Cost-effectiveness of childhood cancer treatment in Egypt: Lessons to promote high-value care in a resource-limited setting based on real-world evidence

Childhood cancer in low-and middle-income countries is a global health priority, however, the perception that treatment is unaffordable has potentially led to scarce investment in resources, contributing to inferior survival. In this study, we analysed real-world data about the cost-effectiveness of treating 8886 children with cancer at a large resource-limited paediatric oncology setting in Egypt, between 2013 and 2017, stratified by cancer type, stage/risk, and disease status.

Childhood cancer costs (USD 2019) were calculated from a health-system perspective, and 5-year overall survival was used to represent clinical effectiveness. We estimated cost-effectiveness as the cost per disability-adjusted life-year (cost/DALY) averted, adjusted for utility decrement for late-effect morbidity and mortality.

For all cancers combined, cost/DALY averted was $1384 (0.5 × GDP/capita), which is very cost-effective according to WHO–CHOICE thresholds. Ratio of cost/DALY averted to GDP/capita varied by cancer type/sub-type and disease severity (range: 0.1–1.6), where it was lowest for Hodgkin lymphoma, and retinoblastoma, and highest for high-risk acute leukaemia, and high-risk neuroblastoma. Treatment was cost-effective (ratio <3 × GDP/capita) for all cancer types/subtypes and risk/stage groups, except for relapsed/refractory acute leukaemia, and relapsed/progressive patients with brain tumours, hepatoblastoma, Ewing sarcoma, and neuroblastoma. Treatment cost-effectiveness was affected by the high costs and inferior survival of advanced-stage/high-risk and relapsed/progressive cancers.

Childhood cancer treatment is cost-effective in a resource-limited setting in Egypt, except for some relapsed/progressive cancer groups. We present evidence-based recommendations and lessons to promote high-value in care delivery, with implications on practice and policy.

Egypt Cancer Network; NIHR School for Primary Care Research; ALSAC.

Burn Admissions Across Low- and Middle-income Countries: A Repeated Cross-sectional Survey

Burn injuries have decreased markedly in high-income countries while the incidence of burns remains high in Low- and Middle-Income Countries (LMICs) where more than 90% of burns are thought to occur. However, the cause of burns in LMIC is poorly documented. The aim was to document the causes of severe burns and the changes over time. A cross-sectional survey was completed for 2014 and 2019 in eight burn centers across Africa, Asia, and Latin America: Cairo, Nairobi, Ibadan, Johannesburg, Dhaka, Kathmandu, Sao Paulo, and Guadalajara. The information summarised included demographics of burn patients, location, cause, and outcomes of burns. In total, 15,344 patients were admitted across all centers, 37% of burns were women and 36% of burns were children. Burns occurred mostly in household settings (43–79%). In Dhaka and Kathmandu, occupational burns were also common (32 and 43%, respectively). Hot liquid and flame burns were most common while electric burns were also common in Dhaka and Sao Paulo. The type of flame burns varies by center and year, in Dhaka, 77% resulted from solid fuel in 2014 while 74% of burns resulted from Liquefied Petroleum Gas in 2019. In Nairobi, a large proportion (32%) of burns were intentional self-harm or assault. The average length of stay in hospitals decreased from 2014 to 2019. The percentage of deaths ranged from 5% to 24%. Our data provide important information on the causes of severe burns which can provide guidance in how to approach the development of burn injury prevention programs in LMIC.

