Cytopathology including fine-needle aspiration in sub-Saharan Africa: a Cameroon experience

Economic Evaluations of Breast Cancer Care in Low- and Middle-Income Countries: A Scoping Review

BACKGROUND

Understanding the cost of delivering breast cancer (BC) care in low- and middle-income countries (LMICs) is critical to guide effective care delivery strategies. This scoping review summarizes the scope of literature on the costs of BC care in LMICs and characterizes the methodological approaches of these economic evaluations.

MATERIALS AND METHODS

A systematic literature search was performed in five databases and gray literature up to March 2020. Studies were screened to identify original articles that included a cost outcome for BC diagnosis or treatment in an LMIC. Two independent reviewers assessed articles for eligibility. Data related to study characteristics and methodology were extracted. Study quality was assessed using the Drummond et al. checklist.

RESULTS

Ninety-one articles across 38 countries were included. The majority (73%) of studies were published between 2013 and 2020. Low-income countries (2%) and countries in Sub-Saharan Africa (9%) were grossly underrepresented. The majority of studies (60%) used a health care system perspective. Time horizon was not reported in 30 studies (33%). Of the 33 studies that estimated the cost of multiple steps in the BC care pathway, the majority (73%) were of high quality, but studies varied in their inclusion of nonmedical direct and indirect costs.

CONCLUSION

There has been substantial growth in the number of BC economic evaluations in LMICs in the past decade, but there remain limited data from low-income countries, especially those in Sub-Saharan Africa. BC economic evaluations should be prioritized in these countries. Use of existing frameworks for economic evaluations may help achieve comparable, transparent costing analyses.

IMPLICATIONS FOR PRACTICE

There has been substantial growth in the number of breast cancer economic evaluations in low- and middle-income countries (LMICs) in the past decade, but there remain limited data from low-income countries. Breast cancer economic evaluations should be prioritized in low-income countries and in Sub-Saharan Africa. Researchers should strive to use and report a costing perspective and time horizon that captures all costs relevant to the study objective, including those such as direct nonmedical and indirect costs. Use of existing frameworks for economic evaluations in LMICs may help achieve comparable, transparent costing analyses in order to guide breast cancer control strategies.

Benjamin Terry and his rapid razor section method for intraoperative diagnosis

Benjamin Taylor Terry (1876-1955), a little-known pathologist, played a critical role in the popularization of intraoperative diagnostic techniques in the 1920s and 1930s. He developed both a stain and his own rapid razor section method. Intraoperative diagnostic techniques were ultimately responsible for the transition of the practice of pathology and laboratory medicine from private commercial laboratories to a hospital-based practice, forever changing the history of pathology and surgery in North America. Although the intraoperative diagnostic technique he personally developed was reportedly better, faster and more economical than frozen sections, the latter ultimately won the battle for intraoperative diagnostic supremacy.

Sustainable Development of Pathology in Sub-Saharan Africa: An Example From Ghana

Context.—

Pathology services are poorly developed in Sub-Saharan Africa. Komfo Anokye Teaching Hospital in Kumasi, Ghana, asked for help from the pathology department of the University Hospital of North Norway, Tromsø.

Objective.—

To reestablish surgical pathology and cytology in an African pathology department in which these functions had ceased completely, and to develop the department into a self-supporting unit of good international standard and with the capacity to train new pathologists.

Design.—

Medical technologists from Kumasi were trained in histotechnology in Norway, they were returned to Kumasi, and they produced histologic slides that were temporarily sent to Norway for diagnosis. Two Ghanaian doctors received pathology training for 4 years in Norway. Mutual visits by pathologists and technologists from the 2 hospitals were arranged for the introduction of immunohistochemistry and cytology. Pathologists from Norway visited Kumasi for 1 month each year during 2007–2010. Microscopes and immunohistochemistry equipment were provided from Norway. Other laboratory equipment and a new building were provided by the Ghanaian hospital.

