Impact of the COVID-19 pandemic on cancer diagnosis, treatment and research in African health systems: a review of current evidence and contextual perspectives

Impact of the COVID-19 pandemic in childhood and adolescent cancer care in northern Tanzania: a cross-sectional study

INTRODUCTION

The SARS-CoV-2 (COVID-19) pandemic has strained healthcare systems and presented unique challenges for children requiring cancer care, particularly in low- and middle-income countries. This study aimed to assess the impact of the COVID-19 pandemic on access to cancer care for children and adolescents in Northern Tanzania.

METHODS

In this cross-sectional study, we assessed the demographic and clinical characteristics of 547 pediatric and adolescent cancer patients (ages 0-19 years old) between 2016 and 2022 using the population-based Kilimanjaro Cancer Registry (KCR). We categorized data into pre-COVID-19 (2016-2019) and COVID-19 (2020-2022) eras, and performed descriptive analyses of diagnostic, treatment, and demographic information. A secondary analysis was conducted on a subset of 167 patients with stage of diagnosis at presentation.

RESULTS

Overall admissions nearly doubled during the pandemic (n = 190 versus 357). The variety of diagnoses attended at KCMC increased during the pandemic, with only five groups of diseases reported in 2016 to twelve groups of diseases in 2021. Most patients were diagnosed at a late stage (stage III or IV) across eras, with the proportion of under-five years old patients increasing late-diagnoses from 29.4% (before the pandemic), 52.8% (during the pandemic), when compared to the overall cohort. Around 95% of children in this age category reported late-stage diagnosis during the pandemic. Six out of the twelve cancer site groups also reported an increase in late-stage diagnosis. During the pandemic, the proportion of children receiving surgery increased from 15.8 to 30.8% (p < 0.001).

CONCLUSION

Childhood and adolescent cancer care changed in Northern Tanzania during the COVID-19 pandemic, with increased late-stage diagnoses presentations among younger patients and the increased use of surgical therapies in the context of a growing practice. Understanding the impact of the COVID-19 pandemic on pediatric and adolescent cancer care can help us better adapt healthcare systems and interventions to the emerging needs of children and adolescents with cancer in the midst of a health crisis.

The impact of the COVID-19 pandemic on cancer care including innovations implemented in Sub-Saharan Africa: A systematic review

Background

The coronavirus 2019 (COVID-19) pandemic has caused disruptions in the delivery and utilisation of cancer services. The impact of these interruptions is disproportionately borne by low- and middle-income countries in Sub-Saharan Africa (SSA). There are speculations of increased late-stage presentation and mortality as services are returning to the pre-pandemic state. This review aims to explore the extent to which the COVID-19 pandemic impacted cancer services across SSA and to identify innovations implemented across SSA to mitigate the impacts.

Methods

Using database-specific search strategies, a systematic literature search was conducted in PubMed, Ovid (MedLine), Web of Science, and African Index Medicus. Eligible studies included original research, reports, perspectives and summaries of national or regional outcomes published in the English language. The primary outcome was changes in the delivery and utilisation of cancer prevention and screening, diagnosis, treatment and follow-up services. The secondary outcome was to identify implemented innovations to mitigate the impact of the pandemic on service delivery.

Results

Out of the 167 articles identified in the literature search, 46 were included in the synthesis. A majority (95.7%) of the included articles described suspension and/or delay of screening, diagnosis, and treatment services, although two studies (4.3%) described the continuation of services despite the lockdown. Care was additionally impacted by transportation limitations, shortages of staff and personal protective equipment, disruption of the medication supply chain and patients' fears and stigma associated with contracting COVID-19. A major innovation was the use of telemedicine and virtual platforms for patient consultation and follow-up during the pandemic in SSA. Furthermore, drones and mobile applications were used for sample collection, medication delivery and scheduling of treatment. In some instances, medication routes and treatment protocols were changed.

