Evaluating the impact of multicancer early detection testing on health and economic outcomes: Toward a decision modeling strategy.

Emerging data provide initial support for the concept that a single, minimally invasive liquid biopsy test, performed in conjunction with confirmatory radiologic or other diagnostic testing, when indicated, could be deployed on a broad scale to screen individuals for multiple types of cancer. Ideally, such a test could do this in a way that yields a clinically important percentage of true-positive indications of cancer while minimizing false-positive signals. Modern decision modeling approaches can and should be deployed to investigate the health and economic consequences of such multicancer early detection (MCED) testing within defined at-risk populations. In this paper, through small-scale analyses involving 3 hypothetical MCED-detectible cancers, the authors illustrate the potential for MCED testing to be cost-effective, along with the pivotal role of test-induced stage shift on results. The time is ripe for additional, prospective investigations of the clinical value of MCED testing, the benefits versus the risks for screened populations, and the overall projected impact on health outcomes and costs over time.

Qualitative exploration of the dynamics of women's dietary diversity. How much does economic empowerment matter?

OBJECTIVE: This study qualitatively examined dietary diversity among married women of reproductive age who engaged in two socio-economic activities to explore the dynamics of food availability, access, costs and consumption. DESIGN: Qualitative in-depth interviews. The food groups in the Minimum Dietary Diversity for women were used to explore women's dietary diversity. IDI were used to develop a roster of daily food consumption over a week. We explored food items that were considered expensive and frequency of consumption, food items that women require permission to consume and frequency of permission sought and the role of economic empowerment. Data analysis followed an inductive-deductive approach to thematic analysis. SETTING: Rural and peri-urban setting in Enugu State, Nigeria. PARTICIPANTS: Thirty-eight married women of reproductive age across two socio-economic groupings (women who work only at home and those who worked outside their homes) were recruited in April 2019. RESULTS: Economic empowerment improved women's autonomy in food purchase and consumption. However, limited income restricted women from full autonomy in consumption decisions and access. Consumption of non-staple food items, especially flesh proteins, would benefit from women's economic empowerment, whereas staple food items would not benefit so much. Dietary diversity is influenced by food production and purchase where factors including seasonal variation in food availability, prices, contextual factors that influence women's autonomy and income are important determinants. CONCLUSION: With limited income, agency and access to household financial resources coupled with norms that restrict women's income earning, women continue to be at risk for not achieving adequate dietary diversity.

Rational design of an essential diagnostics network to support Universal Health Coverage: a modeling analysis.

BACKGROUND: Diagnostic investigations, including pathology and laboratory medicine (PALM) and radiology, have been largely absent from international strategies such as the Sustainable Development Goals. Further, there is little international guidance on which health system tiers different diagnostics should be placed, a critical step in developing a country-level diagnostics network. We describe a modeling strategy to produce tier-specific diagnostic recommendations based on disease burden, current treatment pathways, and existing infrastructure in a country. METHODS: The relational model assumes that diagnostics should be available at the lowest tier where patients might receive medical management. Using Ghana as an exemplar, the 20 diseases forecasted by 2030 and 2040 to cause the greatest burden in low- and middle-income countries were mapped to three generalized tiers in the Ghanaian health system (Primary, Secondary, and Tertiary care) for three levels of each disease (triage, uncomplicated, and complicated). The lowest tier at which a diagnostic could potentially be placed was restricted by existing infrastructure, though placement still required there be a medical justification for the diagnostic at that tier. RESULTS: The model recommended 111 unique diagnostic investigations with 17 at Primary tier, an additional 45 at Secondary tier and a further 49 at Tertiary tier. Estimated capital costs were $8,330 at Primary tier and between $571,000 to $777,000 at Secondary tier. Twenty-eight different laboratory tests were recommended as send-outs from Primary to Secondary tier, and twelve as send-outs to Tertiary tier. CONCLUSIONS: This model provides a transparent framework within which countries can customize diagnostic planning to local disease priorities, health system patient treatment pathways, and infrastructural limitations to best support Universal Health Coverage.

