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Background: Butaro Cancer Center of Excellence (BCCOE) was founded to serve Rwanda's rural low-income population, providing subsidized cancer diagnosis and treatment with transport stipends for the lowest-income patients. We examined whether travel distance to BCCOE was associated with advanced-stage diagnoses and treatment completion., Methods: We conducted a retrospective cohort study using medical record data from BCCOE patients with pathologically-confirmed breast cancer from 2012-2016. Women with no prior surgery were included in the stage analysis; those with non-metastatic disease were included in the treatment analysis. We calculated travel distances using spatial analytic software and used multivariable logistic regression to examine the association of distance and other patient characteristics with late-stage diagnoses and treatment completion within one year of diagnosis., Results: The analytic cohort for stage included 426 patients; 75.1% had late-stage (stage 3 or 4) disease. In univariable analyses, patients residing in BCCOE's surrounding district had a lower proportion of late-stage diagnoses compared to those residing outside the district (57.9% v 76.8%, p = 0.02). In adjusted analyses, odds of late-stage diagnosis were 2.46 (95% CI:1.21-5.12) times higher among those in distance quartile 4 (> 135.8 km) versus 1 (< 55.7 km); the effect of distance was less strong in sensitivity analyses excluding patients from BCCOE's surrounding district. Patients from sectors with > 50% poverty had 2.33 times higher odds of late-stage diagnoses (95% CI:1.07-5.26) relative to those with poverty < 30%. In the treatment completion cohort (n = 348), 49.1% of patients completed surgery and chemotherapy within a year. In adjusted analyses, travel distance and poverty were not linearly associated with treatment completion., Conclusions: At Rwanda's first public cancer facility, sector-level poverty and longer travel distances were associated with late-stage breast cancer diagnoses, but less clearly associated with treatment completion, perhaps partly due to travel stipends provided to the lowest-income individuals undergoing treatment. Our findings support further investigation into wider use of travel stipends to facilitate early diagnosis and treatment completion., Competing Interests: Declarations. Ethics approval and consent to participate: Ethical approval was obtained from the Partners HealthCare Institutional Review Board [2012P002016] (Boston, MA), the Rwanda National Ethics Committee (No 348/RNEC/2012), and the Harvard University Institutional Review Board [IRB20-0699] (Boston, MA). The requirement for informed consent from individuals whose medical records were reviewed for the study was waived. Consent for publication: N/A. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Importance: Limited availability and affordability of cancer drugs contribute to staggering disparities in cancer survival between high-income and low- and middle-income countries (LMICs). As infrastructure for cancer care rapidly develops, there is an urgent need to reduce prices and improve access to cancer medicines in LMICs to advance pharmacoequity globally., Observations: Prior strategies to expand access to cancer medicines in LMICs have primarily relied on charity or differential pricing and have yielded limited results. Policymakers at the World Health Assembly recently proposed several strategies to increase global access to cancer drugs. Reviewing empirical data and lessons learned from medication access programs for HIV, COVID-19, and other infectious diseases, 3 strategies that multilateral organizations can use to reduce prices of cancer drugs in LMICs are discussed herein. These include (1) building regional technology transfer and manufacturing hubs, (2) expanding and streamlining use of compulsory licenses, and (3) implementing global standards for drug price transparency. Counterpoints to the critiques of these policies are critiqued and how programs can use these strategies to build on existing disease-centered initiatives is discussed., Conclusions and Relevance: Lessons learned from the global response to HIV and COVID-19 show that international collaboration and support from the World Health and Trade Organizations can ensure a unified, coordinated agenda for advancing access to care in LMICs. Building on these lessons and implementing similar approaches for cancer drugs can play a critical role in expanding accessibility and affordability of cancer medicines in LMICs. With a growing burden of cancer morbidity and mortality in LMICs, redoubled efforts to deliver essential cancer medications to LMICs would have an immense impact on global cancer control and achieving the United Nations Sustainable Development Goals.

