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Purpose In low- and middle-income countries (LMICs), frequent outages of the stock of cancer drugs undermine cancer care delivery and are potentially fatal for patients with cancer. The aim of this study is to describe a methodologic approach to forecast chemotherapy volume and estimate cost that can be readily updated and applied in most LMICs. Methods Prerequisite data for forecasting are population-based incidence data and cost estimates per unit of drug to be ordered. We used the supplementary guidelines from the WHO list of essential medicines for cancer to predict treatment plans and ordering patterns. We used de-identified aggregate data from the Botswana National Cancer Registry to estimate incident cases. The WHO Management Sciences for Health International Price Indicator was used to estimate unit costs per drug. Results Chemotherapy volume required for incident cancer cases was estimated as the product of the standardized dose required to complete a full treatment regimen per patient, with a given cancer diagnosis and stage, multiplied by the total number of incident cancer cases with the respective diagnosis. The estimated chemotherapy costs to treat the 10 most common cancers in the public health care sector of Botswana is approximately 2.3 million US dollars. An estimated 66% of the budget is allocated to costs of rituximab and trastuzumab alone, which are used by approximately 10% of the cancer population. Conclusion This method provides a reproducible approach to forecast chemotherapy volume and cost in LMICs. The chemotherapy volume and cost outputs of this methodology provide key stakeholders with valuable information that can guide budget estimation, resource allocation, and drug-price negotiations for cancer treatment. Ultimately, this will minimize drug shortages or outages and reduce potential loss of lives that result from an erratic drug supply.

This study explored predictors of timely oncology care and whether being engaged in the medical system for HIV care improved time to access. According to records and interviews of cancer patients in Botswana, the median time from first symptom to specialized oncology care was 13 months. HIV status did not affect time to oncology care; however, advanced cancer stage and use of traditional medicine/healers was associated with earlier oncology access., Background. Three-quarters of cancer deaths occur in resource-limited countries, and delayed presentation contributes to poor outcome. In Botswana, where more than half of cancers arise in HIV-infected individuals, we sought to explore predictors of timely oncology care and evaluate the hypothesis that engagement in longitudinal HIV care improves access. Methods. Consenting patients presenting for oncology care from October 2010 to September 2014 were interviewed and their records were reviewed. Cox and logistic models were used to examine the effect of HIV and other predictors on time to oncology care and presentation with advanced cancer (stage III or IV). Results. Of the 1,146 patients analyzed, 584 (51%) had HIV and 615 (54%) had advanced cancer. The initial clinic visit occurred a mean of 144 days (median 29, interquartile range 0–185) after symptom onset, but subsequent mean time to oncology care was 406 days (median 160, interquartile range 59–653). HIV status was not significantly associated with time to oncology care (adjusted hazard ratio [aHR] 0.91, 95% confidence interval [CI] 0.79–1.06). However, patients who reported using traditional medicine/healers engaged in oncology care significantly faster (aHR 1.23, 95% CI 1.09–1.40) and those with advanced cancer entered care earlier (aHR 1.48, 95% CI 1.30–1.70). Factors significantly associated with advanced cancer included income

Abstract 67 Background: Health system delays are a major contributor to poor outcomes among cancer patients in low- and middle-income countries (LMICs). In Botswana, while median time from cancer-related symptom onset to first presentation at local health facility is 29 days, median time to initiation of cancer treatment is 401 days. Challenges to timely diagnosis and care include clinicians' lack of knowledge, limited diagnostic capacity, poor coordination between facilities, and socioeconomic barriers of patients that impede follow-up. We sought to develop an intervention to improve access to prompt cancer care. Methods: Participating facilities are all public health facilities (21 health posts, 14 clinics, 2 hospitals) in Botswana's Kweneng-East district as well as the national referral hospital. The five components of intervention are a) training of clinicians at primary facilities on evaluation of patients with suspected cancer, b) implementation of a standardized referral algorithm for cancer suspects, c) introduction of care-coordinator role to support patient and clinician navigation of the health system, d) use of SMS-based platform to support follow-up, e) provision of transport support for vulnerable patients. The primary endpoints are stage at cancer diagnosis and time from initial presentation to initiation of cancer treatment. Evaluation of the intervention's impact will include comparing endpoints following intervention with those at baseline and those among patients residing outside the Kweneng-East district. Results: Implementation of the above multi-component intervention will be presented, including a standardized algorithm to guide the evaluation, triage and referral of patients, an intensive one-day didactic training program that adapts curricula employed in the region, and the impact of training on knowledge. Conclusion: In conducting this study, we hope to identify effective program-based measures to reduce delays and improve cancer outcomes in Botswana. These measures may be scaled to other districts, and may be applicable to similar settings in the region. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST: Neo M. Tapela No relationship to disclose Malebogo Pusoentsi No relationship to disclose Kerapetse Botebele No relationship to disclose Michael Peluso No relationship to disclose Isaac Nkele No relationship to disclose Jason Efstathiou Honoraria: Medivation/Astellas, Bayer Healthcare Pharmaceuticals Consulting or Advisory Role: Medivation/Astellas, Bayer Healthcare Pharmaceuticals Tomer Barak No relationship to disclose Scott Dryden-Peterson No relationship to disclose

Abstract 69 Background: One of the challenges to addressing the growing burden of cancer in low- and middle-income countries is insufficient data and limitations in quality of cancer registries. The Botswana National Cancer Registry (BNCR), first established in 1999, is an IARC-endorsed population-based registry covering a population of 2.1 million. Here we assess BNCR's data quality over time. Methods: We conducted a retrospective review of BNCR data that was collected between January 1, 2005 and December 31, 2010. We assessed basis of cancer diagnosis, as well as key data quality indices (completeness, consistency, uniqueness, and accuracy) over two time periods: 2005–2007 and 2008–2010. We assessed cancer incidence and distribution during this time period, and reviewed Botswana Ministry of Health operational documents to identify major health care initiatives that may have had a bearing on cancer registry data quality. Results: In total, 8,938 cancer cases were registered 2005-2010. Kaposi sarcoma was the most commonly diagnosed cancer (n=1766, 19.4%), followed by cervical cancer (n=1252, 13.8%) and then breast cancer (n=801, 8.8%). During 2005-2007, 79% of all cancers were morphologically verified and 6% of were verified by death certificate alone. By 2008-2010, 89% of cancers were morphologically verified while none (0%) were verified by death certificate alone. There was a marked difference for basis of Kaposi sarcoma diagnosis (26% in 2005-2007, 43.8% 2008-2010), which changed from mainly clinical to pathology-based diagnosis. Factors that have contributed to this improvement include targeted initiatives such as clinician training, as well as broader health system developments such as general laboratory diagnostic capacitation that has facilitated use of histopathology services for cancer. Conclusion: BNCR data quality has improved over the years. These improvements enhance utility of cancer registry data for healthcare planning, and highlight the merit of cross-cutting health systems strengthening developments. This assessment, and the initiatives that have contributed to BNCR data improvement may be relevant to cancer registries in similar settings. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST: No COIs from the authors.