Gynecologic Oncology Sub-Specialty Training in Ghana: A Model for Sustainable Impact on Gynecologic Cancer Care in Sub-Saharan Africa

Improving access to safe, quality surgical care for gynecologic cancers through capacity-building interventions in low- and middle-income countries: A scoping review

BACKGROUND

Following the launch of the World Health Organization's Strategy to accelerate the elimination of cervical cancer, diagnosis is expected to increase, especially in low- and middle-income countries (LMICs). A well-integrated surgical system is critical to treat cervical cancer. Two major approaches have been employed to build human capacity: task-sharing and training of gynecologic oncologists (GynOncs).

OBJECTIVES

This review aimed to explore existing literature on capacity-building for surgical management of early-stage gynecologic cancers.

SEARCH STRATEGY

The search strategy was registered on Open Science Framework (doi 10.17605/OSF.IO/GTRCB) and conducted on OVID Medline, Embase, Global Index Medicus, and Web of Science. Search results were exported and screened in COVIDENCE.

SELECTION CRITERIA

Studies published in English, Spanish, French, and/or Portuguese conducted in LMIC settings evaluating capacity building, task-sharing, or outcomes following operation by subspecialists compared to specialists were included.

DATA COLLECTION AND ANALYSIS

Results were synthesized using narrative synthesis approach with emergence of key themes by frequency.

MAIN RESULTS

The scoping review identified 18 studies spanning our themes of interest: capacity building, subspecialized versus non-subspecialized care, and task-shifting/-sharing.

CONCLUSIONS

A multilayered approach is critical to achieve the WHO Strategy to Eliminate Cervical Cancer. Capacity-building and task-sharing programs demonstrate encouraging results to meet this need; nevertheless, a standardized methodology is needed to evaluate these programs, their outcomes, and cost-effectiveness.

Mapping of Radiation Oncology and Gynecologic Oncology Services Available to Treat the Growing Burden of Cervical Cancer in Africa

PURPOSE

To meet the demand for cervical cancer care in Africa, access to surgical and radiation therapy services needs to be understood. We thus mapped the availability of gynecologic and radiation therapy equipment and staffing for treating cervical cancer.

METHODS AND MATERIALS

We collected data on gynecologic and radiation oncology staffing, equipment, and infrastructure capacities across Africa. Data was obtained from February to July 2021 through collaboration with international partners using Research Electronic Data Capture. Cancer incidence was taken from the International Agency for Research on Cancer's GLOBOCAN 2020 database. Treatment capacity, including the numbers of radiation oncologists, radiation therapists, physicists, gynecologic oncologists, and hospitals performing gynecologic surgeries, was calculated per 1000 cervical cancer cases. Adequate capacity was defined as 2 radiation oncologists and 2 gynecologic oncologists per 1000 cervical cancer cases.

RESULTS

Forty-three of 54 African countries (79.6%) responded, and data were not reported for 11 countries (20.4%). Respondents from 31 countries (57.4%) reported access to specialist gynecologic oncology services, but staffing was adequate in only 11 countries (20.4%). Six countries (11%) reported that generalist obstetrician-gynecologists perform radical hysterectomies. Radiation oncologist access was available in 39 countries (72.2%), but staffing was adequate in only 16 countries (29.6%). Six countries (11%) had adequate staffing for both gynecologic and radiation oncology; 7 countries (13%) had no radiation or gynecologic oncologists. Access to external beam radiation therapy was available in 31 countries (57.4%), and access to brachytherapy was available in 25 countries (46.3%). The number of countries with training programs in gynecologic oncology, radiation oncology, medical physics, and radiation therapy were 14 (26%), 16 (30%), 11 (20%), and 17 (31%), respectively.

CONCLUSIONS

We identified areas needing comprehensive cervical cancer care infrastructure, human resources, and training programs. There are major gaps in access to radiation oncologists and trained gynecologic oncologists in Africa.

Descriptive epidemiology of gynaecological cancers in southern Ethiopia: retrospective cross-sectional review

OBJECTIVE

To determine the epidemiology of gynaecological cancer among patients treated at Hawassa University Comprehensive and Specialized Hospital (HUCSH) from 2013 to 2019.

DESIGN

A retrospective cross-sectional review.

SETTING, PARTICIPANTS, AND OUTCOME MEASURE

A total of 3002 patients' cards with a diagnosis of cancer at a tertiary hospital named HUCSH were reviewed between February and May 2020. HUCSH is the only oncological care centre in the southern region of Ethiopia. Of this all-gynaecological cancer charts were extracted and descriptive and trend analyses were done. The review was conducted between February and May 2020.