Can African-Americans Be Encouraged to Become Active Participants in Advanced Care Planning?

The purpose of this study was to encourage African-Americans to become active participants in advanced care planning through increased education and awareness. A quasi-experimental design was used in two local churches in Leon County. Thirty participants (N = 30) were African-Americans, 18 years of age and older, English speaking, from all socioeconomical levels, and from all educational backgrounds. The annotated 2003 Minnesota Survey was used to develop pre-survey and post-survey questions regarding advanced care planning. A paired t test was used to analyze the pre-survey and post-survey responses. The significant value was < 0.05, thus demonstrating a statistically significant difference in pre- and post-survey responses. The educational intervention on advanced directives indicated that all 30 participants would consider completing some form of advanced directive or discussing end-of-life care planning with either another person, a healthcare provider, or they would seek legal advice. African-Americans are more prone to chronic diseases. However, a systemic literature review describes how African-Americans were less likely to participate in advanced care planning and were less likely to receive end-of-life care than other ethnic groups. The 30-minute educational intervention encouraged African-Americans to participate in advanced care planning. Because the sample size was small, results cannot be generalized to all African-Americans. With increased educational opportunities, African-Americans may be encouraged to become active participants in advanced care planning. Advanced practice registered nurse providers should provide advanced care planning information to all patients, but especially to African-Americans. This study should be replicated in a wide variety of settings with larger numbers of participants. Further research is needed to discover additional methods of providing advanced care planning education to African-Americans.

Sustainable care for children with cancer: a Lancet Oncology Commission.

We estimate that there will be 13·7 million new cases of childhood cancer globally between 2020 and 2050. At current levels of health system performance (including access and referral), 6·1 million (44·9%) of these children will be undiagnosed. Between 2020 and 2050, 11·1 million children will die from cancer if no additional investments are made to improve access to health-care services or childhood cancer treatment. Of this total, 9·3 million children (84·1%) will be in low-income and lower-middle-income countries. This burden could be vastly reduced with new funding to scale up cost-effective interventions. Simultaneous comprehensive scale-up of interventions could avert 6·2 million deaths in children with cancer in this period, more than half (56·1%) of the total number of deaths otherwise projected. Taking excess mortality risk into consideration, this reduction in the number of deaths is projected to produce a gain of 318 million life-years. In addition, the global lifetime productivity gains of US$2580 billion in 2020-50 would be four times greater than the cumulative treatment costs of $594 billion, producing a net benefit of $1986 billion on the global investment: a net return of $3 for every $1 invested. In sum, the burden of childhood cancer, which has been grossly underestimated in the past, can be effectively diminished to realise massive health and economic benefits and to avert millions of needless deaths.

Health system strengthening: Integration of breast cancer care for improved outcomes.

The adoption of the goal of universal health coverage and the growing burden of cancer in low- and middle-income countries makes it important to consider how to provide cancer care. Specific interventions can strengthen health systems while providing cancer care within a resource-stratified perspective (similar to the World Health Organization-tiered approach). Four specific topics are discussed: essential medicines/essential diagnostics lists; national cancer plans; provision of affordable essential public services (either at no cost to users or through national health insurance); and finally, how a nascent breast cancer program can build on existing programs. A case study of Zambia (a country with a core level of resources for cancer care, using the Breast Health Global Initiative typology) shows how a breast cancer program was built on a cervical cancer program, which in turn had evolved from the HIV/AIDS program. A case study of Brazil (which has enhanced resources for cancer care) describes how access to breast cancer care evolved as universal health coverage expanded. A case study of Uruguay shows how breast cancer outcomes improved as the country shifted from a largely private system to a single-payer national health insurance system in the transition to becoming a country with maximal resources for cancer care. The final case study describes an exciting initiative, the City Cancer Challenge, and how that may lead to improved cancer services.

The Breast Health Global Initiative 2018 Global Summit on Improving Breast Healthcare Through Resource-Stratified Phased Implementation: Methods and overview.

