Global health from a cancer care perspective

Pharmacogenomics influence on MDR1-associated cancer resistance and innovative drug delivery approaches: advancing precision oncology

Currently, there is a growing concern surrounding the treatment of cancer, a formidable disease. Pharmacogenomics and personalized medicine have emerged as significant areas of interest in cancer management. The efficacy of many cancer drugs is hindered by resistance mechanisms, particularly P-glycoprotein (P-gp) efflux, leading to reduced therapeutic outcomes. Efforts have intensified to inhibit P-gp efflux, thereby enhancing the effectiveness of resistant drugs. P-gp, a member of the ATP-binding cassette (ABC) superfamily, specifically the multidrug resistance (MDR)/transporter associated with antigen processing (TAP) sub-family B, member 1, utilizes energy derived from ATP hydrolysis to drive efflux. This review focuses on genetic polymorphisms associated with P-gp efflux and explores various novel pharmaceutical strategies to address this challenge. These strategies encompass SEDDS/SNEDDS, liposomes, immunoliposomes, solid lipid nanoparticles, lipid core nanocapsules, microemulsions, dendrimers, hydrogels, polymer-drug conjugates, and polymeric nanoparticles. The article aims to elucidate the interplay between pharmacogenomics, P-gp-mediated drug resistance in cancer, and formulation strategies to improve cancer therapy by tailoring formulations to genetically susceptible patients.

Fruit exosomes: a sustainable green cancer therapeutic

Fruit exosomes are the source of natural cancer therapeutic tools.

Access of Low-Resource Areas to ASCO Quality Initiatives: Initial Experience and Lessons Learned

With the aim of improving the quality of cancer care globally, ASCO began to offer its quality improvement programs to interested international oncology practices. In this manuscript, we describe the experiences with ASCO quality initiatives in low- and middle-income countries (LMICs). The experience acquired from different practices in Latin America and Africa was reviewed and various action steps were summarized. Encountered challenges and implemented solutions to mitigate these challenges were identified to list as lessons learned for oncology practices in LMICs or low-resource settings to use in their future quality improvement initiatives and providing a proactive approach for those practices considering starting quality improvement programs. Having programs tailored to LMICs may facilitate the participation of more practices and help them take advantage of these programs to enhance patient care. The preliminary data and learning are promising and demonstrate that participation in quality improvement activities can have a positive effect. Although this early experience is encouraging, each country and resource-limited practice will have its own unique challenges as highlighted in this article. Having more practices participate will further enhance the knowledge base, build experience in addressing challenges, and enable oncology patients to reap the benefits worldwide.

The impact of in-house pathology services on downstaging cervical cancer in Tanzania over an 18-year period

PURPOSE

Reducing time between cancer screening, diagnosis, and initiation of treatment is best achieved when services are available in the same hospital. Yet, comprehensive cancer centers are typically unavailable in low- and middle-income countries (LMICs), where resources are limited and services scattered. This study explored the impact of establishing an in-house pathology laboratory at the largest public cancer hospital in Tanzania on the downstaging of cervical cancer.

METHODS

We examined clinical datasets of 8,322 cervical cancer patients treated at the Ocean Road Cancer Institute (ORCI). The first period included patients treated from 2002 to 2016, before establishment of the pathology laboratory at ORCI; the second period (post-pathology establishment) included data from 2017 to 2020. Logistic regression analysis evaluated the impact of the pathology laboratory on stage of cervical cancer diagnosis.

RESULTS

Patients treated during the post-pathology period were more likely to be clinically diagnosed at earlier disease stages compared to patients in the pre-pathology period (pre-pathology population diagnosed at early disease stage: 44.08%; post-pathology population diagnosed at early disease stage: 59.38%, p < 0.001). After adjustment for age, region of residence, and place of biopsy, regression results showed patients diagnosed during the post-pathology period had higher odds of early stage cervical cancer diagnosis than patients in the pre-pathology period (OR 1.35, 95% CI (1.16, 1.57), p < 0.001).

CONCLUSIONS

Integrated and comprehensive cancer centers can overcome challenges in delivering expedited cervical cancer diagnosis and treatment. In-house pathology laboratories play an important role in facilitating timely diagnosis and rapid treatment of cervical and possibly other cancers in LMICs.

Leveraging e-health for enhanced cancer care service models in middle-income contexts: Qualitative insights from oncology care providers

Background

Global cancer research has predominantly favoured high-income countries (HICs). The unique challenges in low- and middle-income countries (LMICs) demand tailored research approaches, accentuated further by the disparities highlighted during the COVID-19 pandemic.

Aim and objectives

This research endeavoured to dissect the intricacies of cancer care in LMICs, with Jordan serving as a case study. Specifically, the study aimed to conduct an in-depth analysis of the prevailing cancer care model and assess the transformative potential of eHealth technologies in bolstering cancer care delivery.

Methods

Utilising a qualitative methodology, in-depth semi-structured interviews with oncology healthcare professionals were executed. Data underwent inductive thematic analysis as per Braun and Clarke's guidelines.

Results

From the analysed data, two dominant themes surfaced. Firstly, "The current state of cancer care delivery" was subdivided into three distinct subthemes. Secondly, "Opportunities for enhanced care delivery via e-health" underscored the urgency of digital health reforms.

