An Assessment of Cancer Pain Control in an LMIC Oncology Clinic

Background: Cancer has become a leading cause of morbidity and mortality in adults globally. Pain is universally one of the most commonly encountered symptoms by health and supportive care providers involved in care of cancer patients. Inadequate pain control negatively impacts the patient´s quality of life, and may slow down the healing process. Health care providers often ignore pain control as a target of treatment as they focus on reducing the tumor burden. Pain management should be considered an important target and end point in the treatment of cancer patients. Aim: To assess the prevalence of pain, oncologists´ prescribing patterns; and efficacy of pain control in the Radiotherapy Department of the Lagos University Teaching Hospital. Methods: Adult cancer outpatients were assessed using a Universal Pain Assessment Tool and followed up for 2-6 weeks thereafter. Pain scores were assessed at first interview and at the follow-up appointment within 2 weeks minimum and 6 weeks maximum. Results: 347 adult clinic attendees were recruited, assessed, and followed up with interviewer-administered questionnaires over a close-out period of 6 weeks. There was an 85% (298 respondents) prevalence of pain in the study group; with over half of respondents characterizing their pain in the moderate to severe ranges. [Figure: see text] 9 out of 10 respondents stated the cancer was the primary source of their pain. Other sources of pain were medical tests; and treatment-related such as chemotherapy and radiation therapy. 86 patients (29% of study group) were not asked about pain by their attending physician, and all respondents stated their physician had not used any pain assessment tool to determine the nature or severity of their pain. [Figure: see text] Oral nonsteroidal analgesics were the most frequently prescribed form of pain control (237 patients), with radiotherapy coming in second (69 patients). The only available strong opioid analgesics at the oncology pharmacy were oral morphine and parenteral pentazocine. Oxycodone, fentanyl pethidine, and hydromorphone were unavailable. Interventional (e.g., cordotomy) and alternative (e.g., massage) forms of pain control were not prescribed in any patients. 43 respondents (15%) despite being in pain, did not receive any form of treatment or recommendation for pain control. At follow-up appointment 2-6 weeks after; 4 out of 10 respondents had not obtained pain relief from instituted measures. [Figure: see text] Conclusion: Undertreatment of cancer pain remains a major concern. The treatment process must begin with a proper and thorough evaluation of the patient's pain; a clear pain control goal and end point target; and regular reevaluation with application of guidelines when adequate control is not achieved. Inclusion of pain assessment and management guidelines in medical training would be of benefit to reduce the prevalence of inadequately controlled pain in patients living with cancer; ultimately improving their quality of life.

Childhood Cancer in an LMIC: Navigating the Wilderness

Background and context: When a child has cancer, the entire family is affected. Parents and caregivers lose work days while caring for the child. Many parents blame themselves and wonder if some action or decision of theirs contributed to; or caused the cancer. In addition, and especially for families falling within the low socioeconomic demographic groups, there may be poor understanding of the treatment process and expectations from treatment. Aim: To assess the most common challenges or concerns faced by parents, family members, or caregivers of a child living with cancer in Nigeria. Strategy/Tactics: A series of 10 focus group sessions were held with different groups of parents, family members, or other caregivers of children being treated for cancer at 2 teaching hospitals in Nigeria. Groups consisted of a minimum 8, and maximum of 12 participants in addition to a moderator. At the beginning of every session, participants were asked to submit 2 most pressing questions. Open-ended questions were also used with every attendee given a turn to give their answer. Participants were also given a chance to ask questions or bring up issues they had difficulty with. The single most prevalent concern raised in every focus group was lack of information or understanding. The 2 most common questions were: 1. What is cancer? 2. Why does my child have cancer? Program/Policy process: Data from the sessions were painstakingly compiled. The questions and concerns the attendee raised; and the degree of understanding they had regarding the diagnosis, treatment process, and expectations bring and after treatment. This data were collated and a team of experts including oncologists, nurses, and health workers in cancer were brought together to answer the questions. A compilation was made and a plan to disseminate the information was formulated. This culminated in the publishing of a free childhood cancer handbook; the first of its kind in Nigeria; with plans to translate the handbook into the common colloquial and vernacular languages in Nigeria. Outcomes: Participants of the focus groups were given a handbook, including some whose child had passed on since the sessions were held. 29% of the original participants were unreachable or declined the handbook. They were assessed to see if the handbook provided information that could have eased their cancer journey. 91% of assessed participants responded that having the handbook at diagnosis would have significantly increased their level of information and made the cancer journey easier. [Figure: see text][Figure: see text] The most appreciated information in the handbook was contact details of an organization dedicated to supporting them financially to pay treatment fees. What was learned: Many Nigerian families go through the entire childhood cancer journey completely in the dark. No dedicated information source on child cancer exists in Nigeria. Many parent and caregiver questions remain unanswered, and concerns remain unresolved.[Figure: see text]

