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Ngabonziza E, Ghebre R, DeBoer RJ, Ntasumbumuyange D, Magriples U, George J, Grover S, Bazzett-Matabele L. Outcomes of neoadjuvant chemotherapy and radical hysterectomy for locally advanced cervical cancer at Kigali University Teaching Hospital, Rwanda: a retrospective descriptive study. BMC Womens Health 2024; 24:204. [PMID: 38555423 PMCID: PMC10981286 DOI: 10.1186/s12905-024-03024-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 03/14/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Half of countries in Africa lack access to radiation (RT), which is essential for standard treatment of locally advanced cervical cancers. We evaluated outcomes for patients treated with neoadjuvant chemotherapy (NACT) followed by radical hysterectomy in settings where no RT is available. METHODS We performed a retrospective descriptive study of all patients with FIGO stage IB2-IIA2 and some exceptional stage IIB cases who received NACT and surgery at Kigali University Teaching Hospital in Rwanda. Patients were treated with NACT consisting of carboplatin and paclitaxel once every 3 weeks for 3-4 cycles before radical hysterectomy. We calculated recurrence rates and overall survival (OS) rate was determined by Kaplan-Meier estimates. RESULTS Between May 2016 and October 2018, 57 patients underwent NACT and 43 (75.4%) were candidates for radical hysterectomy after clinical response assessment. Among the 43 patients who received NACT and surgery, the median age was 56 years, 14% were HIV positive, and FIGO stage distribution was: IB2 (32.6%), IIA1 (7.0%), IIA2 (51.2%) and IIB (9.3%). Thirty-nine (96%) patients received 3 cycles and 4 (4%) received 4 cycles of NACT. Thirty-eight (88.4%) patients underwent radical hysterectomy as planned and 5 (11.6%) had surgery aborted due to grossly metastatic disease. Two patients were lost to follow up after surgery and excluded from survival analysis. For the remaining 41 patients with median follow-up time of 34.4 months, 32 (78%) were alive with no evidence of recurrence, and 8 (20%) were alive with recurrence. One patient died of an unrelated cancer. The 3-year OS rate for the 41 patients who underwent NACT and surgery was 80.8% with a recurrence rate of 20%. CONCLUSIONS Neoadjuvant chemotherapy with radical hysterectomy is a feasible treatment option for locally advanced cervical cancer in settings with limited access to RT. With an increase in gynecologic oncologists skilled at radical surgery, this approach may be a more widely available alternative treatment option in countries without radiation facilities.
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Affiliation(s)
| | - Rahel Ghebre
- University of Rwanda, Kigali, Rwanda
- University of Minnesota Medical School, Minneapolis, MN, USA
| | | | | | - Urania Magriples
- University of Rwanda, Kigali, Rwanda
- Yale School of Medicine, New Haven, CT, USA
| | | | | | - Lisa Bazzett-Matabele
- University of Rwanda, Kigali, Rwanda.
- Yale School of Medicine, New Haven, CT, USA.
- Department of OBGYN, University of Botswana, Sir Ketumile Masire Teaching Hospital, Pvt Bag, 00713, Gaborone, Botswana.
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Van Loon K, Breithaupt L, Ng D, DeBoer RJ, Buckle GC, Bialous S, Hiatt RA, Volberding P, Hermiston ML, Ashworth A. A roadmap to establishing global oncology as a priority initiative within a National Cancer Institute-designated cancer center. J Natl Cancer Inst 2024; 116:345-351. [PMID: 38060289 PMCID: PMC10919326 DOI: 10.1093/jnci/djad255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 11/06/2023] [Accepted: 11/30/2023] [Indexed: 12/08/2023] Open
Abstract
As the burden of cancers impacting low- and middle-income countries is projected to increase, formation of strategic partnerships between institutions in high-income countries and low- and middle-income country institutions may serve to accelerate cancer research, clinical care, and training. As the US National Cancer Institute and its Center for Global Health continue to encourage cancer centers to join its global mission, academic cancer centers in the United States have increased their global activities. In 2015, the Helen Diller Family Comprehensive Cancer Center at the University of California, San Francisco, responded to the call for international partnership in addressing the global cancer burden through the establishment of the Global Cancer Program as a priority initiative. In developing the Global Cancer Program, we galvanized institutional support to foster sustained, bidirectional, equitable, international partnerships in global cancer control. Our focus and intent in disseminating this commentary is to share experiences and lessons learned from the perspective of a US-based, National Cancer Institute-designated cancer center and to provide a roadmap for other high-income institutions seeking to strategically broaden their missions and address the complex challenges of global cancer control. Herein, we review the formative evaluation, governance, strategic planning, investments in career development, funding sources, program evaluation, and lessons learned. Reflecting on the evolution of our program during the first 5 years, we observed in our partners a powerful shift toward a locally driven priority setting, reduced dependency, and an increased commitment to research as a path to improve cancer outcomes in resource-constrained settings.
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Affiliation(s)
- Katherine Van Loon
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (UCSF), San Francisco, CA, USA
- Department of Medicine, Division of Hematology/Oncology, UCSF, San Francisco, CA, USA
| | - Lindsay Breithaupt
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (UCSF), San Francisco, CA, USA
| | - Dianna Ng
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (UCSF), San Francisco, CA, USA
- Department of Pathology, UCSF, San Francisco, CA, USA
| | - Rebecca J DeBoer
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (UCSF), San Francisco, CA, USA
- Department of Medicine, Division of Hematology/Oncology, UCSF, San Francisco, CA, USA
| | - Geoffrey C Buckle
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (UCSF), San Francisco, CA, USA
- Department of Medicine, Division of Hematology/Oncology, UCSF, San Francisco, CA, USA
| | - Stella Bialous
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (UCSF), San Francisco, CA, USA
- School of Nursing, UCSF, San Francisco, CA, USA
| | - Robert A Hiatt
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (UCSF), San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, UCSF, San Francisco, CA, USA
| | - Paul Volberding
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (UCSF), San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, UCSF, San Francisco, CA, USA
| | - Michelle L Hermiston
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (UCSF), San Francisco, CA, USA
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, UCSF, San Francisco, CA, USA
| | - Alan Ashworth
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco (UCSF), San Francisco, CA, USA
- Department of Medicine, Division of Hematology/Oncology, UCSF, San Francisco, CA, USA
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DeBoer RJ, Ho A, Mutoniwase E, Nguyen C, Umutesi G, Bigirimana JB, Nsabimana N, Van Loon K, Shulman LN, Triedman SA, Cubaka VK, Shyirambere C. Ethical dilemmas in prioritizing patients for scarce radiotherapy resources. BMC Med Ethics 2024; 25:12. [PMID: 38297294 PMCID: PMC10829165 DOI: 10.1186/s12910-024-01005-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 01/18/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Radiotherapy is an essential component of cancer treatment, yet many countries do not have adequate capacity to serve all patients who would benefit from it. Allocation systems are needed to guide patient prioritization for radiotherapy in resource-limited contexts. These systems should be informed by allocation principles deemed relevant to stakeholders. This study explores the ethical dilemmas and views of decision-makers engaged in real-world prioritization of scarce radiotherapy resources at a cancer center in Rwanda in order to identify relevant principles. METHODS Semi-structured interviews were conducted with a purposive sample of 22 oncology clinicians, program leaders, and clinical advisors. Interviews explored the factors considered by decision-makers when prioritizing patients for radiotherapy. The framework method of thematic analysis was used to characterize these factors. Bioethical analysis was then applied to determine their underlying normative principles. RESULTS Participants considered both clinical and non-clinical factors relevant to patient prioritization for radiotherapy. They widely agreed that disease curability should be the primary overarching driver of prioritization, with the goal of saving the most lives. However, they described tension between curability and competing factors including age, palliative benefit, and waiting time. They were divided about the role that non-clinical factors such as social value should play, and agreed that poverty should not be a barrier. CONCLUSIONS Multiple competing principles create tension with the agreed upon overarching goal of maximizing lives saved, including another utilitarian approach of maximizing life-years saved as well as non-utilitarian principles, such as egalitarianism, prioritarianism, and deontology. Clinical guidelines for patient prioritization for radiotherapy can combine multiple principles into a single allocation system to a significant extent. However, conflicting views about the role that social factors should play, and the dynamic nature of resource availability, highlight the need for ongoing work to evaluate and refine priority setting systems based on stakeholder views.