BACKGROUND: The Breast Health Global Initiative (BHGI) established a series of resource-stratified, evidence-based guidelines to address breast cancer control in the context of available resources. Here, the authors describe methodologies and health system prerequisites to support the translation and implementation of these guidelines into practice. METHODS: In October 2018, the BHGI convened the Sixth Global Summit on Improving Breast Healthcare Through Resource-Stratified Phased Implementation. The purpose of the summit was to define a stepwise methodology (phased implementation) for guiding the translation of resource-appropriate breast cancer control guidelines into real-world practice. Three expert consensus panels developed stepwise, resource-appropriate recommendations for implementing these guidelines in low-income and middle-income countries as well as underserved communities in high-income countries. Each panel focused on 1 of 3 specific aspects of breast cancer care: 1) early detection, 2) treatment, and 3) health system strengthening. RESULTS: Key findings from the summit and subsequent article preparation included the identification of phased-implementation prerequisites that were explored during consensus debates. These core issues and concepts are key components for implementing breast health care that consider real-world resource constraints. Communication and engagement across all levels of care is vital to any effectively operating health care system, including effective communication with ministries of health and of finance, to demonstrate needs, outcomes, and cost benefits. CONCLUSIONS: Underserved communities at all economic levels require effective strategies to deploy scarce resources to ensure access to timely, effective, and affordable health care. Systematically strategic approaches translating guidelines into practice are needed to build health system capacity to meet the current and anticipated global breast cancer burden.

Real-world effectiveness of nivolumab in patients with non-small-cell lung cancer: a systematic review and meta-analysis.

Background: The effectiveness of immunotherapies for non-small-cell lung cancer under real-world clinical settings remains uncertain. Materials & methods: Systematic searches of PubMed, EMBASE and Web of Science were conducted. Random-effects models were used to estimate pooled median overall survival and progression-free survival estimates. Results: 36 studies of nivolumab were included for narrative synthesis and 11 of these studies were included for meta-analysis. Age, sex, histology and prior lines of treatment did not affect survival outcomes, while Eastern Cooperative Oncology Group Performance Status and brain metastasis were inversely associated with survival. In the meta-analysis, nivolumab was associated with 9.6 months (95% CI: 8.4-10.9) of overall survival and 2.6 months (95% CI: 1.6-3.6) of progression-free survival. Conclusion: Very-low-certainty evidence suggested the real-world effectiveness of nivolumab was consistent with those observed in the clinical trials.

Perceived opportunities and challenges of family and community members in supporting teen mothers in rural Eastern Uganda.

There is tremendous need for feasible and acceptable community-based interventions to address poor nutrition and health among teen mothers in rural Eastern Uganda. To inform such interventions, we identified facilitators/opportunities and challenges for maternal/child nutrition and health at community level, as perceived by those closest to the problem. In-depth interviews were conducted among 101 teens, family and community members in Budondo sub-county using questions based on social cognitive theory constructs related to nutrition/health. Data were analyzed thematically using Atlas-ti7.5.4. Facilitators included family support for positive teen decision-making regarding healthcare and practices and opportunities included income generation training and availability of healthcare services. Challenges included poor attitude of parents towards community workers, harsh treatment, inability to obtain income generation materials, insufficient land, food or medical supplies and medical understaffing. To exploit opportunities for improved maternal/child health and progress towards global sustainable development goals, this study points to needs for local action.

Delivering modern, high-quality, affordable pathology and laboratory medicine to low-income and middle-income countries: a call to action.

