Cancer care challenges in developing countries

The Effect of Switching to Second-Line Antiretroviral Therapy on the Risk of Opportunistic Infections Among Patients Infected With Human Immunodeficiency Virus in Northern Tanzania

Background.  Due to the unintended potential misclassifications of the World Health Organization (WHO) immunological failure criteria in predicting virological failure, limited availability of treatment options, poor laboratory infrastructure, and healthcare providers' confidence in making switches, physicians delay switching patients to second-line antiretroviral therapy (ART). Evaluating whether timely switching and delayed switching are associated with the risk of opportunistic infections (OI) among patients with unrecognized treatment failure is critical to improve patient outcomes. Methods.  A retrospective review of 637 adolescents and adults meeting WHO immunological failure criteria was conducted. Timely and delayed switching to second-line ART were defined when switching happened at <3 and ≥3 months, respectively, after failure diagnosis was made. Cox proportional hazard marginal structural models were used to assess the effect of switching to second-line ART on the risk of developing OI. Results.  Of 637 patients meeting WHO immunological failure criteria, 396 (62.2%) switched to second-line ART. Of those switched, 230 (58.1%) were delayed. Switching to second-line ART reduced the risk of OI (adjusted hazards ratio [AHR], 0.4; 95% CI, .2-.6). Compared with patients who received timely switch after failure diagnosis was made, those who delayed switching were more likely to develop OI (AHR, 2.2; 95% CI, 1.1-4.3). Conclusion.  Delayed switching to second-line ART after failure diagnosis may increase the risk of OI. Serial immunological assessment for switching patients to second-line ART is critical to improve their outcomes.

Sociocultural factors and breast cancer in sub-Saharan Africa: implications for diagnosis and management

The incidence of breast cancer is on the rise in sub-Saharan Africa (SSA) and efforts at early diagnosis have not been very successful because the public has scant knowledge about the disease, a large percentage of breast cancer cases are diagnosed late and mainly rural SSA women's practice of breast self-examination is poor. In this paper, we argue that an examination of the social and cultural contexts of SSA that influence breast cancer diagnosis and management in the region is needed. We discuss the implications of sociocultural factors, such as gender roles and spirituality, on breast cancer diagnosis and management in SSA.

Global cancer surgery: delivering safe, affordable, and timely cancer surgery

Surgery is essential for global cancer care in all resource settings. Of the 15.2 million new cases of cancer in 2015, over 80% of cases will need surgery, some several times. By 2030, we estimate that annually 45 million surgical procedures will be needed worldwide. Yet, less than 25% of patients with cancer worldwide actually get safe, affordable, or timely surgery. This Commission on global cancer surgery, building on Global Surgery 2030, has examined the state of global cancer surgery through an analysis of the burden of surgical disease and breadth of cancer surgery, economics and financing, factors for strengthening surgical systems for cancer with multiple-country studies, the research agenda, and the political factors that frame policy making in this area. We found wide equity and economic gaps in global cancer surgery. Many patients throughout the world do not have access to cancer surgery, and the failure to train more cancer surgeons and strengthen systems could result in as much as US $6.2 trillion in lost cumulative gross domestic product by 2030. Many of the key adjunct treatment modalities for cancer surgery--e.g., pathology and imaging--are also inadequate. Our analysis identified substantial issues, but also highlights solutions and innovations. Issues of access, a paucity of investment in public surgical systems, low investment in research, and training and education gaps are remarkably widespread. Solutions include better regulated public systems, international partnerships, super-centralisation of surgical services, novel surgical clinical trials, and new approaches to improve quality and scale up cancer surgical systems through education and training. Our key messages are directed at many global stakeholders, but the central message is that to deliver safe, affordable, and timely cancer surgery to all, surgery must be at the heart of global and national cancer control planning.

Patient delays and system delays in breast cancer treatment in developed and developing countries

AbstractDelays in treating breast cancer have been associated with a more advanced stage of the disease and a decrease in patient survival rates. The scope of this integrative review was to analyze the main causal factors and types of patient and system delays. The underlying causal factors of delays were compared among studies conducted in developing and developed countries. Of the 53 studies selected, 24 were carried out in developing countries and 29 in developed countries, respectively. Non-attribution of symptoms to cancer, fear of the disease and treatment and low educational level were the most frequent causes of patient delay. Less comprehensive health insurance coverage, older/younger age and false negative diagnosis tests were the three most common causal factors of system delay. The effects of factors such as age were not decisive per se and depended mainly on the social and cultural context. Some factors caused both patient delay and system delay. Studies conducted in developing countries identified more causal factors of patient delay and had a stronger focus on patient delay or the combination of both. Studies conducted in developed countries had a stronger focus on aspects of system delay during treatment and guidance of breast cancer patients in the health care system.

