Level of knowledge and practice of female healthcare providers about early detection methods of breast cancer at Debre Tabor Comprehensive Specialised Hospital: a cross-sectional study

Background: Despite the higher mortality rate of breast cancer in low and middle-income countries, the practice of early detection methods is low and the majority of the patients presenting at an advanced stage of the disease need palliative care with low survival rates. Although healthcare providers are the key for practicing early detection methods of breast cancer for themselves and their clients, little is known about their knowledge and practice of early detection methods of breast cancer in Northcentral Ethiopia.

Methods: An institution-based cross-sectional study was conducted among female healthcare providers at Debre Tabor Comprehensive Specialised Hospital. Data were collected using a structured self-administered questionnaire. The data were analysed using SPSS version 23. Descriptive statistics were used to describe the socio-demographic information of participants. Binary and multivariable logistic regression with adjusted odds ratio (AOR) and 95% confidence interval (CI) was used to identify factors associated with the outcome variable. Statistical significance was declared at p 2 years (AOR = 3.2; 95% CI: 1.72, 5.29), history of any breast problem (AOR = 1.4; 95% CI: 1.02, 2.37), family history of breast cancer (AOR = 4.0; 95% CI: 2.58, 15.84), having good knowledge (AOR = 2.9; 95% CI: 1.3, 6.52) and history of comorbidities (AOR = 1.09; 95% CI: 1.09, 3.59) were the factors associated with the practice of breast self-examination.

Conclusion: Our study found that the knowledge and practice of breast cancer early detection methods was low in the study setting. Only less than half of female healthcare providers practiced regular breast self-examination, which suggests the need to provide training for healthcare providers to fill the gap and to promote early detection of breast cancer cases.

Cancer Screening Programs in Low- and Middle-Income Countries: Strategies for Success

Cancer is a leading global health problem and, as of 2020, accounts for 10 million deaths per year.1 The World Health Organization (WHO) estimates that between 30 and 50% of cancer deaths can be prevented by avoiding risk factors, early detection via screening, and proper treatment. The majority of cases occur in low- and middle-income countries (LMIC).2 Despite awareness of the magnitude of this problem by the global health community and the large-scale efforts to implement screening programs, very few programs are successful and, more importantly, sustainable. Although there are several barriers to implementation of a cancer screening program, the critical barriers are lack of awareness and acceptance of the screening programs by the people residing in the specific geographic regions. In the article by Pak et al. entitled Cancer Awareness and Stigma in Rural Assam India: Baseline Survey of the Detect Early and Save Her/Him (DESH) Program, the authors highlight the cultural and psychosocial barriers to cancer screening.3

The DESH program is a well-organized screening program with multiple components that consists of an initial baseline survey followed by implementation of mobile cancer screening and subsequent follow-up of patients regarding final diagnosis and treatment. The DESH program in Assam, India, focuses on breast, oral, and cervical cancers due to the high incidence of these cancers in this region and the availability of validated screening tests. The baseline survey was validated in a smaller cohort (n = 20) of local participants before widespread implementation to nearly 1000 participants. The survey consisted of multiple sections that focused on areas such as awareness of the carcinogenic effects of certain lifestyle choices, i.e., consumption of betel nuts and smoking, spiritual/religious beliefs, stigma around cancer diagnoses, and knowledge about screening programs and local health care facilities. Through this approach, they found that the majority (92.9%) of participants were not aware of cancer screening availability and had never undergone prior screening. Additionally, over 90% of the survey participants reported consumption of betel nuts, but less than half (46.9%) were aware of the carcinogenic effects of betel nuts. Finally, 42–57% of participants reported negative stigma towards cancer diagnosis. Specifically, more than 30% of participants believed that either cancer is a punishment from God or is caused by bad karma and evil spirits. Furthermore, 20% of participants described fear of cancer screening. These results highlight the complex interplay between knowledge gaps, misconceptions, and cancer stigma that could affect the acceptance, and thereby the success, of a screening program.

