1
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Cuba L, Dürr P, Gessner K, Häcker B, Fietkau R, Siebler J, Pavel M, Neurath MF, Berking C, Wullich B, Brückl V, Beckmann MW, Fromm MF, Dörje F. A Hybrid Type III Effectiveness-Implementation Trial to Optimize Medication Safety With Oral Antitumor Therapy in Real-World: The AMBORA Competence and Consultation Center. JCO Oncol Pract 2024:OP2300694. [PMID: 38848539 DOI: 10.1200/op.23.00694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/30/2024] [Accepted: 04/18/2024] [Indexed: 06/09/2024] Open
Abstract
PURPOSE Implementation science endeavors to facilitate the translation of evidence-based research into clinical routine. The clinical pharmacological/pharmaceutical care program evaluated in the randomized AMBORA trial on medication safety with oral antitumor therapeutics (OAT) optimizes care delivery and provides significant benefits for patients, treatment teams, and health care systems. Thus, we aimed to investigate the implementation of this care program within the AMBORA Competence and Consultation Center (AMBORA Center). METHODS The AMBORA Center within a University Comprehensive Cancer Center offered several services (eg, patient consultations) and was evaluated according to the RE-AIM framework. This multicenter hybrid type III trial focused on implementation outcomes (eg, patient recruitment, referring units, evaluation of services) while concurrently investigating effectiveness (eg, side effects, medication errors). Quantitative and qualitative assessments were combined. RESULTS The AMBORA Center conducted over 800 consultations with 420 patients in seven institutions. The primary end point of counseling 70% of patients treated with OAT was not reached. Patients were referred by 15 treatment units compared with 11 units in the AMBORA trial. On the basis of heterogeneous referral rates and characteristics across the institutions, barriers and facilitators of the implementation process were derived. Several survey results (eg, stakeholder interviews, online/paper-based questionnaires) reflected a high appreciation of services by patients and health care professionals. The severity of 60.1% (178 of 296) of detected side effects improved, and 86.3% (297 of 344) of medication errors were resolved. CONCLUSION Despite not reaching the primary implementation outcome, the AMBORA Center included more treatment units and demonstrated patient benefit of the AMBORA care program by meeting all effectiveness outcomes. We outlined quantitative and qualitative implementation characteristics to enhance outreach and foster further dissemination of centers to optimize medication safety with OAT.
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Affiliation(s)
- Lisa Cuba
- Pharmacy Department, Universitätsklinikum Erlangen and Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Institute of Experimental and Clinical Pharmacology and Toxicology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Universitätsklinikum Erlangen, Erlangen, Germany
- Bavarian Cancer Research Center (BZKF), Erlangen, Germany
| | - Pauline Dürr
- Pharmacy Department, Universitätsklinikum Erlangen and Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Institute of Experimental and Clinical Pharmacology and Toxicology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Universitätsklinikum Erlangen, Erlangen, Germany
- Bavarian Cancer Research Center (BZKF), Erlangen, Germany
| | - Katja Gessner
- Institute of Experimental and Clinical Pharmacology and Toxicology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Universitätsklinikum Erlangen, Erlangen, Germany
- Bavarian Cancer Research Center (BZKF), Erlangen, Germany
| | | | - Rainer Fietkau
- Comprehensive Cancer Center Erlangen-EMN, Universitätsklinikum Erlangen, Erlangen, Germany
- Bavarian Cancer Research Center (BZKF), Erlangen, Germany
- Department of Radiation Oncology, Universitätsklinikum Erlangen and Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Jürgen Siebler
- Comprehensive Cancer Center Erlangen-EMN, Universitätsklinikum Erlangen, Erlangen, Germany
- Bavarian Cancer Research Center (BZKF), Erlangen, Germany
- Department of Medicine 1, Gastroenterology, Pneumology and Endocrinology, Universitätsklinikum Erlangen and Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Marianne Pavel
- Comprehensive Cancer Center Erlangen-EMN, Universitätsklinikum Erlangen, Erlangen, Germany
- Bavarian Cancer Research Center (BZKF), Erlangen, Germany
- Department of Medicine 1, Gastroenterology, Pneumology and Endocrinology, Universitätsklinikum Erlangen and Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Markus F Neurath
- Comprehensive Cancer Center Erlangen-EMN, Universitätsklinikum Erlangen, Erlangen, Germany
- Bavarian Cancer Research Center (BZKF), Erlangen, Germany
- Department of Medicine 1, Gastroenterology, Pneumology and Endocrinology, Universitätsklinikum Erlangen and Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Carola Berking
- Comprehensive Cancer Center Erlangen-EMN, Universitätsklinikum Erlangen, Erlangen, Germany
- Bavarian Cancer Research Center (BZKF), Erlangen, Germany
- Department of Dermatology, Universitätsklinikum Erlangen and Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Bernd Wullich
- Comprehensive Cancer Center Erlangen-EMN, Universitätsklinikum Erlangen, Erlangen, Germany
- Bavarian Cancer Research Center (BZKF), Erlangen, Germany
| | - Valeska Brückl
- Comprehensive Cancer Center Erlangen-EMN, Universitätsklinikum Erlangen, Erlangen, Germany
- Bavarian Cancer Research Center (BZKF), Erlangen, Germany
- Department of Medicine 5, Hematology and Oncology, Universitätsklinikum Erlangen and Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Matthias W Beckmann
- Comprehensive Cancer Center Erlangen-EMN, Universitätsklinikum Erlangen, Erlangen, Germany
- Bavarian Cancer Research Center (BZKF), Erlangen, Germany
- Department of Obstetrics and Gynecology, Universitätsklinikum Erlangen and Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Martin F Fromm
- Institute of Experimental and Clinical Pharmacology and Toxicology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Universitätsklinikum Erlangen, Erlangen, Germany
- Bavarian Cancer Research Center (BZKF), Erlangen, Germany
- FAU NeW - Research Center New Bioactive Compounds, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Frank Dörje