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Affiliation(s)
- Rebecca J DeBoer
- Division of Hematology/Oncology, University of California, San Francisco, San Francisco, CA, USA.
| | - Anita Ho
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Cam Nguyen
- University of Colorado Cancer Center, Aurora, CO, USA
| | | | | | | | - Katherine Van Loon
- Division of Hematology/Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Lawrence N Shulman
- University of Pennsylvania Abramson Cancer Center, Philadelphia, PA, USA
| | - Scott A Triedman
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Sakafu LL, Philipo GS, Malichewe CV, Fundikira LS, Lwakatare FA, Van Loon K, Mushi BP, DeBoer RJ, Bialous SA, Lee AY. Delayed diagnostic evaluation of symptomatic breast cancer in sub-Saharan Africa: A qualitative study of Tanzanian women. PLoS One 2022; 17:e0275639. [PMID: 36201503 PMCID: PMC9536581 DOI: 10.1371/journal.pone.0275639] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 09/21/2022] [Indexed: 11/06/2022] Open
Abstract
Background Women with breast cancer in sub-Saharan Africa are commonly diagnosed at advanced stages. In Tanzania, more than 80% of women are diagnosed with stage III or IV disease, and mortality rates are high. This study explored factors contributing to delayed diagnostic evaluation among women with breast cancer in Tanzania. Methods A qualitative study was performed at Muhimbili National Hospital in Dar es Salaam, Tanzania. Twelve women with symptomatic pathologically proven breast cancer were recruited. In-depth, semi-structured interviews were conducted in Swahili. Interviews explored the women’s journey from symptom recognition to diagnosis, including the influence of breast cancer knowledge and pre-conceptions, health seeking behaviors, psychosocial factors, preference for alternative treatments, and the contribution of culture and norms. Audio-recorded interviews were transcribed and translated into English. Thematic analysis was facilitated by a cloud-based qualitative analysis software. Results All women reported that their first breast symptom was a self-identified lump or swelling. Major themes for factors contributing to delayed diagnostic presentation of breast cancer included lack of basic knowledge and awareness of breast cancer and misconceptions about the disease. Participants faced barriers with their local primary healthcare providers, including symptom mismanagement and delayed referrals for diagnostic evaluation. Other barriers included financial hardships, fear and stigma of cancer, and use of traditional medicine. The advice and influence of family members and friends played key roles in healthcare-seeking behaviors, serving as both facilitators and barriers. Conclusion Lack of basic knowledge and awareness of breast cancer, stigma, financial barriers, and local healthcare system barriers were common factors contributing to delayed diagnostic presentation of breast cancer. The influence of friends and family also played key roles as both facilitators and barriers. This information will inform the development of educational intervention strategies to address these barriers and improve earlier diagnosis of symptomatic breast cancer in Tanzania.
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Affiliation(s)
- Lulu Lunogelo Sakafu
- Department of Radiology, Muhimbili National Hospital, Dar es Salaam, Tanzania
- * E-mail: (LLS); (AYL)
| | | | | | - Lulu S. Fundikira
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Flora A. Lwakatare
- Department of Radiology, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Katherine Van Loon
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco (UCSF), San Francisco, California, United States of America
| | - Beatrice P. Mushi
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Rebecca J. DeBoer
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco (UCSF), San Francisco, California, United States of America
| | - Stella A. Bialous
- Department of Social and Behavioral Sciences, University of California San Francisco (UCSF), San Francisco, California, United States of America
| | - Amie Y. Lee
- Department of Radiology and Biomedical Imaging, University of California San Francisco (UCSF), San Francisco, California, United States of America
- * E-mail: (LLS); (AYL)
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5
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Morgan J, DeBoer RJ, Bigirimana JB, Nguyen C, Ruhangaza D, Paciorek A, Mugabo F, Villaverde C, Nsabimana N, Bihizimana P, Umwizerwa A, Lehmann LE, Shulman LN, Shyirambere C. A Ten-Year Experience of Treating Chronic Myeloid Leukemia in Rural Rwanda: Outcomes and Insights for a Changing Landscape. JCO Glob Oncol 2022; 8:e2200131. [PMID: 35839427 PMCID: PMC9812457 DOI: 10.1200/go.22.00131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE In describing our ten-year experience with treating chronic myeloid leukemia (CML) as part of the Glivec Patient Assistance Program (GIPAP) in rural Rwanda, we evaluate (1) patient characteristics and treatment outcomes, (2) resource-adapted management strategies, and (3) the impact of diagnostic capacity development. METHODS We retrospectively reviewed all patients with BCR-ABL-positive CML enrolled in this GIPAP program between 2009 and 2018. Clinical data were analyzed using descriptive statistics, Kaplan-Meier methods, proportional hazards regression, and the Kruskal-Wallis test. RESULTS One hundred twenty-four patients were included. The median age at diagnosis was 34 (range 8-81) years. On imatinib, 91% achieved complete hematologic response (CHR) after a median of 49 days. Seven (6%) and 12 (11%) patients had primary and secondary imatinib resistance, respectively. The 3-year overall survival was 80% (95% CI, 72 to 87) for the cohort, with superior survival in imatinib responders compared with those with primary and secondary resistance. The median time from imatinib initiation to CHR was 59 versus 38 days (P = .040) before and after in-country diagnostic testing, whereas the median time to diagnosis (P = .056) and imatinib initiation (P = .170) was not significantly different. CONCLUSION Coupling molecular diagnostics with affordable access to imatinib within a comprehensive cancer care delivery program is a successful long-term strategy to treat CML in resource-constrained settings. Our patients are younger and have higher rates of imatinib resistance compared with historic cohorts in high-income countries. High imatinib resistance rates highlight the need for access to molecular monitoring, resistance testing, and second-generation tyrosine kinase inhibitors, as well as systems to support drug adherence. Hematologic response is an accurate resource-adapted predictor of survival in this setting. Local diagnostic capacity development has allowed for continuous, timely CML care delivery in Rwanda.
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Affiliation(s)
- Jennifer Morgan
- Lineberger Comprehensive Cancer Center, Chapel Hill, NC,Jennifer Morgan, MD, Lineberger Comprehensive Cancer Center, University of North Carolina, 170 Manning Dr, CB #7305, Chapel Hill, NC 27599; e-mail:
| | - Rebecca J. DeBoer
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA
| | | | | | | | - Alan Paciorek
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA
| | - Fred Mugabo
- Republic of Rwanda Ministry of Health, Burera District, Rwanda
| | | | | | | | - Aline Umwizerwa
- Partners In Health/Inshuti Mu Buzima, Burera District, Rwanda
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6
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DeBoer RJ, Nguyen C, Mutoniwase E, Ho A, Umutesi G, Bigirimana JB, Triedman SA, Shyirambere C. Procedural fairness for radiotherapy priority setting in a low resource context. Bioethics 2022; 36:500-510. [PMID: 34415636 PMCID: PMC9292884 DOI: 10.1111/bioe.12939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 05/22/2021] [Accepted: 07/21/2021] [Indexed: 06/13/2023]
Abstract
Radiotherapy is an essential component of cancer treatment, yet many countries do not have adequate capacity to serve their populations. This mismatch between demand and supply creates the need for priority setting. There is no widely accepted system to guide patient prioritization for radiotherapy in a low resource context. In the absence of consensus on allocation principles, fair procedures for priority setting should be established. Research is needed to understand what elements of procedural fairness are important to decision makers in diverse settings, assess the feasibility of implementing fair procedures for priority setting in low resource contexts, and improve these processes. This study presents the views of decision makers engaged in everyday radiotherapy priority setting at a cancer center in Rwanda. Semi-structured interviews with 22 oncology physicians, nurses, program leaders, and advisors were conducted. Participants evaluated actual radiotherapy priority setting procedures at the program (meso) and patient (micro) levels, reporting facilitators, barriers, and recommendations. We discuss our findings in relation to the leading Accountability for Reasonableness (AFR) framework. Participants emphasized procedural elements that facilitate adherence to normative principles, such as objective criteria that maximize lives saved. They ascribed fairness to AFR's substantive requirement of relevance more than transparency, appeals, and enforcement. They identified several challenges unresolved by AFR, such as conflicting relevant rationales and unintended consequences of publicity and appeals. Implementing fair procedure itself is resource intensive, a paradox that calls for innovative, context-appropriate solutions. Finally, socioeconomic and structural barriers to care that undermine procedural fairness must be addressed.
