Examination of incidence, mortality and disability-adjusted life years and risk factors of breast cancer in 49 Asian countries, 1990-2019: estimates from Global Burden of Disease Study 2019

BACKGROUND

This study presents an up-to-date, comprehensive and comparative examination of breast cancer's temporal patterns in females in Asia in last three decades.

METHODS

The estimates of incidence, mortality, disability-adjusted-life-years and risk factors of breast cancer in females in 49 Asian countries were retrieved from Global Burden of Disease 2019 study.

RESULTS

In Asia, female breast cancer incidence grew from 245 045[226 259-265 260] in 1990 to 914 878[815 789-1025 502] in 2019 with age-standardized incidence rate rising from 21.2/100 000[19.6-22.9] to 35.9/100 000[32.0-40.2] between 1990 and 2019. The death counts more than doubled from 136 665[126 094-148 380] to 337 822[301 454-375 251]. The age-standardized mortality rate rose marginally between 1990 and 2019 (1990: 12.1[11.0-13.1]; 2019: 13.4[12.0-14.9]). In 2019, age-standardized incidence rate varied from 17.2/100 000[13.95-21.4] in Mongolia to 122.5[92.1-160.7] in Lebanon and the age-standardized mortality rate varied 4-fold from 8.0/100 000 [7.2-8.8] in South Korea to 51.9[39.0-69.8] in Pakistan. High body mass index (5.6%), high fasting plasma glucose (5.6%) and secondhand smoke (3.5%) were the main contributory risk factors to all-age disability-adjusted-life-years due to breast cancer in Asia.

CONCLUSION

With growing incidence, escalating dietary and behavioural risk factors and lower survival rates due to late-disease presentation in low- and medium-income countries of Asia, breast cancer has become a significant public health threat. Its rising burden calls for increasing breast cancer awareness, preventive measures, early-stage detection and cost-effective therapeutics in Asia.

Trends in the incidence and mortality of colorectal cancer in a brazilian city

OBJECTIVES

This study was conducted to analyze the trends in colorectal cancer (CRC) incidence and mortality in the city of Aracaju, Sergipe State, Brazil, between 1996 and 2015 with Joinpoint Regression Program 4.7.0.0 and to identify the geographical distribution of CRC in the municipality.

RESULTS

A total of 1322 cases of CRC and 467 CRC-related deaths during the study period were included. In total, 40% of the incident cases and 43% of the deaths occurred in men, while 60% of the incident cases and 57% of the deaths occurred in women. Males who were 20 to 44 years old had the most significant trend in growth. Among women, those in the group aged 45 to 64 years had the highest observed annual percent change (APC). In both sexes, mortality was stable. Regarding the geographic distribution, there were constant hotspots in the northeast region of the municipality. This study showed a significant increase in incidence, mainly in young men between 20 and 44 years of age, but stable mortality in Aracaju.

Survival analysis of colorectal cancer patients in a Thai hospital-based cancer registry

Background: The study aimed to assess the overall and stage-specific colorectal cancer (CRC) survival and to identify the prognostic factors for survival among Thai patients.Research design and methods: The retrospective data of CRC patients from a university hospital-based cancer registry from 2001 to 2014 were used to estimate five-year overall survival (OS). Kaplan-Meier method and log-rank tests were used to assess the differences in five-year OS by age at diagnosis, diagnostic period, tumor site, stage at diagnosis and treatment modalities. A multivariate Cox's proportional hazard model was used to identify independent prognostic factors for the OS.Results: A total of 1,507 (48%) colon and 1,648 (52%) rectal cancer patients were included. Five-year OS for CRC patients was 44%. It differed significantly by stage, age group, and treatment received. Stage at diagnosis, age group, diagnostic period, receiving surgical and chemotherapy treatments were prognostic factors for OS.Conclusions: An increasing trend in the number of CRC patients mostly at stage III and IV was found. Our results emphasized that an improvement in CRC survival could be achieved through the adoption of advanced cancer therapies, as well as improved access to quality diagnosis and timely treatment.

The current state of African oncology research publication: how to increase Africa's research impact

African oncology professionals face significant obstacles to getting their research published due to geographical bias, funding issues and lack of publication skills. There is a major inequity in the availability of high-quality, local data from African countries and this makes it difficult for the continent's governments to develop robust cancer-control policies based on the latest evidence. Both African and international journal publishers have a duty to work towards increasing the volume of African published research and making it freely available to all.