- Pharmacy Department, Universitätsklinikum Erlangen and Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, Universitätsklinikum Erlangen, Erlangen, Germany
- Bavarian Cancer Research Center (BZKF), Erlangen, Germany
- FAU NeW - Research Center New Bioactive Compounds, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Dee EC, Eala MAB, Robredo JPG, Ramiah D, Hubbard A, Ho FDV, Sullivan R, Aggarwal A, Booth CM, Legaspi GD, Nguyen PL, Pramesh CS, Grover S. Leveraging national and global political determinants of health to promote equity in cancer care. J Natl Cancer Inst 2023; 115:1157-1163. [PMID: 37402623 PMCID: PMC10560599 DOI: 10.1093/jnci/djad123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/26/2023] [Accepted: 06/22/2023] [Indexed: 07/06/2023] Open
Abstract
Health and politics are deeply intertwined. In the context of national and global cancer care delivery, political forces-the political determinants of health-influence every level of the cancer care continuum. We explore the "3-I" framework, which structures the upstream political forces that affect policy choices in the context of actors' interests, ideas, and institutions, to examine how political determinants of health underlie cancer disparities. Borrowing from the work of PA Hall, M-P Pomey, CJ Ho, and other thinkers, interests are the agendas of individuals and groups in power. Ideas represent beliefs or knowledge about what is or what should be. Institutions define the rules of play. We provide examples from around the world: Political interests have helped fuel the establishment of cancer centers in India and have galvanized the 2022 Cancer Moonshot in the United States. The politics of ideas underlie global disparities in cancer clinical trials-that is, in the distribution of epistemic power. Finally, historical institutions have helped perpetuate disparities related to racist and colonialist legacies. Present institutions have also been used to improve access for those in greatest need, as exemplified by the Butaro Cancer Center of Excellence in Rwanda. In providing these global examples, we demonstrate how interests, ideas, and institutions influence access to cancer care across the breadth of the cancer continuum. We argue that these forces can be leveraged to promote cancer care equity nationally and globally.
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Affiliation(s)
- Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Michelle Ann B Eala
- College of Medicine, University of the Philippines, Manila, Philippines
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Janine Patricia G Robredo
- School of Medicine and Public Health, Ateneo de Manila University, Pasig City, Philippines
- Blavatnik Institute of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Duvern Ramiah
- Division of Radiation Oncology, University of the Witwatersrand, Johannesburg and Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Anne Hubbard
- American Society for Radiation Oncology, Arlington, VA, USA
| | | | - Richard Sullivan
- Kings Health Partners Comprehensive Cancer Centre, King's College London, Institute of Cancer Policy, London, UK
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Clinical Effectiveness Unit, Institute of Cancer Policy, King’s College London, London, UK
| | - Christopher M Booth
- Department of Oncology, Queen’s University, Kingston, ON, Canada
- Cancer Care and Epidemiology, Cancer Research Institute, Queen’s University, Kingston, ON, Canada
| | - Gerardo D Legaspi
- Division of Neurosurgery, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Harvard Cancer Center, Boston, MA, USA
| | - C S Pramesh
- Tata Memorial Hospital, Thoracic Surgery (Surgical Oncology) at Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
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Shulman LN. The National Cancer Institute Funding of Global Research: Lessons Learned and Opportunities Going Forward. J Natl Cancer Inst 2022; 114:1212-1213. [PMID: 35640129 DOI: 10.1093/jnci/djac105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/11/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Lawrence N Shulman
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
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4
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Rositch AF, Unger-Saldaña K, DeBoer RJ, Ng'ang'a A, Weiner BJ. The role of dissemination and implementation science in global breast cancer control programs: Frameworks, methods, and examples. Cancer 2021; 126 Suppl 10:2394-2404. [PMID: 32348574 DOI: 10.1002/cncr.32877] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/11/2020] [Accepted: 03/11/2020] [Indexed: 01/24/2023]
Abstract
Global disparities in breast cancer outcomes are attributable to a sizable gap between evidence and practice in breast cancer control and management. Dissemination and implementation science (D&IS) seeks to understand how to promote the systematic uptake of evidence-based interventions and/or practices into real-world contexts. D&IS methods are useful for selecting strategies to implement evidence-based interventions, adapting their implementation to new settings, and evaluating the implementation process as well as its outcomes to determine success and failure, and adjust accordingly. Process models, explanatory theories, and evaluation frameworks are used in D&IS to develop implementation strategies, identify implementation outcomes, and design studies to evaluate these outcomes. In breast cancer control and management, research has been translated into evidence-based, resource-stratified guidelines by the Breast Health Global Initiative and others. D&IS should be leveraged to optimize the implementation of these guidelines, and other evidence-based interventions, into practice across the breast cancer care continuum, from optimizing public education to promoting early detection, increasing guideline-concordant clinical practice among providers, and analyzing and addressing barriers and facilitators in health care systems. Stakeholder engagement through processes such as co-creation is critical. In this article, the authors have provided a primer on the contribution of D&IS to phased implementation of global breast cancer control programs, provided 2 case examples of ongoing D&IS research projects in Tanzania, and concluded with recommendations for best practices for researchers undertaking this work.