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Affiliation(s)
- Rebecca J. DeBoer
- Division of Hematology/OncologyUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Cam Nguyen
- Partners in Health/Inshuti Mu BuzimaKigaliRwanda
| | | | - Anita Ho
- Division of Hematology/OncologyUniversity of California San FranciscoSan FranciscoCaliforniaUSA
- University of British ColumbiaVancouverBritish ColumbiaCanada
| | | | | | - Scott A. Triedman
- Warren Alpert Medical School of Brown University, ProvidenceRhode IslandUSA
- Dana Farber Cancer InstituteBostonMassachusettsUSA
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Wabl CA, Athanas R, Cubaka V, Mushi B, Ngoma M, Nsabimana N, Sama G, Tuyishime H, Uwamahoro P, Sanders JJ, Sudore RL, Van Loon K, Whitaker E, DeBoer RJ. Serious Illness Communication in Cancer Care in Africa: A Scoping Review of Empirical Research. JCO Glob Oncol 2022. [DOI: 10.1200/go.22.53000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Serious illness communication (SIC) in cancer care describes conversations between clinicians, patients, and families about prognosis and treatment decisions. Cultural context influences SIC. Researchers have studied SIC across diverse settings in Africa. We aimed to describe and synthesize the heterogeneous body of research on SIC practices, preferences, and needs in Africa to identify research and training priorities. METHODS Our search strategy identified studies that focused on SIC within cancer or palliative care in Africa. Following PRISMA guidelines, a systematic literature search was performed using PubMed, Embase, Web of Science, CINAHL, African Index Medicus, and PsycINFO, yielding 1811 unique titles. After sequential review of abstracts, full text, and cited references, 42 articles met inclusion criteria. Quantitative and qualitative data describing study characteristics, aims, methods, and findings were abstracted and analyzed using descriptive statistics and thematic analysis. Critical appraisal was performed using the Mixed Methods Appraisal Tool. RESULTS The 42 included articles were published from 1997-2021, half since 2017, representing 16 countries and all African Union regions: West (33%), East (29%), South (21%), North (12%), and Central (5%). Most study designs were qualitative (45%) or quantitative surveys (50%). Study participants included patients (35%), family caregivers (18%), doctors (18%), nurses (12%), and/or other (11%). Study aims focused on disclosure of diagnosis (27%) or prognosis (20%), breaking bad news (15%), general patient-clinician communication (12%), truth-telling (8%), shared decision-making (7%), information needs/preferences (5%), and/or advance care planning (5%). Despite diverse contexts, common themes emerged. Study authors frequently recommended communication skills training. Critical appraisal demonstrated high quality of studies overall. CONCLUSION Research on SIC in Africa has increased in recent years. Most studies have focused on information delivery by clinicians; fewer on eliciting information from patients (eg, shared decision-making, advanced care planning). Significant opportunities exist for further study and for communication skills training.
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Affiliation(s)
| | - Raymond Athanas
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Beatrice Mushi
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Mamsau Ngoma
- Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | | | - Godfrey Sama
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Tsang M, DeBoer RJ, Garrett SB, Dohan D. Decision-making about clinical trial options among older patients with metastatic cancer who have exhausted standard therapies. J Geriatr Oncol 2022; 13:594-599. [PMID: 35125334 PMCID: PMC9232893 DOI: 10.1016/j.jgo.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 01/15/2022] [Accepted: 01/21/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Mazie Tsang
- Division of Hematology/Oncology, University of California San Francisco, 505 Parnassus Avenue, Room M1286, Mailbox 1270, San Francisco, CA 94143, United States.
| | - Rebecca J DeBoer
- Division of Hematology/Oncology, University of California San Francisco, 505 Parnassus Avenue, Room M1286, Mailbox 1270, San Francisco, CA 94143, United States.
| | - Sarah B Garrett
- Institute for Health Policy Studies, University of California San Francisco, 490 Illinois Street, San Francisco, CA 94158, United States.
| | - Daniel Dohan
- Institute for Health Policy Studies, University of California San Francisco, 490 Illinois Street, San Francisco, CA 94158, United States.
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DeBoer RJ, Umutoni V, Bazzett-Matabele L, Katznelson E, Nguyen C, Umwizerwa A, Bigirimana JB, Paciorek A, Nsabimana N, Ruhangaza D, Ntasumbumuyange D, Shulman LN, Triedman SA, Shyirambere C. Cervical cancer treatment in Rwanda: Resource-driven adaptations, quality indicators, and patient outcomes. Gynecol Oncol 2021; 164:370-378. [PMID: 34916066 DOI: 10.1016/j.ygyno.2021.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 11/20/2021] [Accepted: 12/01/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Most cervical cancer cases and deaths occur in low- and middle-income countries, yet clinical research from these contexts is significantly underrepresented. We aimed to describe the treatment quality, resource-driven adaptations, and outcomes of cervical cancer patients in Rwanda. METHODS A retrospective cohort study was conducted of all patients with newly diagnosed cervical cancer enrolled between April 2016 and June 2018. Data were abstracted from medical records and analyzed using descriptive statistics, Kaplan Meier methods, and Cox proportional hazards regression. RESULTS A total of 379 patients were included; median age 54 years, 21% HIV-infected. A majority (55%) had stage III or IV disease. Thirty-four early-stage patients underwent radical hysterectomy. Of 254 patients added to a waiting list for chemoradiation, 114 ultimately received chemoradiation. Of these, 30 (26%) received upfront chemoradiation after median 126 days from diagnosis, and 83 (73%) received carboplatin/paclitaxel while waiting, with a median 56 days from diagnosis to chemotherapy and 207 days to chemoradiation. There was no survival difference between the upfront chemoradiation and prior chemotherapy subgroups. Most chemotherapy recipients (77%) reported improvement in symptoms. Three-year event-free survival was 90% with radical hysterectomy (95% CI 72-97%), 66% with chemoradiation (95% CI 55-75%), and 12% with chemotherapy only (95% CI 6-20%). CONCLUSIONS Multi-modality treatment of cervical cancer is effective in low resource settings through coordinated care and pragmatic approaches. Our data support a role for temporizing chemotherapy if delays to chemoradiation are anticipated. Sustainable access to gynecologic oncology surgery and expanded access to radiotherapy are urgently needed.