Conclusion

The need to restrategise cancer care in LMICs is highlighted by this study, using the Jordanian healthcare context as a reference. The transformative potential of e-health initiatives has been illustrated. However, the relevance of this study might be limited by its region-specific approach. Future research is deemed essential for deeper exploration into the integration of digital health within traditional oncology settings across diverse LMICs, emphasising the significance of telemedicine in digital-assisted care delivery reforms.

Attitude, Perceived Barriers, and Challenges Toward Implementing Resource-Appropriate Guidelines for Hematologic Malignancies: Physicians' Survey in Ethiopia

PURPOSE

Cancer care in low-income countries poses formidable challenges. Care may be facilitated by resource-adapted guidelines, such as the National Comprehensive Cancer Network (NCCN) harmonized guidelines for sub-Saharan Africa (NCCN-HG). Understanding physicians' attitudes and knowledge toward guidelines, as well as patient- and resource-related barriers, is essential for promoting their effective implementation.

METHODS

We conducted an online survey among oncologists, hematologists, internists, residents/fellows, and generalists treating hematologic malignancies in Ethiopia. We assessed attitudes toward the use of guidelines, institutional capacity, and barriers/determinants to effective care.

RESULTS

Among the 47 physicians completing the survey (representing 64% of Ethiopian professionals treating hematologic malignancies), the majority (85%) reported using guidelines; however, only 22.7% (n = 10) used the NCCN-HG. While overall attitudes toward guidelines were favorable, 57.8% of physicians familiar with the NCCN-HG were either undecided or believed that it lowers the standard of care. Perceived lack of institutional regulation was negatively associated with guideline use (B = -3.23; P = .004). Lack of diagnostic facilities including immunohistochemistry and flow cytometry, supportive care, and poor utilization of guidelines were reported to be determinants of poor patient outcome. Regarding patient factors, 57.4% respondents identified treatment abandonment as an important contributor to poor outcome. Availability of chemotherapy/radiotherapy (89.4%), financial status (85.1%), distance from the hospital (74.5%), and harvest season (65%) had major influences on treatment decisions. Over 80% reported that targeted therapies were unavailable or rarely available.

CONCLUSION

Awareness and usage of the NCCN-HG are limited among Ethiopian physicians. Lack of facilities, therapies, and regulation, in addition to patient-related factors, was identified as barriers to guideline adherence and determinants of poor outcome.

Model for Achieving a Coordinated Access to Lung Cancer Care in Selected Public Health Facilities in KwaZulu-Natal, South Africa: Protocol for a Qualitative Study

BACKGROUND

Timely delivery of high-quality cancer care to all patients is barely achieved in South Africa and many other low- and middle-income countries, mainly due to poor care coordination and access to care services. After health care visits, many patients leave facilities confused about their diagnosis, prognosis, options for treatment, and the next steps in their care continuum. They often find the health care system disempowering and inaccessible, thereby making access to health care services inequitable, with the resultant outcome of increased cancer mortality rates.

OBJECTIVE

The aim of this study is to propose a model for cancer care coordination interventions that can be used to guide and achieve coordinated access to lung cancer care in the selected public health care facilities in KwaZulu-Natal.

METHODS

This study will be conducted through a grounded theory design and an activity-based costing approach that will include health care providers, patients, and their caregivers. The study participants will be purposively selected, and a nonprobability sample will be selected based on characteristics, experiences of the health care providers, and the objectives of the study. With the study's objectives in mind, communities in Durban and Pietermaritzburg were selected as study sites, for the study along with the 3 public health facilities that provide cancer diagnosis, treatment, and care in the province. The study involves a range of data collection techniques, namely, in-depth interviews, evidence synthesis reviews, and focus group discussions. A thematic and cost-benefit analysis will be used.

RESULTS

This study receives support from the Multinational Lung Cancer Control Program. The study obtained ethics approval and gatekeeper permission from the University's Ethics Committee and the KwaZulu-Natal Provincial Department of Health, as it is being conducted in health facilities in KwaZulu-Natal province. As of January 2023, we had enrolled 50 participants, both health care providers and patients. Dissemination activities will involve community and stakeholder dissemination meetings, publications in peer-reviewed journals, and presentations at regional and international conferences.

CONCLUSIONS

This study will provide comprehensive data to inform and empower patients, professionals, policy architects, and related decision makers to manage and improve cancer care coordination. This unique intervention or model will address the multifactorial problem of cancer health disparities. If successful, this study will affect the design and implementation of coordination programs to promote optimal cancer care for underserved patients.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/34341.

Geographic Distribution of Cancer Care Providers in the Philippines

PURPOSE

In the Philippines, a lower middle-income country in Southeast Asia, 6 of 10 Filipinos die without seeing a doctor. To ensure universal access to cancer care, providers must be equitably distributed. Therefore, we evaluated the distribution of oncologists across all 17 regions in the Philippines.