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Affiliation(s)
- Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Rebecca J DeBoer
- Global Cancer Program, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California
| | - Anne Ng'ang'a
- National Cancer Control Program, Ministry of Health, Nairobi, Kenya
| | - Bryan J Weiner
- Department of Global Health, University of Washington, Seattle, Washington
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5
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Joshi A, Patil VM, Noronha V, Ramaswamy A, Gupta S, Bhattacharjee A, Bonda A, Chandrakanth MV, Ostwal V, Khattry N, Banavali S, Prabhash K. EMERALD: Emergency visit audit of patients treated under medical oncology in a tertiary cancer center: Logical steps to decrease the burden. South Asian J Cancer 2020; 6:186-189. [PMID: 29404304 PMCID: PMC5763636 DOI: 10.4103/sajc.sajc_128_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: We are a tertiary care cancer center and have approximately 1000–1500 emergency visits by cancer patients undergoing treatment under the adult medical oncology unit each month. However, due to the lack of a systematic audit, we are unable to plan steps toward the improvement in quality of emergency services, and hence the audit was planned. Methods: All emergency visits under the adult medical oncology department in the month of July 2015 were audited. The cause of visit, the demographic details, cancer details, and chemotherapy status were obtained from the electronic medical records. The emergency visits were classified as avoidable or unavoidable. Descriptive statistics were performed. Reasons for avoidable emergency visits were sought. Results: Out of 1199 visits, 1168 visits were classifiable. Six hundred and ninety-six visits were classified as unavoidable (59.6%, 95% CI: 56.7–62.4), 386 visits were classified as probably avoidable visit (33.0%, 95% CI: 30.4–35.8) whereas the remaining 86 (7.4%, 95% CI: 6.0–9.01) were classified as absolutely avoidable. Two hundred and ninety-seven visits happened on weekends (25.6%) and 138 visits converted into an inpatient admission (11.9%). The factors associated with avoidable visits were curative intention of treatment (odds ratio - 2.49), discontinued chemotherapy status (risk ratio [RR] - 8.28), and private category file status (RR – 1.89). Conclusion: A proportion of visits to emergency services can be curtailed. Approximately one-fourth of patients are seen on weekends, and only about one-tenth of patients get admitted.
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Affiliation(s)
- Amit Joshi
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Vijay M Patil
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Vanita Noronha
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Anant Ramaswamy
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Sudeep Gupta
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | | | - Avinash Bonda
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - M V Chandrakanth
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Vikas Ostwal
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Navin Khattry
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Shripad Banavali
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Kumar Prabhash
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
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6
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Hunter N, Dempsey N, Tbaishat F, Jahanzeb M, Al-Sukhun S, Gralow JR. Resource-Stratified Guideline-Based Cancer Care Should Be a Priority: Historical Context and Examples of Success. Am Soc Clin Oncol Educ Book 2020; 40:1-10. [PMID: 32223670 DOI: 10.1200/edbk_279693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Low- and middle-income countries (LMICs) are shouldering most of the burden of the rapidly increasing cancer incidence and mortality worldwide, and this situation is projected to worsen in coming decades. Studies estimate that more than one million deaths could be prevented annually if all patients received high-quality care, but most LMICs lack the resources and infrastructure to adopt U.S. or European clinical oncology practice guidelines. Several organizations have developed resource-stratified guidelines (RSGs) to provide graduated and/or region-specific strategies for cancer diagnosis and treatment. The birth of these efforts traces to 2002, when the World Health Organization (WHO) called for tailoring cancer treatments to the level of available resources by country; the Breast Health Global Initiative (BHGI) formalized the first stratified guidelines for breast cancer shortly thereafter. Since then, multiple organizations including ASCO and the National Comprehensive Cancer Network (NCCN) have created guidelines customized for various cancer subtypes and regions. These RSGs offer roadmaps for policy makers, clinicians, and health care administrators in LMICs to design projects in implementation science that can gradually and strategically raise the quality of cancer care in their nation or region. Although the same resource limitations that complicate cancer care in these areas also pose barriers to data gathering and research, some countries have met the challenge and are improving cancer care using RSGs as a metric for success.
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Affiliation(s)
- Natasha Hunter
- Division of Oncology, University of Washington, Seattle, WA
| | | | - Fayez Tbaishat
- Department of Oncology, Al Bashir Hospital, Amman, Jordan
| | | | | | - Julie R Gralow
- Division of Oncology, University of Washington, Seattle, WA
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7
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DeBoer RJ, Shyirambere C, Driscoll CD, Butera Y, Paciorek A, Ruhangaza D, Fadelu TA, Umwizerwa A, Bigirimana JB, Muhayimana C, Nguyen C, Park PH, Mpunga T, Lehmann L, Shulman LN. Treatment of Hodgkin Lymphoma With ABVD Chemotherapy in Rural Rwanda: A Model for Cancer Care Delivery Implementation. JCO Glob Oncol 2020; 6:1093-1102. [PMID: 32678711 PMCID: PMC7392734 DOI: 10.1200/go.20.00088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2020] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Hodgkin lymphoma (HL) is highly curable in high-income countries (HICs), yet many patients around the world do not have access to therapy. In 2012, cancer care was established at a rural district hospital in Rwanda through international collaboration, and a treatment protocol using doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) without radiotherapy was implemented. METHODS We conducted a retrospective cohort study of all patients with confirmed HL seen at Butaro Hospital from 2012 to 2018 to evaluate quality indicators and clinical outcomes. RESULTS Eighty-five patients were included (median age, 16.8 years; interquartile range, 11.0-30.5 years). Ten (12%) were HIV positive. Most had B symptoms (70%) and advanced stage (56%) on examination and limited imaging. Of 21 specimens evaluated for Epstein-Barr virus, 14 (67%) were positive. Median time from biopsy to treatment was 6.0 weeks. Of 73 patients who started ABVD, 54 (74%) completed 6 cycles; the leading reasons for discontinuation were treatment abandonment and death. Median dose intensity of ABVD was 92%. Of 77 evaluable patients, 33 (43%) are in clinical remission, 27 (36%) are deceased, and 17 (22%) were lost to follow-up; 3-year survival estimate is 63% (95% CI, 50% to 74%). Poorer performance status, advanced stage, B symptoms, anemia, dose intensity < 85%, and treatment discontinuation were associated with worse survival. CONCLUSION Treating HL with standard chemotherapy in a low-resource setting is feasible. Most patients who completed treatment experienced a clinically significant remission with this approach. Late presentation, treatment abandonment, and loss to follow-up contribute to the discrepancy in survival compared with HICs. A strikingly younger age distribution in our cohort compared with HICs suggests biologic differences and warrants further investigation.
