A registry-based systematic review of lifestyle and non-pharmaceutical oncology interventions in Africa

Introduction

Cancer is a major public health burden and the second leading cause of morbidity and mortality in Africa, with cancers of the cervix, breast, liver, colorectal and prostate ranked as the most common in the region (1, 2). By 2030, it is estimated that there will be a 70% increase in new cancer cases and approximately 1 million cancer-related deaths in the region annually (3). This heavy disease burden is associated with aging populations and adoption of unhealthy lifestyle habits, including increased physical inactivity, consumption of unhealthy diets, and harmful tobacco and alcohol consumption (3–7). Besides, many countries in Africa are grappling with weak and inefficient health systems, delays in screening and treatment, unfamiliarity with cancer and related prevention strategies, and inaccessibility to quality and affordable care that further aggravate and contribute to higher mortality rates (1, 8–10).

Lifestyle interventions, such as those that promote a healthy diet and an active and non-smoking lifestyle, have demonstrated benefits in reducing adverse cancer-related outcomes and improving quality of life (11). Lifestyle interventions are defined as having at least one additional component, including behavioral therapy, counseling, and stress management, in addition to both nutritional and physical activity components (12). According to the World Health Organization (WHO), nearly one-third of cancer-related mortality is preventable through lifestyle interventions and behavioral modifications, indicating that effective, evidence-based intervention strategies are urgently needed in Africa (13). Today, several reviews have been conducted demonstrating that healthful lifestyle practices are preventative of the onset, progression, or recurrence of many cancers in both survivors and healthy individuals (11, 14–16). However, a critical analysis of the evidence shows these have largely been generated from high-income settings.

Current approaches to reducing the cancer burden in Africa have often faltered due to a lack of emphasis on lifestyle changes, revealing gaps in understanding and implementing preventive and management measures (17, 18). Given the cost and infrastructure challenges associated with precision oncology, lifestyle interventions could offer a viable solution for cancer prevention and management in Africa (19). Despite substantial evidence of the role of healthy lifestyle habits in cancer prevention and management, the integration of lifestyle intervention in the African cancer landscape remains unexplored (20). The extent to which these low-cost but highly promising interventions are leveraged in Africa remains poorly understood and warrants urgent attention. Therefore, this review aims to synthesize the current evidence on the distribution of cancer-associated lifestyle and non-pharmacological clinical trial interventions for the management of any cancer in Africa highlighting trends, gaps and opportunities for future research by analyzing clinical trial registry data.

Materials and methods

This review does not formally identify as a systematic review, given its scope, was not prospectively registered, and no formal protocol was prepared. However, we aimed to closely align with the standard PRISMA guidelines, which are provided in the Supplementary material.

Information source and search strategy

A search of registered trials was conducted on Clinical Trials.gov International Clinical Trials Registry Platform (ICTRP) and Pan African Clinical Trials Registry (PACTR) from July 01, 2005, to October 30, 2024. The search utilized the following keywords: “cancer” OR “oncology,” OR “lifestyle intervention” OR “non-pharmaceutical intervention.” A comprehensive list of search terms used in the trial registries developed for the PubMed database was subsequently adapted to each trial registry. A final search strategy can be seen in supplemental material (See Supplementary File S1). The search was restricted to countries in Africa.

Eligibility criteria

To be included in this review trials were required to: (1) population: cancer-specific and conducted in at least one African country; (2) Intervention: included lifestyle interventions (i.e. nonpharmacological intervention including a variety of diet or dietary interventions, physical activity, and behavioral components); (3) Study design: interventional study (i.e. non-observational, either randomized or non-randomized). Studies were excluded if primary intervention was pharmacological or not aimed at supporting cancer patients, conference abstracts or protocol papers. Screening was conducted in sequential steps, first assessing the relevance of each trial to the country, followed by its relevance to oncology, and finally the type of intervention. Studies were limited to prospective trials designed to evaluate non-pharmacological interventions registered on or after 1st July 2005, the date of the introduction of mandatory clinical trial registration. (21). All registered trials meeting the eligibility criteria were included regardless of completion status. Withdrawn and unknown status trials were retained in the dataset and reported transparently in Table 1, as this review aimed to capture the full spectrum of registered trial activity including terminated and ongoing studies.

