Innovation in the Surgical Management of Pancreatic Cystic Neoplasms: Same Operations, Narrower Indications, and an Individualized Approach to Decision-Making

Historically, the management of pancreatic cystic neoplasms (PCN) has been operative. Early intervention for premalignant lesions, including intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN), offers an opportunity to prevent pancreatic cancer-with potential decrement to patients' short-term and long-term health. The operations performed have remained fundamentally the same, with most patients undergoing pancreatoduodenectomy or distal pancreatectomy using oncologic principles. The role of parenchymal-sparing resection and total pancreatectomy remains controversial. We review innovations in the surgical management of PCN, focusing on the evolution of evidence-based guidelines, short-term and long-term outcomes, and individualized risk-benefit assessment.

Clinical Diagnoses and Outcomes After Diagnostic Breast Ultrasound by Nurses and General Practitioner Physicians in Rural Rwanda

PURPOSE

To scale up early detection of breast cancer in low- and middle-income countries, research is needed to inform the role of diagnostic breast ultrasound performed by nonradiologists in resource-constrained settings. The authors examined 2-year clinical follow-up and outcomes among women who underwent diagnostic breast ultrasound performed by nonradiologist clinicians participating in a breast ultrasound training and mentorship program at a rural Rwandan hospital.

METHODS

Imaging findings, management plans, and pathologic results were prospectively collected during the training using a standardized form. Data on follow-up and outcomes for patients receiving breast ultrasound between January 2016 and March 2017 were retrospectively collected through medical record review.

RESULTS

Two hundred twenty-nine breast palpable findings (199 patients) met the study's eligibility criteria. Of 104 lesions initially biopsied, 38 were malignant on initial biopsy; 3 lesions were identified as malignant on repeat biopsy. All 34 patients ultimately diagnosed with cancer received initial recommendations for either biopsy or aspiration by trainees. The positive predictive value of trainee biopsy recommendation was 34.8% (95% confidence interval, 24.8%-45.0%). The sensitivity of trainees' biopsy recommendation for identifying malignant lesions was 92.7% (95% confidence interval, 84.2%-100%). Of 46 patients who did not receive biopsy and were told to return for clinical or imaging follow-up, 37.0% did not return.

CONCLUSIONS

Trained nonradiologist clinicians in Rwanda successfully identified suspicious breast lesions on diagnostic breast ultrasound. Loss to follow-up was common among patients instructed to return for surveillance, so lower biopsy thresholds, decentralized surveillance, or patient navigation should be considered for patients with low- or intermediate-suspicion lesions.

Identifying Breast Cancer Care Quality Measures for a Cancer Facility in Rural Sub-Saharan Africa: Results of a Systematic Literature Review and Modified Delphi Process

PURPOSE

The burden of cancer is growing in low- and middle-income countries (LMICs), including sub-Saharan Africa. Ensuring the delivery of high-quality cancer care in such regions is a pressing concern. There is a need for strategies to identify meaningful and relevant quality measures that are applicable to and usable for quality measurement and improvement in resource-constrained settings.

METHODS

To identify quality measures for breast cancer care at Butaro Cancer Center of Excellence (BCCOE) in Rwanda, we used a modified Delphi process engaging two panels of experts, one with expertise in breast cancer evidence and measures used in high-income countries and one with expertise in cancer care delivery in Rwanda.

RESULTS

Our systematic review of the literature yielded no publications describing breast cancer quality measures developed in a low-income country, but it did provide 40 quality measures, which we adapted for relevance to our setting. After two surveys, one conference call, and one in-person meeting, 17 measures were identified as relevant to pathology, staging and treatment planning, surgery, chemotherapy, endocrine therapy, palliative care, and retention in care. Successes of the process included participation by a diverse set of global experts and engagement of the BCCOE community in quality measurement and improvement. Anticipated challenges include the need to continually refine these measures as resources, protocols, and measurement capacity rapidly evolve in Rwanda.

CONCLUSION

A modified Delphi process engaging both global and local expertise was a promising strategy to identify quality measures for breast cancer in Rwanda. The process and resulting measures may also be relevant for other LMIC cancer facilities. Next steps include validation of these measures in a retrospective cohort of patients with breast cancer.

Cluster Randomized Trial to Facilitate Breast Cancer Early Diagnosis in a Rural District of Rwanda

PURPOSE

Feasible and effective strategies are needed to facilitate earlier diagnosis of breast cancer in low-income countries. The goal of this study was to examine the impact of health worker breast health training on health care utilization, patient diagnoses, and cancer stage in a rural Rwandan district.

METHODS

We conducted a cluster randomized trial of a training intervention at 12 of the 19 health centers (HCs) in Burera District, Rwanda, in 2 phases. We evaluated the trainings’ impact on the volume of patient visits for breast concerns using difference-in-difference models. We used generalized estimating equations to evaluate incidence of HC and hospital visits for breast concerns, biopsies, benign breast diagnoses, breast cancer, and early-stage disease in catchment areas served by intervention versus control HCs.

