Access to surgical treatment for hepatopancreaticobiliary cancer in the Philippines

Hepatopancreaticobiliary cancers are among the most diagnosed cancers in the world. However, although high-income countries have the highest incidence rates, low- and middle-income countries have the highest mortality rates. In this article, we describe the geographic distribution of board-certified hepatopancreaticobiliary surgeons who provide surgical management for patients with these diseases in the Philippines. We draw attention to the geographic disparities in the distribution of these surgeons and the other factors that contribute to the lack of access. Lastly, we suggest ways forward.

Factors affecting the economic burden of breast cancer in southern Iran

BACKGROUND

Breast cancer (BC) is the most common cancer in the world, and is associated with significant economic costs for patients and communities. Therefore, the information on the costs of the disease and the identification of its underlying factors will provide insights into designing effective interventions and reducing the costs. Thus, the present study aimed to identify the factors affecting the economic burden of breast cancer from all medical centers providing diagnostic and treatment services in southern Iran.

METHODS

A list of factors affecting the economic burden of breast cancer was obtained based on the effective factors searched in the databases, including PubMed, ProQuest, Scopus, ISI Web of Science, SID, and Magiran, and the opinions of BC cancer specialists. Then, the data on 460 breast cancer patients was collected from March 2020 to March 2022. The relationship between the factors affecting Breast Cancer costs was analyzed using SPSS 13.0 software by the use of multiple regression analysis.

RESULTS

The results of the multiple regression analysis showed that stages (P-value < 0.001), being an extreme user (p = 0.025), type of treatment center (P-value < 0.001), income (P-value < 0.001), chemotherapy side effects (P-value < 0.001), and distance to the nearest health center (P-value < 0.001) were important factors affecting the costs of breast cancer patients.

CONCLUSIONS

According to the results, encouraging people to undergo annual screenings, increasing insurance coverage, assuring the patients about the desirability and adequacy of the provided medical services, deploying specialists in chemotherapy centers (especially nutritionists) to recommend special diets, and establishing cancer diagnostic and treatment centers in high-population cities could help reduce the costs of breast cancer patients.

The African Research Group for Oncology: A decade fostering colorectal cancer research in Nigeria

The African Research Group for Oncology (ARGO) was formed in 2013 to undertake methodologically rigorous cancer research in Nigeria, and to strengthen cancer research capacity in the country through training and mentorship of physicians, scientists, and other healthcare workers. Here, we describe how ARGO's work in colorectal cancer (CRC) has evolved over the past decade. This includes the consortium's scientific contributions to the understanding of CRC in Nigeria and globally and its research capacity-building program.

A Review of the Current State of Global Surgical Oncology and the Role of Surgeons Who Treat Cancer: Our Profession’s Imperative to Act Upon a Worldwide Crisis in Evolution

Worldwide, the capacity of healthcare systems and physician workforce is woefully inadequate for the surgical treatment of cancer. With major projected increases in the global burden of neoplastic disease, this inadequacy is expected to worsen, and interventions to increase the workforce of surgeons who treat cancer and strengthen the necessary supporting infrastructure, equipment, staffing, financial and information systems are urgently called for to prevent this inadequacy from deepening. These efforts must also occur in the context of broader healthcare systems strengthening and cancer control plans, including prevention, screening, early detection, safe and effective treatment, surveillance, and palliation. The cost of these interventions should be considered a critical investment in healthcare systems strengthening that will contribute to improvement in the public and economic health of nations. Failure to act should be seen as a missed opportunity, at the cost of lives and delayed economic growth and development. Surgeons who treat cancer must engage with a diverse array of stakeholders in efforts to address this critical need and are indispensably positioned to participate in collaborative approaches to influence these efforts through research, advocacy, training, and initiatives for sustainable development and overall systems strengthening.