METHODS

We gathered data from the official websites of national medical societies on their members' regional area of practice: Philippine Society of Medical Oncology, Philippine Radiation Oncology Society, Surgical Oncology Society of the Philippines, Society of Gynecologic Oncologists of the Philippines, and Philippine Society of Hospice and Palliative Medicine. We compared this with the regional census to determine the number of board-certified oncologists per 100,000 Filipinos.

RESULTS

For a population of almost 110 million, the Philippines has a total of 348 medical oncologists, 164 surgical oncologists, 99 radiation oncologists, 142 gynecologic oncologists, and 35 hospice and palliative medicine (HPM) specialists. This translates to 0.32 medical oncologists, 0.15 surgical oncologists, 0.09 radiation oncologists, 0.13 gynecologic oncologists, and 0.03 HPM specialists for every 100,000 Filipinos. The number of oncologists is highest in the National Capital Region in Luzon and lowest in the Bangsamoro Autonomous Region in Muslim Mindanao. All regions have at least one medical and gynecologic oncologist. Two regions (12%) have no surgical oncologists, five regions (29%) have no radiation oncologists, and eight regions (47%) have no HPM specialists.

CONCLUSION

Efforts are needed to increase the number of oncologists and improve equity in their distribution to ensure universal access to cancer care in the Philippines.

Economic Perspective of Cancer Care and Its Consequences for Vulnerable Groups

Simple Summary

For cancer patients, many different reasons can cause financial burdens and economic threads. Sociodemographic factors, rural/remote location and income are known determinants for these vulnerable groups. This economic vulnerability is related to the reduced utilization of cancer care and the impact on outcome. Financial burden has been reported in many countries throughout the world and needs to be addressed as part of the sufficient quality of cancer care.

Abstract

Within healthcare systems in all countries, vulnerable groups of patients can be identified and are characterized by the reduced utilization of available healthcare. Many different reasons can be attributed to this observation, summarized as implementation barriers involving acceptance, accessibility, affordability, acceptability and quality of care. For many patients, cancer care is specifically associated with the occurrence of vulnerability due to the complex disease, very different target groups and delivery situations (from prevention to palliative care) as well as cost-intensive care. Sociodemographic factors, such as educational level, rural/remote location and income, are known determinants for these vulnerable groups. However, different forms of financial burdens likely influence this vulnerability in cancer care delivery in a distinct manner. In a narrative review, these socioeconomic challenges are summarized regarding their occurrence and consequences to current cancer care. Overall, besides direct costs such as for treatment, many facets of indirect costs including survivorship costs for the cancer patients and their social environment need to be considered regarding the impact on vulnerability, treatment compliance and abundance. In addition, individual cancer-related financial burden might also affect the society due to the loss of productivity and workforce availability. Healthcare providers are requested to address this vulnerability during the treatment of cancer patients.

Bayesian two-stage sequential enrichment design for biomarker-guided phase II trials for anticancer therapies

Biomarker-guided phase II trials have become increasingly important for personalized cancer treatment. In this paper, we propose a Bayesian two-stage sequential enrichment design for such biomarker-guided trials. We assumed that all patients were dichotomized as marker positive or marker negative based on their biomarker status; the positive patients were considered more likely to respond to the targeted drug. Early stopping rules and adaptive randomization methods were embedded in the design to control the number of patients receiving inferior treatment. At the same time, a Bayesian hierarchical model was used to borrow information between the positive and negative control arms to improve efficiency. Simulation results showed that the proposed design achieved higher empirical power while controlling the type I error and assigned more patients to the superior treatment arms. The operating characteristics suggested that the design has good performance and may be useful for biomarker-guided phase II trials for evaluating anticancer therapies.

Scoping the literature on patient travel abroad for cancer screening, diagnosis and treatment

The incidence of cancer is on the rise globally. Under particular circumstances, patients are willing to travel abroad for healthcare treatments. We know relatively little however about patients travelling overseas for cancer-related screening, diagnosis and treatment. Where do patients go, for what treatments, what are their motivations, decision-making processes and treatment experiences? What do we know about patient safety and risk, and outcomes? More broadly, what are the ethical and legal implications? This review presents the first published assessment of what we term 'transnational oncology treatment', defined as patients travelling overseas or across borders for cancer screening, diagnosis and treatment. The review undertakes detailed search and retrieval of the literature, using an accepted scoping review method. We present a narrative review of existing knowledge and themes, identifying coverage and gaps. There is a five-fold agenda for future investigation: trajectories and itineraries; in depth focus on treatment decisions, experiences and outcomes; locating patient travel within wider health system analysis; exploration of professional perspectives and coordination; and situating travel within the context of health trade. Such an agenda is multidisciplinary and wide-ranging, encompassing epidemiology, health economics, health policy ethics, health politics, health management, and health policy.

Psychosocial influences on help-seeking behaviour for cancer in low-income and lower middle-income countries: a mixed-methods systematic review

Introduction

Starting cancer treatment early can improve outcomes. Psychosocial factors influencing patients’ medical help-seeking decisions may be particularly important in low and lower middle-income countries (LMIC) where cancer outcomes are poor. Comprehensive review evidence is needed to understand the psychosocial influences on medical help-seeking for cancer symptoms, attendance for diagnosis and starting cancer treatment.