Barriers to Cervical Cancer Screening and the Cervical Cancer Care Continuum in Rural Guatemala: A Mixed-Method Analysis

Purpose Cervical cancer is an important cause of mortality in low- and middle-income countries. Although screening technologies continue to improve, systems of care remain fragmented. It is important to better understand factors that affect use of screening services and loss to follow-up along the care continuum. Methods We conducted a mixed-methods study of a cytology-based screening program in rural Guatemala. A retrospective electronic chart review was performed on data from all patients from 2013 to 2014. We analyzed progression through care and calculated loss-to-follow-up rates. We also analyzed the prior experiences of patients with cervical cancer screening on the basis of self-reported historical data available in the chart review. Structured interviews with a subset of individuals to explore social supports and barriers to screening and engagement in care were conducted at the time of screening. Results The analysis included 515 women (median age, 36 years). Cytologic screening showed concern for neoplastic changes in 0.83%; half resulted in biopsy-proven cervical intraepithelial neoplasia. An additional 9.9% showed severe inflammation. The rate of loss to follow-up was 11.3%. All losses to follow-up occurred for severe inflammation, not for cervical intraepithelial neoplasia. Historical data showed that 73% of the cohort had previously been screened and had high levels of loss to follow-up (57.4%). Qualitative interviews revealed factors that promoted loss to follow-up; these included cost, lack of social supports, transportation, distrust in public facilities, long turn-around times, and failure to return test results or offer follow-up treatments. Conclusions Taken together, these quantitative and qualitative results highlight the need for cervical cancer screening programs in Guatemala to improve uptake of screening services by eligible women and to improve follow-up after a first abnormal screen.

Assessing Factors Associated With Survival Among Cervical Cancer Patients in Kenya: A Retrospective Follow-up Study

Background:

Cervical cancer ranks as the fourth most commonly diagnosed cancer and the fourth leading cause of cancer death in women worldwide. In Kenya, cervical cancer is the second most commonly diagnosed cancer after breast cancer and the leading cause of cancer death in women. It is estimated that by the end of 2018, cervical cancer will be responsible for 5,250 (11%) new cases and 3,286 (11.84%) deaths in Kenya.

Methods:

We conducted a retrospective follow-up study to estimate the overall survival of women treated for cervical cancer in Kenya. Medical records were reviewed to extract information for generating a quantitative data set, and the chi-square test was used to test for associations between patient outcomes and various sociodemographic and clinical factors. To estimate overall survival after treatment, we used Kaplan–Meier survival analysis, the logrank test, and Cox proportional hazards regression.

Results:

A total of 481 patient records were included in this study. From the bivariate analysis, 4 factors demonstrated a statistically significant association with survival: access to care (P=.049), stage of disease at diagnosis (P<.001), type of treatment received (P<.001), and whether or not treatment was initiated and completed (P<.001). The overall 5-year survival estimate for women with cervical cancer was 59%. However, 396 (82.3%) women were lost to follow-up; with no deaths observed after the first year, the overall survival estimate is only accurate for the first year.

Conclusion:

The high rate of loss to follow-up appears to be characteristic of cancer care in Kenya and highlights the difficulties in conducting survival studies in low-resource settings with low coverage of vital registration and a lack of centralised national administrative systems. Despite the study's limitations, the results support evidence whereby late-stage diagnosis, deficiencies in cancer management, and limited cancer care services, in particular, have been found to contribute to poor patient outcomes in sub-Saharan Africa.

Delay along the care-seeking journey of patients with ocular surface squamous neoplasia in Kenya

Background

In Africa, accessing eye health services is a major challenge. Ocular surface squamous neoplasia (OSSN) is a substantial ocular health problem in Africa related to solar UV light exposure and HIV infection among other risk factors. The disease causes visual loss and even death in advanced cases. This study was conducted to assess referral pathway and treatment delay for patients with OSSN in Kenya.

Methods

Adults with conjunctival lesions presenting to four eye centres were asked about their occupations, when they noticed the growth, health facilities visited in seeking care, cost of consultation, surgery, medicines and histopathology and dates at each step. The time-to-presentation was divided into quartiles and correlates analysed using ordinal logistic regression.

Results

We evaluated 158 first-time presenters with OSSN. Most were women (102 [65%]), living with HIV (78/110 tested [71%]), with low to medium income (127 [80%]). Most of the HIV patients (49/78 [63%]) were in antiretroviral care programs. About half (88/158, [56%]) presented directly to the study centres while the rest were referred. Indirect presenters sought care earlier than direct presenters (median 2.0 months vs 5.5 months) and travelled a shorter distance to the first health facility (median 20 km vs 30 km) but had surgery later (median 12.5 months vs 5.5 months). Visits beyond the first health facility for indirect presenters markedly increased delay (median 7.3, 29.0, 37.9, and 32.0 months for 1–4 facilities, respectively). Delay was associated with number of health facilities visited (adjusted ordered OR = 9.12; 95%CI 2.83–29.4, p < 0.001) and being female (adjusted ordered OR = 2.42; 95%CI 1.32–4.44, p = 0.004). At the time of presentation at the study centres for surgery the median tumour diameter in both directly and indirectly presenting patients was 6 mm (p = 0.52) and the histological spectrum of OSSN was similar between the groups (p = 0.87).

