Health-related quality of life of pediatric brain tumor survivors after treatment in Jordan.

Background: The number of cancer survivors and survivorship are increasing. Health-related quality of life (HRQOL) has not been widely studied in low-and-middle-income countries (LMICs). The aim of this study is to explore HRQOL of childhood brain tumor survivors and its determinants in Jordan. Methods: Health-related quality of life information was collected from 80 patients treated at the King Hussein Cancer Center and their parents using the Pediatric Quality of Life Inventory (PedsQL) Generic Core Scales questionnaire in Arabic. Multivariable linear OLS regression models were used to analyze correlates of HRQOL and compare differences between child- and parent-reported responses. Results: Health-related quality of life scores reported by survivors and by parents were positively correlated on all subscales and total PedsQL scores (r = 0.59, P = .001). Survivors reported better HRQOL in cognitive subscale (ß = 0.56, P = .03) and worse HRQOL in work subscale (ß = 0.43, P = .04), but no significant differences in the physical, emotional, and social subscales and total PedsQL scores. Significant predictors of HRQOL reported by parents and by children were different. Supratentorial tumor location was associated with a 10.97-unit lower physical HRQOL score, and recurrence of tumors predicted a 17.5-unit lower total HRQOL score, indicating worse quality of life. Male gender (ß = 14.9, P = .002) and diagnosis of hypopituitarism (ß = 16.1, P = .03) were associated with better HRQOL. Furthermore, patients that only had radiotherapy treatment had better emotional HRQOL (ß = 32.9, P = .006) compared to patients that had combined radiotherapy and chemotherapy. Conclusion: This study provides evidence on determinants of HRQOL of pediatric brain tumor patients in Jordan. Future studies need to capitalize on the findings of this study to institute a system for regular assessment of quality of life of pediatric cancer patients in Jordan and other countries with similar health care systems and sociocultural backgrounds.

The impact of in-house pathology services on downstaging cervical cancer in Tanzania over an 18-year period.

PURPOSE: Reducing time between cancer screening, diagnosis, and initiation of treatment is best achieved when services are available in the same hospital. Yet, comprehensive cancer centers are typically unavailable in low- and middle-income countries (LMICs), where resources are limited and services scattered. This study explored the impact of establishing an in-house pathology laboratory at the largest public cancer hospital in Tanzania on the downstaging of cervical cancer. METHODS: We examined clinical datasets of 8,322 cervical cancer patients treated at the Ocean Road Cancer Institute (ORCI). The first period included patients treated from 2002 to 2016, before establishment of the pathology laboratory at ORCI; the second period (post-pathology establishment) included data from 2017 to 2020. Logistic regression analysis evaluated the impact of the pathology laboratory on stage of cervical cancer diagnosis. RESULTS: Patients treated during the post-pathology period were more likely to be clinically diagnosed at earlier disease stages compared to patients in the pre-pathology period (pre-pathology population diagnosed at early disease stage: 44.08%; post-pathology population diagnosed at early disease stage: 59.38%, p < 0.001). After adjustment for age, region of residence, and place of biopsy, regression results showed patients diagnosed during the post-pathology period had higher odds of early stage cervical cancer diagnosis than patients in the pre-pathology period (OR 1.35, 95% CI (1.16, 1.57), p < 0.001). CONCLUSIONS: Integrated and comprehensive cancer centers can overcome challenges in delivering expedited cervical cancer diagnosis and treatment. In-house pathology laboratories play an important role in facilitating timely diagnosis and rapid treatment of cervical and possibly other cancers in LMICs.

Behaviors and Advocacy Related to COVID-19 among Cancer Patients: The Health Belief Model and Opportunities for Messaging and Education.

Cancer patients have an increased risk of severe COVID-19 outcomes and were recommended to be vaccinated, wear a mask, practice social distancing, and increase hand hygiene. We used the Health Belief Model (HBM) to identify constructs that were associated with the likelihood of adhering to and advocating for CDC COVID-19 prevention recommendations. We surveyed adult cancer patients who had an onsite appointment at the Penn State Cancer Institute or at the Hematology and Oncology Associates of Northeastern Pennsylvania. Survey measures included adherence to and informing others of COVID-19 recommendations as well as HBM constructs. Relationships between HBM constructs and outcomes were assessed with Spearman's correlation and multivariable ordinal logistic regression. Of the 106 participants who completed the survey for our objectives of interest, 76% always wore a mask, 29% always practiced social distancing, and 24% washed their hands at least 10 times a day. Limited advocacy behaviors were captured for the COVID-19 vaccine (30%), social distancing (36%), and wearing masks (27%). Perceived benefits, perceived barriers, and cues-to-action were positively associated with the likelihood of adherence or advocacy of COVID-19 recommendations among cancer patients, whereas perceived susceptibility and self-efficacy were negatively associated with the likelihood of adherence or advocacy of COVID-19 recommendations among cancer patients. Perceived benefits may be the strongest predictor for adherence and advocacy for specific COVID-19 guidelines. Future messaging and educational campaigns focused on improving adherence to or advocacy of specific health behaviors should be informed by the HBM and originate from multiple outlets.