Methods

Mixed-methods systematic review registered on PROSPERO (CRD42018099057). Peer-reviewed databases were searched until April 2020 for studies assessing patient-related barriers and facilitators to medical help-seeking for cancer symptoms, diagnosis and treatment in adults (18+ years) living in LMICs. Quality of included studies was assessed using the Critical Appraisal Skills Programme tool. Data were synthesised using meta-analytic techniques, meta-ethnography or narrative synthesis as appropriate.

Results

Of 3963 studies identified, 64 were included. In quantitative studies, use of traditional, complementary and alternative medicine (TCAM) was associated with 3.60 higher odds of prolonged medical help-seeking (95% CI 2.06 to 5.14). Qualitative studies suggested that use of TCAM was a key barrier to medical help-seeking in LMICs, and was influenced by causal beliefs, cultural norms and a preference to avoid biomedical treatment. Women face particular barriers, such as needing family permission for help-seeking, and higher stigma for cancer treatment. Additional psychosocial barriers included: shame and stigma associated with cancer such as fear of social rejection (eg, divorce/disownment); limited knowledge of cancer and associated symptoms; and financial and access barriers associated with travel and appointments.

Conclusion

Due to variable quality of studies, future evaluations would benefit from using validated measures and robust study designs. The use of TCAM and gender influences appear to be important barriers to help-seeking in LMIC. Cancer awareness campaigns developed with LMIC communities need to address cultural influences on medical help-seeking behaviour.

NCCN resource-stratified and harmonized guidelines: A paradigm for optimizing global cancer care

Clinical practice guidelines in oncology lead to improved outcomes in care. However, the most frequently used guidelines are developed for highly resourced systems. Recognizing the significant and increasing burden of cancer in low- and middle-income countries, the National Comprehensive Cancer Network (NCCN) has developed resource-stratified framework and harmonization processes that allow the NCCN Guidelines to be tailored and optimized for specific geographical areas, resource levels, and settings. The critical need for local expertise and involvement in successful development and uptake is emphasized, and the promise of this collaboration for advancement in oncology programs is illustrated.

The Value of Navigators in Breast Cancer Management in a South African Hospital

BACKGROUND

Specialist breast cancer nurses (BCNs) have improved the psychological care and follow-up rates of breast cancer (BC) patients. This study sought to determine if breast cancer research workers (BCRWs) as de facto BCNs impacted patients' adherence to treatment by comparing groups with and without these patient navigators; hence assessing our need for BCNs.

METHODS

Two groups BC patients booked for primary chemotherapy compared. Study group 1 (SG1): no BCRWs/BCNs. Study group 2 (SG2): BCRWs involvement. Assessment of numbers completing primary chemotherapy, undergoing surgery post-neoadjuvant chemotherapy and BCRWs interventions.

RESULTS

SG1: n = 281, 25-89y, mean 52.7y, Stage 4: 35.6%, Stage 3: 64.4%. SG2: n = 154, 21-85y, mean 52.6y, Stage 4: 47.4%, Stage 3: 43.3%, Stage 2: 9%. Primary chemotherapy not completed SG1: 40.2% (113) versus SG2: 13.5% (21); p < 0.00001. SG1: 88% not completing were lost to follow-up. Excluding peri-chemotherapy deaths and discontinuation: SG1: 37.1% did not complete chemotherapy versus SG2: 2.6%, p < 0.00001. SG2: BCRWs: 107 interventions for 58 (37.7%) patients. Therapeutic breast surgery SG1: 103/181 (56.9%) versus SG2: 66/81 (81.5%); p < 0.0001. SG1: main reasons for not having surgery: lost to follow-up during (n = 58) or after (n = 9) chemotherapy. Follow-up SG2: 12-43 months, mortality: 52% (80/154), no lost to follow-ups. SG1: No mortality data.

CONCLUSIONS

In our setting, BC patients often do not attend or complete treatments. In this study, BCRWs as de-facto BCNs were beneficial for BC patient care, improving chemotherapy compliance and therapeutic surgical interventions. This highlights the need for BCNs for the management of BC patients in South Africa.

Elicitation and prioritization of requirements for electronic health records for oncology in low resource settings: A concept mapping study

BACKGROUND

Understanding functional and non-functional requirements is essential to successfully implement electronic medical record (EMR) systems. Actual requirements will be different for different contexts.

OBJECTIVE

To elicit and prioritize requirements for implementing EMRs in oncology in low and middle income countries (LMICs), and to relate these to requirements from high-income countries.

PARTICIPANTS AND SETTING

Cancer care stakeholders including oncologists, general doctors, nurses, biostatisticians, information technologists, from different LMICs, were involved.

METHODS

Concept mapping was used. Statements of requirements were obtained during focus group discussions (FGDs) and interviews. Using surveys, the requirements were clustered and ranked on importance and feasibility. Data were analyzed in SPSS using agglomerative hierarchical clustering and multidimensional scaling, to create cluster maps and go-zone maps reflecting the relationships between the requirements and their prioritization.