Conclusions

The delivery and utilisation of cancer services decreased substantially during the pandemic. Cancer centres initiated innovative methods of care delivery, including telehealth and drone use, with long-term potential to mitigate the impact of the pandemic on service delivery. Cancer centres in SSA must explore sustainable, facility or country-specific innovations as services return to the pre-pandemic state.

Registration

The review was registered in PROSPERO with registration number CRD42022351455.

Determining the Relationship Between Intolerance of Uncertainty and Attitudes Toward Complementary and Alternative Medicine in Patients With Cancer

Disease-related uncertainty and the factors associated with uncertainty in patients with cancer have not been adequately investigated. This study aimed to determine the relationship between intolerance of uncertainty and attitudes toward complementary and alternative medicine (CAM) in patients with cancer. This cross-sectional descriptive study included 351 patients treated in the oncology clinic of a university hospital. All participants completed the Holistic Complementary and Alternative Medicine Questionnaire (HCAMQ) and the 12-item Intolerance of Uncertainty Scale (IUS-12). Most patients (84.3%) said that they had information about CAM, 39.7% reported obtaining this information from their social environment, 83.2% said that they believed that CAM methods are effective, and 76.0% reported not telling health care professionals about their CAM use. Mean IUS-12 and HCAMQ total scores were 46.53 ± 2.05 and 32.11 ± 2.32, respectively, and showed a weak negative correlation. The patients in our study showed high intolerance of uncertainty and a moderately positive attitude toward CAM, and most patients did not notify health care professionals of their CAM use. Therefore, we recommend assessing intolerance of uncertainty and CAM use in this patient group. By identifying patients experiencing uncertainty and seeking different treatment, nurses can support patients physiologically, psychologically, and socially, and can explain the effects of CAM use.

Cancer Care During the COVID-19 Pandemic: The African Narrative and Prospects

The COVID-19 pandemic has had a significant impact on healthcare services globally. Whilst it has been particularly disruptive for cancer care in low-resource settings, a few African countries have been able to adapt strategies to enable continued delivery of medical care to persons with cancer. This study seeks to highlight how much effect the coronavirus pandemic has had on oncological care in Africa and to indicate the way forward. For this narrative review, PubMed and Google Scholar were used to search for literature addressing the effect of the coronavirus pandemic on the care of patients with cancer in Africa with ensuing coping strategies. Selection criteria were manuscripts published since the onset of the pandemic in 2019 and written in the English language with Africa being the focus. In total, 52 research papers involving up to 21 African nations were found and reviewed. Across the board, the COVID-19 pandemic resulted in the deferral of oncological screening programs and a halt in immunization activities routinely scheduled for preventable cancers. It caused a colossal shortage in the availability of appropriately trained medical personnel, reduced frequency and duration of outpatient consultations, and a delay in cancer investigations and diagnosis. It also stirred up the substandard modification of chemotherapy regimens and radiotherapy due to the scarcity of anticancer medications and radioisotopes and engendered the cancellation of cancer surgical procedures. Palliative care for patients with locally advanced and metastatic disease was in many cases interrupted and cancer research activities were abruptly deferred. Ultimately, these led to poor patient outcomes and increased cancer-related fatalities. However, a few African countries - Rwanda, Ghana, and Tunisia - have continued to adapt telemedicine, small unmanned aircraft systems (sUAS), and home therapy to facilitate cancer care. To date, there is a paucity of data concerning the successes and cost-effectiveness of these relatively new methods recently adapted to cater to the medical needs of cancer patients in Africa. The pandemic has presented the African community an opportunity to advance her healthcare systems, especially as it pertains to the delivery of medical care to persons with cancer. The need of the hour is to study further the alternative cancer care delivery systems initiated during the pandemic in order to determine their sustainability in Africa at large.

Impact of COVID-19 on delivery of oncology services in Northern Tanzania: a cross-sectional study of community health workers and patients undergoing cancer treatment at the Kilimanjaro Christian Medical Centre

OBJECTIVE

To ascertain how the COVID-19 pandemic was perceived by oncology patients and community health workers (CHWs) and whether this contributed to disruptions in cancer care.

