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Fadelu TA, Buswell L, Anderson BO. Improving Adherence to Adjuvant Endocrine Therapy in Sub-Saharan Africa: Challenges and Innovative Nurse-Driven Solutions. Oncologist 2022; 27:607-609. [PMID: 35699645 PMCID: PMC9355825 DOI: 10.1093/oncolo/oyac112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 05/11/2022] [Indexed: 11/21/2022] Open
Affiliation(s)
- Temidayo A Fadelu
- Center for Global Cancer Medicine, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Lori Buswell
- Center for Global Cancer Medicine, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Benjamin O Anderson
- World Health Organization, Geneva, Switzerland.,Department of Surgery and Global Health-Medicine, University of Washington, Seattle, WA, USA
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Fadelu TA, Erfani P, Lormil J, Damuse R, Pierre V, Slater S, Triedman SA, Shulman LN, Rebbeck TR. Gaps in completion and timeliness of breast surgery and adjuvant therapy: a retrospective cohort of Haitian patients with nonmetastatic breast cancer. Breast Cancer Res Treat 2022; 193:625-635. [PMID: 35420316 PMCID: PMC9114044 DOI: 10.1007/s10549-022-06582-8] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/27/2022] [Indexed: 11/28/2022]
Abstract
Background There are limited data on breast surgery completion rates and prevalence of care-continuum delays in breast cancer treatment programs in low-income countries. Methods This study analyzes treatment data in a retrospective cohort of 312 female patients with non-metastatic breast cancer in Haiti. Descriptive statistics were used to summarize patient characteristics; treatments received; and treatment delays of > 12 weeks. Multivariate logistic regressions were performed to identify factors associated with receiving surgery and with treatment delays. Exploratory multivariate survival analysis examined the association between surgery delays and disease-free survival (DFS). Results Of 312 patients, 249 (80%) completed breast surgery. The odds ratio (OR) for surgery completion for urban vs. rural dwellers was 2.15 (95% confidence interval [CI]: 1.19–3.88) and for those with locally advanced vs. early-stage disease was 0.34 (95%CI: 0.16–0.73). Among the 223 patients with evaluable surgery completion timelines, 96 (43%) experienced delays. Of the 221 patients eligible for adjuvant chemotherapy, 141 (64%) received adjuvant chemotherapy, 66 of whom (47%) experienced delays in chemotherapy initiation. Presentation in the later years of the cohort (2015–2016) was associated with lower rates of surgery completion (75% vs. 85%) and with delays in adjuvant chemotherapy initiation (OR [95%CI]: 3.25 [1.50–7.06]). Exploratory analysis revealed no association between surgical delays and DFS. Conclusion While majority of patients obtained curative-intent surgery, nearly half experienced delays in surgery and adjuvant chemotherapy initiation. Although our study was not powered to identify an association between surgical delays and DFS, these delays may negatively impact long-term outcomes. Supplementary Information The online version contains supplementary material available at 10.1007/s10549-022-06582-8.
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Affiliation(s)
- Temidayo A Fadelu
- Dana-Farber Cancer Institute, 450 Brookline Avenue, MA- 1B-17, Boston, MA, 02215, USA. .,Harvard Medical School, Boston, MA, USA.
| | - Parsa Erfani
- Harvard Medical School, Boston, MA, USA.,Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Joarly Lormil
- Hôpital Universitaire de Mirebalais, Mirebalais, Haiti.,Zanmi Lasante, 8A, Santo 22H,, Croix-des-Bouquet, Haiti
| | - Ruth Damuse
- Hôpital Universitaire de Mirebalais, Mirebalais, Haiti.,Zanmi Lasante, 8A, Santo 22H,, Croix-des-Bouquet, Haiti
| | - Viergela Pierre
- Hôpital Universitaire de Mirebalais, Mirebalais, Haiti.,Zanmi Lasante, 8A, Santo 22H,, Croix-des-Bouquet, Haiti
| | - Sarah Slater
- Dana-Farber Cancer Institute, 450 Brookline Avenue, MA- 1B-17, Boston, MA, 02215, USA.,Harvard Medical School, Boston, MA, USA
| | - Scott A Triedman
- Dana-Farber Cancer Institute, 450 Brookline Avenue, MA- 1B-17, Boston, MA, 02215, USA.,The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Lawrence N Shulman
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Timothy R Rebbeck
- Dana-Farber Cancer Institute, 450 Brookline Avenue, MA- 1B-17, Boston, MA, 02215, USA.,Harvard T.H. Chan School of Public Health, Boston, MA, USA
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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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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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