Effectiveness of interventions for improving timely diagnosis of breast and cervical cancers in low-income and middle-income countries: a systematic review

A Competency-Based Ultrasound-Guided Breast Biopsy Training Program for Radiologists From Low-and-Middle-Income Countries that Leverages Mobile Health Technology (NCT04501419): A Study Protocol

IntroductionWhile ultrasound-guided breast biopsy (UGBB) performed by a radiologist is the standard of care in high-income countries for diagnosing breast cancer, blind or surgical biopsy has been the norm in low-and middle-income countries (LMIC) in part because LMIC radiologists lack the skill to perform UGBB. We present the study protocol of a competency-based UGBB training program for LMIC Nigerian radiologists that leverages mobile health technology.MethodsThis institutional review board-approved prospective multi-institutional single-arm clinical trial (ClinicalTrials.gov identifier: NCT04501419) involves 13 Nigerian radiologists from eight tertiary hospitals in South West and South East Nigeria. Our training program is unique because it uses a competency-based curriculum developed specifically for LMIC radiologists. The competency-based curriculum incorporates blended learning (e-learning and trainer-led), simulation (supervised and unsupervised), and patient biopsy (supervised and unsupervised) components. The study time frame is two years: 1 year for the trainees to complete active training and patient recruitment and another 1 year for patient follow-up. Primary outcome measures include trainees' competency (measured using the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE)), the radiology-pathology concordance rate, and the complication rate. Secondary outcome measures include the diagnostic interval and the positive predictive value of UGBB.ConclusionBuilding capacity for UGBB in Nigeria and other LMIC can potentially improve breast cancer outcomes through early diagnosis. This training program is part of an implementation multi-component strategy package in Nigeria to improve breast cancer outcomes. This training program can also be adapted for other image-guided procedures that could impact global cancer control through diagnosis, therapeutic intervention, and/or palliation.

Individual-level determinants of breast and cervical cancer screening and early testing in two regionally representative urban Indian populations

Introduction

Region-specific data on individual factors associated with uptake of breast and cervical cancer screening or early testing in diverse Indian populations are limited.

Aim

To assess the prevalence and individual determinants of uptake of breast and/or cervical cancer screening or testing among women aged 30-69 years in regionally representative populations of two large Indian cities: New Delhi and Chennai.

Methods

We conducted an analysis of the cross-sectional data (2016-2017) nested within the Centre for Cardiometabolic Risk Reduction in South Asia cohort, established in 2010-2011 with 12,271 participants (5365 in New Delhi; 6906 in Chennai). Among 3310 women participants, we evaluated the associations of demographic, socioeconomic, lifestyle, medical, psychosocial, and reproductive factors with breast and/or cervical cancer screening or testing using multivariable logistic regression models with results expressed as adjusted odds ratios (OR) and 95% confidence intervals (CI).

Results

At any point prior to 2016-2017, 193 women self-reported having undergone evaluations for breast and/or cervical cancer. The reasons for evaluation were 'general examination' or 'physician's advice' (i.e., screening) or 'being symptomatic' (i.e., early testing). The overall prevalence was 5.8% for screening or testing and 2.5% for screening alone. Formal education (OR:1.88; 95% CI:1.12-3.15), high monthly household income (OR:2.27; 95% CI:1.59-3.25) and less 'fear-of-judgement' (OR:1.65; 95% CI:1.05-2.58) were positively associated with screening or testing uptake. When screening uptake was analysed separately, the results were generally similar.

Conclusion

Our findings may have important implications for interventions at community-level (e.g., reducing 'fear-of-judgement', increasing awareness to screening programs and early symptoms) and health-system level (e.g., opportunistic screening).

Evaluation of Breast Health Promotion Intervention Among Catholic Nuns in Lake Zone 'Tanzania

Objective

Despite facing unique barriers, Catholic nuns in Tanzania require accessible breast health promotion. This study explores interventions to empower nuns through knowledge, improved attitudes, and positive practices, ultimately promoting well-being and early detection for better breast cancer outcomes.

