Willingness and ability to pay for breast cancer treatment among patients from Addis Ababa, Ethiopia: A cross-sectional study.

INTRODUCTION: Breast cancer (BC) is the most common malignant neoplasm among women in Addis Ababa, Ethiopia. The willingness and ability to pay (WATP) for treatment is a contributing factor in the utilization of health care services. The World Health Organization Breast Cancer Initiative calls for 80% of patients to complete multimodality treatment and indicates payment as central factor to improve BC outcome. The objectives of this study are to identify how much female BC patients paid in Addis Ababa for BC treatment, their WATP for BC treatment, and the factors that affect WATP. METHODS: The researchers collected data from 204 randomly selected BC patients who were treated in one of four different health facilities (one public and three private) between September 2018 and May 2019. A structured questionnaire was used to assess their WATP for BC treatment and multivariable regression to investigate factors associated with patients' WATP. RESULTS: Of interviewed patients, 146 (72%) were at reproductive age. Patients' median expenditure for all BC treatment services was 336 US dollars (USD) in a public cancer center and 926 USD in privately owned health facilities. These amounts are in contrast with a reported WATP of 50 USD and 149 USD. WATP increased with increasing expenditure (OR 1.43; 95% CI 1.09 to 1.89 per 100 US), educational level (OR 1.37; 95% CI 1.02 to 1.85) and service quality (OR 1.34; 95% CI 1.04 to 1.72). In contrast, a monthly income increase by 100 USD corresponds to a 17% decrease of WATP (OR 0.83; 95% CI 0.70 to 0.99). CONCLUSIONS: We demonstrated that BC treatment was very expensive for patients, and the cost was much higher than their WATP. Thus, we suggest that BC should be included in both social and community-based health insurance plans and treatment fees should consider patients' WATP.

Ovarian cancer survival in sub-Saharan Africa by human development index and histological subtypes: A population-based registry study.

Ovarian cancer (OC) is the fourth most common cancer of women in sub-Saharan Africa (SSA), although few data have been published on population-level survival. We estimate ovarian cancer survival in SSA by human development index and histological subtype, using data from seven population-based cancer registries in six countries: Kenya (Nairobi and Eldoret), Mauritius, Uganda (Kampala), Cote d'Ivoire (Abidjan), Ethiopia (Addis Ababa) and South Africa (Eastern Cape). A total of 644 cases diagnosed during 2008-2014 were included, with 77% being of epithelial subtypes (range 47% [Abidjan]-80% [Mauritius]). The overall observed survival in the study cohort was 73.4% (95% CI: 69.8, 77.0) at 1 year, 54.4% (95% CI: 50.4, 58.7) at 3 years and 45.0% (95% CI: 41.0, 49.4) at 5 years. Relative survival at Year 1 ranged from 44.4% in Kampala to 86.3% in Mauritius, with a mean for the seven series of 67.4%. Relative survival was highest in Mauritius at 72.2% and lowest in Kampala, Uganda at 19.5%, with a mean of 47.8%. There was no difference in survival by age at diagnosis. Patients from high and medium HDI countries had significantly better survival than those from low HDI countries. Women with cancers of epithelial cell origin had much lower survival compared to women with other histological subtypes (p = .02). Adjusted for the young age of the African patients with ovarian cancer (44% aged <50) survival is much lower than in USA or Europe, and underlines the need for improvements in the access to diagnosis and treatment of OC in SSA.

Establishment of Twinning Partnership to Improve Pediatric Radiotherapy Outcomes Globally.