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Affiliation(s)
- Rebecca J DeBoer
- University of California San Francisco, San Francisco, CA, United States.
| | - Victoria Umutoni
- Vanderbilt University Medical Center, Nashville, TN, United States
| | - Lisa Bazzett-Matabele
- University of Botswana, Gaborone, Botswana; Yale University, New Haven, CT, United States
| | | | - Cam Nguyen
- University of Colorado Cancer Center, Aurora, CO, United States
| | | | | | - Alan Paciorek
- University of California San Francisco, San Francisco, CA, United States
| | | | | | | | - Lawrence N Shulman
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, United States
| | - Scott A Triedman
- Warren Alpert Medical School of Brown University, Providence, RI, United States; Dana Farber Cancer Institute, Boston, MA, United States
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10
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DeBoer RJ, Rugo HS, Shulman LN. Reconceptualizing Risk-Benefit Assessment of Novel Cancer Therapies to Expand Global Access and Reduce Worldwide Mortality. JAMA Oncol 2021; 8:203-204. [PMID: 34882172 DOI: 10.1001/jamaoncol.2021.5945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Rebecca J DeBoer
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco
| | - Hope S Rugo
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco
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11
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Nyagabona SK, Luhar R, Ndumbalo J, Mvungi N, Ngoma M, Meena S, Siu S, Said M, Mwaiselage J, Tarimo E, Buckle G, Selekwa M, Mushi B, Mmbaga EJ, Van Loon K, DeBoer RJ. Views from Multidisciplinary Oncology Clinicians on Strengthening Cancer Care Delivery Systems in Tanzania. Oncologist 2021; 26:e1197-e1204. [PMID: 34041817 PMCID: PMC8265360 DOI: 10.1002/onco.13834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 05/14/2021] [Indexed: 12/26/2022] Open
Abstract
Background In response to the increasing burden of cancer in Tanzania, the Ministry of Health, Community Development, Gender, Elderly and Children launched National Cancer Treatment Guidelines (TNCTG) in February 2020. The guidelines aimed to improve and standardize oncology care in the country. At Ocean Road Cancer Institute (ORCI), we developed a theory‐informed implementation strategy to promote guideline‐concordant care. As part of the situation analysis for implementation strategy development, we conducted focus group discussions to evaluate clinical systems and contextual factors that influence guideline‐based practice prior to the launch of the TNCTG. Materials and Methods In June 2019, three focus group discussions were conducted with a total of 21 oncology clinicians at ORCI, stratified by profession. A discussion guide was used to stimulate dialogue about facilitators and barriers to delivery of guideline‐concordant care. Discussions were audio recorded, transcribed, translated, and analyzed using thematic framework analysis. Results Participants identified factors both within the inner context of ORCI clinical systems and outside of ORCI. Themes within the clinical systems included capacity and infrastructure, information technology, communication, efficiency, and quality of services provided. Contextual factors external to ORCI included interinstitutional coordination, oncology capacity in peripheral hospitals, public awareness and beliefs, and financial barriers. Participants provided pragmatic suggestions for strengthening cancer care delivery in Tanzania. Conclusion Our results highlight several barriers and facilitators within and outside of the clinical systems at ORCI that may affect uptake of the TNCTG. Our findings were used to inform a broader guideline implementation strategy, in an effort to improve uptake of the TNCTGs at ORCI. Implications for Practice This study provides an assessment of cancer care delivery systems in a low resource setting from the unique perspectives of local multidisciplinary oncology clinicians. Situational analysis of contextual factors that are likely to influence guideline implementation outcomes is the first step of developing an implementation strategy for cancer treatment guidelines. Many of the barriers identified in this study represent actionable targets that will inform the next phases of our implementation strategy for guideline‐concordant cancer care in Tanzania and comparable settings. Guidelines to improve and standardize oncology care in Tanzania were developed in 2020. This study utilized focus group discussions to assess the barriers and facilitators to guideline implementation at Ocean Road Cancer Institute.
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Affiliation(s)
| | - Rohan Luhar
- Global Cancer Program, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California, USA
| | | | | | - Mamsau Ngoma
- Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | - Stephen Meena
- Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | - Sadiq Siu
- Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | - Mwamvita Said
- Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | | | - Edith Tarimo
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Geoffrey Buckle
- Global Cancer Program, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California, USA
| | - Msiba Selekwa
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Beatrice Mushi
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Elia John Mmbaga
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.,University of Oslo, Norway
| | - Katherine Van Loon
- Global Cancer Program, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California, USA
| | - Rebecca J DeBoer
- Global Cancer Program, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California, USA
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DeBoer RJ, Mutoniwase E, Nguyen C, Ho A, Umutesi G, Nkusi E, Sebahungu F, Van Loon K, Shulman LN, Shyirambere C. Moral Distress and Resilience Associated with Cancer Care Priority Setting in a Resource-Limited Context. Oncologist 2021; 26:e1189-e1196. [PMID: 33969927 PMCID: PMC8265342 DOI: 10.1002/onco.13818] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 05/05/2021] [Indexed: 12/24/2022] Open
Abstract
Background Moral distress and burnout are highly prevalent among oncology clinicians. Research is needed to better understand how resource constraints and systemic inequalities contribute to moral distress in order to develop effective mitigation strategies. Oncology providers in low‐ and middle‐income countries are well positioned to provide insight into the moral experience of cancer care priority setting and expertise to guide solutions. Methods Semistructured interviews were conducted with a purposive sample of 22 oncology physicians, nurses, program leaders, and clinical advisors at a cancer center in Rwanda. Interviews were recorded, transcribed verbatim, and analyzed using the framework method. Results Participants identified sources of moral distress at three levels of engagement with resource prioritization: witnessing program‐level resource constraints drive cancer disparities, implementing priority setting decisions into care of individual patients, and communicating with patients directly about resource prioritization implications. They recommended individual and organizational‐level interventions to foster resilience, such as communication skills training and mental health support for clinicians, interdisciplinary team building, fair procedures for priority setting, and collective advocacy for resource expansion and equity. Conclusion This study adds to the current literature an in‐depth examination of the impact of resource constraints and inequities on clinicians in a low‐resource setting. Effective interventions are urgently needed to address moral distress, reduce clinician burnout, and promote well‐being among a critical but strained oncology workforce. Collective advocacy is concomitantly needed to address the structural forces that constrain resources unevenly and perpetuate disparities in cancer care and outcomes. Implications for Practice For many oncology clinicians worldwide, resource limitations constrain routine clinical practice and necessitate decisions about prioritizing cancer care. To the authors’ knowledge, this study is the first in‐depth analysis of how resource constraints and priority setting lead to moral distress among oncology clinicians in a low‐resource setting. Effective individual and organizational interventions and collective advocacy for equity in cancer care are urgently needed to address moral distress and reduce clinician burnout among a strained global oncology workforce. Lessons from low‐resource settings can be gleaned as high‐income countries face growing needs to prioritize oncology resources. Oncology providers in low‐ and middle‐income countries face resource priority setting decisions on a routine basis. This article describes the moral experience and recommendations of oncology clinicians, advisors, and program leaders engaged in clinical priority setting at a cancer center in Rwanda.
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Affiliation(s)
- Rebecca J DeBoer
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California, USA
| | | | - Cam Nguyen
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | - Anita Ho
- Program in Bioethics, University of California, San Francisco, California, USA.,University of British Columbia, Vancouver, Canada
| | - Grace Umutesi
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | - Eugene Nkusi
- Republic of Rwanda Ministry of Health, Kigali, Rwanda
| | | | - Katherine Van Loon
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California, USA
| | - Lawrence N Shulman
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Rositch AF, Unger-Saldaña K, DeBoer RJ, Ng'ang'a A, Weiner BJ. The role of dissemination and implementation science in global breast cancer control programs: Frameworks, methods, and examples. Cancer 2021; 126 Suppl 10:2394-2404. [PMID: 32348574 DOI: 10.1002/cncr.32877] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/11/2020] [Accepted: 03/11/2020] [Indexed: 01/24/2023]
Abstract
Global disparities in breast cancer outcomes are attributable to a sizable gap between evidence and practice in breast cancer control and management. Dissemination and implementation science (D&IS) seeks to understand how to promote the systematic uptake of evidence-based interventions and/or practices into real-world contexts. D&IS methods are useful for selecting strategies to implement evidence-based interventions, adapting their implementation to new settings, and evaluating the implementation process as well as its outcomes to determine success and failure, and adjust accordingly. Process models, explanatory theories, and evaluation frameworks are used in D&IS to develop implementation strategies, identify implementation outcomes, and design studies to evaluate these outcomes. In breast cancer control and management, research has been translated into evidence-based, resource-stratified guidelines by the Breast Health Global Initiative and others. D&IS should be leveraged to optimize the implementation of these guidelines, and other evidence-based interventions, into practice across the breast cancer care continuum, from optimizing public education to promoting early detection, increasing guideline-concordant clinical practice among providers, and analyzing and addressing barriers and facilitators in health care systems. Stakeholder engagement through processes such as co-creation is critical. In this article, the authors have provided a primer on the contribution of D&IS to phased implementation of global breast cancer control programs, provided 2 case examples of ongoing D&IS research projects in Tanzania, and concluded with recommendations for best practices for researchers undertaking this work.
