Mapping Geospatial Access to Comprehensive Cancer Care in Nigeria

Psychosocial wellbeing of patients with breast cancer following surgical treatment in Northern Nigeria

BACKGROUND

Breast cancer is the most commonly diagnosed cancer and a leading cause of cancer-related deaths among women globally. The cases of breast cancer have continued to rise in Nigeria and surgery remains one of the commonest treatment modalities. However, little is known about the psychosocial wellbeing of patients with breast cancer following surgery in Sub-Saharan Africa. The study investigates the psychosocial well-being and its determinants among patients with breast cancer post-surgery.

METHODS

This cross-sectional study was conducted among 72 patients with breast cancer post-surgery in Northern Nigeria. A clinico-demographic questionnaire, the World Health Organization Quality of Life Brief (WHOQOL-BREF), and the 12-item General Health Questionnaire (GHQ-12) were administered to all participants to gather information on their background and psychosocial wellbeing.

RESULTS

The participants' mean (± SD) age was 45.94 (± 9.05) years. The prevalence of psychological distress was 36.1% based on GHQ-12. A three-factor analysis of the GHQ-12 showed participants' mean (± SD) scores for anxiety/depression, social dysfunction, and loss of confidence were 9.25 (± 3.93), 14.17 (± 5.62) and 4.59 (± 1.97) respectively. About 15% (n = 11) of the participants reported their QoL as poor with mean total score of 50.91 (± 12.62), and social relationship 9.81 (± 5.09) was mostly affected across the four domains of WHOQOL-BREF. A lack of psychological counseling pre-surgery, unemployment, low level of education, post-surgical complications, and presence of psychological distress were associated with poor QoL. However, a lack of psychological counseling, post-surgical complications, and psychological distress were key predictors of poor QoL after controlling for cofounders.

CONCLUSION

Evidence informed holistic care is indicated among individuals with surgical treatment for breast cancer. There is a need for resources, capacity development and training of healthcare professionals involved in the management of breast cancer to deliver holistic care to enhance their psychosocial wellbeing. Future prospective studies are needed to inform evidence-based psychosocial interventions.

Age modulates, religious coping mediates: the role of attitude to self in cancer patients' quality of life

Background

Cancer significantly impacts psychological well-being and health-related quality of life (HRQoL). This is particularly evident in low and middle-income countries (LMICs) where healthcare disparities exacerbate distress. Cognitive vulnerabilities, including negative generalization, self-criticism, and high standards, may influence HRQoL through their effects on coping mechanisms. Religious coping, shaped by cultural norms in LMICs, may mediate these relationships, with age as a potential moderator.

Objective

This study examines how attitudes toward self (ATS), religious coping, and age influence HRQoL among cancer patients in an LMIC context.

Methods

A cross-sectional study of 565 cancer patients in a University Teaching Hospital, Southwest Nigeria completed a standardized and validated self-report measures of ATS, HRQoL, and religious coping. Mediation and moderation analyses were conducted using SPSS (Version 29) and SmartPLS (Version 4).

Results

Negative generalization (β = -0.25, p < 0.001) and self-criticism (β = -0.19, p < 0.001) reduced physical well-being, while high standards positively influenced emotional well-being (β = 0.27, p < 0.001) but negatively impacted functional well-being (β = -0.13, p < 0.01). Negative religious coping (NRC) mediated the relationships between ATS and HRQoL, amplifying negative effects on physical (β = -0.25, p < 0.001) and functional well-being (β = -0.32, p < 0.001). Age moderated these relationships, with older patients showing sharper declines in physical (β = -0.09, p < 0.01) and functional well-being (β = -0.10, p < 0.01). Positive religious coping had limited effects.

Conclusion

The study highlights the significant impact of cognitive vulnerabilities and maladaptive religious coping on the HRQoL of older cancer patients in LMICs. These findings underscore the urgent need for tailored interventions that integrate cognitive-behavioral therapy (CBT) with culturally and religiously sensitive approaches to improve patient outcomes. Policymakers and healthcare providers should prioritize training and resource allocation to address these challenges. Future research should focus on longitudinal patterns of coping, as well as gender-related differences, to develop more inclusive and effective strategies for enhancing the well-being of cancer patients.