Tobacco Use Among Dental Students in Morocco: Opportunities for Professional Cancer Education.

The study aimed to evaluate tobacco use, attitudes, knowledge, and perceptions about tobacco control policies and smoking cessation counseling among dental students in Morocco. This cross-sectional study was conducted at the Dentistry Faculty of the Mohammed VI University of Health Sciences of Casablanca, using the Global Health Professions Student Survey (GHPSS) tool. Participants completed a self-administered survey questionnaire, including information on socio-demographic characteristics, tobacco use, exposure to secondhand smoke, attitudes, behavior and cessation, curriculum, and training. A total of 426 dental students were included in the study. Over 15% of the participants were current smokers, and 31.2% had tried smoking at least once. About 29.3% reported having been exposed to secondhand smoke in family settings and 49.5% in other environments. The majority of the students had felt that health professionals were role models for their patients. However, only 20% had felt they had received formal training in smoking cessation approaches. More than 70% of smokers had tried to quit smoking in the past year; however, only 41.7% reported having received help or advice. It is crucial that education and public health officials join efforts to plan and carry out programs aimed at training dental students in evidence-based cessation counseling methods, in order to change their own smoking behavior and assist their future patients. Improving dental school curriculums with regard to tobacco use prevention and cessation is also a powerful means of alleviating the national burden of cancer.

Breast Cancer Screening in Low-Income Countries: A New Program for Downstaging Breast Cancer in Tanzania.

Background: Most breast cancer diagnoses in Tanzania are in advanced stages. The Ocean Road Cancer Institute (ORCI) established a new breast cancer screening program in 2014 to reduce advanced-stage diagnoses. This study is aimed at describing the screening program's referral process and at identifying patient and health system factors that contribute to patients completing diagnostic testing referrals. Methods: Six-hundred and forty patients were included in the study. Testing types, outcomes, and date of diagnostic results were abstracted from records at ORCI and Muhimbili National Hospital (MNH) to determine the proportion of testing completed and the duration between initial referrals and diagnostic tests. Prediction of completion of diagnostic testing was investigated in logistic regression. Results: Of the patients who received referrals for further testing, fifty-two percent completed the recommended ultrasound (USS), mammography (MMG), and fine-needle aspiration cytology (FNAC). Only 33.0% of patients completed the recommended MMG referrals compared to 55.0% for ultrasound and 68.7% for FNAC. The average number of days between initial screening and results was 42 days for MMG, 20 days for USS, and 18 days for FNAC. Significant predictors for completing referrals for USS, FNAC, and MMG included age < 44 and >55 years, presenting with symptoms at the initial appointment, and education. The odds of completing an USS was 3.03 (95% CI, 1.65-5.64) for patients 25-34, 2.27 (95% CI, 1.17-4.48) for patients 35-44, and 4.41 (95% CI, 1.66-10.11) for patients older than 55 years compared to the reference group (age 19-24). The presence of symptoms at the initial appointment was a significant predictor of FNAC. The odds of completing an FNAC was 1.55 (95% CI, 1.02-3.72) for symptomatic compared to nonsymptomatic patients. Education was a significant predictor of MMG. The odds of receiving MMG was 4.29 (95% CI, 1.05-21.00) for patients with tertiary education or higher compared to primary education or lower. Possession of health insurance for treatment and living in Dar es Salaam were not significant predictors. Discussion. Future research should focus on patients' understanding of recommended referrals and factors that influence decision-making. Investigating the cost effectiveness of scaling up screening programs and setting up a patient navigation program that follow patients as they complete the recommended treatment plan will be crucial for Tanzania and other developing countries as they seek to launch and strengthen screening programs.

Return on Investment of a Breast Cancer Screening Program in Tanzania: Opportunity for Patient and Public Education.

