AMPATH-Oncology: A model for comprehensive cancer care in sub-Saharan Africa

Breast Health Awareness: Understanding Health-Seeking Behavior in Western Kenya

INTRODUCTION

In Kenya, patients with breast cancer predominantly present with late-stage disease and experience poor outcomes. To promote early-stage diagnosis, we implemented the Academic Model Providing Access to Healthcare (AMPATH) Breast and Cervical Cancer Control Program (ABCCCP) in Western Kenya.

OBJECTIVE

The aim of this study was to assess differences between patients presenting to health facilities and health fairs.

METHODS

This was an institutional Review and Ethics Commitee-approved retrospective cohort study of all individuals who underwent clinical breast examination (CBE) via local healthcare workers in Western Kenya. From 2017 to 2021, the program hosted health fairs, and trained healthcare providers at health facilities to complete CBEs. Results were analyzed using the Chi-square and Kruskal-Wallis tests, with an α < 0.05.

RESULTS

Over a 5-year period, the ABCCCP completed 61,812 CBEs with 75.9% (n = 46,902) performed at a health facility. Patients presenting to health fairs were older (44 vs. 38 years; p < 0.0001) and had higher risk factor rates including early menarche, family history of breast and ovarian cancer, and use of alcohol or smoking. Only 27.6% of patients with an abnormal CBE underwent core needle biopsy, and only 5.2% underwent repeat CBE over the 5-year period, of whom 90.3% presented to health facilities.

CONCLUSIONS

Successful uptake of CBE through the ABCCCP is the first step to introduce breast health awareness (BHA). Benefits of broad advertisements for health fairs in promoting BHA may be limited to a single event. Poor rates of repeat examinations and diagnostic testing of abnormal CBEs indicate additional resources should be allocated to educating patients, including about possible treatment trajectories for breast cancer.

The impact of in-house pathology services on downstaging cervical cancer in Tanzania over an 18-year period

PURPOSE

Reducing time between cancer screening, diagnosis, and initiation of treatment is best achieved when services are available in the same hospital. Yet, comprehensive cancer centers are typically unavailable in low- and middle-income countries (LMICs), where resources are limited and services scattered. This study explored the impact of establishing an in-house pathology laboratory at the largest public cancer hospital in Tanzania on the downstaging of cervical cancer.

METHODS

We examined clinical datasets of 8,322 cervical cancer patients treated at the Ocean Road Cancer Institute (ORCI). The first period included patients treated from 2002 to 2016, before establishment of the pathology laboratory at ORCI; the second period (post-pathology establishment) included data from 2017 to 2020. Logistic regression analysis evaluated the impact of the pathology laboratory on stage of cervical cancer diagnosis.

RESULTS

Patients treated during the post-pathology period were more likely to be clinically diagnosed at earlier disease stages compared to patients in the pre-pathology period (pre-pathology population diagnosed at early disease stage: 44.08%; post-pathology population diagnosed at early disease stage: 59.38%, p < 0.001). After adjustment for age, region of residence, and place of biopsy, regression results showed patients diagnosed during the post-pathology period had higher odds of early stage cervical cancer diagnosis than patients in the pre-pathology period (OR 1.35, 95% CI (1.16, 1.57), p < 0.001).

CONCLUSIONS

Integrated and comprehensive cancer centers can overcome challenges in delivering expedited cervical cancer diagnosis and treatment. In-house pathology laboratories play an important role in facilitating timely diagnosis and rapid treatment of cervical and possibly other cancers in LMICs.

Global Cancer Surgery: pragmatic solutions to improve cancer surgery outcomes worldwide

The first Lancet Oncology Commission on Global Cancer Surgery was published in 2015 and serves as a landmark paper in the field of cancer surgery. The Commission highlighted the burden of cancer and the importance of cancer surgery, while documenting the many inadequacies in the ability to deliver safe, timely, and affordable cancer surgical care. This Commission builds on the first Commission by focusing on solutions and actions to improve access to cancer surgery globally, developed by drawing upon the expertise from cancer surgery leaders across the world. We present solution frameworks in nine domains that can improve access to cancer surgery. These nine domains were refined to identify solutions specific to the six WHO regions. On the basis of these solutions, we developed eight actions to propel essential improvements in the global capacity for cancer surgery. Our initiatives are broad in scope, pragmatic, affordable, and contextually applicable, and aimed at cancer surgeons as well as leaders, administrators, elected officials, and health policy advocates. We envision that the solutions and actions contained within the Commission will address inequities and promote safe, timely, and affordable cancer surgery for every patient, regardless of their socioeconomic status or geographic location.

Role of digital health in coordinating patient care in a hub-and-spoke hierarchy of cancer care facilities: a scoping review

Background

Coordinating cancer care is complicated due to the involvement of multiple service providers which often leads to fragmentation. The evolution of digital health has led to the development of technology-enabled models of healthcare delivery. This scoping review provides a comprehensive summary of the use of digital health in coordinating cancer care via hub-and-spoke models.

