Wilms’ tumor in low- and middle-income countries: survey of current practices, challenges, and priorities

Purpose
To identify the current practices and priorities in Wilms’ tumor management for surgeons in low- and middle-income countries (LMICs).

Methods
One hundred thirty-seven pediatric surgeons from 44 countries completed surveys on Wilms’ tumor surgical strategy in LMIC. This survey was distributed through the Global Initiative for Children’s Surgery, Pan-African Pediatric Surgical Association, and Latin American Pediatric Surgical Oncology Group.

Results
Ninety-two respondents (67.2%) participated from 19 lower middle-income countries (43.2%). Twenty-one respondents (15.3%) participated from nine lower income countries (20.5%). Nineteen respondents (13.9%) participated from 13 upper middle-income countries (29.5%). Most providers do not obtain biopsy for suspected Wilms’ tumor (79%). Delayed resection after preoperative chemotherapy is the preferred approach (70%), which providers chose due to protocol (45%), to decrease tumor rupture (22%), and to decrease complications (8%). The providers’ goal was to prevent tumor spillage and upstaging (46%) or to prevent bleeding, complication, or other organ resections (21%). Most surgeons believed that upfront resection increased the risk of tumor spillage (72%).

Conclusion
Providers in LMICs prefer delayed resection after preoperative chemotherapy to reduce the incidence of tumor spillage and upstaging of Wilms’ tumor. An evidence-based guideline tailored to the LMIC context can be developed from these findings.

Evolution of patterns of care for women with cervical cancer in Morocco over a decade

Background
We conducted a Pattern-of-care (POC) study at two premier-most public-funded oncology centers in Morocco to evaluate delays in care continuum and adherence to internationally accepted treatment guidelines of cervical cancer.

Method
Following a systematic sampling method, cervical cancer patients registered at Centre Mohammed VI (Casablanca) and Institut National d’Oncologie (Rabat) during 2 months of every year from 2008 to 2017, were included in this retrospective study. Relevant information was abstracted from the medical records.

Results
A total of 886 patients was included in the analysis; 59.5% were at stage I/II. No appreciable change in stage distribution was observed over time. Median access and treatment delays were 5.0 months and 2.3 months, respectively without any significant temporal change. Concurrent chemotherapy was administered to 57.7% of the patients receiving radiotherapy. Surgery was performed on 81.2 and 34.8% of stage I and II patients, respectively. A very high proportion (85.7%) of operated patients received post-operative radiation therapy. Median interval between surgery and initiation of radiotherapy was 3.1 months. Only 45.3% of the patients treated with external beam radiation received brachytherapy. Radiotherapy was completed within 10 weeks in 77.4% patients. An overall 5-year disease-free survival (DFS) was observed in 57.5% of the patients – ranging from 66.1% for stage I to 31.1% for stage IV. Addition of brachytherapy to radiation significantly improved survival at all stages. The study has the usual limitations of retrospective record-based studies, which is data incompleteness.

Conclusion
Delays in care continuum need to be further reduced. Increased use of chemoradiation and brachytherapy will improve survival further.

Awareness of colorectal cancer signs and symptoms: a national cross-sectional study from Palestine