Results.—

The Ghanaian hospital had a surgical pathology service from the first project year. At 11 years after the start of the project, the services included autopsy, surgical pathology, cytopathology, frozen sections, and limited use of immunohistochemistry, and the department had 10 residents at different levels of training.

Conclusions.—

A Ghanaian pathology department that performed autopsies only was developed into a self-supported department with surgical pathology, cytology, immunohistochemistry, and frozen section service, with an active residency program and the capacity for further development that is independent from assistance abroad.

High-selectivity cytology via lab-on-a-disc western blotting of individual cells

Cytology of sparingly available cell samples from both clinical and experimental settings would benefit from high-selectivity protein tools. To minimize cell handling losses in sparse samples, we design a multi-stage assay using a lab-on-a-disc that integrates cell handling and subsequent single-cell western blotting (scWestern). As the two-layer microfluidic device rotates, the induced centrifugal force directs dissociated cells to dams, which in turn localize the cells over microwells. Cells then sediment into the microwells, where the cells are lysed and subjected to scWestern. Taking into account cell losses from loading, centrifugation, and lysis-buffer exchange, our lab-on-a-disc device handles cell samples with as few as 200 cells with 75% cell settling efficiencies. Over 70% of microwells contain single cells after the centrifugation. In addition to cell settling efficiency, cell-size filtration from a mixed population of two cell lines is also realized by tuning the cell time-of-flight during centrifugation (58.4% settling efficiency with 6.4% impurity). Following the upstream cell handling, scWestern analysis detects four proteins (GFP, β-TUB, GAPDH, and STAT3) in a glioblastoma cell line. By integrating the lab-on-a-disc cell preparation and scWestern analysis, our platform measures proteins from sparse cell samples at single-cell resolution.

Cytopathology practice in Kumasi: A 2-year retrospective audit

Aim:

Surgical pathology service is generally unavailable in most developing countries and comes with challenges. Cytopathology is a reliable, inexpensive adjunct to surgical histopathology. We present a retrospective review of the various cytopathology cases received at the department.

Materials and Methods:

A retrospective review of 836 cytopathology cases from January 2010 to December 2011 at the Department of Pathology of our hospital was conducted. All cytopathology reports and records from the department were retrieved and analyzed using the Statistical Package for the Social Sciences version 16 for windows.

Results:

A total of 836 (mean age 38.18 ± 22.18) cases were reviewed, at an average of approximately 418 cases performed a year (5.7% of the total workload). More than half (58.0%) of the cases received had no clinical diagnosis indicated on request forms. Seventy-seven percent (77%) of the cases were diagnosed as either definite or nondefinite. The breast was the most aspirated specimen site (20.2%). Benign cases formed 45.0% of all the cases and 29.0% were malignant. There were more benign than malignant cases with respect to all sites aspirated except the breast (18.3%), lymph nodes (35.0%), and soft tissues (11.7%) where the reverse occurred.

Conclusion:

Patronage of cytopathology in Kumasi is increasing and serves as a quick, cheap, and effective alternate means for diagnosis. Improving and expanding on the current practice will ensure that pathologists in practice sustain and improve diagnostic cytopathology and provide material for training young pathologists.

Fine-needle aspiration cytology in Ethiopia

CONTEXT

Most of the population in Ethiopia lives below the poverty line with severely limited access to health care. The burden of infectious diseases is high, but benign and malignant neoplasms are also encountered frequently. For diagnosis of palpable lesions in this setting, fine-needle aspiration biopsy is the method of choice.

OBJECTIVE

To present findings from several patients from 3 major hospitals in Ethiopia who underwent fine-needle aspiration biopsy.

DATA SOURCES

Representative cytopathology cases of routinely encountered problems are shown. Often patients present with clinically advanced lesions. Staffing, technique, and equipment used for fine-needle aspiration biopsy are described at Black Lion Hospital (Addis Ababa), the University of Gonder Hospital (Gonder), and Ayder Referral Hospital of Mekelle University in the Tigray region of northern Ethiopia.