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Affiliation(s)
- Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Rebecca J DeBoer
- Global Cancer Program, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California
| | - Anne Ng'ang'a
- National Cancer Control Program, Ministry of Health, Nairobi, Kenya
| | - Bryan J Weiner
- Department of Global Health, University of Washington, Seattle, Washington
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Abstract
Importance The coronavirus disease 2019 (COVID-19) pandemic has forced oncology clinicians and administrators in the United States to set priorities for cancer care owing to resource constraints. As oncology practices adapt to a contracted health care system, expertise gained from partnerships in low-resource settings can be used for guidance. This article provides a primer on priority setting in oncology and ethical guidance based on lessons learned from experience with cancer care priority setting in low-resource settings. Observations Lessons learned from real-world experiences are myriad. First, in the setting of limited resources, a utilitarian approach to maximizing survival benefit should guide decision-making. Second, conflicting principles will often arise among stakeholders and decision makers. Third, fair decision-making procedures should be established to ensure moral legitimacy and accountability. Fourth, proactive safeguards must be implemented to protect vulnerable individuals, or disparities in cancer treatment and outcomes will only widen further. Fifth, communication with patients and families about priority setting decisions should be intentional and standardized. Sixth, moral distress among clinicians must be addressed to avoid burnout during a time when resilience is critical. Conclusions and Relevance Although the need to triage cancer care may be new to those who underwent training and now practice oncology in high-resource settings, it is familiar for those who practice in low- and middle-income countries. Oncologists in the United States facing unprecedented decisions about prioritization can draw on ethical frameworks and lessons learned from real-world cancer care priority setting in resource-constrained environments.
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Affiliation(s)
- Rebecca J DeBoer
- Division of Hematology/Oncology, University of California, San Francisco.,UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Temidayo A Fadelu
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Katherine Van Loon
- Division of Hematology/Oncology, University of California, San Francisco.,UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
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15
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Luhar R, Nyagabona SK, Tarimo E, Said M, Selekwa M, Meena SS, Mushi B, Mvungi N, Siu S, Ngoma M, Van Loon K, Ndumbalo J, DeBoer RJ. Implementation of Tanzania’s National Cancer Treatment Guidelines: A Qualitative Approach to Clinical Systems. JCO Glob Oncol 2020. [DOI: 10.1200/go.20.34000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE In response to the increasing burden of cancer in Tanzania, the Tanzanian Ministry of Health Community Development, Gender, Elderly, and Children plans to launch their first National Cancer Treatment Guidelines. These guidelines will provide an opportunity to improve and standardize care at Ocean Road Cancer Institute (ORCI), the national cancer center, where previous data suggest that patients do not consistently receive standard treatment. A theory-informed implementation strategy will be conducted to facilitate the routine use of guidelines among health care providers at ORCI. As part of the needs assessment for this effort, this study explored the barriers to and facilitators of guideline-concordant care at ORCI. METHODS We conducted three focus groups with participants stratified by profession, which included oncologists, radiotherapists, oncology residents, and nurses. A discussion guide was used to generate discussion about multiple aspects of current clinical processes at ORCI. Audio recordings were transcribed and translated to English, and data were analyzed using the framework method. RESULTS A total of 21 participants helped identify institutional and systemic factors that were internal and external to the clinical systems at ORCI that may affect guideline-concordant care. These can be categorized into the following: strengths and facilitators, barriers, and suggestions for improvement. Internal facilitators include multidisciplinary patient management, government-sponsored free cancer care, community engagement, and providers’ motivation for continuous learning and improvement. Internal barriers include interdepartmental and interinstitutional communication gaps, resource limitations for specialized services, high patient volumes, and patient misconceptions and nonadherence. Participants offered many practical suggestions for improving clinical systems at ORCI. CONCLUSION Our results highlight several barriers and facilitators within and outside of the clinical systems at ORCI that may affect the uptake of the National Cancer Treatment Guidelines. Findings have been used to recommend quality improvement and environmental restructuring measures at ORCI that will inform the broader guideline implementation strategy.
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Affiliation(s)
- Rohan Luhar
- University of California, San Francisco, San Francisco, CA
| | - Sarah K. Nyagabona
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Edith Tarimo
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Mwamvita Said
- Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | - Msiba Selekwa
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Beatrice Mushi
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Sadiq Siu
- Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | - Mamsau Ngoma
- Ocean Road Cancer Institute, Dar es Salaam, Tanzania
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Ndumbalo J, Mvungi N, Meena S, Ngoma M, Mseti M, Buckle G, Van Loon K, DeBoer RJ, Mwaiselage J. Development of Tanzania’s First National Cancer Treatment Guidelines. JCO Glob Oncol 2020. [DOI: 10.1200/go.20.30000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Tanzania and other low-income countries face a growing burden of cancer and a pressing need to strengthen cancer care delivery systems. The overall case fatality from cancer is disproportionately higher in low-income countries, and adherence to standard treatment guidelines is a critical component of addressing disparities in outcomes. In 2017, Tanzania’s Ministry of Health, Community Development, Gender, Elderly, and Children (MOHCDGEC) commissioned leaders at Ocean Road Cancer Institute to develop Tanzania’s first National Cancer Treatment Guidelines. METHODS In 2017, we convened 90 stakeholders from 15 institutions in Tanzania to form 10 different technical working groups (TWGs). TWGs were organized according to disease-specific categories and were composed of representatives from relevant disciplines, including surgeons, gynecologists, pediatricians, radiologists, pathologists, oncologists, social workers, dieticians, and nurses. Each TWG conducted a review of the current literature and prepared a summary of the epidemiology, diagnostic, and staging procedures; options for management; and essential medicines currently available in Tanzania. In 2018, after multiple revisions and meetings of each TWG, the guidelines underwent an external review with 2 oncologists from Tanzania participating in consultations with approximately 30 disease-specific experts at the University of California, San Francisco. RESULTS Guidelines were developed for a total of 70 diseases. The guidelines are intended to be facilitative, enabling, and providing the basis for the attainment of high standards in the management of cancers in a resource-constrained setting. Guidelines were formatted for dissemination in both hard copy and soft copy using the AgileMD platform. CONCLUSION In February 2020, Tanzania’s MOHCDGEC disseminated its first-ever National Cancer Treatment Guidelines. After dissemination, MOHCDGEC will implement a monitoring and evaluation strategy that ensures and promotes the use of the guidelines. We have developed a theory-informed implementation strategy that focuses on education, workflow modifications, and behavior change that will be piloted at Ocean Road Cancer Institute.