Taneja et al. identified similar sociocultural barriers regarding cervical cancer screening in India. Specifically, barriers identified included lack of awareness about screening, poor knowledge about initial symptoms, social stigma, cost, and familial obligations. Hence, it is not surprising that only 5% of eligible women have undergone screening for cervical cancer in India, compared with up to 84% in developed countries.4 This is disconcerting since cervical cancer has the potential for prevention and/or cure due to the length of the premalignant and preinvasive period, emphasizing the importance of a population-based screening program. The benefits of an effective screening program for this disease were demonstrated by Sankaranarayanan et al. in a study of over 130,000 healthy women, in which participants were randomly assigned to undergo cervical cancer screening with either human papillomavirus (HPV) testing, cytologic testing, or visual inspection with acetic acid (VIA). Single-round HPV testing was associated with a significantly reduced number of advanced cases [hazard ratio (HR) 0.47, 95% confidence interval (CI) 0.32–0.69] and mortality5 (HR 0.53, 95% CI 0.33–0.83) compared with the control group. The results of this study highlight that implementation of a successful screening program with the right screening test is associated with decreased mortality, even in low-resource settings. However, the main challenge is to screen enough people for the screening program to be effective. The National Cancer Prevention and Control Program launched in 2010 in Morocco, with augmented and expanded infrastructure and considered an exemplar for screening programs in LMIC, had major challenges with uptake of screening and poor participation in early identification of precancerous lesions.

Prevalence and Mortality of Triple-Negative Breast Cancer in West Africa: Biologic and Sociocultural Factors

Key Objective
Triple-negative breast cancer (TNBC) is a malignant breast cancer, lacking targeted therapy, which would benefit from further research to understand its nature and the observed variation in its malignancy between women of differing ancestries. This large-scale systematic literature review examines the current and emerging biologic and nonbiologic factors, which have been shown to influence TNBC disease outcomes among indigenous West African (WA) females while discussing some prospective steps that could be adopted by health care systems for the reduction of this burden.

Knowledge Generated
WA women are the most burdened populations in relation to TNBC. Biologic and economic factors have been shown to significantly influence the TNBC disease outcomes. Women’s education initiatives, specialist training, and accessible health care are needed in WA countries.

Relevance
The determination of WA-specific biologic, cultural, and socioeconomic TNBC factors could align efforts in developing treatment options and physician recommendations to cancer-burdened women.

Research to improve surgical oncological care on the surgical department, Maputo Central Hospital

Purpose: Regarding adequate care for oncological patients, requiring surgical interventions at the Surgical Department of Maputo Central Hospital (MCH), the largest hospital in Mozambique, the aim of those studies, was first to assess the surgical resources, surgical oncology team skills, identify and characterize prevalent cancers treated and general knowledge in oncology and surgical oncology, expecting the development of a comprehensive curriculum in surgical oncology fellowship fit for the Hospital and all Mozambique country. Methods: The study 1, done in 2017, was based on surgeons questionnaire (The Cancer Units Assessment Checklist for low- or middle-income African countries (annex I), visiting the unities (oncology service, ICU, operations room, etc.) collecting information according to the Portuguese-speaking African Countries Assessment of Surgical Oncology Capacity Survey (PSAC-Surgery – annex II). The study 2, done in 2018, by retrospective analysis of individual cancer patient registries of MCH, the prevalent cancers has been identified and characterized (annex IV). And the general knowledge in oncology and surgical oncology, this issue was evaluated by simple test administered anonymously and without prior notice to all surgeons and residents at the Surgical Department (annex V). The domains was about basis of Oncology, Radiotherapy, Pathology, Chemotherapy, Pain management, Surgical oncology and Clinical pathway. The study 3, done in 2019, a three-round modified-Delphi approach was implemented to obtain consensus on surgical oncology training curriculum. The participants were purposefully selected 23 experts in surgical oncology working in Mozambique. In round one, participants answered a questionnaire regarding the content of the curriculum and the timing and venue of training. Draft of the curriculum was produced. In round 2, answers from the first round and the curriculum draft were presented to a purposeful selected sample of nationally recognized experts in oncology and surgical oncology, including members of the Mozambican College of Surgeons and leadership of the Ministry of Health. A final round was carried out to discuss the final version of the training program in surgical oncology with extensive participation of majority of african experts in surgical oncology (Aortic, Maputo). Results: Breast, esophagus and colorectal cancers were the most commonly treated neoplasms in MCH (at Surgical department). A range of technical and resource needs as well as the gaps in knowledge and skills were identified. All surgeons recognized the need to create a training program in oncology at the undergraduate level, specific training for residents and continuing oncological education for general surgeons, to improve the practice of surgical oncology. Basic principles of oncology and basic principles of surgical oncology should be included in the curriculum of surgical residency in Mozambique, a 24-months fellowship in surgical oncology should take place after residency in the surgical field and should occur at Maputo Central Hospital and at comprehensive cancer centers. The final proposal for the program was divided into the following structure: a – theoretical components; b – duration; c – location; d – methodology; e – technical skills in oncology; and f – competency and paid particular attention to the oncological diseases prevalent in Mozambique.