PURPOSE: Pediatric radiotherapy is a necessary and challenging component of oncologic care for children in low- and middle-income countries (LMICs). Collaboration between institutions in LMICs and high-income countries (HICs) has been shown to be effective in improving oncologic treatment outcomes; however, literature regarding pediatric radiotherapy twinning partnerships is limited. METHODS: Emory University has a long-standing twinning collaboration with Tikur Anbessa Specialized Hospital (TASH) for certain medical specialties. After securing institutional funding, a faculty member and a resident from the Emory University Department of Radiation Oncology set out to establish a twinning program with TASH for pediatric radiotherapy. RESULTS: Emory and TASH faculty and residents established initial communications virtually via email and video correspondence. TASH residents and faculty completed surveys regarding pediatric radiotherapy institutional and educational needs to outline goals of collaboration. Five lectures and case-based practicums were identified focused on Wilms tumor, medulloblastoma, rhabdomyosarcoma, Hodgkin lymphoma, and palliative radiotherapy. The Emory team then conducted a visit to TASH during which lectures and practicums were delivered. The Emory team directly observed and guided simulation and treatment planning procedures. TASH residents practiced decision making, simulation, contouring, and field placement for Wilms tumor cases on the basis of didactics and feedback provided by the Emory team. Additionally, a needs assessment regarding pediatric oncologic resources was completed. Clinical care pathways and standard operating procedures were drafted by collaborators. Virtual peer-review sessions were established to continue collaborations abroad and plan for next in-person visit. CONCLUSION: Collaborative efforts by global experts have helped to establish and improve treatment protocols for childhood cancer. The presented twinning experience may serve as a model for other LMIC and HIC centers for establishing similar partnerships.

Treatment and Survival Among Patients With Colorectal Cancer in Sub-Saharan Africa: A Multicentric Population-Based Follow-Up Study.

BACKGROUND: The burden of colorectal cancer (CRC) is increasing in Sub-Saharan Africa (SSA). However, little is known about CRC treatment and survival in the region. METHODS: A random sample of 653 patients with CRC diagnosed from 2011 to 2015 was obtained from 11 population-based cancer registries in SSA. Information on clinical characteristics, treatment, and/or vital status was obtained from medical records in treating hospitals for 356 (54%) of the patients ("traced cohort"). Concordance of CRC treatment with NCCN Harmonized Guidelines for SSA was assessed. A Cox proportional hazards model was used to examine the association between survival and human development index (HDI). RESULTS: Of the 356 traced patients with CRC, 51.7% were male, 52.8% were from countries with a low HDI, 55.1% had colon cancer, and 73.6% were diagnosed with nonmetastatic (M0) disease. Among the patients with M0 disease, however, only 3.1% received guideline-concordant treatment, 20.6% received treatment with minor deviations, 31.7% received treatment with major deviations, and 35.1% received no treatment. The risk of death in patients who received no cancer-directed therapy was 3.49 (95% CI, 1.83-6.66) times higher than in patients who received standard treatment or treatment with minor deviations. Similarly, the risk of death in patients from countries with a low HDI was 1.67 (95% CI, 1.07-2.62) times higher than in those from countries with a medium HDI. Overall survival at 1 and 3 years was 70.9% (95% CI, 65.5%-76.3%) and 45.3% (95% CI, 38.9%-51.7%), respectively. CONCLUSIONS: Fewer than 1 in 20 patients diagnosed with potentially curable CRC received standard of care in SSA, reinforcing the need to improve healthcare infrastructure, including the oncology and surgical workforce.

Survival and predictors of breast cancer mortality in South Ethiopia: A retrospective cohort study.