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Affiliation(s)
| | | | - Stephen Meena
- Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | - Mamsau Ngoma
- Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | - Mark Mseti
- Ocean Road Cancer Institute, Dar es Salaam, Tanzania
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DeBoer RJ, Shyirambere C, Driscoll CD, Butera Y, Paciorek A, Ruhangaza D, Fadelu TA, Umwizerwa A, Bigirimana JB, Muhayimana C, Nguyen C, Park PH, Mpunga T, Lehmann L, Shulman LN. Treatment of Hodgkin Lymphoma With ABVD Chemotherapy in Rural Rwanda: A Model for Cancer Care Delivery Implementation. JCO Glob Oncol 2020; 6:1093-1102. [PMID: 32678711 PMCID: PMC7392734 DOI: 10.1200/go.20.00088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2020] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Hodgkin lymphoma (HL) is highly curable in high-income countries (HICs), yet many patients around the world do not have access to therapy. In 2012, cancer care was established at a rural district hospital in Rwanda through international collaboration, and a treatment protocol using doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) without radiotherapy was implemented. METHODS We conducted a retrospective cohort study of all patients with confirmed HL seen at Butaro Hospital from 2012 to 2018 to evaluate quality indicators and clinical outcomes. RESULTS Eighty-five patients were included (median age, 16.8 years; interquartile range, 11.0-30.5 years). Ten (12%) were HIV positive. Most had B symptoms (70%) and advanced stage (56%) on examination and limited imaging. Of 21 specimens evaluated for Epstein-Barr virus, 14 (67%) were positive. Median time from biopsy to treatment was 6.0 weeks. Of 73 patients who started ABVD, 54 (74%) completed 6 cycles; the leading reasons for discontinuation were treatment abandonment and death. Median dose intensity of ABVD was 92%. Of 77 evaluable patients, 33 (43%) are in clinical remission, 27 (36%) are deceased, and 17 (22%) were lost to follow-up; 3-year survival estimate is 63% (95% CI, 50% to 74%). Poorer performance status, advanced stage, B symptoms, anemia, dose intensity < 85%, and treatment discontinuation were associated with worse survival. CONCLUSION Treating HL with standard chemotherapy in a low-resource setting is feasible. Most patients who completed treatment experienced a clinically significant remission with this approach. Late presentation, treatment abandonment, and loss to follow-up contribute to the discrepancy in survival compared with HICs. A strikingly younger age distribution in our cohort compared with HICs suggests biologic differences and warrants further investigation.
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Affiliation(s)
- Rebecca J. DeBoer
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | | | | | - Yvan Butera
- Republic of Rwanda Ministry of Health, Kigali, Rwanda
| | - Alan Paciorek
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | | | | | - Aline Umwizerwa
- Partners In Health/Inshuti Mu Buzima, Burera District, Rwanda
| | | | | | - Cam Nguyen
- Partners In Health/Inshuti Mu Buzima, Burera District, Rwanda
| | | | | | - Leslie Lehmann
- Dana-Farber/Boston Children’s Hospital Cancer Center, Boston, MA
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DeBoer RJ, Ndumbalo J, Meena S, Ngoma MT, Mvungi N, Siu S, Selekwa M, Nyagabona SK, Luhar R, Buckle G, Lin TK, Breithaupt L, Kennell-Heiling S, Mushi B, Philipo GS, Mmbaga EJ, Mwaiselage J, Van Loon K. Development of a theory-driven implementation strategy for cancer management guidelines in sub-Saharan Africa. Implement Sci Commun 2020; 1:24. [PMID: 32885183 PMCID: PMC7427872 DOI: 10.1186/s43058-020-00007-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/09/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Despite recent international efforts to develop resource-stratified clinical practice guidelines for cancer, there has been little research to evaluate the best strategies for dissemination and implementation in low- and middle-income countries (LMICs). Guideline publication alone is insufficient. Extensive research has shown that structured, multifaceted implementation strategies that target barriers to guideline use are most likely to improve adherence; however, most of this research has been conducted in high-income countries. There is a pressing need to develop and evaluate guideline implementation strategies for cancer management in LMICs in order to address stark disparities in cancer outcomes. METHODS In preparation for the launch of Tanzania's first National Cancer Treatment Guidelines, we developed a theory-driven implementation strategy for guideline-based practice at Ocean Road Cancer Institute (ORCI). Here, we use the Intervention Mapping framework to provide a detailed stepwise description of our process. First, we conducted a needs assessment to identify barriers and facilitators to guideline-based practice at ORCI. Second, we defined both proximal and performance objectives for our implementation strategy. Third, we used the Capability, Opportunity, Motivation and Behavior/Behavior Change Wheel (COM-B/BCW) framework to categorize the barriers and facilitators, choose behavior change techniques most likely to overcome targeted barriers and leverage facilitators, and select a feasible mode of delivery for each technique. Fourth, we organized these modes of delivery into a phased implementation strategy. Fifth, we operationalized each component of the strategy. Sixth, we identified the indicators of the process, outcome, and impact of our intervention and developed an evaluation plan to measure them using a mixed methods approach. DISCUSSION We developed a robust, multifaceted guideline implementation strategy derived from a prominent behavior change theory for use in Tanzania. The barriers and strategies we generated are consistent with those well established in the literature, enhancing the validity and generalizability of our process and results. Through our rigorous evaluation plan and systematic account of modifications and adaptations, we will characterize the transferability of "proven" guideline implementation strategies to LMICs. We hope that by describing our process in detail, others may endeavor to replicate it, meeting a widespread need for dedicated efforts to implement cancer guidelines in LMICs.
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Affiliation(s)
- Rebecca J. DeBoer
- Global Cancer Program, University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center, San Francisco, CA USA
| | | | - Stephen Meena
- Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | | | | | - Sadiq Siu
- Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | - Msiba Selekwa
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Sarah K. Nyagabona
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Rohan Luhar
- Global Cancer Program, University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center, San Francisco, CA USA
| | - Geoffrey Buckle
- Global Cancer Program, University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center, San Francisco, CA USA
| | - Tracy Kuo Lin
- Global Cancer Program, University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center, San Francisco, CA USA
| | - Lindsay Breithaupt
- Global Cancer Program, University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center, San Francisco, CA USA
| | - Stephanie Kennell-Heiling
- Global Cancer Program, University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center, San Francisco, CA USA
| | - Beatrice Mushi
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Elia J. Mmbaga
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Katherine Van Loon
- Global Cancer Program, University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center, San Francisco, CA USA
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DeBoer RJ, Ndumbalo J, Buckle G, Meena S, Lin T, Selekwa M, Bialous SA, Dharsee N, Purcell G, Moshi B, Zhang L, Mmbaga E, Van Loon K, Mwaiselage J. Implementation of Guideline-Based Clinical Practice at Ocean Road Cancer Institute in Tanzania. J Glob Oncol 2018. [DOI: 10.1200/jgo.18.10130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Low-income countries (LICs) face a growing cancer burden and a pressing need to strengthen cancer care delivery systems. Overall case fatality from cancer is estimated to be 30% higher in LICs than in high-income countries, and adherence to standard treatment guidelines is a critical component of addressing this disparity. Despite several recent international efforts to develop resource-stratified cancer treatment guidelines, little research has been done on their implementation. In 2018, Tanzania’s Ministry of Health will publish a new set of national cancer treatment guidelines for all cancers. The objective of this work is to evaluate the feasibility, adoption, and effectiveness of a theory-informed implementation strategy to facilitate the uptake of guideline-based clinical practice at the national referral center, Ocean Road Cancer Institute (ORCI). Our central hypothesis is that this implementation strategy will be undertaken with fidelity and context-appropriate adaptations and will effectively increase guideline-concordant treatment at ORCI. Methods Qualitative data demonstrate that major barriers