Cancer genetic data from Sub-Saharan African (SSA) are limited. Patients with female breast (fBC), male breast (mBC), and prostate cancer (PC) in Rwanda underwent germline genetic testing and counseling. Demographic and disease-specific information was collected. A multi-cancer gene panel was used to identify germline Pathogenic Variants (PV) and Variants of Uncertain Significance (VUS). 400 patients (201 with BC and 199 with PC) were consented and recruited to the study. Data was available for 342 patients: 180 with BC (175 women and 5 men) and 162 men with PC. PV were observed in 18.3% fBC, 4.3% PC, and 20% mBC. BRCA2 was the most common PV. Among non-PV carriers, 65% had ≥1 VUS: 31.8% in PC and 33.6% in BC (female and male). Our findings highlight the need for germline genetic testing and counseling in cancer management in SSA., Competing Interests: Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Purpose: Procalcitonin (PCT) is an inflammatory marker elevated in bacteremia and bacterial pneumonia. We aimed to assess the real-world diagnostic accuracy of PCT in hospitalized patients with malignancy., Methods: A retrospective cohort of 715 patients with cancer who had PCT measured during 750 admissions was analyzed. Diagnosis of bacteremia was determined using blood culture data. Diagnosis of bacterial pneumonia was based on radiographic infiltrate and/or sputum culture. PCT's performance was assessed using receiver operating characteristic (ROC) curves, sensitivity, and specificity., Results: Patients had bacteremia, bacterial pneumonia, or both during 210 admissions (28%). PCT elevation above 0.5 ng/mL was significantly associated with diagnosed infection in the overall population (p < 0.0001) and in subgroups with solid tumor malignancies (p < 0.0001) and hematologic malignancies (p = 0.008). PCT was associated with infectious status in patients with any metastases, but not those with primary lung cancer, lung metastases, neuroendocrine tumors, febrile neutropenia, or history of bone marrow transplant (BMT). The area under the ROC curve for PCT in the overall population was 0.655. An ideal cutoff of 0.21 ng/mL led to a sensitivity of 60% and specificity of 59%. At cutoffs of 0.5 ng/mL and 0.05 ng/mL, PCT's sensitivity was 39% and 94%, while specificity was 79% and 17%, respectively., Conclusion: In this large cohort of hospitalized oncology patients, PCT elevation was associated with diagnosed bacteremia and/or bacterial pneumonia. However, specificity was limited, and PCT elevation was not associated with diagnosed infection in some subpopulations. While PCT may have some diagnostic utility for hospitalized oncology patients, values must be interpreted cautiously and considering clinical context., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Cancer is an increasing global public health burden. Lately, more emphasis has emerged on the importance of heredity in cancer, mostly driven by the introduction of germline genetic variants-directed therapeutics. It is true that 40% of cancer risk is attributed to modifiable environmental and lifestyle factors; still, 16% of cancers could be heritable, accounting for 2.9 of the 18.1 million cases diagnosed worldwide. At least two third of those will be diagnosed in countries with limited resources-low- and middle-income countries, especially where high rates of consanguine marriage and early age at diagnosis are already prevalent. Both are hallmarks of hereditary cancer. This creates a new opportunity for prevention, early detection, and recently therapeutic intervention. However, this opportunity is challenged by many obstacles along the path to addressing germline testing in patients with cancer in the clinic worldwide. Global collaboration and expertise exchange are important to bridge the knowledge gap and facilitate practical implementation. Adapting existing guidelines and prioritization according to local resources are essential to address the unique needs and overcome the unique barriers of each society.

Introduction: Patient education can facilitate early cancer diagnosis, enhance treatment adherence, and improve outcomes. While there is increasing cancer burden in low- and middle-income countries (LMICs), there is little research to inform successful patient education in these regions. This systematic review summarizes the existing literature on oncology education and evaluation strategies in LMICs, identifies best practices, and highlights areas which require further investigation., Methods: The review was conducted using PRISMA guidelines and an a priori protocol. Four databases (Ovid Medline, Cochrane Libraries, Embase, and Cabi) were searched in December 2021. Two independent reviewers evaluated studies for inclusion. Using a coded data extraction form, information was collected about the study site, intervention characteristics, and evaluation methods., Results: Of the 2047 articles generated in the search, 77 met the inclusion criteria. Twenty-four countries were represented; only 6 studies (8%) were in low-income countries. The most common education methods included technology-based interventions (31, 40%) and visual pamphlets or posters (20, 26%). More than one education method was used in 57 (74%) studies. Nurses were the most frequent educators (25, 33%). An evaluation was included in 74 (96%) studies, though only 41 (55%) studies used a validated tool. Patient knowledge was the most common measured outcome in 35 (47%) studies., Conclusions: There is limited empiric research on oncology patient education in LMICs. The available data show heterogeneity in education approaches and gaps in evaluation. Further research to determine successful patient education and evaluation strategies is urgently needed to improve treatment cancer outcomes in LMICs., (© The Author(s) 2022. Published by Oxford University Press.)

Objective: To compare the financial and time cost of breast cancer biomarker analysis by immunohistochemistry with that by the Xpert ® STRAT4 assay., Methods: We estimated costs (personnel, location, consumables and indirect) and time involved in breast cancer diagnosis at the Butaro Cancer Centre of Excellence, Rwanda, using time-driven activity-based costing. We performed a cost-minimization analysis to compare the cost of biomarker analysis for estrogen receptor, progesterone receptor and human epidermal growth factor receptor-2 status with immunohistochemistry versus STRAT4. We performed sensitivity analyses by altering laboratory-specific parameters for the two methods., Findings: We estimated that breast cancer diagnosis in Rwanda costs 138.29 United States dollars (US$) per patient when conducting biomarker analysis by immunohistochemistry. At a realistic immunohistochemistry antibody utilization efficiency of 70%, biomarker analysis comprises 48.7% (US$ 67.33) of diagnostic costs and takes 33 min. We determined that biomarker analysis with STRAT4 yields a reduction in diagnosis cost of US$ 7.33 (10.9%; 7.33/67.33), and in pathologist and technician time of 20 min (60.6%; 20/33), per patient. Our sensitivity analysis revealed that no cost savings would be made in laboratories with antibody utilization efficiencies over 90%, or where only estrogen and/or progesterone receptor status are assessed; however, such operational efficiencies are unlikely, and more laboratories are pursuing human epidermal growth factor receptor-2 analysis as targeted therapies become increasingly available., Conclusion: Breast cancer biomarker analysis with STRAT4 has the potential to reduce the required human and capital resources in sub-Saharan African laboratories, leading to improved treatment selection and better clinical outcomes., ((c) 2023 The authors; licensee World Health Organization.)