DESIGN

Cross-sectional study using (1) structured telephone interviews with patients and (2) structured questionnaires completed by CHWs.

SETTING

Outpatient and community care at Kilimanjaro Christian Medical Centre's Cancer Care Centre (KCMCCCC), Northern Tanzania.

PARTICIPANTS

300 oncology patients (158 men and 142 women) who had attended KCMCCCC between January and April 2020 and 78 CHWs (16 men and 62 women) in the KCMC regional palliative care network who conducted home visits to patients with cancer during the period January to April 2020.

PRIMARY OUTCOME MEASURES

For patients, missed appointments and fear of COVID-19 more than postponement of their treatment. For CHWs, no primary outcome (a broad range of questions on perception of the pandemic were asked).

RESULTS

30% of patients said they missed appointments due to the pandemic, the most commonly cited reasons being financial problems (37%) and fear of acquiring COVID-19 infection during travel and/or in the hospital (37%). Only 12.7% of patients said they feared COVID-19 more than postponement of cancer treatment. 88% of CHWs noticed differences in delivering home care since the start of the pandemic, with 58% saying they had noticed more patients dying and 74% saying that more patients were relying on local healers. 31% of CHWs said they feared home visits because of COVID-19 and 46% perceived patients feared home visits due to COVID-19. However, 92% felt home visits should continue.

CONCLUSION

These results indicated that while there was a significant degree of disruption and fear around the COVID-19 pandemic, the majority of patients and CHWs did not fear of COVID-19 more than disruption to cancer care. This highlights the importance to these groups of maintaining access to vital cancer services.

A Synthetic Overview of Benzoxazines and Benzoxazepines as Anticancer Agents

Benzoxazines and benzoxazepines are nitrogen and oxygen-containing six and seven-membered benzo-fused heterocyclic scaffolds, respectively. Benzoxazepines and benzoxazines are well-known pharmacophores in pharmaceutical chemistry, which are of significant interest and have been extensively studied because of their promising activity against various diseases including their wide range of anticancer activity. Several reports are known for synthesizing benzoxazine and benzoxazepine-based compounds in the literature. Herein this review provides a critical analysis of synthetic strategies towards benzoxazines and benzoxazepines along with various ranges of anticancer activities based on these molecules that have been reported from 2010 onwards. This review also focuses on the structure-activity relationship of the benzoxazine and benzoxazepine scaffolds containing bioactive compounds and describes how the structural modification affects their anticancer activity.

Multisystem Imaging Recommendations/Guidelines: In the Pursuit of Precision Oncology

With an increasing rate of cancers in almost all age groups and advanced screening techniques leading to an early diagnosis and longer longevity of patients with cancers, it is of utmost importance that radiologists assigned with cancer imaging should be prepared to deal with specific expected and unexpected circumstances that may arise during the lifetime of these patients. Tailored integration of preventive and curative interventions with current health plans and global escalation of efforts for timely diagnosis of cancers will pave the path for a cancer-free world. The commonly encountered circumstances in the current era, complicating cancer imaging, include coronavirus disease 2019 infection, pregnancy and lactation, immunocompromised states, bone marrow transplant, and screening of cancers in the relevant population. In this article, we discuss the imaging recommendations pertaining to cancer screening and diagnosis in the aforementioned clinical circumstances.

How COVID-19 exposed pre-existing roadblocks for cancer control in Africa: strategies, lessons and recommendations from the 2019-2020 Africa Cancer Research and Control ECHO

Background

The COVID-19 related mitigation measures adversely affected various cancer control activities in Africa, with cancer prevention and screening activities amongst the most significantly impacted. When the COVID-19 pandemic struck, the Africa Cancer Research and Control ECHO utilised their virtual platform to share experiences and knowledge of how to continue cancer service delivery during the pandemic. This analysis describes the evolved strategies, dilemmas, and recommendations to strengthen the health systems for cancer control in Africa.

Methods

Eleven 1-hour-long sessions about the then newly emerging coronavirus infection and its impact on cancer control in Africa were held from April 2020 to August 2020, using Zoom®. An average of 39 participants attended the sessions including scientists, clinicians, policymakers and global partners. Sessions were analysed thematically.

