Access to cancer care in Colombia, a middle-income country with universal health coverage

Advances and challenges of reducing adult educational inequalities in stomach cancer: a time series study, Colombia, 1998-2015

Trends in educational inequalities in adult (25 years old and over) gastric cancer mortality by sex and age group in Colombia from 1998-2015 were analyzed. An ecological time series study was conducted using Colombian vital statistics and official population estimations. Age-standardized mortality rates (ASMR per 100,000 person-years) for gastric cancer were calculated separately by educational level, sex, and grouped age. A Poisson regression model was used to calculate rates ratios (RR) and the Relative Index of Inequalities (RII). The changes over time of the ASMR and RII were analyzed using a joinpoint analysis. During the study period, 80,520 deaths from gastric cancer were recorded among adults, 60% among men. Higher ASMRs were found in the lower educational levels. The inequality measured by the RII was lower among women compared to men. Young and middle-aged men suffered from the highest relative inequalities, while older men bore the toll of higher mortality rates and a greater increase in relative inequalities. It is necessary to address public health programs aimed at strengthening the quality of life of the populations identified as at risk of stomach cancer.

Quality of care in Colombian women with early-onset breast cancer in two time periods: findings from a nationwide administrative registry cohort

Background

Early-onset breast cancer (EOBC) refers to breast cancer diagnosed in women aged 18-45 years, being in many cases associated with hereditary breast cancer syndromes, diagnosed at more advanced stages and worse prognosis. In this paper, we sought to describe the main characteristics of EOBC and quality of care within the framework of the national health system in Colombia.

Methods

Cross-sectional study. We used a national administrative cancer registry, including women diagnosed with EOBC between 2017 and 2022. Demographic and clinical characteristics, as well as quality healthcare indicators, were compared (numbers and percentages) over two periods (2017-2019, 2020-2022), stratified by health insurance scheme.

Findings

7621 women with incident EOBC were included, constituting 19.4% (7621/39,238) of all breast cancers reported in the study period. The mean age was 39.2 (SD 5.2). Most of the cases (23% [1753/7621]) were diagnosed at stage IIA. Systemic therapy was the most frequent first treatment. When comparing both periods, the main areas of improvement were related to breast-conserving surgery for early stages (from 60.3% [459/761] to 68.3% [699/1024]), access to palliative care for metastatic cancer (from 29.5% [59/199] to 54.9% [101/184]), and reduction of waiting times. The time from collecting biopsy samples to receiving results showed the biggest improvement between periods (from a mean of 24.5 to 5.0 days). However, delays in initiating treatment persist, with an average of over two months.

Interpretation

While the quality of breast cancer care in women with EOBC has improved in recent years in Colombia, mainly due to better access to specific technologies and treatments, there are important challenges regarding early detection and health services delays that require corrective measures.

Funding

Work at the IARC/WHO was supported by regular budget funding.

Real world data on cervical cancer treatment patterns, healthcare access and resource utilization in the Brazilian public healthcare system

The aim of the study is to evaluate the treatment patterns, time to start treatment, and healthcare resources utilization (HCRU) of cervical cancer (CC) patients within the Brazilian public health system (SUS). This is an observational retrospective study using SUS administrative database (DATASUS). Data from January-2014 to December-2020 was gathered from patients with the ICD-10 C53 codes. From 2014 to 2020, 206,861 women were included, among whom 90,073 (43.5%) had stage information. Of staged patients, 60.7% (54,719) had advanced disease (stages III and IV) and the most performed treatments were chemoradiotherapy (CRT) (41.6%), surgery + CRT (19.1%), radiotherapy (RT) only (16.8%) and chemotherapy (CT) only (13.3%). The proportion of patients submitted to CT in advanced stages was higher than in non-advanced stages (I and II), in contrast to RT, which was more frequent in stage I than stage IV. Median time to initiate treatment surpassed two months in approximately 30% of the cases, regardless of stage. Conization was the most performed surgical procedure. The hospitalization rate per patient per month for stage IV was twice as high as stage I (0.05 [95%CI 0.05-0.05] and 0.11 [0.11-0.11], respectively). The same trend was observed for outpatient visits (0.54 [95%CI 0.53-0.55] and 0.96 [0.93-0.98], respectively). This study demonstrated a high proportion of advanced CC at diagnosis in Brazil. The treatment pattern showed that chemoradiotherapy was the most frequent regimen overall and the use of chemotherapy and HCRU increased with staging. These results could provide information to improve public policies towards access to prevention, diagnosis, and treatment of CC in Brazil.

Relationship between universal health insurance benefits and prostate cancer mortality in Colombia

PURPOSE

Prostate cancer is the most common cause for cancer mortality among men in Colombia. Law 100, in 1993, created a contributory regime (private insurance) and subsidized regime (public insurance) in which the subsidized regime had fewer benefits. However, Ruling T760 in July 2012 mandated that both systems must offer equal quality and access to healthcare. This study examines the impact of this change on prostate cancer mortality rates before and after 2012.

METHODOLOGY

Prostate cancer mortality records from 2006 to 2020 were collected from Colombia's National Administrative Department of Statistics (DANE). Crude mortality was calculated by health insurance for different geographic areas and analyzed for changes between 2006 and 2012 and 2013-2020. Join-Point regressions were used to analyze trends by health insurance.