Table 1. Summary characteristics of relevant studies included in the review.

Screening and data extraction

Four reviewers (M.W, B.M, G.M, and E.N) independently screened all title and abstracts and full articles against inclusion criteria. Disagreements were resolved by a fifth reviewer (L.O). Using a pre-specified Microsoft Excel spreadsheet, data was extracted electronically by (B.M. and M.W). Reviewers were blinded to each other's decisions throughout the process, and any conflicts were resolved with a fifth reviewer (L.O). The following information was extracted from the trials: trial identifiers, information source, country, cancer type, a summary of the study, sponsors, study type, study start date and end date, population, intervention, sex, and age eligibility. Discrepancies were resolved through ongoing team discussion. A summary of all information extracted from the trial registries can be found in the Supplementary Table S1. Consistent with the purpose of the review, no quality or bias assessment were conducted for individual trials.

Data analysis and synthesis

All data visualization and statistical analyses were performed using R software (version 4.4.2) (R Core Team, 2024) (22). Descriptive statistics, mainly frequency and percentage, were used to describe and summarize the characteristics of the eligible trials. The findings are reported in a summary table and further described narratively.

Results

Figure 1 shows the literature screening process. The initial search of the trial registries identified 193,789 trial records. After removing 1,000 duplicates, 192,789 records were screened of which 185,770 were excluded during title and abstract screening. Full text assessment of 142 reports for eligibility was conducted; 89 reports were excluded., Ultimately, 53 trials across nine African countries met the inclusion criteria and were included in the review. A complete list of trial records included in this review is provided in the Supplementary Table S2.

Trial design characteristics

Table 1 provides a summary of study characteristics. A total of 53 trials evaluating lifestyle and other non-pharmaceutical interventions were identified across 9 African countries, with majority conducted in Egypt. Additional trials were undertaken in Nigeria, Kenya, Malawi, Ethiopia, Tunisia, Rwanda, Botswana and Uganda.

Most trials were randomized (92.5%) and blinded studies (71.7%), with only a small number not explicitly reporting randomization. Sample sizes varied substantially, ranging from small pilot trials (n = 20–40) to large implementation or system based studies (up to n = 6,600 participants). In terms of recruitment a large proportion of the studies were completed (32/53) while (13/53) were ongoing (recruiting, not yet recruiting or enrolling by invitation). A small number of the trials were withdrawn.

Most trials 88.7% of the studies recruited patients as the primary beneficiary or recipient of the intervention and 69.8% of all the studies were in adult populations. Notably, these trials were not limited to cancer patients. About six trials investigated interventions in caregivers (11.3%), and a further eight studies sought to understand the efficacy or effectiveness in cancer survivors (15.1%). Furthermore, a growing interest in studies recruiting Pediatric populations was also observed. Nearly one-third of lifestyle interventions in oncology trials included pediatric populations (30.5%), as shown in Figure 2A.

Regarding gender distribution, females were the single most included gender, although over half of the studies (52.8%) included both sexes. Only one study exclusively recruited male participants (NCT06605846), as presented in Figure 2B. This is particularly unsurprising, as this is largely determined by the cancers under investigation. A high number of breast cancer studies was observed (24/53), which implied a higher number of female-only studies.

Most trials in this review were locally sponsored studies (69.8%). Locally sponsored studies refer to those funded by governmental or non-governmental institutions based in the same country where the study was conducted. However, studies in Sub-Saharan Africa (SSA) were far more commonly externally sponsored compared to those outside of SSA. For instance, 92.9% of studies from SSA were funded by external sponsors, while 92.3% of studies outside SSA were funded by local sponsors. For both studies in and outside SSA, universities/academia were the major sponsors of studies included in the review (84.9%). For SSA studies, these were academic institutions outside of the continent. Additionally, post-surgical interventions; studies evaluating the effectiveness of an intervention following a surgical procedure, accounted for 35.8% of all trials.