Results

Most strategies to maintain cancer services during the COVID-19 pandemic centred around cancer treatment, with few strategies on maintaining cancer prevention services, early detection, palliative care and research services. The most mentioned challenge during the pandemic was fear of exposure to COVID-19 infection at the health facility during diagnosis, treatment or follow-up for cancer care. Other challenges were disruptions to service delivery, inaccessibility of cancer treatment, disruption of research activities and a lack of psychosocial support for COVID-19 related fear/anxiety. Significantly, this analysis shows that the COVID-19 related mitigation measures exacerbated existing predicaments in Africa, such as inadequate attention to cancer prevention strategies, psychosocial and palliative services and cancer research. The Africa Cancer ECHO recommends African countries to leverage the infrastructure developed in response to COVID-19 pandemic to strengthen the health system along the entire cancer control continuum. This calls for urgent action to develop and implement evidence-based frameworks and comprehensive National Cancer Control Plans that will withstand any future disruptions.

Cancer service delivery and the impact of the COVID-19 pandemic in sub-Saharan Africa: a scoping review

Background

The impact of the Coronavirus Disease 2019 (COVID-19) pandemic on health systems is widely reported worldwide. However, what remains unclear is the relative extent of the pandemic's effects on cancer management in sub-Saharan Africa (SSA). This review provides an up-to-date synthesis of the literature to inform post-pandemic policy and practice efforts in the region.

Methods

Sources searched for published research include MEDLINE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, African Index Medicus, African Wide Information and Web of Science. Using predefined criteria, the retrieved citations were screened for primary research describing the direct and indirect impacts of the COVID-19 pandemic on the cancer care and service delivery landscape in SSA since March 2020. Evidence was summarised using narrative synthesis.

Results

Fourteen studies reporting findings from 19 SSA countries were included in this review. Studies were conducted mostly in the first wave of the pandemic (between March and July 2020) (10/14). The most commonly reported impact on cancer treatment (including surgery) were cancellations, delays and modifications (11/14). Half (7/14) of the studies reported on the impact of the pandemic on cancer care resource availability and service restructuring. Other notable impacts included temporary suspension, total cancellations or alterations in cancer screening (3/14) and diagnostic (3/14) services or programmes. Disruptions in cancer research and outreach activities were also reported (3/14). The availability and maintenance of cancer healthcare depended on multiple factors like availability of clinical supplies, existing oncology workforce, adequate supply of personal protective equipment and local pandemic mitigation measures. Notably, no studies reported on the impact of the pandemic on psychosocial support programmes, physiotherapy and other rehabilitation care for cancer patients.

Conclusion

Changes in cancer care and service delivery due to the COVID-19 pandemic varied considerably across countries in SSA. This review underscores the need for urgent actions to mitigate current setbacks while recommending evidence-based and contextualised approaches to revitalising cancer care in the post-pandemic era.

Effectiveness of interventions for improving timely diagnosis of breast and cervical cancers in low-income and middle-income countries: a systematic review

OBJECTIVES

To systematically synthesise available evidence on the nature and effectiveness of interventions for improving timely diagnosis of breast and cervical cancers in low and middle-income countries (LMICs).

DESIGN

A systematic review of published evidence. The review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses.

DATA SOURCES

A comprehensive search of published literature was conducted. In addition, relevant grey literature sources and bibliographical references of included studies were searched for potentially eligible evidence.

STUDY SELECTION

Studies published between January 2010 and November 2020 were eligible for inclusion. To be eligible, studies had to report on interventions/strategies targeted at women, the general public or healthcare workers, aimed at improving the timely diagnosis of breast and/or cervical cancers in LMIC settings.

DATA EXTRACTION AND SYNTHESIS

Literature search, screening, study selection, data extraction and quality appraisal were conducted by two independent reviewers. Evidence was synthesised and reported using a global taxonomy framework for early cancer diagnosis.