Competing Interests: Michael BatesEmployment: Cepheid/DanaherStock and Other Ownership Interests: Danaher Dan A. MilnerThis author is a member of the JCO Global Oncology Editorial Board. Journal policy recused the author from having any role in the peer review of this manuscript.Employment: Libragem Consulting LLC Timothy R. RebbeckHonoraria: AstraZenecaConsulting or Advisory Role: AstraZeneca Lawrence N. ShulmanThis author is a member of the JCO Global Oncology Editorial Board. Journal policy recused the author from having any role in the peer review of this manuscript.Consulting or Advisory Role: GenentechResearch Funding: Celgene (Inst), Independence Blue Cross (Inst) Temidayo FadeluResearch Funding: Celgene (Inst), Cepheid (Inst)No other potential conflicts of interest were reported.

Purpose: Local researchers must be engaged in research conducted in their populations. However, local authors from low- and middle-income countries are often under-represented in global health journals. This report aims to assess and describe the representation of authors in the Journal of Clinical Oncology Global Oncology ( JCO GO )., Methods: This retrospective cross-sectional study describes data from JCO GO articles published between October 2015 and March 2020. Data were collected on studied countries, authorship position, classified as first, middle, or last, and country of authors' institutional affiliations. Countries were then categorized on the basis of their World Bank region and income classifications. We describe aggregate authorship distribution and distribution by region and income classification. Additionally, we explore the relationships between author's country and studied country., Results: Of the 608 articles identified, 420 (69.1%) studied a single country population. Although articles represented studies from all World Bank regions, the sub-Saharan Africa (SSA) region accounted for the highest number (n = 145; 34.5%). In all other regions except SSA, most of the first (66.7%-100%) and last authors (56.6%-95.2%) had primary institutional affiliations based in the same region as the studied country. However, among articles about SSA countries, SSA first authors (n = 65; 44.8%) and last authors (n = 59; 40.7%) were under-represented. In fact, there were more North American first (n = 74; 51.0%) and last authors (n = 72; 49.6%) than SSA authors. There was higher SSA representation among middle authors (n = 97; 68.8%) in studies from the region. A similar trend was also noted with the under-representation of authors from low-income compared with high-income countries., Conclusion: SSA authors are under-represented in global oncology articles. Concerted strategies are needed to build local capacity, promote meaningful engagement, and foster equity., Competing Interests: Miriam MutebiThis author is a member of the JCO Global Oncology Editorial Board. Journal policy recused the author from having any role in the peer review of this manuscript. Temidayo FadeluResearch Funding: Celgene (Inst), Cepheid (Inst)No other potential conflicts of interest were reported.

Introduction: While travel distance and time are important proxies of physical access to health facilities, obtaining valid measures with an appropriate modelling method remains challenging in many settings. We compared five measures of geographic accessibility in Haiti, producing recommendations that consider available analytic resources and geospatial goals., Methods: Eight public hospitals within the ministry of public health and population were included. We estimated distance and time between hospitals and geographic centroids of Haiti's section communes and population-level accessibility. Geographic feature data were obtained from public administrative databases, academic research databases and government satellites. We used validated geographic information system methods to produce five geographic access measures: (1) Euclidean distance (ED), (2) network distance (ND), (3) network travel time (NTT), (4) AccessMod 5 (AM5) distance (AM5D) and (5) AM5 travel time (AM5TT). Relative ranking of section communes across the measures was assessed using Pearson correlation coefficients, while mean differences were assessed using analysis of variance (ANOVA) and pairwise t-tests., Results: All five geographic access measures were highly correlated (range: 0.78-0.99). Of the distance measures, ED values were consistently the shortest, followed by AM5D values, while ND values were the longest. ND values were as high as 2.3 times ED values. NTT models generally produced longer travel time estimates compared with AM5TT models. ED consistently overestimated population coverage within a given threshold compared with ND and AM5D. For example, population-level accessibility within 15 km of the nearest studied hospital in the Center department was estimated at 68% for ED, 50% for AM5D and 34% for ND., Conclusion: While the access measures were highly correlated, there were significant differences in the absolute measures. Consideration of the benefits and limitations of each geospatial measure together with the intended purpose of the estimates, such as relative proximity of patients or service coverage, are key to guiding appropriate use., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Geographic access to care is an important measure of health equity. In this study, we describe geographic access to cancer care centers (CCCs) in Rwanda with the current facilities providing care and examine how access could change with expanded care infrastructure., Methods: Health facilities included are public hospitals administered by the Rwanda Ministry of Health. The WorldPop Project was used to estimate population distribution, and OpenStreetMap was used to determine travel routes. On the basis of geolocations of the facilities, AccessMod 5 was used to estimate the percentage of the population that live within 1 hour, 2 hours, and 4 hours of CCCs under the current (two facilities) and expanded care (seven facilities) scenarios. Variations in access by region, poverty, and level of urbanization were described., Results: Currently, 13%, 41%, and 85% of Rwandans can access CCCs within one, two, and 4 hours of travel, respectively. With expansion of CCCs to seven facilities, access increases to 37%, 84%, and 99%, respectively. There is a substantial variation in current geographic access by province, with 1-hour access in Kigali at 98%, whereas access in the Western Province is 0%; care expansion could increase 2-hour access in the Western Province from 1% to 71%. Variation in access is also seen across the level of urbanization, with current 1-hour access in urban versus rural areas of 45% and 8%, respectively. Expanded care results in improvement of 1-hour access to 67% and 33%, respectively. Similar trends were also noted across poverty levels., Conclusion: Geographical access to CCCs varies substantially by province, level of urbanization, and poverty. These disparities can be alleviated by strategic care expansion to other tertiary care facilities across Rwanda., Competing Interests: Temidayo FadeluResearch Funding: Celgene (Inst), Cepheid (Inst) Timothy R. RebbeckHonoraria: AstraZeneca (I)Consulting or Advisory Role: AstraZeneca (I) Lawrence N. ShulmanResearch Funding: Celgene (Inst), Independence Blue Cross (Inst)No other potential conflicts of interest were reported.

