Dataset evaluating the treatment timeliness of cervical cancer in Zambia

Cervical cancer is the fourth most common cancer diagnosed among women globally. Effective screening routines and early detection are vital in reducing its disease burden and mortality. Several factors can influence the timely detection and treatment of cervical cancer, especially in low middle-income countries where the burden of this disease is highest. The data presented in this paper relates to the research article “Cervical cancer diagnosis and treatment delays in the developing world: Evidence from a hospital-based study in Zambia”. The raw and analysed data include the studied patients’ social demographic factors, clinical data concerning the stage and histological subtype of cancer, dates at which the various activities within the cancer treatment pathway occurred and delays to definitive treatment of cervical cancer at Zambia’s only cancer treatment facility. Detailing delays to the treatment of cervical cancer allows recognition of specific points in the cancer treatment pathway requiring intervention to effectively improve cancer care and reduce the morbidity and mortality associated with the disease.

Cervical cancer diagnosis and treatment delays in the developing world: Evidence from a hospital-based study in Zambia

Expedited diagnostic processes for all suspected cervical cancer cases remain essential in the effort to improve clinical outcomes of the disease. However, in some developing countries like Zambia, there is paucity of data that assesses factors influencing diagnostic and treatment turnaround time (TAT) and other metrics vital for quality cancer care. We conducted a retrospective hospital-based study at the Cancer Diseases Hospital (CDH) for cervical cancer cases presenting to the facility between January 2014 and December 2018. Descriptive statistics were used to summarize demographic characteristics while a generalized linear model of the negative binomial was used to assess determinants of overall TAT. Our study included 2121 patient case files. The median age was 49 years (IQR: ±17) and most patients (n=634, 31%) were aged between 41–50 years. The International Federation of Gynaecology and Obstetrics (FIGO) Cancer stage II (n =941, 48%) was the most prevalent while stage IV (n=103, 5.2%) was the least. The average diagnostic TAT in public laboratories was 1.48 (95%CI: 1.21–1.81) times longer than in private laboratories. Furthermore, referral delay was 55 days (IQR: 24–152) and the overall TAT (oTAT) was 110 days (IQR: 62–204). The age of the patient, HIV status, stage of cancer and histological subtype did not influence oTAT while marital status influenced oTAT. The observed longer oTAT may increase irreversible adverse health outcomes among cervical cancer patients. There is a need to improve cancer care in Zambia through improved health expenditure especially in public health facilities.

The role of Mitrofanoff appendicovesicostomy in the management of a pelvic fracture distraction defect in a 24- year-old man after multiple failed reconstruction attempts

Failed Pelvic Fracture Distraction Defect repairs present a considerable challenge for management. Re-do urethroplasties for failed repairs are associated with higher recurrence and morbidity rates. The case presented describes a male patient with a pelvic fracture urethral distraction defect (PFUDD) who had undergone multiple failed repairs. The Mitrofanoff appendicovesicostomy was successfully carried out and the patient remains continent to date. The Mitrofanoff appendicovesicostomy is not commonly employed in the management of adult urethral stricture disease. We present our experience with managing a pelvic fracture urethral disruption defect (PFUDD) after multiple failed urethroplasties using a continent catheterisable urinary diversion techniqu

User Experience With Low-Cost Virtual Reality Cancer Surgery Simulation in an African Setting

PURPOSE
Limited access to adequate cancer surgery training is one of the driving forces behind global inequities in surgical cancer care. Affordable virtual reality (VR) surgical training could enhance surgical skills in low- and middle-income settings, but most VR and augmented reality systems are too expensive and do not teach open surgical techniques commonly practiced in these contexts. New low-cost VR can offer skill development simulations relevant to these settings, but little is known about how knowledge is gained and applied by surgeons training and working in specific resource-constrained settings. This study addresses this gap, exploring gynecologic oncology trainee learning and user experience using a low-cost VR simulator to learn to perform an open radical abdominal hysterectomy in Lusaka, Zambia.

METHODS
Eleven surgical trainees rotating through the gynecologic oncology service were sequentially recruited from the University Teaching Hospital in Lusaka to participate in a study evaluating a VR radical abdominal hysterectomy training designed to replicate the experience in a Zambian hospital. Six participated in semi-structured interviews following the training. Interviews were analyzed using open and axial coding, informed by grounded theory.

RESULTS
Simulator participation increased participants’ perception of their surgical knowledge, confidence, and skills. Participants believed their skills transferred to other related surgical procedures. Having clear goals and motivation to improve were described as factors that influenced success.

CONCLUSION
For cancer surgery trainees in lower-resourced settings learning medical and surgical skills, even for those with limited VR experience, low-cost VR simulators may enhance anatomical knowledge and confidence. The VR simulator reinforced anatomical and clinical knowledge acquired through other modalities. VR-enhanced learning may be particularly valuable when mentored learning opportunities are limited.