Colorectal Surgery Practice, Training, and Research in Low-Resource Settings

Colorectal surgery (CRS) practice, training, and research differ between low- and middle-income countries (LMICs) and high-income countries due to disparity in resources. LMIC CRS is primarily done by general surgeons due to the paucity of fully trained colorectal surgeons. The majority of colon and rectal resections are done using open techniques, and laparoscopy and robotic platforms are only available in select private or academic centers. Multi-disciplinary teams are not available in most hospitals, so surgeons must have a broad knowledge base, and learn to adapt their practice. Formal CRS training opportunities through accredited post-residency fellowships and professional colorectal surgical associations are limited in LMICs. CRS is less established as an academic field, and less data are generated in LMICs. There are fewer staff and less dedicated funding for CRS research. However, LMIC colorectal surgeons and researchers can contribute valuable clinical findings especially on conditions of higher prevalence in their settings such as anal squamous cell carcinoma and obstetric fistulas. Effective surgical care for colorectal conditions requires significant investment in infrastructure, training, and governance in LMICs. This is critical to improve access to safe surgical care for all.

Economic Perspective of Cancer Care and Its Consequences for Vulnerable Groups

Simple Summary

For cancer patients, many different reasons can cause financial burdens and economic threads. Sociodemographic factors, rural/remote location and income are known determinants for these vulnerable groups. This economic vulnerability is related to the reduced utilization of cancer care and the impact on outcome. Financial burden has been reported in many countries throughout the world and needs to be addressed as part of the sufficient quality of cancer care.

Abstract

Within healthcare systems in all countries, vulnerable groups of patients can be identified and are characterized by the reduced utilization of available healthcare. Many different reasons can be attributed to this observation, summarized as implementation barriers involving acceptance, accessibility, affordability, acceptability and quality of care. For many patients, cancer care is specifically associated with the occurrence of vulnerability due to the complex disease, very different target groups and delivery situations (from prevention to palliative care) as well as cost-intensive care. Sociodemographic factors, such as educational level, rural/remote location and income, are known determinants for these vulnerable groups. However, different forms of financial burdens likely influence this vulnerability in cancer care delivery in a distinct manner. In a narrative review, these socioeconomic challenges are summarized regarding their occurrence and consequences to current cancer care. Overall, besides direct costs such as for treatment, many facets of indirect costs including survivorship costs for the cancer patients and their social environment need to be considered regarding the impact on vulnerability, treatment compliance and abundance. In addition, individual cancer-related financial burden might also affect the society due to the loss of productivity and workforce availability. Healthcare providers are requested to address this vulnerability during the treatment of cancer patients.

A Comprehensive Comparison of Early-Onset and Average-Onset Colorectal Cancers

BACKGROUND

The causative factors for the recent increase in early-onset colorectal cancer (EO-CRC) incidence are unknown. We sought to determine if early-onset disease is clinically or genomically distinct from average-onset colorectal cancer (AO-CRC).

METHODS

Clinical, histopathologic, and genomic characteristics of EO-CRC patients (2014-2019), divided into age 35 years and younger and 36-49 years at diagnosis, were compared with AO-CRC (50 years and older). Patients with mismatch repair deficient tumors, CRC-related hereditary syndromes, and inflammatory bowel disease were excluded from all but the germline analysis. All statistical tests were 2-sided.

RESULTS

In total, 759 patients with EO-CRC (35 years, n = 151; 36-49 years, n = 608) and AO-CRC (n = 687) were included. Left-sided tumors (35 years and younger = 80.8%; 36-49 years = 83.7%; AO = 63.9%; P < .001 for both comparisons), rectal bleeding (35 years and younger = 41.1%; 36-49 years = 41.0%; AO = 25.9%; P = .001 and P < .001, respectively), and abdominal pain (35 years and younger = 37.1%; 36-49 years = 34.0%; AO = 26.8%; P = .01 and P = .005, respectively) were more common in EO-CRC. Among microsatellite stable tumors, we found no differences in histopathologic tumor characteristics. Initially, differences in TP53 and Receptor Tyrosine Kinase signaling pathway (RTK-RAS)alterations were noted by age. However, on multivariate analysis including somatic gene analysis and tumor sidedness, no statistically significant differences at the gene or pathway level were demonstrated. Among advanced microsatellite stable CRCs, chemotherapy response and survival were equivalent by age cohorts. Pathogenic germline variants were identified in 23.3% of patients 35 years and younger vs 14.1% of AO-CRC (P = .01).