to guideline-based practice at ORCI include a lack of familiarity with standard treatment guidelines and a culture that prioritizes experience-based expertise over guidelines. We developed a multifaceted intervention to target these barriers using the Capability, Opportunity, Motivation and Behavior/Behavior Change Wheel framework. Our intervention has three phases: distribution of national cancer treatment guidelines in hard and soft copy, with an accompanying publicity campaign; dedicated multidisciplinary trainings for oncology providers and implementation champions; and reinforcement strategies, such as environmental restructuring and point-of-care clinical forms, to promote guideline-based practice. We will use a pre–post design that uses a mixed-methods approach to measure process and outcomes, including clinical data collection, survey administration, and qualitative interviews, focus groups, and field observation. Conclusion In Tanzania and other LICs, shifting to guideline-based practice entails a change in clinical culture and behavior, and guideline publication alone is unlikely to result in meaningful change. A theory-informed implementation strategy is the optimal way to ensure the adoption and sustained use of guideline-based practice. Systematic evaluation will allow us to make necessary modifications, disseminate findings, and advance knowledge in the field of cancer treatment guideline implementation in LICs. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . Li Zhang Consulting or Advisory Role: Dendreon, Unity
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Affiliation(s)
- Rebecca J. DeBoer
- Rebecca J. DeBoer, Geoffrey Buckle, Tracy Lin, Stella Aguinaga Bialous, Gabrielle Purcell, Li Zhang, and Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Jerry Ndumbalo, Stephen Meena, Nazima Dharsee, and Julius Mwaiselage, Ocean Road Cancer Institute; and Msiba Selekwa, Beatrice Moshi, and Elia Mmbaga, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jerry Ndumbalo
- Rebecca J. DeBoer, Geoffrey Buckle, Tracy Lin, Stella Aguinaga Bialous, Gabrielle Purcell, Li Zhang, and Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Jerry Ndumbalo, Stephen Meena, Nazima Dharsee, and Julius Mwaiselage, Ocean Road Cancer Institute; and Msiba Selekwa, Beatrice Moshi, and Elia Mmbaga, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Geoffrey Buckle
- Rebecca J. DeBoer, Geoffrey Buckle, Tracy Lin, Stella Aguinaga Bialous, Gabrielle Purcell, Li Zhang, and Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Jerry Ndumbalo, Stephen Meena, Nazima Dharsee, and Julius Mwaiselage, Ocean Road Cancer Institute; and Msiba Selekwa, Beatrice Moshi, and Elia Mmbaga, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Stephen Meena
- Rebecca J. DeBoer, Geoffrey Buckle, Tracy Lin, Stella Aguinaga Bialous, Gabrielle Purcell, Li Zhang, and Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Jerry Ndumbalo, Stephen Meena, Nazima Dharsee, and Julius Mwaiselage, Ocean Road Cancer Institute; and Msiba Selekwa, Beatrice Moshi, and Elia Mmbaga, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Tracy Lin
- Rebecca J. DeBoer, Geoffrey Buckle, Tracy Lin, Stella Aguinaga Bialous, Gabrielle Purcell, Li Zhang, and Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Jerry Ndumbalo, Stephen Meena, Nazima Dharsee, and Julius Mwaiselage, Ocean Road Cancer Institute; and Msiba Selekwa, Beatrice Moshi, and Elia Mmbaga, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Msiba Selekwa
- Rebecca J. DeBoer, Geoffrey Buckle, Tracy Lin, Stella Aguinaga Bialous, Gabrielle Purcell, Li Zhang, and Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Jerry Ndumbalo, Stephen Meena, Nazima Dharsee, and Julius Mwaiselage, Ocean Road Cancer Institute; and Msiba Selekwa, Beatrice Moshi, and Elia Mmbaga, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Stella Aguinaga Bialous
- Rebecca J. DeBoer, Geoffrey Buckle, Tracy Lin, Stella Aguinaga Bialous, Gabrielle Purcell, Li Zhang, and Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Jerry Ndumbalo, Stephen Meena, Nazima Dharsee, and Julius Mwaiselage, Ocean Road Cancer Institute; and Msiba Selekwa, Beatrice Moshi, and Elia Mmbaga, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Nazima Dharsee
- Rebecca J. DeBoer, Geoffrey Buckle, Tracy Lin, Stella Aguinaga Bialous, Gabrielle Purcell, Li Zhang, and Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Jerry Ndumbalo, Stephen Meena, Nazima Dharsee, and Julius Mwaiselage, Ocean Road Cancer Institute; and Msiba Selekwa, Beatrice Moshi, and Elia Mmbaga, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Gabrielle Purcell
- Rebecca J. DeBoer, Geoffrey Buckle, Tracy Lin, Stella Aguinaga Bialous, Gabrielle Purcell, Li Zhang, and Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Jerry Ndumbalo, Stephen Meena, Nazima Dharsee, and Julius Mwaiselage, Ocean Road Cancer Institute; and Msiba Selekwa, Beatrice Moshi, and Elia Mmbaga, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Beatrice Moshi
- Rebecca J. DeBoer, Geoffrey Buckle, Tracy Lin, Stella Aguinaga Bialous, Gabrielle Purcell, Li Zhang, and Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Jerry Ndumbalo, Stephen Meena, Nazima Dharsee, and Julius Mwaiselage, Ocean Road Cancer Institute; and Msiba Selekwa, Beatrice Moshi, and Elia Mmbaga, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Li Zhang
- Rebecca J. DeBoer, Geoffrey Buckle, Tracy Lin, Stella Aguinaga Bialous, Gabrielle Purcell, Li Zhang, and Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Jerry Ndumbalo, Stephen Meena, Nazima Dharsee, and Julius Mwaiselage, Ocean Road Cancer Institute; and Msiba Selekwa, Beatrice Moshi, and Elia Mmbaga, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Elia Mmbaga
- Rebecca J. DeBoer, Geoffrey Buckle, Tracy Lin, Stella Aguinaga Bialous, Gabrielle Purcell, Li Zhang, and Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Jerry Ndumbalo, Stephen Meena, Nazima Dharsee, and Julius Mwaiselage, Ocean Road Cancer Institute; and Msiba Selekwa, Beatrice Moshi, and Elia Mmbaga, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Katherine Van Loon
- Rebecca J. DeBoer, Geoffrey Buckle, Tracy Lin, Stella Aguinaga Bialous, Gabrielle Purcell, Li Zhang, and Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Jerry Ndumbalo, Stephen Meena, Nazima Dharsee, and Julius Mwaiselage, Ocean Road Cancer Institute; and Msiba Selekwa, Beatrice Moshi, and Elia Mmbaga, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Julius Mwaiselage
- Rebecca J. DeBoer, Geoffrey Buckle, Tracy Lin, Stella Aguinaga Bialous, Gabrielle Purcell, Li Zhang, and Katherine Van Loon, University of California, San Francisco, San Francisco, CA; Jerry Ndumbalo, Stephen Meena, Nazima Dharsee, and Julius Mwaiselage, Ocean Road Cancer Institute; and Msiba Selekwa, Beatrice Moshi, and Elia Mmbaga, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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DeBoer RJ, Driscoll CD, Butera Y, Bigirimana JB, Muhayimana C, Fadelu T, Park PH, Shyirambere C, Uwizeye FR, Mpunga T, Lehmann L, Shulman LN. Report on the Treatment of Hodgkin Lymphoma With ABVD Chemotherapy at Two Rural District Hospitals in Rwanda. J Glob Oncol 2016. [DOI: 10.1200/jgo.2016.003764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract 34 Background: While Hodgkin lymphoma (HL) is highly curable with standard chemotherapy in high resource settings, there are few reports of HL treatment in low resource settings. In Rwanda, a treatment protocol using six cycles of ABVD chemotherapy (doxorubicin, bleomycin, vinblastine, dacarbazine) without radiotherapy has been implemented at two rural district hospitals. Here we report on the feasibility of this approach, our patient characteristics, and preliminary outcomes. Methods: We conducted a retrospective cohort study of all patients with biopsy confirmed HL seen at Butaro and Rwinkwavu hospitals between June 2012 and August 2015. Data was extracted from clinical charts and analyzed using descriptive statistics. Results: 43 HL patients were seen at Butaro (n=38) and Rwinkwavu (n=5); 58% male, median age 17 (range 4-54). Five (12%) were HIV positive. Of 22 patients with biopsy specimens evaluated for EBV, 12 (55%) were positive, 9 (41%) negative, and one indeterminate. Most patients were staged with chest x-ray (79%); fewer had liver ultrasound (33%) or CT (9%). With that, Ann Arbor stages were I (28%), II (23%), III (21%), IV (21%), and undetermined (7%). Of 39 patients who started ABVD, 25 (64%) completed all 6 cycles. Median time to completion of the 24 week ABVD regimen was 26.1 weeks (IQR 25-27); 26 patients (67%) experienced at least one treatment delay. Dose reductions were rare. At the time of data extraction, 5 (12%) were still on treatment, 18 (43%) in remission, 2 (5%) alive with relapse, 15 (35%) deceased, and 2 (5%) lost to follow up. Conclusions: Here we demonstrate the feasibility of treating HL with standard chemotherapy in a low resource setting through international partnership. Our preliminary results suggest that a majority of patients who complete treatment may experience a clinically significant remission with this approach. Further data analysis will identify areas for improvement with the hope of increasing sustained remissions. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST: No COIs from the authors.
