Delays in Presentation, Diagnosis, and Treatment Among Patients With GI Cancer in Southwest Nigeria

PURPOSE

The incidence of GI cancers is increasing in sub-Saharan African countries. We described the oncological care pathway and assessed presentation, diagnosis, and treatment intervals and delays among patients with GI cancer who presented to the Obafemi Awolowo University Teaching Hospitals Complex in Ile-Ife, Nigeria.

METHODS

We analyzed data from 545 patients with GI cancer in the African Research Group for Oncology (ARGO) database. We defined presentation interval as the interval between symptom onset and presentation to tertiary hospital, diagnostic interval as between presentation and diagnosis, and treatment interval as between diagnosis and initiation of treatment. We considered >3 months, >1 month, and >1 month to be presentation, diagnosis, and treatment delays, respectively. We compared lengths of intervals using Mann-Whitney U tests and logistic regression.

RESULTS

The most frequent cancer types were pancreatic (32%) and colorectal (28%). Most patients presented at stages III (38%) and IV (30%). The median presentation interval was 84 days (IQR, 56-191), and 49% presented after 3 months or longer. The median diagnosis and treatment intervals were 0 (IQR, 0-8) and 7 (IQR, 0-23) days, respectively. There was no relationship between age, sex, education, or distance to tertiary hospital and presentation delay, but patients with stage III to IV versus I to II had higher odds of presentation delay (odds ratio [OR], 1.68 [95% CI, 1.13 to 2.50]). Among patients with pancreatic cancer, older patients were less likely to have a diagnosis delay (OR, 0.50 [95% CI, 0.25 to 0.98]).

CONCLUSION

About half of patients with GI cancer in Ile-Ife, Nigeria, did not present to tertiary hospitals until more than 90 days after noticing symptoms. Efforts are warranted to improve public knowledge of GI cancer symptoms and to strengthen health systems for prompt diagnosis and referral to specialty care.

The African Research Group for Oncology: A decade fostering colorectal cancer research in Nigeria

The African Research Group for Oncology (ARGO) was formed in 2013 to undertake methodologically rigorous cancer research in Nigeria, and to strengthen cancer research capacity in the country through training and mentorship of physicians, scientists, and other healthcare workers. Here, we describe how ARGO's work in colorectal cancer (CRC) has evolved over the past decade. This includes the consortium's scientific contributions to the understanding of CRC in Nigeria and globally and its research capacity-building program.

Impact of malnutrition on early outcomes after cancer surgery: an international, multicentre, prospective cohort study

BACKGROUND

Malnutrition represents a key priority for global health policy, yet the impact of nutritional state on cancer surgery worldwide remains poorly described. We aimed to analyse the effect of malnutrition on early postoperative outcomes following elective surgery for colorectal or gastric cancer.

METHODS

We did an international, multicentre, prospective cohort study of patients undergoing elective surgery for colorectal or gastric cancer between April 1, 2018, and Jan 31, 2019. Patients were excluded if the primary pathology was benign, they presented with cancer recurrence, or if they underwent emergency surgery (within 72 h of hospital admission). Malnutrition was defined with the Global Leadership Initiative on Malnutrition criteria. The primary outcome was death or a major complication within 30 days of surgery. Multilevel logistic regression and a three-way mediation analysis were done to establish the relationship between country income group, nutritional status, and 30-day postoperative outcomes.

FINDINGS

This study included 5709 patients (4593 with colorectal cancer and 1116 with gastric cancer) from 381 hospitals in 75 countries. The mean age was 64·8 years (SD 13·5) and 2432 (42·6%) patients were female . Severe malnutrition was present in 1899 (33·3%) of 5709 patients, with a disproportionate burden in upper-middle-income countries (504 [44·4%] of 1135) and low-income and lower-middle-income countries (601 [62·5%] of 962). After adjustment for patient and hospital risk factors, severe malnutrition was associated with an increased risk of 30-day mortality across all country income groups (high income: adjusted odds ratio [aOR] 1·96 [95% CI 1·14-3·37], p=0·015; upper-middle income: 3·05 [1·45-6·42], p=0·003; low income and lower-middle income: 11·57 [5·87-22·80], p<0·0001). Severe malnutrition mediated an estimated 32% of early deaths in low-income and lower-middle-income countries (aOR 1·41 [95% CI 1·22-1·64]) and an estimated 40% of early deaths in upper-middle-income countries (1·18 [1·08-1·30]).