Conclusions

Referral delays definitive treatment for OSSN. Women were more likely to experience delay. Despite regular contact with the health system for those with known HIV infection, delays occurred. Early detection and referral of OSSN in the HIV service might reduce delays, but reassuringly delay did not give rise to a larger proportion with more advanced grade of OSSN.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2428-4) contains supplementary material, which is available to authorized users.

Emergence of Colorectal Cancer in West Africa: Accepting the Inevitable

It seems not too long ago that colon and rectal cancer is a "rare" disease in rural Africa; however, over the last 30 years in West Africa, published evidence has shown decade by decade increases in the incidence of colorectal cancer (CRC). Therefore, CRC should now be accepted as a recognized disease in native Africans; nevertheless, we must acknowledge that the incidence is a fraction of what obtains in the developed countries of Europe and America. This presentation will attempt to examine the emergence of CRC within the West African axis over the last four decades.

Global patterns and trends in colorectal cancer incidence and mortality

OBJECTIVE

The global burden of colorectal cancer (CRC) is expected to increase by 60% to more than 2.2 million new cases and 1.1 million deaths by 2030. In this study, we aim to describe the recent CRC incidence and mortality patterns and trends linking the findings to the prospects of reducing the burden through cancer prevention and care.

DESIGN

Estimates of sex-specific CRC incidence and mortality rates in 2012 were extracted from the GLOBOCAN database. Temporal patterns were assessed for 37 countries using data from Cancer Incidence in Five Continents (CI5) volumes I-X and the WHO mortality database. Trends were assessed via the annual percentage change using joinpoint regression and discussed in relation to human development levels.

RESULTS

CRC incidence and mortality rates vary up to 10-fold worldwide, with distinct gradients across human development levels, pointing towards widening disparities and an increasing burden in countries in transition. Generally, CRC incidence and mortality rates are still rising rapidly in many low-income and middle-income countries; stabilising or decreasing trends tend to be seen in highly developed countries where rates remain among the highest in the world.

CONCLUSIONS

Patterns and trends in CRC incidence and mortality correlate with present human development levels and their incremental changes might reflect the adoption of more western lifestyles. Targeted resource-dependent interventions, including primary prevention in low-income, supplemented with early detection in high-income settings, are needed to reduce the number of patients with CRC in future decades.

American Society of Clinical Oncology Multidisciplinary Cancer Management Course: Connecting Lives, Cancer Care, Education, and Compassion in Zimbabwe-A Pilot for Efforts of Sustainable Benefit?

The burden of cancer in low- to middle-income countries is growing and is expected to rise dramatically while resources to manage this disease remain inadequate. All authorities for the management of cancer recommend multidisciplinary care. Educational efforts by international organizations to assist local professionals in caring for their patients tend to have a lasting impact because they empower local professionals and enhance their skills. A multidisciplinary cancer management course was designed by American Society of Clinical Oncology staff and local experts to provide a roadmap for cross-specialty interaction and coordination of care in Zimbabwe. The outcome of the course was measured through feedback obtained from participants and impact on local workforce. The cancer management course was relevant to daily practice and fostered long-lasting partnerships and collaborations. Furthermore, it resulted in a more motivated local workforce and strengthened existing multidisciplinary practices. Cancer care is in a critical state in low- to middle-income countries. Educational efforts and collaborative partnerships may provide a cost-effective strategy with sustainable benefits. A multidisciplinary approach to optimize therapy is desirable. Evaluation of the course impact after a period of 6 months to 1 year is needed to determine the sustainability and impact of such efforts.

