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Objective Thermal ablation (TA) was implemented in public sector cervical cancer prevention services in Zambia in 2012. Initially introduced as a treatment modality in primary healthcare clinics, it was later included in mobile outreach campaigns and clinical research trials. We report the feasibility, acceptability, safety, and provider uptake of TA in diverse clinical contexts. Methods Screening services based on visual inspection with acetic acid were offered by trained nurses to non-pregnant women aged 25-59 years. Women with a type 1 transformation zone (TZ) were treated with same-visit TA. Those with a type 2 or 3 TZ, or suspicious for cancer, were managed with same-visit electrosurgical excision or punch biopsy, respectively. A provider survey was conducted. Results Between 2012 and 2020, 2123 women were treated with TA: primary healthcare clinics, n = 746; mobile outreach clinics, n = 1127; research clinics, n = 250. Of the 996 women treated in primary healthcare and research clinics, 359 (48%) were HIV positive. Mild cramping during treatment was the most common adverse effect. No treatment interruptions occurred. No major complications were reported in the early (6 weeks) follow-up period. Providers expressed an overwhelming preference for TA over cryotherapy. Conclusion TA was feasible, safe, and acceptable in diverse clinical contexts. It was the preferred ablation method of providers when compared with cryotherapy.

The presence of preexisting morbidities poses a challenge to cancer patient care. There is little information on the profile and prevalence of multi-morbidities in breast cancer patients across middle income countries (MIC) to lower income countries (LIC) in sub-Saharan Africa (SSA). The African Breast Cancer–Disparities in Outcomes (ABC-DO) breast cancer cohort spans upper MICs South Africa and Namibia, lower MICs Zambia and Nigeria and LIC Uganda. At cancer diagnosis, seven morbidities were assessed: obesity, hypertension, diabetes, asthma/chronic obstructive pulmonary disease, heart disease, tuberculosis and HIV. Logistic regression models were used to assess determinants of morbidities and the influence of morbidities on advanced stage (stage III/IV) breast cancer diagnosis. Among 2189 women, morbidity prevalence was the highest for obesity (35%, country-specific range 15-57%), hypertension (32%, 15-51%) and HIV (16%, 2-26%) then for diabetes (7%, 4%-10%), asthma (4%, 2%-10%), tuberculosis (4%, 0%-8%) and heart disease (3%, 1%-7%). Obesity and hypertension were more common in upper MICs and in higher socioeconomic groups. Overall, 27% of women had at least two preexisting morbidities. Older women were more likely to have obesity (odds ratio: 1.09 per 10 years, 95% CI 1.01-1.18), hypertension (1.98, 1.81-2.17), diabetes (1.51, 1.32-1.74) and heart disease (1.69, 1.37-2.09) and were less likely to be HIV positive (0.64, 0.58-0.71). Multi-morbidity was not associated with stage at diagnosis, with the exception of earlier stage in obese and hypertensive women. Breast cancer patients in higher income countries and higher social groups in SSA face the additional burden of preexisting non-communicable diseases, particularly obesity and hypertension, exacerbated by HIV in Southern/Eastern Africa.

Most breast cancer patients in sub‐Saharan Africa are diagnosed at advanced stages after prolonged symptomatic periods. In the multicountry African Breast Cancer‐Disparities in Outcomes cohort, we dissected the diagnostic journey to inform downstaging interventions. At hospital presentation for breast cancer, women recalled their diagnostic journey, including dates of first noticing symptoms and health‐care provider (HCP) visits. Negative binomial regression models were used to identify correlates of the length of the diagnostic journey. Among 1429 women, the median (inter‐quartile range) length (months) of the diagnostic journey ranged from 11.3 (5.7‐21.2) in Ugandan, 8.2 (3.4‐16.4) in Zambian, 6.5 (2.4‐15.7) in Namibian‐black to 5.6 (2.3‐13.1) in Nigerian and 2.4 (0.6‐5.5) in Namibian‐non‐black women. Time from first HCP contact to diagnosis represented, on average, 58% to 79% of the diagnostic journey in each setting except Nigeria where most women presented directly to the diagnostic hospital with advanced disease. The median number of HCPs visited was 1 to 4 per woman, but time intervals between visits were long. Women who attributed their initial symptoms to cancer had a 4.1 months (absolute) reduced diagnostic journey than those who did not, while less‐educated (none/primary) women had a 3.6 months longer journey than more educated women. In most settings the long journey to breast cancer diagnosis was not primarily due to late first presentation but to prolonged delays after first presentation to diagnosis. Promotion of breast cancer awareness and implementation of accelerated referral pathways for women with suspicious symptoms are vital to downstaging the disease in the region., What's new? In sub‐Saharan Africa, most women with breast cancer are diagnosed long after symptoms first arise. Here, the authors studied the diagnostic journey for breast cancer among the African Breast Cancer‐Disparities in Outcome cohort. This is the largest study to quantify the length of the diagnostic journey across various settings in sub‐Saharan Africa. Time to final diagnosis decreased substantially when a woman recognized her symptoms as cancer. Most delays, they found, were due to extended time between first examination and final diagnosis. Promotion of breast cancer awareness among both women and healthcare providers could help reduce these delays.

Accurate survival estimates are needed for guiding cancer control efforts in sub-Saharan Africa, but previous studies have been hampered by unknown biases due to excessive loss to follow-up (LTFU). In the African Breast Cancer—Disparities in Outcomes Study, a prospective breast cancer cohort study, we implemented active mobile health follow-up, telephoning each woman or her next-of-kin (NOK) trimonthly on her mobile phone to update information on her vital status. Dates of every contact with women/NOK were analyzed from diagnosis in 2014–2017 to the earliest of September 1, 2018, death, or 3 years postdiagnosis. The cumulative incidence of being LTFU was calculated considering deaths as competing events. In all, 1,490 women were followed for a median of 24.2 (interquartile range (IQR), 14.2–34.5) months, corresponding to 8,529 successful contacts (77% of total contacts) with the women/NOK. Median time between successful contacts was 3.0 (IQR, 3.0–3.7) months. In all, 71 women (5.3%) were LTFU at 3 years: 0.8% in Nigeria, 2.2% in Namibia, and 5.6% in Uganda. Because of temporary discontinuity of active follow-up, 20.3% of women were LTFU after 2 years in Zambia. The median time to study notification of a death was 9.1 (IQR, 3.9–14.0) weeks. Although the present study was not a randomized controlled trial, in this cancer cohort with active mobile health follow-up, LTFU was much lower than in previous studies and enabled estimation of up-to-date and reliable cancer survival.