RESULTS

From the total of 10 593 records identified, 21 studies conducted across 20 LMICs were included in this review. Most of the included studies (16/21) focused primarily on interventions addressing breast cancers; two focused on cervical cancer while the rest examined multiple cancer types. Reported interventions targeted healthcare workers (12); women and adolescent girls (7) and both women and healthcare workers (3). Eight studies reported on interventions addressing access delays; seven focused on interventions addressing diagnostic delays; two reported on interventions targeted at addressing both access and diagnostic delays, and four studies assessed interventions addressing access, diagnostic and treatment delays. While most interventions were demonstrated to be feasible and effective, many of the reported outcome measures are of limited clinical relevance to diagnostic timeliness.

CONCLUSIONS

Though limited, evidence suggests that interventions aimed at addressing barriers to timely diagnosis of breast and cervical cancer are feasible in resource-limited contexts. Future interventions need to address clinically relevant measures to better assess efficacy of interventions.

PROSPERO REGISTRATION NUMBER

CRD42020177232.

The impact of COVID-19 on communicable and non-communicable diseases in Africa: a narrative review

The global pandemic of coronavirus disease 2019 (COVID-19) has disproportionately impacted global human health, economy, and security. Because of weaker health-care systems, existing comorbidities burden (HIV, malaria, tuberculosis, and non-communicable conditions), and poor socioeconomic determinants, initial predictive models had forecast a disastrous impact of COVID-19 in Africa in terms of transmission, severity, and deaths. Nonetheless, current epidemiological data seem not to have matched expectations, showing lower SARS-CoV-2 infection and fatality rates compared to Europe, the Americas and Asia. However, only few studies were conducted in low- and middle-income African settings where high poverty and limited access to health services worsen underlying health conditions, including endemic chronic infectious diseases such as HIV and tuberculosis. Furthermore, limited, and heterogeneous research was conducted to evaluate the indirect impact of the pandemic on general health services and on major diseases across African countries. International mitigation measures, such as resource reallocation, lockdowns, social restrictions, and fear from the population have had multi-sectoral impacts on various aspects of everyday life, that shaped the general health response. Despite the vast heterogeneity of data across African countries, available evidence suggests that the COVID-19 pandemic has severely impacted the control and prevention programs, the diagnosis capacity and the adherence to treatment of major infectious diseases (HIV, TB, and Malaria) - including neglected diseases - and non-communicable diseases. Future research and efforts are essential to deeply assess the medium- and long-term impact of the pandemic, and to implement tailored interventions to mitigate the standstill on decades of improvement on public health programs.

Quality of Life of People with Cancer in the Era of the COVID-19 Pandemic in India: A Systematic Review

Background:

The recent pandemic of COVID-19 caused havoc on the health system globally and raised a lot of questions and issues. Treatment for cancer is an emergency that cannot be taken back, particularly in an era of global pandemics. Cancer treatment mainly includes chemotherapy, surgery, radiotherapy, and palliative care, and because of the pandemic, all of these treatments are affected. The COVID-19 pandemic also had a potential effect on the quality of life and mental health of patients as well as health workers.

Objective:

This systematic review was intended to discuss the quality of life of people with cancer in the era of the COVID-19 pandemic in India in the light of the best available facts.

Methods:

An extensive literature search was done on PubMed, Medline, Embase, Clinical Key and Google Scholar databases till 3rd Feb 2021. Out of 1455 research articles, 06 research articles were included in this systematic review.

Results:

The results showed that cancer treatment delivery was as per standard safety protocol and the best treatment decisions were made by scheduling and setting priority. Till data, no direct research was conducted on the Indian continent to assess the quality of life of cancer patients in the COVID-19 era. The effect on the quality of life of cancer patients is very large and needs to be explored more by further research. Issues to be discussed with health care administrators and policy makers further. The tele-oncology method of cancer care delivery to patients is another rational option which is applicable as well.