CONCLUSIONS

EO-CRCs are more commonly left-sided and present with rectal bleeding and abdominal pain but are otherwise clinically and genomically indistinguishable from AO-CRCs. Aggressive treatment regimens based solely on the age at CRC diagnosis are not warranted.

Scholarly Activity of Radiation Oncologists in High-Income Developing Countries: Saudi Arabia as an Example

PURPOSE

To examine the trends and quality metrics of publications by radiation oncologists in Saudi Arabia.

METHODS

PubMed was searched using names of all Saudi radiation oncologists to retrieve published articles between January 2010 and December 2019. International collaboration, journal impact factor and country of origin, and number of citations were collected. Each article was assessed for epidemiologic type and independently assigned a level of evidence (LOE) by two authors. The trend in publications was examined and compared in the first and second 5-year periods (2010-2014 and 2015-2019) using relevant parameters.

RESULTS

A total of 186 publications were found and included. The most common type of research was cohort studies followed by case reports and case series in 24%, 14%, and 13% of all publications, respectively. Dosimetry, clinical, and preclinical studies formed 7%, 8.6%, and 7.5% of the total publications, respectively. The LOE was I, II, III, IV, and not applicable in 8.6%, 22%, 25.8%, 29%, and 14.5% of the included publications, respectively. Comparing the first and second 5-year periods, there was an increase in international collaboration (P < .001) in the second period. The number of citations (P < .001) and journal impact factor (P = .028) were lower in the second period. LOE and publications in international journals were not statistically different between the two periods.

CONCLUSION

Although radiation oncology research activity in Saudi Arabia has gained momentum in terms of volume and international collaboration over time, the LOE has not improved. This calls for a national effort to make the contribution to the literature a priority, allocate adequate resources, and apply appropriate measures to enhance research productivity and quality.

The International Collaboration for Research methods Development in Oncology (CReDO) workshops: shaping the future of global oncology research

Low-income and middle-income countries (LMICs) have a disproportionately high burden of cancer and cancer mortality. The unique barriers to optimum cancer care in these regions necessitate context-specific research. The conduct of research in LMICs has several challenges, not least of which is a paucity of formal training in research methods. Building capacity by training early career researchers is essential to improve research output and cancer outcomes in LMICs. The International Collaboration for Research methods Development in Oncology (CReDO) workshop is an initiative by the Tata Memorial Centre and the National Cancer Grid of India to address gaps in research training and increase capacity in oncology research. Since 2015, there have been five CReDO workshops, which have trained more than 250 oncologists from India and other countries in clinical research methods and protocol development. Participants from all oncology and allied fields were represented at these workshops. Protocols developed included clinical trials, comparative effectiveness studies, health services research, and observational studies, and many of these protocols were particularly relevant to cancer management in LMICs. A follow-up of these participants in 2020 elicited an 88% response rate and showed that 42% of participants had made progress with their CReDO protocols, and 73% had initiated other research protocols and published papers. In this Policy Review, we describe the challenges to research in LMICs, as well as the evolution, structure, and impact of CReDO and other similar workshops on global oncology research.

Healthcare utilisation, cancer screening and potential barriers to accessing cancer care in rural South West Nigeria: a cross-sectional study

BACKGROUND/AIMS

Cancer burden is predicted to double by 2030 in sub-Saharan Africa; access to healthcare services for cancer management is a priority in the region. In Nigeria, National Cancer Control Plan aims to ensure >50% cancer screening of eligible populations by 2022 for all Nigerians. We describe healthcare utilisation, cancer screening activities and potential barriers to accessing cancer care within an understudied rural community-based adult population in South West Nigeria.