Surgical service monitoring and quality control systems at district hospitals in Malawi, Tanzania and Zambia: a mixed-methods study

Background In low-income and middle-income countries, an estimated one in three clinical adverse events happens in non-complex situations and 83% are preventable. Poor quality of care also leads to inefficient use of human, material and financial resources for health. Improving outcomes and mitigating the risk of adverse events require effective monitoring and quality control systems.

Aim To assess the state of surgical monitoring and quality control systems at district hospitals (DHs) in Malawi, Tanzania and Zambia.

Methods A mixed-methods cross-sectional study of 75 DHs: Malawi (22), Tanzania (30) and Zambia (23). This included a questionnaire, interviews and visual inspection of operating theatre (OT) registers. Data were collected on monitoring and quality systems for surgical activity, processes and outcomes, as well as perceived barriers.

Results 53% (n=40/75) of DHs use more than one OT register to record surgical operations. With the exception of standardised printed OT registers in Zambia, the register format (often handwritten books) and type of data collected varied between DHs. Monthly reports were seldom analysed by surgical teams. Less than 30% of all surveyed DHs used surgical safety checklists (n=22/75), and <15% (n=11/75) performed surgical audits. 73% (n=22/30) of DHs in Tanzania and less than half of DHs in Malawi (n=11/22) and Zambia (n=10/23) conducted surgical case reviews. Reports of surgical morbidity and mortality were compiled in 65% (n=15/23) of Zambian DHs, and in less than one-third of DHs in Tanzania (n=9/30) and Malawi (n=4/22). Reported barriers to monitoring and quality systems included an absence of formalised guidelines, continuous training opportunities as well as inadequate accountability mechanisms.

Conclusions Surgical monitoring and quality control systems were not standard among sampled DHs. Improvements are needed in standardisation of quality measures used; and in ensuring data completeness, analysis and utilisation for improving patient outcomes.

Silver linings: a qualitative study of desirable changes to cancer care during the COVID-19 pandemic

Introduction: Public health emergencies and crises such as the current COVID-19 pandemic can accelerate innovation and place renewed focus on the value of health interventions. Capturing important lessons learnt, both positive and negative, is vital. We aimed to document the perceived positive changes (silver linings) in cancer care that emerged during the COVID-19 pandemic and identify challenges that may limit their long-term adoption.

Methods: This study employed a qualitative design. Semi-structured interviews (n = 20) were conducted with key opinion leaders from 14 countries. The participants were predominantly members of the International COVID-19 and Cancer Taskforce, who convened in March 2020 to address delivery of cancer care in the context of the pandemic. The Framework Method was employed to analyse the positive changes of the pandemic with corresponding challenges to their maintenance post-pandemic.

Results: Ten themes of positive changes were identified which included: value in cancer care, digital communication, convenience, inclusivity and cooperation, decentralisation of cancer care, acceleration of policy change, human interactions, hygiene practices, health awareness and promotion and systems improvement. Impediments to the scale-up of these positive changes included resource disparities and variation in legal frameworks across regions. Barriers were largely attributed to behaviours and attitudes of stakeholders.

Conclusion: The COVID-19 pandemic has led to important value-based innovations and changes for better cancer care across different health systems. The challenges to maintaining/implementing these changes vary by setting. Efforts are needed to implement improved elements of care that evolved during the pandemic.

Factors Associated with Waiting Time for Patients Scheduled for Elective Surgical Procedures at the University Teaching Hospital (UTH) in Zambia

Background: Measuring waiting times for elective surgical procedures is vital because it is considered as a proxy for evaluating the quality of surgical care. The aim was to examine waiting time for elective surgery at the University Teaching Hospital (UTH) in Zambia, looking at both patient and facility factors. Methods: This was a crosssectional study utilizing data from medical records of patients who were scheduled for elective surgical procedures at the UTH, between 1st December 2018 and 31st January 2019. The Weibull regression model was used to examine waiting times from admission to surgery using patient profiles and to assess the factors associated with waiting time. Results: During the study period, 182 patients underwent elective surgical procedures. The overall median waiting time was 9 days (interquartile range 4 to – 18 days). Significant differences in waiting time were observed by the surgical unit (log-rank test, p=0.01). Lack of blood products from the blood bank and lack of operating theatre time were significant determinants of longer times (p=0.02, event time ratio [ETR] 2.23), and (p=0.01, ETR 1.96) respectively. Patients from the neuro-surgical unit experienced a waiting time that was 2.72 (p=0.04) times more than patients from other surgical units. Conclusion: We were able to determine waiting times for elective surgical procedures and this can be used to plan for surgery given patient profiles. Additionally, we found that the unavailability of blood products for transfusion and lack of operating theatre time increase waiting time for elective surgery. Ensuring the availability of blood products may reduce waiting time for surgery.

