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Klootwijk L, Osamong LA, Langat S, Njuguna F, Kimaiyo S, Vik TA, Kaspers G, Mostert S. Childhood Cancer Awareness Program in Bungoma County, Kenya. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2024:10.1007/s13187-024-02468-z. [PMID: 38907906 DOI: 10.1007/s13187-024-02468-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/16/2024] [Indexed: 06/24/2024]
Abstract
BACKGROUND Awareness could play a key role in reducing underdiagnosis and accelerating referral of childhood cancer in low- and middle-income countries and ultimately improve outcomes. This study describes the implementation of a childhood cancer awareness program in Bungoma County in Kenya, containing five components: (1) baseline data collection of primary healthcare facilities; (2) live training session for healthcare providers (HCP); (3) early warning signs posters; (4) online SMS course for HCP; and (5) radio campaign. METHODS This study was conducted between January and June 2023. All 144 primary healthcare facilities (level 2 and 3 health facilities) within Bungoma County were visited by the field team. RESULTS All 125 level 2 (87%) and 19 level 3 (13%) facilities participated in the study. National Health Insurance Fund (NHIF) failed to cover services in 37 (26%) facilities. HCP were more often reported absent at level 3 (89%) than level 2 (64%) facilities (P = 0.034). The 144 live training sessions were attended by over 2000 HCP. Distribution of 144 early warning signs posters resulted in 50 phone calls about suspected childhood cancer cases. Sixteen children were later confirmed with childhood cancer and treated. Online SMS learning was completed by 890 HCP. Knowledge mean scores improved between pre-test (7.1) and post-test (8.1; P < 0.001). Finally, 540 radio messages about childhood cancer and a live question-and-answer session were broadcasted. CONCLUSION This study described the implementation of a childhood cancer awareness program in Kenya involving both HCP and the general public. The program improved HCP's knowledge and increased the number of referrals for children with cancer.
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Affiliation(s)
- Larissa Klootwijk
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.
- Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.
| | | | - Sandra Langat
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Festus Njuguna
- Department of Child Health and Pediatrics, Moi Teaching and Referral Hospital, Moi University, Eldoret, Kenya
| | - Sally Kimaiyo
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Terry A Vik
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, USA
| | - Gertjan Kaspers
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Saskia Mostert
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
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Labban M, Chen CR, Frego N, Nguyen DD, Lipsitz SR, Reich AJ, Rebbeck TR, Choueiri TK, Kibel AS, Iyer HS, Trinh QD. Disparities in Travel-Related Barriers to Accessing Health Care From the 2017 National Household Travel Survey. JAMA Netw Open 2023; 6:e2325291. [PMID: 37498602 PMCID: PMC10375305 DOI: 10.1001/jamanetworkopen.2023.25291] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
Abstract
Importance Geographic access, including mode of transportation, to health care facilities remains understudied. Objective To identify sociodemographic factors associated with public vs private transportation use to access health care and identify the respondent, trip, and community factors associated with longer distance and time traveled for health care visits. Design, Setting, and Participants This cross-sectional study used data from the 2017 National Household Travel Survey, including 16 760 trips or a nationally weighted estimate of 5 550 527 364 trips to seek care in the United States. Households that completed the recruitment and retrieval survey for all members aged 5 years and older were included. Data were analyzed between June and August 2022. Exposures Mode of transportation (private vs public transportation) used to seek care. Main Outcomes and Measures Survey-weighted multivariable logistic regression models were used to identify factors associated with public vs private transportation and self-reported distance and travel time. Then, for each income category, an interaction term of race and ethnicity with type of transportation was used to estimate the specific increase in travel burden associated with using public transportation compared a private vehicle for each race category. Results The sample included 12 092 households and 15 063 respondents (8500 respondents [56.4%] aged 51-75 years; 8930 [59.3%] females) who had trips for medical care, of whom 1028 respondents (6.9%) were Hispanic, 1164 respondents (7.8%) were non-Hispanic Black, and 11 957 respondents (79.7%) were non-Hispanic White. Factors associated with public transportation use included non-Hispanic Black race (compared with non-Hispanic White: adjusted odds ratio [aOR], 3.54 [95% CI, 1.90-6.61]; P < .001) and household income less than $25 000 (compared with ≥$100 000: aOR, 7.16 [95% CI, 3.50-14.68]; P < .001). The additional travel time associated with use of public transportation compared with private vehicle use varied by race and household income, with non-Hispanic Black respondents with income of $25 000 to $49 999 experiencing higher burden associated with public transportation (mean difference, 81.9 [95% CI, 48.5-115.3] minutes) than non-Hispanic White respondents with similar income (mean difference, 25.5 [95% CI, 17.5-33.5] minutes; P < .001). Conclusions and Relevance These findings suggest that certain racial, ethnic, and socioeconomically disadvantaged populations rely on public transportation to seek health care and that reducing delays associated with public transportation could improve care for these patients.