METHODS

In April 2018, we conducted a cross-sectional study of community-based adults (>18 years) ~130 km east of Ibadan, 250 km from Lagos in Osun State, South West Nigeria. Participants completed a face-to-face survey in local dialect. We used a questionnaire to assess demographics, health status, income, medical expenditures, doctor visits and cancer screening history.

RESULTS

We enrolled 346 individuals: with median age of 52 years and 75% women. Of the entire cohort, 4% had medical insurance. 46% reported a major medical cost in the last year. Cancer screening activities were infrequent in eligible participants: 1.5% reported having had cervical cancer screening, 3.3% mammogram and 5% colonoscopy screening. Cancer screening assessment was less frequent in those with less income and lower education levels. Using a multivariable logistic regression model including personal income, insurance status and education, higher personal income was associated with more cancer screening activity (OR 2.7, 95% CI 1.3 to 5.7, p<0.01). Despite this, most individuals had contact with a primary healthcare doctor (52% in the last year), and over 70% access to radio and TV suggesting the opportunity to expand community-based screening interventions and awareness exists.

CONCLUSIONS

Despite national increases in cancer cases, we highlight a deficiency in cancer screening and universal healthcare coverage within a community-based adult Nigerian population. Subject to availability of governmental resources, increasing financial risk protection, awareness and targeted resource allocation may help expand access in Nigeria.

Landscape of Global Oncology Research and Training at National Cancer Institute-Designated Cancer Centers: Results of the 2018 to 2019 Global Oncology Survey

PURPOSE

The National Cancer Institute (NCI)-Designated Cancer Centers (NDCCs) are active in global oncology research and training, leading collaborations to support global cancer control. To better understand global oncology activities led by NDCCs, the NCI Center for Global Health collaborated with ASCO to conduct the 2018/2019 NCI/ASCO Global Oncology Survey of NDCCs.

METHODS

Seventy NDCCs received a two-part survey that focused on global oncology programs at NDCCs and non-National Institutes of Health (NIH)-funded global oncology projects with an international collaborator led by the NDCCs. Sixty-seven NDCCs responded to the survey. Data were coded and analyzed by NCI-Center for Global Health staff.

RESULTS

Thirty-three NDCCs (47%) reported having a global oncology program, and 61 (87%) reported a collective total of 613 non-NIH-funded global oncology projects. Of the NDCCs with global oncology programs, 17 reported that trainees completed rotations outside the United States and the same number enrolled trainees from low- and middle-income countries (LMIC). Primary focus areas of non-NIH-funded projects were research (469 [76.5%]) and capacity building or training (197 [32.1%]). Projects included collaborators from 110 countries; 68 of these were LMIC.

CONCLUSION

This survey shows that there is a substantial amount of global oncology research and training conducted by NDCCs and that much of this is happening in LMIC. Trends in these data reflect those in recent literature: The field of global oncology is growing, advancing scientific knowledge, contributing to building research and training capacity in LMIC, and becoming a recognized career path. Results of the 2018 Global Oncology Survey can be used to foster opportunities for NDCCs to work collaboratively on activities and to share their findings with relevant stakeholders in their LMIC collaborator countries.

Academic Partnerships in Global Surgery: An Overview American Surgical Association Working Group on Academic Global Surgery

: Most surgeons from high-income countries who work in global surgery will do so through partnerships between their institutions and institutions in low- and middle-income countries (LMICs). In this article, the American Surgical Association Working Group for Global Surgery lays out recommendations for criteria that contribute to equitable, sustainable, and effective partnerships. These include ethically engaging with the LMIC partner institution by putting its interests first and by proactively seeking to be aware of cultural issues. Formally structuring the partnership with a memorandum of understanding and clearly designating leaders at both institutions are important criteria for assuring long-term sustainability. Needs assessments can be done using existing methods, such as those established for development of national surgical, obstetric, and anesthesia plans. Such assessments help to identify opportunities for partnerships to be most effective in addressing the biggest surgical needs in the LMIC. Examples of successful high-income countries-LMIC partnerships are provided.