RESULTS

Crude mortality rates in the contributory regime had a non-statistically significant decrease from 2006 to 2012 (AAPC= -1.32%, P = 0.14, 95% CI= -3.12, 0.52). In contrast, between 2013 and 2020 there was a non-statistically significant increase in crude mortality (AAPC 1.10%, P = 0.07, 95% CI= -0.09, 2.31). Comparatively, crude mortality in the subsidized regime, from 2006 to 2012, increased with a statistically significant AAPC of 2.51% (P < 0.001, 95% CI = 1.21, 3.83). From 2013 to 2020, mortality continued to increase with statistically significant AAPC of 5.52% (P < 0.001, 95% CI = 4.77, 6.27). Compared to their crude mortality differences from 2006 to 2020, from 2013 to 2020, the departments of Atlántico, Córdoba, Sucre, Arauca, Cesar, and Cauca had the highest rates in prostate cancer mortality in the subsidized regime compared to the contributory regime.

CONCLUSION

Ruling T760 did not positively impact prostate cancer mortality, particularly of men in the subsidized regime.

Population-based overall and net survival of childhood leukemia at 1-, 5-, and 10-years of follow-up in three regions of Colombia

Background

Childhood leukemia (CL) is the most common type of childhood cancer worldwide and in Colombia. Thanks to therapeutic innovations and improved access, the survival of children and adolescents with leukemia has increased considerably worldwide, especially in high-income countries. In Colombia, a middle-income country, survival has also been observed to increase in big cities. However, the survival rate in intermediate cities is still unknown.

Objective

This study aimed to assess short- and long-term survival rates of children with leukemia coming from three intermediate Colombian cities as well as to compare overall survival (OS) rates versus relative survival (RS) rates of this population of children.

Methods

Data from population-based cancer registries in three Colombian cities (Bucaramanga metropolitan area, Manizales and Pasto) were analyzed. OS and RS of up to 10 years were estimated for children who were diagnosed with leukemia at ages 0-18 years between 1998 and 2018 and followed up for vital status. RS was calculated using the Pohar-Perme method. We performed a separate survival analysis by gender and by period of diagnosis (before and after 2010).

Results

We included data from 507 children and adolescents diagnosed with leukemia. RS at 1, 5 and 10 years after diagnosis were similar between the populations for the respective timeframes (RS Bucaramanga 86.5%, 66.9% and 52.5%; Manizales 81.1%, 62.8% and 61.1%; Pasto 81.7% at 1 year, 66.2% at 5 years and 59.4% at 10 years). OS and RS were very similar for all estimates and periods. There were no clear differences in RS between genders across the three population-based cancer registries and there was an improvement in RS after 2010, particularly in Bucaramanga and Pasto.

Conclusion

Our study reports similar 5-year survival rates for CL in these Colombian cities compared to rates documented in other Latin American countries and larger Colombian cities. These are far below what is reported in high-income settings. This highlights opportunities for improvement in the Colombian health system, where numerous barriers persist in terms of suspicion, diagnosis and continuity of treatment for CL.

Genetic ancestry is related to potential sources of breast cancer health disparities among Colombian women

Breast cancer health disparities are linked to clinical-pathological determinants, socioeconomic inequities, and biological factors such as genetic ancestry. These factors collectively interact in complex ways, influencing disease behavior, especially among highly admixed populations like Colombians. In this study, we assessed contributing factors to breast cancer health disparities according to genetic ancestry in Colombian patients from a national cancer reference center. We collected non-tumoral paraffin embedded (FFPE) blocks from 361 women diagnosed with breast cancer at the National Cancer Institute (NCI) to estimate genetic ancestry using a 106-ancestry informative marker (AIM) panel. Differences in European, Indigenous American (IA) and African ancestry fractions were analyzed according to potential sources of breast cancer health disparities, like etiology, tumor-biology, treatment administration, and socioeconomic-related factors using a Kruskal-Wallis test. Our analysis revealed a significantly higher IA ancestry among overweight patients with larger tumors and those covered by a subsidized health insurance. Conversely, we found a significantly higher European ancestry among patients with smaller tumors, residing in middle-income households, and affiliated to the contributory health regime, whereas a higher median of African ancestry was observed among patients with either a clinical, pathological, or stable response to neoadjuvant treatment. Altogether, our results suggest that the genetic legacy among Colombian patients, measured as genetic ancestry fractions, may be reflected in many of the clinical-pathological variables and socioeconomic factors that end up contributing to health disparities for this disease.

Translation and linguistic validation of the Sheffield Profile for Assessment and Referral for Care (SPARC) to Colombian Spanish

OBJECTIVES

We aimed to translate and linguistically and cross-culturally validate Sheffield Profile for Assessment and Referral for Care (SPARC) in Spanish for Colombia (SPARC-Sp).

METHODS

The linguistic validation of SPARC followed a standard methodology. We conducted focus groups to assess the comprehensibility and feasibility. The acceptability was assessed using a survey study with potential users.

RESULTS

The comprehensibility assessment showed that additional adjustments to those made during the translation-back-translation process were required to apply SPARC-Sp in rural and low-schooled populations. It also identified the need for alternative administration mechanisms for illiterate people. The acceptability survey showed that potential users found SPARC-Sp as not only acceptable but also highly desirable. However, they desired to expand the number of items in all domains.

SIGNIFICANCE OF RESULTS

Beyond the semantic and conceptual validity attained through the back-translation process, actual cultural validity could be acquired thanks to the comprehensibility tests. Although extending the instrument is something potential users would like to do, it would make it less feasible to utilize the SPARC-Sp in clinical settings. Nonetheless, the instrument might benefit from the inclusion of a domain that evaluates challenges encountered when accessing the health-care system. For communities lacking literacy, alternate administration methods must also be considered.

