Understanding the challenges of delivering radiotherapy in low- and middle-income countries in Africa.

BACKGROUND: Access to high quality radiotherapy (RT) continues to be a major issue across Africa with Africa having just 34% of its optimal capacity. METHODS: We co-developed a survey with clinical, academic and policy stakeholders designed to provide a structured assessment of the barriers and enablers to RT capacity building in Africa. The survey covered nine key themes including funding, procurement, education and training. The survey was sent to RT professionals in 28 countries and the responses underwent qualitative and quantitative assessment. RESULTS: We received completed questionnaires from 26 African countries. Funding was considered a major issue, specifically the lack of a ring fenced funds from the Ministry of Health for radiotherapy and the consistency of revenue streams which relates to a lack of prioritisation for RT. In addition to a significant shortfall in RT workforce disciplines, there is a general lack of formal education and training programmes. 13/26 countries reported having some IAEA support for RT for education and training. Solutions identified to improve access to RT include a) increasing public awareness of its essential role in cancer treatment; b) encouraging governments to simplify procurement and provide adequate funding for equipment; c) increasing training opportunities for all radiotherapy disciplines and d) incentivizing staff retention. CONCLUSION: This survey provides unique information on challenges to delivering and expanding radiotherapy services in Africa. The reasons are heterogonous across countries but one key recommendation would be for national Cancer Control plans to directly consider radiotherapy and specifically issues of funding, equipment procurement, servicing and training. POLICY SUMMARY: The study demonstrates the importance of mixed methods research to inform policy and overcome barriers to radiotherapy capacity and capability in LMICs.

The UK's contribution to cancer control in low-income and middle-income countries.

Cancer mortality rates in low-income and middle-income countries (LMICs) are unacceptably high, requiring both collaborative global effort and in-country solutions. Experience has shown that working together in policy, clinical practice, education, training, and research leads to bidirectional benefit for LMICs and high-income countries. For over 60 years, the UK National Health Service has benefited from recruitment from LMICs, providing the UK with a rich diaspora of trained health-care professionals with links to LMICs. A grassroots drive to engage with partners in LMICs within the UK has grown from the National Health Service, UK academia, and other organisations. This drive has generated a model that rests on two structures: London Global Cancer Week and the UK Global Cancer Network, providing a high-value foundation for international discussion and collaboration. Starting with a historical perspective, this Series paper describes the UK landscape and offers a potential plan for the future UK's contribution to global cancer control. We also discuss the opportunities and challenges facing UK partnerships with LMICs in cancer control. The UK should harness the skills, insights, and political will from all partners to make real progress.

The impact of the COVID-19 pandemic on radiotherapy services in England, UK: a population-based study.

BACKGROUND: The indirect impact of the COVID-19 pandemic on cancer outcomes is of increasing concern. However, the extent to which key treatment modalities have been affected is unclear. We aimed to assess the impact of the pandemic on radiotherapy activity in England. METHODS: In this population-based study, data relating to all radiotherapy delivered for cancer in the English NHS, between Feb 4, 2019, and June 28, 2020, were extracted from the National Radiotherapy Dataset. Changes in mean weekly radiotherapy courses, attendances (reflecting fractions), and fractionation patterns following the start of the UK lockdown were compared with corresponding months in 2019 overall, for specific diagnoses, and across age groups. The significance of changes in radiotherapy activity during lockdown was examined using interrupted time-series (ITS) analysis. FINDINGS: In 2020, mean weekly radiotherapy courses fell by 19·9% in April, 6·2% in May, and 11·6% in June compared with corresponding months in 2019. A relatively greater fall was observed for attendances (29·1% in April, 31·4% in May, and 31·5% in June). These changes were significant on ITS analysis (p<0·0001). A greater reduction in treatment courses between 2019 and 2020 was seen for patients aged 70 years or older compared with those aged younger than 70 years (34·4% vs 7·3% in April). By diagnosis, the largest reduction from 2019 to 2020 in treatment courses was for prostate cancer (77·0% in April) and non-melanoma skin cancer (72·4% in April). Conversely, radiotherapy courses in April, 2020, compared with April, 2019, increased by 41·2% in oesophageal cancer, 64·2% in bladder cancer, and 36·3% in rectal cancer. Increased use of ultra-hypofractionated (26 Gy in five fractions) breast radiotherapy as a percentage of all courses (0·2% in April, 2019, to 60·6% in April, 2020; ITS p<0·0001) contributed to the substantial reduction in attendances. INTERPRETATION: Radiotherapy activity fell significantly, but use of hypofractionated regimens rapidly increased in the English NHS during the first peak of the COVID-19 pandemic. An increase in treatments for some cancers suggests that radiotherapy compensated for reduced surgical activity. These data will assist health-care providers in understanding the indirect consequences of the pandemic and the role of radiotherapy services in minimising these consequences. FUNDING: None.

Saving the critically injured trauma patient: a retrospective analysis of 1000 uses of intraosseous access.