Colorimetric assessment of BCR-ABL1 transcripts in clinical samples via gold nanoprobes

Gold nanoparticles functionalized with thiolated oligonucleotides (Au-nanoprobes) have been used in a range of applications for the detection of bioanalytes of interest, from ions to proteins and DNA targets. These detection strategies are based on the unique optical properties of gold nanoparticles, in particular, the intense color that is subject to modulation by modification of the medium dieletric. Au-nanoprobes have been applied for the detection and characterization of specific DNA sequences of interest, namely pathogens and disease biomarkers. Nevertheless, despite its relevance, only a few reports exist on the detection of RNA targets. Among these strategies, the colorimetric detection of DNA has been proven to work for several different targets in controlled samples but demonstration in real clinical bioanalysis has been elusive. Here, we used a colorimetric method based on Au-nanoprobes for the direct detection of the e14a2 BCR-ABL fusion transcript in myeloid leukemia patient samples without the need for retro-transcription. Au-nanoprobes directly assessed total RNA from 38 clinical samples, and results were validated against reverse transcription-nested polymerase chain reaction (RT-nested PCR) and reverse transcription-quantitative polymerase chain reaction (RT-qPCR). The colorimetric Au-nanoprobe assay is a simple yet reliable strategy to scrutinize myeloid leukemia patients at diagnosis and evaluate progression, with obvious advantages in terms of time and cost, particularly in low- to medium-income countries where molecular screening is not routinely feasible. Graphical abstract Gold nanoprobe for colorimetric detection of BCR-ABL1 fusion transcripts originating from the Philadelphia chromosome.

Development of immunohistochemistry services for cancer care in western Kenya: Implications for low- and middle-income countries

Background

Cancer is becoming a major cause of mortality in low- and middle-income countries. Unlike infectious disease, malignancy and other chronic conditions require significant supportive infrastructure for diagnostics, staging and treatment. In addition to morphologic diagnosis, diagnostic pathways in oncology frequently require immunohistochemistry (IHC) for confirmation. We present the experience of a tertiary-care hospital serving rural western Kenya, which developed and validated an IHC laboratory in support of a growing cancer care service.

Objectives, methods and outcomes

Over the past decade, in an academic North-South collaboration, cancer services were developed for the catchment area of Moi Teaching and Referral Hospital in western Kenya. A major hurdle to treatment of cancer in a resource-limited setting has been the lack of adequate diagnostic services. Building upon the foundations of a histology laboratory, strategic investment and training were used to develop IHC services. Key elements of success in this endeavour included: translation of resource-rich practices to a resource-limited setting, such as using manual, small-batch IHC instead of disposable- and maintenance-intensive automated machinery, engagement of outside expertise to develop reagent-efficient protocols and supporting all levels of staff to meet the requirements of an external quality assurance programme.

Conclusion

Development of low- and middle-income country models of services, such as the IHC laboratory presented in this paper, is critical for the infrastructure in resource-limited settings to address the growing cancer burden. We provide a low-cost model that effectively develops these necessary services in a challenging laboratory environment.

Novel Humanitarian Aid Program: The Glivec International Patient Assistance Program-Lessons Learned From Providing Access to Breakthrough Targeted Oncology Treatment in Low- and Middle-Income Countries

Imatinib was the first targeted therapy approved for the treatment of cancer. With its approval, it was immediately clear to Novartis that this breakthrough therapy would require an innovative approach to worldwide access, with special consideration of low- and middle-income countries. Lack of government reimbursement, universal health care, or health insurance coverage, few trained specialty physicians or diagnostic services, and poor health care infrastructure were, and continue to be, contributing barriers to access to treatment in low- and middle-income countries. The Glivec International Patient Assistance Program (GIPAP) is an international drug donation program established by Novartis Pharma AG and implemented in partnership with The Max Foundation, a nonprofit, nongovernmental organization. GIPAP was established in 2001, essentially in parallel with the first approval of imatinib for chronic myeloid leukemia. Since 2001, GIPAP has made imatinib accessible to all medically and financially eligible patients within 80 countries on an ongoing basis as long as their physicians prescribe it and no other means of access exists. To date, more than 49,000 patients have benefited from GIPAP, and 2.3 million monthly doses of imatinib have been approved through the program. GIPAP represents an innovative drug donation model that has set the standard for access programs for other targeted or innovative therapies. The purpose of this article is to describe the structure of GIPAP, as well as important lessons that have contributed to the success of the program. This article may assist other companies with the development of successful and far-reaching patient assistance programs in the future.

Regional variation in identified cancer care needs of early-career oncologists in China, India, and Pakistan

BACKGROUND

Cancer incidence and mortality is increasing in the developing world. Inequities between low-, middle-, and high-income countries affect disease burden and the infrastructure needs in response to cancer. We surveyed early-career oncologists attending workshops in clinical research in three countries with emerging economies about their perception of the evolving cancer burden.

METHODS

A cross-sectional survey questionnaire was distributed at clinical trial concept development workshops held in Beijing, Lahore, Karachi, and Mumbai at major hospitals to acquire information regarding home-country health conditions and needs.