Caring for patients with surgically resectable cancers: experience from a specialised centre in rural Rwanda

SETTING

Butaro Cancer Centre of Excellence (BCCOE), Burera District, Rwanda.

OBJECTIVES

To describe characteristics, management and 6-month outcome of adult patients presenting with potentially surgically resectable cancers.

DESIGN

Retrospective cohort study of patients presenting between 1 July and 31 December 2012.

RESULTS

Of 278 patients, 76.6% were female, 51.4% were aged 50-74 years and 75% were referred from other district or tertiary hospitals in Rwanda. For the 250 patients with treatment details, 115 (46%) underwent surgery, with or without chemotherapy/radiotherapy. Median time from admission to surgery was 21 days (IQR 2-91). Breast cancer was the most common type of cancer treated at BCCOE, while other forms of cancer (cervical, colorectal and head and neck) were mainly operated on in tertiary facilities. Ninety-nine patients had no treatment; 52% of these were referred out within 6 months, primarily for palliative care. At 6 months, 6.8% had died or were lost to follow-up.

CONCLUSION

Surgical care was provided for many cancer patients referred to BCCOE. However, challenges such as inadequate surgical infrastructure and skills, and patients presenting late with advanced and unresectable disease can limit the ability to manage all cases. This study highlights opportunities and challenges in cancer care relevant to other hospitals in rural settings.

Socio-economic and cultural vulnerabilities to cervical cancer and challenges faced by patients attending care at Tikur Anbessa Hospital: a cross sectional and qualitative study

BACKGROUND

Cervical cancer is a leading cause of death among women in Ethiopia, affecting them at a time of their life when they are critical to social and economic stability. This study was mainly focused on assessing different socioeconomic and cultural related factors that make women vulnerable to cervical cancer and challenges women face in the process of diagnosis and treatment.

METHODS

To achieve the objective of the study both qualitative and quantitative methods were utilized.198 participants were enrolled in a cross- sectional survey and 10 in-depth interviews were conducted with patients in Tikur Anbessa Hospital. A consecutive sampling method was used to select participants in the survey while purposive sampling was employed to select participants in the qualitative design.

RESULTS

For the population covered in the study, poverty along with other socio-cultural practices such as early marriage, high parity and to certain extent polygamy were identified as factors that increased the vulnerability of women to cervical cancer. In addition, the study has uncovered several challenges faced by cervical cancer patients in the diagnosis and treatment process. Three types of challenges that include, health care based, psychological and economic were identified. System and practitioner delay were found as the main hurdles within the variable of health care related challenges. What's more, the psychological challenges identified included, fear of recurrence, negative social attitude and distress associated with the side effects from treatments such as fecal & urinary leakage. Furthermore, inability of bearing costs related to treatment and accommodation were cited as the main economic challenges.

CONCLUSION

The study showed various socio-economic and cultural vulnerabilities that expose women to cervical cancer and the challenges encountered by cervical cancer patients after their diagnosis. Addressing this issue largely lies in strengthening primary and secondary preventive mechanisms, providing public education about safer sex practices, family planning and eliminating cultural practices such as early marriage and polygamy in connection to cervical cancer. Furthermore, improving the diagnostic and treatment procedures and facilities is also a crucial component that needs due emphasis in the fight against cervical cancer.

Gene-Expression-Based Predictors for Breast Cancer

An important and often complicated management decision in early stage hormone receptor (HR)-positive breast cancer relates to the use of adjuvant systemic chemotherapy. Although traditional clinicopathologic markers exist, tremendous progress has been achieved in the field of predictive biomarkers and genomics with both prognostic and predictive capabilities to identify patients who will potentially benefit from additional therapy. The use of these genomic tests in the neoadjuvant setting is also being studied and may lead to these tests providing clinical benefit even earlier in the disease course. Landmark articles published in the last few years have expanded our knowledge of breast cancer genomics to an unprecedented level, and mutational analysis via next-generation sequencing methods allows the identification of molecular targets for novel targeted therapeutic agents and clinical trials testing efficacy of targeted therapies, such as PI3K inhibitors, in addition to endocrine therapy for HR-positive breast cancer, are ongoing. We provide an in-depth review on the role of gene expression-based predictors in early stage breast cancer and an overview of future directions, including next-generation sequencing. Over the coming years, we anticipate a significant increase in utilization of genomic-based predictors for individualized selection and duration of endocrine therapy with and without genotype-driven targeted therapy, and a major decrease in the use of chemotherapy, possibly even leading to a chemotherapy-free road for early stage HR-positive breast cancer.