As reported in Table 1, differences were observed in nearly all characteristics across studies within and outside SSA. Figure 3 summarizes a few quantitative summary characteristics of studies. Studies in SSA were, on average, larger by sample size (median: 109 vs. 60 patients) and conducted for a longer duration (median: 16.6 months vs. 7 months) compared to those outside of SSA.

Trends in lifestyle intervention studies in oncology

There has been a steady increase in studies investigating non-pharmaceutical and lifestyle interventions in Africa. The earliest trial was initiated in 2009 (ACTRN12612000256875) and since then, there have been, on average, 2–3 new registrations per year until 2022, from which there have been 5+ new trials per year. The highest record of trial registrations was observed in the years post-pandemic (2022 onwards), especially in 2023, where 16+ studies were registered.

The study trends reported In Figure 4 demonstrate geographical disparities in study coverage across the continent Figure 4A.

Notably, the majority of trials (73.5%) were conducted outside of Sub-Saharan Africa Figure 4B. The trends show consistently growing numbers of oncology lifestyle intervention studies ongoing outside of SSA, especially in Northern Africa. Besides the North, the East African region hosted a considerable number of studies, followed by West Africa. There were only two studies from Southern Africa, one initiated in 2016 and another in 2023.

Types of cancers under investigation

Figure 5 summarizes the characteristics of the types of cancers under investigation in the included trials. Most trials focused on breast cancer (n = 24, 45.3%), followed by colorectal (n = 6, 11.3%), while a small fraction (n = 8, 15.1%) did not specify the cancer types. Overall, the most prevalent cancer in SSA included breast cancer (50%), colorectal (14.3%), cervical, prostate, Hematological, Kaposi sarcoma each (7.1%), and variety-unspecified cancer (28.6%). A fraction of the trials targeted multiple cancers (n = 2, 3.8%).

Types of lifestyle interventions under investigation

Table 2 and Figure 2C presents a summary of the interventions under investigation for various cancers. A total of 64 lifestyle interventions were identified across six broad categories: dietary, educational, financial, physical activity, psychological and technological interventions. Physical activity interventions were the most prevalent, constituting (43.8%, n = 28) of all the interventions, followed by psychological intervention (23.4%, n = 15) and dietary interventions (9.4%). Of the two leading interventions, only 28.6% (n = 4) of each were SSA studies. Educational, financial, and technological interventions were less frequently reported, accounting for 7.8% (n = 5), 6.3% (n = 4), and 9.4% (n = 6) of interventions, respectively. Financial interventions were those that empowered patients and caregivers to make sustainable long-term choices in managing their health. Educational interventions involved providing patients or caregivers with information and guidance about the benefits of certain health practices, while technological interventions involved the use of a device or gadget as part of the intervention delivery. Physical activity interventions encompassed a broad range of approaches, including rehabilitation, strength training, and mobility and posture training, extending beyond traditional exercise alone. A notable number of cancer trials involved more than one modality of intervention.

Table 2. Summary of interventions under investigation across various cancers.

Dietary: nutritional/diet modifications; Educational: health information provision to patients/caregivers; Financial: support for sustainable health management choices; Physical Activity: exercise, rehabilitation, and mobility training; Psychological: counseling, stress management, and behavioral therapy; Technological: device- or digital tool-assisted intervention delivery.

Physical activity and psychological intervention were frequently applied interventions to breast cancer, accounting for 52.8 and 26.1%, respectively, while dietary interventions were limited but utilized mostly in breast and colorectal cancer. Furthermore, educational and technological interventions were primarily used in various unspecified breast cancers.

Geographical distribution

Figure 6 and Supplementary Table S3 present the geographical distribution of the trials included in this review. Of the 53 studies included in this review, the vast majority (98.1%, n = 52) were single-country studies, with one conducted across multiple countries and located within SSA. Thirteen of the 52 studies were conducted exclusively in SSA.