INTERPRETATION

Severe malnutrition is common in patients undergoing surgery for gastrointestinal cancers and is a risk factor for 30-day mortality following elective surgery for colorectal or gastric cancer. There is an urgent need to examine whether perioperative nutritional interventions can improve early outcomes following gastrointestinal cancer surgery worldwide.

FUNDING

National Institute for Health Research Global Health Research Unit.

Ensuring Global Access to Cancer Medicines: A Generational Call to Action

SUMMARY

Essential cancer treatments are not accessible, affordable, or available to patients who need them in many parts of the world. A new Access to Oncology Medicines (ATOM) Coalition, using public-private partnerships, aims to bring essential cancer medicines and diagnostics to patients in low- and lower middle-income countries.

Priorities for cancer research in low- and middle-income countries: a global perspective

Cancer research currently is heavily skewed toward high-income countries (HICs), with little research conducted in, and relevant to, the problems of low- and middle-income countries (LMICs). This regional discordance in cancer knowledge generation and application needs to be rebalanced. Several gaps in the research enterprise of LMICs need to be addressed to promote regionally relevant research, and radical rethinking is needed to address the burning issues in cancer care in these regions. We identified five top priorities in cancer research in LMICs based on current and projected needs: reducing the burden of patients with advanced disease; improving access and affordability, and outcomes of cancer treatment; value-based care and health economics; quality improvement and implementation research; and leveraging technology to improve cancer control. LMICs have an excellent opportunity to address important questions in cancer research that could impact cancer control globally. Success will require collaboration and commitment from governments, policy makers, funding agencies, health care organizations and leaders, researchers and the public.

Growing academic global surgery: opportunities for Canadian trainees

Global surgery has seen exponential growth over the past few years, and Canadian trainees’ interest in the field has followed. Global surgery is defined by a commitment to health equity and community partnership. Engagement with its core principles is relevant for all Canadian surgical trainees and offers a perspective into inequities in surgical access and outcomes for patients and communities, both locally and globally. Several opportunities in academic global surgery for trainees have emerged in Canada, but appear to be underutilized. This article highlights existing Canadian global surgery initiatives, including formal postgraduate curricula, research and policy collaborations, trainee networks, advocacy projects, dedicated fellowships, and conferences. We identify areas in which institutions and departments of surgery can better support trainees in exploring each of these categories during training. Canadian trainees’ exposure to global surgery can nurture their roles as future health advocates, communicators, and leaders locally and beyond.

Abstract PO-247: Is colorectal cancer screening in West Africa worthwhile? A prospective multi-institutional study of 2,330 average-risk Nigerians using fecal immunochemical testing (FIT)

