Updates in global oncology: Advancements and future directions.

Globally, cancer is the second leading cause of death, and low- and middle-income countries bear most of the disease burden. While cancer is increasingly recognized as a major global health issue, more work remains. Understanding the status of global cancer care will shape the next steps in ensuring equitable global access to cancer care. This article highlights ongoing initiatives in global oncology and the next steps in advancing the field.

Improving access to breast cancer screening and treatment in Nigeria: The triple mobile assessment and patient navigation model (NCT05321823): A study protocol.

BACKGROUND: In Nigeria, breast cancer incidence is rising, late presentation is common, and outcomes are poor. Patient-related factors such as lack of awareness and misperceptions in addition to health system deficiencies such as lack of a clearly defined framework for breast cancer screening and referral are some of the major drivers of this poor outlook. Guidelines for breast cancer screening in high-income countries have limited applicability in low-middle-income countries, hence the need for innovative, resource-compatible strategies to combat the negative trend. This manuscript presents our study protocol which aims to evaluate the impact of a novel breast cancer early detection program developed to address delayed presentation and lack of access to diagnostic and treatment facilities in South-West Nigeria. This entails the use of mobile technology (innovative handheld iBreast Exam [iBE] device, mobile breast ultrasound, and mobile mammography) and patient navigation as interventions at the community level. METHODS: The study (ClinicalTrials.gov identifier: NCT05321823) will adopt a randomized two group clinical trial design with one local government area (LGA) serving as an intervention arm and another serving as the control. Both LGAs will receive breast cancer awareness education but only one will receive the interventions. In the intervention arm, asymptomatic (40-70 years) and symptomatic (30-70 years) women will be invited for breast evaluation which will be performed by trained Community Health Nurses using Clinical Breast Exam (CBE), and iBE. Those with positive findings will proceed to imaging using mobile mammography and ultrasound brought to the LGA every month. Symptomatic women with negative findings on CBE and iBE will be scheduled for repeat clinical evaluation on a short-term basis (one month). The Radiologist will obtain core needle biopsies as indicated and transfer them for prompt pathological assessment. Women presenting to the Primary Healthcare Centers in the control LGA will be referred directly to Obafemi Awolowo University Teaching Hospitals Complex as per the current standard of care. Records of all breast cancer cases seen in the two LGAs during the study period will be obtained. The program metrics will include screening participation rate, cancer detection rate, stage at diagnosis, and timeline from detection to initiation of treatment. The stage at diagnosis and timeline from detection to treatment compared between the two LGAs will be used to assess the impact of the intervention. The study is proposed for 2 years; however, a descriptive analysis will be carried out at 1.5 years to evaluate the retention of the study participants. STUDY SIGNIFICANCE: It is anticipated that this study will provide vital data to support wider breast cancer screening efforts in Nigeria.

The out-of-pocket cost of breast cancer care at a public tertiary care hospital in Nigeria: an exploratory analysis.

Introduction: in Nigeria, the incidence of breast cancer has increased by over 80% in the last four decades. This study quantifies the out-of-pocket (OOP) cost of breast cancer management and the associated rate of catastrophic healthcare expenditure (CHE) at a public tertiary care facility in Ile-Ife, Nigeria. Methods: patients treated between December 2017 - August 2018 were identified from a prospective breast cancer database. A questionnaire was developed to capture the total cost of care, including direct and indirect expenses. Three commonly used thresholds for a CHE were used in this analysis. The cost of radiotherapy and targeted therapy were captured separately. Results: data was collected from 22 eligible patients. Sixty-eight percent had no form of health insurance. The mean cost of diagnosis and treatment was $2,049 (SD $1,854). At a threshold of 10% and 25% of annual income, 95% and 86% of households experienced a CHE. Based on a household´s capacity-to-pay, 90% experienced a CHE. The mean cost of radiotherapy was $462 (SD $223) and the mean cost of trastuzumab was $6,568 (SD $2,766). Cost precluded surgery in 14% of patients with resectable disease. As a result of accessing treatment, 72% of households had to borrow money and 9% of households interrupted a child´s education. Conclusion: the out-of-pocket cost of breast cancer care in Nigeria is significant. This results in a CHE for 68-95% of households, which has significant health and economic sequelae. Greater financial protection is essential as the burden of breast cancer increases in Nigeria.

Healthcare utilisation, cancer screening and potential barriers to accessing cancer care in rural South West Nigeria: a cross-sectional study.