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Affiliation(s)
- Rebecca J. DeBoer
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | | | | | - Yvan Butera
- Republic of Rwanda Ministry of Health, Kigali, Rwanda
| | - Alan Paciorek
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | | | | | - Aline Umwizerwa
- Partners In Health/Inshuti Mu Buzima, Burera District, Rwanda
| | | | | | - Cam Nguyen
- Partners In Health/Inshuti Mu Buzima, Burera District, Rwanda
| | | | | | - Leslie Lehmann
- Dana-Farber/Boston Children’s Hospital Cancer Center, Boston, MA
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8
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Integration of Chronic Oncology Services in Noncommunicable Disease Clinic in Rural Rwanda. Ann Glob Health 2020; 86:33. [PMID: 32257833 PMCID: PMC7101006 DOI: 10.5334/aogh.2697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: In rural sub-Saharan Africa, access to care for severe non-communicable diseases (NCDs) is limited due to myriad delivery challenges. We describe the implementation, patient characteristics, and retention rate of an integrated NCD clinic inclusive of cancer services at a district hospital in rural Rwanda. Methods: In 2006, the Rwandan Ministry of Health at Rwinkwavu District Hospital (RDH) and Partners In Health established an integrated NCD clinic focused on nurse-led care of severe NCDs, within a single delivery platform. Implementation modifications were made in 2011 to include cancer services. For this descriptive study, we abstracted medical record data for 15 months after first clinic visit for all patients who enrolled in the NCD clinic between 1 July 2012 and 30 June 2014. We report descriptive statistics of patient characteristics and retention. Results: Three hundred forty-seven patients enrolled during the study period: oncology – 71.8%, hypertension – 10.4%, heart failure – 11.0%, diabetes – 5.5%, and chronic respiratory disease (CRD) – 1.4%. Twelve-month retention rates were: oncology – 81.6%, CRD – 60.0%, hypertension – 75.0%, diabetes – 73.7%, and heart failure – 47.4%. Conclusions: The integrated NCD clinic filled a gap in accessible care for severe NCDs, including cancer, at rural district hospitals. This novel approach has illustrated good retention rates.
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DeBoer RJ, Ndumbalo J, Meena S, Ngoma MT, Mvungi N, Siu S, Selekwa M, Nyagabona SK, Luhar R, Buckle G, Lin TK, Breithaupt L, Kennell-Heiling S, Mushi B, Philipo GS, Mmbaga EJ, Mwaiselage J, Van Loon K. Development of a theory-driven implementation strategy for cancer management guidelines in sub-Saharan Africa. Implement Sci Commun 2020; 1:24. [PMID: 32885183 PMCID: PMC7427872 DOI: 10.1186/s43058-020-00007-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/09/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Despite recent international efforts to develop resource-stratified clinical practice guidelines for cancer, there has been little research to evaluate the best strategies for dissemination and implementation in low- and middle-income countries (LMICs). Guideline publication alone is insufficient. Extensive research has shown that structured, multifaceted implementation strategies that target barriers to guideline use are most likely to improve adherence; however, most of this research has been conducted in high-income countries. There is a pressing need to develop and evaluate guideline implementation strategies for cancer management in LMICs in order to address stark disparities in cancer outcomes. METHODS In preparation for the launch of Tanzania's first National Cancer Treatment Guidelines, we developed a theory-driven implementation strategy for guideline-based practice at Ocean Road Cancer Institute (ORCI). Here, we use the Intervention Mapping framework to provide a detailed stepwise description of our process. First, we conducted a needs assessment to identify barriers and facilitators to guideline-based practice at ORCI. Second, we defined both proximal and performance objectives for our implementation strategy. Third, we used the Capability, Opportunity, Motivation and Behavior/Behavior Change Wheel (COM-B/BCW) framework to categorize the barriers and facilitators, choose behavior change techniques most likely to overcome targeted barriers and leverage facilitators, and select a feasible mode of delivery for each technique. Fourth, we organized these modes of delivery into a phased implementation strategy. Fifth, we operationalized each component of the strategy. Sixth, we identified the indicators of the process, outcome, and impact of our intervention and developed an evaluation plan to measure them using a mixed methods approach. DISCUSSION We developed a robust, multifaceted guideline implementation strategy derived from a prominent behavior change theory for use in Tanzania. The barriers and strategies we generated are consistent with those well established in the literature, enhancing the validity and generalizability of our process and results. Through our rigorous evaluation plan and systematic account of modifications and adaptations, we will characterize the transferability of "proven" guideline implementation strategies to LMICs. We hope that by describing our process in detail, others may endeavor to replicate it, meeting a widespread need for dedicated efforts to implement cancer guidelines in LMICs.
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Affiliation(s)
- Rebecca J. DeBoer
- Global Cancer Program, University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center, San Francisco, CA USA
| | | | - Stephen Meena
- Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | | | | | - Sadiq Siu
- Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | - Msiba Selekwa
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Sarah K. Nyagabona
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Rohan Luhar
- Global Cancer Program, University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center, San Francisco, CA USA
| | - Geoffrey Buckle
- Global Cancer Program, University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center, San Francisco, CA USA
| | - Tracy Kuo Lin
- Global Cancer Program, University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center, San Francisco, CA USA
| | - Lindsay Breithaupt
- Global Cancer Program, University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center, San Francisco, CA USA
| | - Stephanie Kennell-Heiling
- Global Cancer Program, University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center, San Francisco, CA USA
| | - Beatrice Mushi
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Elia J. Mmbaga
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Katherine Van Loon
- Global Cancer Program, University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center, San Francisco, CA USA
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Kabukye JK, de Keizer N, Cornet R. Elicitation and prioritization of requirements for electronic health records for oncology in low resource settings: A concept mapping study. Int J Med Inform 2019; 135:104055. [PMID: 31877404 DOI: 10.1016/j.ijmedinf.2019.104055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 12/09/2019] [Accepted: 12/17/2019] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Johnblack K Kabukye
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, Location AMC, Meibergdreef 15, Amsterdam, the Netherlands; Uganda Cancer Institute, Upper Mulago Hill Road, P.O. Box 3935 Kampala, Uganda.