Breast cancer is the second incident and second cause of cancer mortality among women in Tanzania due to late-stage presentation. The screening clinic at the Ocean Road Cancer Institute (ORCI) can help detect cases early and reduce cost of treatment. We calculated the return on investment (ROI) of the ORCI breast screening clinic. Screening and treatment data of all newly diagnosed breast cancer patients seen at ORCI during 2016-2018 were abstracted from the medical records. Also, data on time, resources, and cost of screening and treatment were obtained. The cost of treating screened patients was compared with cost of treating unscreened patients, and differences in cost of treatment were compared with cost of operating the screening program. Of the 730 total patients, 58 were screened prior to treatment, and 672 were not. There was no significant difference between stage at diagnosis and treatments received by screened and unscreened patients (79.3% late- stage vs 72.2% late-stage diagnosis, respectively (p = .531), or cost of treatment between the two groups (cost, in Tanzanian Shillings, for screened (2,167,155.14 or $954.27) vs unscreened (1,918,592.28 or $844.52), (p = .355). There was also no significant difference in cost of treatment between the screened and unscreened groups and a slightly negative ROI (- 0.05%) from implementing the program. The breast screening clinic in Tanzania has not yet proven its cost-effectiveness in reducing stage with screening. The likelihood that patients have utilized the clinic for treatment rather than early detection is a possible reason for the lack of cost-effectiveness. Future studies should focus on educational initiatives to encourage screening at early disease stage. Public education should increase awareness about the clinic for early detection. The experience of this program is ideal for dissemination to other low-income countries that are initiating cancer early detection and cancer education programs.

Argentina's National Program for Control of Breast Cancer: Time 1, Patient Navigation, and Patient Cancer Education Experience.

Argentina has the second highest mortality rate for breast cancer (BC) in South America. The age-standardized incidence of BC in Argentina is 73 per 100,000. Despite the availability of early detection services, 30% of BCs are diagnosed at advanced disease stages. The National Cancer Institute (NCI) of Argentina and the National Program for Control of Breast Cancer (NPCBC) focus on two main objectives: guaranteeing adequate and timely BC treatment and reducing BC mortality in Argentina. These objectives are addressed by maintaining three core concepts: quality control, disease monitoring, and wide coverage of available early detection and treatment services. The NPCBC is currently implementing the "Time 1 Survey Study." Time 1 is defined as the time from the first appearance of BC signs or symptoms to the first consult within the public healthcare system. This timeframe is important in Argentina because it is outside of the health timeframes and data parameters monitored by the national cancer data registry system. The Time 1 Survey study has the potential to serve as an informational tool for BC patient navigation efforts in Argentina because it can be used to identify and characterize the barriers and delays that women face during Time 1. Lessons and experiences included in this study could be translated to other Latin American and middle-income countries for developing cancer control programs that can lead to improving treatment and reducing mortality through patient navigation and cancer education efforts for the public, health professionals, and patients.

Age-specific burden of cervical cancer associated with HIV: A global analysis with a focus on sub-Saharan Africa.

HIV substantially worsens human papillomavirus (HPV) carcinogenicity and contributes to an important population excess of cervical cancer, particularly in sub-Saharan Africa (SSA). We estimated HIV- and age-stratified cervical cancer burden at a country, regional and global level in 2020. Proportions of cervical cancer (a) diagnosed in women living with HIV (WLHIV), and (b) attributable to HIV, were calculated using age-specific estimates of HIV prevalence (UNAIDS) and relative risk. These proportions were validated against empirical data and applied to age-specific cervical cancer incidence (GLOBOCAN 2020). HIV was most important in SSA, where 24.9% of cervical cancers were diagnosed in WLHIV, and 20.4% were attributable to HIV (vs 1.3% and 1.1%, respectively, in the rest of the world). In all world regions, contribution of HIV to cervical cancer was far higher in younger women (as seen also in empirical series). For example, in Southern Africa, where more than half of cervical cancers were diagnosed in WLHIV, the HIV-attributable fraction decreased from 86% in women ≤34 years to only 12% in women ≥55 years. The absolute burden of HIV-attributable cervical cancer (approximately 28 000 cases globally) also shifted toward younger women: in Southern Africa, 63% of 5341 HIV-attributable cervical cancer occurred in women <45 years old, compared to only 17% of 6901 non-HIV-attributable cervical cancer. Improved quantification of cervical cancer burden by age and HIV status can inform cervical cancer prevention efforts in SSA, including prediction of the impact of WLHIV-targeted vs general population approaches to cervical screening, and impact of HIV prevention.

Effects of HIV infection on metastatic cervical cancer and age at diagnosis among patients in Lusaka, Zambia.