RESULTS

Four FGD sessions, with twenty participants, were conducted. In addition, six participants were interviewed. Twenty-two participants clustered the requirements and sixty-three participants ranked them on importance and feasibility. One hundred and sixty requirement statements were generated which were reduced to sixty-four after de-duplication and merging. Nine clusters were obtained encompassing the following domains, in order of importance: Security, Conducive organization, Management/Governance, General EMR functionalities, Computer infrastructure, Data management, Usability, Oncology decision support, and Ancillary requirements. On ranking, the requirements scored between 3.74 and 4.80 on importance, and between 3.55 and 4.46 on feasibility, on a 5-point Likert scale. We generated concept maps for use when communicating with stakeholders.

CONCLUSION

For oncology EMRs in LMICs, requirements overlap those from high-income countries, but generic EMR functionalities, Infrastructural and organizational requirements are still considered priority in LMICs compared to oncology-specific requirements or advanced EMR features e.g. computerized decision support or interoperability. Concept mapping is a fast and cost-effective method for eliciting and prioritizing EMR requirements in a user-centered manner.

Hepatitis C virus and risk of extrahepatic malignancies: a case-control study

Epidemiological studies have demonstrated an increased risk of non-Hodgkin lymphoma (NHL) in patients with chronic hepatitis C virus (HCV) infection. Therefore, we investigated the risk of extrahepatic malignancies associated with HCV infection. Inpatients diagnosed with lymphoma, breast, thyroid, kidney, or pancreatic cancer (research group, n = 17,925) as well as inpatients with no malignancies (control group, n = 16,580) matched by gender and age were enrolled from The First Affiliated Hospital of Nanjing Medical University between January 2008 and December 2016. A case-control study was conducted by retrospective analysis. The difference in HCV prevalence was analyzed between the research group and the control group. Also, the research group was compared to the 2006 National Hepatitis C sero-survey in China. A total of 86 cases were positive for anti-HCV in the research group. Compared with the control group (103 cases were anti-HCV positive), no significant associations between extrahepatic malignancies and HCV infection were observed. Meanwhile, compared to the 2006 National Hepatitis C sero-survey, we observed a significant association between the chronic lymphoma leukemia/small lymphocytic lymphoma (CLL/SLL) and HCV seropositivity in females in the research group aged 1–59 years old (OR = 14.69; 95% CI, 1.94–111.01). HCV infection had a potential association with CLL/SLL in females aged 1–59 years old. Our study did not confirm an association between HCV infection and the risk of extrahepatic malignancies. In regions with a low HCV prevalence, the association between HCV infection and extrahepatic malignancies needs further investigation.

Patient navigation services for cancer care in low-and middle-income countries: A scoping review

BACKGROUND

Nearly 70% of all cancer deaths occur in low- and middle-income countries (LMICs) and many of these cancer deaths are preventable. In high-income countries (HICs), patient navigation strategies have been successfully implemented to facilitate the patient's journey at multiple points along the cancer care continuum. The purpose of this scoping review is to understand and describe the scope of patient navigation interventions and services employed in LMICs.

METHODS

A systematic search of published articles was conducted including Medline, Biosis, Embase, Global Health, and Web of Science. Articles were examined for evidence of patient navigation interventions used in cancer care in LMICs. Evidence was synthesized by navigation service provided and by type of outcome.

RESULTS

Fourteen studies reported on patient navigation interventions in cancer care in low-income and middle-income countries in Asia, South America, and Africa. Most studies reported on women's cancers and included navigation interventions at most points along the cancer care continuum i.e. awareness, education, screening participation, adherence to treatment and surveillance protocols.

CONCLUSION

Few studies report on cancer patient navigation in LMICs. With the use of an implementation science framework, patient navigation research can explore a broader range of outcomes to better evaluate its potential role in improving cancer control in LMICs.

Exploring barriers to lung cancer patient access, diagnosis, referral and treatment in Kwazulu-Natal, South Africa: the health providers' perspectives

Background

The burden of cancer is increasingly emerging as a key public health problem in South Africa. This burden is aggravated by low suspicion index by patients and healthcare providers alike, limited financial and human resource investment, weak healthcare systems, and limited quality care. Patients typically present to health facilities very late, resulting in poor treatment outcomes, hence there is a pervasive hopelessness associated with a diagnosis of lung cancer in South African public health systems. Research on the barriers to lung cancer patient care, especially from the perspectives of the healthcare professionals, is limited. Therefore, the aim of this study was to explore the health professionals' understanding and experiences on the barriers to lung cancer care in the three health facilities providing oncology services in KwaZulu-Natal, South Africa.

Methods

This was a grounded theory study comprising of 18 health providers (seven specialist oncologists, four radiotherapists, one pulmonologist, two social workers, one psychologist and three nurses) from three health facilities providing oncology services in KwaZulu-Natal. Theoretical saturation was achieved at 19 in-depth interviews with consenting participants. In-depth interview transcripts were thematically analysed.

Results

The in-depth interviews generated rich data on the diverse issues regarding barriers to lung cancer care. The healthcare professionals perceived limited access to oncology services and poor diagnosis, as some of the leading barriers to effective lung cancer care. Lack of psycho-social and supportive care, resources and basic infrastructure mean that, for most patients, there is limited access to lung cancer screening, early diagnosis, treatment and/or palliative care.