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Affiliation(s)
- Muhieddine Labban
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Nicola Frego
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Urology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - David-Dan Nguyen
- Division of Urology, University of Toronto, Toronto, Ontario, Canada
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amanda J Reich
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy R Rebbeck
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Epidemiology and Zhu Family Center for Global Cancer Prevention, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Toni K Choueiri
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Adam S Kibel
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hari S Iyer
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
- Section of Cancer Epidemiology and Health Outcomes, Rutgers Cancer Institute of New Jersey, New Brunswick
| | - Quoc-Dien Trinh
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Kasule M, Matshaba M, Wonkam A, de Vries J. Feeding back of individual genetic results in Botswana: mapping opportunities and challenges. BMC Med Ethics 2023; 24:37. [PMID: 37270597 PMCID: PMC10239568 DOI: 10.1186/s12910-023-00912-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 05/04/2023] [Indexed: 06/05/2023] Open
Abstract
PURPOSE We explored the views of Botswana stakeholders involved in developing, implementing and applying ethical standards for return of individual study results from genomic research. This allowed for mapping opportunities and challenges regarding actionability requirements that determine whether individual genomic research results should be fed back. METHODS Using in-depth interviews, this study explored the views of sixteen (16) stakeholders about the extent, nature and timing of feedback of individual genomic research findings, including incidental findings that arise in the context of African genomics research. Coded data was analyzed through an iterative process of analytic induction to document and interpret themes. RESULTS Overall, respondents were of the view that feedback of actionable individual genomic results was an important outcome that could benefit participants. However, a number of themes surfaced that pointed to opportunities and challenges that exist in Botswana that could help in planning for feeding back of individual genomic results that were mapped. Some of the opportunities cited by the respondents included the existence of good governance; democracy and humanitarianism; universal healthcare system; national commitment to science; research and innovation to transform Botswana into a knowledge-based economy; and applicable standard of care which could promote actionability. On the other hand, contextual issues like the requirement for validation of genomic research results in accredited laboratories, high cost of validation of genomic results, and linkage to care, as well as lack of experts like genomic scientists and counselors were considered as challenges for return of individual results. CONCLUSION We propose that decisions whether and which genomic results to return take into consideration contextual opportunities and challenges for actionability for return of results in a research setting. This is likely to avoid or minimize ethical issues of justice, equity and harm regarding actionability decisions.
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Affiliation(s)
- Mary Kasule
- Botswana-Baylor Children's Clinical Centre of Excellence, Gaborone, Botswana.
| | - Mogomotsi Matshaba
- Botswana-Baylor Children's Clinical Centre of Excellence, Gaborone, Botswana
- Baylor College of Medicine, Houston, TX, USA
| | - Ambroise Wonkam
- Deputy Dean's Office, Faculty of Health Sciences and Groote Schuur, Cape Town, South Africa
- Department of Medicine and NeuroScience Institute , The Ethics Lab, Cape Town, South Africa
| | - Jantina de Vries
- Department of Medicine and NeuroScience Institute , The Ethics Lab, Cape Town, South Africa
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Oldfield LE, Jones V, Gill B, Kodous N, Fazelzad R, Rodin D, Sandhu H, Umakanthan B, Papadakos J, Giuliani ME. Synthesis of Existent Oncology Curricula for Primary Care Providers: A Scoping Review With a Global Equity Lens. JCO Glob Oncol 2023; 9:e2200298. [PMID: 37141562 DOI: 10.1200/go.22.00298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
PURPOSE Global increases in cancer, coupled with a shortage of cancer specialists, has led to an increasing role for primary care providers (PCP) in cancer care. This review aimed to examine all extant cancer curricula for PCPs and to analyze the motivations for curriculum development. METHODS A comprehensive literature search was conducted from inception to October 13, 2021, with no language restrictions. The initial search yielded 11,162 articles and 10,902 articles underwent title and abstract review. After full-text review, 139 articles were included. Numeric and thematic analyses were conducted and education programs were evaluated using Bloom's taxonomy. RESULTS Most curricula were developed in high-income countries (HICs), with 58% in the United States. Cancer-specific curricula focused on HIC priority cancers, such as skin/melanoma, and did not represent the global cancer burden. Most (80%) curricula were developed for staff physicians and 73% focused on cancer screening. More than half (57%) of programs were delivered in person, with a shift toward online delivery over time. Less than half (46%) of programs were codeveloped with PCPs and 34% did not involve PCPs in the program design and development. Curricula were primarily developed to improve cancer knowledge, and 72 studies assessed multiple outcome measures. No studies included the top two levels of Bloom's taxonomy of learning (evaluating; creating). CONCLUSION To our knowledge, this is the first review to assess the current state of cancer curricula for PCPs with a global focus. This review shows that extant curricula are primarily developed in HICs, do not represent the global cancer burden, and focus on cancer screening. This review lays a foundation to advance the cocreation of curricula that are aligned to the global cancer burden.