BACKGROUND: Breast cancer is the most frequently diagnosed cancer and the leading cause of cancer death in over 100 countries. In March 2021, the World Health Organization called on the global community to decrease mortality by 2.5% per year. Despite the high burden of the disease, the survival status and the predictors for mortality are not yet fully determined in many countries in Sub-Saharan Africa, including Ethiopia. Here, we report the survival status and predictors of mortality among breast cancer patients in South Ethiopia as crucial baseline data to be used for the design and monitoring of interventions to improve early detection, diagnosis, and treatment capacity. METHODS: A hospital-based retrospective cohort study was conducted among 302 female breast cancer patients diagnosed from 2013 to 2018 by reviewing their medical records and telephone interviews. The median survival time was estimated using the Kaplan-Meier survival analysis method. A log-rank test was used to compare the observed differences in survival time among different groups. The Cox proportional hazards regression model was used to identify predictors of mortality. Results are presented using the crude and adjusted as hazard ratios along with their corresponding 95% confidence intervals. Sensitivity analysis was performed with the assumption that loss to follow-up patients might die 3 months after the last hospital visit. RESULTS: The study participants were followed for a total of 4,685.62 person-months. The median survival time was 50.81 months, which declined to 30.57 months in the worst-case analysis. About 83.4% of patients had advanced-stage disease at presentation. The overall survival probability of patients at two and three years was 73.2% and 63.0% respectively. Independent predictors of mortality were: patients residing in rural areas (adjusted hazard ratio = 2.71, 95% CI: 1.44, 5.09), travel time to a health facility ≥7 hours (adjusted hazard ratio = 3.42, 95% CI: 1.05, 11.10), those who presented within 7-23 months after the onset of symptoms (adjusted hazard ratio = 2.63, 95% CI: 1.22, 5.64), those who presented more than 23 months after the onset of symptoms (adjusted hazard ratio = 2.37, 95% CI: 1.00, 5.59), advanced stage at presentation (adjusted hazard ratio = 3.01, 95% CI: 1.05, 8.59), and patients who never received chemotherapy (adjusted hazard ratio = 6.69, 95% CI: 2.20, 20.30). CONCLUSION: Beyond three years after diagnosis, patients from southern Ethiopia had a survival rate of less than 60% despite treatment at a tertiary health facility. It is imperative to improve the early detection, diagnosis, and treatment capacities for breast cancer patients to prevent premature death in these women.

The effect of cognitive behavioural therapy integrated with activity pacing on cancer-related fatigue, depression and quality of life among patients with breast cancer undergoing chemotherapy in Ethiopia: A randomised clinical trial.

Fatigue is a common symptom experienced by 80% of individuals who receive chemotherapy and is one of the major factors that affect quality of life (QoL) of patients with breast cancer. Our study aimed to assess the effect of cognitive behavioural therapy integrated with activity pacing (CBT-AP) on cancer-related fatigue among patients with breast cancer undergoing chemotherapy. A parallel-group, randomised controlled trial was conducted. Severely fatigued patients were randomly assigned to the CBT-AP or usual care (UC) groups using a computer-generated random sequence. The new intervention was designed for seven sessions: three 2-hour face-to-face and four 30-minute telephone sessions. The primary outcome (fatigue severity) and the secondary outcomes (depression and QoL) were assessed at the end of the intervention and after 3 months. The data were analysed by repeated measures analyses of covariance (RM-ANCOVA). CBT-AP had a significant time effect (P < .001, ηp2  = 0.233) in reducing fatigue from baseline (adjusted mean = 7.48) to the end of the intervention (adjusted mean = 6.37) and the 3-month follow-up (adjusted mean = 6.54). Compared to the UC group, the CBT-AP group had lower fatigue and depression scores, and higher global health status scores. The group × time interaction revealed a significant reduction in fatigue and depression in the CBT-AP group compared to the UC group. Therefore, CBT-AP appears to be effective in reducing fatigue and depression and improving QoL in patients with breast cancer undergoing chemotherapy. It is highly recommended to integrate a CBT-AP intervention in routine cancer care.

A pilot study of cognitive behavioural therapy integrated with activity pacing for fatigued breast cancer patients undergoing chemotherapy in Ethiopia.

