A Multimodal Generative AI Copilot for Human Pathology.

The field of computational pathology[1,2] has witnessed remarkable progress in the development of both task-specific predictive models and task-agnostic self-supervised vision encoders[3,4]. However, despite the explosive growth of generative artificial intelligence (AI), there has been limited study on building general purpose, multimodal AI assistants and copilots[5] tailored to pathology. Here we present PathChat, a vision-language generalist AI assistant for human pathology. We build PathChat by adapting a foundational vision encoder for pathology, combining it with a pretrained large language model and finetuning the whole system on over 456,000 diverse visual language instructions consisting of 999,202 question-answer turns. We compare PathChat against several multimodal vision language AI assistants and GPT4V, which powers the commercially available multimodal general purpose AI assistant ChatGPT-4[7]. PathChat achieved state-of-the-art performance on multiple-choice diagnostic questions from cases of diverse tissue origins and disease models. Furthermore, using open-ended questions and human expert evaluation, we found that overall PathChat produced more accurate and pathologist-preferable responses to diverse queries related to pathology. As an interactive and general vision-language AI Copilot that can flexibly handle both visual and natural language inputs, PathChat can potentially find impactful applications in pathology education, research, and human-in-the-loop clinical decision making.

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.

Impact of the universal health insurance benefits on cervical cancer mortality in Colombia.

BACKGROUND: Cervical cancer patients in Colombia have a lower likelihood of survival compared to breast cancer patients. In 1993, Colombia enrolled citizens in one of two health insurance regimes (contributory-private insurance and subsidized- public insurance) with fewer benefits in the subsidized regime. In 2008, the Constitutional Court required the Colombian government to unify services of both regimes by 2012. This study evaluated the impact of this insurance change on cervical cancer mortality before and after 2012. METHODS: We accessed 24,491 cervical cancer mortality records for 2006-2020 from the vital statistics of Colombia's National Administrative Department of Statistics (DANE). We calculated crude mortality rates by health insurance type and departments (geopolitical division). Changes by department were analyzed by rate differences between 2006 and 2012 and 2013-2020, for each health insurance type. We analyzed trends using join-point regressions by health insurance and the two time-periods. RESULTS: The contributory regime (private insurance) exhibited a significant decline in cervical cancer mortality from 2006 to 2012, characterized by a noteworthy average annual percentage change (AAPC) of -3.27% (P = 0.02; 95% CI [-5.81, -0.65]), followed by a marginal non-significant increase from 2013 to 2020 (AAPC 0.08%; P = 0.92; 95% CI [-1.63, 1.82]). In the subsidized regime (public insurance), there is a non-significant decrease in mortality between 2006 and 2012 (AAPC - 0.29%; P = 0.76; 95% CI [-2.17, 1.62]), followed by a significant increase from 2013 to 2020 (AAPC of 2.28%; P < 0.001; 95% CI [1.21, 3.36]). Examining departments from 2013 to 2020 versus 2006 to 2012, the subsidized regime showed fewer cervical cancer-related deaths in 5 out of 32 departments, while 6 departments had higher mortality. In 21 departments, mortality rates remained similar between both regimes. CONCLUSION: Improvement of health benefits of the subsidized regime did not show a positive impact on cervical cancer mortality in women enrolled in this health insurance scheme, possibly due to unresolved administrative and socioeconomic barriers that hinder access to quality cancer screening and treatment.

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.

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.

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%.

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.

Factors influencing cervical cancer screening among pregnant women in Nairobi, Kenya.

To characterize cervical cancer screening knowledge, beliefs, behaviors, and sociodemographic factors among women aged 25-45 years who access and utilize prenatal care services in Nairobi, Kenya. A descriptive cross-sectional design using a convenience sample of pregnant women receiving prenatal health services at a public and a private hospital in Nairobi, Kenya. Constructs from the Health Belief Model (HBM) guided the design, interpretation of the results, and recommendations. Data were analyzed using SPSS version 24. Bivariate analyses were conducted to examine associations between variables. There was a significant association (p=0.001) between knowledge and screening behaviors. There was no association (p=0.066) between cervical cancer beliefs (perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and self-efficacy) and screening behaviors. Knowledge and beliefs influence cervical cancer screening behavior. Low cervical cancer screening uptake substantiates the need for tailoring culturally specific health behavior change communication to address misconceptions about cervical cancer screening in Kenya.