Objective: The estimated incidence of CRC is rising in many African countries. In Nigeria, it is the fourth most common cause of cancer death. More than half of CRC patients in Nigeria present with metastatic disease. Early detection and screening for CRC is a goal of the Nigerian National Cancer Control Plan. This study assessed the performance of the fecal immunochemical test (FIT) as a CRC screening modality in an average-risk population in Nigeria. Methods: A population-based, cross-sectional study of FIT-based CRC screening was undertaken. Asymptomatic average-risk participants aged 45-75 years in three states in Southwest Nigeria were screened using a qualitative (50ng/mL) FIT test. Participants were invited to enroll using age- and sex-stratified convenience sampling following community outreach. Participants with positive test results underwent colonoscopy and the positive predictive value (PPV) of FIT-based CRC screening for CRC and advanced adenomas (tubulovillous, villous or high grade dysplasia) was calculated. Information on demographics, cancer knowledge, and acceptability of the FIT test and colonoscopy were also collected. Results: Between January-April 2021, 2330 participants in 3 states (Osun, Kwara, Lagos) were enrolled in the study. The median age was 57 years. 68% had at least secondary level education. Participants were evenly spread across wealth quintiles. Baseline knowledge of CRC symptoms among participants was low, especially outside of Lagos. The test return rate was 90.6%, and FIT positivity rate was 20.5% overall (n=432); 11.2% in Lagos, 20.4% in Osun, and 27.8% in Kwara states. Among the FIT positive patients who completed colonoscopy (n=285; 66.0%), the positive predictive value (PPV) for invasive adenocarcinoma was 1.1%, and for advanced adenoma was 1.8%.[KTP1] [AD2] The acceptability of fecal-based CRC screening among participants was very high. Conclusions: CRC screening with qualitative FIT testing in Southwest Nigeria is feasible and acceptable to average-risk asymptomatic participants. The high false-positive rates and low PPV for advanced neoplasia, however, suggest it is not an optimal screening tool in this environment, particularly given the health resources required for endoscopic evaluation.

Citation Format: Olusegun I. Alatise, Anna J. Dare, Patrick A. Akinyemi, Fatima B. Abdulkareem, Samuel A. Olatoke, Gregg C. Knapp, Peter T. Kingham. Is colorectal cancer screening in West Africa worthwhile? A prospective multi-institutional study of 2,330 average-risk Nigerians using fecal immunochemical testing (FIT) [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-247.

Unveiling research training gaps in oncology: Evaluating a research capacity-building effort among Nigerian physicians

Background

Cancers are a disease of growing public health importance in Africa, but cancer research capacity in the region is underdeveloped. The quest to foster and promote locally conceptualized and conducted oncology research in Africa have informed the African Research Group for Oncology's (ARGO) research capacity-building efforts in Nigeria.

Aim

To evaluate the effectiveness of oncology research capacity-building initiatives among Nigerian senior trainees and junior faculty physicians.

Subjects and Methods

Panel study design was employed to study Nigerian senior trainees and junior faculty physicians who participated in two research capacity-building symposia. Data were collected pre-and immediate post-symposia, and 3-month post-first symposium. Changes in knowledge were assessed using the Chi-square test and confidence levels using the Wilcoxon signed rank test. A P value of <0.05 was considered statistically significant.

Results

: In the first symposium, the participants' pass rate in the knowledge-based questions improved from 9.8% to 46.7% to 81.5% at the baseline, immediate post-symposium, and 3-month post-symposium, respectively (P < 0.001). Likewise, the participants' confidence level in carrying out certain research-related activities increased after the second symposium (P < 0.001).

Conclusion

The study concludes that building capacity for oncology research in low- and middle-income countries is possible with focused symposia and educational programs.

High-burden Cancers in Middle-income Countries: A Review of Prevention and Early Detection Strategies Targeting At-risk Populations

Cancer incidence is rising in low- and especially middle-income countries (MIC), driven primarily by four high-burden cancers (breast, cervix, lung, colorectal). By 2030, more than two-thirds of all cancer deaths will occur in MICs. Prevention and early detection are required alongside efforts to improve access to cancer treatment. Successful strategies for decreasing cancer mortality in high-income countries are not always effective, feasible or affordable in other countries. In this review, we evaluate strategies for prevention and early detection of breast, cervix, lung, and colorectal cancers, focusing on modifiable risk factors and high-risk subpopulations. Tobacco taxation, human papilloma virus vaccination, cervical cancer screen-and-treat strategies, and efforts to reduce patient and health system-related delays in the early detection of breast and colorectal cancer represent the highest yield strategies for advancing cancer control in many MICs. An initial focus on high-risk populations is appropriate, with increasing population coverage as resources allow. These strategies can deliver significant cancer mortality gains, and serve as a foundation from which countries can develop comprehensive cancer control programs. Investment in national cancer surveillance infrastructure is needed; the absence of national cancer data to identify at-risk groups remains a barrier to the development of context-specific cancer control strategies.