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Affiliation(s)
- Rebecca J. DeBoer
- Rebecca J. DeBoer, University of Chicago Center for Global Health (United States); Caitlin D. Driscoll, Icahn School of Medicine at Mount Sinai (United States); Yvan Butera, University of Global Health Equity (Rwanda); Jean Bosco Bigirimana, Paul H. Park, Cyprien Shyirambere, and Frank Regis Uwizeye, Partners In Health / Inshuti Mu Buzima (Rwanda); Clemence Muhayimana and Tharcisse Mpunga, Rwanda Ministry of Health (Rwanda); Temidayo Fadelu and Leslie Lehmann, Dana Farber Cancer Institute (United States
| | - Caitlin D. Driscoll
- Rebecca J. DeBoer, University of Chicago Center for Global Health (United States); Caitlin D. Driscoll, Icahn School of Medicine at Mount Sinai (United States); Yvan Butera, University of Global Health Equity (Rwanda); Jean Bosco Bigirimana, Paul H. Park, Cyprien Shyirambere, and Frank Regis Uwizeye, Partners In Health / Inshuti Mu Buzima (Rwanda); Clemence Muhayimana and Tharcisse Mpunga, Rwanda Ministry of Health (Rwanda); Temidayo Fadelu and Leslie Lehmann, Dana Farber Cancer Institute (United States
| | - Yvan Butera
- Rebecca J. DeBoer, University of Chicago Center for Global Health (United States); Caitlin D. Driscoll, Icahn School of Medicine at Mount Sinai (United States); Yvan Butera, University of Global Health Equity (Rwanda); Jean Bosco Bigirimana, Paul H. Park, Cyprien Shyirambere, and Frank Regis Uwizeye, Partners In Health / Inshuti Mu Buzima (Rwanda); Clemence Muhayimana and Tharcisse Mpunga, Rwanda Ministry of Health (Rwanda); Temidayo Fadelu and Leslie Lehmann, Dana Farber Cancer Institute (United States
| | - Jean Bosco Bigirimana
- Rebecca J. DeBoer, University of Chicago Center for Global Health (United States); Caitlin D. Driscoll, Icahn School of Medicine at Mount Sinai (United States); Yvan Butera, University of Global Health Equity (Rwanda); Jean Bosco Bigirimana, Paul H. Park, Cyprien Shyirambere, and Frank Regis Uwizeye, Partners In Health / Inshuti Mu Buzima (Rwanda); Clemence Muhayimana and Tharcisse Mpunga, Rwanda Ministry of Health (Rwanda); Temidayo Fadelu and Leslie Lehmann, Dana Farber Cancer Institute (United States
| | - Clemence Muhayimana
- Rebecca J. DeBoer, University of Chicago Center for Global Health (United States); Caitlin D. Driscoll, Icahn School of Medicine at Mount Sinai (United States); Yvan Butera, University of Global Health Equity (Rwanda); Jean Bosco Bigirimana, Paul H. Park, Cyprien Shyirambere, and Frank Regis Uwizeye, Partners In Health / Inshuti Mu Buzima (Rwanda); Clemence Muhayimana and Tharcisse Mpunga, Rwanda Ministry of Health (Rwanda); Temidayo Fadelu and Leslie Lehmann, Dana Farber Cancer Institute (United States
| | - Temidayo Fadelu
- Rebecca J. DeBoer, University of Chicago Center for Global Health (United States); Caitlin D. Driscoll, Icahn School of Medicine at Mount Sinai (United States); Yvan Butera, University of Global Health Equity (Rwanda); Jean Bosco Bigirimana, Paul H. Park, Cyprien Shyirambere, and Frank Regis Uwizeye, Partners In Health / Inshuti Mu Buzima (Rwanda); Clemence Muhayimana and Tharcisse Mpunga, Rwanda Ministry of Health (Rwanda); Temidayo Fadelu and Leslie Lehmann, Dana Farber Cancer Institute (United States
| | - Paul H. Park
- Rebecca J. DeBoer, University of Chicago Center for Global Health (United States); Caitlin D. Driscoll, Icahn School of Medicine at Mount Sinai (United States); Yvan Butera, University of Global Health Equity (Rwanda); Jean Bosco Bigirimana, Paul H. Park, Cyprien Shyirambere, and Frank Regis Uwizeye, Partners In Health / Inshuti Mu Buzima (Rwanda); Clemence Muhayimana and Tharcisse Mpunga, Rwanda Ministry of Health (Rwanda); Temidayo Fadelu and Leslie Lehmann, Dana Farber Cancer Institute (United States
| | - Cyprien Shyirambere
- Rebecca J. DeBoer, University of Chicago Center for Global Health (United States); Caitlin D. Driscoll, Icahn School of Medicine at Mount Sinai (United States); Yvan Butera, University of Global Health Equity (Rwanda); Jean Bosco Bigirimana, Paul H. Park, Cyprien Shyirambere, and Frank Regis Uwizeye, Partners In Health / Inshuti Mu Buzima (Rwanda); Clemence Muhayimana and Tharcisse Mpunga, Rwanda Ministry of Health (Rwanda); Temidayo Fadelu and Leslie Lehmann, Dana Farber Cancer Institute (United States
| | - Frank Regis Uwizeye
- Rebecca J. DeBoer, University of Chicago Center for Global Health (United States); Caitlin D. Driscoll, Icahn School of Medicine at Mount Sinai (United States); Yvan Butera, University of Global Health Equity (Rwanda); Jean Bosco Bigirimana, Paul H. Park, Cyprien Shyirambere, and Frank Regis Uwizeye, Partners In Health / Inshuti Mu Buzima (Rwanda); Clemence Muhayimana and Tharcisse Mpunga, Rwanda Ministry of Health (Rwanda); Temidayo Fadelu and Leslie Lehmann, Dana Farber Cancer Institute (United States
| | - Tharcisse Mpunga
- Rebecca J. DeBoer, University of Chicago Center for Global Health (United States); Caitlin D. Driscoll, Icahn School of Medicine at Mount Sinai (United States); Yvan Butera, University of Global Health Equity (Rwanda); Jean Bosco Bigirimana, Paul H. Park, Cyprien Shyirambere, and Frank Regis Uwizeye, Partners In Health / Inshuti Mu Buzima (Rwanda); Clemence Muhayimana and Tharcisse Mpunga, Rwanda Ministry of Health (Rwanda); Temidayo Fadelu and Leslie Lehmann, Dana Farber Cancer Institute (United States
| | - Leslie Lehmann
- Rebecca J. DeBoer, University of Chicago Center for Global Health (United States); Caitlin D. Driscoll, Icahn School of Medicine at Mount Sinai (United States); Yvan Butera, University of Global Health Equity (Rwanda); Jean Bosco Bigirimana, Paul H. Park, Cyprien Shyirambere, and Frank Regis Uwizeye, Partners In Health / Inshuti Mu Buzima (Rwanda); Clemence Muhayimana and Tharcisse Mpunga, Rwanda Ministry of Health (Rwanda); Temidayo Fadelu and Leslie Lehmann, Dana Farber Cancer Institute (United States
| | - Lawrence N. Shulman
- Rebecca J. DeBoer, University of Chicago Center for Global Health (United States); Caitlin D. Driscoll, Icahn School of Medicine at Mount Sinai (United States); Yvan Butera, University of Global Health Equity (Rwanda); Jean Bosco Bigirimana, Paul H. Park, Cyprien Shyirambere, and Frank Regis Uwizeye, Partners In Health / Inshuti Mu Buzima (Rwanda); Clemence Muhayimana and Tharcisse Mpunga, Rwanda Ministry of Health (Rwanda); Temidayo Fadelu and Leslie Lehmann, Dana Farber Cancer Institute (United States
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