Cancer care delivery innovations, experiences and challenges during the COVID-19 pandemic: The Rwanda experience

Globally, cancer is the second leading cause of mortality. In 2018, 9.6 million lives were lost to cancer of which over 70% occurred in low and middle-income countries (LMICs) where limited access to cancer care and overwhelming late disease presentations negatively impact cancer related survival and quality of life [1]. Moreover, globally, new cancer cases are expected to increase from 18.1 million in 2018 to 21.4 million by 2030 [2]. In settings of poor health care systems and impoverished communities, the scarcity of and limited access to diagnostic and treatment modalities negatively impacts health outcomes and undermines achievement of the universal health care coverage (UHC) targets.

Over the past 20 years, Rwanda has recorded gains in key health indicators including increased life expectancy (from 48.6 in 2000 to 67.4 in 2015); declines in maternal mortality (from 1071 in 2000 to 210 per 100 000 live births in 2015) [3]. Concurrently, impressive gains were registered in the control of infectious diseases such as HIV, tuberculosis and malaria [3]. However, little gains have been recorded for the management of non-communicable diseases (NCDs) where age-standardized NCD mortality rates slightly decreased from 894.9 to 548.6 deaths per 100 000 people from 2000 to 2016 [4,5]. Anecdotally, plausible hindrances to the prevention and control of NCDs in Rwanda include low community awareness, lack of trained providers, limited access to diagnostic services and treatment capacity for complicated cases

Organized breast cancer screening not only reduces mortality from breast cancer but also significantly decreases disability-adjusted life years: analysis of the Global Burden of Disease Study and screening programme availability in 130 countries

Multiple studies over the past 4 decades have shown the significant benefit of breast cancer screening (BCS) in reducing mortality rates from breast cancer (BC). However, significant debate exists about the role of BCS in this regard, with some studies also showing no benefit in terms of mortality along with issues such as overdiagnosis, health care utilisation costs, psychological distress or overtreatment. To date, no BCS study has focused on disability. Hence the aim of this study is to evaluate the relative contribution of BCS approaches to age-standardized mortality and disability-adjusted life years (DALYs) rates along with other related risk factors, from a country-level perspective.

Patients and methods
This study created a country-dataset by merging information from the Global Burden of Disease study regarding female age-standardized BC mortality, DALYs rates and other risk factors with the BCS programme availability at the national or regional level (versus no or only pilot such programme), BCS type (mammography, digital screening, breast self-examination and clinical breast examination) and other BCS-related information among 130 countries. Mixed-effect multilevel regression models were run to examine the associations of interest.

Results
The most important factor predictive of lower mortality was the more advanced type of BCS programme availability [mammography: −4.16, 95% CI −6.76 to −1.55; digital mammography/ultrasound: −3.64, 95% CI −6.59 to −0.70] when compared with self- or clinical breast examinations. High levels of low-density lipoprotein cholesterol (LDL-c) and smoking were also related to higher mortality and DALYs from BC. In terms of BC DALYs, BCS had a 21.9 to 22.3-fold increase in the magnitude of effect compared with that in terms of mortality. Data on mortality and DALYs in relation to BCS programmes were also calculated for high-, middle- and low-income countries.

Conclusions
These data further support the positive effects of BCS in relation to age-standardized BC mortality rates, and for the first time show the impact of BCS on DALYs too. Additional factors, such as diabetes, high levels of LDL-c or smoking seemed to be related to BC mortality and disability, and could be considered as additional components of possible interventions to be used alongside BCS to optimize the BCS benefit on patients.

The implementation of a national paediatric oncology protocol for neuroblastoma in South Africa

Purpose
The aim of the World Health Organization-International Paediatric Oncology Society is to improve childhood cancer survival in low- and middle-income countries to 60% by 2030. This can be achieved using standardised evidence-based national treatment protocols for common childhood cancers. The aim of the study was to describe the development and implementation of the SACCSG NB-2017 neuroblastoma (NB) treatment protocol as part of the treatment harmonisation process of the South African Children’s Cancer Study Group.

Methods
The Consolidated Framework for Implementation Research was used to identify factors that could influence the implementation of the national NB protocol as a health care intervention. The evaluation was done according to five interactive domains for implementation: intervention characteristics, inner setting, outer setting, individual or team characteristics and the implementation process.

Results
The protocol was developed over 26 months by 26 physicians involved in childhood cancer management. The process included an organisational phase, a resource identification phase, a development phase and a research ethics approval phase. Challenges included nationalised inertia, variable research ethical approval procedures with delays and uncoordinated clinical trial implementation.