Unpacking the Public Health Triad of Social Inequality in Health, Health Literacy, and Quality of Life-A Scoping Review of Research Characteristics

Social inequalities in health, health literacy, and quality of life serve as distinct public health indicators, but it remains unclear how and to what extent they are applied and combined in the literature. Thus, the characteristics of the research have yet to be established, and we aim to identify and describe the characteristics of research that intersects social inequality in health, health literacy, and quality of life. We conducted a scoping review with systematic searches in ten databases. Studies applying any design in any population were eligible if social inequality in health, health literacy, and quality of life were combined. Citations were independently screened using Covidence. The search yielded 4111 citations, with 73 eligible reports. The reviewed research was mostly quantitative and aimed at patient populations in a community setting, with a scarcity of reports specifically defining and assessing social inequality in health, health literacy, and quality of life, and with only 2/73 citations providing a definition for all three. The published research combining social inequality in health, health literacy, and quality of life is heterogeneous regarding research designs, populations, contexts, and geography, where social inequality appears as a contextualizing variable.

Temporal patterns of breast cancer incidence, mortality, disability-adjusted life years and risk factors in 12 South American Countries, 1990-2019: an examination using estimates from the global burden of disease 2019 study

BACKGROUND AND AIM

Breast cancer (BC) is one of the leading causes of cancer deaths in females in South America. This study aims to examine the BC burden in 12 South American countries between 1990 and 2019.

DATA AND METHODS

The estimates of BC burden and risk factors were procured from the Global Burden of Disease 2019 study for the period 1990-2019. Development levels of countries were gauged using socio-demographic index (SDI). Decomposition analysis was employed to categorize the change in incidence between 1990 and 2019 into three factors: population growth, population aging and age-specific incidence rate. Estimated annual percent changes were calculated for each country and bivariate association between country-level age-standardized rates and SDI was examined using pooled regression.

RESULTS

The age-standardized rates of breast cancer were the highest in Uruguay [incidence: 72.65 per 100,000 (55.79-92.57); mortality: 29.97 per 100,000 (27.54-32.27); disability-adjusted life years (DALYs: 810.49 per 100,000 (746.22-884.55)] and lowest in Peru [incidence: 27.63 per 100,000 (20.44-36.85); mortality: 10.79 per 100,000 (8.14-14.11); DALYs: 318.27 per 100,000 (234.47-421.16)]. Mortality-to-incidence ratio (MIR) across countries varied from 0.30 in Colombia to 0.55 in Bolivia in 2019. SDI had a positive and strong association with age-standardized incidence rate [Formula: see text] and weaker positive association with age-standardized mortality rate [Formula: see text] and age-standardized DALYs rate [Formula: see text]. Most countries experienced more than 70% increase in incident cases owing to population aging and age-specific incidence rates. Alcohol Use, diet high in red meat and smoking contributed the maximum DALYs in most countries in 2019 whereas DALYs due to high body-mass index and high fasting plasma glucose increased most substantially between 1990 and 2019.

CONCLUSION

With increasing incidence, high MIR and rising BC burden due to modifiable risk factors, several public health interventions are required in South America focusing on prevention, BC awareness among general public, cost-effective early detection and treatments that suit the socio-economic setup of South American countries.

Mathematical Modeling for the Assessment of Public Policies in the Cancer Health-Care System Implemented for the Colombian Case

The incidence of cancer has been constantly growing worldwide, placing pressure on health systems and increasing the costs associated with the treatment of cancer. In particular, low- and middle-income countries are expected to face serious challenges related to caring for the majority of the world's new cancer cases in the next 10 years. In this study, we propose a mathematical model that allows for the simulation of different strategies focused on public policies by combining spending and epidemiological indicators. In this way, strategies aimed at efficient spending management with better epidemiological indicators can be determined. For validation and calibration of the model, we use data from Colombia-which, according to the World Bank, is an upper-middle-income country. The results of the simulations using the proposed model, calibrated and validated for Colombia, indicate that the most effective strategy for reducing mortality and financial burden consists of a combination of early detection and greater efficiency of treatment in the early stages of cancer. This approach is found to present a 38% reduction in mortality rate and a 20% reduction in costs (% GDP) when compared to the baseline scenario. Hence, Colombia should prioritize comprehensive care models that focus on patient-centered care, prevention, and early detection.

Survivorship Care in Middle-Income Countries: A Guideline Development for Colombia Using Breast Cancer as a Model

Cancer survival has significantly increased during the past few decades, making survivorship care a key element of cancer control and posing several challenges for long-term care in low- and middle-income countries (LMIC). Most survivorship care guidelines emphasize the potential role of primary care physicians and the need for comprehensive care, with a preference for patient-centered over disease-centered approaches. However, guidelines developed in high-income countries are not always suitable for LMIC, where a shortage of oncology workforce, deficient training in primary care, and low access to comprehensive centers frequently induce undertreatment and a lack of follow-up. Despite universal health insurance coverage, Colombia has fragmented cancer care with deficient survivorship care, given its focus on relapse surveillance without integration of supportive care and comorbidity management, in addition to unequal access for low-income populations and distant regions. Using the breast cancer framework, we describe the development of a guideline for survivorship care on the basis of a risk approach and the proper integration of oncology specialists and family physicians. We used a three-phase process to develop recommendations for disease control (disease-centered review), interventions aimed at improving patients' quality of life (patient-centered review), and care delivery (delivery model review). We deem our proposal suitable for middle-income countries, which represents an input for more standardized survivorship care in these settings.