RESULTS

From April 2015 to April 2017, 1,484 patients visited intervention HCs, and 308 visited control HCs for breast concerns. The intervention led to an increase of 4.7 visits/month for phase 1 HCs (P = .001) and 7.9 visits/month for phase 2 HCs (P = .007) compared with control HCs. The population served by intervention HCs had more hospital visits (115.1 v 20.5/100,000 person-years, P < .001) and biopsies (36.6 v 8.9/100,000 person-years, P < .001) and higher breast cancer incidence (6.9 v 3.3/100,000 person-years; P = .28). The incidence of early-stage breast cancer was 3.3 per 100,000 in intervention areas and 0.7 per 100,000 in control areas (P = .048).

CONCLUSION

In this cluster randomized trial in rural Rwanda, the training of health workers and establishment of regular breast clinics were associated with increased numbers of patients who presented with breast concerns at health facilities, more breast biopsies, and a higher incidence of benign breast diagnoses and early-stage breast cancers.

Assessing and Addressing the Need for Cancer Patient Education in a Resource-Limited Setting in Haiti

PURPOSE

Misinformation and lack of information about cancer and its treatment pose significant challenges to delivering cancer care in resource-limited settings and may undermine patient engagement in care. We aimed to investigate patients' knowledge and attitudes toward cancer and its treatment and to adapt, implement, and evaluate a low-literacy cancer patient education booklet at the Hôpital Universitaire de Mirebalais (HUM) in rural Haiti.

MATERIALS AND METHODS

A low-literacy cancer patient education booklet was adapted into Haitian Creole in collaboration with clinicians at HUM. Patients were recruited for structured interviews (n = 20) and two focus groups (n = 13) designed to explore patients' attitudes toward cancer and its treatment and to assess whether the booklet increased patients' knowledge via an investigator-designed knowledge test.

RESULTS

Participants reported a subjective lack of knowledge about cancer and its treatments and described views of cancer as deadly or incurable. Patients of varying education levels valued receiving written materials that set expectations about cancer treatment and expressed a desire to share the booklet with caregivers and others in their community. Participants across all levels of education significantly increased their performance on a knowledge test after counseling using the booklet (p < .001).

CONCLUSION

We found that an educational booklet about cancer developed in collaboration with local providers was well received by patients with variable literacy levels and improved their knowledge of cancer and its treatment in a resource-limited setting. Such educational materials have the potential to serve as tools to engage patients with cancer and their families in care.

IMPLICATIONS FOR PRACTICE

Misinformation and lack of information pose significant challenges to delivering cancer care in resource-limited settings; however, there are often no culturally and literacy appropriate tools available to aid in patient education. This article shows that written educational materials are well received by patients of variable literacy levels and can be effective tools for increasing patients' knowledge of cancer and its treatment in a limited-resource setting. Furthermore, the authors have made their educational booklet, Cancer and You, freely available online and welcome the opportunity to connect with readers of The Oncologist interested in implementing this educational booklet in clinical care.

Barriers to timely surgery for breast cancer in Rwanda

BACKGROUND

Ensuring timely and high-quality surgery must be a key element of breast cancer control efforts in sub-Saharan Africa. We investigated delays in preoperative care and the impact of on-site versus off-site operation on time to operative treatment of patients with breast cancer at Butaro Cancer Center of Excellence in Rwanda.

METHODS

We used a standardized data abstraction form to collect demographic data, clinical characteristics, treatments received, and disease status as of November 2017 for all patients diagnosed with breast cancer at Butaro Cancer Center of Excellence in 2014 to 2015.

RESULTS

From 2014 to 2015, 89 patients were diagnosed with stage I to III breast cancer and treated with curative intent. Of those, 68 (76%) underwent curative breast operations, 12 (14%) were lost to follow-up, 7 (8%) progressed, and 2 declined the recommended operation. Only 32% of patients who underwent operative treatment had the operation within 60 days from diagnosis or last neoadjuvant chemotherapy. Median time to operation was 122 days from biopsy if no neoadjuvant treatments were given and 51 days from last cycle of neoadjuvant chemotherapy. Patients who received no neoadjuvant chemotherapy experienced greater median times to operation at Butaro Cancer Center of Excellence (180 days) than at a referral hospital in Kigali (93 days, P = .04). Most patients (60%) experienced a disruption in preoperative care, frequently at the point of surgical referral. Documented reasons for disruptions and delays included patient factors, clinically indicated treatment modifications, and system factors.

