The every woman study™ low- and middle-income countries edition protocol: A multi-country observational study to assess opportunities and challenges to improving survival and quality of life for women with ovarian cancer.

BACKGROUND: Ovarian cancer is a challenging disease to diagnose and treat effectively with five-year survival rates below 50%. Previous patient experience research in high-income countries highlighted common challenges and opportunities to improve survival and quality of life for women affected by ovarian cancer. However, no comparable data exist for low-and middle-income countries, where 70% of women with the disease live. This study aims to address this evidence gap. METHODS: This is an observational multi-country study set in low- and middle-income countries. We aim to recruit over 2000 women diagnosed with ovarian cancer across multiple hospitals in 24 countries in Asia, Africa and South America. Country sample sizes have been calculated (n = 70-96 participants /country), taking account of varying national five-year disease prevalence rates. Women within five years of their diagnosis, who are in contact with participating hospitals, are invited to take part in the study. A questionnaire has been adapted from a tool previously used in high-income countries. It comprises 57 multiple choice and two open-ended questions designed to collect information on demographics, women's knowledge of ovarian cancer, route to diagnosis, access to treatments, surgery and genetic testing, support needs, the impact of the disease on women and their families, and their priorities for action. The questionnaire has been designed in English, translated into local languages and tested according to local ethics requirements. Questionnaires will be administered by a trained member of the clinical team. CONCLUSION: This study will inform further research, advocacy, and action in low- and middle-income countries based on tailored approaches to the national, regional and global challenges and opportunities. In addition, participating countries can choose to repeat the study to track progress and the protocol can be adapted for other countries and other diseases.

Implementation of cervical cancer prevention and screening across five tertiary hospitals in Nepal and its policy implications: A mixed-methods study.

In Nepal, cervical cancer is the most common cancer among women despite the existing policies. This study intends to assess the implementation of cervical cancer prevention and screening through service utilization by women, knowledge and attitude among health professionals, and the perceptions of stakeholders in Nepal. This mixed-methods study was conducted in 2022 across five tertiary hospitals in Kathmandu, Nepal. The quantitative study comprised the health professionals and women attending gynecology outpatient clinics from the selected hospitals. The qualitative study comprised stakeholders including service providers and experts on cervical cancer from selected hospitals, civil societies, and the Ministry of Health and Population. The utilization of screening through pap smear among 657 women across five hospitals was 22.2% and HPV vaccination was 1.5%. The utilization of cervical cancer screening was associated with older age [adjusted odds ratio (AOR) = 1.09, CI: 1.07, 8.19], married (AOR = 3.024, CI: 1.12, 8.19), higher education (AOR = 3.024, CI:1.12, 8.42), oral contraceptives use (AOR = 2.49, CI: 1.36, 4.39), and ever heard of cervical cancer screening (AOR = 13.28, CI: 6.85, 25.73). Among 254 health professionals, the knowledge score was positively associated with them ever having a training [Standardized Beta (ß) = 0.20, CI: 0.44, 2.43)] and having outreach activities in their hospital (ß = 0.19 CI: 0.89, 9.53) regarding cervical cancer screening. The female as compared to male health professionals (ß = 0.16, CI: 0.41, 8.16, P = 0.03) and having a cervical cancer screening guideline as compared to none (ß = 0.19 CI: 0.89, 9.53, P = 0.026) were more likely to have a better attitude for screening. The qualitative findings among 23 stakeholders reflected implementation challenges in policy, supply, service delivery, providers, and community. This study showed low utilization of prevention and services by women and implementation gaps on cervical cancer prevention and screening services across five tertiary hospitals in Kathmandu, Nepal. The findings could help designing more focused interventions.

A questionnaire study on disparity of cervical cancer prevention programs in Asia-Oceania.

BACKGROUND: Despite the introduction of cervical cancer screening and human papillomavirus (HPV) vaccines, the utilization pattern was not standardized. The aim of this study was to elicit the current prevention care in Asia-Oceania. METHODS: An online questionnaire was circulated to different countries/cities in Asia-Oceania. The primary objective was to evaluate the coverage of HPV vaccination and cervical screening programs. The secondary objectives were to study the structures of these programs. Five case scenarios were set to understand how the respondents manage the abnormal screening results. RESULTS: Fourteen respondents from 10 countries/cities had participated. Cervical cancer ranked the first in Myanmar and Nepal. About 10%-15% did not have national vaccination or screening program. The estimated coverage rate for vaccination and screening varied from less than 1% to 70%, which the coverage ran in parallel with the incidence and mortality rates of cervical cancer. All regions approved HPV vaccines, although only four provided free or subsidized programs for nonavalent vaccine. Cervical cytology remained the most common screening tool, and 20%-30% relied heavily on visual inspection using acetic acid. The screening age groups varied in different regions. From the case scenarios, it was noted that some respondents tended to offer more frequent screening tests or colposcopy than recommended by international guidelines. CONCLUSION: This study revealed discrepancy in the practice of cervical cancer prevention in Asia-Oceania especially access to HPV vaccines. There is an urgent need for a global collaboration to eliminate cervical cancer by public education, reforming services, and medical training.