RESULTS

A total of 100 respondents participated in the workshops held at major hospitals in the region (India = 29, China = 25, Pakistan = 42, and other = 4). Expected consensus on many issues (e.g., emergence of cancer as a significant health issue) was balanced with significant variation in priorities, opportunities, and challenges. Chinese respondents prioritized improvements in cancer-specific care and palliative care, Indian respondents favored improved cancer detection and advancing research in cancer care, and Pakistani respondents prioritized awareness of cancer and improvements in disease detection and cancer care research. For all, the most frequently cited opportunity was help in improving professional cancer education and training.

CONCLUSION

Predominantly early-career oncologists attending clinical research workshops (in China, India, and Pakistan) identified needs for increasing clinical cancer research, professional education, and public awareness of cancer. Decision makers supporting efforts to reduce the burden of cancer worldwide will need to factor the specific needs and aspirations of health care providers in their country in prioritizing health policies and budgets.

Policies and programs to facilitate access to targeted cancer therapies in Thailand

BACKGROUND

Increasing access to clinically beneficial targeted cancer medicines is a challenge in every country due to their high cost. We describe the interplay of innovative policies and programs involving multiple stakeholders to facilitate access to these medicines in Thailand, as well as the utilization of selected targeted therapies over time.

METHODS

We selected two medicines on the 2013 Thai national list of essential medicines (NLEM) [letrozole and imatinib] and three unlisted medicines for the same indications [trastuzumab, nilotinib and dasatinib]. We created timelines of access policies and programs for these products based on scientific and grey literature. Using IMS Health sales data, we described the trajectories of sales volumes of the study medicines between January 2001 and December 2012. We compared estimated average numbers of patients treated before and after the implementation of policies and programs for each product.

RESULTS

Different stakeholders implemented multiple interventions to increase access to the study medicines for different patient populations. During 2007-2009, the Thai Government created a special NLEM category with different coverage requirements for payers and issued compulsory licenses; payers negotiated prices with manufacturers and engaged in pooled procurement; pharmaceutical companies expanded patient assistance programs and lowered prices in different ways. Compared to before the interventions, estimated numbers of patients treated with each medicine increased significantly afterwards: for letrozole from 645 (95% CI 366-923) to 3683 (95% CI 2,748-4,618); for imatinib from 103 (95% CI 72-174) to 350 (95% CI 307-398); and for trastuzumab from 68 (95% CI 45-118) to 412 (95% CI 344-563).

CONCLUSIONS

Government, payers, and manufacturers implemented multi-pronged approaches to facilitate access to targeted cancer therapies for the Thai population, which differed by medicine. Routine monitoring is needed to assess clinical and economic impacts of these strategies in the health system.

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.

Breast cancer in the global south and the limitations of a biomedical framing: a critical review of the literature

Public health researchers are devoting increasing attention to the growing burden of breast cancer in low-and middle-income countries (LMICs), previously thought to be minimally impacted by this disease. A critical examination of this body of literature is needed to explore the assumptions, advantages and limitations of current approaches. In our critical literature review, we find that researchers and public health practitioners predominantly privilege a biomedical perspective focused on patients' adherence (or non-adherence) to 'preventive' practices, screening behaviours and treatment regimens. Cost-effective 'quick fixes' are prioritized, and prevention is framed in terms of individual 'risk behaviours'. Thus, individuals and communities are held responsible for the success of the biomedical system; traditional belief systems and 'harmful' social practices are problematized. Inherently personal, social and cultural experiences of pain and suffering are neglected or reduced to the issue of chemical palliation. This narrow approach obscures the complex aetiology of the disease and perpetuates silence around power relations. This article calls for a social justice-oriented interrogation of the role of power and inequity in the global breast cancer epidemic, which recognizes the agency and experiences of women (and men) who experience breast cancer in the global south.

Radiation therapy: a major factor in the five-year survival analysis of women with breast cancer in Lagos, Nigeria

PURPOSE

This retrospective study was carried out to examine five-year survival from breast cancer cases diagnosed between 2005 and May 2008 in Nigerian women.

MATERIAL AND METHODS

Two hundred and twenty-four patients were entered into the study. Five-year survival was evaluated using proportional hazard model proposed by Cox to assess variables such as age of diagnosis, menopausal status, and stage of the disease in the two treatment groups: surgery/chemotherapy or surgery/chemotherapy/radiotherapy.