Breast cancer is the leading cause of cancer morbidity, disability and mortality in women, worldwide. Overall, in 2020, it was the most diagnosed malignancy. Differences in breast cancer mortality have been historically evidenced, as a result of disparities in access to diagnosis, treatment and palliative care. Epidemiologic trends in the last decades display three main patterns of breast cancer mortality: some high-income countries report continuous substantial improvements exceeding 2% annual mortality reduction; however, many low- and middle-income countries (LMICs) have stagnant or even increasing mortality rates. Population-based studies show that investing in breast cancer control, based on a primary health care approach, and expanding the cancer treatment capacity can portend population health benefits, with positive changes of the epidemiological adverse trajectories. Framed as part of the political commitment to the Sustainable Development Goals Agenda, World Health Organization (WHO) has recently launched a global initiative to tackle disparities in breast cancer mortality. The WHO-led Global Breast Cancer Initiative (GBCI) is framed across 3 pillars, to address key determinants of the cancer-related outcomes: health promotion and early detection, timely access to diagnosis and treatment, comprehensive breast cancer treatment, palliative and survivorship care. GBCI is a systematized approach, with the goal to (i) increase the fraction of newly diagnosed invasive cancers being stage 1 or 2 at diagnosis (60% or more), (ii) ensure diagnostic work-up to be completed within 60 days from the first connection with the primary healthcare providers to avoid delays in diagnosis and treatment and (iii) assure 80% or more women with breast cancer to undergo and complete multimodal treatments. GBCI will pursue a comprehensive and multisectoral approach, to deliver population health, social and economic benefits, ultimately intended as an entry point for health system strengthening and for the broader cancer control., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Purpose: Authorship gender disparities persist across academic disciplines, including oncology. However, little is known about global variation in authorship gender distribution., Methods: This retrospective cross-sectional study describes the distribution of author gender as determined from the first name across variables such as authorship position (first, middle, and last), country region, and country income level. The 608 articles with 5,302 authors included in this analysis were published in the Journal of Clinical Oncology Global Oncology , from its inception in October 2015 through March 2020. Primary outcome measure was author gender on the basis of first name probabilities assessed by genderize.io. World Bank classification was used to categorize the country region and income level. Odds ratios were used to describe associations between female last authorship and representation in other authorship positions., Results: Although female authors were in the minority across all authorship positions, they were more under-represented in the last author position with 190 (32.1%) female, compared with 252 (41.4%) female first authors and 1,564 (38.1%) female middle authors. Female authors were most under-represented among authors from low-income countries, where they made up 21.6% of first authors and 9.1% of last authors. Of all the regions, sub-Saharan Africa and South Asia had the lowest percentage of female authors. Compared with articles with male last authors, those with female last authors had odds ratios (95% CI) of 2.2 (1.6 to 3.2) of having female first authors and 1.4 (0.9 to 2.1) of having 50% or more female middle authors., Conclusion: There are wide regional variations in author gender distribution in global oncology. Female authors remain markedly under-represented, especially in lower-income countries, sub-Saharan Africa, and South Asia. Future interventions should be tailored to mitigate these disparities., Competing Interests: Miriam MutebiThis author is a member of the JCO Global Oncology Editorial Board. Journal policy recused the author from having any role in the peer review of this manuscript. Temidayo FadeluResearch Funding: Celgene (Inst), Cepheid (Inst)No other potential conflicts of interest were reported.

Objective: This review will describe the scope of the literature on the cost of breast cancer care in low- and middle-income countries and summate the methodological characteristics and approaches of these economic evaluations., Introduction: In the past decade, there has been global momentum to improve capacity for breast cancer care in low- and middle-income countries, which have higher rates of breast cancer mortality compared to high-income countries. Understanding the cost of delivering breast cancer care in low- and middle-income countries is critical to guide effective cancer care delivery strategies and policy., Inclusion Criteria: Studies that estimate the cost of breast cancer diagnosis and treatment in low- and middle-income countries will be included. Studies not available in English will be excluded., Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Review guidelines will be utilized. The search strategy has been developed in consultation with a medical librarian and will be carried out on five electronic databases from their inception (MEDLINE, Embase, Web of Science, Global Health, WHO Global Index Medicus) as well as in gray literature sources. Two independent reviewers will review all abstracts and titles in the primary screen and full-text articles in the secondary screen. A third reviewer will adjudicate conflicts. One reviewer will perform data extraction. Study demographics, design, and methodological characteristics (such as costing perspective, time horizon, and included cost categories) will be summarized in narrative and tabular formats. The methodological quality of studies will be evaluated using a validated economic evaluation tool., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 JBI.)