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Affiliation(s)
| | - Vivien Jones
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Bhajan Gill
- Cancer Education, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Nardeen Kodous
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Rouhi Fazelzad
- Library and Information Services, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Danielle Rodin
- Royal College of Surgeons in Ireland, Dublin, Ireland
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - Ben Umakanthan
- Cancer Education, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Janet Papadakos
- Cancer Education, Princess Margaret Cancer Centre, Toronto, ON, Canada
- The Institute for Education Research, University Health Network, Toronto, ON, Canada
| | - Meredith Elana Giuliani
- Cancer Education, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
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Assessing the cost and economic impact of tertiary-level pediatric cancer care in Tanzania. PLoS One 2022; 17:e0273296. [PMCID: PMC9674137 DOI: 10.1371/journal.pone.0273296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 06/14/2022] [Indexed: 11/19/2022] Open
Abstract
Background Worldwide, an estimated 400,000 children develop cancer each year. The bulk of the mortalities from these cases occur in low-and-middle-income countries (LMICs). In Sub-Saharan Africa, there is a tremendous need to strengthen the capacity of health systems to provide high-quality cancer care for children. However, a lack of data on the economic impact of cancer treatment in low-resource settings hinders its consideration as a healthcare priority. To address this gap, this study models the clinical and financial impact of pediatric cancer care in Tanzania, a lower-middle income country in East Africa. Methods We conducted a retrospective review of patients with cancer under the age of 19 years treated at Bugando Medical Centre from January 2010 to August 2014. Information was collected from a total of 161 children, including demographics, type of cancer, care received, and five-year survival outcomes. This data was used to calculate the number of averted disability-adjusted life-years (DALYs) with treatment. Charges for all direct medical costs, fixed provider costs, and variable provider costs were used to calculate total cost of care. The societal economic impact of cancer treatment was modeled using the value of statistical life (VSL) and human capital methods. Findings The total health impact for these 161 children was 819 averted DALYs at a total cost of $846,743. The median cost per patient was $5,064 ($4,746–5,501 interquartile range). The societal economic impact of cancer treatment ranged from $590,534 to $3,647,158 using VSL method and $1,776,296 using a human capital approach. Interpretation Despite the limitations of existing treatment capacity, economic modeling demonstrates a positive economic impact from providing pediatric cancer care in Tanzania. As many countries like Tanzania progress towards achieving Universal Health Coverage, these key economic indicators may encourage future investment in comprehensive pediatric cancer care programs in low-resource settings to achieve clinically and economically beneficial results not only for the individual patients, but for the country as a whole.
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Friebel-Klingner TM, Iyer HS, Ramogola-Masire D, Bazzett-Matabele L, Monare B, Seiphetlheng A, Ralefala TB, Mitra N, Wiebe DJ, Rebbeck TR, Grover S, McCarthy AM. Evaluating the geographic distribution of cervical cancer patients presenting to a multidisciplinary gynecologic oncology clinic in Gaborone, Botswana. PLoS One 2022; 17:e0271679. [PMID: 35925976 PMCID: PMC9352107 DOI: 10.1371/journal.pone.0271679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 07/05/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE In Botswana, cervical cancer is the leading cause of cancer death for females. With limited resources, Botswana is challenged to ensure equitable access to advanced cancer care. Botswana's capital city, Gaborone, houses the only gynecologic oncology multi-disciplinary team (MDT) and the one chemoradiation facility in the country. We aimed to identify areas where fewer women were presenting to the MDT clinic for care. METHODS This cross-sectional study examined cervical cancer patients presenting to the MDT clinic between January 2015 and March 2020. Patients were geocoded to residential sub-districts to estimate age-standardized presentation rates. Global Moran's I and Anselin Local Moran's I tested the null hypothesis that presentation rates occurred randomly in Botswana. Community- and individual-level factors of patients living in sub-districts identified with higher (HH) and lower (LL) clusters of presentation rates were examined using ordinary least squares with a spatial weights matrix and multivariable logistic regression, respectively, with α level 0.05. RESULTS We studied 990 patients aged 22-95 (mean: 50.6). Presentation rates were found to be geographically clustered across the country (p = 0.01). Five sub-districts were identified as clusters, two high (HH) sub-district clusters and three low (LL) sub-district clusters (mean presentation rate: 35.5 and 11.3, respectively). Presentation rates decreased with increased travel distance (p = 0.033). Patients residing in LL sub-districts more often reported abnormal vaginal bleeding (aOR: 5.62, 95% CI: 1.31-24.15) compared to patients not residing in LL sub-districts. Patients in HH sub-districts were less likely to be living with HIV (aOR: 0.59; 95% CI: 0.38-0.90) and more likely to present with late-stage cancer (aOR: 1.78; 95%CI: 1.20-2.63) compared to patients not in HH sub-districts. CONCLUSIONS This study identified geographic clustering of cervical cancer patients presenting for care in Botswana and highlighted sub-districts with disproportionately lower presentation rates. Identified community- and individual level-factors associated with low presentation rates can inform strategies aimed at improving equitable access to cervical cancer care.