Conclusion
The implementation of the national NB protocol demonstrated the complexity of the implementation of a national childhood cancer treatment protocol. However, standardised paediatric cancer treatment protocols based on local expertise and resources in limited settings are feasib

Consensus on Prostate Cancer Treatment of Localized Disease With Very Low, Low, and Intermediate Risk: A Report From the First Prostate Cancer Consensus Conference for Developing Countries (PCCCDC)

PURPOSE
A group of international urology and medical C developed and completed a survey on prostate cancer (PCa) in developing countries. The results are reviewed and summarized, and recommendations on consensus statements for very low-, low-, and intermediate-risk PCa focused on developing countries were developed.

METHODS
A panel of experts developed more than 300 survey questions of which 66 questions concern the principal areas of interest of this paper: very low, low, and intermediate risk of PCa in developing countries. A larger panel of 99 international multidisciplinary cancer experts voted on these questions to create the recommendations for treatment and follow-up for very low-, low-, and intermediate-risk PCa in areas of limited resources discussed in this manuscript.

RESULTS
The panel voted publicly but anonymously on the predefined questions. Each question was deemed consensus if 75% or more of the full panel had selected a particular answer. These answers are based on panelist opinion not a literature review or meta-analysis. For questions that refer to an area of limited resources, the recommendations consider cost-effectiveness and the possible therapies with easier and greater access. Each question had five to seven relevant answers including two nonanswers. The results were tabulated in real time.

CONCLUSION
The voting results and recommendations presented in this document can be used by physicians to support management for very low, low, and intermediate risk of PCa in areas of limited resources. Individual clinical decision making should be supported by available data; however, as guidelines for treatment for very low, low, and intermediate risk of PCa in developing countries have not been developed, this document will serve as a point of reference when confronted with this disease.

Consensus on Treatment and Follow-Up for Biochemical Recurrence in Castration-Sensitive Prostate Cancer: A Report From the First Global Prostate Cancer Consensus Conference for Developing Countries

PURPOSE
To present a summary of the treatment and follow-up recommendations for the biochemical recurrence in castration-sensitive prostate cancer (PCa) acquired through a questionnaire administered to 99 PCa experts from developing countries during the Prostate Cancer Consensus Conference for Developing Countries.

METHODS
A total of 27 questions were identified as related to this topic from more than 300 questions. The clinician’s responses were tallied and presented in a percentage format. Topics included the use of imaging for staging biochemical recurrence, treatment recommendations for three different clinical scenarios, the field of radiation recommended, and follow-up. Each question had 5-7 relevant response options, including “abstain” and/or “unqualified to answer,” and investigated not only recommendations but also if a limitation in resources would change the recommendation.

RESULTS
For most questions, a clear majority (> 50%) of clinicians agreed on a recommended treatment for imaging, treatment scenarios, and follow-up, although only a few topics reached a consensus > 75%. Limited resources did affect several areas of treatment, although in many cases, they reinforced more stringent criteria for treatment such as prostate-specific antigen values > 0.2 ng/mL and STAMPEDE inclusion criteria as a basis for recommending treatment.

CONCLUSION
A majority of clinicians working in developing countries with limited resources use similar cutoff points and selection criteria to manage patients treated for biochemically recurrent castration-sensitive PCa.

Financial toxicity due to breast cancer treatment in low- and middle-income countries: evidence from Vietnam

Background
This study examined the financial toxicity faced by breast cancer (BC) patients in Vietnam and the factors associated with the risk and degree of that toxicity.

Methods
A total of 309 BC patients/survivors completed an online survey (n=209) or a face-to-face interview (n=100) at two tertiary hospitals. Descriptive statistics and χ2 tests were used to identify and analyse the forms and degree of financial toxicity faced by BC patients/survivors. A Cragg hurdle model assessed variation in risk and the degree of financial toxicity due to treatment.

Results
41% of respondents faced financial toxicity due to BC treatment costs. The mean amount of money that exceeded BC patients/survivors’ ability to pay was 153 million Vietnamese Dong (VND) ($6602) and ranged from 2.42 million VND to 1358 million VND ($104–58,413). A diagnosis at stage II or III of BC was associated with 16.0 and 18.0 million VND (~$690–777) more in the degree of financial toxicity compared with patients who were diagnosed at stage 0/I, respectively. Being retired or married or having full (100%) health insurance was associated with a decrease in the degree of financial toxicity.