RESULTS

Findings revealed that the different staging of disease and treatment are independent predictors of disease outcome whereas age of diagnosis and menopausal status although associated with low hazards, are not significant. TNM Stage I (Hazard Ratio=0.153, 95% CI 0.45-0.51, P=0.003), II (Hazard Ratio=0.245, 95% CI 0.12-0.46, P=0.0001), and III (Hazard Ratio=0.449, 95% CI 0.31-0.46, P=0.0001) showed significantly greater survival rates compared to TNM Stage IV for patients receiving surgery/chemotherapy. Similarly, for patients receiving surgery/chemotherapy/radiotherapy TNM Stage II (Hazard Ratio=0.110, 95% CI 0.02-0.46, P=0.003) and III (Hazard Ratio=0.238, 95% CI 0.07-0.73, P=0.012) also showed significantly greater survival rates compared to TNM Stage IV. Treatment had a significant impact on survival independent of stage, age, and menopausal status. Patients receiving surgery/chemotherapy/radiotherapy had a significant increase in survival outcome for TNM Stage (II, P=0.045; III, P=0.0001); age groups (40-49, P=0.021; 50-59, P=0.016; 60-69, P=0.017; >70, P=0.025); and menopausal status (premenopausal, P=0.049; postmenopausal, P=0.0001) compared to those receiving surgery/chemotherapy.

CONCLUSION

The five-year breast cancer survival rate in Lagos, Nigeria 24.1% (54/224) is relatively poor compared to most countries in the world and needs to be improved. Poor survival rates are mainly attributed to late presentation and poor follow-up, hence early detection through breast cancer awareness programs, appropriate logistics and better management of patients through guidelines for the treatment of breast need to be implemented to improve survival.

Closing the global cancer divide--performance of breast cancer care services in a middle income developing country

Background

Cancer is the leading cause of deaths in the world. A widening disparity in cancer burden has emerged between high income and low-middle income countries. Closing this cancer divide is an ethical imperative but there is a dearth of data on cancer services from developing countries.

Methods

This was a multi-center, retrospective observational cohort study which enrolled women with breast cancer (BC) attending 8 participating cancer centers in Malaysia in 2011. All patients were followed up for 12 months from diagnosis to determine their access to therapies. We assess care performance using measures developed by Quality Oncology Practice Initiative, American Society of Clinical Oncology/National Comprehensive Cancer Network, American College of Surgeons’ National Accreditation Program for Breast Centers as well as our local guideline.

Results

Seven hundred and fifty seven patients were included in the study; they represent about 20% of incident BC in Malaysia. Performance results were mixed. Late presentation was 40%. Access to diagnostic and breast surgery services were timely; the interval from presentation to tissue diagnosis was short (median = 9 days), and all who needed surgery could receive it with only a short wait (median = 11 days). Performance of radiation, chemo and hormonal therapy services showed that about 75 to 80% of patients could access these treatments timely, and those who could not were because they sought alternative treatment or they refused treatment. Access to Trastuzumab was limited to only 19% of eligible patients.

Conclusions

These performance results are probably acceptable for a middle income country though far below the 95% or higher adherence rates routinely reported by centres in developed countries. High cost trastuzumab was inaccessible to this population without public funding support.

Improving access to care in low and middle-income countries: institutional factors related to enrollment and patient outcome in a cancer drug access program

BACKGROUND

Limited access to drugs is a crucial barrier to reducing the growing impact of cancer in low- and middle-income countries. Approaches based on drug donations or adaptive pricing strategies yield promising but varying results across countries or programs, The Glivec International Patient Assistance Program (GIPAP) is a program designed to provide imatinib free of charge to patients with chronic myeloid leukemia (CML) or gastrointestinal stromal tumors (GIST). The objective of this work was to identify institutional factors associated with enrollment and patient survival in GIPAP.

METHODS

We analyzed follow-up data from 4,946 patients participating in 47 institutions within 44 countries between 2003 and 2010. Active status in the program was considered as a proxy for survival.

RESULTS

Presence of ≥1 hematologist or oncologist at the institution was associated with increased patient enrollment. After adjusting for individual factors such as age (>55 years: Hazard Ratio [HR] = 1.42 [1.16; 1.73]; p = 0.001) and initial stage of disease (accelerated or blast crisis at diagnosis: HR = 4.16 [1.87; 9.25]; p < 10⁻⁴), increased survival was found in institutions with research capabilities (HR = 0.55 [0.35; 0.86]; p = 0.01) and those with enrollment of >5 patients/year into GIPAP (HR = 0.48 [0.35; 0.67]; p < 10⁻⁴), while a non-significant trend for decreased survival was found for treatment at a public institution (HR = 1.32 [0.95; 1.84]; p = 0.10). The negative impact of an accelerated form of CML was attenuated by the presence of ≥1 hematologist or oncologist at the institution (interaction term HR = 0.43 [0.18; 0.99]; p = 0.05).