Conclusion:

This systematic review demonstrated up-to-date evidence regarding the quality of life of cancer patients in the COVID-19 era in India. No research has been done to assess the quality of life of cancer patients. Still, the area is unrevealed, but evidence from other global studies indicates an altered quality of life for cancer patients. To maintain quality of life, cancer physicians should make evidence-based decisions and incorporate multidisciplinary management into decision making.

Exploring primary care level provider interpretation and management of potential breast and cervical cancer signs and symptoms in South Africa

Objectives

Women with potential breast and cervical cancer symptoms in South Africa (SA) usually self-present to primary health care (PHC) clinics. The aim of this study was to explore PHC provider interpretation and management of potential breast and cervical cancer signs and symptoms.

Methods

In-depth interviews with PHC providers incorporating vignettes were conducted between April and May 2019 in two sites in SA. Four vignettes (two breast and two cervical) were developed by the research team to capture aspects of provider symptom interpretation, reasoning, actions and challenges. The content of the vignettes was informed by a preceding community-based survey and qualitative interviews with symptomatic women. Interviews were audio recorded, transcribed verbatim and analysed using a thematic analysis approach.

Results

Twenty-four PHC providers were interviewed (12 urban, 12 rural; median age: 43 years). Four main themes relating to clinical assessment and reasoning; referral and feedback challenges; awareness of breast and cervical cancer policy guidelines and training and education needs emerged. Vignette-prompted questions relating to presenting symptoms, and possible accompanying symptoms and signs, demonstrated comprehensive proposed history taking and clinical assessment by PHC providers. Cancer was considered as a potential diagnosis by the majority of PHC providers. PHC providers also considered the possibility of infectious causes for both breast and cervical vignettes indicating they would ask questions around human immunodeficiency virus status, use of anti-retroviral therapy, and, for those with cervical symptoms, would need to rule out a sexually transmitted infection. Sexual assault was considered in assessing the cervical symptom scenarios. Providers raised issues around cumbersome booking systems and lack of feedback from referral centres. The need for provider and patient education and training to improve timely diagnosis of breast and cervical cancer was raised. Most providers were not aware of current breast or cervical cancer policy guidelines.

Conclusion

Clinical assessment at PHC level is complex and influenced by local health issues. Providing context-relevant training and support for PHC providers, and improving referral and feedback systems, could assist timely diagnosis of women with symptomatic breast and cervical cancer.

Eliminating Cervical Cancer: Progress and Challenges for High-income Countries

In 2020, the World Health Organization launched a major initiative to eliminate cervical cancer globally. The initiative is built around the three key pillars of human papillomavirus (HPV) vaccination, cervical screening and treatment, with associated intervention targets for the year 2030. The '90-70-90' targets specify that 90% of adolescent girls receive prophylactic HPV vaccination, 70% of adult women receive a minimum twice-in-a-lifetime cervical HPV test and 90% receive appropriate treatment for preinvasive or invasive disease. Modelling has shown that if these targets are met, the elimination of cervical cancer, defined as fewer than four cases per 100 000 women per annum, will be achieved within a century. Many high-income countries are well positioned to eliminate cervical cancer within the coming decades, but few have achieved '90-70-90' and many challenges must still be addressed to deliver these critical interventions effectively. This review considers the current status of cervical cancer control in relation to each of the three elimination pillars in high-income countries and discusses some of the developments that will assist countries in reaching these ambitious targets by 2030.

The 9th Symposium on Global Cancer Research: Looking Back and Charting a Path Forward in Global Cancer Control

The NCI Center for Global Health convened the 9th Annual Symposium on Global Cancer Research as a virtual 2-day meeting alongside the Consortium of Universities for Global Health Annual Conference, March 10–11, 2021. The virtual format allowed for diverse and inclusive participation by over 400 attendees from 70 countries, 25+ speakers from 12 countries, and sharing of research conducted in 68 countries. The highly interactive 2-day program explored the science and complex considerations around resilience and equity in global cancer research and control. The Symposium convened individuals working in global oncology to discuss trends in global cancer research and control and map out collaborative efforts to move the field forward. The accepted scientific abstracts are published in this special supplement of AACR Cancer Epidemiology, Biomarkers, and Prevention.