The Burden of Comorbidities in Cancer Patients in Southwestern Nigeria

Background: Noncommunicable diseases (NCDs) in sub-Saharan Africa are a major cause of morbidity and mortality. There is especially a paucity of data on the burden of hypertension, diabetes mellitus and other NCDs coexisting with cancer in Nigerian cancer patients. Comorbidities influence the survival of patients with cancer; lead to presentation at advanced disease stages; and result in increased risk of treatment complications, higher rates of postoperative mortality, and a greater consumption of medical resources. Aim: To determine the magnitude and pattern of comorbidities in Nigerian cancer patients. Methods: This is a retrospective study, for which data were extracted from hospital records of patients presenting for oncology care between January 2015 and December 2016 in the Departments of Radiotherapy and Oncology of two tertiary health facilities in Lagos, Nigeria. Comorbidities were identified, ranked and weighted using the Charlson Comorbidity Index (CCI). Results: Eight hundred and forty-eight (848) cancer cases were identified, with breast (50.1%) and cervical (11.1%) cancers being the most prevalent. Comorbidities were present in 228 (26.9%) patients, and the most common comorbidities were hypertension (75.9%), diabetes (25.0%), and peptic ulcer disease (7.9%). Patients with prostate (41.5%), colorectal (34.0%), cervical (25.5%), nasopharyngeal (25.0%), and breast (24.0%) cancers are most likely to have comorbidities. The mean ages of patients with comorbidities and without was 60.1 ± 11.8 years and 52.5 ± 13.7 years respectively ( P < 0.0001). Hypertension-augmented CCI scores were 0 (15.6%), 1-3 (62.1%), 4-6 (21.7%), and ≥ 7 (0.6%). Patients with lower mean CCI scores were more likely to receive chemotherapy (2.2 ± 1.6 vs. 2.5 ± 1.9; P < 0.05) and/or surgery (2.1 ± 1.5 vs. 2.4 ± 1.7; P < 0.05). Conclusion: Comorbidities occur in at least one in four Nigerian cancer patients, and significantly influence the treatment outcome and prognosis of these patients. There is a need for a high index of suspicion and routine evaluation of cancer patients for comorbidities, with the aim of instituting appropriate and immediate multidisciplinary management measures where necessary.

