A pilot randomized controlled trial of an online intervention for Hodgkin lymphoma survivors to increase knowledge about late effects and recommended screening.

BACKGROUND: Hodgkin lymphoma (HL) survivors who received chest radiotherapy are at risk for breast cancer and cardiovascular disease, but screening adherence is low. We assessed the acceptability/feasibility of a web-based educational intervention and its impact on knowledge of health risks and screening. METHODS: HL survivors were randomized to either an interactive online educational intervention or handouts only. Surveys were completed at baseline and 3 months post-intervention. We described the acceptability/feasibility of the intervention and compared knowledge between groups. RESULTS: Fifty-two HL survivors participated; 27 in the intervention group and 25 in the control group. Eighteen (66%) intervention participants completed the intervention and reported high acceptability (89-100%). At baseline, adherence to breast cancer screening was low across all participants. Post-intervention, those in the intervention group more often than controls correctly identified breast cancer and echocardiogram screening guidelines (35% vs. 28%, P = 0.02 and 82% vs. 52%, P = 0.04) and reported knowing how to address potential complications from cancer treatments (87% vs. 64%, P = 0.03). We detected no increase in screening behavior post-intervention. CONCLUSION: Online education modules for high-risk HL survivors are an acceptable method to improve knowledge of health risks and screening guidelines. Future interventions should focus on improving screening uptake in this population. IMPLICATIONS FOR CANCER SURVIVORS: Web-based learning can be useful in increasing cancer survivor knowledge of their unique risks and screening recommendations but does not necessarily change patient behavior. Involvement in a cancer survivorship program can help assess individual barriers and monitor uptake of screening.

Health Care Students' Perceptions of Bias During Their Clinical Training and Insights on Mitigating It.

PURPOSE: To understand health care students' perception of implicit bias and examine their insights to create a bias-free training environment. METHODS: Clinical phase students from one university's 4 health care programs participated in this study. Students were surveyed regarding their knowledge of implicit bias and perception of their experiences in the clinical learning environment. RESULTS: The response rate was 50.9%, N = 161. In total, 52.6% reported having prior training on implicit bias, and 55% self-reported that they had personally observed preceptors who exhibited an implicit bias toward patients based on race, ethnicity, or other qualities. There was no statistically significant relationship between those with prior training on implicit bias and being able to identify implicit bias exhibited by preceptors. Participants also expressed their unwillingness to report an incident unless it is confidential due to fear of retribution. CONCLUSION: This study found that health care students from one university's 4 health care programs perceived implicit bias in their clinical learning environment, which they believe could be improved by taking intentional steps. Some suggestions provided were "Safe space to report and openly discuss bias," "Education/training on implicit bias," "Time for self-reflection," and "Hiring process that evaluates/trains against implicit bias." The implication of our study is to create a bias-free training environment that will help interrupt the propagation of biases contributing to health disparity. Further research should examine a national population and identify interventional methods and outcomes in multiple health care disciplines.

The development and flux of the University of Minnesota Survivorship Program: progress, challenges, and opportunities.

For the past 30 years, the University of Minnesota's Cancer Survivorship Program has been dedicated to providing exceptional care to patients who have lived the cancer experience. Our model is consultative, risk-stratified, and oncologist-led but executed predominately by advanced practice providers. Care is personalized and serves three survivor populations: children, adults, and patients who received BMT with over 500 new patients evaluated annually. As guidelines and survivorship standards have changed, our clinical programs have evolved from a focus on survivorship care plans to supportive care. The program offers a wide range of supportive services from acupuncture to nutritional services as well as several educational programs for patients. The program has a strong research legacy, notably as the birthplace of research that led to the Children's Oncology Group Guidelines as well as advancements in cardio-oncology and frailty after bone marrow transplantation. In 2021, we hosted the first annual Survivorship Research Forum, providing the opportunity and space for experts across disciplines to exchange ideas on a broad range of survivorship topics not possible at other national cancer-related conferences. With successes and challenges, we have identified opportunities for growth as our program continues to evolve and grow in our goal to improve cancer outcomes along a wide spectrum of physical, emotional, functional, and social dimensions. IMPLICATIONS FOR CANCER SURVIVORS: The University of Minnesota Cancer Survivorship Program provides care, education, and research opportunities for patients across the cancer continuum.

Clinicopathology and Treatment Patterns of Head and Neck Cancers in Ethiopia.