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Affiliation(s)
- Tara M. Friebel-Klingner
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Hari S. Iyer
- Dana-Farber Cancer Institute and Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
- Department of Obstetrics and Gynecology, Yale University, New Haven, Connecticut, United States of America
| | - Lisa Bazzett-Matabele
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
- Department of Obstetrics and Gynecology, Yale University, New Haven, Connecticut, United States of America
| | - Barati Monare
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | | | | | - Nandita Mitra
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Douglas J. Wiebe
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Timothy R. Rebbeck
- Dana-Farber Cancer Institute and Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Surbhi Grover
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Anne Marie McCarthy
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
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Molebatsi K, Iyer HS, Kohler RE, Gabegwe K, Nkele I, Rabasha B, Botebele K, Barak T, Balosang S, Tapela NM, Dryden-Peterson SL. Improving identification of symptomatic cancer at primary care clinics: A predictive modeling analysis in Botswana. Int J Cancer 2022; 151:1663-1673. [PMID: 35716138 PMCID: PMC10286759 DOI: 10.1002/ijc.34178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/26/2022] [Accepted: 03/08/2022] [Indexed: 12/24/2022]
Abstract
In resource-limited settings, augmenting primary care provider (PCP)-based referrals with data-derived algorithms could direct scarce resources towards those patients most likely to have a cancer diagnosis and benefit from early treatment. Using data from Botswana, we compared accuracy of predictions of probable cancer using different approaches for identifying symptomatic cancer at primary clinics. We followed cancer suspects until they entered specialized care for cancer treatment (following pathologically confirmed diagnosis), exited from the study following noncancer diagnosis, or died. Routine symptom and demographic data included baseline cancer probability assessed by the primary care provider (low, intermediate, high), age, sex, performance status, baseline cancer probability by study physician, predominant symptom (lump, bleeding, pain or other) and HIV status. Logistic regression with 10-fold cross-validation was used to evaluate classification by different sets of predictors: (1) PCPs, (2) Algorithm-only, (3) External specialist physician review and (4) Primary clinician augmented by algorithm. Classification accuracy was assessed using c-statistics, sensitivity and specificity. Six hundred and twenty-three adult cancer suspects with complete data were retained, of whom 166 (27%) were diagnosed with cancer. Models using PCP augmented by algorithm (c-statistic: 77.2%, 95% CI: 73.4%, 81.0%) and external study physician assessment (77.6%, 95% CI: 73.6%, 81.7%) performed better than algorithm-only (74.9%, 95% CI: 71.0%, 78.9%) and PCP initial assessment (62.8%, 95% CI: 57.9%, 67.7%) in correctly classifying suspected cancer patients. Sensitivity and specificity statistics from models combining PCP classifications and routine data were comparable to physicians, suggesting that incorporating data-driven algorithms into referral systems could improve efficiency.
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Affiliation(s)
- Kesaobaka Molebatsi
- Department of Statistics, University of Botswana, Gaborone, Botswana.,Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Hari S Iyer
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Racquel E Kohler
- Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, New Jersey, USA.,Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Kemiso Gabegwe
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Isaac Nkele
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Bokang Rabasha
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Tomer Barak
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Neo M Tapela
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana.,Nuffield Department of Population Health, Oxford University, Oxford, UK
| | - Scott L Dryden-Peterson
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Department of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Nnaji CA, Kuodi P, Walter FM, Moodley J. Effectiveness of interventions for improving timely diagnosis of breast and cervical cancers in low-income and middle-income countries: a systematic review. BMJ Open 2022; 12:e054501. [PMID: 35470184 PMCID: PMC9039388 DOI: 10.1136/bmjopen-2021-054501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
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.
