Implementation of a colorectal cancer screening intervention in Malaysia (CRC-SIM) in the context of a pandemic: study protocol

Introduction Colorectal cancer (CRC) is the second most common cancer in Malaysia and cases are often detected late. Improving screening uptake is key in down-staging cancer and improving patient outcomes. The aim of this study is to develop, implement and evaluate an intervention to improve CRC screening uptake in Malaysia in the context of the COVID-19 pandemic. The evaluation will include ascertaining the budgetary impact of implementing and delivering the intervention.

Methods and analysis The implementation research logic model guided the development of the study and implementation outcome measures were informed by the ‘Reach, Effectiveness, Adoption, Implementation and Maintenance’ (RE-AIM) framework. This CRC screening intervention for Malaysia uses home-testing and digital, small media, communication to improve CRC screening uptake. A sample of 780 people aged 50–75 years living in Segamat district, Malaysia, will be selected randomly from the South East Asia Community Observatory (SEACO) database. Participants will receive a screening pack as well as a WhatsApp video of a local doctor to undertake a stool test safely and to send a photo of the test result to a confidential mobile number. SEACO staff will inform participants of their result. Quantitative data about follow-up clinic attendance, subsequent hospital tests and outcomes will be collected. Logistic regression will be used to investigate variables that influence screening completion and we will conduct a budget impact-analysis of the intervention and its implementation. Qualitative data about intervention implementation from the perspective of participants and stakeholders will be analysed thematically.

Ethics and dissemination Ethics approval has been granted by Monash University Human Research Ethics Committee (MUHREC ID: 29107) and the Medical Review and Ethics Committee (Reference: 21-02045-O7G(2)). Results will be disseminated through publications, conferences and community engagement activities.

Trial registration number National Medical Research Register Malaysia: 21-02045-O7G(2).

Relapse-free survival in Sudanese women with non-metastatic breast cancer

Background
Breast cancer (BC) is the most frequently diagnosed cancer and a major cause of cancer mortality in Sudan. However, there is lack of data related to BC relapse. Therefore, this study was undertaken to estimate the 5-year relapse free survival (RFS) rate and factors related to BC relapse in Sudanese women with non-metastatic BC.

Methods
Data of BC women with BC diagnosed and treated at the National Cancer Institute-University of Gezira during 2012 were retrieved from medical records. The cases were followed-up through hospital records and telephone contact. Survival functions were calculated using Kaplan-Meier method and compared by log-rank test. The prognostic factors were tested using univariate and multivariable Cox regression analyses.

Results
We included 168 women with median age of 45 years (range, 22–83 years). 53.5%of women had stage III at time of diagnosis, whereas 4.2% and 42.3% of women presented with stage I and stage II, respectively. At the end of 5 years follow-up, with median follow-up period of 64 months, 94 (56.0%) women were alive in remission, 11 (6.5%) were alive with BC relapse, 49 (29.2%) were dead, and survival status was unknown in 14 (8.3%) women. Most of the occurred relapses were distant relapses. The 5-year RFS was 59%. The independent predictors of relapse were: larger primary tumor size (HR:1.84, 95% CI: 1.54-5.48, p=0.018); involved axillary lymph nodes with tumour (HR: 2.91, 95% CI: 1.53–7.91, p=0.001); not receiving adjuvant radiotherapy (HR: 2.2, 95% CI: 1.22–3.95, p=0.009); and not receiving hormone therapy (HR: 1.67, 95% CI: 1.01–2.76, p= 0.046).

Conclusion
We found a high risk of BC relapse in our resource-constrained settings. Advanced stages, not receiving adjuvant radiotherapy, and not receiving adjuvant hormone therapy were independent predictors associated with worse 5-year RFS. Therefore, enhancing the early diagnosis of BC and improving timely access to appropriate treatments represent key approaches to achieving better treatment outcomes.