Methods

A scoping review of the literature was undertaken using the framework developed by Arksey and O'Malley. Research articles published between 2010 and 2022 were retrieved from four electronic databases (PubMed/MEDLINE, Web of Sciences, Cochrane Reviews and Global Health Library). The preferred reporting items for systematic reviews and meta-analyses extension for the scoping reviews (PRISMA-ScR) checklist were followed to present the findings.

Result

In total, 311 articles were found of which 7 studies that met the inclusion criteria were included. The use of videoconferencing was predominant across all the studies. The number of spokes varied across the studies ranging from 1 to 63. Three studies aimed to evaluate the impact on access to cancer care among patients, two studies were related to capacity building of the health care workers at the spoke sites, one study was based on a peer review of radiotherapy plans, and one study was related to risk assessment and patient navigation. The introduction of digital health led to reduced travel time and waiting period for patients, and standardisation of radiotherapy plans at spokes. Tele-mentoring intervention aimed at capacity-building resulted in higher confidence and increased knowledge among the spoke learners.

Conclusion

There is limited evidence for the role of digital health in the hub-and-spoke design. Although all the studies have highlighted the digital components being used to coordinate care, the bottlenecks, Which were overcome during the implementation of the interventions and the impact on cancer outcomes, need to be rigorously analysed.

Bilateral trauma case conferences: an approach to global surgery equity through a virtual education exchange

Purpose

With increased interest in international surgical experiences, many residency programs have integrated global surgery into their training curricula. For surgical trainees in low- and middle-income countries (LMICs), physical exchange can be costly, and laws in high-income countries (HICs) prevent LMIC trainees from practicing surgery while on visiting rotations. To enrich the educational experience of trainees in both settings, we established a monthly virtual trauma conference between surgery training programs.

Methods

General surgery teams from two public institutions, a public university with two surgical training programs in Kenya and a public university with two level I trauma centers in the United States, meet monthly to discuss complex and interesting trauma patients. A trainee from each institution presents a clinical case vignette and supplements the case with pertinent peer-reviewed literature. The attendees then answer a series of multiple-choice questions like those found on surgery board exams.

Results

Monthly case conferences began in September 2017 with an average of 24 trainees and consultant surgeons. Case discussions serve to stimulate dialogue on patient presentation and management, highlighting cost-conscious, high-quality care and the need to adapt practice patterns to meet resource constraints and provide culturally appropriate care.

Conclusion

Our 5-year experience with this virtual case conference has created a unique and robust surgical education experience for trainees and surgeons who have withstood the effects of the pandemic. These case conferences have not only strengthened the camaraderie between our departments, but also promoted equity in global surgery education and prioritized the learning of trainees from both settings.

Cancer research across Africa: a comparative bibliometric analysis

INTRODUCTION

Research is a critical pillar in national cancer control planning. However, there is a dearth of evidence for countries to implement affordable strategies. The WHO and various Commissions have recommended developing stakeholder-based needs assessments based on objective data to generate evidence to inform national and regional prioritisation of cancer research needs and goals.

METHODOLOGY

Bibliometric algorithms (macros) were developed and validated to assess cancer research outputs of all 54 African countries over a 12-year period (2009-2020). Subanalysis included collaboration patterns, site and domain-specific focus of research and understanding authorship dynamics by both position and sex. Detailed subanalysis was performed to understand multiple impact metrics and context relative outputs in comparison with the disease burden as well as the application of a funding thesaurus to determine funding resources.

RESULTS

African countries in total published 23 679 cancer research papers over the 12-year period (2009-2020) with the fractional African contribution totalling 16 201 papers and the remaining 7478 from authors from out with the continent. The total number of papers increased rapidly with time, with an annual growth rate of 15%. The 49 sub-Saharan African (SSA) countries together published just 5281 papers, of which South Africa's contribution was 2206 (42% of the SSA total, 14% of all Africa) and Nigeria's contribution was 997 (19% of the SSA total, 4% of all Africa). Cancer research accounted for 7.9% of all African biomedical research outputs (African research in infectious diseases was 5.1 times than that of cancer research). Research outputs that are proportionally low relative to their burden across Africa are paediatric, cervical, oesophageal and prostate cancer. African research mirrored that of Western countries in terms of its focus on discovery science and pharmaceutical research. The percentages of female researchers in Africa were comparable with those elsewhere, but only in North African and some Anglophone countries.

CONCLUSIONS

There is an imbalance in relevant local research generation on the continent and cancer control efforts. The recommendations articulated in our five-point plan arising from these data are broadly focused on structural changes, for example, overt inclusion of research into national cancer control planning and financial, for example, for countries to spend 10% of a notional 1% gross domestic expenditure on research and development on cancer.