Breast Cancer Pathology Reporting in a LMIC: Filling in the Gaps

Background: Breast cancer biology has been studied extensively over the past 5 decades, with a deeper understanding of the epidemiologic, clinical, and prognostic value of specific pathologic features. Tumor characterization beyond histologic type has been shown to guide treatment choices and ultimately improve outcomes. Pathologic features such as tumor grade, margin involvement, hormone and growth factor receptor overexpression, are all pieces of the puzzle that a clinician must put together to adequately map out the best treatment options available to the present-day breast cancer patient. Guidelines for breast cancer pathology reporting have been published, with universal consensus regarding the basic elements required to make a breast cancer pathology report complete. Aim: The aim of this study was to assess the completeness of pathology reports of breast cancer patients at all stages of diagnosis or treatment, presenting in an oncology department of a Nigerian teaching hospital over the period of one year. Methods: Pathology reports of 981 breast cancer patients attending the oncology clinic in 2016 were analyzed. Reports originated both from within the teaching hospital and from external pathology centers all over the country. Eight parameters were selected to analyze completeness of the reports: Specimen type, histologic type, immunohistochemistry, margin involvement, lymphovascular space invasion, pathologic stage, and tumor grade. Results: Of 981 pathology reports analyzed, 20.9% originated from the hospitals' pathology department. Specimen type was documented in 86% of reports. 24% of did not specify the histologic type, and almost half (44%) of reports did not specify the grade. 72% of the pathology reports did not have immunohistochemistry results ( Fig 1 ). Presence or absence of lymphovascular space invasion was reported in 10%; margin status in 32.3% ( Fig 2 ). Tumor stage was documented in 45%. Ki-67 was not reported in 99% of the pathology reports (Fig 3). Conclusion: Breast cancer survival has improved significantly globally; however LMICs such as Nigeria continue to lag behind. The reasons for this are undoubtedly multifactorial, however inadequate pathology reporting is worth exploring in the context of assessing the consequences of clinicians making decisions, armed with limited information regarding the biology of the tumor they are treating. In general, reports originating from within the hospital's pathology department were more complete than those from referring centers, with up to 7 out of 8 parameters present in at least 50%. Pathology reporting of breast cancer must be standardized in LMICs. Hundreds of years after Cheatle and Cutler first published their pathologic findings from breast cancer specimens; clinicians should no longer be subjected to the practice of making treatment decisions using inadequate data. Perhaps this will bring us one small step closer to achieving survival rates comparable to the rest of the world.[Figure: see text]

E-Patients: Online Health Seeking Behaviour of Cancer Patients in South Western Nigeria

Background: Cancer has been reported to be one of the top three diseases that patients research on the Internet. This is because the Internet is an evolving hub of cancer information and social support for patients. With the increasing connectivity and over 92,000,000 Internet enabled devices in Nigeria, it is expected that mobile health will proliferate and this will change the way cancer patients gather health information and resources, propagating a new age of e-patients. An e-patient is a health consumer who uses the Internet as a health resource. With over 100,000 new cancer cases diagnosed yearly in Nigeria, low doctor to patient ratio, constrained consultation time and limited access to specialist care, the need to promote patients to become e-patients could efficiently empower them to become better-educated healthcare consumers. However, there is a paucity of data on how Nigerian cancer patients use the Internet. Aim: To measure the utilization rate and patient attitudes toward the Internet. Methods: This descriptive cross-sectional study was carried out among 281 cancer patients across the department of radiotherapy in three teaching hospitals in south-western Nigeria in March 2018, using a self-administered questionnaire. The analysis was done with SPSS version 20, and the level of significance was set at < 0.05. Results: The mean age for the 281 participants was 50.8±14.2 years; with the majority between 41 and 60 years (46.6%); and females (78.3%). About 67.6% owned a smartphone ( Table 1 ); and 32% possessed a personal laptop/desktop computer, or lived in households with people with smartphones (66.9%). Majority of the respondents had consistent access to the Internet (59.1%) ( Table 2 ). They also had an e-mail and social media account (52%) in order of decreasing frequency: Facebook, 52.7%; WhatsApp, 18.1%; and Instagram, 17.1% ( Fig. 1 ). At least 43.1% had searched for cancer information online with the purpose of understanding the disease better (41.6%) ( Fig. 2 ). About 45.2% of the respondents also indicated that they would be comfortable having an online medical consultation with their oncologist; however, they had not used any health/cancer app before (71.2%). Patients aged 41-60 years, married, with tertiary level of education, and monthly incomes ≤ N50,000 (∼$140) were more likely to search for cancer information online ( P < 0.05). About 56.9% of the respondents did not use the Internet for cancer information because they preferred getting information directly from doctors (43.2%), lacked the knowledge of Internet use (33.6%), and lacked access to Internet-enabled devices (20.8%). Conclusion: With more cancer patients being connected to the Internet and an increasing trend to be e-patients, there is a need to leverage technology to provide patient education, consultation, navigation and social support services.[Table: see text]

