Understanding referral of patients with cancer in rural Ethiopia: a qualitative study.

BACKGROUND: Cancer incidence is increasing in Ethiopia mainly due to increased life expectancy, while oncological capacities remain limited. Strong referral linkages between different levels of the healthcare system are key to provide timely access to cancer care. In this qualitative study, we assessed limitations and potential of cancer patient referral in the rural Southwest of Ethiopia. METHODS: We held four focus group discussions (FGD) with health professionals at one primary and three secondary hospitals and conducted eight in-depth interviews (IDI) with the hospitals´ medical executives and local health bureau representatives. Data was analysed inductively using thematic analysis and emerging themes were categorized within the revised concept of access by Penchansky and Saurman. RESULTS: The inevitable referral of patients with cancer in the rural Southwest of Ethiopia is characterized by the absence of clear communication protocols and the lack of formal referral linkages. The newly implemented hub-system has improved emergency referrals and could be expanded to non-emergency referrals, sensitive to the needs of advanced oncological care. Liaison officers can pave the way but need to be trained and equipped adequately. Referred patients struggle with inadequate transportation systems, the lack of accommodation close to specialized facilities as well as the inability to navigate at those sites due to language barriers, illiteracy, and stigmatization. Few Non-Governmental Organizations (NGOs) help but cannot compensate the limited governmental support. The shortage of medications at public hospitals leads to patients being directed to costly private pharmacies. In the light of those challenges, cancer remains to be perceived as a "death sentence" within the rural communities. CONCLUSIONS: Standardized referral linkages and a multi-faceted support network throughout the cancer care continuum are necessary to make oncology care accessible to Ethiopia´s large rural population.

Expanding best practices for implementing evidence-based cancer control strategies in Africa: The 2019-2020 Africa Cancer Research and Control ECHO Program.

BACKGROUND: Cancer is a major public health problem which requires evidence-based, resourced and well-managed National Cancer Control Plans (NCCPs). However, challenges exist for African countries in developing and implementing functional NCCPs. Hence, the Africa Cancer Research and Control ECHO Program (Africa Cancer ECHO) aims to increase knowledge and utilization of evidence-based practices to strengthen NCCPs in Africa. METHODS: The 2019-2020 Africa Cancer ECHO employed the Project ECHO® model™ to conduct monthly hour-long sessions about cancer control, among cancer control professionals in Africa and international partners. Sessions ran from March 2019 to August 2020. Sessions outcomes were documented throughout the year, followed by an online self-evaluation survey of the participants in July 2020. Quantitative data was analysed using Excel and qualitative data analysed thematically. RESULTS: 157 participants registered for the Africa Cancer ECHO. 24 sessions were conducted for the year 2019-2020. More than 70 % of the participants increased their knowledge, confidence, and ability to implement evidence-based cancer control strategies in their settings. Over 80% indicated that sessions were relevant to their work and met their learning goals and expectations. Recommendations included: use of evidence from population-based cancer registries to direct cancer control; encouraging clinician scientists to generate locally-relevant research questions; embracing information technology and electronic medical records systems; forming partnership and leveraging existing initiatives; and using regular costed cancer control priorities for advocacy and government involvement. CONCLUSION: The 2019-2020 Africa Cancer ECHO increased utilization of evidence-based cancer control practices among cancer control leaders; and recommends use of data, partnerships, and locally-driven solutions to direct the cancer control effort in Africa. POLICY SUMMARY: The Africa Cancer ECHO is a viable method for engaging leaders and partners in a continuous learning and networking process. There is value to investing in such initiatives, as they advance knowledge, familiarity, confidence, partnerships, and leadership in cancer control.

Toward Optimization of Cancer Care in Sub-Saharan Africa: Development of National Comprehensive Cancer Network Harmonized Guidelines for Sub-Saharan Africa.

PURPOSE: Standard treatment guidelines improve patient outcomes, including disease-specific survival, in cancer care. The African Cancer Coalition was formed in 2016 to harmonize cancer treatment guidelines for sub-Saharan Africa. METHODS: The African Cancer Coalition collaborated with the National Comprehensive Cancer Network (NCCN) and the American Cancer Society to harmonize 46 cancer treatment guidelines for use in sub-Saharan Africa. Harmonization for each guideline was completed by a group of approximately 6-10 African cancer experts from a range of specialties and with representation across resource levels. Each working group was chaired by an African oncologist and included a member of the appropriate NCCN guidelines panel. Treatment recommendations from the parent guidelines were distinguished as options that are generally available and should be considered standard care in most of the region or as highly advanced options for which cost or other resources may limit widespread availability. Additional recommendations specific to sub-Saharan Africa were added. RESULTS: The NCCN Harmonized Guidelines for sub-Saharan Africa, available for download on the NCCN website and mobile application, provide flexible recommendations appropriate for the range of resources seen in African cancer programs, from private comprehensive cancer centers to resource-constrained public hospitals. IBM (Armonk, NY) has developed a digital interface-the Cancer Guidelines Navigator-that allows oncologists to access the treatment recommendations for the first five guidelines through an interactive web-based application. CONCLUSION: Harmonized guidelines that reflect the diversity of resource levels that characterize the current state of clinical care for cancer in Africa have the potential to fill a crucial gap in efforts to standardize and improve cancer care in Africa.