EDITORIAL: LUNG CANCER WORLDWIDE

Lung Cancer in Tanzania

Alex Mremi, MD,a,b Jerry Ndumbalo, MD,c Harrison Chuwa, MD,d,e
Oliver Henke, MD,f,g Maximilian Rost, MDg,h,*

Background approach, where healthcare practitioners are paid for the

The United Republic of Tanzania is a country located services, they render. Health care providers must adhere
in East Africa, bordered by several countries and the to fee schedules established by the NHIF for various
Indian Ocean. With a population exceeding 61.7 million, medical operations, including cancer treatment. Never-
according to the most recent census, Tanzania has a theless, the full expense of cancer treatment may not al-
youthful demographic, with 42.8% of the population ways be covered by reimbursement policies and price
aged below 15 years and only 3.8% aged 65 years or schedules, particularly for more cutting-edge or experi-
above—a proportion unchanged from 2012 to 2022. mental therapies like immunotherapy or targeted therapy.
Most Tanzanians (65.1%) live in rural areas, where Patients may be required to pay out-of-pocket in such
healthcare access is often limited owing to a critical circumstances or request financial aid from non-
shortage of healthcare personnel, among the lowest governmental groups or other sources.
globally.1 Recent government initiatives have increased health
Its healthcare system faces significant challenges, sector funding, with the 2022/2023 budget allocation
including high maternal and child mortality rates, and a rising to TZS 1109 billion, reflecting a commitment to
high burden of infectious diseases such as human im- strengthening the health care system.4
munodeficiency virus infection and acquired immune
deficiency syndrome, pneumonia, and malaria. The Tan- Epidemiology
zanian healthcare system is predominantly public, with Globally, lung cancer is the leading cause of cancer-
over 60% of facilities managed by the government, sup- related deaths and the second most diagnosed cancer
plemented by faith-based organizations and private as of 2020. In Africa, its relatively low incidence has been
entities. attributed to the lower prevalence of smoking and the
Health care services are structured hierarchically, shorter life expectancy of the population.5
starting at the community level with dispensaries and
health centers, progressing to district hospitals, and if
necessary, to regional, zonal, and national referral hos- *Corresponding author.
pitals. Faith-based and private facilities play a supple- a
Faculty of Medicine, Kilimanjaro Christian Medical University College,
mentary role, comprising 17% and 18% of all registered Moshi, Tanzania, bDepartment of Pathology, Kilimanjaro Christian
Medical Centre, Moshi, Tanzania, cOcean Road Cancer Institute, Dar es
facilities, respectively.2 Currently, only 8% of the popu- Salaam, Tanzania, dDepartment of Oncology, The Aga Khan Hospital,
lation receives health care coverage within the National Dar Es Salaam, Tanzania, eTanzania Comprehensive Cancer Project, Dar
es Salaam, Tanzania, fCancer Care Centre, Kilimanjaro Christian Med-
Health Insurance Fund.3 The country is striving for ical Centre, Moshi, Tanzania, gSection Global Health, Institute for Hy-
universal health coverage, with significant financial giene and Public Health, University Hospital Bonn, Bonn, Germany, and
h
Department of Medicine II, Hematology and Oncology, University
support from international donors such as the United Hospital, Goethe University Frankfurt, Frankfurt, Germany.
States Agency for International Development and the Drs. Mremi and Ndumbalo contributed equally to this work.
Centers for Disease Control and Prevention, which Address for correspondence: Maximilian Rost, MD, Department of
Medicine II, Hematology and Oncology, University Hospital, Goethe
contribute nearly 40% of the national health budget. University Frankfurt, Theodor-Stern-Kai 7, Frankfurt 60596, Germany.
Tanzania’s National Health Insurance Fund (NHIF) E-mail: [email protected]

offers its members coverage for cancer treatment. Most Cite this article as: Mremi A, Ndumbalo J, Chuwa H, et al. Lung cancer
in Tanzania. J Thorac Oncol. 2025;20:560-564.
cancer treatments, such as chemotherapy, radiotherapy, ª 2025 International Association for the Study of Lung Cancer.
and surgery, are covered by the NHIF; nevertheless, Published by Elsevier Inc. All rights are reserved, including those for
text and data mining, AI training, and similar technologies.
patients may be responsible for certain out-of-pocket costs,
ISSN: 1556-0864
particularly for more complicated or expensive proced-
https://doi.org/10.1016/j.jtho.2025.02.002
ures. The NHIF uses a fee-for-service reimbursement