Zambian women's experiences and understanding of cervical cancer: a qualitative study

OBJECTIVE

Cervical cancer is the most common cancer in Zambian women, and approximately 28% of all patients with cancer seen at the Cancer Diseases Hospital in Lusaka experience this disease. Our objective was to gain insight into the knowledge, understanding, and experiences of women treated for cervical cancer at the specific hospital.

METHODS

We selected a qualitative research design and descriptive phenomenological approach for the study. Twenty-one (n = 21) semistructured interviews directed by an interview schedule were conducted. We used Patton's open coding steps and a template analyses style guided by the 4 themes of the interview schedule to analyze the data.

RESULTS

Most participants indicated that they did not know and understand anything of cervical cancer. They believed they were bewitched and consulted traditional healers and used traditional medicine. Most described that they experienced symptoms for extended periods of time before they were diagnosed. They described how the offensive vaginal bleeding and watery discharge they experienced led to isolation, rejection, and humiliation. The participants said they did not understand how they would be treated and treatment was described as a terrible experience.

CONCLUSIONS

The women's lived experiences of cervical cancer tell of severe suffering. They knew and understood very little about this disease. Their suffering became so unbearable that some wanted to end their lives. They were subjected to the opinions of others who knew equally as little but were quite willing to speak out, judge, and reject. Most battled through the treatment and the distressing adverse effects because it was their only hope to become better.

RECOMMENDATIONS

Zambian women must be empowered with knowledge and skills to protect themselves against cervical cancer. Suggestions for improving outcomes include changing high-risk behavior, taking advantage of screening opportunities, recognizing the signs of cervical cancer, and seeking health care without delay.

Global cancer consortiums: moving from consensus to practice

PURPOSE AND DESIGN

The failure to translate cancer knowledge into action contributes to regional, national, and international health inequities. Disparities in cancer care are the most severe in low-resource settings, where delivery obstacles are compounded by health infrastructure deficits and inadequate basic services. Global cancer consortiums (GCCs) have developed to strengthen cancer care expertise, advance knowledge on best practices, and bridge the cancer gap worldwide. Within the complex matrix of public health priorities, consensus is emerging on cost-effective cancer care interventions in low- and medium-resource countries, which include the critical role of surgical services. Distinct from traditional health partnerships that collaborate to provide care at the local level, GCCs collaborate more broadly to establish consensus on best practice models for service delivery. To realize the benefit of programmatic interventions and achieve tangible improvements in patient outcomes, GCCs must construct and share evidence-based implementation strategies to be tested in real world settings.

REVIEW AND CONCLUSIONS

Implementation research should inform consensus formation, program delivery, and outcome monitoring to achieve the goals articulated by GCCs. Fundamental steps to successful implementation are: (1) to adopt an integrated, multisectoral plan with local involvement; (2) to define shared implementation priorities by establishing care pathways that avoid prescriptive but suboptimal health care delivery; (3) to build capacity through education, technology transfer, and surveillance of outcomes; and (4) to promote equity and balanced collaboration. GCCs can bridge the gap between what is known and what is done, translating normative sharing of clinical expertise into tangible improvements in patient care.

Risk factors for Kaposi's sarcoma among HIV-positive individuals in a case control study in Cameroon

BACKGROUND

Individuals co-infected with Kaposi's sarcoma herpesvirus (KSHV) and Human Immunodeficiency Virus (HIV) are at greatly increased risk of developing Kaposi's sarcoma (KS). The objective of the current analysis is to identify risk cofactors for KS among HIV-positive individuals.

METHODS

We conducted a case-control study of KS in Cameroon on 161 HIV-positive and 14 HIV-negative cases and 680 HIV-positive and 322 HIV-negative controls. Participants answered a physician-administered questionnaire and provided blood and saliva specimens. Antibodies against KSHV lytic, K8.1, and latent, ORF73, antigens were measured by ELISA to determine KSHV serostatus. Conditional logistic regression was performed to determine multivariate odds ratios (OR) and 95% confidence intervals (CI) for risk factors associated with KS among HIV-positive cases and controls.