| | - Nicolet de Keizer
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, Location AMC, Meibergdreef 15, Amsterdam, the Netherlands
| | - Ronald Cornet
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, Location AMC, Meibergdreef 15, Amsterdam, the Netherlands
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11
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Wagner CM, Antillón F, Uwinkindi F, Thuan TV, Luna-Fineman S, Anh PT, Huong TT, Valverde P, Eagan A, Binh PV, Quang TN, Johnson S, Binagwaho A, Torode J. Establishing Cancer Treatment Programs in Resource-Limited Settings: Lessons Learned From Guatemala, Rwanda, and Vietnam. J Glob Oncol 2019; 4:1-14. [PMID: 30085895 PMCID: PMC6223537 DOI: 10.1200/jgo.17.00082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Purpose The global burden of cancer is slated to reach 21.4 million new cases in 2030 alone, and the majority of those cases occur in under-resourced settings. Formidable changes to health care delivery systems must occur to meet this demand. Although significant policy advances have been made and documented at the international level, less is known about the efforts to create national systems to combat cancer in such settings. Methods With case reports and data from authors who are clinicians and policymakers in three financially constrained countries in different regions of the world—Guatemala, Rwanda, and Vietnam, we examined cancer care programs to identify principles that lead to robust care delivery platforms as well as challenges faced in each setting. Results The findings demonstrate that successful programs derive from equitably constructed and durable interventions focused on advancement of local clinical capacity and the prioritization of geographic and financial accessibility. In addition, a committed local response to the increasing cancer burden facilitates engagement of partners who become vital catalysts for launching treatment cascades. Also, clinical education in each setting was buttressed by international expertise, which aided both professional development and retention of staff. Conclusion All three countries demonstrate that excellent cancer care can and should be provided to all, including those who are impoverished or marginalized, without acceptance of a double standard. In this article, we call on governments and program leaders to report on successes and challenges in their own settings to allow for informed progression toward the 2025 global policy goals.
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Affiliation(s)
- Claire M Wagner
- Claire M. Wagner, Arielle Eagan, and Agnes Binagwaho, Harvard Medical School, Boston, MA; Sonali Johnson and Julie Torode, Union for International Cancer Control, Geneva, Switzerland; Federico Antillón, Unidad Nacional de Oncología Pediatrica; and Universidad Francisco Marroquín; Patricia Valverde, Unidad Nacional de Oncología Pediatrica, Guatemala City, Guatemala; François Uwinkindi and and Arielle Eagan, Rwanda Biomedical Center; Agnes Binagwaho, University of Global Health Equity, Kigali, Rwanda; Tran Van Thuan, Pham Tuan Anh, Tran Thanh Huong, Pham Van Binh, and Nguyen Tien Quang, National Cancer Hospital of Viet Nam; Tran Van Thuan and Tran Thanh Huong, National Institute for Cancer Control; Tran Thanh Huong, Hanoi Medical University, Hanoi, Viet Nam; Sandra Luna-Fineman, Children's Hospital Colorado and University of Colorado, Denver, CO; and Agnes Binagwaho and Arielle Eagan, Dartmouth College, Hanover, NH
| | - Federico Antillón
- Claire M. Wagner, Arielle Eagan, and Agnes Binagwaho, Harvard Medical School, Boston, MA; Sonali Johnson and Julie Torode, Union for International Cancer Control, Geneva, Switzerland; Federico Antillón, Unidad Nacional de Oncología Pediatrica; and Universidad Francisco Marroquín; Patricia Valverde, Unidad Nacional de Oncología Pediatrica, Guatemala City, Guatemala; François Uwinkindi and and Arielle Eagan, Rwanda Biomedical Center; Agnes Binagwaho, University of Global Health Equity, Kigali, Rwanda; Tran Van Thuan, Pham Tuan Anh, Tran Thanh Huong, Pham Van Binh, and Nguyen Tien Quang, National Cancer Hospital of Viet Nam; Tran Van Thuan and Tran Thanh Huong, National Institute for Cancer Control; Tran Thanh Huong, Hanoi Medical University, Hanoi, Viet Nam; Sandra Luna-Fineman, Children's Hospital Colorado and University of Colorado, Denver, CO; and Agnes Binagwaho and Arielle Eagan, Dartmouth College, Hanover, NH
| | - François Uwinkindi
- Claire M. Wagner, Arielle Eagan, and Agnes Binagwaho, Harvard Medical School, Boston, MA; Sonali Johnson and Julie Torode, Union for International Cancer Control, Geneva, Switzerland; Federico Antillón, Unidad Nacional de Oncología Pediatrica; and Universidad Francisco Marroquín; Patricia Valverde, Unidad Nacional de Oncología Pediatrica, Guatemala City, Guatemala; François Uwinkindi and and Arielle Eagan, Rwanda Biomedical Center; Agnes Binagwaho, University of Global Health Equity, Kigali, Rwanda; Tran Van Thuan, Pham Tuan Anh, Tran Thanh Huong, Pham Van Binh, and Nguyen Tien Quang, National Cancer Hospital of Viet Nam; Tran Van Thuan and Tran Thanh Huong, National Institute for Cancer Control; Tran Thanh Huong, Hanoi Medical University, Hanoi, Viet Nam; Sandra Luna-Fineman, Children's Hospital Colorado and University of Colorado, Denver, CO; and Agnes Binagwaho and Arielle Eagan, Dartmouth College, Hanover, NH
| | - Tran Van Thuan
- Claire M. Wagner, Arielle Eagan, and Agnes Binagwaho, Harvard Medical School, Boston, MA; Sonali Johnson and Julie Torode, Union for International Cancer Control, Geneva, Switzerland; Federico Antillón, Unidad Nacional de Oncología Pediatrica; and Universidad Francisco Marroquín; Patricia Valverde, Unidad Nacional de Oncología Pediatrica, Guatemala City, Guatemala; François Uwinkindi and and Arielle Eagan, Rwanda Biomedical Center; Agnes Binagwaho, University of Global Health Equity, Kigali, Rwanda; Tran Van Thuan, Pham Tuan Anh, Tran Thanh Huong, Pham Van Binh, and Nguyen Tien Quang, National Cancer Hospital of Viet Nam; Tran Van Thuan and Tran Thanh Huong, National Institute for Cancer Control; Tran Thanh Huong, Hanoi Medical University, Hanoi, Viet Nam; Sandra Luna-Fineman, Children's Hospital Colorado and University of Colorado, Denver, CO; and Agnes Binagwaho and Arielle Eagan, Dartmouth College, Hanover, NH