Living Flat: Stories from Women of Color After Mastectomy

BACKGROUND

There remain persistent racial and ethnic disparities in the receipt of post-mastectomy breast reconstruction for breast cancer. Yet, patient-reported outcomes and advocacy efforts around living flat overwhelmingly have focused on white women. We sought to characterize the lived experiences among women of color living flat after mastectomy for breast cancer.

PATIENTS AND METHODS

Our community-partnered study included a sociodemographic and health questionnaire followed by semistructured interviews. Using an interview guide designed in an interdisciplinary manner, we explored themes related to culture and community after mastectomy. Women ≥ 18 years old who underwent mastectomy without reconstruction for breast cancer were included. Interviews were performed by formally trained community-based research fellows and conducted virtually over video conferencing, recorded, and transcribed. Data were analyzed on NVivo using an integrated (inductive and deductive) team-based approach.

RESULTS

The final cohort included 20 women, 60% identified as Black, 20% as Asian, 10% as multiracial, 5% as Latina, and 5% as white. Key concepts included: (a) cancer stigma, (b) privacy around breasts, (c) finding support through shared experiences, (d) sacrifice of breast for life/health, (e) spirituality, (f) patients' familial roles and relationship to breast, and (g) societal expectations. Women described the intersection of cancer stigma and privacy around breasts influencing knowledge of family history and support during cancer treatment.

CONCLUSION

Among women of color, breast cancer stigma and spirituality are key contributors to quality of life after mastectomy without breast reconstruction, domains not routinely included in contemporary patient-reported outcome measures. Representation of diverse experiences is critical to achieving equity.

Is the incidence rate of colorectal cancer increasing in Mozambique?

Background

Colorectal cancer (CRC) is a significant global health concern, ranking as the third most common cancer and the second leading cause of cancer-related deaths. However, in Africa, CRC is the fifth most common invasive malignancy. Limited data hinder our understanding of the evolving burden of CRC in sub-Saharan Africa. This study explores CRC trends in Mozambique, utilising data from population-based oncological registries.

Methods

CRC data were gathered from Beira and Maputo population-based cancer registries, along with supplementary information from pathology-based and hospital-based registries. Comparative analyses were performed across different time periods, focusing on trends and epidemiological characteristics.

Results

Incidence rates of CRC in Maputo and Beira were relatively low historically. However, data from recent years showed an increase, especially in age groups above 50. Analyses from pathology-based and hospital-based registries affirmed the rising trend. The age-standardised incidence rate in Maputo (2015-2017) was 3.17 for males and 2.55 for females. Beira exhibited increasing rates between 2009 and 2020, particularly in individuals aged 50 and above.

Conclusion

The study reveals an emerging burden of CRC in Mozambique, challenging the perception of low incidence. The rising trend underscores the necessity for tailored interventions, emphasizing early diagnosis, preventive strategies, and investments in healthcare infrastructure to address the increasing CRC burden in the region.

Translation and psychometric assessment of the mastectomy module of the BREAST-Q questionnaire for use in Nigeria

BACKGROUND

The majority of non-metastatic breast cancer patients in sub-Saharan Africa are recommended to have mastectomy. The impact of mastectomy on a predominantly young African patient population requires evaluation. The BREAST-Q is a validated patient-reported outcome measure of quality-of-life following breast surgery that has been translated into 30 languages-none in Africa. This study aimed to translate and assess the psychometric properties of the mastectomy module of the BREAST-Q for use in Nigeria.

METHODS

The BREAST-Q mastectomy module was translated from English to Yoruba and its psychometric properties assessed using best practice guidelines. Translation was performed in 4 steps: forward translation (x2), back translation, back translation review, and cognitive interviews with post-mastectomy patients. The translated BREAST-Q instrument was administered to post-mastectomy patients (n = 21) alongside the EORTC-QLQ BR23 to evaluate construct validity. Test-retest reliability was evaluated using intraclass correlation coefficients (ICC); surveys were re-administered 4 weeks apart.

RESULTS

The translation process identified English phrases not amenable to direct translation, including "emotionally healthy" and descriptions of pain ("nagging," "throbbing," "sharp"). Translations were amended to reflect local context and question intent. During cognitive interviews, patients provided suggestions to simplify complex phrases, e.g. "discomfort in your breast area.". Internal consistency within scales was over 0.70 for psychosocial wellbeing (α = 0.84-0.87), sexual wellbeing (α = 0.98-0.99), physical wellbeing in chest (α = 0.84-0.86), and satisfaction with care (α = 0.89-0.93). ICC for test-retest reliability was moderate (0.46-0.63).