Background: Fatigue is a common symptom in breast cancer patients, and it is one of the major factors that influence the quality of life (QoL). Cognitive behavioural therapy (CBT) has been recommended to manage cancer-related fatigue. In this study, CBT will be integrated with activity pacing (AP), which can help breast cancer patients achieve a balance between activity and rest. Therefore, this pilot study aimed to investigate the acceptability, feasibility, and efficacy of the CBT-AP intervention. Methods: A total of 10 fatigued breast cancer patients undergoing chemotherapy were included in the study. The acceptability and feasibility of the study were measured by the patient recruitment rate, attrition rate, intervention fidelity, intervention compliance, and therapist's and participant's evaluations of the intervention. The outcomes were measured at baseline and at 6 weeks of intervention. Results: The pre-post study suggested that CBT-AP was found to be acceptable and feasible for fatigued breast cancer patients undergoing chemotherapy. Among 27 eligible participants, 10 (37.03%) participants accepted our invitation to participate in the study. One participant dropped out from the intervention because of serious illness, and the dropout rate was 10%.Both the intervention fidelity and intervention compliance were found to be satisfactory.Fatigue severity [Brief Fatigue Inventory (BFI)] was reduced in 77.77% of participants from baseline to 6 weeks of intervention. The global health status/QoL scale and physical, emotional, and social functioning scales were improved from baseline to 6 weeks of intervention. All symptom scales, except constipation, diarrhea, and financial difficulties, were decreased after the intervention. Depression [Public Health Questionnaire (PHQ)-9] was reduced in 55.55% of participants. Conclusion: This study suggested that CBT-AP is an acceptable, feasible, and potentially efficacious intervention to reduce fatigue and improve the QoL of breast cancer patients. The efficacy of a CBT-AP programme is going to be investigated in subsequent larger randomized clinical trials.

Translation and validation of the EORTC QLQ-BR45 among Ethiopian breast cancer patients.

This study aimed to examine the validity and reliability of the EORTC QLQ-BR45 questionnaire among breast cancer patients in Ethiopia. This study included 248 breast cancer patients who completed the QLQ-BR45 and QLQ-C30 questionnaires. The internal reliability, test-retest reliability, and the content, concurrent, convergent, divergent, and clinical validity of the tool were examined. The statistical analyses included Cronbach's α coefficient, Pearson's correlation coefficient, standardised root mean square residual (SRMR), comparative fit index (CFI), t-test, and root mean square error of approximation (RMSEA). All items were marked as relevant, and item-level content validity index (I-CVI) scores ranged from 0.83 to 1. The S-CVI/Ave was calculated by dividing the sum of I-CVI values by the total number of items, which was found to be 0.94. The average CVR value was 0.76. The Cronbach's α coefficient was 0.80 for all domains. All subscales met the minimal standards of reliability except the arm symptom scale (0.66). The test-retest reliability coefficient was 0.77 for all domains. Seven out of the 12 hypothesised scales showed positive correlations (r > 0.40) between the QLQ-BR45 and QLQ-C30 scales. Multitrait scaling analysis showed that the item-scale correlations exceeded the 0.40 criterion for item-convergent validity for 11 of the 12 hypothesised scales. The correlation coefficients between an item and its own subscale were significantly higher than with other subscales. The EORTC QLQ-BR45 had good reliability and validity, and it can be used to measure the quality of life of breast cancer patients in Ethiopia.

Breast Nurse Intervention to Improve Adherence to Endocrine Therapy Among Breast Cancer Patients in South Ethiopia.

INTRODUCTION: Many women in rural Ethiopia do not receive adjuvant therapy following breast cancer surgery despite the majority being diagnosed with estrogen-receptor-positive breast cancer and tamoxifen being available in the country. We aimed to compare a breast nurse intervention to improve adherence to tamoxifen therapy for breast cancer patients. METHODS AND MATERIALS: The 8 hospitals were randomized to intervention and control sites. Between February 2018 and December 2019, patients with breast cancer were recruited after their initial surgery. The primary outcome of the study was adherence to tamoxifen therapy by evaluating 12-month medication-refill data with medication possession ratio (MPR) and using a simplified medication adherence scale (SMAQ) in a subjective assessment. RESULTS: A total of 162 patients were recruited (87 intervention and 75 control). Trained nurses delivered education and provided literacy material, gave additional empathetic counselling, phone call reminders, and monitoring of medication refill at the intervention hospitals. Adherence according to MPR at 12 months was high in both the intervention (90%) and control sites (79.3%) (P = .302). The SMAQ revealed that adherence at intervention sites was 70% compared with 44.8% in the control sites (P = .036) at 12 months. Persistence to therapy was found to be 91.2% in the intervention and 77.8% in the control sites during the one-year period (P = .010). CONCLUSION: Breast nurses can improve cost-effective endocrine therapy adherence at peripheral hospitals in low-resource settings. We recommend such task sharing to overcome the shortage of oncologists and distances to central cancer centers.

