participants were asked about the number of patients with HBV and HCC in their centers, the availability of alpha fetoprotein and ultrasound testing, as well as the available manpower to perform ultrasound. A summary of the findings is displayed in Table 1. None of the centers had an HCC surveillance program in place. However, outpatient HBV clinics are available in 3/5 centers and planned in the fourth. The estimated number of patients fre quenting these HBV clinics varies between <100 and 500–1,000. Given a nationwide HBsAg seroprevalence of 10% in Uganda, these varying numbers might point to the regional differences in HBV-infected patients, but they may also point to variations in linkage to care.8 Ultrasound machines are widely available in all centers and except for 2, all were manufactured within the last decade (Table 1). The number of staff trained to perform ultrasound largely varies between centers, ranging between 1 and 39, but corresponds to a coverage of 87% for the total number of medical staff at the radiology departments (radiologists/radiographers). Regular post-graduate training for ultrasound staff is provided in 3/5 centers. AFP testing is avail able in 2 centers; in a third center testing is offered based on reagent availability. A registry of the number of HCC cases is available in 1 center, though survival data are not systematically recorded. Diagnosis of HCC is based on clinical signs, such as a palpable liver mass or liver lesions on ultrasound in patients with clinical deterioration and not identified during screening of patients at risk. Liver surgery for non-advanced HCC is available in 1 center. Our survey highlights the feasibility of rolling out an HCC surveillance program in Uganda, as manpower, US equipment and treatment options are available. Further investment should aim at establishing HBV clinics with optimal linkage to care and broadening HCC treatment capacities. Our findings may guide other groups aiming to roll out surveillance programs in different countries. keywords: Challenges, HCC surveillance, and sub-Saharan Africa