Background: In low-resource settings, the awareness level of colorectal cancer (CRC) signs and symptoms plays a crucial role in early detection and treatment. This study examined the public awareness level of CRC signs and symp‑ toms in Palestine and investigated the factors associated with good awareness.
Methods: This was a national cross-sectional study conducted at hospitals, primary healthcare centers, and public spaces in 11 governorates across Palestine between July 2019 and March 2020. A translated-into-Arabic version of the validated bowel cancer awareness measure (BoCAM) was utilized to assess the awareness level of CRC signs and symptoms. For each correctly identifed CRC sign/symptom, one point was given. The total score (ranging from 0 to12) was calculated and categorized into three categories based on the number of symptoms recognized: poor (0 to 4), fair (5 to 8), and good awareness (9 to 12).
Results: Of 5254 approached, 4877 participants completed the questionnaire (response rate=92.3%). A total of 4623 questionnaires were included in the analysis; 1923 were from the Gaza Strip and 2700 from the West Bank and Jerusalem (WBJ). Participants from the Gaza Strip were younger, gained lower monthly income, and had less chronic diseases than participants in the WBJ The most frequently identifed CRC sign/symptom was ‘lump in the abdomen’ while the least was ‘pain in the back passage’. Only 1849 participants (40.0%, 95% CI: 39.0%-41.0%) had a good awareness level of CRC signs/symptoms. Participants living in the WBJ were more likely to have good awareness than participants living in the Gaza Strip (42.2% vs. 37.0%; p=0.002). Knowing someone with cancer (OR=1.37, 95% CI: 1.21–1.55; p<0.001) and visiting hos‑ pitals (OR=1.46, 95% CI: 1.25–1.70; p<0.001) were both associated with higher likelihood of having good awareness. However, male gender (OR=0.80, 95% CI: 0.68–0.94; p=0.006) and following a vegetarian diet (OR=0.59, 95% CI: 0.48–0.73; p<0.001) were both associated with lower likelihood of having good awareness.
Conclusion: Less than half of the study participants had a good awareness level of CRC signs and symptoms. Future education interventions are needed to improve public awareness of CRC in Palestin

The role of telepathology in diagnosis of premalignant and malignant cervical lesions Implementation at a tertiary hospital in Northern Tanzania

Introduction
Adequate and timely access to pathology services is a key to scale up cancer control, however, there is an extremely shortage of pathologists in Tanzania. Telepathology (scanned images microscopy) has the potential to increase access to pathology services and it is increasingly being employed for primary diagnosis and consultation services. However, the experience with the use of telepathology in Tanzania is limited. We aimed to investigate the feasibility of using scanned images for primary diagnosis of pre-malignant and malignant cervical lesions by assessing its equivalency to conventional (glass slide) microscopy in Tanzania.

Methods
In this laboratory-based study, assessment of hematoxylin and eosin stained glass slides of 175 cervical biopsies were initially performed conventionally by three pathologists independently. The slides were scanned at x 40 and one to three months later, the scanned images were reviewed by the pathologists in blinded fashion. The agreement between initial and review diagnoses across participating pathologists was described and measured using Cohen’s kappa coefficient (κ).

Results
The overall concordance of diagnoses established on conventional microscopy compared to scanned images across three pathologists was 87.7%; κ = 0.54; CI (0.49–0.57).The overall agreement of diagnoses established by local pathologist on conventional microscopy compared to scanned images was 87.4%; κ = 0.73; CI (0.65–0.79). The concordance of diagnoses established by senior pathologist compared to local pathologist on conventional microscopy and scanned images was 96% and 97.7% respectively. The inter-observer agreement (κ) value were 0.93, CI (0.87–1.00) and 0.94, CI (0.88–1.00) for conventional microscopy and scanned images respectively.

Conclusions
All κ coefficients expressed good intra- and inter-observer agreement, suggesting that telepathology is sufficiently accurate for primary diagnosis in surgical pathology. The discrepancies in interpretation of pre-malignant lesions highlights the importance of p16 immunohistochemistry in definitive diagnosis in these lesions. Sustainability factors including hardware and internet connectivity are essential components to be considered before telepathology may be deemed suitable for widely use in Tanzania.

Cancer Groundshot: Building a Robust Cancer Control Platform in Addition To Launching the Cancer Moonshot

Cancer Groundshot is a philosophy that calls for prioritization of strategies in global cancer control. The underlying principle of Cancer Groundshot is that one must ensure access to interventions that are already proven to work before focusing on the development of new interventions. In this article, we discuss the philosophy of Cancer Groundshot as it pertains to priorities in cancer care and research in low- and middle-income countries and the utility of technology in addressing global cancer disparities; we also address disparities seen in high-income countries. The oncology community needs to realign our priorities and focus on improving access to high-value cancer control strategies, rather than allocating resources primarily to the development of technologies that provide only marginal gains at a high cost. There are several “low-hanging fruit” actions that will improve access to quality cancer care in low- and middle-income countries and in high-income countries. Worldwide, cancer morbidity and mortality can be averted by implementing highly effective, low-cost interventions that are already known to work, rather than investing in the development of resource-intensive interventions to which most patients will not have access (i.e., we can use Cancer Groundshot to first save more lives before we focus on the “moonshots”).

