Breaking barriers: supporting hematopoietic stem cell transplant program through collaborative radiation therapy service from a physically distant center.

BACKGROUND: Total body irradiation (TBI) for hematopoietic stem cell transplant (HSCT) has certain distinct advantages, such as uniform dose distribution and lack of drug resistance, but it is not widely available in resource-constrained settings. To overcome the limitations of in-house radiotherapy services in hematology centers, we evaluated the feasibility of conducting HSCT programs in coordination with two physically distant centers using a reduced-intensity TBI protocol. METHODS: Thirty-two patients with a median age of 20.5 years were included in the study. Fifteen patients were diagnosed with aplastic anemia, 10 patients with acute myeloid leukemia (AML), 3 patients with acute lymphocytic leukemia (ALL), and 4 patients with other hematological conditions. Conditioning regimens used were fludarabine plus cyclophosphamide in 29 cases, fludarabine-cytarabine ATG in 2 cases, and busulfan plus fludarabine in 1 case. The TBI dose was 3 Gy in 28 cases and 2 Gy in 4 cases. Patients were followed monthly after TBI, and the major toxicities were recorded. RESULTS: The median follow-up was 22 months. The most common acute complication was acute graft-versus-host disease (GVHD), which occurred in 15.6% of patients. The major late complications were chronic GVHD (9.3%), Cytomegalovirus (CMV) infection (34.3%), and CMV-induced secondary graft failure (6.2%). Seventy-five percent of patients were alive, 21.9% were dead, and 1 patient was lost to follow-up. CONCLUSIONS: HSCT based on TBI is feasible even if the center lacks a radiotherapy facility by coordinating with a remote radiotherapy facility. without compromising the patient's outcome.

Ethno-geographic distribution and histopathological classification of nasopharyngeal carcinoma in a single center in Nepal.

INTRODUCTION: Nasopharyngeal carcinoma (NPC) shows geographic and ethnic variation with specific etiopathogenesis. This study characterized the distribution of NPC patients stratified by ethnicity, geography, and histology in a tertiary-level cancer center in Nepal. METHODS: A descriptive retrospective study was designed to analyze NPC cases from different regions among patients visiting the hospital from 2016 to 2021. Demographic and clinical information was obtained from medical records. Ethical approval was granted by the Nepal Health Research Council (NHRC). Data analyses and visualization were carried out with R software. RESULTS: During the six-year period, a total of 65 individuals were diagnosed with NPC, comprising 42 males and 23 females. Patient median age was 43 years (range 11-85 years). A bimodal age distribution of cases was observed with peaks in patients aged 30-39 years and 50-59 years. Of the NPC patients studied, 29 were from Koshi Province, with 7 cases from Ilam district and 6 cases from Morang district. There were 18 patients in Bagmati Province, and Kathmandu district had the highest number of cases within this region, with 8 patients. The highest proportion of cases were observed among patients of Janajati ethnicity (60%), including Rai, Limbu, and Sherpa people. Histologically, undifferentiated non-keratinizing NPC was the most commonly observed subtype, accounting for 43.1% of cases, followed by 20% differentiated non-keratinizing NPC and 4.6% keratinizing NPC across the entire sample population. The majority of patients (75.3%) were diagnosed at an advanced stage (stage III or IV) with none diagnosed at stage I. CONCLUSIONS: In our study, most cases of NPC occurred in patients from provinces in eastern Nepal (Koshi province), and of the Janajati ethnic community. The most common histological subtype was undifferentiated non-keratinizing carcinoma. Further epidemiological studies could address differences in prevalence and the challenge of late presentation of NPC patients in Nepal.

Understanding of disease status, prognosis and estimated cost of treatment among cancer patients: experience from a tertiary cancer centre in Nepal.