| | - Sandra Luna-Fineman
- Claire M. Wagner, Arielle Eagan, and Agnes Binagwaho, Harvard Medical School, Boston, MA; Sonali Johnson and Julie Torode, Union for International Cancer Control, Geneva, Switzerland; Federico Antillón, Unidad Nacional de Oncología Pediatrica; and Universidad Francisco Marroquín; Patricia Valverde, Unidad Nacional de Oncología Pediatrica, Guatemala City, Guatemala; François Uwinkindi and and Arielle Eagan, Rwanda Biomedical Center; Agnes Binagwaho, University of Global Health Equity, Kigali, Rwanda; Tran Van Thuan, Pham Tuan Anh, Tran Thanh Huong, Pham Van Binh, and Nguyen Tien Quang, National Cancer Hospital of Viet Nam; Tran Van Thuan and Tran Thanh Huong, National Institute for Cancer Control; Tran Thanh Huong, Hanoi Medical University, Hanoi, Viet Nam; Sandra Luna-Fineman, Children's Hospital Colorado and University of Colorado, Denver, CO; and Agnes Binagwaho and Arielle Eagan, Dartmouth College, Hanover, NH
| | - Pham Tuan Anh
- Claire M. Wagner, Arielle Eagan, and Agnes Binagwaho, Harvard Medical School, Boston, MA; Sonali Johnson and Julie Torode, Union for International Cancer Control, Geneva, Switzerland; Federico Antillón, Unidad Nacional de Oncología Pediatrica; and Universidad Francisco Marroquín; Patricia Valverde, Unidad Nacional de Oncología Pediatrica, Guatemala City, Guatemala; François Uwinkindi and and Arielle Eagan, Rwanda Biomedical Center; Agnes Binagwaho, University of Global Health Equity, Kigali, Rwanda; Tran Van Thuan, Pham Tuan Anh, Tran Thanh Huong, Pham Van Binh, and Nguyen Tien Quang, National Cancer Hospital of Viet Nam; Tran Van Thuan and Tran Thanh Huong, National Institute for Cancer Control; Tran Thanh Huong, Hanoi Medical University, Hanoi, Viet Nam; Sandra Luna-Fineman, Children's Hospital Colorado and University of Colorado, Denver, CO; and Agnes Binagwaho and Arielle Eagan, Dartmouth College, Hanover, NH
| | - Tran Thanh Huong
- Claire M. Wagner, Arielle Eagan, and Agnes Binagwaho, Harvard Medical School, Boston, MA; Sonali Johnson and Julie Torode, Union for International Cancer Control, Geneva, Switzerland; Federico Antillón, Unidad Nacional de Oncología Pediatrica; and Universidad Francisco Marroquín; Patricia Valverde, Unidad Nacional de Oncología Pediatrica, Guatemala City, Guatemala; François Uwinkindi and and Arielle Eagan, Rwanda Biomedical Center; Agnes Binagwaho, University of Global Health Equity, Kigali, Rwanda; Tran Van Thuan, Pham Tuan Anh, Tran Thanh Huong, Pham Van Binh, and Nguyen Tien Quang, National Cancer Hospital of Viet Nam; Tran Van Thuan and Tran Thanh Huong, National Institute for Cancer Control; Tran Thanh Huong, Hanoi Medical University, Hanoi, Viet Nam; Sandra Luna-Fineman, Children's Hospital Colorado and University of Colorado, Denver, CO; and Agnes Binagwaho and Arielle Eagan, Dartmouth College, Hanover, NH
| | - Patricia Valverde
- Claire M. Wagner, Arielle Eagan, and Agnes Binagwaho, Harvard Medical School, Boston, MA; Sonali Johnson and Julie Torode, Union for International Cancer Control, Geneva, Switzerland; Federico Antillón, Unidad Nacional de Oncología Pediatrica; and Universidad Francisco Marroquín; Patricia Valverde, Unidad Nacional de Oncología Pediatrica, Guatemala City, Guatemala; François Uwinkindi and and Arielle Eagan, Rwanda Biomedical Center; Agnes Binagwaho, University of Global Health Equity, Kigali, Rwanda; Tran Van Thuan, Pham Tuan Anh, Tran Thanh Huong, Pham Van Binh, and Nguyen Tien Quang, National Cancer Hospital of Viet Nam; Tran Van Thuan and Tran Thanh Huong, National Institute for Cancer Control; Tran Thanh Huong, Hanoi Medical University, Hanoi, Viet Nam; Sandra Luna-Fineman, Children's Hospital Colorado and University of Colorado, Denver, CO; and Agnes Binagwaho and Arielle Eagan, Dartmouth College, Hanover, NH
| | - Arielle Eagan
- Claire M. Wagner, Arielle Eagan, and Agnes Binagwaho, Harvard Medical School, Boston, MA; Sonali Johnson and Julie Torode, Union for International Cancer Control, Geneva, Switzerland; Federico Antillón, Unidad Nacional de Oncología Pediatrica; and Universidad Francisco Marroquín; Patricia Valverde, Unidad Nacional de Oncología Pediatrica, Guatemala City, Guatemala; François Uwinkindi and and Arielle Eagan, Rwanda Biomedical Center; Agnes Binagwaho, University of Global Health Equity, Kigali, Rwanda; Tran Van Thuan, Pham Tuan Anh, Tran Thanh Huong, Pham Van Binh, and Nguyen Tien Quang, National Cancer Hospital of Viet Nam; Tran Van Thuan and Tran Thanh Huong, National Institute for Cancer Control; Tran Thanh Huong, Hanoi Medical University, Hanoi, Viet Nam; Sandra Luna-Fineman, Children's Hospital Colorado and University of Colorado, Denver, CO; and Agnes Binagwaho and Arielle Eagan, Dartmouth College, Hanover, NH
| | - Pham Van Binh
- Claire M. Wagner, Arielle Eagan, and Agnes Binagwaho, Harvard Medical School, Boston, MA; Sonali Johnson and Julie Torode, Union for International Cancer Control, Geneva, Switzerland; Federico Antillón, Unidad Nacional de Oncología Pediatrica; and Universidad Francisco Marroquín; Patricia Valverde, Unidad Nacional de Oncología Pediatrica, Guatemala City, Guatemala; François Uwinkindi and and Arielle Eagan, Rwanda Biomedical Center; Agnes Binagwaho, University of Global Health Equity, Kigali, Rwanda; Tran Van Thuan, Pham Tuan Anh, Tran Thanh Huong, Pham Van Binh, and Nguyen Tien Quang, National Cancer Hospital of Viet Nam; Tran Van Thuan and Tran Thanh Huong, National Institute for Cancer Control; Tran Thanh Huong, Hanoi Medical University, Hanoi, Viet Nam; Sandra Luna-Fineman, Children's Hospital Colorado and University of Colorado, Denver, CO; and Agnes Binagwaho and Arielle Eagan, Dartmouth College, Hanover, NH
