Quality indicators for evaluating cancer care in low-income and middle-income country settings: a multinational modified Delphi study.

This Policy Review sourced opinions from experts in cancer care across low-income and middle-income countries (LMICs) to build consensus around high-priority measures of care quality. A comprehensive list of quality indicators in medical, radiation, and surgical oncology was identified from systematic literature reviews. A modified Delphi study consisting of three 90-min workshops and two international electronic surveys integrating a global range of key clinical, policy, and research leaders was used to derive consensus on cancer quality indicators that would be both feasible to collect and were high priority for cancer care systems in LMICs. Workshop participants narrowed the list of 216 quality indicators from the literature review to 34 for inclusion in the subsequent surveys. Experts' responses to the surveys showed consensus around nine high-priority quality indicators for measuring the quality of hospital-based cancer care in LMICs. These quality indicators focus on important processes of care delivery from accurate diagnosis (eg, histologic diagnosis via biopsy and TNM staging) to adequate, timely, and appropriate treatment (eg, completion of radiotherapy and appropriate surgical intervention). The core indicators selected could be used to implement systems of feedback and quality improvement.

Cancer screening programs in South-east Asia and Western Pacific.

BACKGROUND: The burden of cancer can be altered by screening. The field of cancer screening is constantly evolving; from the initiation of program for new cancer types as well as exploring innovative screening strategies (e.g. new screening tests). The aim of this study was to perform a landscape analysis of existing cancer screening programs in South-East Asia and the Western Pacific. METHODS: We conducted an overview of cancer screening in the region with the goal of summarizing current designs of cancer screening programs. First, a selective narrative literature review was used as an exploration to identify countries with organized screening programs. Second, representatives of each country with an organized program were approached and asked to provide relevant information on the organizations of their national or regional cancer screening program. RESULTS: There was wide variation in the screening strategies offered in the considered region with only eight programs identified as having an organized design. The majority of these programs did not meet all the essential criteria for being organized screening. The greatest variation was observed in the starting and stopping ages. CONCLUSIONS: Essential criteria of organized screening are missed. Improving organization is crucial to ensure that the beneficial effects of screening are achieved in the long-term. It is strongly recommended to consider a regional cancer screening network.

Mapping Palliative Care Availability and Accessibility: A First Step to Eradicating Access Deserts in the Low- and Middle-Income Settings.

OBJECTIVE: Palliative care is unavailable and/or inaccessible for the majority of people in low- and middle-income countries (LMIC). This study aims to determine the availability and accessibility of palliative care services in Malaysia, a middle-income country that has made good progress toward universal health coverage (UHC). METHOD: Publicly available data, and databases of registered palliative care services were obtained from governmental and nongovernmental sources. Google Maps and Rome2Rio web-based applications were used to assess geographical disparities by estimating the median distance, travel time, and travel costs from every Malaysian district to the closest palliative care service. RESULTS: Substantial variations in availability, components, and accessibility (distance, time, and cost to access care) of palliative care services were observed. In the highly developed Central Region of Peninsular Malaysia, specialty care was available within 4 km whereas in the less-developed East Coast of Peninsular Malaysia, patients had to travel approximately 46 km. In the predominantly rural East Malaysia, basic palliative care services were 82 km away and, in some instances, where land connectivity was scarce, it took 2.5 h to access care via boat. The corresponding median travel costs were USD2 (RM9) and USD23 (RM114) in Peninsular Malaysia and East Malaysia. CONCLUSION: The stark urban-rural divide in the availability and accessibility of palliative care services even in a setting that has made good progress toward UHC highlights the urgent need for decentralization of palliative care in the LMICs. This may be achieved by capacity building and task shifting in primary care and community settings.

The Development and Validation of a Psychometric Tool to Assess Behavioral Factors Impacting Personal Dosimeter Use among Medical Radiation Workers.