The impact of health insurance affiliation and socioeconomic status on cervical cancer survival in Bucaramanga, Colombia

Cervical cancer is still an important cause of death in countries like Colombia. We aimed to determine whether socioeconomic status of residential address (SES) and type of health insurance affiliation (HIA) might be associated with cervical cancer survival among women in Bucaramanga, Colombia. All patients residing in the Bucaramanga Metropolitan Area diagnosed with invasive cervical cancer (ICD-0-3 codes C53.X) between 2008 and 2016 (n = 725) were identified through the population-based cancer registry, with 700 women having follow-up data for >5 years (date of study closure: Dec 31, 2021), yielding an overall 5-year survival estimate (95 % CI) of 56.4 % (52.7 - 60.0 %). KM estimates of 5-year overall survival were obtained to assess differences in cervical cancer survival by SES and HIA. Multivariable Cox-proportional hazards modeling was also conducted, including interaction effects between SES and HIA. Five-year overall survival was lower when comparing low vs. high SES (41.9 % vs 57.9 %, p < 0.0001) and subsidized vs. contributive HIA (45.1 % vs 63.0 %, p < 0.0001). Multivariable Cox modeling showed increased hazard ratios (HR) of death for low vs. high SES (HR = 1.78; 95 % CI = 1.18-2.70) and subsidized vs. contributive HIA (HR = 1.44; 95 % CI = 1.13-1.83). The greatest disparity in HR was among women of low SES affiliated to subsidized HIA (vs. contributive HIA and high SES) (HR=2.53; 95 % CI = 1.62-3.97). Despite Colombia's universal healthcare system, important disparities in cervical cancer survival by health insurance affiliation and socioeconomic status remain.

Association of genetic ancestry with HER2, GRB7 AND estrogen receptor expression among Colombian women with breast cancer

Background

Our previous study reported higher mRNA levels of the human epidermal growth factor receptor 2 (HER2)-amplicon genes ERBB2 and GRB7 in estrogen receptor (ER)-positive breast cancer patients with relatively high Indigenous American (IA) ancestry from Colombia. Even though the protein expression of HER2 and GRB7 is highly correlated, they may also express independently, an event that could change the patients' prognosis. In this study, we aimed to explore the differences in ER, HER2 and GRB7 protein expression according to genetic ancestry, to further assess the clinical implications of this association.

Methods

We estimated genetic ancestry from non-tumoral breast tissue DNA and assessed tumoral protein expression of ER, HER2, and GRB7 by immunohistochemistry in a cohort of Colombian patients from different health institutions. We used binomial and multinomial logistic regression models to test the association between genetic ancestry and protein expression. Kaplan-Meier and log-rank tests were used to evaluate the effect of HER2/GRB7 co-expression on patients' survival.

Results

Our results show that patients with higher IA ancestry have higher odds of having HER2+/GRB7- breast tumors, compared to the HER2-/GRB7- subtype, and this association seems to be stronger among ER-positive tumors (ER+/HER2+/GRB7-: OR=3.04, 95% CI, 1.47-6.37, p<0.05). However, in the multivariate model this association was attenuated (OR=1.80, 95% CI, 0.72-4.44, p=0.19). On the other hand, it was observed that having a higher European ancestry patients presented lower odds of ER+/HER2+/GRB7- breast tumors, this association remained significant in the multivariate model (OR=0.36, 95% CI, 0.13 - 0.93, p= 0.0395). The survival analysis according to HER2/GRB7 co-expression did not show statistically significant differences in the overall survival and recurrence-free survival.

Conclusions

Our results suggest that Colombian patients with higher IA ancestry and a lower European fraction have higher odds of ER+/HER2+/GRB7- tumors compared to ER+/HER2-/GRB7- disease. However, this association does not seem to be associated with patients' overall or recurrence-free survival.

Dynamic geographical accessibility assessments to improve health equity: protocol for a test case in Cali, Colombia

This protocol proposes an approach to assessing the place of residence as a spatial determinant of health in cities where traffic congestion might impact health services accessibility. The study provides dynamic travel times presenting data in ways that help shape decisions and spur action by diverse stakeholders and sectors.  Equity assessments in geographical accessibility to health services typically rely on static metrics, such as distance or average travel times. This new approach uses dynamic spatial accessibility measures providing travel times from the place of residence to the health service with the shortest journey time. It will show the interplay between traffic congestion, accessibility, and health equity and should be used to inform urban and health services monitoring and planning. Available digitised data enable efficient and accurate accessibility measurements for urban areas using publicly available sources and provide disaggregated sociodemographic information and an equity perspective. Test cases are done for urgent and frequent care (i.e., repeated ambulatory care). Situational analyses will be done with cross-sectional urban assessments; estimated potential improvements will be made for one or two new services, and findings will inform recommendations and future studies. This study will use visualisations and descriptive statistics to allow non-specialized stakeholders to understand the effects of accessibility on populations and health equity. This includes "time-to-destination" metrics or the proportion of the people that can reach a service by car within a given travel time threshold from the place of residence. The study is part of the AMORE Collaborative Project, in which a diverse group of stakeholders seeks to address equity for accessibility to essential health services, including health service users and providers, authorities, and community members, including academia.