CONCLUSIONS

Application of these findings to the support and selection of institutions participating in GIPAP may help to optimize care and outcomes for CML and GIST patients in the developing world. These results may also be applicable to the treatment of patients with other forms of cancer, due to the overlap of infrastructure and staff resources used to treat a variety of cancer indications. A multi-sector approach is required to address these barriers.

Today's evidence, tomorrow's agenda: implementation of strategies to improve global reproductive health

The Alliance for Women's Health deliberated on critical gaps and emerging issues related to women's health, focusing on contraception, safe abortion care, HIV, and cervical cancer prevention. Despite the health, socioeconomic, and development benefits of family planning, up to 222 million women have an unmet need for modern contraception. The number of unsafe abortions increased globally, 98% of which occurred in low-resource countries. Fragmentation of services for HIV and cervical cancer prevention and treatment fail to maximize opportunities to reach women within reproductive, maternal, and child health services. The FIGO 2012 PreCongress Workshop elaborated the role of societies of obstetricians-gynecologists in implementation of actions to increase access to modern methods of contraception to help individuals meet family planning intentions. Human rights principles underpin the imperative to ensure equitable access to a wide range of modern methods of contraception. The role of task shifting/sharing in different models of service delivery was elaborated. Actions from the International Conference on Population and Development on safe abortion care and integration of effective contraception were reaffirmed. A call was made to increase access to integrated HIV and cervical cancer prevention, screening, and management. Cross-cutting strategic approaches to accelerate progress include evidence-based information to stakeholders and continued education in these areas at all levels of training. A call was made to advocate for a budget line item for sexual and reproductive health, including family planning and engaging the demand side of family planning, while involving men to enhance uptake and continuation.

Sexual and reproductive health and HIV services: integrating HIV/AIDS and cervical cancer prevention and control

People living with HIV are at an increased risk of acquiring HPV and of developing evolutive cervical cancers (women) and penile and anal cancers (men). Low-cost screening-visual inspection with acetic acid, HPV DNA diagnostics and primary care level treatment, cryotherapy for cervical intraepithelial neoplasia (CIN 2), and primary prevention through HPV vaccination of girls aged 9-13 years-makes the goal of eliminating cervical cancer possible in the long term. Integration of cervical cancer screening and treatment into a sexual and reproductive health service package raises programmatic questions and calls for a continuum of care. The latter is only possible when adequate cytopathology skills and treatment for advanced cancer conditions are available. The present paper highlights the role of member societies of the International Federation of Gynecology and Obstetrics (FIGO) in developing the base for an integrated package that responds to women's sexual and reproductive health needs.

Breast cancer research in Asia: adopt or adapt Western knowledge?

The incidence and mortality of breast cancer continues to rise rapidly in Asian countries. However, most of our current knowledge on breast cancer has been generated in Western populations. As the socio-economic profile, life style and culture of Asian and Western women are substantially different, and genetic backgrounds vary to some extent, we need to answer the question on whether to 'adopt' or 'adapt' Western knowledge before applying it in the Asian setting. It is generally accepted that breast cancer risk factors, which have mainly been studied in Western populations are similar worldwide. However, the presence of gene-environment or gene-gene interactions may alter their importance as causal factors across populations. Diagnostic and prognostic study findings, including breast cancer prediction rules, are increasingly shown to be 'setting specific' and must therefore be validated in Asian women before implementing them in clinical care in Asia. Interventional research findings from Caucasian patients may not be applicable in patients in Asia due to differences in tumour biology/profiles, metabolism of drugs and also health beliefs which can influence treatment acceptance and adherence. While breast cancer research in Asia is warranted in all domains of medical research, it is felt that for Asian breast cancer patients, needs are highest for diagnostic and prognostic studies. International clinical trials meanwhile need to include breast cancer patients from various Asian settings to provide an insight into the effectiveness of new treatment modalities in this part of the world.

The oncology pharmacy in cancer care delivery in a resource-constrained setting in western Kenya

The movement to deliver cancer care in resource-limited settings is gaining momentum, with particular emphasis on the creation of cost-effective, rational algorithms utilizing affordable chemotherapeutics to treat curable disease. The delivery of cancer care in resource-replete settings is a concerted effort by a team of multidisciplinary care providers. The oncology pharmacy, which is now considered integral to cancer care in resourced medical practice, developed over the last several decades in an effort to limit healthcare provider exposure to workplace hazards and to limit risk to patients. In developing cancer care services in resource-constrained settings, creation of oncology pharmacies can help to both mitigate the risks to practitioners and patients, and also limit the costs of cancer care and the environmental impact of chemotherapeutics. This article describes the experience and lessons learned in establishing a chemotherapy pharmacy in western Kenya.