COVID-19 and gynecological cancers: Asia and Oceania Federation of Obstetrics and Gynecology oncology committee opinion.

Since the outbreak of COVID-19, there have already been over 26 million people being infected and it is expected that the pandemic will not end in near future. Not only the daily activities and lifestyles of individuals have been affected, the medical practice has also been modified to cope with this emergency catastrophe. In particular, the cancer services have faced an unprecedented challenge. While the services may have been cut by the national authorities or hospitals due to shortage of manpower and resources, the medical need of cancer patients has increased. Cancer patients who are receiving active treatment may develop various kinds of complications especially immunosuppression from chemotherapy, and they and their carers will need additional protection against COVID-19. Besides, there is also evidence that cancer patients are more prone to deteriorate from COVID-19 if they contract the viral infection. Therefore, it is crucial to establish guidelines so that healthcare providers can triage their resources to take care of the most needed patients, reduce less important hospitalization and visit, and to avoid potential complications from treatment. The Asia and Oceania Federation of Obstetrics and Gynecology (AOFOG) hereby issued this opinion statement on the management of gynecological cancer patients during the COVID-19.

American Society of Clinical Oncology (ASCO) Cervical Cancer Prevention Program: A Hands-On Training Course in Nepal.

Cervical cancer is the leading cause of death among women in Nepal. The American Society of Clinical Oncology (ASCO) and The University of Texas MD Anderson Cancer Center collaborated with international and local experts to hold a cervical cancer prevention course in Nepal in November 2019. The course included didactic lectures and a hands-on workshop. The didactic lectures included the epidemiology of cervical cancer globally and locally, cervical cancer screening guidelines, human papillomavirus vaccination, colposcopy and visual inspection with acetic acid (VIA), cervical dysplasia, and cervical cancer treatment. The hands-on workshop consisted of four stations: (1) VIA; (2) colposcopy, cervical biopsy, and endocervical curettage; (3) thermal ablation; and (4) loop electrosurgical excision procedure (LEEP). A train-the-trainer model short course was held by the international faculty to assist six local faculty to become familiar with the instruments, procedures, and models used in the hands-on training stations. Forty-two people (84% gynecologist, 8% radiation oncologist, and 8% other) attended the course. Following the course, the international faculty visited the regional hospitals for additional educational activities. Increased knowledge in cervical cancer screening guidelines and ability in performing VIA, colposcopy and cervical biopsy, thermal ablation, and LEEP were reported by 89%, 84%, 84%, 87%, and 84% of participants, respectively, from the postcourse on-site evaluations. From the 6-month follow-up survey, all respondents reported that they had made practice changes based on what they learned in the course and had implemented or tried to implement the cervical cancer screening guidelines presented at the course. In conclusion, the course evaluations suggested an improvement in participants' ability to perform cervical cancer screening and diagnostic procedures and reported the changes in practices after training.

Laparoscopic Management of Dermoid Cyst of Ovary is a Safe Procedure.

BACKGROUND: Dermoid cyst, a common benign neoplasm of ovary in women, needs treatment because of the risk of torsion, rupture, and malignant change. Laparoscopic surgery nowadays is the preferred treatment modality, but the only issue is its safety in case of rupture and spillage of its contents with the risk of chemical peritonitis and malignant dissemination. Aim of the study was to find out the safety of laparoscopic surgery for dermoid cyst of ovary. METHODS: It was a retrospective study done from January 2017 to December 2019. All the women with diagnosis of dermoid cyst of ovary managed laparoscopically either salpingoophorectomy or cystectomy were taken into study. Analysis of size of the cyst operated, the time taken, spillage rate, duration of hospital stay, and post-operative complications especially chemical peritonitis was done. RESULTS: There were 61 women who had undergone laparoscopic surgery. Laparoscopic cystectomy was done in 68.9% (n=42), laparoscopic salpingoophorectomy in 29.5% (n=18). Mean age of the patient was 31.74±8.38 years. Mean size was 6.21±1.99 cm. Rupture and spillage were observed in 21.3% (n=13) that were > 5cm in diameter (X2= 3.62, p=0.05). Larger the size of the cyst, more the surgical time was noted (X2=6.26, p=0.04). Significant difference in mean operating time in case of cyst rupture and spillage (p=0.004) was observed. Mean hospital stay was 53.5±1.3 hours. No case of chemical peritonitis was observed with spillage. All cases had histopathology of mature cystic teratoma. CONCLUSIONS: Laparoscopic surgery is safe for dermoid cyst of ovary even with rupture and spillage of its contents.