CONCLUSIONS

The Yoruba version of the BREAST-Q mastectomy module presents a unique opportunity to adequately capture the experiences of Nigerian women post mastectomy. This instrument is being used in a pilot study of Nigerian patients to identify targets for intervention to improve the patient experience and compliance with breast cancer surgery.

Geographic Accessibility and Availability of Radiotherapy in Ghana

IMPORTANCE

Radiotherapy is critical for comprehensive cancer care, but there are large gaps in access. Within Ghana, data on radiotherapy availability and on the relationship between distance and access are unknown.

OBJECTIVES

To estimate the gaps in radiotherapy machine availability in Ghana and to describe the association between distance and access to care.

DESIGN, SETTING, AND PARTICIPANTS

This is a cross-sectional, population-based study of radiotherapy delivery in Ghana in 2020 and model-based analysis of radiotherapy demand and the radiotherapy utilization rate (RUR) using the Global Task Force on Radiotherapy for Cancer Control investment framework.

EXPOSURES

Receipt of radiotherapy and the number of radiotherapy courses delivered.

MAIN OUTCOMES AND MEASURES

Geocoded location of patients receiving external beam radiotherapy (EBRT); median Euclidean distance from the district centroids to the nearest radiotherapy centers; proportion of population living within geographic buffer zones of 100, 150, and 200 km; additional capacity required for optimal utilization; and geographic accessibility after strategic location of a radiotherapy facility in an underserviced region.

RESULTS

A total of 2883 patients underwent EBRT courses in 2020, with an actual RUR of 11%. Based on an optimal RUR of 48%, 11 524 patients had an indication for radiotherapy, indicating that only 23% of patients received treatment. An investment of 23 additional EBRT machines would be required to meet demand. The median Euclidean distance from the district centroids to the nearest radiotherapy facility was 110.6 km (range, 0.62-513.2 km). The proportion of the total population living within a radius of 100, 150 and 200 km of a radiotherapy facility was 47%, 61% and 70%, respectively. A new radiotherapy facility in the northern regional capital would reduce the median of Euclidean distance by 10% to 99.4 km (range, 0.62-267.7 km) and increase proportion of the total population living within a radius of 100, 150 and 200 km to 53%, 69% and 84%, respectively. The greatest benefit was seen in regions in the northern half of Ghana.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of geographic accessibility and availability of radiotherapy, Ghana had major national deficits of radiotherapy capacity, with significant geographic disparities among regions. Well-planned infrastructure scale-up that accounts for the population distribution could improve radiotherapy accessibility.

Evaluating urban-rural access to pathology and laboratory medicine services in Tanzania

Placement of pathology and laboratory medicine (PALM) services requires balancing efficiency (maximizing test volume) with equitable urban-rural access. We compared the association between population density (proxy for efficiency) and travel time to the closest facility (proxy for equitable access) across levels of Tanzania's public sector health system. We linked geospatial data for Tanzania from multiple sources. Data on facility locations and other geographic measures were collected from government and non-governmental databases. We classified facilities assuming increasing PALM availability by tier: (1) dispensaries, (2) health centres, (3) district hospitals and (4) regional/referral hospitals. We used the AccessMod 5 algorithm to estimate travel time to the closest facility for each tier across Tanzania with 500-m resolution. District-level average population density and travel time to the closest facility were calculated and presented using medians and interquartile ranges. Spatial correlations between these variables were estimated using the global Moran's I and bivariate Local Indicator of Spatial Autocorrelation, specifying a queen's neighbourhood matrix. Spatial analysis was restricted to 171 contiguous districts. The study included 5406 dispensaries, 675 health centres, 186 district hospitals and 37 regional/referral hospitals. District-level travel times were shortest for Tier 1 (median: [IQR]: 45.4 min [30.0-74.7]) and longest for Tier 4 facilities (160.2 min [107.3-260.0]). There was a weak spatial autocorrelation across tiers (Tier 1: -0.289, Tier 2: -0.292, Tier 3: -0.271 and Tier 4: -0.258) and few districts were classified as significant spatial outliers. Across tiers, geographic patterns of populated districts surrounded by neighbours with short travel time and sparsely populated districts surrounded by neighbours with long travel time were observed. Similar spatial correlation measures across health system levels suggest that Tanzania's health system reflects equitable urban-rural access to different PALM services. Longer travel times to hospital-based care could be ameliorated by shifting specialized diagnostics to more accessible lower tiers.