Fighting Cancer around the World: A Framework for Action

Tackling cancer is a major challenge right on the global level. Europe is only the tip of an iceberg of cancer around the world. Prosperous developed countries share the same problems besetting Europe-and the countries and regions with fewer resources and less propitious conditions are in many cases struggling often heroically against a growing tide of disease. This paper offers a view on these geographically wider, but essentially similar, challenges, and on the prospects for and barriers to better results in this ceaseless battle. A series of panels have been organized by the European Alliance for Personalised Medicine (EAPM) to identify different aspects of cancer care around the globe. There is significant diversity in key issues such as NGS, RWE, molecular diagnostics, and reimbursement in different regions. In all, it leads to disparities in access and diagnostics, patients' engagement, and efforts for a better understanding of cancer.

Cross-sector co-creation of a community-based physical activity program for breast cancer survivors in Colombia

Benefits of physical activity (PA) in breast cancer survivors (BCS) are well established. However, programs to promote PA among BCS tailored to real-world contexts within low- to middle-income countries are limited. Cross-sector co-creation can be key to effective and scalable programs for BCS in these countries. This study aimed to evaluate the networking process to engage multisector stakeholders in the co-creation of a PA program for Colombian BCS called My Body. We employed a mixed-methods design including semistructured interviews, workshops and a social network analysis of centrality measures to assess stakeholders' engagement, resources and skills enabling the collaborative work, challenges, outcomes and lessons learned. The descriptive analysis and the centrality measures of the network revealed that 19 cross-sector stakeholders engaged in the My Body collaborative network. Through ongoing communication and cooperation, My Body built relationships between the academic lead institutions (local and international), and local and national public, private and academic institutions working in public health, sports and recreation, social sciences and engineering fields. The outcomes included the co-creation of the community-based PA program for BCS, its implementation through cross-sector synergies, increased relationships and communications among stakeholders, and successful dissemination of evidence and project results to the collaboration partners and other relevant stakeholders and community members. The mixed-methods assessment enabled understanding of ways to advance cross-sector co-creation of health promotion programs. The findings can help to enable continued development of sustainable cross-sector co-creation processes aimed at advancing PA promotion.

Geographic accessibility to cancer treatment in Brazil: A network analysis

Background

Geographic accessibility to healthcare services is a fundamental component in achieving universal health coverage, the central commitment of the Brazilian Unified Health System (SUS). For cancer patients, poor accessibility has been associated with inadequate treatment, worse prognosis, and poorer quality of life.

Methods

We explored nationwide healthcare data from the SUS health information systems, and mapped the geographic accessibility to cancer treatment in two time-frames: 2009-2010 and 2017-2018. We applied social network analysis (SNA) to estimate the commuting route, flow, and distances travelled by cancer patients to undergo surgical, radiotherapy, and chemotherapy treatment.

Findings

A total of 12,751,728 treatment procedures were analyzed. Overall, more than half of the patients (49·2 to 60·7%) needed to travel beyond their municipality of residence for treatment, a fact that did not change over time. Marked regional differences were observed, as patients living in the northern and midwestern regions of the country had to travel longer distances (weighted average of 296 to 870 km). Cancer care hubs and attraction poles were mostly identified in the southeast and northeast regions, with Barretos being the main hub for all types of treatment throughout time.

Interpretation

Important regional disparities in the accessibility to cancer treatment in Brazil were revealed, suggesting the need to review the distribution of specialized care in the country. The data presented here contribute to ongoing research on improving access to cancer care and can provide reference to other countries, offering relevant data for oncological and healthcare service evaluation, monitoring, and strategic planning.

Funding

This work was funded by the Oswaldo Cruz Foundation - Fiocruz (Inova - no. 8451635123 to BPF) and the National Council for Scientific and Technological Development - CNPq (no. 407060/2018-9 to BPF); Coordination for the Improvement of Higher Education Personnel - CAPES (scholarship to PCA, Finance Code 001); and Instituto Nacional de Ciência e Tecnologia de Inovação em Doenças de Populações Negligenciadas (INCT-IDPN).

Resumo

A acessibilidade geográfica aos serviços de saúde é um componente fundamental para o alcance da cobertura universal de saúde, compromisso central do Sistema Único de Saúde (SUS). Para pacientes com câncer, a baixa acessibilidade aos serviços especializados tem sido associada ao tratamento inadequado, piora no prognóstico e na qualidade de vida.Neste estudo, dados de saúde dos sistemas de informação em saúde do SUS foram utilizados para mapear a acessibilidade geográfica ao tratamento do câncer em dois períodos: 2009-2010 e 2017-2018. Aplicamos a análise de redes sociais (ARS) para estimar os fluxos de deslocamento e as distâncias percorridas por pacientes com câncer para receberem tratamento cirúrgico, radioterápico e quimioterápico.Um total de 12.751.728 procedimentos de tratamento foram analisados. Em geral, mais da metade dos pacientes (49,2 a 60,7%) precisaram se deslocar de seus municípios de residência para receber tratamento, fato que não mudou comparando os dois períodos de tempo analisados. Foram observadas importantes diferenças regionais no acesso. Pacientes residentes das regiões norte e centro-oeste do país tiveram que percorrer maiores distâncias para alcançar os serviços (média ponderada = 296 a 870 km). A maioria dos hubs e polos de atração para atendimento oncológico foram identificados nas regiões Sudeste e Nordeste, sendo o município de Barretos o principal hub para todos os tipos de tratamento ao longo do tempo.As disparidades de acessibilidade para o tratamento de câncer, alertam para a necessidade de revisar a distribuição dos serviços de atenção especializada no país. A metodologia e os resultados apresentados neste estudo contribuem para as pesquisas sobre a melhoria do acesso ao tratamento do câncer e podem servir como referência para outros países, oferecendo dados relevantes para avaliação, monitoramento e planejamento estratégico de serviços oncológicos e de saúde em geral.