Background: Understanding the cost of delivering breast cancer (BC) care in low- and middle-income countries (LMICs) is critical to guide effective care delivery strategies. This scoping review summarizes the scope of literature on the costs of BC care in LMICs and characterizes the methodological approaches of these economic evaluations., Materials and Methods: A systematic literature search was performed in five databases and gray literature up to March 2020. Studies were screened to identify original articles that included a cost outcome for BC diagnosis or treatment in an LMIC. Two independent reviewers assessed articles for eligibility. Data related to study characteristics and methodology were extracted. Study quality was assessed using the Drummond et al. checklist., Results: Ninety-one articles across 38 countries were included. The majority (73%) of studies were published between 2013 and 2020. Low-income countries (2%) and countries in Sub-Saharan Africa (9%) were grossly underrepresented. The majority of studies (60%) used a health care system perspective. Time horizon was not reported in 30 studies (33%). Of the 33 studies that estimated the cost of multiple steps in the BC care pathway, the majority (73%) were of high quality, but studies varied in their inclusion of nonmedical direct and indirect costs., Conclusion: There has been substantial growth in the number of BC economic evaluations in LMICs in the past decade, but there remain limited data from low-income countries, especially those in Sub-Saharan Africa. BC economic evaluations should be prioritized in these countries. Use of existing frameworks for economic evaluations may help achieve comparable, transparent costing analyses., Implications for Practice: There has been substantial growth in the number of breast cancer economic evaluations in low- and middle-income countries (LMICs) in the past decade, but there remain limited data from low-income countries. Breast cancer economic evaluations should be prioritized in low-income countries and in Sub-Saharan Africa. Researchers should strive to use and report a costing perspective and time horizon that captures all costs relevant to the study objective, including those such as direct nonmedical and indirect costs. Use of existing frameworks for economic evaluations in LMICs may help achieve comparable, transparent costing analyses in order to guide breast cancer control strategies., (© 2021 The Authors. The Oncologist published by Wiley Periodicals LLC on behalf of AlphaMed Press.)

Purpose: The COVID-19 pandemic has disrupted cancer care globally. There are limited data of its impact in Africa. This study aims to characterize COVID-19 response strategies and impact of COVID-19 on cancer care and explore misconceptions in Africa., Methods: We conducted a web-based cross-sectional survey of oncology providers in Africa between June and August 2020. Descriptive statistics and comparative analysis by income groups were performed., Results: One hundred twenty-two participants initiated the survey, of which 79 respondents from 18 African countries contributed data. Ninety-four percent (66 of 70) reported country mitigation and suppression strategies, similar across income groups. Unique strategies included courier service and drones for delivery of cancer medications (9 of 70 and 6 of 70, respectively). Most cancer centers remained open, but > 75% providers reported a decrease in patient volume. Not previously reported is the fear of infectivity leading to staff shortages and decrease in patient volumes. Approximately one third reported modifications of all cancer treatment modalities, resulting in treatment delays. A majority of participants reported ≤ 25 confirmed cases (44 of 68, 64%) and ≤ 5 deaths because of COVID-19 (26 of 45, 58%) among patients with cancer. Common misconceptions were that Africans were less susceptible to the virus (53 of 70, 75.7%) and decreased transmission of the virus in the African heat (44 of 70, 62.9%)., Conclusion: Few COVID-19 cases and deaths were reported among patients with cancer. However, disruptions and delays in cancer care because of the pandemic were noted. The pandemic has inspired tailored innovative solutions in clinical care delivery for patients with cancer, which may serve as a blueprint for expanding care and preparing for future pandemics. Ongoing public education should address COVID-19 misconceptions. The results may not be generalizable to the entire African continent because of the small sample size.

Purpose: Few studies have explored the relationship between body habitus and breast cancer outcomes in Caribbean women of African ancestry. This study evaluates the association between body mass index (BMI) and disease-free survival (DFS) in a retrospective cohort of 224 female Haitian patients with nonmetastatic breast cancer., Patients and Methods: BMI was obtained from the medical records and categorized as normal weight (< 25 kg/m 2 ), overweight (25-29.9 kg/m 2 ), and obese (≥ 30 kg/m 2 ). DFS was defined as time from surgical resection to disease recurrence, death, or censoring. Kaplan-Meier survival curves were generated, and the association between BMI and DFS was evaluated using Cox proportional hazard models to control for multiple confounders. Exploratory analyses were conducted on weight changes during adjuvant chemotherapy., Results: Eighty-three patients (37.1%) were normal weight, 66 (29.5%) were overweight, and 75 (33.5%) were obese. There were no statistical differences in baseline characteristics or treatments received by BMI group. Twenty-six patients died and 73 had disease recurrence. Median DFS was 41.1 months. Kaplan-Meier estimates showed no significant DFS differences by BMI categories. After controlling for confounders, normal weight patients, when compared with overweight and obese patients, had adjusted hazard ratios of 0.85 (95% CI, 0.49 to 1.49) and 0.90 (95% CI, 0.52 to 1.55), respectively. Overall, mean weight loss of 2% of body weight was noted over the course of adjuvant chemotherapy. Patients who were postmenopausal ( P = .007) and obese ( P = .05) lost more weight than other groups. However, chemotherapy-related weight changes did not have an impact on DFS., Conclusion: Baseline BMI and weight changes during adjuvant chemotherapy did not have an impact on DFS in this cohort. Future prospective studies in similar Caribbean breast cancer cohorts are needed to verify study findings.