RESULTS

Overall, 98% (158) of HIV-positive cases, 100% (14) of HIV-negative cases, 81% (550) of HIV-positive controls, and 80% (257) of HIV-negative controls were KSHV seropositive. Risk factors for KS among HIV-positive individuals included KSHV seropositivity (OR=9.6; 95% CI 2.9, 31.5), non-use of a mosquito bed net (OR 1.9; 95% CI 1.2, 2.9), minority ethnicity (OR=3.1; 95% CI 1.1, 9.3), treatment from a traditional healer (OR=2.3; 95% CI 1.5, 3.7), history of transfusion (OR=2.4; 95% CI 1.5, 3.9), and family history of cancer (OR=1.9; 95% CI 1.1, 3.1).

CONCLUSION

KSHV seroprevalence of ≥80% indicates a high prevalence in the general population in Cameroon. Among HIV-positive individuals, the strong association of KS with non-use of mosquito nets and treatment from traditional healers are compelling findings, consistent with recently reported data from East Africa.

Challenges associated with the management of gynecological cancers in a tertiary hospital in South East Nigeria

BACKGROUND

There are reports of increasing incidence of gynecological cancers in developing countries and this trend increases the need for more attention to gynecological cancer care in these countries.

OBJECTIVE

The purpose of this study was to describe the presentation and treatment of gynecological cancers and identify barriers to successful gynecological cancer treatment in a tertiary hospital in South East Nigeria.

METHODS

This study was a retrospective longitudinal analysis of the presentation and treatment of histologically diagnosed primary gynecological cancers from 2000 to 2010. Analysis was by descriptive and inferential statistics at the 95% level of confidence using Statistical Package for the Social Sciences version 17 software.

RESULTS

Records of 200 gynecological cancers managed during the study period were analyzed. Over 94% of cervical cancers presented in advanced stages of the disease and received palliative/symptomatic treatment. Only 1.9% of cervical cancer patients had radical surgical intervention, and postoperative mortality from these radical surgeries was 100%. Approximately 76% of patients with ovarian cancer had debulking surgery as the mainstay of treatment followed by adjuvant chemotherapy. Postoperative mortality from ovarian cancer surgery was 63%. Cutting edge cytotoxic drugs were not used as chemotherapy for ovarian and chorionic cancers. Compliance with chemotherapy was poor, with over 70% of ovarian cancer patients failing to complete the prescribed courses of chemotherapy. Most patients with endometrial and vulval cancers had only surgical treatment, as compliance with follow-up for adjuvant chemotherapy or radiotherapy was poor. Functional radiotherapy facilities were not available at the center during the study period, thereby necessitating external referrals to centers hundreds of kilometers away.

CONCLUSION

Late presentation of cases, noncompliance with treatment regimens, lack of use of cutting edge cytotoxic drugs, the poor outcome of radical surgeries, and lack of a functional radiotherapy facility combined to create a very difficult gynecological cancer care environment at the study center.

An mHealth model to increase clinic attendance for breast symptoms in rural Bangladesh: can bridging the digital divide help close the cancer divide?

OBJECTIVE

To demonstrate proof of concept for a smart phone-empowered community health worker (CHW) model of care for breast health promotion, clinical breast examination (CBE), and patient navigation in rural Bangladesh.

METHODS

This study was a randomized controlled trial; July 1 to October 31, 2012, 30 CHWs conducted door-to-door interviews of women aged 25 and older in Khulna Division. Only women who disclosed a breast symptom were offered CBE. Arm A: smart phone with applications to guide interview, report data, show motivational video, and offer appointment for women with an abnormal CBE. Arm B: smart phone/applications identical to Arm A plus CHW had training in "patient navigation" to address potential barriers to seeking care. Arm C: control arm (no smart phone; same interview recorded on paper). Outcomes are presented as the "adherence" (to advice regarding a clinic appointment) for women with an abnormal CBE. This study was approved by Women's College Hospital Research Ethics Board (Toronto, Ontario, Canada) and district government officials (Khulna, Bangladesh). Funded by Grand Challenges Canada.

RESULTS

In 4 months, 22,337 women were interviewed; <1% declined participation, and 556 women had an abnormal CBE. Control group CHWs completed fewer interviews, had inferior data quality, and identified significantly fewer women with abnormal breast exams compared with CHWs in arms A and B. Arm B had the highest adherence.

CONCLUSION

CHWs guided by our smart phone applications were more efficient and effective in breast health promotion compared with the control group. CHW "navigators" were most effective in encouraging women with an abnormal breast examination to adhere to advice regarding clinic attendance.

Risk factors for pregnancy-associated breast cancer: a report from the Nigerian Breast Cancer Study

PURPOSE

Little is known about risk factors for pregnancy-associated breast cancer (PABC), diagnosed during pregnancy or postpartum.

