Cancer pain control in a Nigerian oncology clinic: treating the disease and not the patient

Introduction: inadequate pain control negatively impacts the quality of life of patients with cancer while potentially affecting the outcome. Proper pain evaluation and management are therefore considered an important treatment goal. This study assessed the prevalence of pain, the prescribing patterns, and the efficacy of pain control measures in cancer patients at the Radiation Oncology Unit of the Lagos University Teaching Hospital, Lagos.
Methods: this was a longitudinal study design recruiting adults attending outpatient clinics. Participants were assessed at initial contact and again following six weeks using the Universal Pain Assessment Tool developed by the UCLA Department of Anaesthesiology.
Results: among the patients reviewed, 34.0% (118 of 347) were at the clinic, referred for initial assessment following primary diagnosis. All respondents had solid tumours; the most common was breast cancer. The prevalence of pain at initial assessment was 85.9% (298 of 347), with over half of respondents, 74.5% (222 of 347) characterising their pain as moderate to severe. Over a quarter, 28.9% (100 of 347) of patients were not asked about their pain by attending physicians, and none of the patients had a pain assessment tool used during evaluation. In 14.4% (43 of 298) of patients, no intervention was received despite the presence of pain. At six weeks review, 31.5% (94 of 298) of patients had obtained no pain relief despite instituted measures.
Conclusion: under-treatment of cancer pain remains a significant weak link in cancer care in (Low-to-middle-income country) LMICs like Nigeria, with a significant contributor being physician under-evaluation and under-treatment of pain. To ensure pain eradication, the treatment process must begin with a thorough evaluation of the patient’s pain, an explicit pain control goal and regular reevaluation

Views from Multidisciplinary Oncology Clinicians on Strengthening Cancer Care Delivery Systems in Tanzania

Background
In response to the increasing burden of cancer in Tanzania, the Ministry of Health Community Development, Gender, Elderly and Children launched National Cancer Treatment Guidelines (TNCTG) in February 2020. The guidelines aimed to improve and standardize oncology care in the country. At Ocean Road Cancer Institute (ORCI), we developed a theory-informed implementation strategy to promote guideline-concordant care. As part of the situation analysis for implementation strategy development, we conducted focus group discussions to evaluate clinical systems and contextual factors that influence guideline-based practice prior to launching of TNCTG.

Methods
In June 2019, three focus group discussions were conducted with a total of 21 oncology clinicians at ORCI, stratified by profession. A discussion guide was used to stimulate dialogue about facilitators and barriers to delivery of guideline concordant care. Discussions were audio recorded, transcribed, translated, and analyzed using thematic framework analysis.

Results
Participants identified factors both within the inner context of ORCI clinical systems and outside of ORCI. Themes within the clinical systems included: capacity and infrastructure, information technology, communication, efficiency and quality of services provided. Contextual factors external to ORCI included: inter-institutional coordination, oncology capacity in peripheral hospitals, public awareness and beliefs, and financial barriers. Participants provided pragmatic suggestions for strengthening cancer care delivery in Tanzania.

Conclusion
Our results highlight several barriers and facilitators within and outside of the clinical systems at ORCI that may affect uptake of the TNCTG. Our findings were used to inform a broader guideline implementation strategy, in effort to improve uptake of the TNCTGs at ORCI.

Moral Distress and Resilience Associated with Cancer Care Priority Setting in a Resource Limited Context

Background
Moral distress and burnout are highly prevalent among oncology clinicians. Research is needed to better understand how resource constraints and systemic inequalities contribute to moral distress in order to develop effective mitigation strategies. Oncology providers in low- and middle-income countries (LMICs) are well positioned to provide insight into the moral experience of cancer care priority setting and expertise to guide solutions.

Methods
Semi-structured interviews were conducted with a purposive sample of 22 oncology physicians, nurses, program leaders, and clinical advisors at a cancer center in Rwanda. Interviews were recorded, transcribed verbatim, and analyzed using the framework method.

Results
Participants identified sources of moral distress at three levels of engagement with resource prioritization: witnessing program-level resource constraints drive cancer disparities, implementing priority setting decisions into care of individual patients, and communicating with patients directly about resource prioritization implications. They recommended individual and organizational level interventions to foster resilience, such as communication skills training and mental health support for clinicians, interdisciplinary team-building, fair procedures for priority setting, and collective advocacy for resource expansion and equity.

Conclusion
This study adds to the current literature an in-depth examination of the impact of resource constraints and inequities on clinicians in a low resource setting. Effective interventions are urgently needed to address moral distress, reduce clinician burnout, and promote well-being among a critical but strained oncology workforce. Collective advocacy is concomitantly needed to address the structural forces that constrain resources unevenly and perpetuate disparities in cancer care and outcomes.

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.

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.

Tele-health and cancer care in the era of COVID-19: New opportunities in low and middle income countries (LMICs)

In the current era of COVID-19 pandemic where at least some degree of social distancing is the norm and hospitals have emerged as hotspots for acquiring the infection, it has become important for oncologists to devise methods of providing care to cancer patients while minimizing patients’ exposure to healthcare settings. In light of the on-going pandemic, it has been recommended that in-patient visits for cancer patients should be substituted by virtual visits and patients should be advised to proceed directly for infusion treatment. Telemedicine and tele-health based interventions have emerged as reasonably practical solutions to these impediments in the delivery of care to cancer patients. Technological advancements have resolved the issue of connectivity for telemedicine even to the remotest places. Teleconsultation is becoming an acceptable alternative for patients and health care providers in this era of information technology. Albeit the challenges that we are facing are diverse and therefore cannot have a singular full proof answer, telemedicine and tele-health based interventions seem to offer promise in effectively complementing our efforts in that direction. Telemedicine is beneficial for both patients and doctors in term to provide quality care without shifting to physical location.