ABSTRACT: Personal dosimeters are used by medical radiation workers (MRWs) to monitor their radiation dose from external sources and comply with radiation safety guidelines. Nevertheless, there is evidence of inconsistent use of the devices among MRWs. Behavioral factors influencing the use of personal dosimeters have never been explored. Using established behavioral models, we aimed to develop a psychometric tool to measure the behavioral factors influencing dosimeter use and establish its feasibility, reliability, and validity. A 37-item tool was developed based on a qualitative study and review of the literature. The content relevancy was assessed by six field experts before it was piloted and re-tested on MRWs. The construct validity of the tool was analyzed using exploratory factor analysis to confirm its psychometric properties. Face validation was performed by academicians, field experts, and MRWs to enhance the tool's readability. The 37 items in the tool belonged to five constructs in the early phase. However, the validation study revealed a reliable 27 item tool with seven constructs, namely: "Attitude," "Social factors," "Ability to perform if facilitated," "Ability to overcome shortcomings," "Self-efficacy," "Complexity," and "Perceived usefulness." The item-construct validity index of accepted items was >0.83, and Cronbach's alpha for each construct ranged between 0.70 to 0.96, while factor loading for each item was between 0.723 to 0.963. All results were considered "good" and "excellent." The new tool appears to be valid, reliable, and feasible to measure behavioral factors influencing personal dosimeter use among MRWs, which is helpful to facilitate the planning of interventions to improve behaviors in occupational radiation monitoring.

Proposal for improving access to palliative care by enhancing primary care services in an upper middle-income country.

Background: Primary care doctors play an important role in providing palliative care as they are often the first point of contact for most healthcare needs in the community. This mixed-method study aims to 1) determine the accessibility of palliative care services in Malaysia, an upper middle-income country with universal health coverage, 2) explore the knowledge, challenges and opportunities faced by primary care doctors in providing palliative care and 3) identify if minimum standards for palliative care service are clearly defined, available and achieved in primary care facilities. Methods: Data on availability of palliative care services will be sourced from governmental and non-governmental databases and reports. Accessibility will be examined by estimating the distance, travel time and cost to the nearest facility offering palliative care services from various locations throughout Malaysia. In-depth interviews will be conducted with primary care doctors to explore their knowledge, challenges and opportunities in providing palliative care. Alongside, a survey will be conducted to evaluate whether components of palliative care services are available in primary care facilities using the Minimum Standard Tool for Palliative Care from India, which covers all the domains recommended by the World Health Organization. All findings will be inductively analysed and integrated, followed by a strengths, weaknesses, opportunities and threats analysis and a threats, opportunities, weaknesses and strength analysis with relevant stakeholders. Expected results: The mapping study will provide empirical data on availability and accessibility of palliative care services in Malaysia. The qualitative inquiry will provide insights on the experiences and concerns of primary care physicians in providing palliative care in the community settings. The survey meanwhile will provide real-world data on availability of basic palliative care service components in the primary care facilities. Expected conclusion: Findings will facilitate development of framework and policies aiming to optimise provision of sustainable palliative care services at the primary care level in local settings.

Association between pre-existing cardiometabolic comorbidities and the pathological profiles of breast cancer at initial diagnosis: a cross sectional study.

The presence of comorbidities has been associated with later stages of breast cancer diagnosis. It is unclear whether biological mechanisms are partly responsible. We examined the association between the presence of pre-existing comorbidities and tumour profile at initial diagnosis with breast cancer. Data for the present analysis were derived from a prior inception cohort study comprising 2,501 multiethnic women, newly diagnosed with breast cancer between 2015 and 2017 in four hospitals across Klang Valley. At the inception of the cohort, medical and drug histories, height, weight and blood pressure were recorded. Blood samples were taken to measure serum lipid and glucose. Modified Charlson Comorbidity Index (CCI) was calculated using data extracted from medical records. The association of CCI as well as specific comorbidities, with pathological breast cancer profile was analysed. Higher comorbidity burden, namely cardiometabolic conditions were associated with unfavourable pathological features including larger tumours, involvement of >9 axillary lymph nodes, distant metastasis and human epidermal growth factor receptor 2 overexpression. These associations remained largely significant following multivariable analyses. Specifically, diabetes mellitus was independently associated with high nodal metastasis burden. Low level of high-density lipoprotein was associated with larger tumours (>5 cm), and distant metastasis. Evidence from this study seems to support the hypothesis that the later stages of breast cancer diagnosis in women with (cardiometabolic) comorbidities may be partially explained by underlying pathophysiological events.