Coordination Models for Cancer Care in Low- and Middle-Income Countries: A Scoping Review

Background: The coordination of cancer care among multiple providers is vital to improve care quality and ensure desirable health outcomes across the cancer continuum, yet evidence is scarce of this being optimally achieved in low- and middle-income countries (LMICs). Objective: Through this scoping review, our objective was to understand the scope of cancer care coordination interventions and services employed in LMICs, in order to synthesise the existing evidence and identify key models and their elements used to manage and/or improve cancer care coordination in these settings. Methods: A detailed search strategy was conducted, aligned with the framework of Arksey and O’Malley. Articles were examined for evidence of coordination interventions used in cancer care in LMICs. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension Guidelines for Scoping Reviews, which included a checklist and explanation. The PRISMA flow diagram was utilised to report the screening of results. Data were extracted, categorised and coded to allow for a thematic analysis of the results. Results: Fourteen studies reported on coordination interventions in cancer care in LMICs. All studies reported a positive impact of cancer coordination interventions on the primary outcome measured. Most studies reported on a patient navigation model at different points along the cancer care continuum. Conclusions: An evidence-based and culturally sensitive plan of care that aims to promote coordinated and efficient multidisciplinary care for patients with suspicion or diagnosis of cancer in LMICs is feasible and might improve the quality of care and efficiency.

Improving identification of symptomatic cancer at primary care clinics: A predictive modeling analysis in Botswana

In resource-limited settings, augmenting primary care provider (PCP)-based referrals with data-derived algorithms could direct scarce resources towards those patients most likely to have a cancer diagnosis and benefit from early treatment. Using data from Botswana, we compared accuracy of predictions of probable cancer using different approaches for identifying symptomatic cancer at primary clinics. We followed cancer suspects until they entered specialized care for cancer treatment (following pathologically confirmed diagnosis), exited from the study following noncancer diagnosis, or died. Routine symptom and demographic data included baseline cancer probability assessed by the primary care provider (low, intermediate, high), age, sex, performance status, baseline cancer probability by study physician, predominant symptom (lump, bleeding, pain or other) and HIV status. Logistic regression with 10-fold cross-validation was used to evaluate classification by different sets of predictors: (1) PCPs, (2) Algorithm-only, (3) External specialist physician review and (4) Primary clinician augmented by algorithm. Classification accuracy was assessed using c-statistics, sensitivity and specificity. Six hundred and twenty-three adult cancer suspects with complete data were retained, of whom 166 (27%) were diagnosed with cancer. Models using PCP augmented by algorithm (c-statistic: 77.2%, 95% CI: 73.4%, 81.0%) and external study physician assessment (77.6%, 95% CI: 73.6%, 81.7%) performed better than algorithm-only (74.9%, 95% CI: 71.0%, 78.9%) and PCP initial assessment (62.8%, 95% CI: 57.9%, 67.7%) in correctly classifying suspected cancer patients. Sensitivity and specificity statistics from models combining PCP classifications and routine data were comparable to physicians, suggesting that incorporating data-driven algorithms into referral systems could improve efficiency.

Delays Experienced by Patients With Pediatric Cancer During the Health Facility Referral Process: A Study in Northern Tanzania

PURPOSE

It is estimated that 50%-80% of patients with pediatric cancer in sub-Saharan Africa present at an advanced stage. Delays can occur at any time during the care-seeking process from symptom onset to treatment initiation. Referral delay, the time from first presentation at a health facility to oncologist evaluation, is a key component of total delay that has not been evaluated in sub-Saharan Africa.

METHODS

Over a 3-month period, caregivers of children diagnosed with cancer at a regional cancer center (Bugando Medical Centre [BMC]) in Tanzania were consecutively surveyed to determine the number and type of health facilities visited before presentation, interventions received, and transportation used to reach each facility.

RESULTS

Forty-nine caregivers were consented and included in the review. A total of 124 facilities were visited before BMC, with 31% of visits (n = 38) resulting in a referral. The median referral delay was 89 days (mean, 122 days), with a median of two facilities (mean, 2.5 facilities) visited before presentation to BMC. Visiting a traditional healer first significantly increased the time taken to reach BMC compared with starting at a health center/dispensary (103 v 236 days; P = .02). Facility visits in which a patient received a referral to a higher-level facility led to significantly decreased time to reach BMC (P < .0001). Only 36% of visits to district hospitals and 20.6% of visits to health centers/dispensaries yielded a referral, however.

CONCLUSION

The majority of patients were delayed during the referral process, but receipt of a referral to a higher-level facility significantly shortened delay time. Referral delay for pediatric patients with cancer could be decreased by raising awareness of cancer and strengthening the referral process from lower-level to higher-level facilities.

Modeling spatial access to cervical cancer screening services in Ondo State, Nigeria

BACKGROUND

Women in low- and middle-income countries (LMIC) remain at high risk of developing cervical cancer and have limited access to screening programs. The limits include geographical barriers related to road network characteristics and travel behaviors but these have neither been well studied in LMIC nor have methods to overcome them been incorporated into cervical cancer screening delivery programs.

METHODS

To identify and evaluate spatial barriers to cervical cancer prevention services in Ondo State, Nigeria, we applied a Multi-Mode Enhanced Two-Step Floating Catchment Area model to create a spatial access index for cervical cancer screening services in Ondo City and the surrounding region. The model used inputs that included the distance between service locations and population centers, local population density, quantity of healthcare infrastructures, modes of transportation, and the travel time budgets of clients. Two different travel modes, taxi and mini bus, represented common modes of transit. Geocoded client residential locations were compared to spatial access results to identify patterns of spatial access and estimate where gaps in access existed.