Journal of Thoracic Oncology Vol. 20 No. 5: 560–564

May 2025 Lung Cancer in Tanzania 561

Nevertheless, reported figures likely underestimate the form the policy framework for tobacco control. In addi-
true burden of the disease considering the high prevalence tion, the Global Adult Tobacco Survey, the global stan-
in the African setting of some major risk factors for lung dard for monitoring tobacco use and related indicators,
cancer such as pulmonary tuberculosis, exposure to fire- fulfills Tanzania’s commitment to the WHO Framework
wood smoke, smoking, and mining activities.6 Convention on Tobacco Control, ratified in 2007.
In Tanzania, the absence of a national cancer registry The 2018 Global Adult Tobacco Survey provided
means that population-based cancer incidence data is valuable insights into tobacco use in Tanzania, revealing
unavailable. Instead, national estimates are derived from that 8.7% of adults used tobacco products, with men
regional cancer registries: Mwanza Cancer Registry, (14.6%) being more likely than women (3.2%) to use
Bugando Cancer Registry, Kilimanjaro Christian Medical them. Secondhand smoke exposure was significant,
Center Cancer Registry, Dodoma Cancer Registry, and affecting 13.2% of adults at home and 32.9% in work-
the Governmental Ocean Road Cancer Institute (ORCI). places. Encouragingly, 84.4% of adults recognized that
These registries operate independently with support from smoking causes lung cancer.11 Interestingly, of the 35
the African Cancer Registry Network and contribute data lung cancer patients identified at Bugando Medical
to the GLOBCAN database maintained by the International Center, only 23% were current or former smokers, and
Agency for Research on Cancer (Table 1). Single publica- none were miners in the past.12 This highlights the
tions from different cancer registries highlight the rela- impact of potentially unknown or overlooked risk factors
tively low incidence of lung cancer in Tanzania, with only in this setting.
12 documented cases among 2772 reported cancers from The “Investment Case for Tobacco Control in the
2008 to 2016 in the Lake Zone8 and eight cases in the United Republic of Tanzania” outlines a 15-year plan to
Kilimanjaro region between 2013 and 2017.9 A recent implement seven proven tobacco control measures. These
hospital-based study from 39 hospitals in Tanzania interventions are expected to prevent 112,700 deaths and
identified 102 (1.6% of all) and 189 (3%) cancer-related avert economic losses of TZS 2.8 trillion, emphasizing the
deaths between 2006 and 2015 owing to lung cancer in importance of robust tobacco control efforts to improve
female and male individuals, respectively.10 public health and economic outcomes.13

Smoking Prevalence and Smoking Laws Screening

Tobacco use is a major risk factor for non-communicable Screening and timely diagnosis are among the best
diseases (NCDs), which accounted for 27% of all deaths in strategies to reduce mortality rates caused by any can-
Tanzania as per 2010 WHO estimates. In 2008, NCD- cer. Yet in Tanzania, a resource-constrained country,
related mortality was 75.7 per 1000 for male individuals there is limited access to screening and early detection
and 58.8 per 1000 for female individuals, with a signifi- services. Late-stage presentation is a significant chal-
cant proportion of these deaths (42.8% in male individuals lenge in Tanzania, where most lung cancer cases are
and 28.5% in female individuals) occurring before the age diagnosed at advanced stages.12 Currently, no formal
of 60 years. Tobacco use contributes to all four major NCD screening or early detection programs exist. Neverthe-
categories—cancer, cardiovascular diseases, chronic res- less, a recent public-private partnership assessed the
piratory diseases, and diabetes—and is responsible for feasibility of implementing a national lung cancer control
over 22,500 deaths annually, accounting for 6% of all program. This initiative aims to enhance surveillance,
deaths in Tanzania. prevention efforts, patient care pathways, and survival
To address this, an efficient and systematic surveil- outcomes. Out of 150 individuals screened, 85 presented
lance system is vital for monitoring tobacco use and with a lung mass, 67 underwent further diagnostic
evaluating prevention and control strategies. The evaluation, and 45 (67%) were confirmed to have lung
Tanzania Tobacco Act of 2003 and its 2014 regulations cancer.14

