The Symptom Burden and Quality of Life in Cancer Patients in the Gaza Strip, Palestine: A Cross-Sectional Study

Objectives
Cancer is the second leading cause of death in the Gaza Strip, Palestine, but there is an absence of evidence systematically assessing symptom burden and quality of life (QoL) using validated tools. Our objective was to assess associations between socio-demographic and disease-related characteristics, symptom burden and QoL in a sample of cancer patients accessing outpatient services in the Gaza Strip.

Design
A cross-sectional, descriptive survey using interviews and medical record review involving patients with cancer accessing oncology outpatient services at Al Rantisi Hospital and European Gaza Hospital (EGH) in the Gaza Strip was employed. Socio-demographic and disease-related data, the Lebanese version of the Memorial Symptom Assessment Scale (MSAS-Leb), and the Arabic version of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30) were collected. Multiple linear regression was used to judge the relative influence of determinants of QoL.

Results
Of 414 cancer patients approached, 385 patients consented to participation. The majority were women (64.7%) with a mean age of 52 years (SD = 16.7). Common cancer diagnoses were breast (32.2%), haematological (17.9%) and colorectal (9.1%). The median number of symptoms was 10 (IQR 1.5–18.5). Mean overall QoL was 70.5 (SD 19.9) with common physical and psychological symptoms identified. A higher burden of symptoms was associated with marital status, education and income. Limited access to both opioids and psychological support were reported.

Conclusions
A high symptom burden was identified in outpatients with cancer. Increasing provision and access to supportive care for physical and psychological symptoms should be prioritised alongside exploring routine assessment of symptom burden and QoL.

Digital health in oncology in Africa: A scoping review and cross-sectional survey

Background
Low- and middle-income countries, especially in Africa, face a growing cancer burden. Adoption of digital health solutions has the potential to improve cancer care delivery and research in these countries. However, the extent of implementation and the impact of digital health interventions across the cancer continuum in Africa have not been studied.

Aims
To describe the current landscape of digital health interventions in oncology in Africa.

Methods
We conducted a scoping literature review and supplemented this with a survey. Following the PRISMA for Scoping Reviews guidelines, we searched literature in PubMed and Embase for keywords and synonyms for cancer, digital health, and African countries, and abstracted data using a structured form. For the survey, participants were delegates of the 2019 conference of the African Organization for Research and Training in Cancer.

Results
The literature review identified 57 articles describing 40 digital health interventions or solutions from 17 African countries, while the survey included 111 respondents from 18 African countries, and these reported 25 different digital health systems. Six articles (10.5%) reported randomized controlled trials. The other 51 articles (89.5%) were descriptive or quasi-experimental studies. The interventions mostly targeted cancer prevention (28 articles, 49.1%) or diagnosis and treatment (23 articles, 40.4%). Four articles (7.0%) targeted survivorship and end of life, and the rest were cross-cutting. Cervical cancer was the most targeted cancer (25 articles, 43.9%). Regarding WHO classification of digital interventions, most were for providers (35 articles, 61.4%) or clients (13, 22.8%), while the others were for data services or cut across these categories. The interventions were mostly isolated pilots using basic technologies such as SMS and telephone calls for notifying patients of their appointments or results, or for cancer awareness; image capture apps for cervical cancer screening, and tele-conferencing for tele-pathology and mentorship.

Generally positive results were reported, but evaluation focused on structure and process measures such as ease of use, infrastructure requirements, and acceptability of intervention; or general benefits e.g. supporting training and mentorship of providers, communication among providers and clients, and improving data collection and management. No studies evaluated individualized clinical outcomes, and there were no interventions in literature for health system managers although the systems identified in the survey had such functionality, e.g. inventory management. The survey also indicated that none of the digital health systems had all the functionalities for a comprehensive EHR, and major barriers for digital health were initial and ongoing costs, resistance from clinical staff, and lack of fit between the EHR and the clinical workflows.

Conclusion
Digital health interventions in oncology in Africa are at early maturity stages but promising. Barriers such as funding, fit between digital health tools and clinical workflows, and inertia towards technology, shall need to be addressed to allow for advancement of digital health solutions to support all parts of the cancer continuum. Future research should investigate the impact of digital health solutions on long-term cancer outcomes such as cancer mortality, morbidity and quality of lif

Integrative oncology: Addressing the global challenges of cancer prevention and treatment