Background: Cryotherapy is standard practice for treating patients with cervical precancer in see-and-treat programmes in low-income and middle-income countries (LMICs). Because of logistical difficulties with cryotherapy (eg, the necessity, costs, and supply chain difficulties of refrigerant gas; equipment failure; and treatment duration >10 min), a battery-operated thermal ablator that is lightweight and portable has been developed. We aimed to compare thermal ablation using the new device with cryotherapy. Methods: We report the pilot phase of a randomised controlled trial in routine screen-and-treat clinics providing cervical screening using visual inspection with acetic acid (VIA) in Lusaka, Zambia. We recruited non-pregnant women, aged 25 years or older, who were eligible for ablative therapy. We randomly assigned participants (1:1:1) to thermal ablation, cryotherapy, or large loop excision of the transformation zone (LLETZ), using computer-generated allocation. The randomisation was concealed but the nurses providing treatment and the participants were unmasked. Thermal ablation was achieved using the Liger thermal ablator (using 1–5 overlapping applications of the probe heated to 100°C, each application lasting for 40 s), cryotherapy was carried out using the double-freeze technique (freeze for 3 min, thaw for 5 min, and freeze again for 3 min), and LLETZ (using a large loop driven by an electro-surgical unit to excise the transformation zone) was done under local anaesthesia. The primary endpoint was treatment success, defined as either human papillomavirus (HPV) type-specific clearance among participants who were positive for the same HPV type at baseline, or a negative VIA test at 6-month follow-up, if the baseline HPV test was negative. Per protocol analyses were done. Enrolment for the full trial is ongoing. Here, we present findings from a prespecified pilot phase of the full trial. The final analysis of the full trial will assess non-inferiority of the groups for the primary efficacy endpoint. The study is registered with ClinicalTrials.gov, number NCT02956239. Findings: Between Aug 2, 2017, and Jan 15, 2019, 750 participants were randomly assigned (250 per group). 206 (84%) participants in the cryotherapy group, 197 (81%) in the thermal ablation group, and 204 (84%) in the LLETZ group attended the 6-month follow-up examination. Treatment success was reported in 120 (60%) of 200 participants in the cryotherapy group, 123 (64%) of 192 in the thermal ablation group, and 134 (67%) of 199 in the LLETZ group (p=0·31). Few participants complained of moderate to severe pain in any group immediately after the procedure (six [2%] of 250 in the cryotherapy group, four [2%] of 250 in the thermal ablation group, and five [2%] of 250 in the LLETZ group) and 2 weeks after the procedure (one [

Background Arm and shoulder problems (ASP), including lymphedema, were common among women with breast cancer in high-income countries before sentinel lymph node biopsy became the standard of care. Although ASP impair quality of life, as they affect daily life activities, their frequency and determinants in Sub-Saharan Africa remain unclear. Methods All women newly diagnosed with breast cancer at the Namibian, Ugandan, Nigerian, and Zambian sites of the African Breast Cancer-Disparities in Outcomes (ABC-DO) cohort study were included. At each 3-month follow-up interview, women answered the EORTC-QLQ-Br23 questionnaire, including three ASP items: shoulder/arm pain, arm stiffness, and arm/hand swelling. We estimated the cumulative incidence of first self-reported ASP, overall and stratified by study and treatment status, with deaths treated as competing events. To identify determinants of ASP, we estimated cause-specific hazard ratios using Cox models stratified by study site. Results Among 1476 women, up to 4 years after diagnosis, 43% (95% CI 40–46), 36% (33–38) and 23% (20–25), respectively, self-reported having experienced arm/shoulder pain, stiffness and arm/hand swelling at least once. Although risks of self-reported ASP differed between sites, a more advanced breast cancer stage at diagnosis, having a lower socioeconomic position and receiving treatment increased the risk of reporting an ASP. Conclusion ASP are very common in breast cancer survivors in Sub-Saharan Africa. They are influenced by different factors than those observed in high-income countries. There is a need to raise awareness and improve management of ASP within the African setting.

Background Cancer incidence is increasing worldwide. Over the next 20 years, the growing proportion of cases in low- and middle-income countries (LMICs) will account for an estimated 70% of all cancers diagnosed. The vast majority of cancer patients in LMICs will require chemotherapy, due to the advanced stage of their disease at the time of initial presentation. Unfortunately, the availability of cancer drugs in these environments is sparse, resulting in premature death and years of life lost. In an effort to lay a foundation for women's cancer control in the Democratic Republic of the Congo (DRC), we implemented a programme which combined workforce development, infrastructure creation and cancer drug access. This manuscript reports on our experience with the latter. Methods A private sector healthcare facility was selected as the programme implementation site. Workforce capacity was developed through a south-south partnership with an African national cancer centre. Cancer drugs were procured through a global cancer medicine access initiative. Results A new chemotherapy infusion unit was successfully established at the Biamba Marie Mutombo Hospital in Kinshasa, DRC. A team of Congolese healthcare providers was trained at the Cancer Disease Hospital in Zambia to safely and effectively administer chemotherapy for breast and cervical cancer. Over 100 breast and cervical cancer patients have been treated with 337 courses of chemotherapy, without any serious adverse events. Conclusion Common barriers to cancer drug access and its administration can be eliminated using regional educational resources to build oncologic workforce capacity, private sector healthcare facilities for infrastructure support and pharmaceutical consortiums to procure low-cost cancer medicines. By leveraging a matrix of global, regional and local stakeholders, the prevailing status quo of very limited access to chemotherapy for women's cancers was creatively disrupted in DRC, Africa's largest fragile, conflict and violence-affected country.