Safe and Standard Thyroid Cancer Surgery, or Lack Thereof: Patterns and Correlates of Patient Referral to Tertiary Care Centre for Revision Thyroid Surgery in a LMIC

Background A surgeon’s characteristics such as volume and practice setup are essential elements in outcome of thyroid cancer. However, little information is available from the developing world regarding qualities of primary surgeon, such as level of knowledge, skill, and proper documentation while referring to higher center.

Methods Records of 164 patients of differentiated thyroid cancer (DTC) from January 1990 to December 2018 undergoing revision thyroid surgery following primary surgery elsewhere were retrospectively analyzed.

Results Out of 164 patients with postoperative diagnosis of DTC, referral patterns were as follows: low volume (LV) to high volume (HV) (n = 120, 73.2%), followed by HV to HV (n = 44, 26.8%). The primary surgery assessed by the extent of residual disease was in agreement with the documentation in only 55%. The type of thyroidectomy performed was not mentioned in 9.8%. The status of the parathyroid glands was mentioned only in 15.8% and recurrent laryngeal nerve in 12.2%. Less than recommended surgery was performed in 52.5% patients. Despite less than recommended surgery, 44.5% patients were directly referred for radioactive iodine ablation (RAIA). Thirty two percent patients were referred for RAIA after hemithyroidectomy. Central or lateral compartment lymphadenectomy, even after indication, was less likely at LV centers (risk ratio [RR], 0.71; 95% confidence interval [CI], 0.64–0.77). Similarly, for DTC patients, the relationship between LV center surgery and subsequent referral for RAIA was RR, 0.71 (95% CI, 0.48–1.02).

Conclusions Most patients referred from LV surgeons are less likely to have proper thyroidectomy, have inadequate documentation of the primary surgery, and are referred for RAIA after less than total thyroidectomy. Our study highlights the lacunae in the approach to and understanding of thyroid cancer surgery by secondary care physicians in our country. We believe that there is an urgent necessity of educational reform and training to rectify this problem.

Burden and trend of colorectal cancer in 54 countries of Africa 2010–2019: a systematic examination for Global Burden of Disease

Background
Colorectal cancer plays significant role in morbidity, mortality and economic cost in Africa.

Objective
To investigate the burden and trends of incidence, mortality, and disability-adjusted life-years (DALYs) of colorectal cancer in Africa from 2010 to 2019.

Methods
This study was conducted according to Global Burden of Disease (GBD) 2019 analytic and modeling strategies. The recent GBD 2019 study provided the most updated and compressive epidemiological evidence of cancer incidence, mortality, years lived with disability (YLDs), years of life lost (YLLs), and DALYs.

Results
In 2019, there were 58,000 (95% UI: 52,000–65,000), 49,000 (95% UI: 43,000–54,000), and 1.3 million (95% UI: 1.14–1.46) incident cases, deaths and DALYs counts of colorectal cancer respectively in Africa. Between 2010 and 2019, incidence cases, death, and DALY counts of CRC were significantly increased by 48% (95% UI: 34–62%), 41% (95% UI: 28–55%), and 41% (95% UI: 27–56%) respectively. Change of age-standardised rates of incidence, death and DALYs were increased by 11% (95% UI: 1–21%), 6% (95% UI: − 3 to 16%), and 6% (95% UI: − 5 to 16%) respectively from 2010 to 2019. There were marked variations of burden of colorectal cancer at national level from 2010 to 2019 in Africa.

Conclusion
Increased age-standardised death rate and DALYs of colorectal cancer indicates low progress in CRC standard care-diagnosis and treatment, primary prevention of modifiable risk factors and implementation of secondary prevention modality. This serious effect would be due to poor cancer infrastructure and policy, low workforce capacity, cancer center for diagnosis and treatment, low finical security and low of universal health coverage in Africa.