CONCLUSIONS

Fine-needle aspiration biopsy is a highly effective method for diagnosis of mass lesions, especially in an environment with sparse health care resources, such as Ethiopia. This article illustrates the work of Ethiopian cytopathologists and emphasizes the constraints under which they perform their work.

Pediatric Pathology Services in Africa

Context.—Like other pathology services in developing settings, pediatric pathology in Africa is faced with major challenges such as limited access to resources and few opportunities for professional advancement. Additionally, the discrepancy between the large burden of pediatric diseases, many of which individually are rare enough to prove challenging to the general pathologist, and the amount of specialized training available compounds the underlying problems and makes the provision of a high-quality service difficult. Pediatric neoplasms in particular are a chief cause for concern among general pathologists practicing in Africa.

Objectives.—To provide relevant pediatric pathology information with an emphasis on pediatric malignancies to pathologists practicing in Africa, where children represent a very high proportion of the population and training in pediatric pathology is incomplete.

Data Sources.—Authors' experience and relevant literature.

Conclusions.—The limitations inherent in working within a low-resource setting may be reduced by thoughtful and purposeful triaging of specimens, prudent use of cytology in facilitating rapid and inexpensive diagnoses, and collaboration within and outside of the continent. Increased investment in and advocacy for child health, including the creation of additional hospitals dedicated to the care of children, are likely necessary to significantly advance children's health in the region.

Raising the Quality of Care During Medical Missions: A Survey to Assess the Need for Clinical and Anatomic Pathology Services in International Medical Missions

Context.—Providing basic medical care to patients in underserved communities around the world is a valuable service and should not be compromised. Limited publicly available information on the use of pathology services during short-term medical missions (STMMs) shows a dire need for the improved quality of care being provided.

Objective.—To assess the need for clinical and anatomic pathology services in international medical missions by conducting an online survey.

Design.—A survey containing 35 questions aimed to understand the current use and availability of routine laboratory tests during STMMs, identify the need for particular tests that would improve quality of care, and determine the perceived obstacles preventing the delivery of the care to underserved communities worldwide. Answers from 21 health care providers who served on 50 medical missions were assessed.

Results.—Survey results revealed a significant discrepancy between the availability of pathology services in the United States and during STMMs. Statistical significance (P< .001) was found in areas of routine blood work, cytopathology, and histologic evaluation, among many others. More than half of the STMMs did not have access to basic metabolic panel, rapid hepatitis B test, and microbial cultures. Another 28% of health care providers indicated that having human immunodeficiency virus testing would have improved health care quality.

Conclusions.—Survey results show the need for improved pathology support during STMMs. The lack of precise diagnosis and disease monitoring has a negative effect on the quality of care provided during missions and the ability to enhance global health.

Economic analyses of breast cancer control in low- and middle-income countries: a systematic review

BACKGROUND

To support the development of global strategies against breast cancer, this study reviews available economic evidence on breast cancer control in low- and middle-income countries (LMICs).

METHODS

A systematic article search was conducted through electronic scientific databases, and studies were included only if they concerned breast cancer, used original data, and originated from LMICs. Independent assessment of inclusion criteria yielded 24 studies that evaluated different kinds of screening, diagnostic, and therapeutic interventions in various age and risk groups. Studies were synthesized and appraised through the use of a checklist, designed for evaluating economic analyses.

RESULTS

The majority of these studies were of poor quality, particularly in examining costs. Studies demonstrated the economic attractiveness of breast cancer screening strategies, and of novel treatment and diagnostic interventions.

CONCLUSIONS

This review shows that the evidence base to guide strategies for breast cancer control in LMICs is limited and of poor quality. The limited evidence base suggests that screening strategies may be economically attractive in LMICs - yet there is very little evidence to provide specific recommendations on screening by mammography versus clinical breast examination, the frequency of screening, or the target population. These results demonstrate the need for more economic analyses that are of better quality, cover a comprehensive set of interventions and result in clear policy recommendations.