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Affiliation(s)
- Chukwudi A Nnaji
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, Western Cape, South Africa
- Cancer Research Initiative, University of Cape Town Faculty of Health Sciences, Cape Town, Western Cape, South Africa
| | - Paul Kuodi
- Department of Public Health, Faculty of Health Sciences, Lira University, Lira, Uganda
| | - Fiona M Walter
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Wolfson Institute of Population Health, Queen Mary University of London Barts and The London School of Medicine and Dentistry, London, UK
| | - Jennifer Moodley
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, Western Cape, South Africa
- Cancer Research Initiative, University of Cape Town Faculty of Health Sciences, Cape Town, Western Cape, South Africa
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Martei YM, Dauda B, Vanderpuye V. Breast cancer screening in sub-Saharan Africa: a systematic review and ethical appraisal. BMC Cancer 2022; 22:203. [PMID: 35197002 PMCID: PMC8867875 DOI: 10.1186/s12885-022-09299-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 02/08/2022] [Indexed: 11/22/2022] Open
Abstract
Background The aim of this systematic review was to evaluate the evidence and clinical outcomes of screening interventions and implementation trials in sub-Saharan Africa (SSA) and also appraise some ethical issues related to screening in the region through quantitative and qualitative narrative synthesis of the literature. Methods We searched Pubmed, OvidMEDLINE, Embase, and Web of Science to identify studies published on breast cancer screening interventions and outcomes in SSA. Descriptive statistics were used to summarize the frequency and proportions of extracted variables, and narrative syntheses was used to evaluate the clinical outcomes of the different screening modalities. The mixed methods appraisal tool was used to assess the quality of studies included in the review. Results Fifteen studies were included, which consisted of 72,572 women in ten countries in SSA. 63% (8/15) of the included publications evaluated Clinical Breast Examination (CBE), 47% (7/15) evaluated mammography and 7% (1/15) evaluated ultrasound screening. The cancer detection rate was < 1/1000 to 3.3/1000 and 3.3/100 to 56/1000 for CBE and mammography screening respectively. There was a lot of heterogeneity in CBE methods, target age for screening and no clear documentation of screening interval. Cost-effective analyses showed that CBE screening linked to comprehensive cancer care is most cost effective. There was limited discussion of the ethics of screening, including the possible harms of screening in the absence of linkage to care. The gap between conducting good screening program and the appropriate follow-up with diagnosis and treatment remains one of the major challenges of screening in SSA. Discussion There is insufficient real-world data to support the systematic implementation of national breast cancer screening in SSA. Further research is needed to answer important questions about screening, and national and international partnerships are needed to ensure that appropriate diagnostic and treatment modalities are available to patients who screen positive. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09299-5.
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Affiliation(s)
- Yehoda M Martei
- Department of Medicine (Division of Hematology-Oncology), University of Pennsylvania, Philadelphia, PA, USA. .,Botswana UPenn Partnership, Gaborone, Botswana.
| | - Bege Dauda
- Center for Global Genomics and Health Equity, University of Pennsylvania, Philadelphia, PA, USA
| | - Verna Vanderpuye
- National Center for Radiotherapy Oncology and Nuclear Medicine, Korle-Bu Teaching Hospital, Accra, Ghana
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10
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Elmore SNC, Mushonga M, Iyer HS, Kanda C, Chibonda S, Chipidza F, Makunike Mutasa R, Muchuweti D, Muguti EG, Maunganidze A, Ndlovu N, Bellon JR, Nyakabau AM. Breast cancer in Zimbabwe: patterns of care and correlates of adherence in a national referral hospital radiotherapy center cohort from 2014 to 2018. Cancer Med 2021; 10:3489-3498. [PMID: 33973399 PMCID: PMC8178482 DOI: 10.1002/cam4.3764] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/24/2020] [Accepted: 12/26/2020] [Indexed: 12/24/2022] Open
Abstract
Background Breast cancer is the second most common cancer among women in Zimbabwe. Patients face socioeconomic barriers to accessing oncology care, including radiotherapy. We sought to understand patterns of care and adherence for women with breast cancer in sub‐Saharan Africa (SSA) with radiotherapy access. Methods A retrospective cohort was created for women with breast cancer evaluated at the Parirenyatwa Hospital Radiotherapy and Oncology Center (RTC) from 2014 to 2018. Clinical data were collected to define patterns of care. Non‐adherence was modeled as a binary outcome with different criteria for patients with localized versus metastatic disease. Results In total, 351 women presented with breast cancer with median age 51 at diagnosis (IQR: 43–61). Receptor status was missing for 71% (248). 199 (57%) had non‐metastatic disease, and 152 (43%) had metastases. Of women with localized disease, 34% received post‐mastectomy radiation. Of women with metastatic disease, 9.7% received radiotherapy. Metastatic disease and missing HIV status were associated with increased odds of study‐defined non‐adherence (aOR: 1.85, 95% CI: 1.05, 3.28; aOR: 2.13, 95% CI: 1.11, 4.05), while availability of ER/PR status was associated with lower odds of non‐adherence (aOR: 0.18, 95% CI: 0.09, 0.36). Conclusions Radiotherapy is likely underutilized for women with breast cancer, even in a setting with public sector availability. Exploring patient‐level factors that influence adherence to care may provide clinicians with better tools to support adherence and improve survival. Greater investment is needed in multidisciplinary, multimodality care for breast cancer in SSA.