Modern, affordable pathology and laboratory medicine (PALM) systems are essential to achieve the 2030 Sustainable Development Goals for health in low-income and middle-income countries (LMICs). In this last in a Series of three papers about PALM in LMICs, we discuss the policy environment and emphasise three crucial high-level actions that are needed to deliver universal health coverage. First, nations need national strategic laboratory plans; second, these plans require adequate financing for implementation; and last, pathologists themselves need to take on leadership roles to advocate for the centrality of PALM to achieve the Sustainable Development Goals for health. The national strategic laboratory plan should deliver a tiered, networked laboratory system as a central element. Appropriate financing should be provided, at a level of at least 4% of health expenditure. Financing of new technologies such as molecular diagnostics is challenging for LMICs, even though many of these tests are cost-effective. Point-of-care testing can substantially reduce test-reporting time, but this benefit must be balanced with higher costs. Our research analysis highlights a considerable deficiency in advocacy for PALM; pathologists have been invisible in national and international health discourse and leadership. Embedding PALM in LMICs can only be achieved if pathologists advocate for these services, and undertake leadership roles, both nationally and internationally. We articulate eight key recommendations to address the current barriers identified in this Series and issue a call to action for all stakeholders to come together in a global alliance to ensure the effective provision of PALM services in resource-limited settings.

Investment in child and adolescent health and development: key messages from Disease Control Priorities, 3rd Edition.

The realisation of human potential for development requires age-specific investment throughout the 8000 days of childhood and adolescence. Focus on the first 1000 days is an essential but insufficient investment. Intervention is also required in three later phases: the middle childhood growth and consolidation phase (5-9 years), when infection and malnutrition constrain growth, and mortality is higher than previously recognised; the adolescent growth spurt (10-14 years), when substantial changes place commensurate demands on good diet and health; and the adolescent phase of growth and consolidation (15-19 years), when new responses are needed to support brain maturation, intense social engagement, and emotional control. Two cost-efficient packages, one delivered through schools and one focusing on later adolescence, would provide phase-specific support across the life cycle, securing the gains of investment in the first 1000 days, enabling substantial catch-up from early growth failure, and leveraging improved learning from concomitant education investments.

Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition.

The World Bank is publishing nine volumes of Disease Control Priorities, 3rd edition (DCP3) between 2015 and 2018. Volume 9, Improving Health and Reducing Poverty, summarises the main messages from all the volumes and contains cross-cutting analyses. This Review draws on all nine volumes to convey conclusions. The analysis in DCP3 is built around 21 essential packages that were developed in the nine volumes. Each essential package addresses the concerns of a major professional community (eg, child health or surgery) and contains a mix of intersectoral policies and health-sector interventions. 71 intersectoral prevention policies were identified in total, 29 of which are priorities for early introduction. Interventions within the health sector were grouped onto five platforms (population based, community level, health centre, first-level hospital, and referral hospital). DCP3 defines a model concept of essential universal health coverage (EUHC) with 218 interventions that provides a starting point for country-specific analysis of priorities. Assuming steady-state implementation by 2030, EUHC in lower-middle-income countries would reduce premature deaths by an estimated 4·2 million per year. Estimated total costs prove substantial: about 9·1% of (current) gross national income (GNI) in low-income countries and 5·2% of GNI in lower-middle-income countries. Financing provision of continuing intervention against chronic conditions accounts for about half of estimated incremental costs. For lower-middle-income countries, the mortality reduction from implementing the EUHC can only reach about half the mortality reduction in non-communicable diseases called for by the Sustainable Development Goals. Full achievement will require increased investment or sustained intersectoral action, and actions by finance ministries to tax smoking and polluting emissions and to reduce or eliminate (often large) subsidies on fossil fuels appear of central importance. DCP3 is intended to be a model starting point for analyses at the country level, but country-specific cost structures, epidemiological needs, and national priorities will generally lead to definitions of EUHC that differ from country to country and from the model in this Review. DCP3 is particularly relevant as achievement of EUHC relies increasingly on greater domestic finance, with global developmental assistance in health focusing more on global public goods. In addition to assessing effects on mortality, DCP3 looked at outcomes of EUHC not encompassed by the disability-adjusted life-year metric and related cost-effectiveness analyses. The other objectives included financial protection (potentially better provided upstream by keeping people out of the hospital rather than downstream by paying their hospital bills for them), stillbirths averted, palliative care, contraception, and child physical and intellectual growth. The first 1000 days after conception are highly important for child development, but the next 7000 days are likewise important and often neglected.