Conclusions
A significant proportion of Vietnamese BC patients/survivors face serious financial toxicity due to BC treatment costs. There is a need to consider the introduction of measures that would attenuate this hardship and promote uptake of screening for the reduction in financial toxicity as well as the health gains it may achieve through earlier detection of cancer.

The Novel Coronavirus (COVID-19) Pandemic and the Response in Low-to-Middle Income Countries

Purpose of Review
The COVID-19 pandemic has posed an unprecedented challenge to healthcare, particularly in resource-constrained low and middle-income countries (LMICs). We aim to summarize the challenges faced by LMICs in providing breast cancer care during the pandemic and their response during this crisis.

Recent Findings
Conversion of oncology centers into COVID-19 isolation centers and lack of LMIC applicable guidelines for breast cancer treatment worsened the challenge for providers. Few LMICs changed their management framework, taking steps like triaging patients, prioritizing care, therapeutic spacing, and a shift to telehealth.

Summary
Modified protocols where available have served LMICs well for resource allocation; however, effectiveness of these cannot be determined due to lack of outcomes reporting. This pandemic has underscored the importance of flexibility, prompt intervention, good communication, and reassessment to address unexpected healthcare challenges and has been a learning lesson to help tailor guidelines early in the future.

Cancer Care at Stake in Low And Middle Income Countries

Avinash Shankar, MD, a retired endocrinologist in New Delhi, India, was diagnosed with squamous cell carcinoma of the pyriform sinus in December 2018. Even cordectomy and postoperative radiotherapy did not help and, since March 2019, he was on palliative chemotherapy to which he was responding well—even showing partial response on PET-CT after 3 cycles. Shankar was due for PET-CT after completion of 5 cycles of chemotherapy in January 2020.

“Sixth cycle was not planned in view of toxicities, but he had urinary tract infection in February and was managed at home with antibiotics, analgesics, and antipyretics until mid-March,” said Abhishek Shankar, his son. When his father was ready for the next PET-CT and further prognosis, on March 24, 2020, the Prime Minister Narendra Modi announced the world’s largest nationwide lockdown for COVID-19 management. A practicing radiologist at Lady Hardinge Medical College, New Delhi, India, Abhishek Shankar was able to clinically manage his father at home when the lockdown prompted rerouting health care services for “COVID hospitals.”

“When it was hard for me to see every day in our house where I was vigilant and observant about every inconvenience father has been facing, as a physician I am glad I was able to help. However, I am not sure about other cancer patients where most of them have limited access to resources than I do,” Abhishek Shankar noted.

Patients like Avinash Shankar are now more common to be seen worldwide. As of June 2020, per the survey of 155 countries by the World Health Organization, ministry of health staff working in the area of non-communicable diseases in 94 percent of the respondents were partially or fully reassigned to support COVID-19. About 42 percent reported partially or completely disrupted services for cancer treatment and over 50 percent reported a widespread postponement of public screening for breast and cervical cancers.

Reasons for reducing services were cancellations of planned treatments, less frequent public transport facilities, and shortage of health workers. In about 20 percent of the countries that reported disruptions, one of the main reasons for discontinuing services was shortage of medicines, diagnostics, and other care facilities. Though COVID impact on non-COVID care is global, the low- and middle-income countries (LMIC) are the hardest hit.

Many parts of Africa and the poorest regions of Brazil such as the Amazonia have high burden of cancer in these regions, and yet roiling poverty as well as lack of transportation added to the public fear of catching COVID has greatly reduced the number of people appearing for screening, diagnosis, and treatment in these countries.

“The northwest Brazil has been affected harder than the south in this regard since the public health system in Brazil is in imbalance across the country and is severely impacted in poorer regions,” said Leandro Colli, MD, PhD, Assistant Professor of Medical Oncology at University of São Paulo, Brazil. “That the government is not being transparent with the health data is making the situation worse,” he added.

Per a recent report, the average number of cancer diagnoses has plummeted considerably in all Brazilian regions since the start of the pandemic, say about 15,000 undiagnosed cases per month (Semin Oncol 2021; https://doi.org/10.1053/j.seminoncol.2020.12.002).

While in Africa, a continent that has already been through a growing cancer rates, compounding to the lack of personal protective equipment and facilities in many regions of the continent, the public fear was at the highest towards catching COVID and hence the cancer care was at severe stake.

“Because of these reasons, we are seeing significant drop in screening, diagnosis, and treatment for malignancies such as breast and cervical cancers,” said Prebo Barango, MSc, at WHO Afro, Harare, Zimbabwe. A recent report confirms that Africa, home for several low- and middle-income countries, has suffered worse cancer management amid the pandemic compared to higher income countries such as the U.K. and the U.S. (Science 2021; doi: 10.1126/science.abd1016).