BACKGROUND/AIMS: Cancer burden is predicted to double by 2030 in sub-Saharan Africa; access to healthcare services for cancer management is a priority in the region. In Nigeria, National Cancer Control Plan aims to ensure >50% cancer screening of eligible populations by 2022 for all Nigerians. We describe healthcare utilisation, cancer screening activities and potential barriers to accessing cancer care within an understudied rural community-based adult population in South West Nigeria. METHODS: In April 2018, we conducted a cross-sectional study of community-based adults (>18 years) ~130 km east of Ibadan, 250 km from Lagos in Osun State, South West Nigeria. Participants completed a face-to-face survey in local dialect. We used a questionnaire to assess demographics, health status, income, medical expenditures, doctor visits and cancer screening history. RESULTS: We enrolled 346 individuals: with median age of 52 years and 75% women. Of the entire cohort, 4% had medical insurance. 46% reported a major medical cost in the last year. Cancer screening activities were infrequent in eligible participants: 1.5% reported having had cervical cancer screening, 3.3% mammogram and 5% colonoscopy screening. Cancer screening assessment was less frequent in those with less income and lower education levels. Using a multivariable logistic regression model including personal income, insurance status and education, higher personal income was associated with more cancer screening activity (OR 2.7, 95% CI 1.3 to 5.7, p<0.01). Despite this, most individuals had contact with a primary healthcare doctor (52% in the last year), and over 70% access to radio and TV suggesting the opportunity to expand community-based screening interventions and awareness exists. CONCLUSIONS: Despite national increases in cancer cases, we highlight a deficiency in cancer screening and universal healthcare coverage within a community-based adult Nigerian population. Subject to availability of governmental resources, increasing financial risk protection, awareness and targeted resource allocation may help expand access in Nigeria.

Designing Participatory Needs Assessments to Support Global Health Interventions in Time-Limited Settings: A Case Study From Nigeria.

Social scientists have advocated for the use of participatory research methods for Global Health project design and planning. However, community-engaged approaches can be time and resource-intensive. This article proposes a feasible framework for conducting a participatory needs assessment in time-limited settings using multiple, triangulated qualitative methods. This framework is outlined through a case study: a participatory needs assessment to inform the design of an ultrasound-guided biopsy training program in Nigeria. Breast cancer is the leading cause of death for Nigerian women and most cases in Nigeria are diagnosed at an advanced stage; timely diagnosis is impeded by fractious referral pathways, costly imaging equipment, and limited access outside urban centers. The project involved participant observation, surveys, and focus groups at the African Research Group for Oncology (ARGO) in Ile-Ife, Nigeria. Through this timely research and engagement, participants spoke about diagnostic challenges, institutional power dynamics, and infrastructure considerations for program implementation.

A symptom-based model to predict colorectal cancer in low-resource countries: Results from a prospective study of patients at high risk for colorectal cancer.

BACKGROUND: Colorectal cancer (CRC) rates in low-resource countries, which typically lack CRC screening programs, are rising. This study determined whether a risk model for patients with rectal bleeding could identify patients with curable CRC. METHODS: This prospective, cross-sectional study evaluated a model constructed from data from 1 hospital and validated at 2 other hospitals. The primary endpoint was the ability of the model to predict CRC, as diagnosed by colonoscopy, from clinical characteristics. The secondary endpoint was to determine the percentage of patients who had CRC. RESULTS: Consecutive patients who were 45 years old or older and had self-reported rectal bleeding for more than 1 week were evaluated. From January 2014 to July 2016, 362 patients answered a questionnaire and underwent colonoscopy. In the validation cohort, 56% of patients with rectal bleeding, weight loss, and changes in bowel habits had CRC, whereas 2% of patients with bleeding alone did. Overall, 18.2% of the patients had CRC, and 8.6% had adenomas. The proportion of CRC patients with potentially curable stage II or III disease was 74%, whereas the historical rate was 36%. The combination of rectal bleeding with both symptoms significantly predicted CRC in the validation set (odds ratio, 12.8; 95% confidence interval, 4.6-35.4; P < .001). CONCLUSIONS: In low-resource settings, patients with rectal bleeding, weight loss, and changes in bowel habits should be classified as high risk for CRC. Patients with a high risk score should be prioritized for colonoscopy to increase the number of patients diagnosed with potentially curable CRC. Cancer 2018;124:2766-2773. © 2018 American Cancer Society.

Global cancer surgery: delivering safe, affordable, and timely cancer surgery.

Surgery is essential for global cancer care in all resource settings. Of the 15.2 million new cases of cancer in 2015, over 80% of cases will need surgery, some several times. By 2030, we estimate that annually 45 million surgical procedures will be needed worldwide. Yet, less than 25% of patients with cancer worldwide actually get safe, affordable, or timely surgery. This Commission on global cancer surgery, building on Global Surgery 2030, has examined the state of global cancer surgery through an analysis of the burden of surgical disease and breadth of cancer surgery, economics and financing, factors for strengthening surgical systems for cancer with multiple-country studies, the research agenda, and the political factors that frame policy making in this area. We found wide equity and economic gaps in global cancer surgery. Many patients throughout the world do not have access to cancer surgery, and the failure to train more cancer surgeons and strengthen systems could result in as much as US $6.2 trillion in lost cumulative gross domestic product by 2030. Many of the key adjunct treatment modalities for cancer surgery--e.g., pathology and imaging--are also inadequate. Our analysis identified substantial issues, but also highlights solutions and innovations. Issues of access, a paucity of investment in public surgical systems, low investment in research, and training and education gaps are remarkably widespread. Solutions include better regulated public systems, international partnerships, super-centralisation of surgical services, novel surgical clinical trials, and new approaches to improve quality and scale up cancer surgical systems through education and training. Our key messages are directed at many global stakeholders, but the central message is that to deliver safe, affordable, and timely cancer surgery to all, surgery must be at the heart of global and national cancer control planning.