Objectives Surgery is a cornerstone of the management of cervical cancer. Women diagnosed with cervical cancer in sub-Saharan Africa have very little access to specialised (gynaecologic oncology) surgical services. We describe our experiences and challenges of training local general gynaecologists to surgically treat early stage invasive cervical cancer at a private sector healthcare facility in a fragile, low-income African nation. Methods Implementation of the training curriculum began with assigned self-directed learning. It continued with on-site training which consisted of preoperative surgical video reviews, pre- and intra-operative assessment of disease status, deconstruction of the designated surgical procedure into its critical subcomponents and trainees orally communicating the steps of the surgical procedure with the master trainers. High-volume repetition of a single surgical procedure over a short time interval, intra-operative bedside mentoring, post-operative case review and mental narration were critical to the process of surgical skills transfer. Results Nineteen radical abdominal hysterectomies were successfully performed over four training visits; trainees were able to perform the procedure alone after eight cases; surgical complications decreased over time. The trainees have continued to perform the surgical procedures independently. Conclusion Life-saving surgical capacity for the treatment of cervical cancer has been established and sustained at a private sector healthcare facility in a fragile, low-income African setting, through an innovative model of surgical training.

Background Gynecologic malignancies represent a significant proportion of the increasing cancer burden in Zambia. The care and outcomes of cancer patients improves in a multidisciplinary team but insufficient coordination in weak health systems is a barrier to this model of care. The World Health Organization (WHO) identifies digital health interventions as tools to bridge the gap between challenges and health systems’ goals in low resource environments. A low-cost innovative virtual interaction system (VIS) was integrated into the gynecologic oncology multidisciplinary tumor board to enhance patient navigation and management. Methods Paper-based forms used by each specialist group participating in the tumor board were collected and placed on a digital platform. Tumor board members were interviewed to assess their acceptability of the new digital modules and ensure correct nomenclature was being used for data entry. This was followed by an orientation and launch of VIS. Results For a 12-week period following the launch, 197 gynecologic oncology patients were registered at the Zambian national cancer center (Cancer Diseases Hospital), of which 130 were entered in the VIS, and of those less than half had management decisions recorded. The median time from first visit to simulation for radiotherapy was 52 days; from simulation to start of treatment 102.5 days. Eighteen (14 %) of the 130 patients entered into the VIS were recorded as lost to follow up. Conclusion The introduction and implementation of a digital intervention for navigation and management of gynecologic patients in a low resource environment proved both feasible and acceptable. It provides an instant easily accessible platform for important information on time intervals and delays in the patient pathway. End user orientation and support is an integral part to its successful integration and consistent management of the data is required to maximize its impact on efficiency, effectiveness and patient care.

Background The vast majority of women with breast cancer in sub-Saharan Africa present with advanced stage disease, due primarily to the lack of opportunities for early detection and treatment. As part of a larger effort to increase access to diagnostic and therapeutic services for women’s cancers in the Democratic Republic of Congo (DRC), we implemented a curriculum to train the local workforce and a program to build the supportive infrastructure for the diagnosis and treatment of breast cancer at a private sector health facility (Biamba Marie Mutombo Hospital) in Kinshasa. Study design After onsite trainings in the DRC by a US breast surgeon (RT), Congolese surgeons, general physicians, physician assistants, and nurses used the Phillips Lumify smart-phone ultrasound device to perform and interpret the results of whole breast ultrasound on symptomatic women. Surgeons were trained to perform ultrasound-guided core needle biopsy on those who met the criteria for tissue diagnosis, after which they trained nurses to do the same. Results Over 3 years, 5,211 patients were identified as having a breast abnormality on clinical breast examination. Ultrasound abnormalities were noted in 1,493 (27%) patients, of which 632 (42%) met the criteria for ultrasound-guided core needle biopsy or fine needle aspiration. Pathology reports were available on 368 (58%) patients who underwent biopsy, of which 164 were malignant and 204 benign. Conclusions We demonstrated how the “ability to look” using smart technology can be successfully used to augment clinical breast exam and triage patients for biopsy in a resource-constrained African setting.

Background: Studies have shown increased mortality among HIV-positive women with breast cancer compared to HIV-negative women with breast cancer, but none has examined how this differential varies by patient or breast tumour characteristics. Methods: ABC-DO study is a prospective cohort of incident breast cancer women recruited at diagnosis (2014-2017) in Namibia, Nigeria, South Africa, Uganda and Zambia. Detailed clinic-epidemiological data were collected at baseline. Participants were actively followed-up via 3-monthly telephone calls. Using Cox regression, we examined differences in overall survival by HIV status in the cohort, and across country and patient subgroups, adjusted for age at cancer diagnosis, tumour grade and stage at cancer diagnosis. Findings: Among 1,635 women, 313 (19%) were HIV-positive, 1,184 (72%) were HIV-negative and 138 (9%) HIV-unknown. At breast cancer diagnosis, HIV-positive women were younger and had lower BMI than their HIV-negative counterparts, but had similar tumour stage, grade and receptor subtypes. At the end of the follow-up (January 1, 2019), a higher proportion of HIV-positive women (137 (44%)) had died compared to HIV-negative women (432 (37%)). Crude three-year survival was 9% lower for HIV-positive women (46% vs. 55% for HIV-negative women, hazard ratio (HR) 1·41; 95% CI: 1·15-1·74). The difference did not differ by age, BMI, tumour subtype or grade but was stronger in women with non-metastatic disease (52% HIV-positive vs. 63% HIV-negative women, adjusted HR 1·65: 1·30-2·10), whilst women with metastatic cancer had low survival regardless of HIV status. Interpretation: The larger survival deficit among WLWH with non-metastatic breast cancer calls for a better understanding of the reasons underlying this differential e.g. biological mechanisms, health behaviours, detrimental HIV-breast cancer treatment interactions or higher HIV background mortality, to inform strategies for reducing mortality among this young patient group. Funding: Susan G Komen, International Agency for Research on Cancer, National Cancer Institute and UK-Commonwealth Scholarships. Declaration of Interest: No declaration of competing interests. Ethical Approval: The ABC-DO study was approved by all institutional ethics committees (List 1 in Supplementary Material), and all women provided written or thumbprint informed consent, witnessed by the study interviewer.

Key Points Question How many maternal orphans resulted from every 100 breast cancer deaths in sub-Saharan African settings in 2014-2019? Findings In the African Breast Cancer–Disparities in Outcomes cohort study of women with breast cancer, there were 964 children (, Importance Low breast cancer survival in sub-Saharan Africa’s young population increases the likelihood that breast cancer deaths result in maternal orphans, ie, children (, This cohort study estimates the number of maternal orphans in 4 sub-Saharan Africa countries when women die of breast cancer.