The increase in cancer incidence and mortality is challenging current cancer care delivery globally, disproportionally affecting low- and middle-income countries (LMICs) when it comes to receiving evidence-based cancer prevention, treatment, and palliative and survivorship care. Patients in LMICs often rely on traditional, complementary, and integrative medicine (TCIM) that is more familiar, less costly, and widely available. However, spheres of influence and tensions between conventional medicine and TCIM can further disrupt efforts in evidence-based cancer care. Integrative oncology provides a framework to research and integrate safe, effective TCIM alongside conventional cancer treatment and can help bridge health care gaps in delivering evidence-informed, patient-centered care. This growing field uses lifestyle modifications, mind and body therapies (eg, acupuncture, massage, meditation, and yoga), and natural products to improve symptom management and quality of life among patients with cancer. On the basis of this review of the global challenges of cancer control and the current status of integrative oncology, the authors recommend: 1) educating and integrating TCIM providers into the cancer control workforce to promote risk reduction and culturally salient healthy life styles; 2) developing and testing TCIM interventions to address cancer symptoms or treatment-related adverse effects (eg, pain, insomnia, fatigue); and 3) disseminating and implementing evidence-based TCIM interventions as part of comprehensive palliative and survivorship care so patients from all cultures can live with or beyond cancer with respect, dignity, and vitality. With conventional medicine and TCIM united under a cohesive framework, integrative oncology may provide citizens of the world with access to safe, effective, evidence-informed, and culturally sensitive cancer care.

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.

Understanding context: A qualitative analysis of the roles of family caregivers of people living with cancer in Vietnam and the implications for service development in low-income settings

Objectives
Research on the needs of family caregivers of people living with cancer remains disproportionately focused in high income contexts. This research gap adds to the critical challenge on global equitable delivery of cancer care. This study describes the roles of family caregivers of people living with cancer in Vietnam and possible implications for intervention development.

Methods
Semi-structured interviews and focus groups with family caregivers (n = 20) and health care providers (n = 22) were conducted in two national oncology hospitals. Findings were verified via workshops with carers (n = 11) and health care professionals (n = 28) in five oncology hospitals representing different regions of Vietnam. Data was analyzed collaboratively by an international team of researchers according to thematic analysis.

Results
Family caregivers in Vietnam provide an integral role in the delivery of inpatient cancer care. In the hospital environment families are responsible for multiple roles including feeding, hydration, changing, washing, moving, wound care and security of personal belongings. Central to this role is primary decision making in terms of treatment and end-of-life care; relaying information, providing nutritional, emotional and financial support. Families are forced to manage severe complications and health care needs with minimal health literacy and limited health care professional input.

Conclusions
Understanding context and the unique roles of family caregivers of people living with cancer is critical in the development of supportive services. As psycho-oncology develops in low and middle income contexts, it is essential that family caregiver roles are of significant importance.

Impact of the COVID-19 pandemic on paediatric patients with cancer in low-income, middle-income and high-income countries: protocol for a multicentre, international, observational cohort study

Introduction
Childhood cancers are a leading cause of non-communicable disease deaths for children around the world. The COVID-19 pandemic may have impacted on global children’s cancer services, which can have consequences for childhood cancer outcomes. The Global Health Research Group on Children’s Non-Communicable Diseases is currently undertaking the first international cohort study to determine the variation in paediatric cancer management during the COVID-19 pandemic, and the short-term to medium-term impacts on childhood cancer outcomes.

Methods and analysis
This is a multicentre, international cohort study that will use routinely collected hospital data in a deidentified and anonymised form. Patients will be recruited consecutively into the study, with a 12-month follow-up period. Patients will be included if they are below the age of 18 years and undergoing anticancer treatment for the following cancers: acute lymphoblastic leukaemia, Burkitt lymphoma, Hodgkin lymphoma, Wilms tumour, sarcoma, retinoblastoma, gliomas, medulloblastomas and neuroblastomas. Patients must be newly presented or must be undergoing active anticancer treatment from 12 March 2020 to 12 December 2020. The primary objective of the study was to determine all-cause mortality rates of 30 days, 90 days and 12 months. This study will examine the factors that influenced these outcomes. χ2 analysis will be used to compare mortality between low-income and middle-income countries and high-income countries. Multilevel, multivariable logistic regression analysis will be undertaken to identify patient-level and hospital-level factors affecting outcomes with adjustment for confounding factors.

Ethics and dissemination
At the host centre, this study was deemed to be exempt from ethical committee approval due to the use of anonymised registry data. At other centres, participating collaborators have gained local approvals in accordance with their institutional ethical regulations. Collaborators will be encouraged to present the results locally, nationally and internationally. The results will be submitted for publication in a peer-reviewed journal.