Regionally, more than half of these trials (39/53, 73.6%) were conducted in North Africa, followed by 13.2% (n = 7) in East Africa, 9.4% (n = 5) in West Africa and 3.8% (n = 2) in southern Africa. Notably, there were no trials focused on Central Africa. A strong research concentration in North Africa was found to have taken place in Egypt (n = 38, 97.4%), accounting for nearly all North African studies. In SSA, studies were more evenly distributed across Kenya and Nigeria, with four studies each (28.6%). Ethiopia, Malawi, Rwanda, Uganda, Tunisia, and Botswana each contributed (7.1% per country), demonstrating relatively fragmented research distribution in these regions.

Discussion

As a leading cause of mortality globally and in Africa, there is increased demand in research for low-cost innovations for the treatment and management of cancer. As highlighted by Ngwa et. al., these interventions are needed urgently to mitigate the growing cancer crisis in Africa (3). In resource-poor settings such as Africa, affordable, cost-effective, and impactful public health interventions are much needed to counter this ever-growing cancer threat and the burden it exerts on already weak health systems (23, 24). Whilst oncology research in Africa continues to gather pace, this review presents the current status quo of non-pharmaceutical and lifestyle interventions for cancer management in Africa. Clinical trials of non-pharmaceutical interventions offer valuable insights into the scenario of cancer research in Africa, specifically focusing on lifestyle interventions for cancer management.

The review demonstrates that similar to pharmaceutical interventional studies, there is a dearth of studies focusing on lifestyle interventions in oncology in Africa and largely much of sub-Saharan Africa. Studies were generally smaller in a few classes of cancer and spread in a few countries. Reviews that have largely focused on pharmaceutical interventions have also found that the pace of cancer research in Africa is lagging (1, 25). Of the trials ever initiated, ongoing, withdrawn or completed, significant geographical disparities in the distribution of trials was observed. Notable observations were the dominance of North Africa, few studies in SSA, sparse representation from southern Africa, and no trials reported in central Africa. The uneven distribution of trials across Africa reflects existing regional differences in research infrastructure and funding availability (26)accessibility to high- quality care (25) and disease burden prioritization (8, 9). For instance, it was no surprise that studies outside SSA were more commonly locally sponsored, while studies within SSA were often funded by sponsors outside the region. Furthermore, the scant data from central Africa indicates the lag in the clinical research community's responsiveness to emerging health challenges. Such health emergencies may drive the prioritization of research efforts and facilitate rapid advancements in the understanding and management of infectious diseases, while neglecting chronic diseases (27).

Although a majority of studies focused on adult cancer patients, there is a discernible shift toward recognizing the importance of diverse beneficiaries, as evidenced by the marginal but growing inclusivity of Pediatric populations, caregivers, and cancer survivors. These trends reflect an evolving understanding of the multifaceted needs within this field, extending beyond merely addressing the requirements of active cancer patients. Still, female participants dominate most studies, highlighting the dominance of studies particularly in female breast and gynecological cancers (over half of the studies). This emphasizes the pressing need to expand the scope for male inclusivity in trials. This is particularly important given the higher prevalence of certain male cancers, such as prostate, across the continent. Despite relatively greater research attention directed toward female cancers, the burden of cancer among women remains substantial. According to GLOBOCAN 2022, breast and cervical cancers were the most prevalent in Africa (16.8% and 10.6%), with a mortality rate of 11.9 and 10.6% respectively (28). Therefore, while this review highlights the need for more male-centered trials, the importance of sustaining and expanding female-focused cancer research cannot be overlooked.

The analysis of the profile of interventional studies targeting cancer shows that physical activity and psychological interventions are the predominant modalities. However, the representation of these interventions within SSA was small, about one in three studies. This presents a significant gap in evidence-based interventions where resources for cancer management are constrained particularly in SSA. Furthermore, educational, financial, and technological interventions are markedly underrepresented, presenting a unique opportunity for future research. A contextual understanding of these research priorities is essential for developing a comprehensive and culturally relevant cancer management strategy that aligns with the known needs and challenges faced by diverse populations in SSA.