Downstaging of cervical cancer in Tanzania over a 16-year period.

Globally, the highest cervical cancer mortality rates are found in East Africa. Visual inspection with acetic acid (VIA)-based screening in resource-poor settings has been shown to decrease the proportion of women presenting with late-stage cervical cancer, a process known as clinical downstaging. The only cancer treatment center in Tanzania, Ocean Road Cancer Institute (ORCI) in Dar es Salaam, opened a VIA-based cervical cancer screening program in 2002. We reviewed 6,676 medical records of cervical cancer patients at the ORCI from 2002-2011 to 2014-2018 for stage at diagnosis and screening status, among other variables. We investigated whether clinical downstaging occurred in this period among women screened at the ORCI, when compared to unscreened women. Our results indicated that the proportion of women presenting with late-stage cervical cancer among women screened at the ORCI decreased by 27.7% over the 16-year period (χ2 = 16.99; p = 0.0002). Among unscreened women, a non-significant 13.2% decrease in late-stage disease was observed (χ2 = 1.74; p = 0.4179). Our results suggest clinical downstaging occurred among women screened at the ORCI over the 16-year period, and this difference may be attributed to the screening program as the same decrease in stage was not observed among unscreened women during the same time period. At present, less than one percent of Tanzanian women receive yearly cervical cancer screenings. Access to screening through expansion of the ORCI screening clinic and the creation of more clinics should be prioritized.

Comparison of Urban-Rural Readmission Rates After Colorectal Cancer Surgery: Findings From a Privately Insured Population.

OBJECTIVES: We assessed the 30-day readmission rate of a privately insured population diagnosed with colorectal cancer (CRC) who had primary tumor resection in rural and urban communities. METHODS: Claims data of people aged <65 with a diagnosis of CRC between 2012 and 2016 and enrolled in a private health plan administered by BlueCross BlueShield of Nebraska were analyzed. Readmission was defined as the number of discharged patients who were readmitted within 30 days, divided by all discharged patients. Multivariate logistic regression was used to estimate the factors associated with readmission. RESULTS: The urban population had a higher readmission rate (11%) than the rural population (8%). Although the adjusted odds ratio showed that there is no difference in readmission between rural and urban residents, patients with a Charlson Comorbidity Index (CCI) of >1 were more likely than those without CCI to be readmitted (OR 3.59, 1.41-9.11). Patients with open vs. laparoscopic surgery (OR 2.80, 1.39-5.63) and those with an obstructed or perforated colon vs. none (OR 7.17, 3.75-13.72) were more likely to be readmitted. CONCLUSIONS: Readmission after CRC surgery occurs frequently. Interventions that target the identified risk factors should reduce readmission rates in this privately insured population.

Health workers' perspectives on barriers and facilitators to implementing a new national cervical cancer screening program in Ethiopia.