RESULTS

Ondo City was estimated to have the highest access in the region, while the largest city, Akure, was estimated to be in only the middle tier of access. While 73.5% of clients of the hospital in Ondo City resided in the two highest access zones, 21.5% of clients were from locations estimated to be in the lowest access catchment, and a further 2.25% resided outside these limits. Some areas that were relatively close to cervical cancer screening centers had lower access values due to poor road network coverage and fewer options for public transportation.

CONCLUSIONS

Variations in spatial access were revealed based on client residential patterns, travel time differences, distance decay assumptions, and travel mode choices. Assessing access to cervical cancer screening better identifies potentially underserved locations in rural Nigeria that can inform plans for cervical cancer screening including new or improved infrastructure, effective resource allocation, introduction of service options for areas with lower access, and design of public transportation networks.

Elicitation and prioritization of requirements for electronic health records for oncology in low resource settings: A concept mapping study

BACKGROUND

Understanding functional and non-functional requirements is essential to successfully implement electronic medical record (EMR) systems. Actual requirements will be different for different contexts.

OBJECTIVE

To elicit and prioritize requirements for implementing EMRs in oncology in low and middle income countries (LMICs), and to relate these to requirements from high-income countries.

PARTICIPANTS AND SETTING

Cancer care stakeholders including oncologists, general doctors, nurses, biostatisticians, information technologists, from different LMICs, were involved.

METHODS

Concept mapping was used. Statements of requirements were obtained during focus group discussions (FGDs) and interviews. Using surveys, the requirements were clustered and ranked on importance and feasibility. Data were analyzed in SPSS using agglomerative hierarchical clustering and multidimensional scaling, to create cluster maps and go-zone maps reflecting the relationships between the requirements and their prioritization.

RESULTS

Four FGD sessions, with twenty participants, were conducted. In addition, six participants were interviewed. Twenty-two participants clustered the requirements and sixty-three participants ranked them on importance and feasibility. One hundred and sixty requirement statements were generated which were reduced to sixty-four after de-duplication and merging. Nine clusters were obtained encompassing the following domains, in order of importance: Security, Conducive organization, Management/Governance, General EMR functionalities, Computer infrastructure, Data management, Usability, Oncology decision support, and Ancillary requirements. On ranking, the requirements scored between 3.74 and 4.80 on importance, and between 3.55 and 4.46 on feasibility, on a 5-point Likert scale. We generated concept maps for use when communicating with stakeholders.

CONCLUSION

For oncology EMRs in LMICs, requirements overlap those from high-income countries, but generic EMR functionalities, Infrastructural and organizational requirements are still considered priority in LMICs compared to oncology-specific requirements or advanced EMR features e.g. computerized decision support or interoperability. Concept mapping is a fast and cost-effective method for eliciting and prioritizing EMR requirements in a user-centered manner.

Cancer in Kenya: types and infection-attributable. Data from the adult population of two National referral hospitals (2008-2012)

Background: Cancer in Africa is an emerging health problem. In Kenya it ranks third as a cause of death after infectious and cardiovascular diseases. Nearly 31% of the total cancer burden in sub-Saharan Africa is attributable to infectious agents. Information on cancer burden is scanty in Kenya and this study aimed to provide comprehensive hospital based data to inform policies. Method: A cross-sectional retrospective survey was conducted at Kenyatta National Hospital (KNH) and Moi Teaching and Referral Hospital (MTRH) from January 2008 to December 2012.  Data was obtained from the patients files and the study was approved by the KNH/University of Nairobi and MTRH Ethics and Research Committees.   Results: In KNH, the top five cancers were: cervical (62, 12.4%), breast (59, 11.8%), colorectal (31, 6.2%), chronic leukemia (27, 5.4%) and stomach cancer (26, 5.2%). Some 154 (30.8%) of these cancers were associated with infectious agents, while an estimated 138 (27.6%) were attributable to infections. Cancers of the cervix (62, 12.4%), stomach (26, 5.2%) and nasopharynx (17, 3.4%) were the commonest infection-associated cancers. In MTRH, the five common types of cancers were Kaposi's sarcoma (93, 18.6%), breast (77, 15.4%), cervical (41, 8.2%), non-Hodgkin's lymphoma (37, 7.4%) and colorectal, chronic leukemia and esophageal cancer all with 27 (5.4%). Some 241 (48.2%) of these cancers were associated with infectious agents, while an estimated 222 (44.4%) were attributable to infections. Kaposi's sarcoma (93, 18.6%), cancer of the cervix (41, 8.2%) and non-Hodgkin's lymphoma (37, 7.4%) were the commonest infection-associated cancers. Conclusion: Our results suggest that 30.8% and 48.2% of the total cancer cases sampled in KNH and MTRH respectively were associated with infectious agents, while 27.6% and 44.4% were attributable to infections in the two hospitals respectively. Reducing the burden of infection-attributable cancers can translate to a reduction of the overall cancer burden.