Introduction Improving the lives of women with breast and cervical cancer requires a multidimensional approach encompassing the entire continuum of care. Our objective was to identify key quality of life concerns among Zambian women treated for advanced breast and cervical cancer. Methods Survivors participated in focus groups in their local languages. Common themes were analyzed. Results Among breast cancer patients, common themes included social support, financial hardships, delayed access to care, and faith. Some family members supported treatment by traditional healers; others reported strong support for hospital-based care. Financial concerns included transportation costs, medical expenses, and children’s school fees. Unavailable or missing test results and other treatment delays posed further stress. Faith wavered near the time of diagnosis but was renewed after completing treatment. Among cervical cancer patients, common themes included delays in care, financial hardships, and community beliefs that cancer is fatal. Participants described difficulties traveling to the central treatment facility, delays in treatment initiation, and needing to ask others for financial contributions. Many experienced decreased libido and vaginal stenosis. Some had supportive husbands; others experienced marital strife and even abandonment. Among reproductive age women there was confusion over whether pregnancy is possible after treatment. Conclusions/Implication Survivors of advanced breast and cervical cancer expressed many common concerns. Some started at the time of diagnosis and encompassed treatment choices (traditional vs conventional), finances, and sexual dysfunction. Findings from this study can inform survivorship services and underscore the need to decrease delays in diagnosis and treatment.

We examined the geospatial dimension of delays to diagnosis of breast cancer in a prospective study of 1541 women newly diagnosed in the African Breast Cancer—Disparities in Outcomes (ABC‐DO) Study. Women were recruited at cancer treatment facilities in Namibia, Nigeria, Uganda and Zambia. The baseline interview included information used to generate the geospatial features: urban/rural residence, travel mode to treatment facility and straight‐line distances from home to first‐care provider and to diagnostic/treatment facility, categorized into country/ethnicity (population)‐specific quartiles. These factors were investigated in relation to delay in diagnosis (≥3 months since first symptom) and late stage at diagnosis (TNM: III, IV) using logistic regression, adjusted for population group and sociodemographic characteristics. The median (interquartile range) distances to first provider and diagnostic and treatment facilities were 5 (1‐37), 17 (3‐105) and 62 (5‐289) km, respectively. The majority had a delay in diagnosis (74%) and diagnosis at late stage (64%). Distance to first provider was not associated with delay in diagnosis or late stage at diagnosis. Rural residence was associated with delay, but the association did not persist after adjustment for sociodemographic characteristics. Distance to the diagnostic/treatment facility was associated with delay (highest vs lowest quartile: odds ratio (OR) = 1.56, 95% confidence interval (CI) = 1.08‐2.27) and late stage (overall: OR = 1.47, CI = 1.05‐2.06; without Nigerian hospitals where mostly local residents were treated: OR = 1.73, CI = 1.18‐2.54). These findings underscore the need for measures addressing the geospatial barriers to early diagnosis in sub‐Saharan African settings, including providing transport or travel allowance and decentralizing diagnostic services., What's new? Survival from breast cancer is poor in sub‐Saharan Africa, due largely to the high proportion of women who are diagnosed at advanced stages. In this study, the authors examined geospatial information to assess women's prediagnostic journey to breast cancer diagnosis, with special attention to delays in diagnosis, in the regions of Namibia, Nigeria, Uganda, and Zambia. Geospatial factors particularly long travel distances to diagnostic and treatment facilities were identified as major barriers to early diagnosis. The findings underscore the need for policies to address these barriers to ensure breast cancer diagnosis at a curable stage.

Summary Background Breast cancer is the second leading cause of death from cancer in women in sub-Saharan Africa, yet there are few well characterised large-scale survival studies with complete follow-up data. We aimed to provide robust survival estimates in women in this setting and apportion the survival gaps. Methods The African Breast Cancer-Disparities in Outcomes (ABC-DO) prospective cohort study was done at eight hospitals across five sub-Saharan African countries (Namibia, Nigeria, South Africa, Uganda, and Zambia). We prospectively recruited women (aged ≥18 years) who attended these hospitals with suspected breast cancer. Women were actively followed up by use of a telephone call once every 3 months, and a mobile health application was used to keep a dynamic record of follow-up calls due. We collected detailed sociodemographic, clinical, and treatment data. The primary outcome was 3-year overall survival, analysed by use of flexible proportional mortality models, and we predicted survival under scenarios of modified distributions of risk factors. Findings Between Sept 8, 2014, and Dec 31, 2017, 2313 women were recruited from these eight hospitals, of whom 85 did not have breast cancer. Of the remaining 2228 women with breast cancer, 58 women with previous treatment or recurrence, and 14 women from small racial groups (white and Asian women in South Africa), were excluded. Of the 2156 women analysed, 1840 (85%) were histologically confirmed, 129 (6%) were cytologically confirmed, and 187 (9%) were clinically confirmed to have breast cancer. 2156 (97%) women were followed up for up to 3 years or up to Jan 1, 2019, whichever was earlier. Up to this date, 879 (41%) of these women had died, 1118 (52%) were alive, and 159 (7%) were censored early. 3-year overall survival was 50% (95% CI 48–53), but we observed variations in 3-year survival between different races in Namibia (from 90% in white women to 56% in Black women) and in South Africa (from 76% in mixed-race women to 59% in Black women), and between different countries (44–47% in Uganda and Zambia vs 36% in Nigeria). 215 (10%) of all women had died within 6 months of diagnosis, but 3-year overall survival remained low in women who survived to this timepoint (58%). Among survival determinants, improvements in early diagnosis and treatment were predicted to contribute to the largest increases in survival, with a combined absolute increase in survival of up to 22% in Nigeria, Zambia, and Uganda, when compared with the contributions of other factors (such as HIV or aggressive subtypes). Interpretation Large variations in breast cancer survival in sub-Saharan African countries indicate that improvements are possible. At least a third of the projected 416 000 breast cancer deaths that will occur in this region in the next decade could be prevented through achievable downstaging and improvements in treatment. Improving survival in socially disadvantaged women warrants special attention. Funding Susan G Komen and the International Agency for Research on Cancer.