Discriminatory Ability and Clinical Utility of the AJCC7 and AJCC8 Staging Systems for Breast Cancer in a Middle-Income Setting.

(1) Background: Differences in access to biomarker testing and cancer treatment in resource-limited settings may affect the clinical utility of the AJCC8 staging system compared to the anatomical AJCC7 system. (2) Methods: A total of 4151 Malaysian women who were newly diagnosed with breast cancer from 2010 to 2020 were followed-up until December 2021. All patients were staged using the AJCC7 and AJCC8 systems. Overall survival (OS) and relative survival (RS) were determined. Concordance-index was used to compare the discriminatory ability between the two systems. (3) Results: Migration from the AJCC7 to AJCC8 staging system resulted in the downstaging of 1494 (36.0%) patients and the upstaging of 289 (7.0%) patients. Approximately 5% of patients could not be staged using the AJCC8 classification. Five-year OS varied between 97% (Stage IA) and 66% (Stage IIIC) for AJCC7, and 96% (Stage IA) and 60% (Stage IIIC) for AJCC8. Concordance-indexes for predicting OS using the AJCC7 and AJCC8 models were 0.720 (0.694-0.747) and 0.745 (0.716-0.774), and for predicting RS they were 0.692 (0.658-0.728) and 0.710 (0.674-0.748), respectively. (4) Conclusions: Given the comparable discriminatory ability between the two staging systems in predicting the stage-specific survival of women with breast cancer in the current study, the continued use of the AJCC7 staging system in resource-limited settings seems pragmatic and justifiable.

Development and Validation of a Dual-Language (English and Malay) Needs Assessment Tool for Breast Cancer (NeAT-BC).

Background: Needs assessment tools may be used to guide the optimisation of cancer survivorship services. We sought to develop and validate a dual-language needs assessment tool for women with breast cancer. Methods: The study comprised two phases; (I) co-design, and (II) psychometric testing. In Phase I, items were generated based on focus group discussions with patients and a literature review. These items were then translated into the Malay language. Content and face validation were undertaken with an expert panel. In phase II, 315 Malaysian women living with breast cancer were recruited. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted to determine construct validity and reliability. Criterion validity was assessed using the EORTC QLQ-C30 questionnaire. Results: We co-designed and validated a 48-item dual-language needs assessment tool for breast cancer (NeAT-BC). Five underlying constructs were revealed in the EFA: (1) emotional support, (2) social and intimate relationships, (3) hospital appointments, (4) personal care and health, and (5) information and services. The NeAT-BC demonstrated good reliability across all constructs (Cronbach's alpha: 0.90 to 0.96). CFA also demonstrated acceptable convergent and divergent validity, composite reliability ≥ 0.87, and Heterotrait−Monotrait index < 0.85 for all constructs. Criterion validity was established given the significant negative correlation between overall needs and quality of life (r = −0.14; p = 0.02). The NeAT-BC took approximately 25 min to be completed and could be interviewer-administered or self-administered. Conclusion: The utilization of the NeAT-BC is expected to guide establishment of evidence-based cancer survivorship services in Malaysia, with wider potentials for adoption in other multi-ethnic and/or low-and-middle income settings.

Estimating excess mortalities due to the COVID-19 pandemic in Malaysia between January 2020 and September 2021.

Excess mortalities are a more accurate indicator of true COVID-19 disease burden. This study aims to investigate levels of excess all-cause mortality and their geographic, age and sex distributions between January 2020-September 2021. National mortality data between January 2016 and September 2021 from the Department of Statistics Malaysia was utilised. Baseline mortality was estimated using the Farrington algorithm and data between 1 January 2016 and 31 December 2019. The occurrence of excess all-cause mortality by geographic-, age- and sex-stratum was examined from 1 January 2020 to 30 September 2021. A sub-analysis was also conducted for road-traffic accidents, ethnicity and nationality. Malaysia had a 5.5-23.7% reduction in all-cause mortality across 2020. A reversal is observed in 2021, with an excess of 13.0-24.0%. Excess mortality density is highest between July and September 2021. All states and sexes reported excess trends consistent with the national trends. There were reductions in all all-cause mortalities in individuals under the age of 15 (0.4-8.1%) and road traffic accident-related mortalities (36.6-80.5%). These reductions were higher during the first Movement Control Order in 2020. Overall, there appears to be a reduction in all-cause mortality for Malaysia in 2020. This trend is reversed in 2021, with excess mortalities being observed. Surveillance of excess mortalities can allow expedient detection of aberrant events allowing timely health system and public health responses.