[Table: see text][Figure: see text][Figure: see text]

The PAC-SYM questionnaire for chronic constipation: defining the minimal important difference

BACKGROUND

The Patient Assessment of Constipation-Symptoms (PAC-SYM) questionnaire is frequently used in clinical trials of constipation. However, the threshold for reduction in total PAC-SYM score used to define a clinical response on this 0-4 point scale has not undergone formal appraisal, and its relationship with clinical benefit as perceived by patients has not been defined.

AIM

To determine the minimal important difference in PAC-SYM score, and the optimum cut-off value for defining responders.

METHODS

The minimal important difference was estimated using data from six international phase 3/4, double-blind, randomised controlled trials of prucalopride in patients with chronic constipation (NCT01147926, NCT01424228, NCT01116206, NCT00485940, NCT00483886, NCT00488137), with anchor- and distribution-based approaches. Five appropriate patient-reported outcomes were selected as anchors. In addition, receiver operating characteristics (ROC) curve analyses were used to investigate responder discrimination for each anchor.

RESULTS

Data from 2884 patients were included. Minimal important difference estimates ranged from -0.52 to -0.63 across the five anchors. Estimates were not affected by study location but were consistently lower for rectal symptoms than for abdominal and stool symptoms. Distribution-based estimates were considerably lower than anchor-based estimates. ROC curve analyses showed optimum cut-off scores for discriminating responders to be similar to anchor-based minimal important difference estimates.

CONCLUSIONS

Anchor-based methods gave consistent results for the minimal important difference, at approximately -0.6, and this value was close to the ROC-determined optimal cut-off scores for responder discrimination. This value could be considered in clinical practice. A slightly more conservative threshold (eg -0.75) could be used in clinical trials to reduce the placebo response rate.

Health-related quality of life and work productivity of adults with ADHD: A UK web-based survey

Introduction

European data on health-related quality of life (HRQoL) in adults with attention deficit/hyperactivity disorder (ADHD) in the general population is sparse.

Aims and objectives

To report HRQoL in UK adults with ADHD.

Methods

UK residents aged 18–55 years with a diagnosis of adult ADHD completed an online, cross-sectional survey including questions on disease history, the EuroQol Five Dimensions questionnaire with five-levels (EQ-5D-5L) and the Work productivity and activity impairment questionnaire: general health (WPAI:GH). ADHD symptom severity was assessed by telephone using ADHD rating scale version IV with adult prompts (ADHD-RS-IV).

Results

The survey was completed by 233 participants (65.2% women; 77.3% white British), mean age 32.6 years (standard deviation [SD] 9.5), mean ADHD-RS-IV total score 43.46 (SD 7.88). Their mean EQ-5D-5L utility score of 0.74 (SD 0.21) was lower than the UK population norm of 0.86 (SD 0.23).[1] WPAI:GH scores indicated that health problems resulted in impairments of 32.04% in work productivity and 45.79% in regular daily activities. Regression analyses adjusting for gender, age and comorbidities demonstrated associations between EQ-5D-5L utility scores and gender (men had lower scores, P < 0.001), work impairment due to health problems (increasing impairment was associated with lower scores, P = 0.005) and age (for each additional year of age, scores decreased by 0.007, P = 0.010).

Conclusions

These results highlight the impact on health utility, work productivity and regular daily activities, and add to the description of the disease burden of adult ADHD in the UK.

This study was funded by Shire Development LLC.

Disclosure of interest

Kings College London research support account for Asherson received honoraria for consultancy to Shire, Eli-Lilly and Novartis educational/research awards from Shire, Lilly, Novartis, Vifor Pharma, GW Pharma and QbTech speaker at sponsored events for Shire, Lilly and Novartis.