RESULT

Out of all 3002 cancer cases, 522 (17.4%) cases of gynaecological cancers were identified in 7 years. Cervical cancer accounted for 385 (73.8%) of all gynaecological cancers in this study, the next most common gynaecological cancers were ovarian cancer 55(10.5%) and endometrial cancer 51(9.8%), respectively. The mean (SD) age was 44.84 (12.23). Trends of all identified gynaecological cancers showed continuous increments of caseload year to year. Since 2016 increment of cervical cancer is drastically vertical compared with others.

CONCLUSION

Despite the limited use of a registration and referral system in primary health institutions, the burden of gynaecological cancers has increased over time. Treatment steps should be taken as soon as possible after a cancer diagnosis to prevent the disease from progressing.

Targeting elimination of cervical cancer by 2030: a baseline assessment in six African countries-part II

Background

Africa is home to many countries with the highest incidence of cervical cancer in the world. It is encouraging to see that the efforts to prevent and manage this disease are intensifying across the continent. The World Health Organization (WHO) has, in the last years, led a world-wide initiative to eliminate cervical cancer as a public health problem, starting by setting clear targets for 2030.

Aim

To assist those African countries with the largest burden of cervical cancer, to reach the set targets, as a first step, WHO initiated a baseline capacity assessment in African high burden countries. We present and discuss the results thereof in this paper.

Method

The countries selected for the baseline evaluation were Eswatini, Guinea, Malawi, Rwanda, Uganda and Zambia. The data were collected by a mailed questionnaire in English, with 129 questions, most of them with preset answer options. It was answered by national coordinators of non-communicable diseases, cancer control or reproductive health programmes in the ministries of health and by the WHO country representatives. Based on the answers, suggestions were made towards optimising the efforts for cancer control.

Results

Except for Eswatini and Guinea, vaccination against the human papilloma virus (HPV) has reached between 74% and 98% of girls in the age bracket. The main method for cervical screening is still inspection with acid acetic. HPV testing, recommended by WHO, is being introduced slowly. The numbers of women screened are not yet nearing the required levels. Between 30% and 70% of the cervical cancers diagnosed are being treated with palliative intent. A deficit of personnel was reported for all professions involved in cervical cancer care.

Conclusions

Guinea will need assistance to implement HPV immunisations and expand screening. In all six countries surveyed, steps should be taken to introduce or scale up the more precise HPV screening instead of acid acetic inspection of the cervix, to replace the current cryoablation of the preinvasive lesions of the cervix with thermal ablation and to increase the capacity for screening. Solutions need to be found for covering the dearth in gynaecological oncologists and radiotherapy installations and personnel.

Building PRM in sub-Saharan Africa

It is estimated that about 50% of people in low- and middle- income countries who require rehabilitation do not get it. Multidisciplinary rehabilitation services led by Physical and Rehabilitation Medicine (PRM) physicians have been shown to improve functioning, independence and the quality of life of persons with reduced functioning or disability. However, there is a dearth of PRM physicians in low to middle income countries (LMICs), particularly in sub-Saharan Africa. One potential solution to this lack of specialists is the establishment of PRM training programs, which are currently lacking. The International Rehabilitation Forum (IRF) developed and implemented a fellowship program to train physicians in rehabilitation medicine and has been successful in Ghana, Ethiopia and Cameroon, all LMICs in sub-Saharan Africa. However, ongoing challenges include inadequate PRM trainers, availability of logistics and services for hands on experience, and funding. The fellowship program has a promising future and an ultimate goal of having locally trained fellows leading the program and expanding it to other LMICs. There has however been no publication of the process followed to achieve this or of a similar process undertaken anywhere in Africa. The process followed in this publication highlights the journey from engaging stakeholders to the admission of new and current fellows in training.

Health-related quality of life among cervical cancer survivors at a tertiary hospital in Ghana

Introduction

Cervical cancer is the second most common female cancer in Ghana. The disease and its treatment significantly affect survivors’ health-related quality of life (HRQoL). We determined the overall quality of life (QoL) and identified its predictors among cervical cancer survivors after treatment.

Materials and methods

A hospital-based cross-sectional analytical study was conducted on 153 disease-free cervical cancer survivors who completed curative treatment between January 2004 and December 2018 at Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana. We used the European Organization for Research and Treatment of Cancer core-30 item (EORTC QLQ-C30) and cervical cancer module (EORTC QLQ-CX24) to assess the survivors’ overall QoL. QoL domain scores were dichotomised as affected or unaffected by disease and its treatment. Significant differences between the affected and unaffected groups within each QoL domain were determined using the student T-test. We used Kruskal-Wallis and Dunn’s tests to examine the difference in QoL domains between treatment types, with significance based on Bonferroni corrections. Multivariable logistic regression was performed to identify predictors of overall QoL. A p-value of less than 0.05 was considered statistically significant.