Purpose: Lack of adequate knowledge about the disease is one of the key factors that misguide cancer patients and patients' caregivers in choosing a better management plan. The purpose of the study was to assess the patients' and caregivers' knowledge about the disease status and estimated treatment cost. Understanding of disease may improve adherence to treatment plans and quality of care. Methods: It was a cross-sectional study where 120 cancer patients were selected based on convenience sampling and the availability of record files and relevant data. The site, stage and prognosis of disease recorded from patients and caregivers were compared with the record of outpatient department and inpatient files with the help of the Fisher's exact test. The patients' knowledge about their financial estimates was also recorded. Three patients were selected for in-depth interviews based on purposive sampling to further support the findings. Results: Among 120 analysed patients, 60.83% were female. Around two-thirds of male patients (69.2%) and male caregivers (62.2%) knew about the site but only one-third of female patients (30.8%) and female caregivers (37.8%) knew the same. The primary responsibility for managing financial issues was caregivers in 89.16%. Only 7.5% knew the estimated cost. Nepali as the primary language and better education level is correlated with knowledge of disease status, among both patients and caregivers but was statistically significant only in knowing prognosis among native Nepali speaker caregivers (p < 0.001), and better-educated patients (p < 0.001). As per the in-depth interview, all three patients knew the site of their disease, but only the patient with breast cancer was aware of the stage of the disease. None of the patients were aware of their disease prognosis, treatment plan or the estimated cost of their treatment. Conclusion: The level of understanding is low for most patients and their immediate caregivers, particularly among those who are female, not literate and whose primary language is not Nepali. Appropriate strategy should be adopted to enhance basic understanding among patients and caregivers in our setting.

The supportive care needs survey short form 34 (SCNS-SF34): translation and cultural adaptation into the Nepali language among patients with cervical cancer in Nepal.

BACKGROUND: A questionnaire developed in one language must be translated and adapted when it will be used with patients speaking a different language and care should be taken to maintain equivalence between the source language (SL) version and its translated version. The objective of this study was to test the linguistic and cultural validity of a Nepali language version of the Supportive Care Need Survey - Short Form 34 (SCNS-SF34) used with the Nepali population. METHODS: Translation of the SCNS-SF34 was carried out by following Beaton's guidelines and Consensus-based Standards for the Selection of Health Status Measurement Instruments (COSMIN) by a research team. The translated version was administered to patients with cervical cancer in Nepal. The following steps were performed as part of the study: translation, content validity assessment, reliability assessment and measurement of errors. RESULTS: The study reports item content validity (I-CVI) was > 0.78 and scale content validity (S-CVI) was - 0.89, 0.91 and 0.90 respectively in semantic, cultural, and conceptual aspects. The study found a content validity ratio (CVR) of 0.9 to 1, Cronbach's α of 0.90, correlation significant at the 0.01 level (2-tailed), and clarity of the questionnaire at 91.29%. The standard error of measurement (SEM) and small detectable changes (SDC) for overall care need scores were measured 2.70 and 7.47 respectively. All items were accepted as per the original SCNS-SF34. Following the respondents' suggestions, simpler Nepali words were chosen in some items to replace the words in the preliminary Nepali version of SCNS-SF34. CONCLUSION: Preliminary findings show that the Nepali translation of SCNS-SF34 is practical and applicable to the Nepali population. Financial supportive care needs, supportive care for caretakers and problems during patient hospital stays are essential to include in the questionnaire to further explore supportive care needs.

Interstitial brachytherapy for internal mammary node in breast cancer: A case report.

This case study reports the feasibility, safety, and efficacy of interstitial brachytherapy for internal mammary nodal recurrence in a 68-year-old woman with triple-negative breast cancer. The patient had previously undergone mastectomy followed by chemotherapy and radiotherapy. However, an internal mammary node was discovered during a routine follow-up a year later, which was confirmed as metastatic carcinoma by fine needle aspiration, with no other metastatic lesions. The patient underwent interstitial brachytherapy under ultrasound and computed tomography (CT) guidance, with a prescribed dose of 20 Gray in one fraction. Follow-up CT scan imaging over a 2-year period of treatment showed a complete resolution of internal mammary node. Therefore, brachytherapy may be considered a potential treatment option for cases of isolated internal mammary node recurrence in breast cancer.