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Affiliation(s)
- Shekinah Nefreteri Cluff Elmore
- Harvard Radiation Oncology Program, Boston, USA.,Harvard Medical School, Boston, USA.,Department of Radiation Oncology, University of North Carolina, Chapel Hill, USA
| | - Melinda Mushonga
- Parirenyatwa Hospital Radiotherapy and Oncology Center, Harare, Zimbabwe
| | | | - Caroline Kanda
- Parirenyatwa Hospital Radiotherapy and Oncology Center, Harare, Zimbabwe
| | - Shirley Chibonda
- Parirenyatwa Hospital Radiotherapy and Oncology Center, Harare, Zimbabwe
| | - Fallon Chipidza
- Harvard Radiation Oncology Program, Boston, USA.,Harvard Medical School, Boston, USA.,Department of Radiation Oncology, Dana-Faber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rudo Makunike Mutasa
- Department of Pathology, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
| | - David Muchuweti
- Department of Surgery, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
| | - Edwin G Muguti
- Department of Surgery, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
| | - Aspect Maunganidze
- Department of Surgery, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
| | - Ntokozo Ndlovu
- Parirenyatwa Hospital Radiotherapy and Oncology Center, Harare, Zimbabwe.,Department of Oncology, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
| | - Jennifer Ruth Bellon
- Department of Radiation Oncology, Dana-Faber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anna Mary Nyakabau
- Parirenyatwa Hospital Radiotherapy and Oncology Center, Harare, Zimbabwe.,Department of Pathology, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe.,Cancerserve Trust, Harare, Zimbabwe
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11
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Dykstra M, Malone B, Lekuntwane O, Efstathiou J, Letsatsi V, Elmore S, Castro C, Tapela N, Dryden-Peterson S. Impact of Community-Based Clinical Breast Examinations in Botswana. JCO Glob Oncol 2021; 7:17-26. [PMID: 33405960 PMCID: PMC8081526 DOI: 10.1200/go.20.00231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE We evaluated a clinical breast examination (CBE) screening program to determine the prevalence of breast abnormalities, number examined per cancer diagnosis, and clinical resources required for these diagnoses in a middle-income African setting. METHODS We performed a retrospective review of a CBE screening program (2015-2018) by Journey of Hope Botswana, a Botswana-based nongovernmental organization (NGO). Symptomatic and asymptomatic women were invited to attend. Screening events were held in communities throughout rural and periurban Botswana, with CBEs performed by volunteer nurses. Individuals who screened positive were referred to a private tertiary facility and were followed by the NGO. Data were obtained from NGO records. RESULTS Of 6,120 screened women (50 men excluded), 452 (7.4%) presented with a symptom and 357 (5.83%) were referred for further evaluation; 257 ultrasounds, 100 fine-needle aspirations (FNAs), 58 mammograms, and 31 biopsies were performed. In total, 6,031 were exonerated from cancer, 78 were lost to follow-up (67 for ≤ 50 years and 11 for > 50 years), and 11 were diagnosed with cancer (five for 41-50 years and six for > 50 years, 10 presented with symptoms). Overall breast cancer prevalence was calculated to be 18/10,000 (95% CI, 8 to 29/10,000). The number of women examined per breast cancer diagnosis was 237 (95% CI, 126 to 1910) for women of age 41-50 years and 196 (95% CI, 109 to 977) for women of age > 50 years. Median time to diagnosis for all women was 17.5 [1 to 32.5] days. CBE-detected tumors were not different than tumors presenting through standard care. CONCLUSION In a previously unscreened population, yield from community-based CBE screening was high, particularly among symptomatic women, and required modest diagnostic resources. This strategy has potential to reduce breast cancer mortality.