Imaging: towards a global solution to overcome the cancer pandemic

In The Lancet Oncology, Hedvig Hricak and colleagues present a wide and rich review of cancer imaging in low-income and middle-income countries (LMICs).1 This Lancet Oncology Commission on medical imaging and nuclear medicine includes an inventory of resources, identification of needs, and a tightly argued call to action.
The UN has defined global health and access to care as a target for sustainable development.2 In the meantime, the burden of cancer is increasing worldwide and is higher in LMICs than in high-income countries (HICs), with these countries experiencing a greater share of global cancer deaths (57·3% for Asia and 7·3% for Africa) than the share of global cancer incidence (48·4% and 5·8%, respectively).3, 4 However, the proportional level of care for cancer remains low in LMICs.
To provide insights on access to imaging, the IMAGINE (the International Atomic Energy Agency Medical imAGIng and Nuclear mEdicine) global resources database was developed. It has allowed demonstration of high disparities between countries and a paucity of imaging resources in LMICs with, for example, one CT scanner for 1 694 000 people in LMICs versus one for 25 000 people in HICs.
Because insufficient or no access to imaging causes delays in diagnosis, cancer survival in LMICs is still worse than in wealthier countries: more people are diagnosed in LMICs when their cancer has already spread and more people receive less intensive or effective treatment than in HICs. Hence, imaging is an essential step towards staging and better cancer care. Surgical, chemotherapy, and radiotherapy management cannot be optimised without an appropriate imaging plan. Like previous studies,5, 6 the present analysis reveals the potential benefits of scaling up imaging modalities in cancer management by improving 5-year survival.
Hricak and colleagues show the synergy between imaging, treatment, and quality of care for cancer management, and the individual effects are not additive.3, 7 Their microsimulation model demonstrated that simultaneous expansion of imaging, treatment, and quality of care would avert 9 549 500 deaths worldwide between 2020 and 2030, but four times fewer deaths (2 463 500) would be averted with the scale-up of imaging alone. Earlier diagnosis and optimal staging of cancer are efficient8 because treatment for earlier cancer stages is more effective and less costly than treatment for advanced or metastatic disease.
Hricak and colleagues advocate for an integrated cancer care management approach to avoid fragmented or incomplete delivery of care. The provision of affordable and comprehensive cancer care, including imaging, in LMICs will be most effectively and efficiently accomplished with a coordinated and global coalition (involving governments, civil society, patients, health-care professionals, professional associations, researchers, funders, international agencies, private sector, and innovators) to scale up targeted and strategic investments.
Now is the right time for LMICs to increase their use of medical imaging and nuclear medicine.

Effectiveness of interventions for improving timely diagnosis of breast and cervical cancers in low and middle-income countries: a systematic review protocol

Introduction
Breast and cervical cancers pose a major public health burden globally, with disproportionately high incidence, morbidity and mortality in low- and middle-income countries (LMICs). The majority of women diagnosed with cancer in LMICs present with late-stage disease, the treatment of which is often costlier and less effective. While interventions to improve the timely diagnosis of these cancers are increasingly being implemented in LMICs, there is uncertainty about their role and effectiveness. The aim of this review is to systematically synthesise available evidence on the nature and effectiveness of interventions for improving timely diagnosis of breast and cervical cancers in LMICs.

Methods and analysis
A comprehensive search of published and relevant grey literature will be conducted. The following electronic databases will be searched: MEDLINE (via PubMed), Cochrane Library, Scopus, CINAHL, Web of Science and the International Clinical Trials Registry Platform (ICTRP). Evidence will be synthesised in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). Two reviewers will independently screen the search outputs, select studies using predefined inclusion criteria and assess each included study for risk of bias. If sufficient data are available and studies are comparable in terms of interventions and outcomes, a meta-analysis will be conducted. Where studies are not comparable and a meta-analysis is not appropriate, a narrative synthesis of findings will be reported.

Ethics and dissemination
As this will be a systematic review of publicly available data, with no primary data collection, it will not require ethical approval. Findings will be disseminated widely through a peer-reviewed publication and forums such as conferences, workshops and community engagement sessions. This review will provide a user-friendly evidence summary for informing further efforts at developing and implementing interventions for addressing delays in breast and cervical cancer diagnosis in LMICs.

Sword of Damocles: application of the ethical principles of resource allocation to essential cancer surgery patients requiring beds in limited supply during the COVID-19 pandemic

As a surge of COVID-19 (coronavirus disease 2019) patients strains the health care systems, shortages of health care professionals and life-saving equipment such as ventilators are forcing hospitals to make difficult decisions [1, 2]. It is critical that these health care systems consider whether non-essential surgical procedures can be delayed to ration medical equipment and interventions. Theatre list shortages occur for many reasons, including lack of beds, lack of ventilators, lack of anaesthetic staff, lack of surgical staff, lack of nursing staff and material shortages (e.g. personal protective equipment). Contributing to resource scarcity is the prolonged intubation many COVID-19 patients require as they recover from pneumonia, often two to three weeks, with several hours spent in the prone position and then, typically, a very slow weaning. During shortages, health care systems must determine how to fairly distribute these scarce resources to patients. Unfortunately, no single distribution framework applies to all shortages. However, general allocation principles for scarce health care resources, grounded in distributive justice and utility, can be applied, although particular rules will differ depending on the circumstances.