Cervical cancer therapies: Current challenges and future perspectives

Cervical cancer is the fourth most common female cancer worldwide and results in over 300 000 deaths globally. The causative agent of cervical cancer is persistent infection with high-risk subtypes of the human papillomavirus and the E5, E6 and E7 viral oncoproteins cooperate with host factors to induce and maintain the malignant phenotype. Cervical cancer is a largely preventable disease and early-stage detection is associated with significantly improved survival rates. Indeed, in high-income countries with established vaccination and screening programs it is a rare disease. However, the disease is a killer for women in low- and middle-income countries who, due to limited resources, often present with advanced and untreatable disease. Treatment options include surgical interventions, chemotherapy and/or radiotherapy either alone or in combination. This review describes the initiation and progression of cervical cancer and discusses in depth the advantages and challenges faced by current cervical cancer therapies, followed by a discussion of promising and efficacious new therapies to treat cervical cancer including immunotherapies, targeted therapies, combination therapies, and genetic treatment approaches.

Disadvantaged Subgroups Within the Global Head and Neck Cancer Population: How Can We Optimize Care?

Within the global head and neck cancer population, there are subgroups of patients with poorer cancer outcomes independent from tumor characteristics. In this article, we review three such groups. The first group comprises patients with nasopharyngeal cancer in low- and middle-income countries where access to high-volume, well-resourced radiotherapy centers is limited. We discuss a recent study that is aiming to improve outcomes through the instigation of a comprehensive radiotherapy quality assurance program. The second group comprises patients with low socioeconomic status in a high-income country who experience substantial financial toxicity, defined as financial hardship for patients due to health care costs. We review causes and consequences of financial toxicity and discuss how it can be mitigated. The third group comprises older patients who may poorly tolerate and not benefit from intensive standard-of-care treatment. We discuss the role of geriatric assessment, particularly in relation to the use of chemotherapy. Through better recognition and understanding of disadvantaged groups within the global head and neck cancer population, we will be better placed to instigate the necessary changes to improve outcomes and quality of life for patients with head and neck cancer.

The role of telepathology in diagnosis of pre-malignant and malignant cervical lesions: Implementation at a tertiary hospital in Northern Tanzania

Introduction
Adequate and timely access to pathology services is a key to scale up cancer control, however, there is an extremely shortage of pathologists in Tanzania. Telepathology (scanned images microscopy) has the potential to increase access to pathology services and it is increasingly being employed for primary diagnosis and consultation services. However, the experience with the use of telepathology in Tanzania is limited. We aimed to investigate the feasibility of using scanned images for primary diagnosis of pre-malignant and malignant cervical lesions by assessing its equivalency to conventional (glass slide) microscopy in Tanzania.

Methods
In this laboratory-based study, assessment of hematoxylin and eosin stained glass slides of 175 cervical biopsies were initially performed conventionally by three pathologists independently. The slides were scanned at x 40 and one to three months later, the scanned images were reviewed by the pathologists in blinded fashion. The agreement between initial and review diagnoses across participating pathologists was described and measured using Cohen’s kappa coefficient (κ).

Results
The overall concordance of diagnoses established on conventional microscopy compared to scanned images across three pathologists was 87.7%; κ = 0.54; CI (0.49–0.57).The overall agreement of diagnoses established by local pathologist on conventional microscopy compared to scanned images was 87.4%; κ = 0.73; CI (0.65–0.79). The concordance of diagnoses established by senior pathologist compared to local pathologist on conventional microscopy and scanned images was 96% and 97.7% respectively. The inter-observer agreement (κ) value were 0.93, CI (0.87–1.00) and 0.94, CI (0.88–1.00) for conventional microscopy and scanned images respectively.

Conclusions
All κ coefficients expressed good intra- and inter-observer agreement, suggesting that telepathology is sufficiently accurate for primary diagnosis in surgical pathology. The discrepancies in interpretation of pre-malignant lesions highlights the importance of p16 immunohistochemistry in definitive diagnosis in these lesions. Sustainability factors including hardware and internet connectivity are essential components to be considered before telepathology may be deemed suitable for widely use in Tanzania.