Notwithstanding all these situations, selected countries including Zambia in Africa and India, have been adopting positive measures and telemedicine to manage at least a bit better. For instance, the Tata Memorial Hospital has been managing COVID-19 patients as well as cancer patients at the same time.

Another example is Japan. Though cancer has been known to be the leading cause of deaths in Japan, the Ministry of Health rerouted services to COVID management. In Tokyo, the COVID-19 lockdown was issued from April 7 to May 25, during which time the National Cancer Center Hospital (NCCH) was accepting COVID-19 patients, limiting the diagnosis and treatment of cancer patients.

“Cancer Screening Center at our hospital was completely closed; however, our endoscopy center limited to provide emergency endoscopy and diagnostic/treatment endoscopies,” said Takahisa Matsuda, MD, endoscopist at NCCH in Tokyo, Japan. “However, even in such a situation, we made an effort to continue to treat cancer patients as much as possible while paying attention to the risk of COVID-19 infection,” he added.

Whereas in India, telemedicine practices to manage difficult cases remotely and even administration of chemotherapy under tele-hand-holding came into the management of cancers (Cancer Treat Res Commun 2021; https://doi.org/10.1016/j.ctarc.2021.100313). However, Abhishek Shankar and colleagues are warning that India, like many other LMICs, is not prepared for a post-pandemic shock of cancer burden since the care nowadays and after the pandemic is expected to be a major challenge (Asia Pac J Oncol Nurs 2021; doi: 10.4103/apjon.apjon_57_20).

Though there is no apparent prioritization for cancer patients in India for vaccination against COVID-19, national guidelines suggest different timelines for people under various levels of cancer care in order for themselves to be free from COVID-19, if not cancers.

Fears and barriers: problems in breast cancer diagnosis and treatment in Pakistan

Background
Women in Pakistan lack appropriate awareness about diagnosis and treatment for breast cancer due to a range of multifaceted barriers. There is a dearth of literature examining the socio-cultural factors that inhibit women from breast cancer screening, diagnosis and treatment in Punjab, Pakistan. Addressing this gap, this qualitative study sought to identify and explore the barriers that hinder women from seeking timely screening and treatment.

Methods
In this process 45 women (age = 18–50 years) with breast cancer were purposively sampled and interviewed from the Punjab Institute of Nuclear Medicine (PINUM) hospital, Faisalabad, Pakistan.

Results
An inductive approach was used to analyze the data which resulted in the emergence of eight subthemes under the umbrella of three major themes that delineate individual, socio-cultural and structural barriers to seek screening and treatment of breast cancer in Punjab. Individual barriers included lack of awareness, hesitance in accepting social support, and spiritual healing. The identified socio-cultural factors included feminine sensitivity, stigmatization, and aversion to male doctors. Lack of financial resources and apathetic medical services were structural barriers that hinder screening and treatment.

Conclusions
These barriers can be addressed through raising awareness and community mobilization about breast-self exam and treatment. The healthcare system should also pay attention to socio-psychological and cultural factors impeding women’s access to available health facilities.

Is Independent Clinical Research Possible in Low- and Middle-Income Countries? A Roadmap to Address Persistent and New Barriers and Challenges

Cancer is an increasing and significant problem for both high- and low- and middle-income countries. Basic, translational, and clinical research efforts have been instrumental in generating the outstanding improvements we have witnessed over the last few decades, answering important questions, and improving patient outcomes. Arguably, a substantial portion of currently ongoing research is sponsored by the pharmaceutical industy and specifically addresses questions under industry interests, most of which apply to high-income countries, leaving behind problems related to the much larger and underserved population of patients with cancer in low- and middle-income countries. In this scenario, discussing independent academic research is an important challenge, particularly for these countries. Although different countries and institutions face different problems while establishing independent research agendas, some generalizable barriers can be identified. A solid regulatory and ethical framework, a strong and sustainable technical supporting infrastructure, and motivated and experienced investigators are all paramount to build a viable and productive academic research program. Securing funding for research, although not the only hurdle, is certainly one of the most basic hurdles to overcome. Noticeably, and as an added impediment, public and governmental support for cancer research has been decreasing in high-income countries and is almost nonexistent in the rest of the world. We propose an initial careful diagnostic assessment of the research resource scenario of each institution/country and adjustment of the strategic development plan according to four different research resource restriction levels. Although not necessarily applicable to all situations, this model can be helpful if adjusted to each local or regional situation