OUP accepted manuscript

Purpose

About 10% of breast cancer (BC) is diagnosed in stage IV. This study sought to identify factors associated with time to progression (TTP) and overall survival (OS) in a cohort of patients diagnosed with de novo metastatic breast cancer (MBC), from a single cancer center in Colombia, given that information on this aspect is limited.

Methodology

An observational, analytical, and retrospective cohort study was carried out. Time to progression and OS rates were estimated using the Kaplan–Meier survival functions. Cox models were developed to assess association between time to progression and time to death, using a group of fixed variables.

Results

Overall, 175 patients were included in the study; 33.7% of patients had luminal B HER2-negative tumors, 49.7% had bone involvement, and 83.4% had multiple metastatic sites. Tumor biology and primary tumor surgery were the variables associated with TTP and OS. Patients with luminal A tumors had the lowest progression and mortality rates (10 per 100 patients/year (95% CI: 5.0-20.0) and 12.6 per 100 patients/year (95% CI: 6.9-22.7), respectively), and patients with triple-negative tumors had the highest progression and mortality rates (40 per 100 patients/year (95% CI: 23.2-68.8) and 44.1 per 100 patients/year (95% CI: 28.1-69.1), respectively). Across the cohort, the median TTP was 2.1 years (95% CI: 1.6; the upper limit cannot be reached) and the median OS was 2.4 years (95% CI: 2-4.3).

Conclusions

In this cohort, patients with luminal A tumors and those who underwent tumor surgery given that they presented clinical benefit (CB) after initial systemic treatment, had the lowest progression and mortality rates. Overall, OS was inferior to other series due to high tumor burden and difficulties in accessing and continuing oncological treatments.

Cancer as a Chronic Illness in Colombia: A Normative Consensus Approach to Improving Healthcare Services for those Living with and beyond Cancer and Its Treatment

Cancer survivorship care in Colombia is of increasing importance. International survivorship initiatives and studies show that continuing symptoms, psychological distress, and late effects impact the quality of life for survivors. Priorities for quality survivorship according to Colombian patients and clinicians are unknown. We undertook a nominal consensus approach with 24 participants using virtual meeting technology to identify the priorities for cancer survivorship. We applied an iterative approach conducted over eight weeks with five workshops and one patient focus group followed by a priority setting survey. The consensus group established six main themes, which were subsequently evaluated by experts: (i) symptoms and secondary effects of cancer; (ii) care coordination to increase patient access and integration of cancer care; (iii) psychosocial support after cancer treatment; (iv) mapping information resources and available support services for long-term cancer care; (v) identifying socioeconomic and regional inequalities in cancer survival to improve care and outcomes; and (vi) health promotion and encouraging lifestyle change. The order of priorities differed between clinicians and patients: patients mentioned psychosocial support as the number one priority, and clinicians prioritized symptoms and surveillance for cancer recurrence. Developing survivorship care needs consideration of both views, including barriers such as access to services and socioeconomic disparities.

Medical decisions concerning the end of life for cancer patients in three Colombian hospitals - a survey study

Background

Cancer patients’ end-of-life care may involve complex decision-making processes. Colombia has legislation regarding provision of and access to palliative care and is the only Latin American country with regulation regarding euthanasia. We describe medical end-of-life decision-making practices among cancer patients in three Colombian hospitals.

Methods

Cancer patients who were at the end-of-life and attended in participating hospitals were identified. When these patients deceased, their attending physician was invited to participate. Attending physicians of 261 cancer patients (out of 348 identified) accepted the invitation and answered a questionnaire regarding end-of-life decisions: a.) decisions regarding the withdrawal or withholding of potentially life-prolonging medical treatments, b.) intensifying measures to alleviate pain or other symptoms with hastening of death as a potential side effect, and c.) the administration, supply or prescription of drugs with an explicit intention to hasten death. For each question addressing the first two decision types, we asked if the decision was fully or partially made with the intention or consideration that it may hasten the patient’s death.

Results

Decisions to withdraw potentially life-prolonging treatment were made for 112 (43%) patients, 16 of them (14%) with an intention to hasten death. For 198 patients (76%) there had been some decision to not initiate potentially life-prolonging treatment. Twenty-three percent of patients received palliative sedation, 97% of all patients received opioids.

Six patients (2%) explicitly requested to actively hasten their death, for two of them their wish was fulfilled. In another six patients, medications were used with the explicit intention to hasten death without their explicit request. In 44% (n = 114) of all cases, physicians did not know if their patient had any advance care directives, 26% (n = 38) of physicians had spoken to the patient regarding the possibility of certain treatment decisions to hasten death where this applied.

Conclusions

Decisions concerning the end of life were common for patients with cancer in three Colombian hospitals, including euthanasia and palliative sedation. Physicians and patients often fail to communicate about advance care directives and potentially life-shortening effects of treatment decisions. Specific end-of-life procedures, patients’ wishes, and availability of palliative care should be further investigated.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00853-9.

Estimation of the Need for Radiation Therapy Services According to the Incidence of Cancer in Colombia to 2035

Purpose

To estimate the supply and demand of current and future radiation therapy services by 2035 for Colombia.