| | - Tien Nguyen Quang
- Claire M. Wagner, Arielle Eagan, and Agnes Binagwaho, Harvard Medical School, Boston, MA; Sonali Johnson and Julie Torode, Union for International Cancer Control, Geneva, Switzerland; Federico Antillón, Unidad Nacional de Oncología Pediatrica; and Universidad Francisco Marroquín; Patricia Valverde, Unidad Nacional de Oncología Pediatrica, Guatemala City, Guatemala; François Uwinkindi and and Arielle Eagan, Rwanda Biomedical Center; Agnes Binagwaho, University of Global Health Equity, Kigali, Rwanda; Tran Van Thuan, Pham Tuan Anh, Tran Thanh Huong, Pham Van Binh, and Nguyen Tien Quang, National Cancer Hospital of Viet Nam; Tran Van Thuan and Tran Thanh Huong, National Institute for Cancer Control; Tran Thanh Huong, Hanoi Medical University, Hanoi, Viet Nam; Sandra Luna-Fineman, Children's Hospital Colorado and University of Colorado, Denver, CO; and Agnes Binagwaho and Arielle Eagan, Dartmouth College, Hanover, NH
| | - Sonali Johnson
- Claire M. Wagner, Arielle Eagan, and Agnes Binagwaho, Harvard Medical School, Boston, MA; Sonali Johnson and Julie Torode, Union for International Cancer Control, Geneva, Switzerland; Federico Antillón, Unidad Nacional de Oncología Pediatrica; and Universidad Francisco Marroquín; Patricia Valverde, Unidad Nacional de Oncología Pediatrica, Guatemala City, Guatemala; François Uwinkindi and and Arielle Eagan, Rwanda Biomedical Center; Agnes Binagwaho, University of Global Health Equity, Kigali, Rwanda; Tran Van Thuan, Pham Tuan Anh, Tran Thanh Huong, Pham Van Binh, and Nguyen Tien Quang, National Cancer Hospital of Viet Nam; Tran Van Thuan and Tran Thanh Huong, National Institute for Cancer Control; Tran Thanh Huong, Hanoi Medical University, Hanoi, Viet Nam; Sandra Luna-Fineman, Children's Hospital Colorado and University of Colorado, Denver, CO; and Agnes Binagwaho and Arielle Eagan, Dartmouth College, Hanover, NH
| | - Agnes Binagwaho
- Claire M. Wagner, Arielle Eagan, and Agnes Binagwaho, Harvard Medical School, Boston, MA; Sonali Johnson and Julie Torode, Union for International Cancer Control, Geneva, Switzerland; Federico Antillón, Unidad Nacional de Oncología Pediatrica; and Universidad Francisco Marroquín; Patricia Valverde, Unidad Nacional de Oncología Pediatrica, Guatemala City, Guatemala; François Uwinkindi and and Arielle Eagan, Rwanda Biomedical Center; Agnes Binagwaho, University of Global Health Equity, Kigali, Rwanda; Tran Van Thuan, Pham Tuan Anh, Tran Thanh Huong, Pham Van Binh, and Nguyen Tien Quang, National Cancer Hospital of Viet Nam; Tran Van Thuan and Tran Thanh Huong, National Institute for Cancer Control; Tran Thanh Huong, Hanoi Medical University, Hanoi, Viet Nam; Sandra Luna-Fineman, Children's Hospital Colorado and University of Colorado, Denver, CO; and Agnes Binagwaho and Arielle Eagan, Dartmouth College, Hanover, NH
| | - Julie Torode
- Claire M. Wagner, Arielle Eagan, and Agnes Binagwaho, Harvard Medical School, Boston, MA; Sonali Johnson and Julie Torode, Union for International Cancer Control, Geneva, Switzerland; Federico Antillón, Unidad Nacional de Oncología Pediatrica; and Universidad Francisco Marroquín; Patricia Valverde, Unidad Nacional de Oncología Pediatrica, Guatemala City, Guatemala; François Uwinkindi and and Arielle Eagan, Rwanda Biomedical Center; Agnes Binagwaho, University of Global Health Equity, Kigali, Rwanda; Tran Van Thuan, Pham Tuan Anh, Tran Thanh Huong, Pham Van Binh, and Nguyen Tien Quang, National Cancer Hospital of Viet Nam; Tran Van Thuan and Tran Thanh Huong, National Institute for Cancer Control; Tran Thanh Huong, Hanoi Medical University, Hanoi, Viet Nam; Sandra Luna-Fineman, Children's Hospital Colorado and University of Colorado, Denver, CO; and Agnes Binagwaho and Arielle Eagan, Dartmouth College, Hanover, NH
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12
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Park PH, Davey S, Fehr AE, Butonzi J, Shyirambere C, Hategekimana V, Bigirimana JB, Borg R, Uwizeye R, Tapela N, Shulman LN, Randall T, Mpanumusingo E, Mpunga T. Patient Characteristics, Early Outcomes, and Implementation Lessons of Cervical Cancer Treatment Services in Rural Rwanda. J Glob Oncol 2019; 4:1-11. [PMID: 30582433 PMCID: PMC7010450 DOI: 10.1200/jgo.18.00120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Low- and middle-income countries account for 86% of all cervical cancer cases and 88% of cervical cancer mortality globally. Successful management of cervical cancer requires resources that are scarce in sub-Saharan Africa, especially in rural settings. Here, we describe the early clinical outcomes and implementation lessons learned from the Rwanda Ministry of Health's first national cancer referral center, the Butaro Cancer Center of Excellence (BCCOE). We hypothesize that those patients presenting at earlier stage and receiving treatment will have higher rates of being alive. METHODS The implementation of cervical cancer services included developing partnerships, clinical protocols, pathology services, and tools for monitoring and evaluation. We conducted a retrospective study of patients with cervical cancer who presented at BCCOE between July 1, 2012, and June 30, 2015. Data were collected from the electronic medical record system and by manually reviewing medical records. Descriptive, bivariable and multivariable statistical analyses were conducted to describe patient demographics, disease profiles, treatment, and clinical outcomes. RESULTS In all, 373 patients met the study inclusion criteria. The median age was 53 years (interquartile rage, 45 to 60 years), and 98% were residents of Rwanda. Eighty-nine percent of patients had a documented disease stage: 3% were stage I, 48% were stage II, 29% were stage III, and 8% were stage IV at presentation. Fifty percent of patients were planned to be treated with a curative intent, and 54% were referred to chemoradiotherapy in Uganda. Forty percent of patients who received chemoradiotherapy were in remission. Overall, 25% were lost to follow-up. CONCLUSION BCCOE illustrates the feasibility and challenges of implementing effective cervical cancer treatment services in a rural setting in a low-income country.