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Affiliation(s)
- Michael Dykstra
- Beth Israel Deaconess Medical Center, Boston, MA.,Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Brighid Malone
- Bokamoso Private Hospital, Gaborone, Botswana.,Journey of Hope Botswana, Gaborone, Botswana
| | | | | | | | - Shekinah Elmore
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC
| | | | - Neo Tapela
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana.,University of Oxford, Oxford, UK
| | - Scott Dryden-Peterson
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana.,Brigham and Women's Hospital, Boston, MA.,Harvard School of Public Health, Boston, MA
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12
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Zabih W, Thota AB, Mbah G, Freccero P, Gupta S, Denburg AE. Interventions to improve early detection of childhood cancer in low- and middle-income countries: A systematic review. Pediatr Blood Cancer 2020; 67:e28761. [PMID: 33037867 DOI: 10.1002/pbc.28761] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/16/2020] [Accepted: 09/22/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Childhood cancer outcomes in low- and middle-income countries (LMICs) lag behind those in high-income countries (HICs), in part due to late presentation and diagnosis. Though several interventions targeting early detection of childhood cancer have been implemented in LMICs, little is known about their efficacy. METHODS We conducted a systematic review to identify studies describing such interventions. We searched multiple databases from inception to December 4, 2019. Studies were included if they reported on LMIC interventions focused on: (a) training of health care providers on early recognition of childhood cancer, or (ii) public awareness campaigns. We used preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines to conduct our review. The risk of bias in nonrandomized studies of interventions (ROBINS-I) checklist was used to assess quality of studies. RESULTS Twelve studies met inclusion criteria (n = 5 full text, n = 7 abstract only). Five studies focused on retinoblastoma only, while the others focused on all types of childhood cancer. The majority studied multiple interventions of which early detection was one component, but reported overall outcomes. All identified studies used pre-post evaluative designs to measure efficacy. Five studies reported statistically significant results postintervention: decrease in extraocular spread of retinoblastoma, decrease in rates of refusal/abandonment of treatment, increase in number of new referrals, increase in knowledge, and an absolute increase in median 5-year survival. Other studies reported improvements without tests of statistical significance. Two studies reported no difference in survival postintervention. The ROBINS-I checklist indicated that all studies were at serious risk of bias. CONCLUSION Though current evidence suggests that LMIC interventions targeting early detection of childhood cancer through health professional training and/or public awareness campaigns may be effective, this evidence is limited and of poor quality. Robust trials or quasi-experimental designs with long-term follow up are needed to identify the most effective interventions. Such studies will facilitate and inform the widespread uptake of early detection interventions across LMIC settings.
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Affiliation(s)
- Weeda Zabih
- Division of Paediatric Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anilkrishna B Thota
- Division of Paediatric Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Glenn Mbah
- Cameroon Baptist Convention Hospitals, Mbingo, Cameroon
| | | | - Sumit Gupta
- Division of Paediatric Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Avram E Denburg
- Division of Paediatric Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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13
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Maillie L, Masalu N, Mafwimbo J, Maxmilian M, Schroeder K. Delays Experienced by Patients With Pediatric Cancer During the Health Facility Referral Process: A Study in Northern Tanzania. JCO Glob Oncol 2020; 6:1757-1765. [PMID: 33201744 PMCID: PMC7713565 DOI: 10.1200/go.20.00407] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE It is estimated that 50%-80% of patients with pediatric cancer in sub-Saharan Africa present at an advanced stage. Delays can occur at any time during the care-seeking process from symptom onset to treatment initiation. Referral delay, the time from first presentation at a health facility to oncologist evaluation, is a key component of total delay that has not been evaluated in sub-Saharan Africa. METHODS Over a 3-month period, caregivers of children diagnosed with cancer at a regional cancer center (Bugando Medical Centre [BMC]) in Tanzania were consecutively surveyed to determine the number and type of health facilities visited before presentation, interventions received, and transportation used to reach each facility. RESULTS Forty-nine caregivers were consented and included in the review. A total of 124 facilities were visited before BMC, with 31% of visits (n = 38) resulting in a referral. The median referral delay was 89 days (mean, 122 days), with a median of two facilities (mean, 2.5 facilities) visited before presentation to BMC. Visiting a traditional healer first significantly increased the time taken to reach BMC compared with starting at a health center/dispensary (103 v 236 days; P = .02). Facility visits in which a patient received a referral to a higher-level facility led to significantly decreased time to reach BMC (P < .0001). Only 36% of visits to district hospitals and 20.6% of visits to health centers/dispensaries yielded a referral, however. CONCLUSION The majority of patients were delayed during the referral process, but receipt of a referral to a higher-level facility significantly shortened delay time. Referral delay for pediatric patients with cancer could be decreased by raising awareness of cancer and strengthening the referral process from lower-level to higher-level facilities.