Colorectal cancer in northern Tanzania: A retrospective, descriptive study of patients with histologically confirmed diagnoses at a tertiary referral hospital

Background: Colorectal cancer is one of the most common cancers worldwide with increasing incidence and mortality in low- and middle-income countries. Data from Tanzania shows a six-fold increase in incidence in the
past decade with increased morbidity and mortality rates. This study was conducted to characterize the clinicopathological pattern of colorectal cancer as well as to assess the challenges in treatment.
Methods: A retrospective analysis of histologically confirmed colorectal cancer cases at Arusha Lutheran Medical Centre between January 2015 and December 2020 was done. Data were extracted from patients’ clinical records and analysed using SPSS version 25.
Results: Total of 57 patients were included in this study. Males outnumbered females by ratio of 1.2:1. The median age of presentation was 57years with most patients being 61-70years of age. Most of our patients were urban residents (63.2%), 52.6% had health insurance and 35.1% had other comorbid conditions. Most of our patients (68.4%) presented as elective cases, and most (71.5%) had advanced disease (stage 3 and 4). The most common presenting symptoms were rectal bleeding (42%) and abdominal pain (23.3%). The mean duration from symptom onset to presentation was 14.6months. The rectum was the most common involved site (47.4%). Adenocarcinoma was the most common tumor histology (94.7%), majority being moderately differentiated (42.1%). 59.6% underwent surgery, and 25.9% received adjunctive therapy. The mean follow-up time of patients after surgical intervention was low at 5.8months as majority of the patients were lost to follow-up.
Conclusions: There is poor uptake of treatment options – surgery and adjunctive therapy – necessitating further appraisal for related factors. Also, advanced disease presentation and poor patient follow-up highlights underlying system challenges.

Cancer Medicines: What Is Essential and Affordable in India?

PURPOSE The WHO essential medicines list (EML) guides selection of drugs for national formularies. Here, we evaluate which medicines are considered highest priority by Indian oncologists and the extent to which they are
available in routine practice. METHODS This is a secondary analysis of an electronic survey developed by the WHO EML Cancer Medicine Working Group. The survey was distributed globally using a hierarchical snowball method to physicians who prescribe systemic anticancer therapy. The survey captured the 10 medicines oncologists considered highest priority for population health and their availability in routine practice.
RESULTS The global study cohort included 948 respondents from 82 countries; 98 were from India and 67 were from other low- and middle-income countries. Compared with other low- and middle-income countries, the Indian cohort was more likely to be medical oncologist (70% v 31%, P , .001) and work exclusively in the private health system (52% v 17%, P , .001). 14/20 most commonly selected medicines were conventional
cytotoxic drugs. Universal access to these medicines was reported by a minority of oncologists; risks of significant out-of-pocket expenditures for each medicine were reported by 19%-58% of oncologists. Risk of catastrophic expenditure was reported by 58%-67% of oncologists for rituximab and trastuzumab. Risks of financial toxicity were substantially higher within the private health system compared with the public system.
CONCLUSION Most high-priority cancer medicines identified by Indian oncologists are generic chemotherapy agents that provide substantial improvements in survival and are already included in WHO EML. Access to these
treatments remains limited by major financial burdens experienced by patients. This is particularly acute within the private health system. Strategies are urgently needed to ensure that high-quality cancer care is affordable and accessible to all patients in India

Cervical cancer prevention in countries with the highest HIV prevalence: a review of policies

Introduction
Cervical cancer (CC) is the leading cause of cancer-related death among women in sub-Saharan Africa. It occurs most frequently in women living with HIV (WLHIV) and is classified as an AIDS-defining illness. Recent World Health Organisation (WHO) recommendations provide guidance for CC prevention policies, with specifications for WLHIV. We systematically reviewed policies for CC prevention and control in sub-Saharan countries with the highest HIV prevalence.