Cancer in Kenya: types and infection-attributable. Data from the adult population of two National referral hospitals (2008-2012)

Background: Cancer in Africa is an emerging health problem. In Kenya it ranks third as a cause of death after infectious and cardiovascular diseases. Nearly 31% of the total cancer burden in sub-Saharan Africa is attributable to infectious agents. Information on cancer burden is scanty in Kenya and this study aimed to provide comprehensive hospital based data to inform policies. Method: A cross-sectional retrospective survey was conducted at Kenyatta National Hospital (KNH) and Moi Teaching and Referral Hospital (MTRH) from January 2008 to December 2012.  Data was obtained from the patients files and the study was approved by the KNH/University of Nairobi and MTRH Ethics and Research Committees.   Results: In KNH, the top five cancers were: cervical (62, 12.4%), breast (59, 11.8%), colorectal (31, 6.2%), chronic leukemia (27, 5.4%) and stomach cancer 26 (5.2%). Some 154 (30.8%) of these cancers were associated with infectious agents, while an estimated 138 (27.6%) were attributable to infections. Cancers of the cervix (62, 12.4%), stomach (26, 5.2%) and nasopharynx (17, 3.4%) were the commonest infection-associated cancers. In MTRH, the five common types of cancers were Kaposi's sarcoma (93, 18.6%), breast (77, 15.4%), cervical (41, 8.2%), non-Hodgkin's lymphoma (37, 7.4%) and colorectal, chronic leukemia and esophageal cancer all with 27 (5.4%). Some 241 (48.2%) of these cancers were associated with infectious agents, while an estimated 222 (44.4%) were attributable to infections. Kaposi's sarcoma (93, 18.6%), cancer of the cervix (41, 8.2%) and non-Hodgkin's lymphoma (37, 7.4%) were the commonest infection-associated cancers. Conclusion: Our results suggest that 30.8% and 48.2% of the total cancer cases sampled in KNH and MTRH respectively were associated with infectious agents, while 27.6% and 44.4% were attributable to infections in the two hospitals respectively. Reducing the burden of infection-attributable cancers can translate to a reduction of the overall cancer burden.

Developing institutions for cancer care in low-income and middle-income countries: from cancer units to comprehensive cancer centres

Global cancer centres operate across different sizes, scales, and ecosystems. Understanding the essential aspects of the creation, organisation, accreditation, and activities within these settings is crucial for developing an affordable, equitable, and quality cancer care, research, and education system. Robust guidelines are scarce for cancer units, cancer centres, and comprehensive cancer centres in low-income and middle-income countries. However, some robust examples of the delivery of complex cancer care in centres in emerging economies are available. Although it is impossible to create an optimal system to fit the unique needs of all countries for the delivery of cancer care, we summarise what has been published about the development and management of cancer centres in low-income and middle-income countries so far and highlight the need for clinical and political leadership.

Improving pathology and laboratory medicine in low-income and middle-income countries: roadmap to solutions

Insufficient awareness of the centrality of pathology and laboratory medicine (PALM) to a functioning health-care system at policy and governmental level, with the resultant inadequate investment, has meant that efforts to enhance PALM in low-income and middle-income countries have been local, fragmented, and mostly unsustainable. Responding to the four major barriers in PALM service delivery that were identified in the first paper of this Series (workforce, infrastructure, education and training, and quality assurance), this second paper identifies potential solutions that can be applied in low-income and middle-income countries (LMICs). Increasing and retaining a quality PALM workforce requires access to mentorship and continuing professional development, task sharing, and the development of short-term visitor programmes. Opportunities to enhance the training of pathologists and allied PALM personnel by increasing and improving education provision must be explored and implemented. PALM infrastructure must be strengthened by addressing supply chain barriers, and ensuring laboratory information systems are in place. New technologies, including telepathology and point-of-care testing, can have a substantial role in PALM service delivery, if used appropriately. We emphasise the crucial importance of maintaining PALM quality and posit that all laboratories in LMICs should participate in quality assurance and accreditation programmes. A potential role for public-private partnerships in filling PALM services gaps should also be investigated. Finally, to deliver these solutions and ensure equitable access to essential services in LMICs, we propose a PALM package focused on these countries, integrated within a nationally tiered laboratory system, as part of an overarching national laboratory strategic plan.

A descriptive qualitative study of childhood cancer challenges in South Africa: Thematic analysis of 68 photovoice contributions