Effectiveness of social marketing in improving knowledge, attitudes and practice of consumption of vitamin A-fortified oil in Tanzania.

OBJECTIVE: To evaluate the effectiveness of a social marketing intervention in enhancing knowledge, attitudes and practice (KAP) related to consumption of vitamin A-fortified oil. DESIGN: The intervention employed community events, distribution of educational materials and radio broadcasts. The intervention was assessed in a quasi-experimental non-equivalent control group study design by collecting information on KAP regarding vitamin A-fortified oil consumption before and after 9 months of a 13-month intervention. SETTING: Six districts in Manyara and Shinyanga regions in Tanzania were non-randomly selected as the intervention districts and two districts served as the control districts. PARTICIPANTS: At baseline, 568 lactating mothers with children aged <5 years were randomly selected from the intervention and control districts. Of these, 494 mothers were followed up at endline. RESULTS: After 9 months of intervention, knowledge of fortification and actual consumption of adequately fortified oil were significantly higher in the intervention districts compared with the control districts (P <0·05). Knowledge of the health benefits of vitamin A improved significantly from about 33 to 45 % in both the intervention and control districts. The major sources of information for women were health clinics and community health workers (CHW). CONCLUSIONS: The study showed that a social marketing intervention is effective in improving KAP regarding fortified oil consumption at the household level. Clinics and CHW are channels that should be prioritized when communicating health messages, particularly those targeting women.

Acculturation and Dietary Acculturation among Arab Muslim Immigrants in Canada.

Purpose: The purpose of this work was to assess Arab Muslim immigrant mothers' acculturation level, to explore apparent links between acculturation level and experiences of dietary changes, and to gather information on factors affecting dietary acculturation. Methods: Semi-structured individual interviews focusing on food choices were conducted with 24 mothers who had been in Canada 5 years or more. An adapted version of an existing acculturation scale was used to assess participants' perception of their own acculturation. Results: Arab Muslim mothers retain traditional food preparation. However, several factors led to changes in their daily food consumption such as children's preferences, time concerns, and availability of Arabic food. No significant relation was found between measured levels of acculturation and the adoption of Canadian food behaviour or the retention of preparation and consumption of traditional foods (dietary acculturation); however, a greater length of stay in Canada was somewhat associated with limitations on preparing traditional food. The findings indicated that many of the Arab Muslim mothers interviewed retain important aspects of their traditional cuisine. Conclusions: Dietary acculturation for Arab Muslim immigrants to Canada involved a balance between carrying forward food-related traditions and adapting to Canadian culture, including Canada's food culture.

Cost-effectiveness of sunflower oil fortification with vitamin A in Tanzania by scale.

In 2011, Tanzania mandated the fortification of edible oil with vitamin A to help address its vitamin A deficiency (VAD) public health problem. By 2015, only 16% of edible oil met the standards for adequate fortification. There is no evidence on the cost-effectiveness of the fortification of edible oil by small- and medium-scale (SMS) producers in preventing VAD. The MASAVA project initiated the production of sunflower oil fortified with vitamin A by SMS producers in the Manyara and Shinyanga regions of Tanzania. A quasi-experimental nonequivalent control-group research trial and an economic evaluation were conducted. The household survey included mother and child pairs from a sample of 568 households before the intervention and 18 months later. From the social perspective, the incremental cost of fortification of sunflower oil could be as low as $0.13, $0.06, and $0.02 per litre for small-, medium-, and large-scale producers, respectively, compared with unfortified sunflower oil. The SMS intervention increased access to fortified oil for some vulnerable groups but did not have a significant effect on the prevention of VAD due to insufficient coverage. Fortification of vegetable oil by large-scale producers was associated with a significant reduction of VAD in children from Shinyanga. The estimated cost per disability-adjusted life year averted for fortified sunflower oil was $281 for large-scale and could be as low as $626 for medium-scale and $1,507 for small-scale producers under ideal conditions. According to the World Health Organization thresholds, this intervention is very cost-effective for large- and medium-scale producers and cost-effective for small-scale producers.

