New Frontiers for Fairer Breast Cancer Care in a Globalized World

In early 2020, the book “Breast cancer: Global Quality Care” was published by Oxford University Press. In the year since then, publications, interviews (by ecancer), presentations, webinars, and virtual congress have been organized to disseminate further the main message of the project: “A call for Fairer Breast Cancer Care for all Women in a Globalized World.” Special attention is paid to increasing the “value-based healthcare” putting the patient in the center of the care pathway and sharing information on high-quality integrated breast cancer care. Specific recommendations are made considering the local resource facilities. The multidisciplinary breast conference is considered “the jewel in the crown” of the integrated practice unit, connecting multiple specializations and functions concerned with patients with breast cancer. Management and coordination of medical expertise, facilities, and their interfaces are highly recommended. The participation of two world-leading cancer research programs, the CONCORD program and Breast Health Global Initiative, in this project has been particularly important. The project is continuously under review with feedback from the faculty. The future plan is to arrive at an openaccess publication that is freely available to all interested people. This project is designed to help ease the burden and suffering of women with breast cancer
across the glob

Decentralization and Regionalization of Surgical Care as a Critical Scale-up Strategy in Low- and Middle-Income Countries; Comment on “Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries

As global attention to improve the quality, safety and access to surgical care in low- and middle-income countries (LMICs) increases, the need for evidence-based strategies to reliably scale-up the quality and quantity of surgical services becomes ever more pertinent. Iversen et al discuss the optimal distribution of surgical services, whether through decentralization or regionalization, and propose a strategy that utilizes the dimensions of acuity, complexity and prevalence of surgical conditions to inform national priorities. Proposed expansion of this strategy to encompass levels of scale-up prioritization is discussed in this commentary. The decentralization of emergency obstetric services in LMICs shows promising results and should be further explored. The dearth of evidence of regionalization in LMICs, on the other hand, limits extrapolation of lessons learned. Nevertheless, principles from the successful regionalization of certain services such as trauma care in high-income countries (HICs) can be adapted to LMIC settings and can provide the backbone for innovation in service delivery and safety.

A comparison of outcome measures used to report clubfoot treatment with the Ponseti method: results from a cohort in Harare, Zimbabwe.

BACKGROUND:
There are various established scoring systems to assess the outcome of clubfoot treatment after correction with the Ponseti method. We used five measures to compare the results in a cohort of children followed up for between 3.5 to 5 years.

METHODS:
In January 2017 two experienced physiotherapists assessed children who had started treatment between 2011 and 2013 in one clinic in Harare, Zimbabwe. The length of time in treatment was documented. The Roye score, Bangla clubfoot assessment tool, the Assessing Clubfoot Treatment (ACT) tool, proportion of relapsed and of plantigrade feet were used to assess the outcome of treatment in the cohort. Inter-observer variation was calculated for the two physiotherapists. A comparative analysis of the entire cohort, the children who had completed casting and the children who completed more than two years of bracing was undertaken. Diagnostic accuracy was calculated for the five measures and compared to full clinical assessment (gold standard) and whether referral for further intervention was required for re-casting or surgical review.

RESULTS:
31% (68/218) of the cohort attended for examination and were assessed. Of the children who were assessed, 24 (35%) had attended clinic reviews for 4-5 years, and 30 (44%) for less than 2 years. There was good inter-observer agreement between the two expert physiotherapists on all assessment tools. Overall success of treatment varied between 56 and 93% using the different outcome measures. The relapse assessment had the highest unnecessary referrals (19.1%), and the Roye score the highest proportion of missed referrals (22.7%). The ACT and Bangla score missed the fewest number of referrals (7.4%). The Bangla score demonstrated 79.2% (95%CI: 57.8-92.9%) sensitivity and 79.5% (95%CI: 64.7-90.2%) specificity and the ACT score had 79.2% (95%CI: 57.8-92.9%) sensitivity and 100% (95%CI: 92-100%) specificity in predicting the need for referral.

CONCLUSION:
At three to five years of follow up, the Ponseti method has a good success rate that improves if the child has completed casting and at least two years of bracing. The ACT score demonstrates good diagnostic accuracy for the need for referral for further intervention (specialist opinion or further casting). All tools demonstrated good reliability.