Enhancement of paediatric oncology pharmacy practices in a low-middle-income country through teaching and training using the My Child Matters Grant

The development of a successful oncology pharmacy system includes competency training, cost-efficient procurement, proper storage, preparation and administration of chemotherapy, and appropriate waste disposal. Low-middle-income countries such as Pakistan face several challenges within the realm of oncology pharmacy such as the unavailability of training programmes, resources and financial support, and inconsistencies in the safe handling of cytotoxic drugs. The Indus Hospital and Health Network (IHHN) is among the pioneers of oncology pharmacy practices in Pakistan, with a well-established Oncology Pharmacy Team and chemotherapy preparation in accordance with the United States Pharmacopeia 797 and 800 safety guidelines. The My Child Matters Grant was awarded by the Sanofi Espoir Foundation to the Department of Paediatric Hematology and Oncology at IHHN for holistic improvement in childhood cancer care through teaching, training and capacity building. Partnerships were formed with five public-sector paediatric oncology units nationwide. Initiatives were taken to improve oncology pharmacy practices including teaching and training courses, in-person assessment visits, and mentorship and liaison efforts. Despite prevailing challenges, promising improvements were noted at each centre. However, Pakistan needs to establish a national plan for childhood cancer with the creation of regional organisations for the training and monitoring of oncology pharmacists. Centralisation of pharmacy operations within hospitals is essential to maintain the availability, storage, preparation and administration standards of chemotherapy.

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.

Building a Sustainable Comprehensive Multiple Myeloma Program in Western Kenya

Despite improved treatment strategies for multiple myeloma (MM), patient outcomes in low- and middle-income countries remain poor, unlike high-income countries. Scarcity of specialized human resources and diagnostic, treatment, and survivorship infrastructure are some of the barriers that patients with MM, clinicians, and policymakers have to overcome in the former setting. To improve outcomes of patients with MM in Western Kenya, the Academic Model Providing Access to Healthcare (AMPATH) MM Program was set up in 2012. In this article, the program's activities, challenges, and future plans are described distilling important lessons that can be replicated in similar settings. Through the program, training on diagnosis and treatment of MM was offered to healthcare professionals from 35 peripheral health facilities across Western Kenya in 2018 and 2019. Access to antimyeloma drugs including novel agents was secured, and pharmacovigilance systems were developed. Finally, patients were supported to obtain health insurance in addition to receiving peer support through participation in support group meetings. This article provides an implementation blueprint for similar initiatives aimed at increasing access to care for patients with MM in underserved areas.

Access to cancer medication in public hospitals in a middle-income country: The view of stakeholder

BACKGROUND

Access to cancer medicines is a core component of comprehensive cancer care; as such, it is included in Mexico's public health insurance: Seguro Popular de Salud (SPS). Learning about stakeholders' experiences on processes and barriers influencing access to essential cancer medicines within healthcare facilities allows identifying needed policies to improve access to cancer care.

OBJECTIVE

The aim of this study was to obtain the insights of health professionals in public hospitals in Mexico on how SPS influences access to cancer medicines regarding medicine selection, financing, and procurement and supply systems. The purpose is to identify policy areas that need strengthening to improve access to cancer medicines.

METHODS

Semi-structured interviews were conducted with 67 health professionals from 21 public hospitals accredited by SPS across Mexico. A framework analysis was used with categories of analysis derived from the World Health Organization's Access framework.

RESULTS

Most stakeholders reported that the availability of listed cancer medicines was sufficient. However, cancer specialists reported that medicines coverage by SPS was restrictive covering only basic cancer care. Public hospitals followed SPS treatment protocols in selecting and prescribing cancer medicines but used different procurement procedures. When essential cancer medicines were unavailable (not listed or stocked-out), hospitals reported several strategies such as prescribing alternative therapies, resorting to direct purchases, and assisting patients in obtaining medicines elsewhere. Other reported barriers to access to treatment were: distance to health facilities, poor insurance coverage, and financial restrictions.

CONCLUSIONS

Health professionals have encountered benefits and challenges from the implementation of SPS influencing access to cancer medicines and care in Mexico, pointing to areas in which action is necessary. Finding the right balance between expanding the range and cost of cancer treatments covered by insurance and making basic cancer care available to all is a challenge faced by Mexico and other middle-income countries.

Centralization impact and cost-saving study in a Moroccan hospital’s centralized unit of chemotherapy preparation

Purpose

The purpose of this study was to assess the cost saved and the amount of drug wasted when compounding anticancer drugs in the centralized unit for chemotherapy preparation. A secondary objective was to estimate the centralization impact of activities related to the preparation of chemotherapies.

Methods

This was a two-month, single-centre, prospective study conducted at the National Oncology Institute in Rabat. The cost saved and the amount of drug wasted were calculated using a standardized data collection sheet (the prescribed dose, the amount of drug deployed, the amount remaining after compounding, the amount of drug saved and the drug wastage). The centralization impact was calculated using the amount of drug wasted in the centralized unit for chemotherapy preparation and a theoretical amount of drug wasted without centralization of preparation.

Results

During the study period, the total amount of drug saved was 249,959.5 mg (7.2% of drug used), which represented 96,657 USD. The amount of drug wasted was 89,290.5 mg or 42275.5 USD. The drug waste per dilution and per drug was 6.4 mg [1.6-16.1]. While the potential savings over one year (580,000 USD) reached 13.9% of the cytostatic drugs budget for 2018, the potential drug waste cost reached 6.1%. The centralization impact is estimated at an average of 79.5% ± 13.7% waste reduction.