Table 1. Incidence, Mortality and Prevalence Diagnosis

Figure 1 highlights the hospitals in Tanzania equip-
New 5-Y
Lung Cancer Cases Deaths Prevalence ped for lung cancer diagnostic workups. The diagnosis of
lung cancer is established by a history and physical ex-
Number 795 693 1335
amination of the patient, including performance status
Rank among cancer diagnosis 11 10 -
Proportion (%) 1.8 2.3 - and weight loss documentation. National guidelines
Cumulative risk 0.29 0.26 - recommend TNM staging using chest radiographs,
Proportion (per 100.000) - - 2.1 computed tomography (CT) scans of the thorax and
Table adapted from 7. abdomen, and abdominal ultrasound. For SCLC,
562 Mremi et al Journal of Thoracic Oncology Vol. 20 No. 5

Figure 1. Hospitals capable of diagnosis and treatment of lung cancer in Tanzania.

additional imaging, such as brain scans and bone tertiary hospitals that are mostly located in urban set-
marrow evaluation, is advised.15 Advanced imaging ca- tings.19 The situation is much worse in rural areas.
pabilities, including CT and magnetic resonance imaging, A severe shortage of infrastructures and skilled
are available at select public facilities, with the Tanza- personnel such as pathologists, interventional radiolo-
nian Ministry of Health reporting 43 CT scanners and 10 gists, and cardiothoracic surgeons contribute to the
magnetic resonance imaging machines nationwide.16 A unacceptably long turnaround time for pathology test
positron emission tomography scanner was recently results that may range from weeks to months in some
introduced in Dar es Salaam. settings. Uneven distribution and brain drain com-
Pathological investigations are mandatory to confirm pound the shortage. Rural areas are severely under-
the disease, including sputum for cytology, bronchial served by health workers. It is estimated that only 20%
lavage, mediastinoscopy, thoracentesis, and bronchos- of doctors are practicing in rural areas where about
copy with biopsy.13 A recent single-center study 80% of Tanzania’s population lives. Moreover, most
demonstrated the safety and accuracy of thoracic core doctors in Tanzania resist rural placement.20 These
needle biopsy in Tanzania.17 Nevertheless, across much factors deprive the rural community of access to
of Tanzania, there is a critical shortage of screening and specialized oncological care. Yet, the current rate
pathology services.18 At present, it is practically impos- of training suggests that it may take centuries before
sible for many patients to obtain pathology services in a an adequate number of specialized pathologists is
timely manner because the services are only available in obtained.21
May 2025 Lung Cancer in Tanzania 563