Transforming Canada's role in global cancer control

Cancer has not been an explicit priority of Canada's international health and development agenda, but it is key to realising the country's Sustainable Development Goal commitments. Multiple converging political, health, and social forces could now drive support for a more integrated Canadian approach to global cancer control. Success will depend on the extent to which Canadian leaders and institutions can build consensus as a community and agree to work together. Collaboration should include agreement on the framing and prioritisation of the core issues, building a broad coalition base, aligning with priorities of international partners, and on a governance structure that reflects the principles of equity, diversity, and inclusion. This Series paper will discuss global cancer control within Canada's global health agenda, how Canada can address its history of colonisation and present-day disparities in its global work, and the challenges and opportunities of creating a Canadian global cancer control network.

Mitochondria-targeted antioxidant MitoQ ameliorates ischaemia-reperfusion injury in kidney transplantation models

BACKGROUND

Ischaemia-reperfusion (IR) injury makes a major contribution to graft damage during kidney transplantation. Oxidative damage to mitochondria is an early event in IR injury. Therefore, the uptake, safety, and efficacy of the mitochondria-targeted antioxidant MitoQ were investigated in models of transplant IR injury.

METHODS

MitoQ uptake by warm and cooled pairs of pig and declined human kidneys was measured when preserved in cold static storage or by hypothermic machine perfusion. Pairs of pigs' kidneys were exposed to defined periods of warm and cold ischaemia, flushed and stored at 4°C with or without MitoQ (50 nmol/l to 250 µmol/l), followed by reperfusion with oxygenated autologous blood in an ex vivo normothermic perfusion (EVNP). Pairs of declined human kidneys were flushed and stored with or without MitoQ (5-100 µmol/l) at 4°C for 6 h and underwent EVNP with ABO group-matched blood.

RESULTS

Stable and concentration-dependent uptake of MitoQ was demonstrated for up to 24 h in pig and human kidneys. Total blood flow and urine output were significantly greater in pig kidneys treated with 50 µmol/l MitoQ compared with controls (P = 0.006 and P = 0.007 respectively). In proof-of-concept experiments, blood flow after 1 h of EVNP was significantly greater in human kidneys treated with 50 µmol/l MitoQ than in controls (P ≤ 0.001). Total urine output was numerically higher in the 50-µmol/l MitoQ group compared with the control, but the difference did not reach statistical significance (P = 0.054).

CONCLUSION

Mitochondria-targeted antioxidant MitoQ can be administered to ischaemic kidneys simply and effectively during cold storage, and may improve outcomes after transplantation.

Abdominal neoplastic manifestations of neurofibromatosis type 1

Neurofibromatosis type 1 (NF1) is an autosomal dominant hereditary tumor syndrome, with a wide clinicopathologic spectrum. It is defined by characteristic central nervous system, cutaneous and osseous manifestations, and by mutations in the NF1 gene, which is involved in proliferation via p21, RAS, and MAP kinase pathways. Up to 25% of NF1 patients develop intra-abdominal neoplastic manifestations including neurogenic (commonly plexiform neurofibromas and malignant peripheral nerve sheath tumors), interstitial cells of Cajal (hyperplasia, gastrointestinal stromal tumors), neuroendocrine, and embryonal tumors (rhabdomyosarcoma). Nonspecific symptoms, multifocal disease, or coexistence of 2 or more tumor types make patients challenging to diagnose and manage. Screening for intra-abdominal tumors in NF1 patients remains controversial, and currently no guidelines are established. Management decisions are complex and often informed by single-center experiences or case studies in the literature, though the field is rapidly evolving. Thus, NF1 patients should be followed in specialist centers familiar with their wide spectrum of pathology and with multidisciplinary care including specialized pathology and radiology. This review will (1) provide a contemporaneous synthesis of the literature and our multi-institutional clinical experiences with intra-abdominal neoplasms in NF1 patients, (2) present a classification framework for this heterogeneous group of disorders, and (3) outline approaches to screening, surveillance, diagnosis, and management.