The evaluation of the funding overview for clinical research in Africa reveals a predominant reliance on local support, particularly from academic institutions/universities, which suggests a limited influence of commercial entities within the realm of clinical research in the continent. However, SSA was more dependent on external funding for nearly all the studies, reflecting challenges in securing local research funding. This reliance on international sponsors emphasizes the need to strengthen local research funding mechanisms to enhance the sustainability of research in SSA. While industry sponsorship is a key driver for advancing oncology drug development, public and academic institutions significantly contribute to funding research that tackles important health issues, such as public health interventions, which may be less equitable but are equally critical.

The review by Odedina et al. (25) shows that Egypt and South Africa are the leading countries where pharmaceutical companies have supported clinical trials. On the contrary, there were no industry partners funding studies in this review. It is, therefore, evident that industry support is exclusively focused on pharmacological interventions. Even then, the shift toward precision oncology in high-income countries has not yet translated effectively to Africa, where access to innovative targeted therapies remains limited (29, 30). Several targeted oncology therapies have shown significant promise in improving patient outcomes in high income countries, yet access to some of these life-saving therapies remains limited in regions such as Africa.

The contrast with high-income regions is stark. In North America and Europe, lifestyle and non-pharmacological oncology trials have grown substantially over the past two decades, with exercise, dietary programs, and technology-assisted physical activity monitoring now well-established modalities supported by national funding bodies and major academic institutions (31). These trials are typically larger, longer in duration, with well laid out endpoints. A landmark example is the CHALLENGE trial that was conducted across 55 centers in Canada, Australia, and the United Kingdom, which enrolled 889 colon cancer patients between 2009 and 2024 and demonstrated that a structured three-year exercise program significantly improved disease-free survival (HR 0.72; 95% CI 0.55–0.94) (32). Sponsorship in these settings, while predominantly academic, benefits from dedicated funding streams and established cooperative trial networks (33). By contrast, the 53 trials identified in our review were overwhelmingly single-center, smaller in sample size, and shorter in duration, with no industry co-investment. This disparity underscores the quantitative gap in research output and the absence of adequately powered, multi-site lifestyle intervention trials in Africa, thus limiting the generalizability of evidence and the translation of findings into clinical practice and policy. These disparities raise the question and need for the adoption of effective, scalable, affordable, and high-impact public health interventions in Africa.

There are a few limitations to this study. First, we rely exclusively on clinical trial evidence from registry data. However, by reviewing data from trial registries, we obtain a clearer picture of the status quo, identifying trials that would otherwise not appear in research publication databases. Secondly, we did not focus on any non-interventional studies which may otherwise provide additional insights into the status quo. Finally, the dataset includes trials across varying completion stages, including ongoing, terminated, withdrawn, and unknown status trials, which may affect data completeness. However, this was intentional, as the review aimed to document the full representation of registered trial activity.

Conclusions

This review mapped the status of lifestyle and other non-pharmaceutical interventions in oncology. Although the benefits of lifestyle interventions across several cancers have been characterized elsewhere, research from Africa is scanty and largely domiciled outside of SSA, where there is less burden compared to SSA. Our findings suggest that the full spectrum of lifestyle intervention-induced health outcomes is yet to be carefully explored for most, if not all, cancers in Africa. Furthermore, given the lag in precision medicine research in Africa and the high associated cost of promising targeted therapies, there is a greater need for research prioritization, given the affordability, scalability, and access to promising lifestyle interventions.

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Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fcacs.2026.1571038/full#supplementary-material

Supplementary material Supplementary material at the source

Footnotes

Edited by: Elena Amaricai, Victor Babes University of Medicine and Pharmacy, Romania

Reviewed by: Somchai Chutipongtanate, University of Cincinnati, OH, United States

Aishwarya Joglekar, University of Delhi, India