OBJECTIVE: To examine the association between the duration of HIV infection and the stage of cervical cancer in Lusaka, Zambia. METHODS: This retrospective case-case study included 1583 cervical cancer patients from the Cancer Diseases Hospital in Lusaka, Zambia. A sub-population of HIV-positive patients with additional clinical HIV information was identified following linkage of cancer and HIV databases. Logistic regression models examined the relationship between HIV status and early-onset cervical cancer diagnosis, and between HIV infection duration and initial diagnosis of metastatic cervical cancer. RESULTS: The study population had an average age of 49 years and 40.9% had an initial diagnosis of metastatic cancer. HIV-positive women were more than twice as likely to be diagnosed at early-onset cervical cancer compared with HIV-negative women. Among the sub-population of HIV-positive patients, a longer duration of HIV infection was associated with 20% lowered odds of initial metastatic cancer diagnosis. CONCLUSION: The availability, accessibility, and impact of the cervical screening program in this population should be further examined to elucidate the relationship between cervical screening, age, and duration of HIV infection and the the stage of diagnosis of cervical cancer.

Imaging Modalities in Inflammatory Breast Cancer (IBC) Diagnosis: A Computer-Aided Diagnosis System Using Bilateral Mammography Images.

Inflammatory breast cancer (IBC) is an aggressive type of breast cancer. It leads to a significantly shorter survival than other types of breast cancer in the U.S. The American Joint Committee on Cancer (AJCC) defines the diagnosis based on specific criteria. However, the clinical presentation of IBC in North Africa (Egypt, Morocco, and Tunisia) does not agree, in many cases, with the AJCC criteria. Healthcare providers with expertise in IBC diagnosis are limited because of the rare nature of the disease. This paper reviewed current imaging modalities for IBC diagnosis and proposed a computer-aided diagnosis system using bilateral mammograms for early and improved diagnosis. The National Institute of Cancer in Egypt provided the image dataset consisting of IBC and non-IBC cancer cases. Type 1 and Type 2 fuzzy logic classifiers use the IBC markers that the expert team identified and extracted carefully. As this research is a pioneering work in its field, we focused on breast skin thickening, its percentage, the level of nipple retraction, bilateral breast density asymmetry, and the ratio of the breast density of both breasts in bilateral digital mammogram images. Granulomatous mastitis cases are not included in the dataset. The system's performance is evaluated according to the accuracy, recall, precision, F1 score, and area under the curve. The system achieved accuracy in the range of 92.3-100%.

Mentoring in Global Cancer Research Training.

This manuscript illustrates general concepts of mentoring in low- and middle-income countries (LMICs). The focus of this manuscript is on public health research based on our experiences with the Cancer Epidemiology Education in Special Populations (CEESP) Program which is further illustrated in this Supplement. While the CEESP Program provides research training in global and US minority settings, this manuscript is focused on the global aspects of the program. We describe the process of selecting students into the CEESP Program, the process of mentoring them, and the preparation of the mentoring sites. We emphasize the review of the CEESP mentors in LMICs and put forward recommendations for enhancing their mentoring skills and disseminating the experience to other US and global institutions interested in global cancer education.

Lessons learned, Summary, Challenges, and Recommendations.

In this final section, we summarize the different manuscripts included in his Supplement and outline the lessons learned. We also elaborate on the common educational challenges reported in the included articles and the possible recommendations for future global cancer education.

Developing and Maintaining a Global Research Training Infrastructure for Cancer Education.

This manuscript illustrates the 20-year process of establishing research sites that have been developed and maintained by the authors in collaboration with oncology colleagues at institutions in low- and middle-income countries. This infrastructure has been created for research training of US public health graduate students over the past 20 years for the Cancer Epidemiology Education in Special Populations (CEESP) Program funded by the US National Cancer Institute (R25 CA112383). We describe the history and resources that were utilized for developing and maintaining the research training infrastructure. We then define the elements needed for selecting and nurturing these global sites for education and research training of students. The elements include data and field resources, patient population, facilities for cancer management, laboratory resources, academic collaborators, and population parameters and cultural characteristics. These elements have also been essential in our US domestic training sites. We then emphasize the strengths and limitations of our global sites. Finally, we elaborate on our learning experience over the past 20 years. We believe that the material provided in this manuscript will serve as a useful toolkit for faculty, mentors, students, and trainees interested developing and/or utilizing research sites for cancer epidemiology and cancer prevention and control research training programs in global settings.

Grit as a Key Factor in the Ability of Students to Achieve Productive Global Field Research.

