Expert Discussion: Breast Cancer in Low-Resource Countries

Understanding referral of patients with cancer in rural Ethiopia: a qualitative study

BACKGROUND

Cancer incidence is increasing in Ethiopia mainly due to increased life expectancy, while oncological capacities remain limited. Strong referral linkages between different levels of the healthcare system are key to provide timely access to cancer care. In this qualitative study, we assessed limitations and potential of cancer patient referral in the rural Southwest of Ethiopia.

METHODS

We held four focus group discussions (FGD) with health professionals at one primary and three secondary hospitals and conducted eight in-depth interviews (IDI) with the hospitals´ medical executives and local health bureau representatives. Data was analysed inductively using thematic analysis and emerging themes were categorized within the revised concept of access by Penchansky and Saurman.

RESULTS

The inevitable referral of patients with cancer in the rural Southwest of Ethiopia is characterized by the absence of clear communication protocols and the lack of formal referral linkages. The newly implemented hub-system has improved emergency referrals and could be expanded to non-emergency referrals, sensitive to the needs of advanced oncological care. Liaison officers can pave the way but need to be trained and equipped adequately. Referred patients struggle with inadequate transportation systems, the lack of accommodation close to specialized facilities as well as the inability to navigate at those sites due to language barriers, illiteracy, and stigmatization. Few Non-Governmental Organizations (NGOs) help but cannot compensate the limited governmental support. The shortage of medications at public hospitals leads to patients being directed to costly private pharmacies. In the light of those challenges, cancer remains to be perceived as a "death sentence" within the rural communities.

CONCLUSIONS

Standardized referral linkages and a multi-faceted support network throughout the cancer care continuum are necessary to make oncology care accessible to Ethiopia´s large rural population.

Barriers of and strategies for shared decision-making implementation in the care of metastatic breast cancer: A qualitative study among patients and healthcare professionals in an Asian country

BACKGROUND

Shared decision-making has been shown to improve the quality of life in metastatic breast cancer patients in high-literacy and high-resource settings. However, limited studies have examined the cultural preferences of metastatic breast cancer patients with shared decision-making implementation and the barriers encountered in an Asian setting where societal norms predominate and physician decision-making is at the forefront. This paper aims to identify (1) barriers to practising shared decision-making faced by healthcare professionals and patients and (2) strategies for implementing shared decision-making in the context of metastatic breast cancer management in Malaysia.

METHODS

We conducted a qualitative study involving 12 patients diagnosed with metastatic breast cancer, 16 healthcare professionals and 5 policymakers from surgical and oncology departments at public healthcare centres in Malaysia. Semi-structured in-depth interviews and focus group discussions were conducted. The interviews were recorded, transcribed verbatim and analysed using the thematic approach. Nvivo software was used to manage and analyse the data.

RESULTS

Five main themes emerged from the study: healthcare provider-patient communication, workforce availability, cultural and belief systems, goals of care and paternalism versus autonomy. Other strategies proposed to overcome barriers to implementing shared decision-making were training of healthcare professionals and empowering nurses to manage patients' psychosocial issues.

CONCLUSION

This study found that practising shared decision-making in the public health sector remains challenging when managing patients with metastatic breast cancer. The utilization of decision-making tools, patient empowerment and healthcare provider training may help address the system and healthcare provider-patient barriers identified in this study.

PATIENT OR PUBLIC CONTRIBUTION

Patients were involved in the study design, recruitment and analysis.

Radiation Therapy for Breast Cancer During the COVID-19 Pandemic in Low Resource Countries: Consensus Statement from the Iranian Society of Radiation Oncology

Context: COVID-19 pandemic has resulted in considerable overloading of health care systems in almost all regions of the world. Among different malignancies, breast cancer can be considered as a typical example of how the decision-making process for radiation treatment can be adapted to unusual situations. There exist several international guidelines in order to modify radiotherapy treatments during the COVID-19 pandemic, however, some of their recommendations are not applicable in regions with limited resources. In this manuscript, we provided guidance to deliver radiotherapy to patients with breast cancer during the COVID-19 pandemic based on our available nationwide resources. Evidence Acquisition: A team of expert radiation oncologists convened multidisciplinary and cross-institutional meetings and reviewed the major internationally published guidelines and relevant literature in the field of breast radiotherapy during the COVID-19 pandemic in order to establish recommendations for the safe application of radiation regimens based on the national limited resources. Results: Practical guidance in order to deliver radiotherapy to patients with breast cancer during the COVID-19 pandemic based on available nationwide resources was developed. Conclusions: Many of the international recommendations on the breast cancer radiotherapy during COVID-19 outbreak are not applicable in countries with limited resources. Therefore, modifying the guidelines based on the available resources is mandatory in order to achieve the best possible results.