Cancer-related costs, the resulting financial impact and coping strategies among cancer survivors living in a setting with a pluralistic health system: a qualitative study.

Background: Evidence on the financial experiences of cancer survivors living in settings with pluralistic health systems remains limited. We explored the out-of-pocket costs, the resulting financial impact and the coping strategies adopted by cancer survivors in Malaysia, a middle-income country with a government-led tax-funded public health sector, and a predominantly for-profit private health sector. Methods: Data were derived from 20 focus group discussions that were conducted in five public and private Malaysian hospitals, which included 102 adults with breast, cervical, colorectal or prostate cancers. The discussions were segregated by type of healthcare setting and gender. Thematic analysis was performed. Results: Five major themes related to cancer costs emerged: 1) cancer therapies and imaging services, 2) supportive care, 3) complementary therapies, 4) non-medical costs and 5) loss of household income. Narratives on out-of-pocket medical costs varied not only by type of healthcare setting, clinical factors and socioeconomic backgrounds, but also by private health insurance ownership. Non-health costs (e.g. transportation, food) and loss of income were nonetheless recurring themes. Coping mechanisms that were raised included changing of cancer treatment decisions, continuing work despite ill health and seeking financial assistance from third parties. Unmet needs in coping with financial distress were especially glaring among the women. Conclusion: The long-term costs of cancer (medications, cancer surveillance, supportive care, complementary medicine) should not be overlooked even in settings where there is access to highly subsidised cancer care. In such settings, patients may also have unmet needs related to non-health costs of cancer and loss of income.

Priorities for cancer research in low- and middle-income countries: a global perspective.

Cancer research currently is heavily skewed toward high-income countries (HICs), with little research conducted in, and relevant to, the problems of low- and middle-income countries (LMICs). This regional discordance in cancer knowledge generation and application needs to be rebalanced. Several gaps in the research enterprise of LMICs need to be addressed to promote regionally relevant research, and radical rethinking is needed to address the burning issues in cancer care in these regions. We identified five top priorities in cancer research in LMICs based on current and projected needs: reducing the burden of patients with advanced disease; improving access and affordability, and outcomes of cancer treatment; value-based care and health economics; quality improvement and implementation research; and leveraging technology to improve cancer control. LMICs have an excellent opportunity to address important questions in cancer research that could impact cancer control globally. Success will require collaboration and commitment from governments, policy makers, funding agencies, health care organizations and leaders, researchers and the public.

Contingency planning for cancer care in low- and middle-income countries during the COVID-19 pandemic: a rapid assessment for future disaster resilience.

BACKGROUND: Many countries appear to be ill-prepared in their emergency responses towards the Corona Virus Disease 2019 (COVID-19) pandemic, particularly in managing chronic diseases such as cancer. We aimed to gain insight on the preparedness of health systems within low- and middle-income countries (LMICs) in maintaining delivery of cancer care amid the pandemic. METHODS: We performed a rapid review of publications focusing on emergency contingency plans for cancer care during the pandemic in LMICs. An online desk research was conducted to identify relevant policy documents, guidelines or scientific publications. RESULTS: Very few LMICs had readily accessible documents to ensure continuity in delivery of cancer care during the pandemic. A majority of publications were focused on delivery of cancer treatment whereas early detection, diagnosis and delivery of supportive and survivorship care received very little attention. Far fewer of the published guidelines appear to have been formulated at the national level by governmental agencies. A vast majority of publications constituted consensus guidelines from professional societies, followed by sharing of best practices from local institutions. Overall, three main strategies have been recommended to maintain delivery of cancer care amid the pandemic in LMICs: 1) Modification of cancer treatment regimens, 2) Changes in methods of administration of curative and supportive cancer care and 3) Implementation of generic measures to reduce the risk of COVID-19 infection in healthcare settings. CONCLUSION: All LMICs should consider collating best practices from the current pandemic and translating them into an explicit cancer preparedness plan, which can be escalated during future disasters.