Summer Temperature and Spatial Variability of all-Cause Mortality in Surat City, India

Background:

Ample information is available on extreme heat associated mortality for few Indian cities, but scant literature is available on effect of temperature on spatial variability of all-cause mortality for coastal cities.

Objective:

To assess the effect of daily maximum temperature, relative humidity and heat index on spatial variability of all-cause mortality for summer months (March to May) from 2014 to 2015 for the urban population of Surat (coastal) city.

Materials and Methods:

Retrospective analysis of the all-cause mortality data with temperature and humidity was performed on a total of 9,237 deaths for 184 summer days (2014-2015). Climatic and all-cause mortality data were obtained through Tutiempo website and Surat Municipal Corporation respectively. Bivariate analysis performed through SPSS.

Observations:

Mean daily mortality was estimated at 50.2 ± 8.5 for the study period with a rise of 20% all-cause mortality at temperature ≥ 40°C and rise of 10% deaths per day during extreme danger level (HI: > 54°C) days. Spatial (Zone wise) analysis revealed rise of 61% all-cause mortality for Southeast and 30% for East zones at temperature ≥ 40°C.

Conclusions:

All-cause mortality increased on high summer temperature days. Presence of spatial variation in all-cause mortality provided the evidence for high risk zones. Findings may be helpful in designing the interventions at micro level.

Label free measurement of retinal blood cell flux, velocity, hematocrit and capillary width in the living mouse eye

Measuring blood cell dynamics within the capillaries of the living eye provides crucial information regarding the health of the microvascular network. To date, the study of single blood cell movement in this network has been obscured by optical aberrations, hindered by weak optical contrast, and often required injection of exogenous fluorescent dyes to perform measurements. Here we present a new strategy to non-invasively image single blood cells in the living mouse eye without contrast agents. Eye aberrations were corrected with an adaptive optics camera coupled with a fast, 15 kHz scanned beam orthogonal to a capillary of interest. Blood cells were imaged as they flowed past a near infrared imaging beam to which the eye is relatively insensitive. Optical contrast of cells was optimized using differential scatter of blood cells in the split-detector imaging configuration. Combined, these strategies provide label-free, non-invasive imaging of blood cells in the retina as they travel in single file in capillaries, enabling determination of cell flux, morphology, class, velocity, and rheology at the single cell level.

Foxg1-Cre Mediated Lrp2 Inactivation in the Developing Mouse Neural Retina, Ciliary and Retinal Pigment Epithelia Models Congenital High Myopia

Myopia is a common ocular disorder generally due to increased axial length of the eye-globe. Its extreme form high myopia (HM) is a multifactorial disease leading to retinal and scleral damage, visual impairment or loss and is an important health issue. Mutations in the endocytic receptor LRP2 gene result in Donnai-Barrow (DBS) and Stickler syndromes, both characterized by HM. To clearly establish the link between Lrp2 and congenital HM we inactivated Lrp2 in the mouse forebrain including the neural retina and the retinal and ciliary pigment epithelia. High resolution in vivo MRI imaging and ophthalmological analyses showed that the adult Lrp2-deficient eyes were 40% longer than the control ones mainly due to an excessive elongation of the vitreal chamber. They had an apparently normal intraocular pressure and developed chorioretinal atrophy and posterior scleral staphyloma features reminiscent of human myopic retinopathy. Immunomorphological and ultrastructural analyses showed that increased eye lengthening was first observed by post-natal day 5 (P5) and that it was accompanied by a rapid decrease of the bipolar, photoreceptor and retinal ganglion cells, and eventually the optic nerve axons. It was followed by scleral thinning and collagen fiber disorganization, essentially in the posterior pole. We conclude that the function of LRP2 in the ocular tissues is necessary for normal eye growth and that the Lrp2-deficient eyes provide a unique tool to further study human HM.