Background: There are few studies on breast cancer outcomes in the Caribbean region. This study identified a retrospective cohort of female patients with nonmetastatic breast cancer in Haiti and conducted survival analyses to identify prognostic factors that may affect patient outcomes., Methods: The cohort included 341 patients presenting between June 2012 and December 2016. The primary endpoint was event-free survival (EFS), defined as time to disease progression, recurrence, or death. Descriptive summaries of patient characteristics and treatments were reported. Survival curves were plotted using Kaplan-Meier estimation. Multivariate survival analyses were performed using Cox proportional hazards regression., Results: Median age at diagnosis was 49 years, with 64.2% being premenopausal. Most patients (55.1%) were staged as locally advanced. One hundred and sixty patients received neoadjuvant therapy: 33.3% of patients with early stage disease and 61.2% of those with locally advanced stage disease. Curative-intent surgery was performed in 278 (81.5%) patients, and 225 patients received adjuvant therapy. Adjuvant endocrine therapy was used in 82.0% of patients with estrogen receptor-positive disease. During the follow-up period, 28 patients died, 77 had disease recurrence, and 10 had progressive disease. EFS rates at 2 years and 3 years were 80.9% and 63.4%, respectively. After controlling for multiple confounders, the locally advanced stage group had a statistically significant adjusted hazard ratio for EFS of 3.27 compared with early stage., Conclusion: Patients with nonmetastatic breast cancer in Haiti have more advanced disease, poorer prognostic factors, and worse outcomes compared with patients in high-income countries. Despite several limitations, curative treatment is possible in Haiti., Implications for Practice: Patients with breast cancer in Haiti have poor outcomes. Prior studies show that most Haitian patients are diagnosed at later stages. However, there are no rigorous studies describing how late-stage diagnosis and other prognostic factors affect outcomes in this population. This study presents a detailed analysis of survival outcomes and assessment of prognostic factors in patients with nonmetastatic breast cancer treated in Haiti. In addition to late-stage diagnosis, other unfavorable prognostic factors identified were young age and estrogen receptor-negative disease. The study also highlights that the availability of basic breast cancer treatment in Haiti can lead to promising early patient outcomes., (© 2020 The Authors. The Oncologist published by Wiley Periodicals LLC on behalf of AlphaMed Press.)

Rwanda is a densely populated low-income country in East Africa. Previously considered a failed state after the genocide against the Tutsi in 1994, Rwanda has seen remarkable growth over the past 2 decades. Health care in Rwanda is predominantly delivered through public hospitals and is emerging in the private sector. More than 80% of patients are covered by community-based health insurance (Mutuelle de Santé). The cancer unit at the Rwanda Biomedical Center (a branch of the Ministry of Health) is responsible for setting and implementing cancer care policy. Rwanda has made progress with human papillomavirus (HPV) and hepatitis B vaccination. Recently, the cancer unit at the Rwanda Biomedical Center launched the country's 5-year National Cancer Control Plan. Over the past decade, patients with cancer have been able to receive chemotherapy at Butaro Cancer Center, and recently, the Rwanda Cancer Center was launched with 2 linear accelerator radiotherapy machines, which greatly reduced the number of referrals for treatment abroad. Palliative care services are increasing in Rwanda. A cancer registry has now been strengthened, and more clinicians are becoming active in cancer research. Despite these advances, there is still substantial work to be done and there are many outstanding challenges, including the need to build capacity in cancer awareness among the general population (and shift toward earlier diagnosis), cancer care workforce (more in-country training programs are needed), and research.

Purpose: To provide expert guidance to clinicians and policymakers in resource-constrained settings on the management of patients with late-stage colorectal cancer., Methods: ASCO convened a multidisciplinary, multinational Expert Panel that reviewed existing guidelines, conducted a modified ADAPTE process, and used a formal consensus process with additional experts for two rounds of formal ratings., Results: Existing sets of guidelines from four guideline developers were identified and reviewed; adapted recommendations from five guidelines form the evidence base and provided evidence to inform the formal consensus process, which resulted in agreement of ≥ 75% on all recommendations., Recommendations: Common elements of symptom management include addressing clinically acute situations. Diagnosis should involve the primary tumor and, in some cases, endoscopy, and staging should involve digital rectal exam and/or imaging, depending on resources available. Most patients receive treatment with chemotherapy, where chemotherapy is available. If, after a period of chemotherapy, patients become candidates for surgical resection with curative intent of both primary tumor and liver or lung metastatic lesions on the basis of evaluation in multidisciplinary tumor boards, the guidelines recommend patients undergo surgery in centers of expertise if possible. On-treatment surveillance includes a combination of taking medical history, performing physical examinations, blood work, and imaging; specifics, including frequency, depend on resource-based setting.Additional information is available at www.asco.org/resource-stratified-guidelines.