Patterns of care of breast cancer patients in Morocco – A study of variations in patient profile, tumour characteristics and standard of care over a decade

Guided by a national cancer plan (2010–19), Morocco made significant investments in improving breast cancer detection and treatment. A breast cancer pattern-of-care study was conducted to document the socio-demographic profiles of patients and tumour characteristics, measure delays in care, and assess the status of dissemination and impact of state-of-the-art management. The retrospective study conducted among 2120 breast cancer patients registered during 2008–17 at the two premier-most oncology centres (Centre Mohammed VI or CM-VI and Institut National d’Oncologie or INO) also measured temporal trends of the different variables.

Median age (49 years) and other socio-demographic characteristics of the patients remained constant over time. A significant improvement in coverage of the state-financed health insurance scheme for indigent populations was observed over time. Median interval between onset of symptoms and first medical consultation was 6 months with a significant reduction over time. Information on staging and molecular profile were available for more than 90% and 80% of the patients respectively. Approximately 55% of the patients presented at stage I/II and proportion of triple-negative cancers was 16%; neither showing any appreciable temporal variation. Treatment information was available for more than 90% of the patients; 69% received surgery with chemotherapy and/or radiation. Treatment was tailored to stage and molecular profiles, though breast conservation therapy was offered to less than one-fifth. When compared using the EUSOMA quality indicators for breast cancer management, INO performed better than CM-VI. This was reflected in nearly 25% difference in 5-year disease-free survival for early-stage cancers between the centres.

Health system factors that influence diagnostic and treatment intervals in women with breast cancer in sub-Saharan Africa: a systematic review

Background
Breast cancer patients in sub-Saharan Africa experience long time intervals between their first presentation to a health care facility and the start of cancer treatment. The role of the health system in the increasing treatment time intervals has not been widely investigated. This review aimed to identify existing information on health system factors that influence diagnostic and treatment intervals in women with breast cancer in sub-Saharan Africa to contribute to the reorientation of health policies in the region.

Methods
PubMed, ScienceDirect, African Journals Online, Mendeley, ResearchGate and Google Scholar were searched to identify relevant studies published between 2010 and July 2020. We performed a qualitative synthesis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Related health system factors were extracted and classified according to the World Health Organization’s six health system building blocks. The quality of qualitative and quantitative studies was assessed by using the Critical Appraisal Skills Program Quality-Assessment Tool and the National Institute of Health Quality Assessment Tool, respectively. In addition, we used the Confidence in the Evidence from Reviews of Qualitative Research tool to assess the evidence for each qualitative finding.

Results
From 14,184 identified studies, this systematic review included 28 articles. We identified a total of 36 barriers and 8 facilitators that may influence diagnostic and treatment intervals in women with breast cancer. The principal health system factors identified were mainly related to human resources and service delivery, particularly difficulty accessing health care, diagnostic errors, poor management, and treatment cost.

Conclusion
The present review shows that diagnostic and treatment intervals among women with breast cancer in sub-Saharan Africa are influenced by many related health system factors. Policy makers in sub-Saharan Africa need to tackle the financial accessibility to breast cancer treatment by adequate universal health coverage policies and reinforce the clinical competencies for health workers to ensure timely diagnosis and appropriate care for women with breast cancer in this region.