Methods and Materials

The present study was performed by surveying different radiation therapy services identified in Colombia through the Colombian Association of Radiation Oncology. The demand was estimated based on incident cases and published information on the use of radiation therapy by type of cancer. Future demand was estimated under the assumption that incidence rates do not change and therefore the change in the number of cases is due to the change in the age structure of the Colombian population. Sensitivity analyses were conducted on the percentage of radiation therapy use by type of cancer. A Monte Carlo simulation was carried out to estimate the distribution of cases requiring radiation therapy, the amount of equipment, and the number of staff needed for care with the use of this technology.

Results

In total, Colombia has 69 linear accelerators, 2 radiosurgery equipment, 30 high-dose-rate brachytherapy pieces of equipment, 124 radiation therapy oncologists (113 working, 9 not working, and 2 not informed), and 275 radiation therapy technologists as of June 2020. It was estimated that to meet the current cancer burden the country would need a total of 162 radiation therapy oncologists, 121 medical physicists, and 323 radiation therapy technologists and to increase the number of radiation therapy technologists, radiation therapy oncologists, and medical physicists to 491, 246, and 184, respectively, to meet the disease burden by 2035 (73,684-88,743 cases per year).

Conclusions

In Colombia it is estimated that there is a deficit of human resources and technology for radiation therapy; therefore, there is need to investment resources from the public and private sectors to provide timely and quality care to cancer patients requiring this treatment.

Knowledge of end-of-life wishes by physicians and family caregivers in cancer patients

OBJECTIVES

To describe communication regarding cancer patient's end-of-life (EoL) wishes by physicians and family caregivers.

METHODS

An online questionnaire and telephone-based surveys were performed with physicians and family caregivers respectively in three teaching hospitals in Colombia which had been involved in the EoL care of cancer patients.

RESULTS

For 138 deceased patients we obtained responses from physicians and family caregivers. In 32 % physicians reported they spoke to the caregiver and in 17 % with the patient regarding EoL decisions. In most cases lacking a conversation, physicians indicated the treatment option was "clearly the best for the patient" or that it was "not necessary to discuss treatment with the patient". Twenty-six percent of the caregivers indicated that someone from the medical team spoke with the patient about treatment, and in 67% who had a conversation, caregivers felt that the provided information was unclear or incomplete. Physicians and family caregivers were aware if the patient had any advance care directive in 6% and 26% of cases, respectively, with low absolute agreement (34%).

CONCLUSIONS

There is a lack of open conversation regarding EoL in patients with advanced cancer with their physicians and family caregivers in Colombia. Communication strategies are urgently needed.

Recommendations for streamlining precision medicine in breast cancer care in Latin America

Background

The incidence of breast cancer (BC) in LMICs has increased by more than 20% within the last decade. In areas such as Latin America (LA), addressing BC at national levels evoke discussions surrounding fragmented care, limited resources, and regulatory barriers. Precision Medicine (PM), specifically companion diagnostics (CDx), links disease diagnosis and treatment for better patient outcomes. Thus, its application may aid in overcoming these barriers.

Recent findings

A panel of LA experts in fields related to BC and PM were provided with a series of relevant questions to address prior to a multi‐day conference. Within this conference, each narrative was edited by the entire group, through numerous rounds of discussion until a consensus was achieved. The panel proposes specific, realistic recommendations for implementing CDx in BC in LA and other LMIC regions. In these recommendations, the authors strived to address all barriers to the widespread use and access mentioned previously within this manuscript.

Conclusion

This manuscript provides a review of the current state of CDx for BC in LA. Of most importance, the panel proposes practical and actionable recommendations for the implementation of CDx throughout the Region in order to identify the right patient at the right time for the right treatment.

Theoretical reduction of the incidence of colorectal cancer in Colombia from reduction in the population exposure to tobacco, alcohol, excess weight and sedentary lifestyle: a modelling study

AIMS

To determine the potential impact fraction of alcohol and tobacco consumption, high body mass index and low physical activity on colorectal cancer burden in Colombia for the period 2016-2050.

METHODS

Based on age-specific and sex-specific data on colorectal cancer incidence, data from population-based surveys for the exposure data and population projections, the macrosimulation model Prevent V.3.01 was used to model expected colorectal cancer incidence for the period 2016-2050. Baseline models were those where exposure levels were not subject to change because of interventions. Two intervention scenarios were specified: one with elimination of exposure to the risk factor as of 2017 and a second one where over a 10-year period the current prevalence data gradually declined until they reach 90% of the 2016 levels.

RESULTS

Under the reference scenarios, a total number of 274 637 colorectal cancers would be expected to occur in the period 2016-2050. Under the scenario of 10% gradual decline in the prevalence of alcohol and tobacco consumption, physical inactivity and high body mass index, a total of 618, 488, 2954 and 2086 new cases, respectively, would be avoided. Under scenarios of elimination, these numbers of avoided cases would be 6908 (elimination alcohol), 6104 (elimination tobacco), 16 637 (optimizing physical inactivity) and 25 089 (all on ideal weight).

CONCLUSIONS

In order to reduce the burden of colorectal cancer, it is important to take measures to halt the current trends of increasing sedentary behaviour and overweight in the Colombian population. Proportionally, alcohol and tobacco consumption are less important population risk factors for colorectal cancer.

Access to cancer medication in public hospitals in a middle-income country: The view of stakeholder

BACKGROUND

Access to cancer medicines is a core component of comprehensive cancer care; as such, it is included in Mexico's public health insurance: Seguro Popular de Salud (SPS). Learning about stakeholders' experiences on processes and barriers influencing access to essential cancer medicines within healthcare facilities allows identifying needed policies to improve access to cancer care.