PURPOSE: Head and neck cancers are the third most common cancers treated with radiation in Ethiopia. There is, however, a lack of published data on clinical and pathological characteristics and treatment patterns of head and neck cancers in the country. The objective of the study was to assess clinical and pathological characteristics and treatment patterns of head and neck cancers at Tikur Anbessa Specialized Hospital, which housed the only radiotherapy facility in Ethiopia during the study period. MATERIALS AND METHODS: A retrospective cross-sectional study design with a simple random sampling of histologically confirmed head and neck cancers treated from 2014 to 2017 with analysis of descriptive data. RESULTS: Three hundred twenty-one patient charts were analyzed in this study from a total population of 1,377 from the department cancer registry. The male to female ratio was 2:1. The median age was 45 years (interquartile range, 26-59). The most common primary site of head and neck cancers was nasopharynx (128 of 321, 40%), and the major histologic type was squamous cell carcinoma (285 of 321, 89%). Majority of the cases had advanced disease (stage III-IVC, 221 of 251, 88%), but 92% had potentially curable disease (231 of 321). Cobalt radiotherapy was used for 67% of all patients receiving treatment (184 of 273). Induction chemotherapy followed by radiotherapy was frequently used for curative intent patients (75 of 231, 32%). There was long duration between diagnosis and initiation of treatment, with 56% (148 of 264) waiting longer than 3 months. CONCLUSION: Majority of patients with head and neck cancers seen in Ethiopia presented at advanced stage of disease, received cobalt radiotherapy, and had protracted treatment initiation. These findings underscore the need for additional investments to improve research capacity and increase the availability of high-quality radiotherapy and supportive services to deliver optimal care for patients with head and neck cancer and other cancer patients in the country.

Barriers to Cancer Care in Northern Tanzania: Patient and Health-System Predictors for Delayed Presentation.

PURPOSE: Cancer is a growing problem in Africa, and delays in receiving timely cancer care often results in poorer outcomes. The purpose of this study was to identify the patient and health-system factors associated with delayed cancer care in adults living in the Northern Zone of Tanzania. PATIENTS AND METHODS: Between July 2018 and July 2019, we surveyed adult patients presenting to an oncology clinic in Northern Tanzania. Delayed presentation was defined as 12 weeks or longer from initial symptoms to presentation for cancer care. Multivariate logistic regression and adjusted relative risk (aRR) were used to identify factors predicting delayed presentation. RESULTS: Among 244 adult patients with cancer who completed the survey, 78% (n = 191) had delayed presentation. Patient-related factors associated with delayed presentation included lower educational attainment (P = .03), increased travel time (P = .05), lack of cancer knowledge (P < .05), and fear of cancer and cancer treatments (P < .05) on multivariate analysis. On analysis of aRR, patients without private car and those with health insurance had higher risk of delayed presentation (aRR: 1.27; 95% CI, 1.02 to 1.32 and aRR: 1.15; 95% CI, 1.01 to 1.32). There was a strong association with increased number of visits before presentation at the cancer center and delayed presentation (P = .0009). CONCLUSION: Cancer awareness and prevention efforts targeting patients and community-level health care workers are key to reduce delays in cancer care in Northern Tanzania.

Impact of COVID-19 on Cancer Care Delivery in Africa: A Cross-Sectional Survey of Oncology Providers in Africa.

PURPOSE: The COVID-19 pandemic has disrupted cancer care globally. There are limited data of its impact in Africa. This study aims to characterize COVID-19 response strategies and impact of COVID-19 on cancer care and explore misconceptions in Africa. METHODS: We conducted a web-based cross-sectional survey of oncology providers in Africa between June and August 2020. Descriptive statistics and comparative analysis by income groups were performed. RESULTS: One hundred twenty-two participants initiated the survey, of which 79 respondents from 18 African countries contributed data. Ninety-four percent (66 of 70) reported country mitigation and suppression strategies, similar across income groups. Unique strategies included courier service and drones for delivery of cancer medications (9 of 70 and 6 of 70, respectively). Most cancer centers remained open, but > 75% providers reported a decrease in patient volume. Not previously reported is the fear of infectivity leading to staff shortages and decrease in patient volumes. Approximately one third reported modifications of all cancer treatment modalities, resulting in treatment delays. A majority of participants reported ≤ 25 confirmed cases (44 of 68, 64%) and ≤ 5 deaths because of COVID-19 (26 of 45, 58%) among patients with cancer. Common misconceptions were that Africans were less susceptible to the virus (53 of 70, 75.7%) and decreased transmission of the virus in the African heat (44 of 70, 62.9%). CONCLUSION: Few COVID-19 cases and deaths were reported among patients with cancer. However, disruptions and delays in cancer care because of the pandemic were noted. The pandemic has inspired tailored innovative solutions in clinical care delivery for patients with cancer, which may serve as a blueprint for expanding care and preparing for future pandemics. Ongoing public education should address COVID-19 misconceptions. The results may not be generalizable to the entire African continent because of the small sample size.

Radiotherapy Practice for Treatment of Bone Metastasis in Ethiopia.