Breast Cancer Patients’ Experience about Involvement in Health Care: A Qualitative Study

Background: Patient involvement in health care is a basic patient’s right. Effective communication between the health care professional and the patient is associated with improved psychological functioning of the patient, adherence to treatment, and higher quality of life. Objective(s): This study aims to explore qualitatively breast cancer patients’ experience and satisfaction with their involvement in cancer care. Methods: This study was carried out among 30 women in different breast cancer care stages through in depth-interviews. The patients were purposively selected from surgery and oncology outpatient clinics and surgery inpatient wards in Medical Research Institute Hospital- Alexandria University, and in Ayadi El-Mostakbal Cancer Care Center – Ayadi El-Mostakbal Charity Foundation, Alexandria, Egypt. Results: Some patients mentioned that they did not know their diagnosis until late, others complained of the harsh non-empathetic way of breaking the news of their disease. Patients, generally, reported a little understanding of their treatment plan, they just followed physician’s instructions without receiving enough explanation. Patients on chemotherapy and radiotherapy expressed their unsatisfied need for information. Patients’ source of information was mainly other patients who suffered from the same disease. Patients, in general, were not familiar with the concept of giving feedback, it was perceived by the majority of them as equivalent to complaining. Some patients believed that complaining could put them in trouble such as receiving harsh blame or even delaying their medication. Conclusion: Patients’ narratives revealed poor involvement in health care and showed dissatisfaction of the majority of patients with their level of involvement.

Undergraduate Surgical Education: a Global Perspective

Undergraduate surgical education is failing to prepare medical students to care for patients with surgical conditions, and has been significantly compromised by the COVID-19 pandemic. We performed a literature review and undertook semi-structured reflections on the current state of undergraduate surgical education across five countries: Egypt, Morocco, Somaliland, Kenya, and the UK. The main barriers to surgical education at medical school identified were (1) the lack of standardised surgical curricula with mandatory learning objectives and (2) the inadequacy of human resources for surgical education. COVID-19 has exacerbated these challenges by depleting the pool of surgical educators and reducing access to learning opportunities in clinical environments. To address the global need for a larger surgical workforce, specific attention must be paid to improving undergraduate surgical education. Solutions proposed include the development of a standard surgical curriculum with learning outcomes appropriate for local needs, the incentivisation of surgical educators, the incorporation of targeted online and simulation teaching, and the use of technology.

Neurosurgery in Egypt from ancient Egyptians to Modern Neurosurgery, African Perspective

Neurosurgery has been practiced for more than 12,000 years worldwide. Cranial and transnasal approaches to the brain have been practiced for variable religious, mystical, or therapeutic purposes in ancient civilizations of Africa and specifically in Egypt (1). Ancient Egyptian medicine is documented in the paintings on the walls of temples and numerous papyri (figure 1) (2-4).

Ancient Egyptian medicine dates to 3500 BC when Athotis (Hor-Aha), the second king of the first dynasty, was found to have in his tomb the first “Book of the Dead” that was later quoted with modifications till it reached “Practical Medicine and Anatomic Book” in Ani’s papyrus

Postpartum infection, pain and experiences with care among women treated for postpartum hemorrhage in three African countries: A cohort study of women managed with and without condom-catheter uterine balloon tamponade

We aimed to determine the risk of postpartum infection and increased pain associated with use of condom-catheter uterine balloon tamponade (UBT) among women diagnosed with postpartum hemorrhage (PPH) in three low- and middle-income countries (LMICs). We also sought women’s opinions on their overall experience of PPH care.

This prospective cohort study compared women diagnosed with PPH who received and did not receive UBT (UBT group and no-UBT group, respectively) at 18 secondary level hospitals in Uganda, Egypt, and Senegal that participated in a stepped wedge, cluster-randomized trial assessing UBT introduction. Key outcomes were reported pain (on a scale 0–10) in the immediate postpartum period and receipt of antibiotics within four weeks postpartum (a proxy for postpartum infection). Outcomes related to satisfaction with care and aspects women liked most and least about PPH care were also reported.