Clinicopathological Features and Survival of Patients with Hepatocellular Carcinoma in Ethiopia: A Multicenter Study.

(1) Background: Hepatocellular carcinoma (HCC) is one of the deadliest cancers globally, killing over 700,000 people each year. Despite the rising incidence and mortality rates of HCC in Ethiopia, only few single-centered studies have been conducted; therefore, we aimed to explore the clinicopathological characteristics and survival of patients with HCC in multicenter settings. (2) Methods: We conducted a retrospective analysis of 369 patients with confirmed HCC diagnosed between 2016 and 2021. The survival of patients weas determined using the Kaplan−Meier method, and hazard ratios of the prognostic factors were estimated in Cox proportional hazard models. (3) Results: Majority patients were male (67%) and had a mean age of 52.0 ± 15.6 years. The majority of patients (87%) had a large tumor size (>5 cm) at diagnosis and presented with an advanced-stage condition. Cirrhosis (58%) and viral hepatitis (46.5%) were the main risk factors associated with HCC. The median overall survival was 141 days (95% CI: 117−165). Patients who took antivirals for HBV had a higher survival benefit compared to the untreated group (469 vs. 104 days; p < 0.001). The risk of death was 12 times higher in patients with Barcelona Clinic Liver Cancer-D (BCLC-D) terminal stage HCC compared to patients with an early stage (BCLC-A) HCC. The stage of HCC and treatment against HBV are the most significant survival predictors. (4) Conclusions: The overall survival of HCC patients in Ethiopia is poor. Cirrhosis and viral hepatitis are the primary risk factors linked with HCC. Patients who received antiviral therapy for HBV had a better survival outcome.

Study Protocol of CBT-AP Trial: A Randomized Controlled Trial of Cognitive Behavioral Therapy Integrated with Activity Pacing for Fatigued Breast Cancer Patients Undergoing Chemotherapy.

PURPOSE: This paper reports the methodology for undertaking a randomized controlled trial to assess the combined effect of cognitive behavioral therapy (CBT) and activity pacing on fatigue experienced by breast cancer patients undergoing chemotherapy. METHOD: Fifty-eight patients experiencing severe fatigue will be randomized to a CBT group or usual care group. The intervention will be given for 6 sessions by a trained oncology nurse. Primary and secondary outcome measures will be assessed at baseline, the sixth week of intervention and at the third month post intervention. The primary outcome measure is fatigue (Brief Fatigue Inventory) and secondary outcome measures include depression (Patient Health Questionnaire) and quality of life (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire). The protocol is designed using the SPIRIT guidelines which is one of the EQUATOR checklists. DISCUSSION: This is the first RCT that will determine the efficacy of CBT by integrating with activity pacing to reduce fatigue among breast cancer patients receiving chemotherapy. The intervention design is novel in addressing multiple precipitating and perpetuating factors of fatigue and integrated with activity pacing in CBT. CONCLUSION: If the intervention is effective, this therapeutic approach can be incorporated into a routine health care for breast cancer patients receiving chemotherapy. TRIAL REGISTRATION: The study have been registered in Pan-African Clinical Trial Registry (website) on August 24, 2020. The trial registration number is PACTR202008881026130.