Representation of South Asian countries in five high-impact anesthesia journals

Context:

The South Asian region is comprised of eight countries, i.e., Pakistan, India, Bangladesh, Sri Lanka, Afghanistan, Bhutan, Nepal, and Maldives. There is dearth of literature documenting anesthesia research in this region.

Aim:

The aim of this audit was to look at research productivity in the region by examining the volume and the type of anesthesia publication in five high-index anesthesia journals.

Settings and Design:

The study design was a survey of literature in the top five high-impact anesthesiology journals carried out at a tertiary care hospital.

Materials and Methods:

The journal citation report 2016 was accessed to identify the top five anesthesia journals based on their impact factor. We identified articles published in these journals between January 2000 and December 2015.

Statistical Analysis:

Microsoft Excel 2003 worksheet was used for data collection from extracted articles.

Results:

The highest number of publications came from India (n = 487) 95.9%; 58.5% of these were correspondence, 21% were original articles, 12.8% were case reports and case series, 1.2% reviews, and 1% editorials. Fourteen articles were published from Pakistan, with 1.2% original articles, 0.8% letter to editor, 0.6% audits, and 0.2% case reports. Nepal and Sri Lanka contributed seven publications. There were no publications in these journals from authors from Bangladesh, Afghanistan, Bhutan, and Maldives in the reviewed journals. The highest number of publications was equally distributed between two journals, i.e., “Anesthesia and Analgesia” (29.5%) and “Anesthesia” (28.9%).

Conclusion:

We found that scientific contributions from the South Asian region in terms of original anesthesiology research in five high index anesthesiology journals was suboptimal and has not shown an increasing trend over the last 16 years.

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

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

An academic career in global surgery: a position paper from the Society of University Surgeons Committee on Academic Global Surgery

In recent years, as the high burden of surgical disease and poor access to surgical care in low- and middle-income countries have gained recognition as major public health problems, interest in global health has surged among surgical trainees and faculty. Traditionally, clinical volunteerism was at the forefront of the high-income country response to the significant burden of surgical disease in low- and middle-income countries. However, sustainable strategies for providing surgical care in low- and middle-income countries increasingly depend on bilateral clinical, research, and education collaborations to ensure effective resource allocation and contextual relevance. Academic global surgery creates avenues for interested surgeons to combine scholarship and education with their clinical global surgery passions through incorporation of basic/translational, education, clinical outcomes, or health services research with global surgery. Training in global health, either within residency or through advanced degrees, can provide the necessary skills to develop and sustain such initiatives. We further propose that creating cross-continental, bidirectional collaborations can maximize funding opportunities. Academic institutions are uniquely positioned to lead longitudinal and, importantly, sustainable global surgery efforts. However, for the individual global surgeon, the career path forward may be unclear. This paper reviews the development of academic global surgery, delineates the framework and factors critical to training global surgeons, and proposes models for establishing an academic career in this field. Overall, with determination, the academic global surgeon will not only carve out a niche of expertise but will define this critical field for future generations.

Visiting scholarships in cardio-thoracic surgery: a valuable experience for fostering collaboration

Visiting scholarships to other institutions have a rich history in medicine and are an exciting opportunity to exchange ideas, learn new clinical techniques and form collaborative relationships for research advancements. Such experiences are also important in fostering a well-rounded surgical education. In this article we reflect on the valuable nature of international collaboration and provide a few guidelines to optimize the experience.