A Global Collaboration to Develop and Pilot Test a Mobile Application to Improve Cancer Pain Management in Nepal.

Introduction: Quality palliative care, which prioritizes comfort and symptom control, can reduce global suffering from non-communicable diseases, such as cancer. To address this need, the Nepalese Association of Palliative Care (NAPCare) created pain management guidelines (PMG) to support healthcare providers in assessing and treating serious pain. The NAPCare PMG are grounded in World Health Organization best practices but adapted for the cultural and resource context of Nepal. Wider adoption of the NAPCare PMG has been limited due to distribution of the guidelines as paper booklets. Methods: Building on a long-standing partnership between clinicians and researchers in the US and Nepal, the NAPCare PMG mobile application ("app") was collaboratively designed. Healthcare providers in Nepal were recruited to pilot test the app using patient case studies. Then, participants completed a Qualtrics survey to evaluate the app which included the System Usability Scale (SUS) and selected items from the Mobile App Rating Scale (MARS). Descriptive and summary statistics were calculated and compared across institutions and roles. Regression analyses to explore relationships (α = 0.05) between selected demographic variables and SUS and MARS scores were also conducted. Results: Ninety eight healthcare providers (n = 98) pilot tested the NAPCare PMG app. Overall, across institutions and roles, the app received an SUS score of 76.0 (a score > 68 is considered above average) and a MARS score of 4.10 (on a scale of 1 = poor, 5 = excellent). 89.8% (n = 88) "agreed" or "strongly agreed" that the app will help them better manage cancer pain. Age, years of experience, and training in palliative care were significant in predicting SUS scores (p-values, 0.0124, 0.0371, and 0.0189, respectively); institution was significant in predicting MARS scores (p = 0.0030). Conclusion: The NAPCare PMG mobile app was well-received, and participants rated it highly on both the SUS and MARS. Regression analyses suggest end-user variables important to consider in designing and evaluating mobile apps in lower resourced settings. Our app design and pilot testing process illustrate the benefits of cross global collaborations to build research capacity and generate knowledge within the local context.

A survey of cancer care institutions in Nepal to inform design of a pain management mobile application.

BACKGROUND: One way to improve the delivery of oncology palliative care in low and middle-income countries (LMICs) is to leverage mobile technology to support healthcare providers in implementing pain management guidelines (PMG). However, PMG are often developed in higher-resourced settings and may not be appropriate for the resource and cultural context of LMICs. OBJECTIVES: This research represents a collaboration between the University of Virginia and the Nepalese Association of Palliative Care (NAPCare) to design a mobile health application ('app') to scale-up implementation of existing locally developed PMG. METHODS: We conducted a cross-sectional survey of clinicians within Nepal to inform design of the app. Questions focused on knowledge, beliefs, and confidence in managing cancer pain; barriers to cancer pain management; awareness and use of the NAPCare PMG; barriers to smart phone use and desired features of a mobile app. FINDINGS: Surveys were completed by 97 palliative care and/or oncology healthcare providers from four diverse cancer care institutions in Nepal. 49.5% (n = 48) had training in palliative care/cancer pain management and the majority (63.9%, n = 62) reported high confidence levels (scores of 8 or higher/10) in managing cancer pain. Highest ranked barriers to cancer pain management included those at the country/cultural level, such as nursing and medical school curricula lacking adequate content about palliative care and pain management, and patients who live in rural areas experiencing difficulty accessing healthcare services (overall mean = 6.36/10). Most nurses and physicians use an Android Smart Phone (82%, n = 74), had heard of the NAPCare PMG (96%, n = 88), and reported frequent use of apps to provide clinical care (mean = 6.38/10, n = 92). Key barriers to smart phone use differed by discipline, with nurses reporting greater concerns related to cost of data access (70%, n = 45) and being prohibited from using a mobile phone at work (61%; n = 39). CONCLUSIONS: Smart phone apps can help implement PMG and support healthcare providers in managing cancer pain in Nepal and similar settings. However, such tools must be designed to be culturally and contextually congruent and address perceived barriers to pain management and app use.