METHODS

We enrolled 1715 premenopausal women from the Nigerian Breast Cancer Study from 1998 to 2011. Based on recency of last pregnancy from diagnosis, breast cancer cases were categorized as (1) PABC diagnosed 2 years or longer postpartum, (2) PABC diagnosed 3 to 5 years postpartum, or (3) non-PABC diagnosed more than 5 years postpartum. Controls were matched to cases on recency of last pregnancy. Multiple logistic regressions were performed comparing cases and controls within each group.

RESULTS

Of the 718 cases, 152 (21.2%) had PABC 2 or more years postpartum, and 145 (20.2%) 3 to 5 years postpartum. Although not statistically significant, women with higher parity tend to have an elevated risk of PABC but reduced risk of non-PABC (p for heterogeneity = 0.097). Family history of breast cancer might be a strong predictor particularly for PABC 2 or more years postpartum (odds ratio, 3.28; 95% confidence interval, 1.05-10.3). Compared with non-PABC cases, PABC 2 or more years postpartum cases were more likely to carry BRCA1/2 mutations (P = .03).

CONCLUSIONS

Parity may have different roles in the development of PABC versus other premenopausal breast cancer in Nigerian women. Prospective mothers with multiple births and a family history of breast cancer may have an elevated risk of breast cancer during their immediate postpartum period.

Burden of gynaecological cancers in developing countries

Approximately 1:4 of all cancers in women in developing countries (excluding non-melanoma skin cancer) is a gynaecological cancer. The gynaecological cancer burden in developing countries is huge primarily due to the high incidence and mortality of cervical cancer. Cervical cancer accounts for over 60% of the gynaecological cancer burden in developing countries despite being preventable by current technologies. This is due to the absence of effective nationally organized screening programmes in most developing countries. Institution of such programmes, therefore, has the potential to dramatically reduce gynaecological cancer burden in these countries. Subsidized human papilloma virus (HPV) vaccine and HPV typing as well as cheap screening techniques such as visual inspection aided with acetic acid hold the key to effective prevention of cervical cancer in these countries. This is because a significant proportion of patients in developing countries are unable to access and avail themselves of the few available preventive, diagnostic and treatment services because of poverty. Although, advocacy and the political will to invest in the development of human resources and healthcare infrastructure appear critical to gynaecological cancer control and reducing the burden of disease in many developing countries, the proposition assumes that resources are truly available for this investment. This may not be true. Many developing countries rely on foreign aids for developmental programmes and these aids have dwindled significantly with the current global economic meltdown.

Breast-cancer screening with trained volunteers in a rural area of Sudan: a pilot study

BACKGROUND

Breast cancer has a low cure rate in low-income and middle-income countries because patients often present with late-stage disease that has metastasised to other organs. We assessed whether the implementation of a cancer awareness and breast examination programme that uses local, volunteer women could increase the early detection of breast cancer in a rural area of sub-Saharan Africa.

METHODS

We did this pilot study in two counties in Gezira State, Sudan. We chose Keremet (56 villages) as the experimental county and Abugota (79 villages) as the control county. Female volunteers from villages in Keremet were trained in the detection of breast abnormalities. When trained, volunteers visited households in their village and screened women aged 18 years or older for breast abnormalities, referring women with suspected breast cancer for medical diagnosis and, if necessary, treatment at the district hospital. We also ran a cancer awareness programme for both men and women in study villages. Villages in the control population received no intervention. This study is ongoing.

FINDINGS

Between Jan 1, 2010, and Oct 10, 2012, 10 309 (70%) of 14 788 women in Keremet were screened. 138 women were identified as having breast abnormalities and were referred to the district hospital for diagnosis and treatment. 20 of these women did not report to the hospital. Of the 118 women who did report, 101 were diagnosed with benign lesions, eight with carcinoma in situ, and nine had malignant disease. After treatment, 12 of the 17 women with either carcinoma in situ or malignant disease (four had early breast cancer and eight had ductal carcinoma in situ) were disease-free and had a good prognosis. In the control villages, only four women reported to the centre: one was found to have a benign lesion while three were diagnosed with advanced disease.

INTERPRETATION

Our findings show that a screening programme using local volunteers can increase the detection of breast cancer in asymptomatic women in low-income rural communities. These findings can inform policy-makers' decisions in the design of cancer control programmes in Sudan and other similar areas in sub-Saharan Africa.

FUNDING

Sudan National Cancer Institute.