BACKGROUND: Cervical cancer disproportionately affects women in sub-Saharan Africa, compared with other world regions. In Ethiopia, a National Cancer Control Plan published in 2015, outlines an ambitious strategy to reduce the incidence and mortality of cervical cancer. This strategy includes widespread screening using visual inspection with acetic acid (VIA). As the national screening program has rolled out, there has been limited inquiry of provider experiences. This study aims to describe cancer control experts' perspectives regarding the cancer control strategy and implementation of VIA. METHODS: Semi-structured interviews with 18 participants elicited provider perspectives on cervical cancer prevention and screening. Open-ended interview questions queried barriers and facilitators to implementation of a new national screening program. Responses were analyzed using thematic analysis and mapped to the Integrated Behavioral Model. Participants were health providers and administrators with positionality as cancer control experts including screening program professionals, oncologists, and cancer focal persons at town, zone, and federal health offices at eleven government facilities in the Arsi, Bale, and Shoa zones of the Oromia region, and in the capital Addis Ababa. RESULTS: The cancer control plan and screening method, VIA, were described by participants as contextually appropriate and responsive to the unique service delivery challenges in Ethiopia. Screening implementation barriers included low community- and provider-awareness of cervical cancer and screening, lack of space and infrastructure to establish the screening center, lack of materials including cryotherapy machines for the "screen-and-treat" approach, and human resource issues such as high-turnover of staff and administration. Participant-generated solutions included additional training for providers, demand creation to increase patient flow through mass media campaigns, decentralization of screening from large regional hospitals to local health centers, improved monitoring and evaluation, and incentivization of screening services to motivate health providers. CONCLUSIONS: As the Ethiopian government refines its Cancer Control Plan and scales up screening service implementation throughout the country, the findings from this study can inform the policies and practices of cervical cancer screening. Provider perspectives of barriers and facilitators to effective cancer control and screening implementation reveal areas for continued improvement such as provider training and coordination and collaboration in the health system.

Epithelial Ovarian Cancer and Cancer Stem Cells.

Epithelial ovarian cancer is a lethal gynecological cancer. It is related to high mortality because the majority of the patients present in advanced stage and because of the high recurrence rates of the disease. Recurrent ovarian cancer is classified according to the time interval between the last platinum-based chemotherapy and the occurrence of recurrence, to platinum-sensitive and platinum-resistant. Many theories tried to explain development of resistance to platinum-based therapy. "Cancer stem cells" is one of these theories and is being currently under investigation by many groups. This chapter will demonstrate the suggested contribution of cancer stem cells to the development of recurrent ovarian cancer.

Experiential Learning in Career Development.

This manuscript demonstrates the learning experiences of graduate public health students through mentored field research in cancer epidemiology and cancer prevention over the past 13 years. The program has been funded through an R25 grant from the National Cancer Institute (NCI) since 2006 and has supported nearly 200 students from different universities in the USA. Included are data on student recruitment, selection, mentorship, and evaluation of research training in US minority settings as well as foreign countries. Examples of students' learning experiences and life-long skills that shaped students' careers are presented. The insights that fostered the experiential learning idea among key leaders at the NCI Cancer training branch have proven to be sound.

Medical Oncology Education in Egypt Over the Past 50 Years: the Experience of the National Cancer Institute of Cairo University.

This manuscript outlines the progress of education in the field of medical oncology in Egypt over the past 50 years. The manuscript illustrates the origin of the Egyptian medical oncology program since the creation of the only specialized cancer center in the country, the National Cancer Institute of Cairo University (NCI-Cairo) in 1969, from Cairo University Medical School. The manuscript also outlines the NCI-Cairo's educational program for developing a cadre of academic medical oncologists for NCI-Cairo, other Egyptian medical institutions, and countries in the Middle East and Africa. We also emphasize the capacity building that resulted over the past 50 years from academic and professional standpoints, the changing curriculum in medical oncology, and the differences between the medical oncology and clinical oncology education programs in the country. Medical oncology research resulted from international collaborations and highlighted needs for cancer prevention and control. Finally, we propose possible future directions for medical oncology education and research in the country and a roadmap for low- and middle-income countries (LMICs) that are developing their medical oncology programs.

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.

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.

Global Aspects of the Cancer Epidemiology Education in Special Populations (CEESP) Program.

This manuscript provides a brief overview of the global aspects of the Cancer Epidemiology Education in Special Populations (CEESP) Program. The overview illustrates program history, aims, progress, evaluation, and dissemination. This manuscript sets the stage for the CEESP manuscripts included in this supplement that illustrate in the program infrastructure, mentoring, the student experiences, and unique features of students for achieving success. In this manuscript, we briefly outline some of the dissemination examples that resulted from utilizing the CEESP infrastructure, as outlined in some of the articles reporting on global research training sites from Egypt, Morocco, Oman, and Tanzania.

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.