Conclusions

The public sector faces infrastructural and key personnel shortages. Therefore, infrastructural and human resource challenges should be prioritised by policy-makers and administrators. Additionally, the vital contributions of psycho-social professionals should be incorporated in policies and programs supporting cancer care, in order to improve the cancer patient care. The results of this study may help decision makers to further improve cancer care in South Africa.

EPOCK study protocol: a mixed-methods research program evaluating cancer care coordination nursing occupations in France as a complex intervention

Background

Facing the increasing cancer incidence and cancer survivorship, many national strategic cancer plans have identified cancer care coordination as a priority for health service improvement. However, the high variability of practices, the diversity of definitions and underlying concepts increases the existing difficulty to standardise, replicate, transpose and assess care coordination within the French health system context. The EPOCK national study aims at evaluating practices and the working context of hospital-based cancer care coordination nurses, based on a previously designed reference framework for care coordination within the French health system context.

Methods

EPOCK is based on a comprehensive evaluation of nursing professions in cancer care coordination, considered as a complex intervention. Phase 1 (theoretical phase) will define and design a theoretical reference framework for care coordination in France through an international literature review, aiming to identify relevant models and all components of the expected framework and a structured consensus method, the Nominal group technique, aiming to select and prioritise the most relevant components already found in the literature review with regard to the French healthcare system; phase 2 (Operational phase) will consist in an in-depth analysis of practices, contexts, perceptions and attitudes related to care coordination occupations by nurses in oncology and all stakeholders (related professionals, patients and their caregivers) through a multicentric cross-sectional mixed-method evaluative study. The observed practices and contexts will be finally compared with the theoretical reference framework using both inductive and deductive approaches.

Discussion

This study will result in an evaluation framework identifying key models and key elements relative to cancer care coordination interventions that can be used to guide management of cancer care coordination nursing occupations within the French healthcare system. EPOCK would also assist in public decision-making to identify optimal targets, skills profiles and scope of actions for cancer coordination professions. Finally, EPOCK will describe typology of nurse practices in cancer care coordination and thus obtain precise preliminary information essential for drafting a medico-economic evaluation study of these new nursing professions’ impact.

Trial registration

Clinicaltrial.gov registration: NCT03350776, 11/22/2017.

In vivo targeting of DNA vaccines to dendritic cells using functionalized gold nanoparticles

The clinical success of dendritic cell (DC)-based genetic immunization remains critically dependent on the availability of effective and safe nano-carriers for targeting antigen-encoded DNA vaccines to DCs, the most potent antigen-presenting cells in the human body in vivo. Recent studies revealed the efficacies of mannose receptor-mediated in vivo DC-targeted genetic immunization by liposomal DNA vaccine carriers containing both mannose-mimicking shikimoyl and transfection enhancing guanidinyl functionalities. However, to date, the efficacies of this approach have not been examined for metal-based nanoparticle DNA vaccine carriers. Herein, we report for the first time, the design, synthesis, physico-chemical characterization and bioactivities of gold nanoparticles covalently functionalized with a thiol ligand containing both shikimoyl and guanidinyl functionalities (Au-SGSH). We show that Au-SGSH nanoparticles can deliver DNA vaccines to mouse DCs under in vivo conditions. Subcutaneous administration of near infrared (NIR) dye-labeled Au-SGSH showed significant accumulation of the NIR dye in the DCs of the nearby lymph nodes compared to that for the non-targeting NIR-labeled Au-GSH nanoconjugate containing only a covalently tethered guanidinyl group, not the shikimoyl-functionality. Under prophylactic settings, in vivo immunization (s.c.) with the Au-SGSH-pCMV-MART1 nanoplex induced a long-lasting (180 days) immune response against murine melanoma. Notably, mannose receptor-mediated in vivo DC-targeted immunization (s.c.) with the Au-SGSH-MART1 nanoplex significantly inhibited established melanoma growth and increased the overall survivability of melanoma-bearing mice under therapeutic settings. The Au-SGSH nanoparticles reported herein have potential use for in vivo DC-targeted genetic immunization against cancer and infectious diseases.

Operations for Suspected Neoplasms in a Resource-Limited Setting: Experience and Challenges in the Eastern Democratic of Congo

INTRODUCTION

Surgery is an essential component of a functional health system, with surgical conditions accounting for nearly 11-15% of world disability. While communicable diseases continue to burden low- and low-middle-income countries, non-communicable diseases, such as cancer, are an important cause of morbidity and mortality worldwide. Preliminary data on malignancies in low- and middle-income countries, specifically in Africa, suggest a higher mortality compared to other regions of the world, a difference partially explained by limited availability of screening and early detection systems as well as poorer access to treatment.

OBJECTIVE

To evaluate the diagnosed tumor burden in the Eastern Democratic Republic of Congo (DRC) and review literature on existing and suspected barriers to accessing appropriate oncologic care.

METHODS

This is a retrospective study carried out at Healthcare, Education, community Action, and Leadership development Africa, a 197-bed tertiary referral hospital, in the Province of North Kivu, along the eastern border of the DRC from 2012 to 2015. Patient charts were reviewed for diagnoses of presumed malignancy with biopsy results.