PURPOSE In Zambia, more than two-thirds of female patients with breast cancer present with late-stage disease, leading to high mortality rates. Most of the underlying causes are associated with delays in symptom recognition and diagnosis. By implementing breast care specialty services at the primary health care level, we hypothesized that some of the delays could be minimized. METHODS In March 2018, we established a breast care specialty clinic for women with symptomatic disease within 1 of the 5 district hospitals in Lusaka. The clinic offers breast self-awareness education, clinical breast examination, breast ultrasound, ultrasound-guided breast biopsy, surgery, referral for chemoradiation, follow-up care, and electronic medical records. RESULTS Between March 2018 and April 2019, of 1,790 symptomatic women who presented to the clinic, 176 (10%) had clinical and/or ultrasound indications for histologic evaluation. Biopsy specimens were obtained using ultrasound-guided core-needle procedures, all of which were performed on the same day as the initial visit. Of the 176 women who underwent biopsy, 112 (64%) had pathologic findings compatible with a primary breast cancer, and of these, 42 (37%) were early-stage (stage I/II) disease. Surgery for early-stage cancers was performed at the district hospital within 2 weeks of the time of definitive pathologic diagnosis. Patients with advanced disease were referred to the national cancer center for multimodality therapy, within a similar time frame. CONCLUSION Breast care specialty services for symptomatic women were established in a district-level hospital in a resource-constrained setting in Africa. As a result, the following time intervals were minimized: initial presentation and performance of clinical diagnostics; receipt of a definitive pathologic diagnosis and initiation of surgery; receipt of a definitive pathologic diagnosis and referral.

Global cancer centres operate across different sizes, scales, and ecosystems. Understanding the essential aspects of the creation, organisation, accreditation, and activities within these settings is crucial for developing an affordable, equitable, and quality cancer care, research, and education system. Robust guidelines are scarce for cancer units, cancer centres, and comprehensive cancer centres in low-income and middle-income countries. However, some robust examples of the delivery of complex cancer care in centres in emerging economies are available. Although it is impossible to create an optimal system to fit the unique needs of all countries for the delivery of cancer care, we summarise what has been published about the development and management of cancer centres in low-income and middle-income countries so far and highlight the need for clinical and political leadership.

Objectives: A randomized control trial of a battery-operated thermocoagulator for the treatment of precancerous cervical lesions is ongoing in Lusaka, Zambia. We describe preliminary results of treatment efficacy in HIV-positive women. Methods: Visual inspection with acetic acid (VIA) screen-positive women eligible for ablative treatment are randomized to receive thermal ablation (TA), cryotherapy or large loop excision of the transformation zone (LLETZ). Demographic information is collected, including human immunodeficiency virus (HIV) status and antiretroviral therapy (ART) use. Human papillomavirus (HPV) DNA sampling for known or suspected oncogenic HPV types is performed at baseline and follow-up. Treatment efficacy is based on VIA and HPV status at 6- and/or 12-month follow-up. Side-effects, pain and client satisfaction are scored and recorded, however, these data are not included in this analysis. Results: Of the 1,683 women who have been randomized to treatment, 994 (59%) are HIV-positive with the vast majority (97%) on anti-retroviral therapy (ART). HIV-positive women were equally distributed between treatment arms (p=0.28). Among the 1328 (79%) eligible for follow-up, follow-up data are available on 722 women (54%), of which 383 are HIV-positive. Based on VIA results alone for cure, HIV positive women had lower overall cure rates than HIV-negative women (77% vs 88%, respectively, p 2yrs, 55%; p=0.072). Download : Download high-res image (215KB) Download : Download full-size image Conclusions: In May 2020, the 173rd World Health Assembly adopted the Global Strategy to Eliminate Cervical Cancer. This sub-analysis of data from a randomized control trial of locally ablative methods for cervical precancer highlights the challenges in eradicating this disease in women living with HIV. Investigations are underway to determine the underlying causes of these findings. (NCI Grant No. 4UH3CA202721-03)

Breast cancer (BC) survival rates in sub-Saharan Africa (SSA) are low in part due to advanced stage at diagnosis. As one component of a study of the entire journey of SSA women with BC, we aimed to identify shared and setting-specific drivers of advanced stage BC. Women newly diagnosed in the multi-country African Breast Cancer - Disparities in Outcomes (ABC-DO) study completed a baseline interview and their stage information was extracted from medical records. Ordinal logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) for advanced stage (I, II, III, IV) in relation to individual woman-level, referral and biological factors. A total of 1795 women were included from Nigeria, Uganda, Zambia, and the multi-racial populations of Namibia and South Africa, 1091 of whom (61%) were stage III/IV. Stage was lower in women with greater BC knowledge (OR 0.77 (95% CI: 0.70, 0.85) per point on a 6 point scale). More advanced stage was associated with being black (4.00 (2.79, 5.74)), having attended

Introduction: By 2030 cancer will kill one million Africans each year. Women will bear the heaviest burden, as cancers of the breast and cervix are the most common malignancies and causes of cancer-related death in the African region. National-level data that map the status of women's cancer control services are needed to inform strategies for implementing platforms for the early detection and treatment of these "priority" cancers. Methods: Using mixed-methods, we assessed available services for breast and cervical cancer detection and treatment at all provincial hospitals, the national referral hospital, and the national cancer treatment center in Zambia. Results: A system for cervical cancer prevention using visual inspection with acetic acid (VIA) and ablation/excision of precancerous lesions has been established at the provincial level. The potential for mammography, clinical breast examination, diagnostic ultrasound and biopsy exist at the provincial level, albeit on a much smaller scale. Breast wedge resections and mastectomy can be performed in provinces where general surgeons are located; however, breast conserving and reconstructive surgery are not available. Invasive cancers are generally referred to University Teaching Hospital in Lusaka, where services for radiation, chemotherapy and hormonal therapy are available but overburdened. Pathology services nationwide are woefully inadequate. Discussion: The assessment revealed a critical need for centrally coordinated, but decentralized, public service platforms for women's cancer control. Efforts are underway, through multiple stakeholders, to implement recommendations related to training healthcare workers who can provide advanced diagnostic and therapeutic services, improving pathology services, and innovative financing for these initiatives.