Overview of Delivery of Cancer Care in Nepal: Current Status and Future Priorities.

Nepal is a small, low-income country between India and China with a unique health care delivery system. Cancer is becoming an important public health problem in the country, but a systematic plan to cancer control is lacking. In this article, we aim to provide a systematic assessment of the burden of disease and available resources and suggest prioritization approaches for the future to assist with any such future cancer control plans for the country.

Estimates of delays in diagnosis of cervical cancer in Nepal.

BACKGROUND: Cervical cancer is the leading cause of cancer related deaths among women in Nepal. The long symptom to diagnosis interval means that women have advanced disease at presentation. The aim of this study was to identify, estimate and describe the extent of different delays in diagnosis of cervical cancer in Nepal. METHODS: A cross-sectional descriptive study was conducted in two tertiary cancer hospitals of Nepal. Face to face interview and medical records review were carried out among 110 cervical cancer patients. Total diagnostic delay was categorized into component delays: patient delay, health care providers delay, referral delay and diagnostic waiting time. RESULTS: Total 110 patients recruited in the study represented 40 districts from all three ecological regions of the country. Median total diagnostic delay was 157 days with more than three fourth (77.3%) of the patients having longer total diagnostic delay of >90 days. Out of the total diagnostic delay, median patient delay, median health care provider delay, median referral delay and median diagnostic waiting time were 68.5 days, 40 days, 5 days and 9 days respectively. Majority of the patients had experienced longer delay of each type except referral delay. Fifty seven percent of the patients had experienced longer patient delay of >60 days, 90% had suffered longer health care provider delay of >1 week, 31.8% had longer referral delay of >1 week and 66.2% had waited >1 week at diagnostic center for final diagnosis. Variation in each type of delay was observed among women with different attributes and in context of health care service delivery. CONCLUSIONS: Longer delays were observed in all the diagnostic pathways except for referral delay and diagnostic waiting time. Among the delays, patient delay is of crucial importance because of its longer span, although health care provider delay is equally important. In the context of limited screening services in Nepal, the efforts should be to reduce the diagnostic delay especially patient and health care provider delay for early detection and reduction of mortality rate of cervical cancer.

Factors associated with late diagnosis of cervical cancer in Nepal.

BACKGROUND: The majority of cervical cancers, the most prevalent cancer among Nepali women, are diagnosed in advanced stage leading to high mortality in Nepal. The present study explored factors associated with late diagnosis. MATERIALS AND METHODS: A cross-sectional study was carried out in two specialized cancer hospitals of Nepal from August 12 to October 12, 2012. Randomly selected 110 cervical cancer patients were interviewed and their medical records were reviewed. Multivariate logistic regression analysis was performed to predict associations. RESULTS: Mean age of patients was 52.7years (SD=10.6), 66% were illiterate and 77% were rural inhabitants. Medical shops (33.6%) and private hospitals (31%) were major first contact points of patients with health care providers (HCP). There was no cervical/per-speculum examination (78.2%) and symptoms misinterpretation (90%) of patients occurred in initial consultation with HCP. Four in every five cases (80.9%) of cervical cancer had late diagnosis. Literate women (adjusted OR=0.121, CI: 0.030-0.482) and women having abnormal vaginal bleeding as early symptom (adjusted OR=0.160, CI: 0.035-0.741) were less likely to suffer late diagnosis. Women who shared their symptoms late (adjusted OR=4.272, CI: 1.110-16.440) and did so with people other than their husband (adjusted OR=12.701, CI: 1.132-142.55) were more likely for late diagnosis. CONCLUSIONS: High level of illiteracy among women and their problematic health seeking behavior for gynecological symptoms are responsible for late diagnosis of cervical cancer in Nepal. In the absence of a routine screening program, prevention interventions should be focused on raising awareness of gynecological symptoms and improving health seeking behavior of women for such symptoms.