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Affiliation(s)
- Paul H Park
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Sonya Davey
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Alexandra E Fehr
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - John Butonzi
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Cyprien Shyirambere
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Vedaste Hategekimana
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Jean Bosco Bigirimana
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Ryan Borg
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Regis Uwizeye
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Neo Tapela
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Lawrence N Shulman
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Thomas Randall
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Egide Mpanumusingo
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Tharcisse Mpunga
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
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13
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The Role of Quality Measures in Improving Breast Cancer Care in Low-Income Countries. CURRENT BREAST CANCER REPORTS 2018. [DOI: 10.1007/s12609-018-0288-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Randall TC, Chuang L, Orang'o E, Rosen B, Uwinkindi F, Rebbeck T, Trimble EL. Strengthening care and research for women's cancers in Sub-Saharan Africa. Gynecol Oncol Rep 2017; 21:109-113. [PMID: 28819635 PMCID: PMC5548333 DOI: 10.1016/j.gore.2017.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/26/2017] [Accepted: 06/02/2017] [Indexed: 11/29/2022] Open
Abstract
•The burden of gynecologic cancers in low resource settings is overwhelming.•Areas with the highest needs have few human resources and limited infrastructure.•Cancer specialists can best help by leveraging ongoing work to assist local leaders.
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Affiliation(s)
- Thomas C. Randall
- Division of Gynecologic Oncology, The Massachusetts General Hospital, Boston, MA, United States
- The National Cancer Institute, Center for Global Health, Rockville, MD, United States
| | - Linus Chuang
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Mount Sinai Medical Center, New York, NY, United States
| | - ElkanahOmenge Orang'o
- Department of Reproductive Health, Moi University School of Medicine, Eldoret, Kenya
| | - Barry Rosen
- Gynecologic Oncology, Beaumont Hospital, Grosse Point, MI, United States
| | | | - Timothy Rebbeck
- Epidemiology, Harvard T.H. Chan School of Public Health, Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Edward L. Trimble
- The National Cancer Institute, Center for Global Health, Rockville, MD, United States
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Adams LV, Wagner CM, Nutt CT, Binagwaho A. The future of global health education: training for equity in global health. BMC MEDICAL EDUCATION 2016; 16:296. [PMID: 27871276 PMCID: PMC5117699 DOI: 10.1186/s12909-016-0820-0] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 11/09/2016] [Indexed: 05/21/2023]
Abstract
BACKGROUND Among academic institutions in the United States, interest in global health has grown substantially: by the number of students seeking global health opportunities at all stages of training, and by the increase in institutional partnerships and newly established centers, institutes, and initiatives to house global health programs at undergraduate, public health and medical schools. Witnessing this remarkable growth should compel health educators to question whether the training and guidance that we provide to students today is appropriate, and whether it will be applicable in the next decade and beyond. Given that "global health" did not exist as an academic discipline in the United States 20 years ago, what can we expect it will look like 20 years from now and how can we prepare for that future? DISCUSSION Most clinicians and trainees today recognize the importance of true partnership and capacity building in both directions for successful international collaborations. The challenge is in the execution of these practices. There are projects around the world where this is occurring and equitable partnerships have been established. Based on our experience and observations of the current landscape of academic global health, we share a perspective on principles of engagement, highlighting instances where partnerships have thrived, and examples of where we, as a global community, have fallen short. CONCLUSIONS As the world moves beyond the charity model of global health (and its colonial roots), it is evident that the issue underlying ethical global health practice is partnership and the pursuit of health equity. Thus, achieving equity in global health education and practice ought to be central to our mission as educators and advisors when preparing trainees for careers in this field. Seeking to eliminate health inequities wherever they are ingrained will reveal the injustices around the globe and in our own cities and towns.
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Affiliation(s)
- Lisa V. Adams
- Center for Health Equity, Dartmouth’s Geisel School of Medicine, 1 Rope Ferry Road, Room 219, Hanover, NH 03755 USA
| | - Claire M. Wagner
- Union for International Cancer Control, 62 Route de Frontenex, 1207 Geneva, Switzerland
| | - Cameron T. Nutt
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115 USA
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Affiliation(s)
| | - Tony S K Mok
- The Chinese University of Hong Kong, Hong Kong, China
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