Worldwide, more than 80% of people with cancer will require surgery during their disease course, but less than 25% have access to safe, affordable and timely surgery. Among the barriers to increasing surgical capacity are the time and costs required to train novices. Virtual reality (VR) surgical simulations can reduce the time required for novices to reach surgical proficiency, though their costs may exceed USD $100,000. The goal of this study was to determine if a low-cost system, using commercially available technology designed for in-home computer gaming, could be used to create a realistic VR surgical oncology simulation. Standard commercially available VR software and Oculus Rift hardware have been used to provide high-quality visuals and believable surgeon hand interactions. Near identical VR reproduction of an operating room using 1:1 scale matching of real-world elements, including equipment, instruments, supplies and sounds, maintaining frame rate greater than 60 fps to maintain visual fidelity has been created. Internal anatomy was designed as VR replica of human female pelvic anatomy, including organs, veins and other vessels, peritoneum and connective tissue. Internal anatomy was designed to run at 120 fps and to allow for a realistic abdominal radical hysterectomy simulation. Surgical hands were modelled to scale for those with large and small hands. Multiple hand positions were simulated using Oculus touch hardware. Reconstructing the virtual environment to simulate reality as accurately as possible was done to immerse users in the simulator so that they focus on learning and practise without distractions. Training modules were co-designed by experts in learning sciences, human behaviour, VR and gynaecologic oncology. We have successfully created a low-cost VR simulation to help prepare novice surgeons to perform a radical abdominal hysterectomy surgery procedure. The simulation can be used with commercially available computer gaming hardware that currently costs less than USD $1,500. Low-cost VR simulation has the potential to reduce the time and cost to train surgeons to perform surgical oncology procedures, as well as both improve and audit quality. If effective in real-world clinical trials, such simulations have relevance to multiple surgical procedures and applicability in both resource-limited and high-income settings.

Each year, more than 2 million women are diagnosed with breast or cervical cancer, yet where a woman lives largely determines whether she will develop one of these cancers, have access to timely and effective diagnostic and treatment services, and ultimately survive. Premature death and disability from cancer is a preventable tragedy for hundreds of thousands of women and their families every year. In regions with limited resources, and a fragile or fragmented health system, cancer contributes to the cycle of poverty. This is most striking for cervical cancer, as more than eight in ten women diagnosed and nine in ten women who die from cervical cancer live in a low- or middle-income country. There are proven and cost-effective approaches to reduce these disparities, yet for most women there are few opportunities to access life-saving interventions such as HPV vaccination, and cervical cancer screening with timely treatment of pre-cancerous lesions. These longstanding inequities highlight the urgent need for substantive and sustainable investments in cancer control more broadly, including prevention and early detection programs, capacity building for health service infrastructure and human resources for cancer management including all disciplines: pathology, surgery, radiotherapy, systemic therapy as well as palliative care. Equally vital is the development of high-quality population-based cancer registries, particularly in low- and middle-income countries. In this first Series paper we describe the burden of breast and cervical cancer, with an emphasis on global and regional trends in incidence, mortality and survival; the social and economic impact on women and their families; and the disparities in cancer survival among socioeconomically disadvantaged women in different settings.

Surgery is a cornerstone of management of women's cancer care in low- and middle-income countries. As cancer incidence rates and disease burden rise rapidly even in the lowest income nations, the need for investing in surgical care platforms at all levels of the health system (primary health care clinics to tertiary hospitals) is being increasingly recognized. In this article, a conceptual framework for approaching scaling-up surgery platforms for women's cancer care in regions with least resources and substantial burden of disease is presented. A case is made for identifying highest priority conditions that can be managed by resource-appropriate and sustainable interventions. Core-competencies-based training of local health workers for targeted skills-building and utilizing innovative approaches to care delivery by harnessing and incorporating affordable technology for monitoring, outcomes evaluation and ongoing program adaptation are essential. Implementing surgical cancer care within a public health framework will help ensure services are integrated in a manner that strengthens health systems at all levels.

Objective To evaluate how the influence of traditional Chiefs can be leveraged to promote access to cervical cancer prevention services in rural Zambia. Methods A retrospective review of outcome data was conducted for all screening outreach events that occurred in Zambian Chiefdoms between October 4, 2015, and October 3, 2016. Members of the health promotion team of the Cervical Cancer Prevention Program in Zambia visited local Chiefs to inform them of the importance of cervical cancer prevention. The local Chiefs then summoned adults living within their Chiefdoms to assemble for cervical cancer prevention health talks. Screen-and-treat services were implemented within each of the Chiefdoms over a 1-week period. Results VIA-enhanced digital imaging of the cervix (digital cervicography) was offered to 8399 women in ten Chiefdoms as part of a village-based screening (VBS) program. In all, 419 (4.9%) women had positive screening test results. Of these women, 276 (65.8%) were treated immediately with thermocoagulation and 143 (34.1%) were referred to provincial government hospitals to undergo either the loop electrosurgical excision procedure/large loop excision of the transformation zone (n=109, 26.0%) or punch biopsy (n=34, 8.1%). Conclusion The influence of traditional Chiefs was leveraged to facilitate access to cervical cancer prevention services in rural Zambia.

ObjectiveThe World Health Organization recommends visual inspection with acetic acid (VIA) for cervical cancer screening in resource-limited settings. In Cameroon, we use digital cervicography (DC) to capture images of the cervix after VIA. This study evaluated interobserver agreement of DC results

BACKGROUND: Cervical cancer screening efforts linked to HIV/AIDS care programs are being expanded across sub-Saharan Africa. Evidence on the age distribution and determinants of invasive cervical cancer (ICC) cases detected in such programs is limited. METHODS: We analyzed program operations data from the Cervical Cancer Prevention Program in Zambia the largest public sector programs of its kind in sub-Saharan Africa. We examined age distribution patterns by HIV serostatus of histologically confirmed ICC cases and used multivariable logistic regression to evaluate independent risk factors for ICC among younger ( 35 years) women. RESULTS: Between January 2006 and April 2010 of 48626 women undergoing screening 571 (1.2%) were diagnosed with ICC including 262 (46%) HIV seropositive (median age: 35 years) 131 (23%) HIV seronegative (median age: 40 years) and 178 (31%) of unknown HIV serostatus (median age: 38 years). Among younger (