Association Between Adherence to Clinical Practice Guidelines for Adjuvant Therapy for Breast Cancer and Survival in a Resource-Limited Setting.

PURPOSE: Addressing unwarranted clinical variation in oncology practices is expected to lead to improved cancer outcomes. Particularly, the application and impact of treatment guidelines on breast cancer outcomes are poorly studied in resource-limited settings. We measured adherence to a set of locally developed adjuvant treatment guidelines in a middle-income setting. Importantly, the impact of guidelines adherence on survival following breast cancer was determined. METHODS: Data of 3,100 Malaysian women with nonmetastatic breast cancer diagnosed between 2010 and 2017 were analyzed. Adherence to the Malaysian Clinical Practice Guidelines for Management of Breast Cancer second Edition was measured. Outcomes comprised overall survival and event-free survival. RESULTS: Guideline adherence for chemotherapy, radiotherapy, hormonal therapy, and targeted therapy were 61.7%, 79.2%, 85.1%, and 26.2%, respectively. Older age was generally associated with lower adherence to guidelines. Compared with patients who were treated according to treatment guidelines, overall survival and event-free survival were substantially lower in patients who were not treated accordingly; hazard ratios for all-cause mortality were 1.69 (95% CI, 1.29 to 2.22), 2.59 (95% CI, 1.76 to 3.81), 3.08 (95% CI, 1.94 to 4.88), and 4.48 (95% CI, 1.98 to 10.13) for chemotherapy, radiotherapy, hormone therapy, and targeted therapy, respectively. Study inferences remain unchanged following sensitivity analyses. CONCLUSION: Our study findings appear to suggest that adherence to treatment guidelines that have been adapted for resource-limited settings may still provide effective guidance in improving breast cancer outcomes.

Risk of heart disease following treatment for breast cancer - results from a population-based cohort study.

Background: There is a rising concern about treatment-associated cardiotoxicities in breast cancer patients. This study aimed to determine the time- and treatment-specific incidence of arrhythmia, heart failure, and ischemic heart disease in women diagnosed with breast cancer. Methods: A register-based matched cohort study was conducted including 8015 breast cancer patients diagnosed from 2001 to 2008 in the Stockholm-Gotland region and followed up until 2017. Time-dependent risks of arrhythmia, heart failure, and ischemic heart disease in breast cancer patients were assessed using flexible parametric models as compared to matched controls from general population. Treatment-specific effects were estimated in breast cancer patients using Cox model. Results: Time-dependent analyses revealed long-term increased risks of arrhythmia and heart failure following breast cancer diagnosis. Hazard ratios (HRs) within the first year of diagnosis were 2.14 (95% CI = 1.63-2.81) for arrhythmia and 2.71 (95% CI = 1.70-4.33) for heart failure. HR more than 10 years following diagnosis was 1.42 (95% CI = 1.21-1.67) for arrhythmia and 1.28 (95% CI = 1.03-1.59) for heart failure. The risk for ischemic heart disease was significantly increased only during the first year after diagnosis (HR = 1.45, 95% CI = 1.03-2.04). Trastuzumab and anthracyclines were associated with increased risk of heart failure. Aromatase inhibitors, but not tamoxifen, were associated with risk of ischemic heart disease. No increased risk of heart disease was identified following locoregional radiotherapy. Conclusions: Administration of systemic adjuvant therapies appears to be associated with increased risks of heart disease. The risk estimates observed in this study may aid adjuvant therapy decision-making and patient counseling in oncology practices. Funding: This work was supported by the Swedish Research Council (grant no: 2018-02547); Swedish Cancer Society (grant no: CAN-19-0266); and FORTE (grant no: 2016-00081).