Conclusion

The outcome of our study showed that the grouping of prescriptions in centralized unit for chemotherapy preparation could result in significant savings on the amount of drugs deployed. The centralization of cytostatic preparations is of economic interest.

Refining a questionnaire to assess breast cancer knowledge and barriers to screening in Kenya: Psychometric assessment of the BCAM

Background

Our study objective was to determine the validity and reliability of the breast module of a cancer awareness measure (BCAM) among adult women in western Kenya.

Methods

The study was conducted between October and November 2012, following three breast cancer screening events. Purposive and systematic random sampling methods were used to identity 48 women for cognitive focus group discussions, and 1061 (594 who attended vs. 467 who did not attend screening events) for surveys, respectively. Face and psychometric validity of the BCAM survey was assessed using cognitive testing, factor analysis of survey data, and correlations. Internal reliability was assessed using Cronbach’s alpha.

Results

Among survey participants, the overall median age was 34 (IQR: 26–44) years. Compared to those women who did not attend the screening events, women attendees were older (median: 35 vs. 32 years, p = 0.001) more often married (79% vs. 72%, p = 0.006), more educated (52% vs. 46% with more than an elementary level of education, p = 0.001), more unemployed (59% vs. 11%, p = 0.001), more likely to report doing breast self-examination (56% vs. 40%, p = 0.001) and more likely to report having felt a breast lump (16% vs. 7%, p = 0.001). For domain 1 on knowledge of breast cancer symptoms, one factor (three items) with Eigen value of 1.76 emerged for the group that did not attend screening, and 1.50 for the group that attended screening. For both groups two factors (factor 1 “internal influences” and factor 2 “external influences”) emerged among domain 4 on barriers to screening, with varied item loadings and Eigen values. There were no statistically significant differences in the factor scores between attendees and non-attendees. There were significant associations between factor scores and other attributes of the surveyed population, including associations with occupation, transportation type, and training for and practice of breast self-examination. Cronbach’s alpha showed an acceptable internal consistency.

Conclusion

Certain subpopulations are less likely than others to attend breast screening in Kenya. A survey measure of breast cancer knowledge and perceived barriers to screening shows promise for use in Kenya for characterizing clinical and community population beliefs, but needs adaptation for setting, language and culture.

Impact of an educational intervention on breast cancer knowledge in western Kenya

Our objective was to assess the effectiveness of educational sessions that accompanied breast cancer screening events in three communities in western Kenya between October and November 2013. Five hundred and thirty-two women were recruited to complete a test of breast cancer-relevant knowledge and randomly allocated to 'pre-test' or 'post-test' groups that immediately preceded or followed participation in the educational sessions. The education was organized as a presentation by health professionals and focused mainly on causes of breast cancer, early and late cancer presentation signs, high-risk groups, screening methods to find early-stage breast cancer, self-breast exam procedures and treatment options for this disease. Participants were invited to ask questions and practice finding nodules in silicone breast models. The median age was 35 years (interquartile range: 28-45), and 86% had not undergone breast cancer screening previously. Many individual items in our test of knowledge showed statistically significant shifts to better-informed responses. When all items in the assessment questionnaire were scored as a 'test', on average there was a 2.80 point (95% CI: 2.38, 3.22) significant improvement in knowledge about breast cancer after the educational session. Our study provides evidence for the effectiveness of an educational strategy carefully tailored for women in these communities in Kenya.

Exploring the role of the pharmacist in global health

OBJECTIVE

The objective of this commentary is to explore the potential role of the pharmacist in the field of global health by understanding the definition of global health and how it can be applied to the profession of pharmacy.

SUMMARY

While the role of the pharmacist in public health has been defined, the literature is limited with respect to the role of the pharmacist in global health. It is suggested that the "global" in global health should refer to the scope of a problem and not necessarily the geographic location. Through this lens, pharmacists have the opportunity to play an important role in both public health and global health. In particular, pharmacists can look at the varied global health careers established in medicine and use this as a framework to understand the potential role of the pharmacist within global health practice and program delivery, research, and policy.

CONCLUSIONS

To further define the role of the pharmacist in global health, pharmacists may have to change their perception of what services they can provide and where these services can be applied.

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.

Learning lessons from cancer centers in low- and middle-income countries

Infectious Agents and Cancer is introducing a new section on Cancer Centers in Low- and Middle-Income Countries intended to provide the oncology community with detailed information about lessons learned in cancer control in resource-limited settings. The growing burden of cancer and the high rates of infection-related cancers in Low- and Middle-Income Countries (LMICs) argue for exploring the successes and challenges of cancer centers in low-resource settings. Detailed analyses are needed on how successful cancer centers have developed and managed such key components as strategic partnerships, trained cancer professionals, sustainable funding, appropriate technology, and research capacity. Many examples exist wherein local cancer centers have made significant progress and as such, the series will provide a platform to showcase detailed features of cancer institutes in LMICs and provide valuable information for those seeking to replicate successful models and to help invigorate efforts to build cancer capacity.

Essential medicines for pediatric oncology in developing countries

The burden of cancer in children in low and middle income countries (LMICs) is substantial, comprising at least 80% of incident cases globally, and an even higher proportion of cancer-related deaths. With survival rates exceeding 80% in high income countries, it is imperative to transfer these successes to LMICs. A major challenge is the poor availability of safe, cost-effective chemotherapy. A list of 51 drugs-chemotherapeutics, infectious disease agents, and supportive care medications-is proposed as essential to improving the survival of children with cancer in LMICs with an additional 13 drugs identified as being of further value.