Surgery is essential for global cancer care in all resource settings. Of the 15.2 million new cases of cancer in 2015, over 80% of cases will need surgery, some several times. By 2030, we estimate that annually 45 million surgical procedures will be needed worldwide. Yet, less than 25% of patients with cancer worldwide actually get safe, affordable, or timely surgery. This Commission on global cancer surgery, building on Global Surgery 2030, has examined the state of global cancer surgery through an analysis of the burden of surgical disease and breadth of cancer surgery, economics and financing, factors for strengthening surgical systems for cancer with multiple-country studies, the research agenda, and the political factors that frame policy making in this area. We found wide equity and economic gaps in global cancer surgery. Many patients throughout the world do not have access to cancer surgery, and the failure to train more cancer surgeons and strengthen systems could result in as much as US $6.2 trillion in lost cumulative gross domestic product by 2030. Many of the key adjunct treatment modalities for cancer surgery--e.g., pathology and imaging--are also inadequate. Our analysis identified substantial issues, but also highlights solutions and innovations. Issues of access, a paucity of investment in public surgical systems, low investment in research, and training and education gaps are remarkably widespread. Solutions include better regulated public systems, international partnerships, super-centralisation of surgical services, novel surgical clinical trials, and new approaches to improve quality and scale up cancer surgical systems through education and training. Our key messages are directed at many global stakeholders, but the central message is that to deliver safe, affordable, and timely cancer surgery to all, surgery must be at the heart of global and national cancer control planning.

Background Long delays to diagnosis is a major cause of late presentation of breast diseases in sub-Saharan Africa. Aims We designed and implemented a single-visit breast care algorithm that overcomes health system-related barriers to timely diagnosis of breast diseases. Methods A multidisciplinary team of Zambian healthcare experts trained a team of mid- and high-level Zambian healthcare practitioners how to evaluate women for breast diseases, and train trainers to do likewise. Working collaboratively, the two teams then designed a clinical platform that provides multiple breast care services within a single visit. The service platform was implemented using a breast outreach camp format, during which breast self-awareness, psychosocial counseling, clinical breast examination, breast ultrasound, ultrasound-guided biopsy, imprint cytology of biopsy specimens and surgical treatment or referral, were offered within a single visit. Results Eleven hundred and twenty-nine (1129) women attended the camps for breast care. Mean age was 35.9 years. The majority were multiparous (79.4%), breast-fed (76.0%), and reported hormone use (50.4%). Abnormalities were detected on clinical breast examination in 122 (10.8%) women, 114 of whom required ultrasound. Of the 114 who underwent ultrasound, 48 had identifiable lesions and were evaluated with ultrasound-guided core needle biopsy (39) or fine-needle aspiration (9). The concordance between imprint cytology and histopathology was 100%, when breast specimens were classified as either benign or malignant. However, when specimens were classified by histopathologic subtype, the concordance between imprint cytology and histology was 85.7% for benign and 100% for malignant lesions. Six (6) women were diagnosed with invasive cancer. Eighteen (18) women with symptomatic breast lesions had next-day surgery. Significance Similar to its impact on cervical cancer prevention services, a single visit breast care algorithm has the potential to overcome health system-related barriers to timely diagnosis of breast diseases, including cancer, in rural African settings.

A greater understanding of the nature and drivers of poor breast cancer (BC) awareness in sub-Saharan Africa (SSA) will inform much needed awareness programmes. We aimed to assess the level and nature of BC awareness in the multi-country African Breast Cancer—Disparities in Outcome (ABC-DO) cohort of women newly diagnosed with BC during 2014–2017. Awareness indicators were assessed during a baseline interview at/near diagnosis. Logistic/ordinal regression was used to estimate odds ratios (OR) for indicators of BC awareness in relation to woman-level characteristics for individual settings and then meta-analyzed. In the 1,451 women included, almost all Namibian non-black women (n = 104) knew of BC and its curability, while in Namibian black and Zambian women, one in 7 (~ 15%) had not previously heard of BC and 25–40% did not know it was curable. In Uganda and Nigeria awareness was lowest: one in four women had no BC awareness, and 2 in 3 had no knowledge of its cure potential. Low educational level, unskilled employment, low socioeconomic position, rural residence, older age, being unmarried, and in some settings HIV-positivity, were associated with lower BC awareness—e.g., having unskilled employment was associated with not having heard of BC (summary OR 3.37; 95% confidence interval (CI) 2.17–5.23), believing that it is incurable (2.43; 1.81–3.26), and not recognizing a breast lump symptom (1.85; 1.41–2.43) but with between-setting variation (I2 > 68% for all). The findings provide evidence of the level and difference in BC awareness and beliefs across different settings, highlighting the urgent need for context-specific education programmes in the SSA region.

Background With high rates of HIV/AIDS and rising burdens of non-communicable diseases, Zambians increasingly need palliative care. While efforts are underway to grow Zambia’s palliative care system, the most recent situational analysis of palliative care in Zambia, conducted in 2008, revealed substantial gaps in availability. Methods To provide an updated appraisal of breast and cervical cancer services in Zambia, including palliative care, we conducted a nationwide provincial and tertiary hospital survey. All 9 provincial hospitals and the University Teaching Hospital and Cancer Diseases Hospital in Lusaka Province participated (N = 11). The survey was conducted between August 2014 and January 2015 and administered in-person at each facility. Data regarding the availability of inpatient, outpatient, and community-based palliative care services, palliative medications, and psychosocial supports was obtained at each facility. The reported results are descriptive in nature. Results Although the need for palliative care services was recognized, many facilities (64%) lack palliative care policies and only 18% offer palliative care in a coordinated program. The majority of services are only available to inpatients and rarely include community-based programs. While all facilities had adequate supplies of acetaminophen, 82% reported unavailability of codeine and 45% reported no access to oral morphine. Conclusions This assessment confirms the dearth of palliative care services across Zambia. Less than half of its provincial hospitals offer community- or home-based services and only 55% offer opioid analgesics. Immediate and substantial improvements in policy, drug procurement and distribution, and service expansion are needed to ensure high-quality palliative care is available throughout Zambia.