Background: Breast cancer is the most common malignancy encountered during pregnancy. However, the burden of pregnancy-associated breast cancer (PABC) and subsequent care is understudied in sub-Saharan Africa (SSA). Here, we describe the characteristics, diagnostic delays and treatment of women with PABC seeking care at a rural cancer referral facility in Rwanda., Methods: Data from female patients aged 18-50 years with pathologically confirmed breast cancer who presented for treatment between July 1, 2012 and February 28, 2014 were retrospectively reviewed. PABC was defined as breast cancer diagnosed in a woman who was pregnant or breastfeeding. Numbers and frequencies are reported for demographic and diagnostic delay variables and Wilcoxon rank sum and Fisher's exact tests are used to compare characteristics of women with PABC to women with non-PABC at the alpha = 0.05 significance level. Treatment and outcomes are described for women with PABC only., Results: Of the 117 women with breast cancer, 12 (10.3%) had PABC based on medical record review. The only significant demographic differences were that women with PABC were younger (p = 0.006) and more likely to be married (p = 0.035) compared to women with non-PABC. There were no significant differences in diagnostic delays or stage at diagnosis between women with PABC and women with non-PABC women. Eleven of the women with PABC received treatment, three had documented treatment delays or modifications due to their pregnancy or breastfeeding, and four stopped breastfeeding to initiate treatment. At the end of the study period, six patients were alive, three were deceased and three patients were lost to follow-up., Conclusions: PABC was relatively common in our cohort but may have been underreported. Although patients with PABC did not experience greater diagnostic delays, most had treatment modifications, emphasizing the potential value of PABC-specific treatment protocols in SSA. Larger prospective studies of PABC are needed to better understand particular challenges faced by these patients and inform policies and practices to optimize care for women with PABC in Rwanda and similar settings.

Purpose Observational studies have reported increased colon cancer recurrence and mortality in patients with states of hyperinsulinemia, including type 2 diabetes, obesity, sedentary lifestyle, and high glycemic load diet. Nut intake has been associated with a lower risk of type 2 diabetes, metabolic syndrome, and insulin resistance. However, the effect of nut intake on colon cancer recurrence and survival is not known. Patients and Methods We conducted a prospective, observational study of 826 eligible patients with stage III colon cancer who reported dietary intake on food frequency questionnaires while enrolled onto a randomized adjuvant chemotherapy trial. Using Cox proportional hazards regression, we assessed associations of nut intake with cancer recurrence and mortality. Results After a median follow-up of 6.5 years, compared with patients who abstained from nuts, individuals who consumed two or more servings of nuts per week experienced an adjusted hazard ratio (HR) for disease-free survival of 0.58 (95% CI, 0.37 to 0.92; P trend = .03) and an HR for overall survival of 0.43 (95% CI, 0.25 to 0.74; P trend = .01). In subgroup analysis, the apparent benefit was confined to tree nut intake (HR for disease-free survival, 0.54; 95% CI, 0.34 to 0.85; P trend = .04; and HR for overall survival, 0.47; 95% CI, 0.27 to 0.82; P trend = .04). The association of total nut intake with improved outcomes was maintained across other known or suspected risk factors for cancer recurrence and mortality. Conclusion Diets with a higher consumption of nuts may be associated with a significantly reduced incidence of cancer recurrence and death in patients with stage III colon cancer.

Purpose: Gestational trophoblastic neoplasia (GTN) is a highly treatable disease, most often affecting young women of childbearing age. This study reviewed patients managed for GTN at the Butaro Cancer Center of Excellence (BCCOE) in Rwanda to determine initial program outcomes., Patients and Methods: A retrospective medical record review was performed for 35 patients with GTN assessed or treated between May 1, 2012, and November 30, 2014. Stage, risk score, and low or high GTN risk category were based on International Federation of Gynecology and Obstetrics staging and the WHO scoring system and determined by beta human chorionic gonadotropin level, chest x-ray, and ultrasound per protocol guidelines for resource-limited settings. Pathology reports and computed tomography scans were assessed when possible. Treatment was based on a predetermined protocol stratified by risk status., Results: Of the 35 patients (mean age, 32 years), 26 (74%) had high-risk and nine (26%) had low-risk disease. Nineteen patients (54%) had undergone dilation and curettage and 11 (31%) had undergone hysterectomy before evaluation at BCCOE. Pathology reports were available in 48% of the molar pregnancy surgical cases. Systemic chemotherapy was initiated in 30 of the initial 35 patients: 13 (43%) received single-agent oral methotrexate, 15 (50%) received EMACO (etoposide, methotrexate, dactinomycin, cyclophosphamide, and vincristine), and two (7%) received alternate regimens. Of the 13 patients initiating methotrexate, three had their treatment intensified to EMACO. Four patients experienced treatment delays because of medication stockouts. At a median follow-up of 7.8 months, the survival probability for low-risk patients was 1.00; for high-risk patients, it was 0.63., Conclusion: This experience demonstrates the feasibility of GTN treatment in rural, resource-limited settings. GTN is a curable disease and can be treated following the BCCOE model of cancer care., Competing Interests: Authors’ disclosures of potential conflicts of interest and contributions are found at the end of this article.Gestational Trophoblastic Neoplasia Treatment at the Butaro Cancer Center of Excellence in RwandaThe 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.Ignace NzayisengaNo relationship to discloseRoanne SegalNo relationship to discloseNatalie PritchettNo relationship to discloseMary J. XuNo relationship to disclosePaul H. ParkNo relationship to discloseVedaste E. MpanumusingoNo relationship to discloseDenis G. UmuhiziNo relationship to discloseDonald P. GoldsteinNo relationship to discloseRoss S. BerkowitzNo relationship to discloseVedaste HategekimanaNo relationship to discloseClemence MuhayimanaNo relationship to discloseFidel RubagumyaNo relationship to discloseTemidayo FadeluNo relationship to discloseNeo TapelaNo relationship to discloseTharcisse MpungaNo relationship to discloseRahel G. GhebreNo relationship to disclose