Global fieldwork is an invaluable educational experience for students who aspire to pursue careers as global public health professionals and cancer experts. Student-led research projects can be mutually beneficial for students and host institutions by providing opportunities for bilateral learning, sharing resources, building databases, and ultimately creating uniquely informed multi-cultural health research relevant to global communities. The USA-host country partnerships can be delicate, requiring tactful approaches to the investment in the careers of students and the field projects. The US and host institutions must therefore be selective in determining which students have the privilege of participating in global field work. This paper examines the importance of grit as a character trait contributing to the success of student-led global health research projects. Grit has been explored at length as a predictor of student success in domestic educational experiences, yet is underrepresented in the context of global education, field training, and evaluation of research and learning outcomes. This manuscript utilizes testimonials of three public health graduate students recently returned from summer cancer epidemiology education training fellowships to explore the role that grit played in completion of their independent research projects. Ultimately, this paper discusses ways to identify grit in student applicants and to foster an improved capacity for grit before, during, and after their field experiences. We share the experiences with an aim of providing participant perspectives that may be used by educators, students, and administrators at US and international partner institutions to inform global research, experiential learning, and educational and training programs.

Needs for Cancer Education In Oman Based on the Breast Cancer Screening Program.

Most breast cancers in Oman are diagnosed at advanced stages and therefore early detection is important. The Oman Cancer Association (OCA) initiated a mobile mammography program in 2009, but no studies have evaluated its impact. This study aimed at estimating the proportion and predictors of OCA-screened women who had repeated mammography (adherence) and the sensitivity and specificity of the program. Demographic, screening, diagnosis, and treatment data of 13,079 women screened in the OCA mammography clinic from 2009 to 2016, and medical records of all breast cancer patients seen at Royal and Sultan Qaboos University hospitals during the same period were retrieved. Logistic regression analysis was conducted to identify predictors of adherence. A total of 8278 screened women over age 42 years (median age of 50 ± 8 years) were included in the study. Only 18% of initially negative screened women were compliant with recommended subsequent screening. Predictors of adherence included age (50-69 years), family history of cancer, family history of breast cancer, and breast self-examination. The overall cancer detection rate was 4.1/1000 screened women. Positive predictive value of screening was 4.7% with a sensitivity rate of 53% and specificity of 92%. This study showed a low mammography adherence among previously screened women. The study revealed low sensitivity, high specificity, and an acceptable cancer detection rate. Future programs should focus on improving data collection of screened women, maintaining the linkage of databases of screening and treatment clinics, and developing guidelines for breast cancer screening in Oman. The recommendations based on the study results should be incorporated into future professional, patient, and public cancer education programs.

Field Research Experience of Medical Students: Learning and Translation from Global to Underserved US Settings.

While most medical schools in the USA provide opportunities for global health experiences, global health education is not included consistently or emphasized adequately in many medical school curricula. The City University of New York Medical School (CSOM) has a mission to educate and train students who are traditionally underrepresented in medicine to practice primary care in medically underserved communities in New York. This manuscript documents the experience of the CSOM in expanding global health education by introducing a new global health cancer training program, partnering with clinicians at the Ocean Road Cancer Institute (ORCI) in Tanzania. This manuscript illustrates the following points: (1) the CSOM curriculum that focuses on community health and social medicine; (2) the process by which students learn by developing research proposals for global cancer; (3) the field research experience and lessons learned; (4) learning about cancer and medicine in a developing country; and (5) lessons learned for translation from global to domestic underserved populations. We also suggest a checklist for future students interested in pursuing global cancer education and research, and recommendations for maximizing learning and career development of students interested in global cancer research and its application to underserved populations in the USA.

Developing Research Education Groups in African Cancer Centers: The Experience in Tanzania.

Research productivity and outcomes of junior researchers are usually correlated with the degree and quality of mentorship they receive. A bottom-up approach was followed to develop a research group at the Ocean Road Cancer Institute (ORCI), the major cancer center in Tanzania, to build upon the existing clinical and research resources and institutional global collaborations. The ORCI is a clinical center focused on radio- and chemo-therapy treatment of cancer patients from all over Tanzania. In addition, ORCI has a long-standing early detection program for educating women and screening them for cervical cancer. The ORCI physicians have been exposed to cancer research for the past 20 years through non-degree and degree training in the USA and Europe. In addition, US and European groups have been conducting collaborative research and training of oncologists and graduate students at ORCI. The exposure to research through the above-listed venues motivated the clinicians at ORCI to develop their own Research Club (RC) to learn about research methods, seek independent funding, and outline a research agenda for cancer research in Tanzania. However, it seems that mentorship is needed to help the RC members apply the lessons learned from didactic teaching. Mentorship is also needed to enable the RC members to utilize the enormous clinical and epidemiologic data generated by the institutional programs for prevention, treatment, and follow up of patients. This manuscript describes the inception of the program and its achievements, limitations, and suggested opportunities for improvement as a possible model for other LMICs.