Introduction Sub-Saharan African (SSA) women with breast cancer (BC) have low survival rates from this potentially treatable disease. An understanding of context-specific societal, health-systems and woman-level barriers to BC early detection, diagnosis and treatment are needed. Methods The African Breast Cancer—Disparities in Outcomes (ABC-DO) is a prospective hospital-based study of overall survival, impact on quality of life (QOL) and delays along the journey to diagnosis and treatment of BC in SSA. ABC-DO is currently recruiting in Namibia, Nigeria, South Africa, Uganda and Zambia. Women aged 18 years or older who present at participating secondary and tertiary hospitals with a new clinical or histocytological diagnosis of primary BC are invited to participate. For consented women, tumour characteristics, specimen and treatment data are obtained. Over a 2-year enrolment period, we aim to recruit 2000 women who, in the first instance, will be followed for between 1 and 3 years. A face-to-face baseline interview obtains information on socioeconomic, cultural and demographic factors, QOL, health and BC attitudes/knowledge, and timing of all prediagnostic contacts with caregivers in orthodox health, traditional and spiritual systems. Responses are immediately captured on mobile devices that are fed into a tailored mobile health (mHealth) study management system. This system implements the study protocol, by prompting study researchers to phone women on her mobile phone every 3 months and, failing to reach her, prompts contact with her next-of-kin. At follow-up calls, women provide updated information on QOL, care received and disease impacts on family and working life; date of death is asked of her next-of-kin when relevant. Ethics and dissemination The study was approved by ethics committees of all involved institutions. All participants provide written informed consent. The findings from the study will be published in peer-reviewed scientific journals, presented to funders and relevant local organisations and at scientific conferences.

We sought to determine the clinical performance of visual inspection with acetic acid (VIA), digital cervicography (DC), Xpert human papillomavirus (HPV), and OncoE6 for cervical cancer screening in an HIV-infected population.HIV-infected women 18 years or older were included in this cross-sectional validation study conducted in Lusaka, Zambia. The screening tests were compared against a histological gold standard. We calculated sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, and odds ratios using cervical intraepithelial neoplasia grade 2 or worse (CIN 2+) and grade 3 or worse (CIN 3+) thresholds.Between January and June 2015, a total of 200 women were enrolled. Fifteen percent were screen positive by VIA, 20% by DC, 47% by Xpert HPV, and 6% by OncoE6. Using a CIN 2+ threshold, the sensitivity and specificity of VIA were 48% (95% CI = 30%-67%) and 92% (95% CI = 86%-95%), respectively. Similarly, the sensitivity and specificity of DC were 59% (95% CI = 41%-76%) and 88% (95% CI = 82%-93%), respectively. The sensitivity and specificity of Xpert HPV were 88% (95% CI = 71%-97%) and 60% (95% CI = 52%-68%), respectively. Finally, the sensitivity and specificity of OncoE6 were 31% (95% CI = 16%-50%) and 99% (95% CI = 97%-100%), respectively.VIA and DC displayed moderate sensitivity and high specificity. Xpert HPV performed equivalently to currently approved HPV DNA tests, with high sensitivity and moderate specificity. OncoE6 displayed excellent specificity but low sensitivity. These results confirm an important role for VIA, DC, and Xpert HPV in screen-and-treat cervical cancer prevention in low- and middle-income countries, such as Zambia.

Invasive cervical cancer is the second most common cancer among women worldwide, with approximately 85% of the disease burden occurring in developing countries. To date, there have been few systematic efforts to document African women's conceptualization of cervical cancer after participation in a visual inspection with acetic acid (VIA)-based “see and treat” cervical cancer prevention program. In this study, conducted between September, 2009–July, 2010, focus groups and in-depth interviews were conducted with 60 women who had recently undergone cervical cancer screening at a government-operated primary health care clinic in Lusaka, Zambia. Interviewers elicited participants' causal representations of cervical cancer, associated physical signs and symptoms, perceived physical and psychological effects, and social norms regarding the disease. The lay model of illness causation portrayed by participants after recent exposure to program promotion messages departed in several ways from causal models described in other parts of the world. However, causal conceptualizations included both lay and biomedical elements, suggesting a possible shift from a purely traditional causal model to one that incorporates both traditional concepts and recently promoted biomedical concepts. Most, but not all, women still equated cervical cancer with death, and perceived it to be a highly stigmatized disease in Zambia because of its anatomic location, dire natural course, connections to socially-condemned behaviors, and association with HIV/AIDS. No substantive differences of disease conceptualization existed according to HIV serostatus, though HIV positive women acknowledged that their immune status makes them more aware of their health and more likely to seek medical attention. Further attention should be dedicated to the processes by which women incorporate new knowledge into their representations of cervical cancer.

In Zambia, a country with a generalized HIV epidemic, age-adjusted cervical cancer incidence is among the highest worldwide. In 2006, the University of Alabama at Birmingham-Center for Infectious Disease Research in Zambia and the Zambian Ministry of Health launched a visual inspection with acetic acid (VIA) -based "see and treat" cervical cancer prevention program in Lusaka. All services were integrated within existing government-operated primary health care facilities.Study aims were to (i) identify women's motivations for cervical screening, (ii) document women's experiences with screening and (iii) describe the potentially reciprocal influences between women undergoing cervical screening and their social networks.Focus group discussions (FGD) and in-depth interviews (IDI) were conducted with women who accepted screening and with care providers. Low-level content analysis was performed to identify themes evoked by participants. Between September 2009 and July 2010, 60 women and 21 care providers participated in 8 FGD and 10 IDI.Women presented for screening with varying needs and expectations. A majority discussed their screening decisions and experiences with members of their social networks. Key reinforcing factors and obstacles to VIA screening were identified.Interventions are needed to gain support for the screening process from influential family members and peers.

The annual worldwide burden of the preventable disease cervical cancer is more than 530,000 new cases and 275,000 deaths, with the majority occurring in low- and middle-income countries (LMIC), where cervical cancer screening and early treatment are uncommon. Widely used in high-income countries, Pap smear (cytology based) screening is expensive and challenging for implementation in LMICs, where lower-cost, effective alternatives such as visual inspection with acetic acid (VIA) and rapid human papillomavirus (HPV)-based screening tests offer promise for scaling up prevention services. Integrating HPV screening with VIA in “screen-and-treat-or-refer” programs offers the dual benefits of HPV screening to maximize detection and using VIA to triage for advanced lesions/cancer, as well as a pelvic exam to address other gynecologic issues. A major issue in LMICs is coinfection with human immunodeficiency virus (HIV) and HPV, which further increases the risk for cervical cancer and marks a population with perhaps the greatest need of cervical cancer prevention. Public–private partnerships to enhance the availability of cervical cancer prevention services within HIV/AIDS care delivery platforms through initiatives such as Pink Ribbon Red Ribbon present an historic opportunity to expand cervical cancer screening in LMICs. Cancer Prev Res; 5(1); 11–17. ©2011 AACR.