Methods
We included countries with an HIV prevalence ≥ 10% in 2018 and policies published between January 1st 2010 and March 31st 2022. We searched Medline via PubMed, the international cancer control partnership website and national governmental websites of included countries for relevant policy documents. The online document search was supplemented with expert consultation for each included country. We synthesised aspects defined in policies for HPV vaccination, sex education, condom use, tobacco control, male circumcision,cervical screening, diagnosis and treatment of cervical pre-cancerous lesions and cancer, monitoring mechanisms and cost of services to women while highlighting specificities for WLHIV.

Results
We reviewed 33 policy documents from nine countries. All included countries had policies on CC prevention and control either as a standalone policy (77.8%), or as part of a cancer or non-communicable diseases policy (22.2%) or both (66.7%). Aspects of HPV vaccination were reported in 7 (77.8%) of the 9 countries. All countries (100%) planned to develop or review Information, Education and Communication (IEC) materials for CC prevention including condom use and tobacco control. Age at screening commencement and screening intervals for WLHIV varied across countries. The most common recommended screening and treatment methods were visual inspection with acetic acid (VIA) (88.9%), Pap smear (77.8%); cryotherapy (100%) and loop electrosurgical procedure (LEEP) (88.9%) respectively. Global indicators disaggregated by HIV status for monitoring CC programs were rarely reported. CC prevention and care policies included service costs at various stages in three countries (33.3%).

Conclusion
Considerable progress has been made in policy development for CC prevention and control in sub Saharan Africa. However, in countries with a high HIV burden, there is need to tailor these policies to respond to the specific needs of WLHIV. Countries may consider updating policies using the recent WHO guidelines for CC prevention, while adapting them to context realities.

mHealth Interventions to Improve Cancer Screening and Early Detection: Scoping Review of Reviews

Background:
Cancer screening provision in resource-constrained settings tends to be opportunistic, and uptake tends to be low, leading to delayed presentation and treatment and poor survival.

Objective:
The aim of this study was to identify, review, map, and summarize findings from different types of literature reviews on the use of mobile health (mHealth) technologies to improve the uptake of cancer screening.

Methods:
The review methodology was guided by the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). Ovid MEDLINE, PyscINFO, and Embase were searched from inception to May 2021. The eligible criteria included reviews that focused on studies of interventions that used mobile phone devices to promote and deliver cancer screening and described the effectiveness or implementation of mHealth intervention outcomes. Key data fields such as study aims, types of cancer, mHealth formats, and outcomes were extracted, and the data were analyzed to address the objective of the review.

Results:
Our initial search identified 1981 titles, of which 12 (0.61%) reviews met the inclusion criteria (systematic reviews: n=6, 50%; scoping reviews: n=4, 33%; rapid reviews: n=1, 8%; narrative reviews: n=1, 8%). Most (57/67, 85%) of the interventions targeted breast and cervical cancer awareness and screening uptake. The most commonly used mHealth technologies for increasing cancer screening uptake were SMS text messages and telephone calls. Overall, mHealth interventions increased knowledge about screening and had high acceptance among participants. The likelihood of achieving improved uptake-related outcomes increased when interventions used >1 mode of communication (telephone reminders, physical invitation letters, and educational pamphlets) together with mHealth.

Conclusions:
mHealth interventions increase cancer screening uptake, although multiple modes used in combination seem to be more effective.

J Med Internet Res 2022;24(8):e36316

Decolonizing Global Surgery

By bringing health professionals across a variety of disciplines together, we are able to share strategies and create solutions for improving surgical care to these under-serviced regions. The Bethune Round Table 2022 took place virtually, June 16 – 19 and was hosted by BGSC,in co-operation with the Canadian Network for International Surgery. The theme for the BRT 2022 was “Decolonizing Global Surgery”.

The conference program consisted of 28 panelists and speakers and 98 abstracts (46 podium presentations and 52 posters) touching upon diverse aspects of global surgery including women in surgery, indigenous health, and sustainability in global partnerships. All sessions were recorded, including abstracts. All the abstracts presented are contained within this document.