Among women diagnosed with PPH, 58 were in the UBT group and 2188 in the no-UBT group. Self-reported, post-discharge antibiotic use within four weeks postpartum was similar in the UBT (3/58, 5.6%) and no-UBT groups (100/2188, 4.6%, risk ratio = 1.22, 95% confidence interval [CI]: 0.45–3.35). A high postpartum pain score of 8–10 was more common among women in the UBT group (17/46, 37.0%) than in the no-UBT group (360/1805, 19.9%, relative risk ratio = 3.64, 95% CI:1.30–10.16). Most women were satisfied with their care (1935/2325, 83.2%). When asked what they liked least about care, the most common responses were that medications (580/1511, 38.4%) and medical supplies (503/1511, 33.3%) were unavailable.

UBT did not increase the risk of postpartum infection among this population. Women who receive UBT may experience higher degrees of pain compared to women who do not receive UBT. Women’s satisfaction with their care and stockouts of medications and other supplies deserve greater attention when introducing new technologies like UBT.

Completeness of Medical Records of Trauma Patients Admitted to the Emergency Unit of a University Hospital, Upper Egypt

Trauma records in Egyptian hospitals are widely suspected to be inadequate for developing a practical and useful trauma registry, which is critical for informing both primary and secondary prevention. We reviewed archived paper records of trauma patients admitted to the Beni-Suef University Hospital in Upper Egypt for completeness in four domains: demographic data including contact information, administrative data tracking patients from admission to discharge, clinical data including vital signs and Glasgow Coma Scale scores, and data describing the causal traumatic event (mechanism of injury, activity at the time of injury, and location/setting). The majority of the 539 medical records included in the study had significant deficiencies in the four reviewed domains. Overall, 74.3% of demographic fields, 66.5% of administrative fields, 55.0% of clinical fields, and just 19.9% of fields detailing the causal event were found to be completed. Critically, oxygen saturation, arrival time, and contact information were reported in only 7.6%, 25.8%, and 43.6% of the records, respectively. Less than a fourth of the records provided any details about the cause of trauma. Accordingly, the current, paper-based medical record system at Beni-Suef University Hospital is insufficient for the development of a practical trauma registry. More efforts are needed to develop efficient and comprehensive documentation of trauma data in order to inform and improve patient care.

Temporal trends in childhood cancer survival in Egypt, 2007 to 2017: A large retrospective study of 14 808 children with cancer from the Children’s Cancer Hospital Egypt

Childhood cancer is a priority in Egypt due to large numbers of children with cancer, suboptimal care and insufficient resources. It is difficult to evaluate progress in survival because of paucity of data in National Cancer Registry. In this study, we studied survival rates and trends in survival of the largest available cohort of children with cancer (n = 15 779, aged 0‐18 years) from Egypt between 2007 and 2017, treated at Children’s Cancer Hospital Egypt‐(CCHE), representing 40% to 50% of all childhood cancers across Egypt. We estimated 5‐year overall survival (OS) for 14 808 eligible patients using Kaplan‐Meier method, and determined survival trends using Cox regression by single year of diagnosis and by diagnosis periods. We compared age‐standardized rates to international benchmarks in England and the United States, identified cancers with inferior survival and provided recommendations for improvement. Five‐year OS was 72.1% (95% CI 71.3‐72.9) for all cancers combined, and survival trends increased significantly by single year of diagnosis (P < .001) and by calendar periods from 69.6% to 74.2% (P < .0001) between 2007‐2012 and 2013‐2017. Survival trends improved significantly for leukemias, lymphomas, CNS tumors, neuroblastoma, hepatoblastoma and Ewing Sarcoma. Survival was significantly lower by 9% and 11.2% (P < .001) than England and the United States, respectively. Significantly inferior survival was observed for the majority of cancers. Although survival trends are improving for childhood cancers in Egypt/CCHE, survival is still inferior in high‐income countries. We provide evidence‐based recommendations to improve survival in Egypt by reflecting on current obstacles in care, with further implications on practice and policy.