RESULTS

A total of 252 cases of suspected cancer were reviewed during the study period; 39.7% were men. The average age of patients was 43 years. Amongst adult patients, the most common presenting condition involved breast lesions with 5.8% diagnosis of fibrocystic breast changes and 2.9% invasive ductal carcinoma of the breast. 37.3% of female patients had lesions involving the cervix or uterus. The most common diagnosis amongst male adults was prostate disease (16.7% of men). For pediatric patients, the most common diagnoses involved bone and/or cartilage (27.3%) followed by skin and soft tissue lesions (20.0%). All patients underwent surgical resection of lesions; some patients were advised to travel out of country for chemotherapy and radiation for which follow-up data are unavailable.

CONCLUSION

Adequate and timely treatment of malignancy in the DRC faces a multitude of challenges. Access to surgical services for diagnosis and management as well as chemotherapeutic agents is prohibitively limited. Increased collaboration with local clinicians and remote specialist consultants is needed to deliver subspecialty care in resource-poor settings.

Surgical oncology at a major referral center in Ghana: Burden, staging, and outcomes

BACKGROUND AND OBJECTIVES

Outcome data after surgery for cancer in Sub-Saharan Africa are insufficient. We aimed to describe the presentation and outcomes of patients with solid cancers managed at a tertiary hospital in Ghana.

METHODS

Records of cancer patients admitted to Komfo Anokye Teaching Hospital general surgery wards from 2013 to 2016 were reviewed for data on presentation, staging, management, and mortality. Patients discharged alive were followed-up by biannual telephone calls to establish their postdischarge status. Survival analysis was performed for patients with pathologic or radiologic confirmation of cancer and adequate staging.

RESULTS

A total of 343 patients were included. Of these, 76% were female. The most common diagnoses were breast 136 (40%), foregut 70 (20%), and colorectal 63 (18%) cancers. Cancer diagnosis was confirmed by pathology or radiology in 281 (82%) patients, but only 112 (40%) had adequate staging. Seventy-four (66%) patients were stage IV. Two-year overall survival for all 343 patients was 22% to 69%, depending on cancer site. Among those with adequate staging who were alive after postoperative 90 days, 3-year survival was similar for curative compared with palliative operations (P = 0.64).

CONCLUSIONS

Improved capacity for both therapeutic and palliative cancer care is needed to achieve better outcomes by more appropriate allocation of surgery with respect to the goal of treatment.

Choosing wisely in oncology: necessity and obstacles

In the last decades, the survival of many patients with cancer improved thanks to modern diagnostic methods and progresses in therapy. Still for several tumours, especially when diagnosed at an advanced stage, the benefits of treatment in terms of increased survival or quality of life are at best modest when not marginal, and should be weighed against the potential discomfort caused by medical procedures. As in other specialties, in oncology as well the dialogue between doctor and patient should be encouraged about the potential overuse of diagnostic procedures or treatments. Several oncological societies produced recommendations similar to those proposed by other medical disciplines adhering to the Choosing Wisely (CW) campaign. In this review, we describe what was reported in the medical literature concerning adequacy of screening, diagnostic, treatment and follow-up procedures and the potential impact on them of the CW. We only marginally touch on the more complex topic of treatment appropriateness, for which several evaluation methods have been developed (including the European Society for Medical Oncology-magnitude of clinical benefit scale). Finally, we review the possible obstacles for the development of CW in the oncological setting and focus on the strategies which could allow CW to evolve in the cancer field, so as to enhance the therapeutic relationship between medical professionals and patients and promote more appropriate management.

Radiation-induced nausea and vomiting: Is ABO blood group as important as radiation and patient-related factors? An observational study

Despite the improvements in cancer screening and treatment, it still remains as one of the leading causes of mortality worldwide. Nausea and vomiting as the side effects of different cancer treatment modalities, such as radiotherapy, are multifactorial and could affect the treatment continuation and patient quality of life. Therefore, the aim of this study was to assess the possible linkage between ABO blood groups and radiation-induced nausea and vomiting (RINV), also its incidence and affecting factors.One hundred twenty-eight patients referring to Tohid hospital of Sanandaj, Iran, were selected and the patients and treatment-related factors were determined in a cross-sectional study. Patients' nausea and vomiting were recorded from the onset of treatment until 1 week after treatment accomplishment. Also, previous possible nausea and vomiting were recorded. The frequencies of nausea and vomiting and their peak time were examined during the treatment period.The association between ABO blood group and the incidence of radiotherapy-induced nausea and vomiting (RINV) were significant and it seems that A blood group patients are the most vulnerable individuals to these symptoms. The association between Rhesus antigen and the time of maximum severity of RINV may indicate that Rhesus antigen affects the time of maximum severity of RINV. The incidence of RINV was not affected by karnofsky performance status, but it was related to the severity of RINV. Furthermore, among the factors affecting the incidence of nausea and vomiting, nausea and vomiting during patient's previous chemotherapy, radiotherapy region, and background gastrointestinal disease were shown to be three important factors.In addition to familiar RINV-affecting factors, ABO blood group may play an important role and these results address the needs for further studies with larger sample size.