Materials and Methods

A quasi-experimental design study guided by the Health Belief Model was conducted to monitor the implementation of a breast health intervention program aimed at increasing breast cancer screening knowledge among 385 Catholic nuns aged 20 to over 60 years old within Lake Zone, Tanzania. Data were collected at two-time points: pre-intervention (baseline) and implementation phase intervention (after three months). The intervention consisted of a 2-hour educational session. Participants had opportunities to ask questions and provide feedback.

Results

The breast health promotion intervention was well-received by Catholic nuns, with 339 (88%) expressing strong motivation to learn and promote awareness. The training effectively increased knowledge and positive attitudes towards breast cancer screening. Researcher assistants successfully delivered the program, and 354 (92%) of participants expressed interest in continued education and support. The intervention addressed cultural barriers and empowered nuns to take charge of their health, though some challenges remain meanwhile 158 (41%) had limited prior knowledge, 81 (21%) hesitated to discuss breast health due to religious beliefs, and some faced difficulty applying the learnings.

Conclusion

Overall, the breast health promotion intervention had a positive outcome on the Catholic nuns' awareness and knowledge of breast health. However, addressing the identified barriers and challenges is crucial to further enhance the intervention's effectiveness and sustainability.

Use of patient-reported outcome measures after breast reconstruction in low- and middle-income countries: a scoping review

BACKGROUND

Patient-reported outcome measures (PROMs) are increasingly administered in high-income countries to monitor health-related quality of life of breast cancer patients undergoing breast reconstruction. Although low- and middle-income countries (LMICs) face a disproportionate burden of breast cancer, little is known about the use of PROMs in LMICs. This scoping review aims to examine the use of PROMs after post-mastectomy breast reconstruction among patients with breast cancer in LMICs.

METHODS

MEDLINE, Embase, Web of Science, CINAHL, and PsycINFO were searched in August 2022 for English-language studies using PROMs after breast reconstruction among patients with breast cancer in LMICs. Study screening and data extraction were completed. Data were analyzed descriptively.

RESULTS

The search produced 1024 unique studies, 33 of which met inclusion criteria. Most were observational (48.5%) or retrospective (33.3%) studies. Studies were conducted in only 10 LMICs, with 60.5% in China and Brazil and none in low-income countries. Most were conducted in urban settings (84.8%) and outpatient clinics (57.6%), with 63.6% incorporating breast-specific PROMs and 33.3% including breast reconstruction-specific PROMs. Less than half (45.5%) used PROMs explicitly validated for their populations of interest. Only 21.2% reported PROM response rates, ranging from 43.1 to 96.9%. Barriers and facilitators of PROM use were infrequently noted.

CONCLUSIONS

Despite the importance of PROM collection and use in providing patient-centered care, it continues to be limited in middle-income countries and is not evident in low-income countries after breast reconstruction. Further research is necessary to determine effective methods to address the challenges of PROM use in LMICs.

An Overview of Cervical Cancer Prevention and Control in Latin America and the Caribbean Countries

Cervical cancer is a health crisis affecting women and their families across the world. It is known that developed countries have comprehensive protocols with recommendations regarding workforce, expertise, and medical resources to address this common cancer among women. In contrast, disparities in addressing cervical cancer remain present in Latin America and Caribbean countries. Here, we reviewed the current strategies of cervical cancer prevention and control in the region.

Diagnostic and pre-treatment intervals among patients with cervical cancer attending care at the Uganda Cancer Institute: a cross-sectional study

BACKGROUND

Majority of patients with cervical cancer in the low- and middle-income countries experience long diagnostic and pre-treatment intervals. This study sought to determine the factors associated with the diagnostic and pre-treatment intervals among patients with cervical cancer.