OBJECTIVE

The aim of this study was to obtain the insights of health professionals in public hospitals in Mexico on how SPS influences access to cancer medicines regarding medicine selection, financing, and procurement and supply systems. The purpose is to identify policy areas that need strengthening to improve access to cancer medicines.

METHODS

Semi-structured interviews were conducted with 67 health professionals from 21 public hospitals accredited by SPS across Mexico. A framework analysis was used with categories of analysis derived from the World Health Organization's Access framework.

RESULTS

Most stakeholders reported that the availability of listed cancer medicines was sufficient. However, cancer specialists reported that medicines coverage by SPS was restrictive covering only basic cancer care. Public hospitals followed SPS treatment protocols in selecting and prescribing cancer medicines but used different procurement procedures. When essential cancer medicines were unavailable (not listed or stocked-out), hospitals reported several strategies such as prescribing alternative therapies, resorting to direct purchases, and assisting patients in obtaining medicines elsewhere. Other reported barriers to access to treatment were: distance to health facilities, poor insurance coverage, and financial restrictions.

CONCLUSIONS

Health professionals have encountered benefits and challenges from the implementation of SPS influencing access to cancer medicines and care in Mexico, pointing to areas in which action is necessary. Finding the right balance between expanding the range and cost of cancer treatments covered by insurance and making basic cancer care available to all is a challenge faced by Mexico and other middle-income countries.

Medical labour under neoliberalism: an ethnographic study in Colombia

OBJECTIVES

In order to increase the knowledge about the impacts of neoliberal market forces on physician's labour, this article's objectives are to analyse how and why the labour of physicians is transformed by neoliberalism, and the implications of these transformations for patient care.

METHODS

Ethnographic investigation is carried out through semi-structured interviews with 20 general practitioners at public and private facilities in Colombia. The interviews were contrasted with national studies of physician's labour since the 1960s. A "mock" job search was also simulated. The analysis was guided by Marxian frameworks. The study was approved by a Human Research Ethics Committee, and informed consent was obtained from all participants.

RESULTS

The overpowering for-profit administration of the Colombian healthcare system imposes productivity mechanisms on physicians as a result of a deregulated labour market characterized by low salaries, reduced and self-funded social security benefits, and job insecurity. Overworked physicians with reduced autonomy become frustrated for not being able to provide the care their patients need according to clinical standards.

CONCLUSIONS

Under neoliberal conditions, medical labour becomes exploitable and directly productive through its formal and real subsumption to Capital. The negative consequences of a progressive loss in physician's autonomy unveil the incompatibility between neoliberal health systems and people's health.

Influence of Dose Intensity in Consolidation with HIDAC and Other Clinical and Biological Parameters in the Survival of AML

Background

The impact of the dose intensity administered in consolidation in Latin America is unknown. This study aimed to evaluate the relative dose intensity (RDI) in consolidation and its impact in overall survival.

Methods

A retrospective study of 86 patients with AML who were diagnosed between 2010 and 2016 with a 2-year follow-up in a fourth-level Colombian hospital was carried out. Clinical characteristics were reported, Kaplan-Meier was used for estimating the overall survival, and Cox regression was used for multivariate analysis.

Results

The median overall survival (OS) was 20.83 months, and the median event-free survival (EFS) was 16.83 months. 64.3% of the patients achieved remission after the 7 + 3 chemotherapy induction treatment. Patients under 30 years of age, with white blood cell counts less than 100.000 cells/mm3 who responded to induction treatment had a better OS. Additionally, patients receiving an RDI greater than 0.75 of the planned consolidation dose had better survival. The prognostic variables with impact in the OS were the leukocyte count in peripheral blood at diagnosis, the RDI in consolidation treatment with HIDAC and the response obtained after induction.

Conclusion

This retrospective study allowed us to know the epidemiology of AML in a reference Colombian Hospital. Additionally, in our knowledge, it is the first study that reports the RDI in consolidation with HIDAC in Latin America as a prognostic factor that directly impacts the OS.

Prolonged wait time is associated with increased mortality for Chilean waiting list patients with non-prioritized conditions

BACKGROUND

Most data on mortality and prognostic factors of universal healthcare waiting lists come from North America, Australasia, and Europe, with little information from South America. We aimed to determine the relationship between medical center-specific waiting time and waiting list mortality in Chile.

METHOD

Using data from all new patients listed in medical specialist waitlists for non-prioritized health problems from 2008 to 2015 in three geographically distant regions of Chile, we constructed hierarchical multivariate survival models to predict mortality risk at two years after registration for each medical center. Kendall rank correlation analysis was used to measure the association between medical center-specific mortality hazard ratio and waiting times.

RESULT

There were 987,497 patients waiting for care at 77 medical centers, including 33,546 (3.40%) who died within two years after registration. Male gender (hazard ratio [HR] = 1.17, 95% confidence interval [CI] 1.1-1.24), older age (HR = 2.88, 95% CI 2.72-3.05), urban residence (HR = 1.19, 95% CI 1.09-1.31), tertiary care (HR = 2.2, 95% CI 2.14-2.26), oncology (HR = 3.57, 95% CI 3.4-3.76), and hematology (HR = 1.6, 95% CI 1.49-1.73) were associated with higher risk of mortality at each medical center with large region-to-region variations. There was a statistically significant association between waiting time variability and death (Z = 2.16, P = 0.0308).

CONCLUSION

Patient wait time for non-prioritized health conditions was associated with increased mortality in Chilean hospitals.