Improving access to safe, quality surgical care for gynecologic cancers through capacity-building interventions in low- and middle-income countries: A scoping review.

BACKGROUND: Following the launch of the World Health Organization's Strategy to accelerate the elimination of cervical cancer, diagnosis is expected to increase, especially in low- and middle-income countries (LMICs). A well-integrated surgical system is critical to treat cervical cancer. Two major approaches have been employed to build human capacity: task-sharing and training of gynecologic oncologists (GynOncs). OBJECTIVES: This review aimed to explore existing literature on capacity-building for surgical management of early-stage gynecologic cancers. SEARCH STRATEGY: The search strategy was registered on Open Science Framework (doi 10.17605/OSF.IO/GTRCB) and conducted on OVID Medline, Embase, Global Index Medicus, and Web of Science. Search results were exported and screened in COVIDENCE. SELECTION CRITERIA: Studies published in English, Spanish, French, and/or Portuguese conducted in LMIC settings evaluating capacity building, task-sharing, or outcomes following operation by subspecialists compared to specialists were included. DATA COLLECTION AND ANALYSIS: Results were synthesized using narrative synthesis approach with emergence of key themes by frequency. MAIN RESULTS: The scoping review identified 18 studies spanning our themes of interest: capacity building, subspecialized versus non-subspecialized care, and task-shifting/-sharing. CONCLUSIONS: A multilayered approach is critical to achieve the WHO Strategy to Eliminate Cervical Cancer. Capacity-building and task-sharing programs demonstrate encouraging results to meet this need; nevertheless, a standardized methodology is needed to evaluate these programs, their outcomes, and cost-effectiveness.

Financial Toxicity Among Patients With Breast Cancer Worldwide: A Systematic Review and Meta-analysis.

Importance: Financial toxicity (FT) is the negative impact of cost of care on financial well-being. Patients with breast cancer are at risk for incurring high out-of-pocket costs given the long-term need for multidisciplinary care and expensive treatments. Objective: To quantify the FT rate of patients with breast cancer and identify particularly vulnerable patient populations nationally and internationally. Data Sources: A systematic review and meta-analysis were conducted. Four databases-Embase, PubMed, Global Index Medicus, and Global Health (EBSCO)-were queried from inception to February 2021. Data analysis was performed from March to December 2022. Study Selection: A comprehensive database search was performed for full-text, English-language articles reporting FT among patients with breast cancer. Two independent reviewers conducted study screening and selection; 462 articles underwent full-text review. Data Extraction and Synthesis: A standardized data extraction tool was developed and validated by 2 independent authors; study quality was also assessed. Variables assessed included race, income, insurance status, education status, employment, urban or rural status, and cancer stage and treatment. Pooled estimates of FT rates and their 95% CIs were obtained using the random-effects model. Main Outcomes and Measures: FT was the primary outcome and was evaluated using quantitative FT measures, including rate of patients experiencing FT, and qualitative FT measures, including patient-reported outcome measures or patient-reported severity and interviews. The rates of patients in high-income, middle-income, and low-income countries who incurred FT according to out-of-pocket cost, income, or patient-reported impact of expenditures during breast cancer diagnosis and treatment were reported as a meta-analysis. Results: Of the 11 086 articles retrieved, 34 were included in the study. Most studies were from high-income countries (24 studies), and the rest were from low- and middle-income countries (10 studies). The sample size of included studies ranged from 5 to 2445 people. There was significant heterogeneity in the definition of FT. FT rate was pooled from 18 articles. The pooled FT rate was 35.3% (95% CI, 27.3%-44.4%) in high-income countries and 78.8% (95% CI, 60.4%-90.0%) in low- and middle-income countries. Conclusions and Relevance: Substantial FT is associated with breast cancer treatment worldwide. Although the FT rate was higher in low- and middle-income countries, more than 30% of patients in high-income countries also incurred FT. Policies designed to offset the burden of direct medical and nonmedical costs are required to improve the financial health of vulnerable patients with breast cancer.