<strong>Background:</strong> Many childhood cancers are treatable with cure rates between 70% and 80% in well-resourced countries, while approximately 80% of African children with cancer die without access to adequate care. South Africa has an established oncology health care service with overburdened infrastructure, low cancer awareness in the primary health care service and widespread service delivery challenges.<br /><strong>Aim:</strong> The aim of this study was to explore, document and analyse the subjective experience of childhood cancer-related challenges in South Africa, and to make the results available to stakeholders.<br /><strong>Setting:</strong> A total of 58 patient-participants (childhood cancer patients, parents and guardians of children with cancer) and 10 paediatric oncology workers (oncology social workers, oncology nurses and interim home carers) were selected from tertiary oncology centres and from the Childhood Cancer Foundation of South Africa (CHOC) interim care homes across South Africa.<br /><strong>Method:</strong> Participants were selected via convenience sampling and qualitative data were derived from face-to-face photovoice interviews conducted by psychologists and social workers and supported by translators when necessary.<br /><strong>Results:</strong> Nine themes of cancer challenges were identified via thematic content analysis of the photo-narratives, that is, physical and treatment challenges, emotional, poor services, transport, finances, information, powerlessness, stigma and schooling challenges.<br /><strong>Conclusion:</strong> Lack of awareness and knowledge about cancer at the African traditional healer, primary and regional health care service levels were frequent challenges. Important feedback included lack of patient-centred care, separation of children with cancer from guardians, diagnostic delays, permanent disabilities for children because of cancer, emotional trauma, special needs of teenagers and a lack of community and palliative care support.

Guidelines in lower-middle income countries

Guidelines include recommendations intended to optimize patient care; used appropriately, they make healthcare consistent and efficient. In most lower-middle income countries (LMICs), there is a paucity of well-designed guidelines; as a result, healthcare workers depend on guidelines developed in Higher Income Countries (HICs). However, local guidelines are more likely to be implemented because they are applicable to the specific environment; and consider factors such as availability of resources, specialized skills and local culture. If guidelines developed in HICs are to be implemented in LMICs, developers need to incorporate local experts in their development. Involvement of local stakeholders may improve the rates of implementation by identifying and removing barriers to implementation in LMICs. Another option is to encourage local experts to adapt them for use in LMICs; these guidelines may recommend strategies different from those used in HICs, but will be aimed at achieving the best practicable standard of care. Infrastructural deficits in LMICs could be improved by learning from and building on the successful response to the human immunodeficiency virus/acquired immunodeficiency syndrome pandemic through interactions between HICs and LMICs. Similarly, collaborations between postgraduate medical colleges in both HICs and LMICs may help specialist doctors training in LMICs develop skills required for guideline development and implementation.

Changing global policy to deliver safe, equitable, and affordable care for women's cancers

Breast and cervical cancer are major threats to the health of women globally, particularly in low-income and middle-income countries. Radical progress to close the global cancer divide for women requires not only evidence-based policy making, but also broad multisectoral collaboration that capitalises on recent progress in the associated domains of women's health and innovative public health approaches to cancer care and control. Such multisectoral collaboration can serve to build health systems for cancer, and more broadly for primary care, surgery, and pathology. This Series paper explores the global health and public policy landscapes that intersect with women's health and global cancer control, with new approaches to bringing policy to action. Cancer is a major global social and political priority, and women's cancers are not only a tractable socioeconomic policy target in themselves, but also an important Trojan horse to drive improved cancer control and care.

Understanding the Challenges of Providing Holistic Oncology Nursing Care in Nigeria

This article describes the current state of cancer nursing and the various challenges that hinder the provision of effective nursing care to cancer patients in Nigeria. The major issue identified was the lack of specialized oncology nursing education which should actually form a basis for nurses to practice in the oncology setting. Other issues include poor facilities for oncology nursing care, lack of specific cancer centers resulting in the management of cancer patients in non-specialist wards. It is therefore recommended that solidified structure be put in place in order to establish and strengthen the nursing curriculum which has a strong potential for improving the knowledge and skills of nurses to care for people living with cancer in Nigeria.

Initiating Childhood Cancer Treatment in Rural Rwanda: A Partnership-Based Approach

BACKGROUND

More than 85% of pediatric cancer cases and 95% of deaths occur in resource-poor countries that use less than 5% of the world's health resources. In the developed world, approximately 81% of children with cancer can be cured. Models applicable in the most resource-poor settings are needed to address global inequities in pediatric cancer treatment.

PROCEDURE

Between 2006 and 2011, a cohort of children received cancer therapy using a new approach in rural Rwanda. Children were managed by a team of a Rwandan generalist doctor, Rwandan nurse case manager, Rwanda-based US-trained pediatrician, and US-based pediatric oncologist. Biopsies and staging studies were obtained in-country. Pathologic diagnoses were made at US or European laboratories. Rwanda-based clinicians and the pediatric oncologist jointly generated treatment plans by telephone and email.

RESULTS

Treatment was provided to 24 patients. Diagnoses included lymphomas (n = 10), sarcomas (n = 9), leukemias (n = 2), and other malignancies (n = 3). Standard chemotherapy regimens included CHOP, ABVD, VA, COP/COMP, and actino-VAC. Thirteen patients were in remission at the completion of data collection. Two succumbed to treatment complications and nine had progressive disease. There were no patients who abandoned treatment. The mean overall survival was 31 months and mean disease-free survival was 18 months.

CONCLUSIONS

These data suggest that chemotherapy can be administered with curative intent to a subset of cancer patients in this setting. This approach provides a platform for pediatric cancer care models, relying on local physicians collaborating with remote specialist consultants to deliver subspecialty care in resource-poor settings.