CONCLUSION

We observed frequent delays to operative treatment, disruptions in preoperative care, and loss to follow-up, particularly at the point of surgical referral. There are opportunities to improve breast cancer survival in Rwanda and other low- and middle-income countries through interventions that facilitate more timely surgical care.

Impact of an Early Detection Program on Breast Cancer Services, Incidence, and Stage in Rural Rwanda

Purpose

In low-income countries, most women with breast cancer present with advanced-stage disease. To facilitate earlier diagnoses of symptomatic disease, feasible and effective early detection strategies are needed. We assessed health care use and patient outcomes from a randomized pilot study of an early detection program in Burera, a rural Rwandan district, where the Butaro Cancer Center of Excellence (BCCOE) is located.

Methods

The intervention included training for community health workers in breast health, training for health center (HC) nurses in the evaluation of breast concerns, and weekly breast clinics at HCs and BCCOE. Twelve of 18 eligible HCs were randomly assigned to receive the intervention—seven beginning in April and May 2015, and five in November and December 2015—and six served as controls for the entire study period. We abstracted HC and hospital records of patients seen between April 2015 and April 2017 and used generalized linear models to compare the incidence of biopsies, breast cancer diagnoses, and early-stage diagnoses in the geographic sectors served by intervention versus control HCs.

Results

Overall, 276,282 person-years were in intervention sectors and 302,856 in control sectors. Of patients, 1,500 patients sought care at intervention HCs for breast concerns versus 600 at control HCs. Three hundred eighteen patients that were referred from intervention HCs were evaluated at BCCOE compared with 62 from control HCs. The biopsy rate was 36.6 per 100,000 person-years from intervention sectors versus 8.9 per 100,000 from control sectors ( P < .001). Breast cancer was diagnosed in 19 of 101 patients from intervention HCs who underwent biopsy (18.8%) compared with 10 (37.0%) of 27 patients from control HCs. Breast cancer incidence was 6.9 per 100,000 in intervention sectors versus 3.3 per 100,000 in control sectors ( P = .35). Nine patients from intervention HCs had early-stage disease (47.4%) versus two from control HCs (20.0%). The incidence rate of early-stage breast cancer was 3.7 per 100,000 in intervention sectors versus 0.7 per 100,000 in control sectors ( P = .08).

Conclusion

Over 2 years, our early detection program was associated with more patients referred for hospital-level evaluation and requiring biopsies. Most patients referred by intervention HCs had benign conditions; however, there was a trend toward a higher incidence of early-stage breast cancer among patients from intervention regions.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . Lydia E. Pace Stock or Other Ownership: Firefly Health

Review of Quality Measures for Breast Cancer Care by Country Income Level

Purpose

Measurement of the quality of cancer care is essential for quality improvement and is widely implemented in oncology programs in high-income countries. Growing efforts are being made to measure care quality in emerging cancer care delivery systems in low- and middle-income countries (LMICs). This will require the development of measures that are clinically important, actionable, relevant to existing resources, and feasible to routinely evaluate. As part of a project to develop resource-adapted quality measures for Rwanda and other LMICs, we conducted a systematic review of the literature to identify published quality measures for the diagnosis and treatment of breast cancer.

Methods

We performed a literature search in accordance with PRISMA guidelines using the following terms in PubMed: ‘breast cancer’ and ‘quality indicator,’ ‘quality measure,’ or ‘quality metric’; and the following MeSH terms: ‘breast neoplasms’ and ‘healthcare quality indicator.’ We included English-language articles published before August 2017 that described the systematic identification of process measures for breast cancer diagnosis or treatment through literature review, clinical validation, and/or expert panel determination. We directly searched the Web sites of prominent cancer care organizations to identify additional publicly available measures. Income level was classified using World Bank definitions.

Results

We identified 521 published quality measures, including 419 measures from 27 peer-reviewed journal articles and 102 measures from the Web sites of national and international cancer care organizations. Twenty-five peer-reviewed publications (93%) originated from high-income countries, one from an upper-middle income country (People’s Republic of China), and one from the international Breast Health Global Initiative with process measures to assess the phased implementation of breast cancer services. No resources or articles other than that from the Breast Health Global Initiative provided suggestions for adapting measures to limited resources.

Conclusion

A large number of quality measures for breast cancer care have been identified and published in high-income countries; however, no breast cancer care quality measures have been systematically developed and validated for use in settings where resource limitations crucially affect care delivery and measurement feasibility. We are collaborating with clinicians in LMICs and global breast cancer experts to develop and validate quality measures that will enable quality improvement initiatives in Rwanda and other emerging cancer care delivery systems.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . No COIs from the authors.

Barriers to Timely Surgery for Breast Cancer in Rwanda

Abstract 81

Purpose

Surgery is the mainstay of treatment for nonmetastatic breast cancer. Little is known about the quality of breast surgical care in sub-Saharan Africa. Research at the Butaro Cancer Center of Excellence (BCCOE), Rwanda’s first public cancer center, has suggested that access to timely surgery is inadequate, but barriers have not been systematically examined. The aim of the current study was to gain an understanding of the barriers to breast cancer surgery among patients who were diagnosed at BCCOE by investigating delays and interruptions in care.