Purpose: Success in treating nephroblastoma in high-income countries has been transferred to some resource-constrained settings; multicenter studies report disease-free survival of greater than 70%. However, few reports present care models with rural-based components, care tasks shifted to internists and pediatricians, and data collection structured for monitoring and evaluation. Here, we report clinical outcomes and protocol compliance for patients with nephroblastoma evaluated at Butaro Cancer Center of Excellence in Rwanda., Patients and Methods: This retrospective study reports the care of 53 patients evaluated between July 1, 2012, and June 30, 2014. Patients receiving less than half of their chemotherapy at Butaro Cancer Center of Excellence were excluded., Results: Of the 53 patients included, 9.4% had stage I, 13.2% had stage II, 24.5% had stage III, 26.4% had stage IV, and 5.7% had stage V disease; the remaining 20.8% had unknown stage disease from inadequate work-up or unavailable surgical report. The incidence of neutropenia increased with treatment progression, and the greatest proportion of delays occurred during the surgical referral phase. At the end of the study period, 32.1% of patients (n = 17) remained alive after treatment; 24.5% (n = 13) remained alive while continuing treatment, including one patient with recurrent disease; 30.2% (n = 16) died; and 13.2% (n = 7) were lost to follow-up., Conclusion: Our findings confirm that nephroblastoma can be effectively treated in resource-constrained settings. Using an approach in which chemotherapy is delivered at a rural-based center by nononcologists and data are used for routine evaluation, care can be delivered in safe, novel ways. Protocol modifications to mitigate chemotherapy toxicities and strong communication between the multidisciplinary team members will likely minimize delays and further improve outcomes in similar settings., Competing Interests: Authors' disclosures of potential conflicts of interest and contributions are found at the end of this article. 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 jco.ascopubs.org/site/ifc. Cyprien ShyirambereNo relationship to discloseMary Jue XuEmployment: Merck Research Funding: MerckShekinah Nefreteri ElmoreNo relationship to discloseTemidayo FadeluNo relationship to discloseLeana MayConsulting or Advisory Role: Best DoctorsNeo TapelaNo relationship to discloseDenis Gilbert UmuhiziNo relationship to discloseFrank Regis UwizeyeNo relationship to discloseCaitlin DriscollStock or Other Ownership: Gilead Sciences, Exact SciencesClemence MuhayimanaNo relationship to discloseVedaste HategekimanaNo relationship to discloseFidel RubagumyaNo relationship to discloseIgnace NzayisengaNo relationship to discloseLawrence N. ShulmanNo relationship to discloseTharcisse MpungaNo relationship to discloseLeslie E. LehmannNo relationship to disclose

Purpose: The development of cancer care treatment facilities in resource-constrained settings represents a challenge for many reasons. Implementation science-the assessment of how services are set up and delivered; contextual factors that affect delivery, treatment safety, toxicity, and efficacy; and where adaptations are needed-is essential if we are to understand the performance of a treatment program, know where the gaps in care exist, and design interventions in care delivery models to improve outcomes for patients., Methods: The field of implementation science in relation to cancer care delivery is reviewed, and the experiences of the integrated implementation science program at the Butaro Cancer Center of Excellence in Rwanda are described as a practical application. Implementation science of HIV and tuberculosis care delivery in similar challenging settings offers some relevant lessons., Results: Integrating effective implementation science into cancer care in resource-constrained settings presents many challenges, which are discussed. However, with carefully designed programs, it is possible to perform this type of research, on regular and ongoing bases, and to use the results to develop interventions to improve quality of care and patient outcomes and provide evidence for effective replication and scale-up., Conclusion: Implementation science is both critical and feasible in evaluating, improving, and supporting effective expansion of cancer care in resource-limited settings. In ideal circumstances, it should be a prospective program, established early in the lifecycle of a new cancer treatment program and should be an integrated and continual process., (© 2015 by American Society of Clinical Oncology.)

The knowledge and tools to cure many cancer patients exist in developed countries but are unavailable to many who live in the developing world, resulting in unnecessary loss of life. Bringing cancer care to the poor, particularly to low-income countries, is a great challenge, but it is one that we believe can be met through partnerships, careful planning and a set of guiding principles. Alongside vaccinations, screening and other cancer-prevention efforts, treatment must be a central component of any cancer programme from the start. It is also critical that these programmes include implementation research to determine programmatic efficacy, where gaps in care still exist and where improvements can be made. This article discusses these issues using the example of Rwanda's expanding national cancer programme.