Breast Cancer in Sub-Saharan Africa: Challenges and Opportunities to Reduce Mortality

: The objective of this review is to describe existing data on breast cancer incidence and mortality in low- and middle-income countries (LMICs), in particular in sub-Saharan Africa; identify the limitations of these data; and review what is known about breast cancer control strategies in sub-Saharan African countries and other LMICs. Available estimates demonstrate that breast cancer incidence and mortality are rising in LMICs, including in Africa, although high-quality data from LMICs (and particularly from sub-Saharan Africa) are largely lacking. Case fatality rates from breast cancer appear to be substantially higher in LMICs than in high-income countries. Significant challenges exist to developing breast cancer control programs in LMICs, perhaps particularly in sub-Saharan Africa, and the most effective strategies for treatment and early detection in the context of limited resources are uncertain. High-quality research on breast cancer incidence and mortality and implementation research to guide effective breast cancer control strategies in LMICs are urgently needed. Enhanced investment in breast cancer research and treatment in LMICs should be a global public health priority.

IMPLICATIONS FOR PRACTICE

The numbers of new cases of breast cancer, and breast cancer deaths per year, in low- and middle-income countries are rising. Engagement by the international breast cancer community is critical to reduce global disparities in breast cancer outcomes. Cancer specialists and institutions in high-income countries can serve as key partners in training initiatives, clinical care, protocol and program development, and research. This article provides an overview of what is known about breast cancer incidence, mortality, and effective strategies for breast cancer control in sub-Saharan Africa and identifies key gaps in the literature. This information can help guide priorities for engagement by the global cancer community.

Joining Forces to Overcome Cancer: The Kenya Cancer Research and Control Stakeholder Program

BACKGROUND

Cancer is the third leading cause of mortality in Kenya, accounting for 7% of annual deaths. The Kenyan Ministry of Health (MOH) is committed to reducing cancer mortality, as evidenced by policies such as the National Cancer Control Strategy (2011-2016). There are many Kenyan and international organizations devoted to this task; however, coordination is lacking among stakeholders, resulting in inefficient and overlapping expenditure of resources.

METHODS

The MOH and the NCI Center for Global Health collaboratively executed a two day workshop to improve coordination among government, NGO, and private organizations. Over 80 stakeholders participated from leading cancer research and control institutions in Kenya and the international sphere.

FINDINGS

Actionable recommendations include: establishment of a nationally representative population-based cancer registry; enhanced training for community health workers, nurses, researchers, pathologists, and oncology specialists; a reconfigured referral process, including leveraging of existing resources to improve access to cancer care; and coordinated community outreach and education. The MOH is in the process of forming a Technical Working Group (TWG) and has elected a Board of Directors for the newly established Kenyan National Cancer Institute (KNCI), with both entities committed to advancing the cancer control work of the MOH.

INTERPRETATION

This stakeholder meeting enhanced in-country networks, identified priority needs and developed actionable proposals for coordinated improvement of cancer research and control. Active, persistent follow-up by the TWG, KNCI, and other partners will be needed to turn proposals into reality and ensure that partners' investments are integrated into larger cancer control efforts prioritized by MOH.

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.

Global Health Equity: Cancer Care Outcome Disparities in High-, Middle-, and Low-Income Countries

Breakthroughs in our global fight against cancer have been achieved. However, this progress has been unequal. In low- and middle-income countries and for specific populations in high-income settings, many of these advancements are but an aspiration and hope for the future. This review will focus on health disparities in cancer within and across countries, drawing from examples in Kenya, Brazil, and the United States. Placed in context with these examples, the authors also draw basic recommendations from several initiatives and groups that are working on the issue of global cancer disparities, including the US Institute of Medicine, the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries, and the Union for International Cancer Control. From increasing initiatives in basic resources in low-income countries to rapid learning systems in high-income countries, the authors argue that beyond ethics and equity issues, it makes economic sense to invest in global cancer control, especially in low- and middle-income countries.

Implementation Science for Global Oncology: The Imperative to Evaluate the Safety and Efficacy of Cancer Care Delivery

PURPOSE

The development of cancer care treatment facilities in resource-constrained settings represents a challenge for many reasons. Implementation science-the assessment of how services are set up and delivered; contextual factors that affect delivery, treatment safety, toxicity, and efficacy; and where adaptations are needed-is essential if we are to understand the performance of a treatment program, know where the gaps in care exist, and design interventions in care delivery models to improve outcomes for patients.

METHODS

The field of implementation science in relation to cancer care delivery is reviewed, and the experiences of the integrated implementation science program at the Butaro Cancer Center of Excellence in Rwanda are described as a practical application. Implementation science of HIV and tuberculosis care delivery in similar challenging settings offers some relevant lessons.

RESULTS

Integrating effective implementation science into cancer care in resource-constrained settings presents many challenges, which are discussed. However, with carefully designed programs, it is possible to perform this type of research, on regular and ongoing bases, and to use the results to develop interventions to improve quality of care and patient outcomes and provide evidence for effective replication and scale-up.

CONCLUSION

Implementation science is both critical and feasible in evaluating, improving, and supporting effective expansion of cancer care in resource-limited settings. In ideal circumstances, it should be a prospective program, established early in the lifecycle of a new cancer treatment program and should be an integrated and continual process.