METHODS

This was a cross-sectional study conducted at the Uganda Cancer Institute (UCI) during October 2019 to January 2020. Patients aged ≥ 18 years with histological diagnosis of cervical cancer were consecutively sampled. Data were collected using a pre-tested semi-structured questionnaire and a data abstraction form. Diagnostic intervals, defined as the time between first visit of a patient to a primary healthcare provider to time of getting confirmed diagnosis, of ≤ 3 months was defined as early & >3 months as late. Pre-treatment intervals, which is the time from histological diagnosis to starting cancer chemo-radiotherapy of ≤ 1 month was defined as early and > 1 month as late. Data were analysed using STATA version 14.0. We used modified Poisson regression models with robust variance to determine socio-demographic and clinical factors associated with the intervals.

RESULTS

The mean age of the participants was 50.0 ± 11.7 years. The median diagnostic and pre-treatment intervals were 3.1 (IQR: 1.4-8.2) months and 2.4 (IQR: 1.2-4.1) months respectively. Half of the participants, 49.6% (200/403) were diagnosed early; one in 5 patients, 20.1% (81/403) promptly (within one month) initiated cancer chemo-radiotherapy. Participants more likely to be diagnosed early included those referred from district hospitals (level 5) (aPR = 2.29; 95%CI: 1.60-3.26) and with squamous cell carcinomas (aPR = 1.55; 95%CI: 1.07-2.23). Participants more likely to be diagnosed late included those who first discussed their symptoms with relatives, (aPR = 0.77; 95%CI: (0.60-0.98), had > 2 pre-referral visits (aPR = 0.75; 95%CI (0.61-0.92), and had advanced stage (stages 3 or 4) (aPR = 0.68; 95%CI: 0.55-0.85). Participants more likely to initiate cancer chemo-radiotherapy early included older patients (≥ 60 years) (aPR = 2.44; 95%CI: 1.18-5.03). Patients likely to start treatment late were those who had ≥2 pre-referral visits  (aPR = 0.63; 95%CI: 0.41-0.98) and those that took 3 - 6 months with symptoms before seeking healthcare (aPR = 0.52;95%CI: 0.29 - 0.95).

CONCLUSION

Interventions to promote prompt health-seeking and early diagnosis of cervical cancer need to target primary healthcare facilities and aim to enhance capacity of primary healthcare professionals to promptly initiate diagnostic investigations. Patients aged < 60 years require targeted interventions to promote prompt initiation of chemo-radiation therapy.

Relationship between Health Inequalities and Breast Cancer Survival in Mexican Women

OBJECTIVE

We aimed to analyze the relationship between the survival of patients with breast cancer and health inequalities.

METHODS

A retrospective cohort study of women with stage III breast cancer according to public healthcare was conducted. Groups were stratified according to the course of treatment and the presence of chronic disease other than cancer. Survival functions were estimated by using the Kaplan-Meier estimator, while the Cox proportional hazards model was employed for prognostic assessment.

RESULTS

The study was performed on 964 breast cancer patients. One hundred and seventy-six patients (18.23%) died during the follow-up period and 788 (81.77%) were alive at the end of the follow-up period. Education, marital status, personal history of prior biopsies, and socioeconomic status (SES) were found to be linked with survival. However, only SES exceeded the baseline risk of mortality when the treatment cycle was interrupted (full treatment: unadjusted 4.683, p = 0.001; adjusted 4.888 p = 0.001, partial treatment: unadjusted 1.973, p = 0.012; adjusted 4.185, p = 0.001). The same effect was observed when stratifying by the presence of chronic disease other than cancer (with chronic disease adjusted HR = 4.948, p = 0.001; unadjusted HR = 3.303, p = 0.001; without chronic disease adjusted HR = 4.850, p = 0.001; unadjusted HR = 5.121, p = 0.001).

CONCLUSION

Since lower SES was linked with a worse prognosis, strategies to promote preventive medicine, particularly breast cancer screening programs and prompt diagnosis, are needed.