Methods

We used a standardized chart abstraction instrument to collect demographic, treatment, and outcome data as of November 2017 for all patients who were diagnosed with breast cancer at BCCOE in 2014 and 2015. We recorded all visits and treatments received until surgery, disease progression, or loss to follow-up for all patients with stage I to III breast cancer.

Results

During 2014 and 2015, 91 patients were diagnosed with stage I to III breast cancer and were treated with curative intent—67 patients (74%) underwent surgery, with 22 undergoing surgery at BCCOE and 45 elsewhere. Of the 24 patients with no surgery, 16 were lost to follow-up and eight experienced disease progression before surgical evaluation. Median time from diagnosis to surgery was 103 days (range, 30 to 826 days) for patients without neoadjuvant chemotherapy (NAC) and 268 days (range, 108 to 794 days) for patients with NAC. We defined surgical delays as > 120 days from diagnosis without NAC or > 365 days from diagnosis if NAC was administered. Of the 67 patients who had surgery, 26 patients (39%) experienced delays. When documented, reasons for delay included patient factors, such as social and/or financial issues (n = 5), seeking alternate treatment (n = 2), refusing referral to Kigali (n = 3), or any surgery (n = 1); system factors, such as surgeon nonavailability (n = 1); and changes in clinical status, such as pregnancy (n = 5), treatment-associated adverse events (n = 4), or the need for a second surgical opinion (n = 2). Unexplained failure to complete the initial surgical referral (n = 5) and missed NAC treatment appointments (n = 6) were frequent contributors. Some patients had multiple reasons for delay. For five patients, there was no documented explanation.

Conclusion

We observed high rates of loss to follow-up, surgical delays, and lapses in care at the point of surgical referral. Identification of the barriers to completing referrals could guide strategies for improving access to timely surgery. Efforts are needed to address social and financial barriers and explore patients’ refusals to undergo surgery.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

No COIs from the authors.

Developing and Evaluating Culturally and Literacy Appropriate Cancer Patient Education Materials for Haiti

Abstract 21

Background:

New efforts are being made to bring modern cancer medicine to patients in low- resource settings, where limited public awareness of cancer and health literacy pose significant challenges. Partners In Health (PIH) launched its first cancer program in Haiti in collaboration with Dana-Farber Cancer Institute and Brigham and Women's Hospital; however, no patient education materials appropriate for Haiti existed. Global Oncology has developed written educational materials based on cancer patient needs in low-resource settings. Objectives are to: 1) Adapt Global Oncology's patient education materials to be culturally and literacy appropriate for Haiti; 2) Assess the effectiveness of written materials for cancer patient education in a low-resource setting.

Methods:

Feedback from staff at the PIH-affiliated Hôpital Universitaire de Mirebalais (HUM) was incorporated into the pilot materials. We recruited 33 chemotherapy patients at HUM for interviews (n=20) and two focus groups (n=13). Patients were presented the booklet by the Oncology social worker, and pre- and post-counseling tests were administered. Qualitative data regarding booklet design and content was collected through observation of counseling sessions, interview questions and focus group discussions. Providers were surveyed with a questionnaire and proposed modifications to the booklet were discussed during a provider focus group.

Results:

Patients across all levels of education significantly increased their knowledge from pre-test (m=49.2%, sd= 19.5%) to post-test (m=87.9% sd = 8.9%; t(19)=10.07, p<0.0001). Patients felt reassured by the booklet. Many wanted to share the booklet with family and friends to teach them about cancer. Patients valued hearing about the side effects of chemotherapy and the precautions to take during treatment, but they also wanted more information about the causes of cancer and whether a cure is possible. Providers expressed a desire for the materials to include a definition of palliative versus curative treatment and to improve the explanation of cancer as a disease.

Conclusion:

Written patient education materials designed for low-resource settings enhance discussions between patients and providers, and can be a tool for disseminating information beyond the hospital to the family, friends and caregivers of cancer patients. Incorporating patient and provider feedback is essential to ensure written materials are culturally and literacy appropriate for the local patient population.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST:

Lauren E. Schleimer No relationship to disclose Peter-Gens Desameau No relationship to disclose Ruth Damuse No relationship to disclose Maia Olsen No relationship to disclose Veronica Manzo No relationship to disclose Rachael Guay No relationship to disclose Ami S. Bhatt No relationship to disclose Carlos Cardenas No relationship to disclose Franklin W. Huang Stock or Other Ownership: GlaxoSmithKline, Abbvie Lawrence N. Shulman No relationship to disclose