OBJECTIVE: Intraosseous access (IO) is becoming increasingly accepted in adult populations as an alternative to peripheral vascular access; however, there is still insufficient evidence in large patient groups supporting its use. METHODS: Retrospective review. This paper reports on the use of IO devices over a 7-year period from August 2006 to August 2013 during combat operations in Afghanistan. A database search of the Joint Theatre Trauma Registry (JTTR) was carried out looking for all the incidences of IO access use during this time. Excel (Microsoft) was used to manage the dataset and perform descriptive statistics on the patient demographics, injuries, treatments and complications that were retrieved. RESULTS: 1014 IO devices were used in 830 adult patients with no major complications. The rate of minor complications, the majority of which were device failure, was 1.38%. 5124 separate infusions of blood products or fluids occurred via IO access, with 36% being of packed red cells. On average, each casualty received 6.95 different infusions of blood products and fluids, and 3.28 separate infusions of drugs through IO access. 32 different drugs were infused to 367 patients via IO, the most frequent being anaesthetic agents. IO access was used in the prehospital environment, during tactical helicopter evacuation and within hospitals. CONCLUSIONS: IO access can be used to administer a wide variety of life-saving medications quickly, easily and with low-complication rates. This highlights its valuable role as an alternative method of obtaining vascular access, vital when resuscitating the critically injured trauma patient.

Development of a community nursing drug chart.

In April 2011, three providers of community services in Brent and Ealing, in London, and Harrow, in Middlesex, integrated with an acute NHS provider, Ealing Hospital. As part of a newly merged integrated care organisation, the community health services pharmacist undertook an extensive review of all medicines management processes and activities to ensure that they were safe. One of the recommendations of the review was to harmonise processes, practices, policies and guidance documents between the three community services providers. This article describes the process of developing a community nursing drug chart, which involved auditing drug administration in community nursing sites across the three boroughs, consulting a focus group of nursing service leads and assessing how the chart compared with national standards. The aim of the article is to share the process and the drug chart with other community service providers.

Unilateral Optic Disc Papilloedema following Administration of Carboplatin Chemotherapy for Ovarian Carcinoma.

A 48-year-old woman with a positive BRCA1 gene mutation was diagnosed with stage 3b high-grade ovarian endometrioid carcinoma. She was treated with adjuvant carboplatin at a dose of 740 mg (AUC 6) in 3-weekly cycles. Five days after her fifth cycle of carboplatin, she awoke with new-onset blurred vision in her left eye. An ophthalmology review showed left-sided disc oedema with normal optic nerve function tests and 6/24 visual acuity. A CT scan of the head and orbits was performed which showed no evidence of metastasis or raised intracranial pressure. An autoimmune screen was performed which did not reveal any explanation for her visual symptoms. Fundus fluorescein angiography showed bilateral intense late disc leakage with no evidence of vasculitis. Her chemotherapy was stopped in view of a radiological and biochemical remission and her visual symptoms were monitored. She was also started on a tapering dose of prednisolone 40 mg daily. Five months after the initial review, she has developed left optic disc atrophy with 6/18 visual acuity, while the right eye remains asymptomatic. The diagnosis was felt to be that of carboplatin-induced unilateral disc oedema, a very rare side effect of this chemotherapy.

Rational care or rationing care? The case of cervical screening across the United Kingdom.

In 2003, The National Health Service Cervical Screening Programme (NHSCSP) in England modified its recommendation by increasing the age at which to begin screening from 20 to 25. This was on the grounds that normal changes in the cervix before the age of 25 are often identified during screening as being abnormal, resulting in many young women receiving unnecessary treatment at both a significant psychological cost to the patient and a financial cost to the service. In 2011, the cervical screening programme in Northern Ireland was also amended followed closely by Scotland in late 2012. Some 10 years later, Wales finally altered cervical screening policy in January 2013 and now invite women for an initial screen at the age of 25, in line with the rest of the United Kingdom (UK). The withdrawal of cervical screening from 20 to 24 years in England was the first occasion globally, where a population cancer screening programme was withdrawn. Although the changes in England were perceived by some as "rational care" - as they encourage utilisation of beneficial services while discouraging use of those that may lead to more harms than benefits, many people also believe them to be "rationing care". In fact, even now, a decade on from the policy alterations in England, people are still vociferously exhibiting their discontent at the decision; exacerbated by national media headlines such as: "Denying young women smear tests is a disgrace". Yet with recent, rather alarming analysis of trends in England suggesting a rise in the incidence of cervical cancer in young women, it seems of great public health interest to consider whether such a rise is attributable to reduced cervical screening activity and reflect on whether the decision to alter cervical screening policy for those under the age of 25 was, in fact, a rational and correct decision.

Enhanced primary care. A rural perspective.

BACKGROUND: The Enhanced Primary Care (EPC) program is designed to promote better management of and improved health outcomes for people with chronic illness. Specific Medicare item numbers provide government funding to encourage general practitioners to take up health assessments, care plans and case conferences. AIM: We investigated elements of the EPC program from a rural general practice perspective. METHOD: Questionnaires summarising experience of EPC for patients and health care providers, undertaken over four weeks at three rural general practices, and observation. RESULTS: The EPC program assisted the management and coordination of care for patients with multidisciplinary care needs. General practitioners were generally positive about the EPC program. The main barrier was the extra time required. The main concern of allied health workers was the lack of appropriate remuneration for their participation. Patients were positive in their responses, but many appeared to lack the motivation and self management skills to take full advantage of the program. DISCUSSION: Strategies seeking to increase the uptake of EPC items need to address efficiency and accessibility, and funding for participating health professionals.