Proposing Essential Medicines to Treat Cancer: Methodologies, Processes, and Outcomes

PURPOSE

A great proportion of the world's cancer burden resides in low- and middle-income countries where cancer care infrastructure is often weak or absent. Although treatment of cancer is multidisciplinary, involving surgery, radiation, systemic therapies, pathology, radiology, and other specialties, selection of medicines that have impact and are affordable has been particularly challenging in resource-constrained settings. In 2014, at the invitation of the WHO, the Union for International Cancer Control convened experts to develop an approach to propose essential cancer medicines to be included in the WHO Model Essential Medicines Lists (EML) for Adults and for Children, as well as a resulting new list of cancer medicines.

METHODS

Experts identified 29 cancer types with potential for maximal treatment impact, on the basis of incidence and benefit of systemic therapies. More than 90 oncology experts from all continents drafted and reviewed disease-based documents outlining epidemiology, diagnostic needs, treatment options, and benefits and toxicities.

RESULTS

Briefing documents were created for each disease, along with associated standard treatment regimens, resulting in a list of 52 cancer medicines. A comprehensive application was submitted as a revision to the existing cancer medicines on the WHO Model Lists. In May 2015, the WHO announced the addition of 16 medicines to the Adult EML and nine medicines to the Children's EML.

CONCLUSION

The list of medications proposed, and the ability to link each recommended medicine to specific diseases, should allow public officials to apply resources most effectively in developing and supporting nascent or growing cancer treatment programs.

Medical Education and Training: Building In-Country Capacity at All Levels

Poorly trained workers and limited workforce capacity contribute immensely to barriers in cancer control in low- and middle-income countries (LMICs). Because of an increasing disease burden and the gap in trained personnel, it is critical that LMICs must develop appropriate in-country training programs at all levels to adequately address their cancer-related outcomes. The training in LMICs of cancer health personnel should address priority cancer diseases in the specific country by developing caregivers, trainers, researchers, and administrators at all levels of health care and all cadres of staff, from the community level to the national level. The Academic Model of Providing Access to Health care is a representative model of how a public tertiary hospital like the Moi Teaching and Referral Hospital in an LMIC setting can leverage its resources, collaborate with partners from high-resource countries, and assist in the development of a training center to spearhead a sustainable education program.

Integration of Palliative Care Into Comprehensive Cancer Treatment at Moi Teaching and Referral Hospital in Western Kenya

PURPOSE

The prognosis for the majority of patients with cancer in Kenya is poor, with most patients presenting with advanced disease. In addition, many patients are unable to afford the optimal therapies required. Therefore, palliative care is an essential part of comprehensive cancer care. This study reviews the implementation of a palliative care service based at the Moi Teaching and Referral Hospital in Eldoret, Kenya, and describes the current scope and challenges of providing palliative care services in an East African tertiary public referral hospital.

METHODS

This is a review of the palliative care clinical services at the only tertiary public referral hospital in western Kenya from January 2012 through September 2014. Palliative care team members documented each patient's encounter on standardized palliative care assessment forms; data were then entered into the Academic Model Providing Access to Health Care (AMPATH)-Oncology database. Interviews were also conducted to identify current challenges and opportunities for program improvement.

RESULTS

This study documents the implementation of a palliative care service line in Eldoret, Kenya. Barriers to providing optimal palliative cancer care include distance to pharmacies that stock opioids, limited selection of opioid preparations, education of health care workers in palliative care, access to palliative chemoradiation, and limited availability of outpatient and inpatient hospice services.

CONCLUSION

Palliative care services in Eldoret, Kenya, have become a key component of its comprehensive cancer treatment program.

Challenges in the detection, prevention, and treatment of HIV-associated malignancies in low- and middle-income countries in Africa

Cancers associated with immunosuppression and infections have long been recognized as a major complication of HIV/AIDS. More recently, persons living with HIV are increasingly diagnosed with a wider spectrum of HIV-associated malignancies (HIVAM) as they live longer on combination antiretroviral therapy. This has spurred research to characterize the epidemiology and determine the optimal management of HIVAM with a focus on low-and middle-income countries (LMICs). Given background coinfections, environmental exposures, host genetic profiles, antiretroviral therapy usage, and varying capacities for early diagnosis and treatment, one can expect the biology of cancers in HIV-infected persons in LMICs to have a significant impact on chronic HIV care, as is now the case in high-income countries. Thus, new strategies must be developed to effectively prevent, diagnose, and treat HIVAM in LMICs; provide physical/clinical infrastructures; train the cancer and HIV workforce; and expand research capacity-particularly given the challenges posed by the limitations on available transportation and financial resources and the population's general rural concentration. Opportunities exist to extend resources supported by the President's Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis, and Malaria to improve the health-care infrastructure and train the personnel required to prevent and manage cancers in persons living with HIV. These HIV chronic care infrastructures could also serve cancer patients regardless of their HIV status, facilitating long-term care and treatment for persons who do not live near cancer centers, so that they receive the same degree of care as those receiving chronic HIV care today.