Cancer care challenges in developing countries

BACKGROUND

Health systems in Sub-Saharan Africa are not prepared for the rapid rise in cancer rates projected in the region over the next decades. More must be understood about the current state of cancer care in this region to target improvement efforts. Yaounde General Hospital (YGH) currently is the only site in Cameroon (population: 18.8 million) where adults can receive chemotherapy from trained medical oncologists. The experiences of patients at this facility represent a useful paradigm for describing cancer care in this region.

METHODS

In July and August 2010, our multidisciplinary team conducted closed-end interviews with 79 consecutive patients who had confirmed breast cancer, Kaposi sarcoma, or lymphoma.

RESULTS

Thirty-five percent of patients waited >6 months to speak to a health care provider after the first sign of their cancer. The delay between first consultation with a health care provider and receipt of a cancer diagnosis was >3 months for 47% of patients. The total delay from the first sign of cancer to receipt of the correct diagnosis was >6 months for 63% of patients. Twenty-three percent of patients traveled for >7 hours to reach YGH, and 40% of patients interviewed spent >$200 on a single round of chemotherapy.

CONCLUSIONS

Cancer patients experienced numerous geographic and health care system challenges, resulting in significant delays in receiving diagnosis and treatment, even for cancers highly amenable to early intervention. This unacceptable and unethical situation is likely explained by limited knowledge about cancer among patients and health care professionals, government neglect, poverty, and reliance on traditional healers.

Role of American Society of Clinical Oncology in low- and middle-income countries

The American Society of Clinical Oncology (ASCO) is a global community of health care professionals whose stated purpose is to "make a world of difference" by improving cancer care around the world. Unfortunately, cancer survival rates vary significantly among countries with differing financial and infrastructural resources. Because ASCO is a professional oncology society committed to conquering cancer through research, education, prevention, and delivery of high-quality patient care, it is ideally suited to address this issue. ASCO could bring together oncology professionals and other necessary stakeholders from around the world to improve cancer care and lessen suffering for patients worldwide. As part of the ongoing commitment of ASCO to the future of cancer care, the Leadership Development Program was created to foster the leadership skills of early and midcareer oncologists and provide these participants with a working knowledge of the depth and breadth of the organization. As participants in the inaugural class of the ASCO Leadership Development Program, we were charged with investigating how ASCO might favorably affect cancer prevention and treatment in resource-poor countries in a cost-effective, scalable, and sustainable fashion. ASCO can significantly influence cancer care in low- and middle-income countries through a comprehensive approach that promotes cancer awareness and education, improves clinical practice by identifying and removing barriers to delivery of quality cancer care, and fosters innovation to initiate novel solutions to complex problems.

Scaling up global health interventions: a proposed framework for success

Drawing upon interviews with experts and a review of the literature, Gavin Yamey proposes a new framework for scaling up global health interventions.

Breast cancer in developing countries: opportunities for improved survival

Breast cancer survival in the USA has continually improved over the last six decades and has largely been accredited to the use of mammography, advanced surgical procedures, and adjuvant therapies. Data indicate, however, that there were substantial improvements in survival in the USA even prior to these technological and diagnostic advances, suggesting important opportunities for early detection and treatment in low- and middle-income countries where these options are often unavailable and/or unaffordable. Thus, while continuing to strive for increased access to more advanced technology, improving survival in these settings should be more immediately achievable through increased awareness of breast cancer and of the potential for successful treatment, a high-quality primary care system without economic or cultural barriers to access, and a well-functioning referral system for basic surgical and hormonal treatment.

Expansion of cancer care and control in countries of low and middle income: a call to action

Substantial inequalities exist in cancer survival rates across countries. In addition to prevention of new cancers by reduction of risk factors, strategies are needed to close the gap between developed and developing countries in cancer survival and the effects of the disease on human suffering. We challenge the public health community's assumption that cancers will remain untreated in poor countries, and note the analogy to similarly unfounded arguments from more than a decade ago against provision of HIV treatment. In resource-constrained countries without specialised services, experience has shown that much can be done to prevent and treat cancer by deployment of primary and secondary caregivers, use of off-patent drugs, and application of regional and global mechanisms for financing and procurement. Furthermore, several middle-income countries have included cancer treatment in national health insurance coverage with a focus on people living in poverty. These strategies can reduce costs, increase access to health services, and strengthen health systems to meet the challenge of cancer and other diseases. In 2009, we formed the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries, which is composed of leaders from the global health and cancer care communities, and is dedicated to proposal, implementation, and evaluation of strategies to advance this agenda.