The cost and cost-effectiveness of childhood cancer treatment in El Salvador, Central America: A report from the Childhood Cancer 2030 Network.

BACKGROUND: Although previous studies have examined the cost of treating individual childhood cancers in low-income and middle-income countries, to the authors' knowledge none has examined the overall cost and cost-effectiveness of operating a childhood cancer treatment center. Herein, the authors examined the cost and sources of financing of a pediatric cancer unit in Hospital Nacional de Ninos Benjamin Bloom in El Salvador, and make estimates of cost-effectiveness. METHODS: Administrative data regarding costs and volumes of inputs were obtained for 2016 for the pediatric cancer unit. Similar cost and volume data were obtained for shared medical services provided centrally (eg, blood bank). Costs of central nonmedical support services (eg, utilities) were obtained from hospital data and attributed by inpatient share. Administrative data also were used for sources of financing. Cost-effectiveness was estimated based on the number of new patients diagnosed annually and survival rates. RESULTS: The pediatric cancer unit cost $5.2 million to operate in 2016 (treating 90 outpatients per day and experiencing 1385 inpatient stays per year). Approximately three-quarters of the cost (74.7%) was attributed to 4 items: personnel (21.6%), pathological diagnosis (11.5%), pharmacy (chemotherapy, supportive care medications, and nutrition; 31.8%), and blood products (9.8%). Funding sources included government (52.5%), charitable foundations (44.2%), and a social security contribution scheme (3.4%). Based on 181 new patients per year and a 5-year survival rate of 48.5%, the cost per disability-adjusted life-year averted was $1624, which is under the threshold considered to be very cost effective. CONCLUSIONS: Treating childhood cancer in a specialized unit in low-income and middle-income countries can be done cost-effectively. Strong support from charitable foundations aids with affordability. Cancer 2018;124:391-7. © 2017 American Cancer Society.

Cost-effectiveness analysis of single-session walk-in counselling.

BACKGROUND: An increasing number of family service agencies and community-based mental health service providers are implementing a single-session walk-in counselling (SSWIC) as an alternative to traditional counselling. However, few economic evaluations have been undertaken. AIMS: To conduct a cost-effectiveness analysis of two models of service delivery, SSWIC compared to being waitlisted for traditional counselling. METHODS: A quasi-experimental design was employed. Data were collected from two community-based Family Service Agencies, one using SSWIC and one using traditional counselling. Participants were assessed at baseline and four weeks after the baseline. Cost-effectiveness was estimated from the societal and payer's perspective. RESULTS: The societal and payer's costs for SSWIC were higher than for those waiting for traditional counselling, and health outcomes were better. SSWIC is not cost-effective compared to being on the waitlist for traditional counselling (or, for a few patients, having received counselling, but after a wait of several weeks). CONCLUSIONS: SSWIC has the potential to reduce the pressure on the mental health care system by reducing emergency visits and wait lists for ongoing mental health services and eliminating costly-no shows at counselling appointments. Long-term studies involving multiple walk-in counselling services and comparison services are needed to support the findings of this study.

Why invest, and what it will take to improve breastfeeding practices?

Despite its established benefits, breastfeeding is no longer a norm in many communities. Multifactorial determinants of breastfeeding need supportive measures at many levels, from legal and policy directives to social attitudes and values, women's work and employment conditions, and health-care services to enable women to breastfeed. When relevant interventions are delivered adequately, breastfeeding practices are responsive and can improve rapidly. The best outcomes are achieved when interventions are implemented concurrently through several channels. The marketing of breastmilk substitutes negatively affects breastfeeding: global sales in 2014 of US$44·8 billion show the industry's large, competitive claim on infant feeding. Not breastfeeding is associated with lower intelligence and economic losses of about $302 billion annually or 0·49% of world gross national income. Breastfeeding provides short-term and long-term health and economic and environmental advantages to children, women, and society. To realise these gains, political support and financial investment are needed to protect, promote, and support breastfeeding.