Essential Package of Palliative Care for Women With Cervical Cancer: Responding to the Suffering of a Highly Vulnerable Population

Women with cervical cancer, especially those with advanced disease, appear to experience suffering that is more prevalent, complex, and severe than that caused by other cancers and serious illnesses, and approximately 85% live in low- and middle-income countries where palliative care is rarely accessible. To respond to the highly prevalent and extreme suffering in this vulnerable population, we convened a group of experienced experts in all aspects of care for women with cervical cancer, and from countries of all income levels, to create an essential package of palliative care for cervical cancer (EPPCCC). The EPPCCC consists of a set of interventions, medicines, simple equipment, social supports, and human resources, and is designed to be safe and effective for preventing and relieving all types of suffering associated with cervical cancer. It includes only inexpensive and readily available medicines and equipment, and its use requires only basic training. Thus, the EPPCCC can and should be made accessible everywhere, including for the rural poor. We provide guidance for integrating the EPPCCC into gynecologic and oncologic care at all levels of health care systems, and into primary care, in countries of all income levels.

Global Landscape of Glioblastoma Multiforme Management in the Stupp Protocol Era: Systematic Review Protocol

Background: Glioblastoma multiforme is the most common and aggressive primary adult brain neoplasm. The current standard of care is maximal safe surgical resection, radiotherapy with concomitant temozolomide, followed by adjuvant temozolomide according to the Stupp protocol. Although the protocol is well adopted in high-income countries (HICs), little is known about its adoption in low- and middle-income countries (LMICs). The aim of this study is to describe a protocol design for a systematic review of published studies outlining the differences in GBM management between HICs and LMICs.

Methods: A systematic review will be conducted. MedLine via Ovid, Embase and Global Index Medicus will be searched from inception to date in order to identify the relevant studies. Adult patients (>18 years) with histologically confirmed primary unifocal GBM will be included. Surgical and chemoradiation management of GBM tumours will be considered. Commentaries, original research, non-peer reviewed pieces, opinion pieces, editorials and case reports will be included.

Results: Primary outcomes will include rates of complications, disability-adjusted life years (DALYs), prognosis, progression-free survival (PFS), overall survival (OS) as well as rate of care abandonment and delay. Secondary outcomes will include the presence of neuro-oncology subspecialty training programs.

Discussion: This systematic review will be the first to compare the current landscape of GBM management in HICs and LMICs, highlighting pertinent themes that may be used to optimise treatment in both financial brackets.

Systematic Review Registration: The protocol has been registered on the International Prospective Register of Systematic Reviews (PROSPERO; registration number: CRD42020215843).

Tracking the Workforce 2020-2030: Making the Case for a Cancer Workforce Registry

Existing literature has described the projected increase in cancer incidence and the associated deficiencies in the cancer workforce. However, there is currently a lack of research into the necessary policy and planning steps that can be taken to mitigate this issue. Herein, we review current literature in this space and highlight the importance of implementing oncology workforce registries. We propose the establishment of cancer workforce registries using the WHO Minimum Data Set for Health Workforce Registry by adapting the data set to suit the multidisciplinary nature of the cancer workforce. The cancer workforce registry will track the trends of the workforce, so that evidence can drive decisions at the policy level. The oncology community needs to develop and optimize methods to collect information for these registries. National cancer societies are likely to continue to lead such efforts, but ministries of health, licensing bodies, and academic institutions should contribute and collaborate.

Augmented Package of Palliative Care for Women With Cervical Cancer: Responding to Refractory Suffering

The essential package of palliative care for cervical cancer (EPPCCC), described elsewhere, is designed to be safe and effective for preventing and relieving most suffering associated with cervical cancer and universally accessible. However, it appears that women with cervical cancer, more frequently than patients with other cancers, experience various types of suffering that are refractory to basic palliative care such as what can be provided with the EPPCCC. In particular, relief of refractory pain, vomiting because of bowel obstruction, bleeding, and psychosocial suffering may require additional expertise, medicines, or equipment. Therefore, we convened a group of experienced experts in all aspects of care for women with cervical cancer, and from countries of all income levels, to create an augmented package of palliative care for cervical cancer with which even suffering refractory to the EPPCCC often can be relieved. The package consists of medicines, radiotherapy, surgical procedures, and psycho-oncologic therapies that require advanced or specialized training. Each item in this package should be made accessible whenever the necessary resources and expertise are available.