PUROSE: Ethiopia has one cobalt radiotherapy (RT) machine to serve a population of more than 100 million. The purpose of this study was to report on patterns of palliative RT of bone metastasis in a severely low-capacity setting. PATIENTS AND METHODS: Patient and treatment characteristics of patients irradiated for palliation of symptomatic bone metastasis were extracted from a retrospective database of patients treated between May 2015 and January 2018. This database included a random sample of 1,823 of the estimated 4,000 patients who were treated with RT within in the study period. Associations between the applied RT schedule and patient and tumor characteristics were evaluated with the χ2 test. Hypothetical savings of RT sessions and time were compared in the case of a single-fraction policy. RESULTS: From the database, 234 patients (13%) were treated for bone metastasis. Most patients were ≤ 65 years of age (n = 189; 80%) and female (n = 125; 53%). The most common primary sites were breast (n = 82; 35%) and prostate (n = 36; 15%). Fractionated regimens were preferred over single fraction: 20 Gy in 5 fractions (n = 192; 82.1%), 30 Gy in 10 fractions (n = 7; 3%), and 8 Gy in 1 fraction (n = 28; 12%). Factors associated with single-fraction RT included nonaxial sites of bone metastasis (P < .01) and an address outside Addis Ababa (P ≤ .01). If single-fraction RT would have been given uniformly for bone metastasis, this would have resulted in a 78% reduction in the number of RT sessions and 76% reduction in total RT time. CONCLUSION: The pattern of palliative RT for bone metastasis in Ethiopia favors fractionated regimens over single fraction. Efforts should be made to adopt evidence-based and cost-effective guidelines.

Patterns of Care of Cancers and Radiotherapy in Ethiopia.

PURPOSE: Radiotherapy (RT) is an essential component of cancer treatment. There is a lack of RT services in sub-Saharan Africa as well as limited knowledge regarding clinical practices. The purpose of this study was to identify and describe the patterns for RT treatment in Ethiopia. METHODS AND MATERIALS: We performed a retrospective analysis of 1,823 patients treated with cobalt RT at a large referral hospital in Addis Ababa, Ethiopia, from May 2015 through January 2018. Paper charts were reviewed for patient and treatment characteristics. Descriptive statistics were computed using SPSS (IBM, Armonk, NY). RESULTS: Among patients treated for cancer, 98% (n = 1,784) were adults, 78% (n = 1,426) were female, 5% (n = 85) were HIV positive, 30% (n = 555) were from Addis Ababa, and the median age was 48 years (interquartile range [IQR], 38-58 years). Cervical cancer was the most frequent cancer treated (47%, n = 851), followed by breast cancer (15%, n = 274) and head and neck cancer (10%, n = 184). Seventy-three percent of patients (n = 1,339) presented at a late stage, and 62% (n = 1,138) received palliative RT. The wait times were the shortest for patients receiving palliative treatment (median, 0 days; IQR, 0-15 days; n = 1,138), whereas wait times were longer for patients receiving curative treatment (median, 150 days; IQR, 60-210 days; n = 685). Three percent of patients (n = 56) had documented grade 3 or 4 acute toxicity; of these, 59% (n = 33) were patients with head and neck cancer. CONCLUSION: Cervical cancer accounted for half of patients treated; thus, a majority of patients were adult females. Most patients had advanced-stage cancer, and goals of care were palliative. Wait times were long for patients with curative-intent cancer as a result of low capacity for RT services.

Cancer Training for Frontline Healthcare Providers in Tanzania.

Cervical and breast cancer are responsible for the highest cancer-related mortality in Tanzania, although both are preventable or curable if diagnosed at an early stage. Limited knowledge of cervical cancer by clinic and dispensary level healthcare providers in Tanzania is a barrier for prevention and control strategies. The purpose of the study was to provide basic oncology training to frontline healthcare workers with a focus on cervical and breast cancer in order to increase knowledge. A 1-day cancer training symposium was conducted in Arusha, Tanzania, with 43 clinicians. Pre- and post-intervention surveys assessed cancer knowledge and confidence of clinicians in risk assessment. Sixty-nine percent of the participants reported never receiving any cervical cancer training in the past. A significant difference was found between the pre- and post-test in a majority of knowledge questions and in reported confidence recognizing signs and symptoms of breast and cervical cancer (p < 0.05). The 1-day community oncology training symposium was effective in delivering and increasing basic knowledge about cervical and breast cancers to these healthcare providers. The low level of baseline cancer knowledge among frontline medical providers in Tanzania illustrates the need for increased training around the country.

The Tanzanian assistant medical officer.

Tanzania, in East Africa, has one of the lowest numbers of physician per population in the world, especially in rural areas where most people live. To address this shortage, assistant medical officers (AMOs) were developed in the 1960s. AMOs are trained in an abbreviated medical school program, work independently, remain the highest-trained practitioners in rural practice, and provide most emergency surgical obstetric care in nonurban settings. Although information on AMOs is limited, no evidence has emerged that their patient care outcomes differ from physicians. These healthcare professionals, similar to physician assistants, have expanded access to care in severely underserved areas of the country. With a growing demand for contemporary healthcare and stretched service delivery, more research is needed on the ameliorating effect AMOs have on Tanzanian healthcare, especially as the country considers converting AMO training programs to medical school programs.

Physician Assistants and the Expanding Global Health-Care Workforce.

The physician assistant and other types of medical providers with accelerated and focused training were developed to serve the specific health-care needs of individual countries. They have an important role in providing care globally in response to physician shortages. Working in over 50 nations, these clinicians increase access to team-based health care. This perspective explores the successes and challenges of these professionals as an international community. Steps are proposed to increase global awareness and acceptance of these professionals including platforms to increase discussion, scholarly activity, and collaboration.