Polymorphisms in TIM-3 and breast cancer susceptibility in Chinese women: A case-control study

Previous studies have found associations between polymorphisms in T cell immunoglobulin and mucin domain 3 (TIM-3) and increased risks of various cancers. However, the association between TIM-3 polymorphisms and breast cancer (BC) remains uncertain. In this study, a total of 560 BC patients and 583 age, sex, and ethnicity-matched healthy controls from Northwest China were included. The polymorphisms were genotyped using Sequenom MassARRAY. The expression level of TIM-3 protein was detected by immunohistochemistry. We observed rs10053538 had a significantly increased risk of BC, comparing with the wild-type genotype even after Bonferroni correction. In addition, the rs4704853 G>A variants were more frequent among BC patients than the controls (GA + AA vs. GG: OR = 1.32, 95% CI = 1.03-1.69, P = 0.026); However, the significance was lost after Bonferroni correction (P = 0.078). Furthermore, rs10053538 was associated with lymph node metastasis. Age stratification revealed that among patients aged <49 years, those with the rs4704853 GA/AA genotype had a higher risk of BC; But there was no difference when Bonferroni correction was conducted. Immunohistochemical analysis showed that the expression of TIM-3 protein in the breast cancer tissues was higher in patients carrying the rs10053538 GT+TT genotype than those with GG genotype (P = 0.012). However, we failed to find any difference between BC patients and controls in any rs1036199 genetic model. These findings suggested that rs10053538 in TIM-3 might increase susceptibility to BC and promote the progression of BC in Chinese women.

Therapeutic application of anti-angiogenic nanomaterials in cancers

Angiogenesis, the formation of new blood vessels from pre-existing vasculature, plays a vital role in physiological and pathological processes (embryonic development, wound healing, tumor growth and metastasis). The overall balance of angiogenesis inside the human body is maintained by pro- and anti-angiogenic signals. The processes by which drugs inhibit angiogenesis as well as tumor growth are called the anti-angiogenesis technique, a most promising cancer treatment strategy. Over the last couple of decades, scientists have been developing angiogenesis inhibitors for the treatment of cancers. However, conventional anti-angiogenic therapy has several limitations including drug resistance that can create problems for a successful therapeutic strategy. Therefore, a new comprehensive treatment strategy using antiangiogenic agents for the treatment of cancer is urgently needed. Recently researchers have been developing and designing several nanoparticles that show anti-angiogenic properties. These nanomedicines could be useful as an alternative strategy for the treatment of various cancers using anti-angiogenic therapy. In this review article, we critically focus on the potential application of anti-angiogenic nanomaterial and nanoparticle based drug/siRNA/peptide delivery systems in cancer therapeutics. We also discuss the basic and clinical perspectives of anti-angiogenesis therapy, highlighting its importance in tumor angiogenesis, current status and future prospects and challenges.

Management of locally advanced and metastatic breast cancer: guidelines, infrastructures and low resource settings

Breast cancer incidence is rising and it accounts for over 1.6 million cases per year worldwide. It represents about one-third of female cancers and is a significant health issue in countries at all economic levels. In this article, we review global cancer statistics, breast cancer staging including late-stage presentation in limited resource settings, disparities in the breast cancer outcomes and requirements for optimal management, including infrastructure needs for optimal surgery, radiation treatment and systemic therapy. We will discuss controversies related to drug pricing and availability, process and delays in registration of new drugs as well as resource stratification and resource-stratified guidelines for locally advanced breast cancer and metastatic breast cancer.

Association among Dietary Flavonoids, Flavonoid Subclasses and Ovarian Cancer Risk: A Meta-Analysis

Background

Previous studies have indicated that intake of dietary flavonoids or flavonoid subclasses is associated with the ovarian cancer risk, but presented controversial results. Therefore, we conducted a meta-analysis to derive a more precise estimation of these associations.

Methods

We performed a search in PubMed, Google Scholar and ISI Web of Science from their inception to April 25, 2015 to select studies on the association among dietary flavonoids, flavonoid subclasses and ovarian cancer risk. The information was extracted by two independent authors. We assessed the heterogeneity, sensitivity, publication bias and quality of the articles. A random-effects model was used to calculate the pooled risk estimates.

Results

Five cohort studies and seven case-control studies were included in the final meta-analysis. We observed that intake of dietary flavonoids can decrease ovarian cancer risk, which was demonstrated by pooled RR (RR = 0.82, 95% CI = 0.68–0.98). In a subgroup analysis by flavonoid subtypes, the ovarian cancer risk was also decreased for isoflavones (RR = 0.67, 95% CI = 0.50–0.92) and flavonols (RR = 0.68, 95% CI = 0.58–0.80). While there was no compelling evidence that consumption of flavones (RR = 0.86, 95% CI = 0.71–1.03) could decrease ovarian cancer risk, which revealed part sources of heterogeneity. The sensitivity analysis indicated stable results, and no publication bias was observed based on the results of Funnel plot analysis and Egger’s test (p = 0.26).

Conclusions

This meta-analysis suggested that consumption of dietary flavonoids and subtypes (isoflavones, flavonols) has a protective effect against ovarian cancer with a reduced risk of ovarian cancer except for flavones consumption. Nevertheless, further investigations on a larger population covering more flavonoid subclasses are warranted.