Opportunities for Improvement in the Administration of Neoadjuvant Chemotherapy for T4 Breast Cancer: A Comparison of the U.S. and Nigeria

BACKGROUND

Neoadjuvant chemotherapy (NAC) is an integral component of T4 breast cancer (BCa) treatment. We compared response to NAC for T4 BCa in the U.S. and Nigeria to direct future interventions.

MATERIALS AND METHODS

Cross-sectional retrospective analysis included all patients with non-metastatic T4 BCa treated from 2010 to 2016 at Memorial Sloan Kettering Cancer Center (New York, New York) and Obafemi Awolowo University Teaching Hospitals Complex (Ile Ife, Nigeria). Pathologic complete response (pCR) and survival were compared and factors contributing to disparities evaluated.

RESULTS

Three hundred and eight patients met inclusion criteria: 157 (51%) in the U.S. and 151 (49%) in Nigeria. All U.S. patients received NAC and surgery compared with 93 (62%) Nigerian patients. Fifty-six out of ninety-three (60%) Nigerian patients completed their prescribed course of NAC. In Nigeria, older age and higher socioeconomic status were associated with treatment receipt. Fewer patients in Nigeria had immunohistochemistry performed (100% U.S. vs. 18% Nigeria). Of those with available receptor subtype, 18% (28/157) of U.S. patients were triple negative versus 39% (9/23) of Nigerian patients. Overall pCR was seen in 27% (42/155) of U.S. patients and 5% (4/76) of Nigerian patients. Five-year survival was significantly shorter in Nigeria versus the U.S. (61% vs. 72%). However, among the subset of patients who received multimodality therapy, including NAC and surgery with curative intent, 5-year survival (67% vs. 72%) and 5-year recurrence-free survival (48% vs. 61%) did not significantly differ between countries.

CONCLUSION

Addressing health system, socioeconomic, and psychosocial barriers is necessary for administration of complete NAC to improve BCa outcomes in Nigeria.

IMPLICATIONS FOR PRACTICE

This cross-sectional retrospective analysis of patients with T4 breast cancer in Nigeria and the U.S. found a significant difference in pathologic complete response to neoadjuvant chemotherapy (5% Nigeria vs. 27% U.S.). Five-year survival was shorter in Nigeria, but in patients receiving multimodality treatment, including neoadjuvant chemotherapy and surgery with curative intent, 5-year overall and recurrence-free survival did not differ between countries. Capacity-building efforts in Nigeria should focus on access to pathology services to direct systemic therapy and promoting receipt of complete chemotherapy to improve outcomes.

Geospatial access predicts cancer stage at presentation and outcomes for patients with breast cancer in southwest Nigeria: A population-based study

BACKGROUND

The majority of women in Nigeria present with advanced-stage breast cancer. To address the role of geospatial access, we constructed a geographic information-system-based model to evaluate the relationship between modeled travel time, stage at presentation, and overall survival among patients with breast cancer in Nigeria.

METHODS

Consecutive patients were identified from a single-institution, prospective breast cancer database (May 2009-January 2019). Patients were geographically located, and travel time to the hospital was generated using a cost-distance model that utilized open-source data. The relationships between travel time, stage at presentation, and overall survival were evaluated with logistic regression and survival analyses. Models were adjusted for age, level of education, and socioeconomic status.

RESULTS

From 635 patients, 609 were successfully geographically located. The median age of the cohort was 49 years (interquartile range [IQR], 40-58 years); 84% presented with ≥stage III disease. Overall, 46.5% underwent surgery; 70.8% received systemic chemotherapy. The median estimated travel time for the cohort was 45 minutes (IQR, 7.9-79.3 minutes). Patients in the highest travel-time quintile had a 2.8-fold increase in the odds of presenting with stage III or IV disease relative to patients in the lowest travel-time quintile (P = .006). Travel time ≥30 minutes was associated with an increased risk of death (HR, 1.65; P = .004).

CONCLUSIONS

Geospatial access to a tertiary care facility is independently associated with stage at presentation and overall survival among patients with breast cancer in Nigeria. Addressing disparities in access will be essential to ensure the development of an equitable health policy.