Compliance and Barriers Facing Nurses with Surgical Site Infection Prevention Guidelines

Background: Surgical Site Infection (SSI) is defined as infection that occurring within 30 days after surgical procedure or within a year of implantation of prosthesis. Surgical Site Infection can happen in up to 30% of surgical procedures and records for up to 14% of Hospital Acquired Infection (HAIs). Aim of the Study: The aim of this study was to assess levels of nurse’s Compliance; knowledge and practice regarding prevention of surgical site infection Guidelines and identify the barriers facing nurses’ compliance with surgical site infection prevention Guidelines. Design: Cross sectional descriptive study design self-reported survey. Settings: Data was collected from surgical departments from selected Menoufia Governorate Hospitals, Egypt. Sample: A large convenience sample of 450 nurses was selected. Initially 600 questionnaires were distributed, of which only 400 returned completed, a response rate of 66.6%. Tools: was comprised of the: 1) Pre-designed structured questionnaire to assess nurses’ socio-demographic characteristics’ and Nurses’ knowledge, 2) Likert-scale: to assess nurses’ compliance, nurses’ practice and nurses’ barriers facing nurses with surgical site infection prevention guidelines. Study period: The study was conducted from July to November 2019 in the selected hospitals. Results: nurses’ compliance mean scores were in low level with a mean of 13.01, it is clear that most of the nurses have poor knowledge, most of the nurses have poor practice about surgical site infection, concerning the most barriers of compliance facing nurses with surgical site infection prevention guidelines, were lack of a professional model, having no enough time, and some measures for the prevention of surgical site infection are not nurses’ responsibilities. Conclusions: Nurses working in the surgical related wards reported a low level of knowledge, practice and compliance regarding the prevention of surgical site infection guidelines. The most barriers of compliance with surgical site infection prevention guidelines that reported by nurses were, lack of a professional model, nurses do not have enough time, and some measures for the prevention of surgical site infection are not nurses’ responsibilities. Recommendations: Evaluation of nurses’ and hospitals’ application of the guidelines is important to improve the quality of care. Education and training program should be conducted to improve nurses’ knowledge and practice in some areas using evidence-based practice.

Vulvar cancer: surgical management and survival trends in a low resource setting

This study aims to analyze risk factors, clinical profiles, treatment protocols, and disease outcomes in histologically proven resectable vulvar cancer (VC) patients according to tumor stage. This is a retrospective analysis of a prospectively collected database of 20 VC patients from May 2014 to June 2019.

The mean age of VC diagnosis was 55 years, with a range of 38–84 years. The incidence was four cases per year. The disease incidence was significantly more in post-menopausal (65%) and multiparous (90%) women. According to FIGO staging of vulvar cancer, stages I, II, and III were assigned to 6, 1, and 11 patients respectively. Two patients suffered from stage IVa vulvar melanoma. All patients had undergone surgical interventions. Patients treated with only nonsurgical (chemotherapy/radiotherapy/chemo-radiotherapy) treatment modalities were excluded from the study. Fifteen patients were treated with wide local excision (WLE), bilateral inguinofemoral dissection (B/L IFLND), and primary repair. Four and one patients were treated with radical vulvectomy (RV) and modified radical vulvectomy (MRV) [with or without B/L IFLND and PLND] respectively. Reconstruction with V-Y gracilis myocutaneous and local rotation advancement V-Y fasciocutaneous flaps were done in two patients. Therapeutic groin nodal dissection was performed in 19 patients except in one patient who was treated by palliative radical vulvectomy. In the final histopathology reports, tumor size varies from 0.5 to 6.5 cm (mean 3.35 cm) with the predominance of squamous cell carcinoma (18 out of 20 patients). Only 10 out of 18 eligible patients received adjuvant treatment. Poor patient compliance has been one of the major reasons for adjuvant treatment attrition rate. Systemic and loco-regional metastasis occurred in 3 patients each arm respectively. Poor follow up of patients is the key limitation of our study.

Vulvar cancer incidence was significantly high in post-menopausal and multiparous women. The most important prognostic factors were tumor stage and lymph node status. Oncological resection should be equated with functional outcome. The multidisciplinary team approach should be sought for this rare gynecological malignancy.