Currently, only 43 anatomical pathologists serve Conclusion

hospitals across the country. Pathology reports are Although the overall number of cases is small, the
mainly morphological descriptions of endoscopic or high prevalence of never-smokers among lung cancer
resection specimens. Molecular diagnostic and prog- patients underscores the need for further investigation,
nostic techniques such as EGFR mutation, KRAS muta- particularly given the scarcity of data on genomic vari-
tion, ALK rearrangement, ROS1 gene fusion, BRAF ants in Western Africa. Evidence indicates that in-
mutation, and PD-L1 testing are essentially not available. dividuals of African heritage exhibit unique genomic
Telepathology services for reference pathology exist at alterations, some of which may be actionable targets.24
some centers. Studying these differences is essential to understanding
cultural and biological variations, optimizing treatment
strategies, and developing tailored recommendations.
Treatment Many health care facilities across the country lack
Lung cancer treatment requires a multidisciplinary advanced imaging equipment, or specialized laboratories
approach involving surgery, chemotherapy, and radia- for lung cancer diagnosis. Also, the existing health care
tion, tailored to the disease’s stage and location. These facilities are grossly overstretched, prioritizing infectious
treatment modalities are sparsely available within the diseases like tuberculosis, human immunodeficiency virus
public sector, where most patients receive care. infection and acquired immune deficiency syndrome, and
Radiation therapy is offered at two public hospitals: malaria over NCDs such as cancer. In regions with a high
ORCI in Dar es Salaam and Bugando Medical Center in tuberculosis burden—such as Tanzania - this risk factor
Mwanza and three private facilities: Aga Khan Hospital must be carefully considered in the context of lung cancer
and Besta Hospital in Dar es Salaam, and Good Samaritan diagnosis. Reports of misdiagnosis between tuberculosis
Cancer Hospital in Ifakara, Morogoro. Two additional and lung cancer highlight the need for improved diag-
radiation units are under construction at Benjamin nostic approaches in such settings and may lead to un-
Mkapa Medical Center in Dodoma and Kilimanjaro derrepresentation of the cancer statistics.25
Christian Medical Center in Moshi. Currently, Tanzania Another important challenge that is hindering the
has 28 radiation oncologists, but there is no data avail- wide availability of screening, diagnosis, and sufficient
able on the number of lung cancer patients treated. treatment is the financial barrier. Most people are not
Poverty and travel distance often hinder broader insured; thus, they have to pay from their pocket, leading
utilization.22 to delayed presentation and a lack of curative treatment
Chemotherapy services are accessible at public zonal options. A severe shortage of trained and experienced
referral hospitals in major cities, including Mbeya, workforce, such as pathologists, radiologists, oncologists,
Dodoma, Mwanza, Moshi, Dar es Salaam, Morogoro, and and cardiothoracic surgeons, complicates the problem
Zanzibar’s Stone Town. Recommended regimens for even further. Moreover, low health literacy is another
NSCLC include platinum-based therapies with paclitaxel, challenge since most people are not familiar with the
whereas SCLC treatment involves platinum with etopo- signs and symptoms of the disease. In addition, insuffi-
side. Irinotecan and gemcitabine are also available op- cient funding for cancer control programs contributes to
tions.15 Also bevacizumab is widely available and covered the lack of a national widespread cancer screening
by the NHIF. program.
Although it is generally possible to procure state-of- Addressing these challenges requires a combination
the-art targeted immunotherapy in the private hospital of tailored interventions, including investment in ca-
sector, there is very limited experience with these sub- pacity building, integration of services, public awareness
stances owing to the low incidence of lung cancer and campaigns, advocacy for comprehensive cancer care,
the general unavailability of such agents. Through Max collaboration with local and international partners, and
Foundation, a non-governmental organization delivering innovative approaches to reduce costs and improve ac-
free-of-cost targeted cancer medicines to low- and mid- cess to care.
dle-income countries, crizotinib is potentially available
in the two partnering hospitals of Max Foundation, ORCI,
and Kilimanjaro Christian Medical Center. CRediT Authorship Contribution
Thoracic surgery has yet to be established as a Statement
distinct specialty in Tanzania. A recent analysis of sur- Alex Mremi: Conceptualization & design, Writing -
gical oncology cases in public hospitals revealed that, out original draft, Supervision, Writing - review & editing.
of more than 4000 procedures, only five involved lung Jerry Ndumbalo: Conceptualization & design,
resections, underscoring the significant gap in special- Writing - original draft, Supervision, Writing - review &
ized surgical care for lung cancer patients.23 editing.
564 Mremi et al Journal of Thoracic Oncology Vol. 20 No. 5

Harrison Chuwa: Review & medical validation. across sub- Saharan Africa. https://www.medrxiv.org/
Oliver Henke: Writing - original draft, Writing - re- content/10.1101/2024.04.29.24306530v1. Accessed
view & editing. December 23, 2024.
13. United Nations Development Programme. Investment
Maximilian Rost: Conceptualization, Design, Writing -
case for tobacco control in the United Republic of
original draft, Supervision, Writing - review & editing. Tanzania. https://www.undp.org/sites/g/files/zskgke326/
files/2024-08/the_investment_case_for_tobacco_control_
in_the_united_republic_of_tanzania.pdf. Accessed
Disclosure November 11, 2024.
The authors declare no conflict of interest. 14. Bristol-Myers Squibb Foundation. Multinational lung
cancer control program: Tanzania catholic university of
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