The magnitude and perceived reasons for childhood cancer treatment abandonment in Ethiopia: from health care providers’ perspective

Background
Treatment abandonment is one of major reasons for childhood cancer treatment failure and low survival rate in low- and middle-income countries. Ethiopia plans to reduce abandonment rate by 60% (2019–2023), but baseline data and information about the contextual risk factors that influence treatment abandonment are scarce.

Methods
This cross-sectional study was conducted from September 5 to 22, 2021, on the three major pediatric oncology centers in Ethiopia. Data on the incidence and reasons for treatment abandonment were obtained from healthcare professionals. We were unable to obtain data about the patients’ or guardians’ perspective because the information available in the cancer registry was incomplete to contact adequate number of respondents. We used a validated, semi-structured questionnaire developed by the International Society of Pediatric Oncology Abandonment Technical Working Group. We included all (N = 38) health care professionals (physicians, nurses, and social workers) working at these centers who had more than one year of experience in childhood cancer service provision (a universal sampling and 100% response rate).

Results
The perceived mean abandonment rate in Ethiopia is 34% (SE 2.5%). The risk of treatment abandonment is dependent on the type of cancer (high for bone sarcoma and brain tumor), the phase of treatment and treatment outcome. The highest risk is during maintenance and treatment failure or relapse for acute lymphoblastic leukemia, and during pre- or post-surgical phase for Wilms tumor and bone sarcoma. The major influencing risk factors in Ethiopia includes high cost of care, low economic status, long travel time to treatment centers, long waiting time, belief in the incurability of cancer and poor public awareness about childhood cancer.

Conclusions
The perceived abandonment rate in Ethiopia is high, and the risk of abandonment varies according to the type of cancer, phase of treatment or treatment outcome. Therefore, mitigation strategies to reduce the abandonment rate should include identifying specific risk factors and prioritizing strategies based on their level of influence, effectiveness, feasibility, and affordability.

Breast cancer in a teenage girl with BRCA mutation: A case report from a low middle-income country

Introduction
A staggering majority of pediatric breast masses are benign (mostly fibroadenoma) and so a biopsy is not readily performed as it can potentially lead to a future breast disfigurement. However, this should not be standard practice as this can lead to a delayed diagnosis, and hence, the treatment of pediatric breast cancer (BC); this was also seen in our patient’s scenario.

Case history
Here, we report the case of the youngest known breast cancer patient in Pakistan, a 15-year-old girl. The right-sided breast lump which was diagnosed clinically as a fibroadenoma later turned out to be stage IIb pT3N0M0 metaplastic breast carcinoma with BRCA1 positivity and mutations in SMARCA4. Being young and unmarried, the patient and her family decided to opt for breast-conserving surgery with high-risk surveillance for breast and ovaries.

Discussion
We believe that prophylactic surgeries can be delayed with strict surveillance and thorough counseling. As pediatric BC is linked to a less favorable prognosis, every young patient diagnosed with breast cancer and their family should undergo genetic testing. BC management should be handled by specialists in the field and doctors should be trained for initial diagnostics and timely referral of patients.

Conclusion
It is important to improve our understanding of genetic predisposition and testing in lower-middle-income countries. Considering the changing global trends, we suggest that the utilization of genetic services is direly needed to improve preventative care for at-risk individuals with breast and other cancers.

Breast Cancer in Asia: Incidence, Mortality, Early Detection, Mammography Programmes, and Risk-based Screening Initiatives

Close to half (45.4%) of 2.3 million breast cancers (BC) diagnosed in 2020 were from Asia. While the burden of breast cancer has been examined on the level of broad geographic regions, literature on more in-depth coverage of the individual countries and subregions of the Asian continent is lacking. This review examines the breast cancer burden in 47 Asian countries. Breast cancer screening guidelines and risk-based screening initiatives are discussed.