Establishing a Cancer Research Consortium in Low- and Middle-Income Countries: Challenges Faced and Lessons Learned

PURPOSE

There is an increasing effort in the global public health community to strengthen research capacity in low- and middle-income countries, but there is no consensus on how best to approach such endeavors. Successful consortia that perform research on HIV/AIDS and other infectious diseases exist, but few papers have been published detailing the challenges faced and lessons learned in setting up and running a successful research consortium.

METHODS

Members of the African Research Group for Oncology (ARGO) participated in generating lessons learned regarding the foundation and maintenance of a cancer research consortium in Nigeria.

RESULTS

Drawing on our experience of founding ARGO, we describe steps and key factors needed to establish a successful collaborative consortium between researchers from both high- and low-income countries. In addition, we present challenges we encountered in building our consortium, and how we managed those challenges. Although our research group is focused primarily on cancer, many of our lessons learned can be applied more widely in biomedical or public health research in low-income countries.

CONCLUSIONS

As the need for cancer care in LMICs continues to grow, the ability to create sustainable, innovative, collaborative research groups will become vital. Assessing the successes and failures that occur in creating and sustaining research consortia in LMICs is important for expansion of research and training capacity in LMICs.

Outcomes of the Memorial Sloan Kettering Cancer Center International General Surgical Oncology Fellowship

BACKGROUND

Training of foreign medical graduates in surgical oncology is an undervalued intervention for improving global cancer care. The aim of this work was to describe the design and results of a clinical training program for international surgeons from a single comprehensive cancer center.

STUDY DESIGN

Of 39 international fellows trained during 20 years, 34 were surveyed about education, research, and current context of surgical practice. A citation and H-index calculation (ie h number of publications that each has at least h citations) was performed to assess scientific productivity of each graduated fellow.

RESULTS

Twenty-one of 39 (54%) fellows came from countries in which English is not the primary language. Europe was the continent with the most graduates (17 of 39 [43%]), and only 5 of 39 (13%) were from Latin America. Three of 39 (8%) were women. Thirty-one of 39 graduated fellows (80%) returned to their countries of origin. The survey response rate was 73% (25 of 34). Seventeen of twenty-five (68%) work in an academic setting and 13 (52%) reported surgical oncology as their main clinical practice. Total number of citations and H-index are homogeneous among the different regions from which the fellows originated, with a median of 165 citations and median H-index of 5.

CONCLUSIONS

The International General Surgical Oncology Fellowship has successfully trained foreign surgeons for academic practice in surgical oncology. Most of the graduates have returned to their country of origin and contributed to education and research there.

Global cancer surgery: delivering safe, affordable, and timely cancer surgery

Surgery is essential for global cancer care in all resource settings. Of the 15.2 million new cases of cancer in 2015, over 80% of cases will need surgery, some several times. By 2030, we estimate that annually 45 million surgical procedures will be needed worldwide. Yet, less than 25% of patients with cancer worldwide actually get safe, affordable, or timely surgery. This Commission on global cancer surgery, building on Global Surgery 2030, has examined the state of global cancer surgery through an analysis of the burden of surgical disease and breadth of cancer surgery, economics and financing, factors for strengthening surgical systems for cancer with multiple-country studies, the research agenda, and the political factors that frame policy making in this area. We found wide equity and economic gaps in global cancer surgery. Many patients throughout the world do not have access to cancer surgery, and the failure to train more cancer surgeons and strengthen systems could result in as much as US $6.2 trillion in lost cumulative gross domestic product by 2030. Many of the key adjunct treatment modalities for cancer surgery--e.g., pathology and imaging--are also inadequate. Our analysis identified substantial issues, but also highlights solutions and innovations. Issues of access, a paucity of investment in public surgical systems, low investment in research, and training and education gaps are remarkably widespread. Solutions include better regulated public systems, international partnerships, super-centralisation of surgical services, novel surgical clinical trials, and new approaches to improve quality and scale up cancer surgical systems through education and training. Our key messages are directed at many global stakeholders, but the central message is that to deliver safe, affordable, and timely cancer surgery to all, surgery must be at the heart of global and national cancer control planning.