External injuries, trauma and avoidable deaths in Agincourt, South Africa: a retrospective observational and qualitative study

OBJECTIVE

Injury burden is highest in low-income and middle-income countries. To reduce avoidable deaths, it is necessary to identify health system deficiencies preventing timely, quality care. We developed criteria to use verbal autopsy (VA) data to identify avoidable deaths and associated health system deficiencies.

SETTING

Agincourt, a rural Bushbuckridge municipality, Mpumalanga Province, South Africa.

PARTICIPANTS

Agincourt Health and Socio-Demographic Surveillance System and healthcare providers (HCPs) from local hospitals.

METHODS

A literature review to explore definitions of avoidable deaths after trauma and barriers to access to care using the 'three delays framework' (seeking, reaching and receiving care) was performed. Based on these definitions, this study developed criteria, applicable for use with VA data, for identifying avoidable death and which of the three delays contributed to avoidable deaths. These criteria were then applied retrospectively to the VA-defined category external injury deaths (EIDs-a subset of which are trauma deaths) from 2012 to 2015. The findings were validated by external expert review. Key informant interviews (KIIs) with HCPs were performed to further explore delays to care.

RESULTS

Using VA data, avoidable death was defined with a focus on survivability, using level of consciousness at the scene and ability to seek care as indicators. Of 260 EIDs (189 trauma deaths), there were 104 (40%) avoidable EIDs and 78 (30%) avoidable trauma deaths (41% of trauma deaths). Delay in receiving care was the largest contributor to avoidable EIDs (61%) and trauma deaths (59%), followed by delay in seeking care (24% and 23%) and in reaching care (15% and 18%). KIIs revealed context-specific factors contributing to the third delay, including difficult referral systems.

CONCLUSIONS

A substantial proportion of EIDs and trauma deaths were avoidable, mainly occurring due to facility-based delays in care. Interventions, including strengthening referral networks, may substantially reduce trauma deaths.

Geospatial, racial, and educational variation in firearm mortality in the USA, Mexico, Brazil, and Colombia, 1990-2015: a comparative analysis of vital statistics data

BACKGROUND

Firearm mortality is a leading, and largely avoidable, cause of death in the USA, Mexico, Brazil, and Colombia. We aimed to assess the changes over time and demographic determinants of firearm deaths in these four countries between 1990 and 2015.

METHODS

In this comparative analysis of firearm mortality, we examined national vital statistics data from 1990-2015 from four publicly available data repositories in the USA, Mexico, Brazil, and Colombia. We extracted medically-certified deaths and underlying population denominators to calculate the age-specific and sex-specific firearm deaths and the risk of firearm mortality at the national and subnational level, by education for all four countries, and by race or ethnicity for the USA and Brazil. Analyses were stratified by intent (homicide, suicide, unintentional, or undetermined). We quantified avoidable mortality for each country using the lowest number of subnational age-specific and period-specific death rates.

FINDINGS

Between 1990 and 2015, 106·3 million medically-certified deaths were recorded, including 2 472 000 firearm deaths, of which 851 000 occurred in the USA, 272 000 in Mexico, 855 000 in Brazil, and 494 000 in Colombia. Homicides accounted for most of the firearm deaths in Mexico (225 000 [82·7%]), Colombia (463 000 [93·8%]), and Brazil (766 000 [89·5%]). Suicide accounted for more than half of all firearm deaths in the USA (479 000 [56·3%]). In each country, firearm mortality was highest among men aged 15-34 years, accounting for up to half of the total risk of death in that age group. During the study period, firearm mortality risks increased in Mexico and Brazil but decreased in the USA and Colombia, with marked national and subnational geographical variation. Young men with low educational attainment were at increased risk of firearm homicide in all four countries, and in the USA and Brazil, black and brown men, respectively, were at the highest risk. The risk of firearm homicide was 14 times higher in black men in the USA aged 25-34 years with low educational attainment than comparably-educated white men (1·52% [99% CI 1·50-1·54] vs 0·11% [0·10-0·12]), and up to four times higher than in comparably-educated men in Brazil, Colombia, and Mexico. In the USA, the risk of firearm homicide was more than 30 times higher in black men with post-secondary education than comparably educated white men. If countries could achieve the same firearm mortality rates nationally as in their lowest-burden states, 1 777 800 firearm deaths at all ages and in both sexes could be avoided, including 1 028 000 deaths in men aged 15-34 years.

