Impact of a capacity building initiative to improve cancerdiagnosis using bone marrow and fine needle aspiration biopsy techniques in two Level- 5 Hospitals In Kenya.

Abstract

Background: GLOBOCAN (Global Cancer Incidence, Mortality and Prevalence) estimates project cancer burden to have shifted to low and middle income countries (LMICs), posing both social and economic challenges. Kenya is not a stranger to this trend and under diagnosis and late diagnosis has been identified as critical aspects associated with poor outcomes. Simple, relatively easy to perform tests used in cancer diagnosis such as fine needle aspiration (FNA) and bone marrow aspiration (BMA) are underutilized in Kenya. To tackle this limitation, University of Nairobi in conjunction with Aga Khan University in collaboration with the Ministry of Health and the National Cancer Institute (NCI, United States) initiated a capacity building program to increase the use of FNA, BMA and trephine biopsy for cancer diagnosis. The project intended to provide capacity building in performing the FNA, BMA and trephine biopsy techniques in the two hospitals through training, administrative support logistics, quality control and monitoring and evaluation. Objective: The main aim of this study was to assess the impact of training clinicians and laboratory technologists on bone marrow and fine needle aspiration procedures in two level-5 hospitals in order to improve cancer diagnosis. Study Design: This was an interventional study that assessed the impact of training nonpathologists in Nyeri Provincial General Hospital (NPGH) and the Coast Provincial General Hospital (CPGH). Methodology: The study subjects included clinicians and laboratory technologists. The clinicians were trained on sample collection using two techniques of bone marrow and fine needle aspiration. The laboratory technologists were trained on quality aspects of sample preparation and processing. Necessary equipment and supplies were provided to get the institutions started as well as expertise support in terms of laboratory result generation was offered by the University of Nairobi (UoN) and the Aga Khan University Hospital (AKUH). Monitoring and evaluation sessions were organized periodically to assess progress. Ethical approval was sought from the Kenyatta National Hospital/ University of Nairobi Ethics and Research Committee, and permission to perform the study from the hospitals involved before carrying out the study. Data Analysis: Data collected included qualitative and quantitative variables. Data was entered in the statistical software SPSS version 22 for analysis. Descriptive analysis using frequencies and proportions was computed. Association between dependent variables and independent variables was analyzed using binary logistic regression. Results: Of the 23 participants that were trained in this capacity building initiative, 15 (65%) were medical officers from different departments. In total, 13 were certified proficient ( due to drop-outs and staff attrition) in sample collection using bone marrow evaluation (BME) and FNAB techniques through practical steps including pre and post-testevaluations. There was an increase in the number of fine needle aspiration biopsy (FNAB), BMA and trephine procedures performed in both CPGH and Nyeri PGH in the year 2016 when the study was carried out. A total of 588 cases were reported in CPGH compared to 225 in the previous year (2015); while 783 cases were reported in Nyeri Provincial General Hospital (NPGH) compared to 420 cases in the year 2015. There was a marked improvement in the sample quality attributes of smear making, staining and overall specimen quality in terms of cellularity and diagnostic capability. Similarly, the unsatisfactory rates improved in both facilities as well as at individual operator level given by low (2.6%-25%) unsatisfactory rates registered.

Both study sites reported an increase in the number of new cancer cases diagnosed using BME and FNAB techniques compared to the previous year. A total of 50(8.5%) new cases were reported in CPGH compared to 27(6.0%) in the year 2015(p-value= 0.132); while 36 (4.6%) new cases were diagnosed in NPGH compared to 23 (2.7%) in the previous year (p-value=0.047). Conclusions: Prior the initiative, few diagnostic procedures were performed due to lack of supporting infrastructure. Training as an intervention helped improve on quality diagnosis through proper sample collection and processing therefore reducing the unsatisfactory rates in both facilities. An increase in the number and proficiency of those performing the diagnostic techniques led to an increase in the number of new cancer cases diagnosed. Recommendations: Training of non-pathologists in BME and FNAB should be maintained and the curriculum delivery up-scaled to include in-service training at the county and national hospitals. Review of facility infrastructure support and adoption of standard operating procedures (SOPs) for the diagnostic tests should be implemented in all level-4 and level-5 hospitals in Kenya.