Results

One hundred and fifty-three (153) women having a mean age of 58.3 (SD 11.4) years were studied. The overall QoL score was 79.6 (SD 16.0), and 74.5% of survivors reported good QoL score within the median follow up time of 41.8 months (interquartile range [IQR], 25.5–71.1 months) after cervical cancer diagnosis. Although the majority (66.0–84.3%) of the QoL functioning scale were unaffected, about a fifth (22.2%) to a third (34.5%) of the subjects had perceptual impairment in cognitive and role functioning. Financial difficulties, peripheral neuropathy and pain were most common symptoms reported as affected. A third of the survivors were worried that sex would be painful, and 36.6% indicated that their sexual activity as affected. The overall QoL scores for survivors who had surgery, chemoradiation and radiation-alone were 86.1 (SD 9.7), 76.9 (SD 17.7), and 80.7 (SD 14.7), respectively (p = 0.025). The predictors of survivor’s overall QoL were loss of appetite [Adjusted Odd Ratio (AOR) = 9.34, 95% Confidence Interval (CI) = 2.13–35.8, p = 0.001], pain (AOR = 3.53, 95% CI = 1.25–9.31, p = 0.017) and body image (AOR = 5.89, 95% CI = 1.80–19.27, p = 0.003).

Conclusion

About 75% of the survivors had a good overall quality of life. Primary surgical treatment affords the best prospects for quality of life with the least symptom complaints and financial burden. Loss of appetite, pain or diminution in body image perception predicted the overall quality of life of cervical cancer survivors after treatment.

Gynecologic pathology services in low- and middle-income countries

OBJECTIVE

The International Gynecologic Cancer Society (IGCS) offers multidisciplinary conferences to underserved communities. Mentor pathologists have become an integral part of these tumor boards, as pathology services in low-to-middle-income countries are often inadequate and disjointed. The IGCS Pathology Working Group conducted a survey to assess barriers to quality pathology services in low-to-middle-income countries and identified potential solutions.

METHODS

A 69-question cross-sectional survey assessing different aspects of pathology services was sent to 15 IGCS Extension for Community Healthcare Outcomes (ECHO) training sites in Africa, Asia, Central America, and the Caribbean. Local gynecologic oncologists distributed the survey to their pathology departments for review. The responses were tabulated in Microsoft Excel.

RESULTS

Responses were received from nine training sites: five sites in Africa, two in Asia, one in Central America, and one in the Caribbean. There were no pathologists with subspecialty training in gynecologic pathology. Most (7/9, 78%) surveyed sites indicated that they have limited access to online education and knowledge transfer resources. Of the eight sites that responded to the questions, 50% had an electronic medical system and 75% had a cancer registry. Synoptic reporting was used in 75% of the sites and paper-based reporting was predominant (75%). Most (6/7, 86%) laboratories performed limited immunohistochemical stains on site. None of the sites had access to molecular testing.

CONCLUSIONS

Initial goals for collaboration with local pathologists to improve diagnostic pathology in low- and middle-income countries could be defining minimal gross, microscopic, and reporting pathology requirements, as well as wisely designed educational programs intended to mentor local leaders in pathology. Larger studies are warranted to confirm these observations.

Incidence, Treatment and Outcomes of Cervical Cancer in Low- and Middle-income Countries

Cervical cancer is one of the most common cancers in developing nations. It has had a tremendous impact on the lifetime of millions of women over the last century and continues to do so. In this collaborative clinicians' review, we highlight the incidence, treatment and clinical outcomes of cervical cancer in low-income (LICs) and low- and middle-income countries (LMICs) across Asia, South America, South Africa and Eastern Europe. With the cervical cancer burden and locally advanced cancers being high, the majority of LICs/LMICs have been striving to adhere to optimal evaluation and treatment guidelines. However, the huge gap in resource availability, rural versus urban disparity and access to resources have led to poor compliance to evaluation, treatment and post-treatment rehabilitation. To mitigate the overwhelming numbers, various treatment strategies like neoadjuvant chemotherapy, hypofractionation radiation schedules (both external and brachytherapy) have been attempted with no major success. Also, the compliance to concurrent chemoradiation in various regions is a major challenge. With the burden of advanced cancers, the lack of palliative care services and their integration in cancer care is still a reality.