INTERPRETATION

Firearm mortality in the USA, Mexico, Brazil, and Colombia is highest among young adult men, and is strongly associated with race and ethnicity, and low education levels. Reductions in firearm deaths would improve life expectancy, particularly for black men in the USA, and would reduce racial and educational disparities in mortality.

FUNDING

Canadian Institutes of Health Research and the University of Toronto Connaught Global Challenge.

Perioperative therapies - Enhancing the impact of cancer surgery with repurposed drugs

Surgical resection remains the major modality for modern curative treatment for solid tumours. However, post-surgical recurrence, even following clear-margin resection and adjuvant treatment, remains common in many types of cancer. Reducing recurrence rates, therefore, offers the potential to increase cure rates and increase overall survival. Perioperative therapies, simple interventions during the perioperative period, are designed to address some of the factors which influence post-surgical recurrence. A range of perioperative therapies are introduced and the rationale for further clinical investigation outlined.

Financial contributions to global surgery: an analysis of 160 international charitable organizations

Background

The non-profit and volunteer sector has made notable contributions to delivering surgical services in low-and middle-income countries (LMICs). As an estimated 55 % of surgical care delivered in some LMICs is via charitable organizations; the financial contributions of this sector provides valuable insight into understanding financing priorities in global surgery.

Methods

Databases of registered charitable organizations in five high-income nations (United States, United Kingdom, Canada, Australia, and New Zealand) were searched to identify organizations committed exclusively to surgery in LMICs and their financial data. For each organization, we categorized the surgical specialty and calculated revenues and expenditures. All foreign currency was converted to U.S. dollars based on historical yearly average conversion rates. All dollars were adjusted for inflation by converting to 2014 U.S. dollars.

Results

One hundred sixty organizations representing 15 specialties were identified. Adjusting for inflation, in 2014 U.S. dollars (US$), total aggregated revenue over the years 2008–2013 was $3·4 billion and total aggregated expenses were $3·1 billion. Twenty-eight ophthalmology organizations accounted for 45 % of revenue and 49 % of expenses. Fifteen cleft lip/palate organizations totaled 26 % of both revenue and expenses. The remaining 117 organizations, representing a variety of specialties, accounted for 29 % of revenue and 25 % of expenses. In comparison, from 2008 to 2013, charitable organizations provided nearly $27 billion for global health, meaning an estimated 11.5 % went towards surgery.

Conclusion

Charitable organizations that exclusively provide surgery in LMICs primarily focus on elective surgeries, which cover many subspecialties, and often fill deep gaps in care. The largest funding flows are directed at ophthalmology, followed by cleft lip and palate surgery. Despite the number of contributing organizations, there is a clear need for improvement and increased transparency in tracking of funds to global surgery via charitable organizations.

Costs, affordability, and feasibility of an essential package of cancer control interventions in low-income and middle-income countries: key messages from Disease Control Priorities, 3rd edition

Investments in cancer control--prevention, detection, diagnosis, surgery, other treatment, and palliative care--are increasingly needed in low-income and particularly in middle-income countries, where most of the world's cancer deaths occur without treatment or palliation. To help countries expand locally appropriate services, Cancer (the third volume of nine in Disease Control Priorities, 3rd edition) developed an essential package of potentially cost-effective measures for countries to consider and adapt. Interventions included in the package are: prevention of tobacco-related cancer and virus-related liver and cervical cancers; diagnosis and treatment of early breast cancer, cervical cancer, and selected childhood cancers; and widespread availability of palliative care, including opioids. These interventions would cost an additional US$20 billion per year worldwide, constituting 3% of total public spending on health in low-income and middle-income countries. With implementation of an appropriately tailored package, most countries could substantially reduce suffering and premature death from cancer before 2030, with even greater improvements in later decades.