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Affiliation(s)
- Luke Maillie
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nestory Masalu
- Department of Oncology, Bugando Medical Centre, Mwanza, Tanzania
| | - Judy Mafwimbo
- Department of Oncology, Bugando Medical Centre, Mwanza, Tanzania
| | | | - Kristin Schroeder
- Department of Oncology, Bugando Medical Centre, Mwanza, Tanzania.,Division of Pediatric Hematology/Oncology and Duke Global Cancer Program, Duke University Medical Center, Durham, NC
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14
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Ginsburg O, Yip CH, Brooks A, Cabanes A, Caleffi M, Dunstan Y. J, Gyawali B, McCormack V, de Anderson MM, Mehrotra R, Mohar A, Murillo R, Pace LE, Paskett ED, Romanoff A, Rositch AF, Scheel J, Schneidman M, Unger-Saldana K, Vanderpuye V, Wu TY, Yuma S, Dvaladze A, Duggan C, Anderson BO. Breast cancer early detection: A phased approach to implementation. Cancer 2020; 126 Suppl 10:2379-2393. [PMID: 32348566 PMCID: PMC7237065 DOI: 10.1002/cncr.32887] [Citation(s) in RCA: 203] [Impact Index Per Article: 50.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 02/24/2020] [Accepted: 02/25/2020] [Indexed: 12/16/2022]
Abstract
When breast cancer is detected and treated early, the chances of survival are very high. However, women in many settings face complex barriers to early detection, including social, economic, geographic, and other interrelated factors, which can limit their access to timely, affordable, and effective breast health care services. Previously, the Breast Health Global Initiative (BHGI) developed resource-stratified guidelines for the early detection and diagnosis of breast cancer. In this consensus article from the sixth BHGI Global Summit held in October 2018, the authors describe phases of early detection program development, beginning with management strategies required for the diagnosis of clinically detectable disease based on awareness education and technical training, history and physical examination, and accurate tissue diagnosis. The core issues address include finance and governance, which pertain to successful planning, implementation, and the iterative process of program improvement and are needed for a breast cancer early detection program to succeed in any resource setting. Examples are presented of implementation, process, and clinical outcome metrics that assist in program implementation monitoring. Country case examples are presented to highlight the challenges and opportunities of implementing successful breast cancer early detection programs, and the complex interplay of barriers and facilitators to achieving early detection for breast cancer in real-world settings are considered.
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Affiliation(s)
- Ophira Ginsburg
- Perlmutter Cancer Center, Section for Global Health, Division of Health and Behavior, Department of Population Health, New York University Langone Health, NY, USA
| | - Cheng-Har Yip
- University of Malaya, Kuala Lumpur, Malaysia
- Ramsay Sime Darby Health Care Kuala Lumpur, Malaysia
| | - Ari Brooks
- Dept. of Surgery, University of Pennsylvania, PA, USA
| | | | - Maira Caleffi
- Breast Center Hospital Moinhos de Vento Porto Alegre, Brazil
| | - Jorge Dunstan Y.
- Department of Breast, Skin and Soft Tissue Sarcomas Surgery Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Bishal Gyawali
- Department of Oncology, Department of Public Health Sciences and Division of Cancer Care and Epidemiology, Queen’s University, Kingston, Ontario, Canada
| | | | | | | | - Alejandro Mohar
- Unidad de Investigación Biomédica en Cáncer, Instituto Nacional de Cancerología, UNAM, Mexico
| | - Raul Murillo
- Centro Javeriano de Oncología – Hospital Universitario San Ignacio. Colombia
- Facultad de Medicina – Pontificia Universidad Javeriana, Colombia
| | - Lydia E. Pace
- Division of Women’s Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
| | - Electra D. Paskett
- Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, OH
| | - Anya Romanoff
- Department of Surgery, Division of Surgical Oncology, Breast Surgery, The Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, USA
| | - Anne F. Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - John Scheel
- Dept. of Radiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington Seattle, WA, USA
| | - Miriam Schneidman
- Health, Nutrition and Population Global Practice, The World Bank Group
| | - Karla Unger-Saldana
- Unidad de Investigación Biomédica en Cáncer, Instituto Nacional de Cancerología, UNAM, Mexico
| | - Verna Vanderpuye
- National Center for Oncology, Radiotherapy and Nuclear Medicine, Accra, Ghana
| | - Tsu-Yin Wu
- Center for Health Disparities Innovation and Studies, Eastern Michigan University, MI, USA
| | - Safina Yuma
- Dept. of Reproductive and Child Health, Ministry of Health, Community Development, Gender, Elderly & Children, Dodoma, Tanzania
| | - Allison Dvaladze
- Breast Health Global Initiative, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Catherine Duggan
- Breast Health Global Initiative, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Benjamin O. Anderson
- Breast Health Global Initiative, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Departments of Surgery and Global Health Medicine, University of Washington, Seattle, Washington, USA
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