Simulation Based Training in Basic Life Support for Medical and Non-medical Personnel in Resource Limited Settings

Medical and non-medical personnel commonly encounter victims of life threatening injuries inflicted by various causes in diverse settings. More than 90% of global deaths and disability adjusted life-years (DALYs) lost because of injuries reportedly occur in low-income and middle-income countries (LMICs). The degree of readiness and competence to manage victims of accidents is likely to vary among individual care givers for knowledge, skill and confidence which would also depend on their training status. It would thus be justified that training in basic life support and other emergency clinical skills be administered to enhance competences in resuscitating the accident victims. Whatever the scale of a mass casualty incident, the first response will be carried out by members of the local community-not just health care staff and designated emergency workers,but also many ordinary citizens. Therefore, both medical and non-medical personnel should be targeted to receive training in basic life support (BLS). In medical training, the traditional (didactic) approach has been suggested to be an efficient and well-experienced training method while with the advances in technology the use of simulation-based medical training (SBMT) is increasing since SBMT provides a safe and supportive educational setting, so that students can improve their performance without causing adverse clinical outcomes. Similarly, the use of simulation based training in BLS would not only reduce the procedural associated risks but also benefit more participants from the public domain than would be the case if the training was conducted on human subjects. Compared with the developed world set-up simulation based training in resource constrained settings may not be that well established. This paper will therefore seek to examine the role of medical simulation as a necessary advancement and supplementary method of training in basic life support for medical and non-medical personnel in resource limited settings

Minimizing Delays in the Breast Cancer Pathway by Integrating Breast Specialty Care Services at the Primary Health Care Level in Zambia

PURPOSE
In Zambia, more than two-thirds of female patients with breast cancer present with late-stage disease, leading to high mortality rates. Most of the underlying causes are associated with delays in symptom recognition and diagnosis. By implementing breast care specialty services at the primary health care level, we hypothesized that some of the delays could be minimized.

METHODS
In March 2018, we established a breast care specialty clinic for women with symptomatic disease within 1 of the 5 district hospitals in Lusaka. The clinic offers breast self-awareness education, clinical breast examination, breast ultrasound, ultrasound-guided breast biopsy, surgery, referral for chemoradiation, follow-up care, and electronic medical records.

RESULTS
Between March 2018 and April 2019, of 1,790 symptomatic women who presented to the clinic, 176 (10%) had clinical and/or ultrasound indications for histologic evaluation. Biopsy specimens were obtained using ultrasound-guided core-needle procedures, all of which were performed on the same day as the initial visit. Of the 176 women who underwent biopsy, 112 (64%) had pathologic findings compatible with a primary breast cancer, and of these, 42 (37%) were early-stage (stage I/II) disease. Surgery for early-stage cancers was performed at the district hospital within 2 weeks of the time of definitive pathologic diagnosis. Patients with advanced disease were referred to the national cancer center for multimodality therapy, within a similar time frame.

CONCLUSION
Breast care specialty services for symptomatic women were established in a district-level hospital in a resource-constrained setting in Africa. As a result, the following time intervals were minimized: initial presentation and performance of clinical diagnostics; receipt of a definitive pathologic diagnosis and initiation of surgery; receipt of a definitive pathologic diagnosis and referral.

Delivery Mode for Prolonged, Obstructed Labour Resulting in Obstetric Fistula: A Retrospective Review of 4396 Women in East and Central Africa

Objective: To evaluate the mode of delivery and stillbirth rates over time among women with obstetric fistula.

Design: Retrospective record review.

Setting: Tanzania, Uganda, Kenya, Malawi, Rwanda, Somalia, South Sudan, Zambia and Ethiopia.

Population: A total of 4396 women presenting with obstetric fistulas for repair who delivered previously in facilities between 1990 and 2014.

Methods: Retrospective review of trends and associations between mode of delivery and stillbirth, focusing on caesarean section (CS), assisted vaginal deliveries and spontaneous vaginal deliveries.

Main outcome measures: Mode of delivery, stillbirth.

Results: Out of 4396 women with fistula, 3695 (84.1%) delivered a stillborn baby. Among mothers with fistula giving birth to a stillborn baby, the CS rate (overall 54.8%, 2027/3695) rose from 45% (162/361) in 1990-94 to 64% (331/514) in 2010-14. This increase occurred at the expense of assisted vaginal delivery (overall 18.3%, 676/3695), which declined from 32% (115/361) to 6% (31/514).

Conclusions: In Eastern and Central Africa, CS is increasingly performed on women with obstructed labour whose babies have already died in utero. Contrary to international recommendations, alternatives such as vacuum extraction, forceps and destructive delivery are decreasingly used. Unless uterine rupture is suspected, CS should be avoided in obstructed labour with intrauterine fetal death to avoid complications related to CS scars in subsequent pregnancies. Increasingly, women with obstetric fistula add a history of unnecessary CS to their already grim experiences of prolonged, obstructed labour and stillbirth.