Validation, Assessment, and Application of the Bugando Cancer Registry for Radiotherapy Planning for the Lake Zone of Tanzania

Purpose: To validate, assess, and utilize the Bugando Cancer Registry (BCR) of Bugando Medical Centre (BMC), Mwanza, Tanzania for radiotherapy (RT) services planning.

Methods: For BCR validation, we randomly sampled 63 total registry cases. Two reviewers not associated with the BCR manually collected data elements from medical records and compared them with BCR data to measure concordance and completeness.

For BCR assessment, we described the pattern of pediatric and adult malignancies from 2008 to 2016 and classified them by GLOBOCAN standards. Primary tumor sites, means of diagnosis, HIV status, and the number of AIDS-defining malignancies (cervix, non-Hodgkin lymphoma, and Kaposi sarcoma) were reported. The 2012 GLOBOCAN estimates for Tanzania were then scaled to the Lake Zone using 2012 national census data and adjusted for population growth to compare BCR cases in 2016.

Finally, for BCR utilization for RT planning, all notifiable cancer cases diagnosed in 2016 were used as the basis for analysis. RT utilization based on primary site was calculated using the latest version of the evidence-based estimation method from the Collaboration for Cancer Outcomes Research and Evaluation’s (CCORE-EBEST), a RT utilization model based on Australian incidence of notifiable cancers. CCORE-EBEST was modified to account for the high number of cases of Kaposi sarcoma seen at BMC. A time-driven activity-based costing (TD-ADC) model was used to compute the total resources and operational costs for three situations: the capacity to treat 500 patients per year, the required capacity to meet 100% of the clinical need, and the clinical need that could be met with maximal equipment and staff capacity (four teletherapy units, one orthovoltage unit, one brachytherapy afterloader, two simulators).

Results:

BCR validation: All 63 reviewed registry records had complete cancer site and morphology information included in the registry. For the majority (n=41), the basis of diagnosis was pathology. Of sampled registry cases, primary tumor site and morphology were 74% and 70% concordant, respectively. Of the fifteen parameters entered into the BRC, twelve (80%) were 100% complete and the overall completeness was 97%. The median concordance rate was 79% (interquartile range 72%-86%).

BCR assessment: A total of 2,772 cases were reported. 2,286 cases were adult (82.5%) and 486 cases were pediatric (17.5%). 2,522 patients (91%) lived in one of the six Lake Zone regions. Number of cancer cases reported in the registry by year increased from 19 in 2008 to 1,272 in 2016. Means of diagnosis were histologic or cytologic confirmation for 1,923 cases (85%), clinical investigations (e.g., radiologic studies) for 528 cases (19%), clinical diagnosis for 298 cases (11%), serologic tumor markers for 13 cases (0.5%), unknown for 7 (0.2%) cases, and death certificate for 3 (0.1%) cases. The most common adult cancers were cervix (n=520, 22.7%), breast (n=288, 12.6%), prostate (n=195, 8.5%), others (n=198, 8.7%), and Kaposi sarcoma (n=184, 8.0%). The most common pediatric cancers were non-Burkitt non-Hodgkin lymphoma (n=84, 17.3%), Burkitt lymphoma (n=80, 16.5%), Wilms tumor (n=71, 14.6%), soft tissue sarcoma (n=56, 11.5%), and leukemia (n=50, 10.3%). The number of unique BCR cases logged in 2016 was 12.2% of the expected number based on GLOBOCAN estimates (1,116 v. 9,165, p<0.001).

RT utilization: A total of 1,088 unique cancer cases were analyzed. Casemix was significantly different between BMC and the modified CCORE-EBEST model, with significantly higher cases of cervix (29.5% v. 1.0%, p<0.001) at BMC and fewer cases of breast cancer (9% v. 12.2%, p<0.001) and prostate cancer (10.1% v. 18.4%, p<0.001). The proportion of new cancer cases requiring RT at BMC was 56.4%, significantly higher than the original CCORE-EBEST expected rate of 48.4% (p<0.001). In 2016, had RT been available, 614 patients at BMC would have received RT for a total of 11,837 fractions. To treat 500 patients per year, BMC has sufficient teletherapy capacity with a single Co-60 teletherapy unit operating 12 hours per day, but a brachytherapy afterloader and C-arm are required. To scale up capacity to meet current clinical need in the least expensive fashion, an afterloader and C-arm are needed, as are 4 radiation oncologists, 3 medical physicists, 5 radiation therapists, and increasing the Co-60 workday from 8 to 14 hours. If BMC installed teletherapy equipment in every bunker, 1,900 patients could be treated a year. This would require 11 ROs, 6 MPs, 16 RTTs, 3 dosimetrists, 2 nurses, 0.3 information technologists, 0.5 mechanical engineers, and 1.4 electrical engineers.

Conclusions: Data quality metrics of the BCR indicate it is of sufficient quality for local planning. This first comprehensive report of the BCR shows a cancer diagnosis pattern typical of many hospital registries in low-income countries. For RT services planning. application of the CCORE-EBEST and TD-ADC models to a hospital-based cancer registry is feasible with minor modifications. The high RT utilization rate at BMC supports the clinical value of RT; however, current capacity at BMC is not sufficient to meet the clinical need. Scaling up RT services requires a combination of equipment and staffing to maximize efficiency and clinical outcomes.