Search

Background: To assess population-based quality of cancer care in sub-Saharan Africa and to identify specific gaps and joint opportunities, we assessed concordance of diagnostics and treatments with National Comprehensive Cancer Network Harmonized Guidelines for leading cancer types in 10 countries., Methods: Adult patients with female breast cancer, cervical cancer, colorectal cancer, non-Hodgkin lymphoma, and prostate cancer were randomly drawn from 11 population-based cancer registries. Guideline concordance of diagnostics and treatment was assessed using clinical records. In a subcohort of 906 patients with potentially curable cancer (stage I-III breast cancer, cervical cancer, colorectal cancer, prostate cancer, aggressive non-Hodgkin lymphoma [any stage]) and documentation for more than 1 month after diagnosis, we estimated factors associated with guideline-concordant treatment or minor deviations., Results: Diagnostic information based on guidelines was complete for 1030 (31.7%) of a total of 3246 patients included. In the subcohort with curable cancer, guideline-concordant treatment was documented in 374 (41.3%, corresponding to 11.7% of 3246 patients included in the population-based cohort): aggressive non-Hodgkin lymphoma (59.8%/9.1% population based), breast cancer (54.5%/19.0%), prostate cancer (39.0%/6.1%), colorectal cancer (33.9%/9.5%), and cervical cancer (27.8%/11.6%). Guideline-concordant treatment was most frequent in Namibia (73.1% of the curable cancer subcohort/32.8% population based) and lowest in Kampala, Uganda (13.5%/3.1%). Guideline-concordant treatment was negatively associated with poor ECOG-ACRIN performance status, locally advanced disease stage, origin from low Human Development Index countries, and a diagnosis of colorectal cancer or cervical cancer., Conclusions: The quality of diagnostic workup and treatment showed major deficits, with considerable disparities among countries and cancer types. Improved diagnostic services are necessary to increase the share of curable cancer in sub-Saharan Africa. Treatment components within National Comprehensive Cancer Network Guidelines for several cancers should be prioritized., (© The Author(s) 2024. Published by Oxford University Press.)

Background: In response to climate change (CC), medicine needs to consider new aspects in health counselling of patients. Such climate-sensitive health counselling (CSHC) may include counselling patients on preventing and coping with climate-sensitive diseases or on leading healthy and climate-friendly lifestyles. This study aimed to identify previous participation in and preferences for CSHC as well as associated sociodemographic and attitudinal factors among the general public in Germany., Methods: We conducted a cross-sectional study in a population-based online panel in five German federal states (04-06/2022). We performed descriptive statistics and multivariable regression analysis to assess prior participation in CSHC and content preferences regarding CSHC, as well as associations between sociodemographic variables and general preference for CSHC., Results: Among 1491 participants (response rate 47.1%), 8.7% explicitly reported having participated in CSHC, while 39.9% had discussed at least one CSHC-related topic with physicians. In the studied sample, 46.7% of participants would like CSHC to be part of the consultation with their physician, while 33.9% rejected this idea. Participants aged 21 to 40 years (versus 51 to 60), individuals alarmed about CC (versus concerned/cautious/disengaged/doubtful/dismissive), and those politically oriented to the left (vs. centre or right) showed greater preference for CSHC in the multivariable regression model. Most participants wanted to talk about links to their personal health (65.1%) as opposed to links to the health of all people (33.2%)., Conclusions: Almost half of the participants in this sample would like to receive CSHC, especially those who are younger, more alarmed about CC and more politically oriented to the left. More research and training on patient-centred implementation of CSHC is needed., (© 2024. The Author(s).)

Background: In recent decades, Germany has experienced flood events that posed a threat to the health of the local population. However, there is a paucity of studies on the health consequences of these events. Therefore, the aim of the study was to investigate the health consequences of the Ahr Valley flood in 2021., Methods: The data basis of this longitudinal study are nationwide billing data (inpatient/outpatient) of the BKK-Landesverband Nordwest. The study region was Ahrweiler and the study periods were the third quarters of 2020 and 2021. Among other things, prevalence rate ratio tests were used to determine which diagnoses (inpatient/outpatient) were spatially and temporally associated with the flood event on the basis of ICD-10 coding., Results: The results show a significant increase in billed services for some diagnosis groups in the inpatient sector. In particular, there was an increase in F diagnoses (mental and behavioural disorders), S diagnoses (injuries) and various diagnosis codes within Z codes (factors influencing health status and leading to healthcare utilisation). In the outpatient sector, a decrease was observed in many diagnosis groups (F and Z diagnoses)., Conclusion: The results of the study showed that the mental health of the local population was particularly affected by the floods. Healthcare was also affected. As floods are expected to become more frequent and severe in the future, measures to protect the population and health infrastructure need to be adapted accordingly., (© 2023. The Author(s).)

Introduction: The climate crisis has serious consequences for many areas of life. This applies in particular to human health - also in Europe. While cardiovascular, pneumological and dermatological diseases related to the climate crisis are often discussed, the crisis' significant gastroenterological consequences for health must also be considered., Methods: A literature search (Pubmed, Cochrane Library) was used to identify papers with relevance particularly to the field of gastroenterology in (Central) Europe. Findings were supplemented and discussed by an interdisciplinary team., Results: The climate crisis impacts the frequency and severity of gastrointestinal diseases in Europe due to more frequent and severe heat waves, flooding and air pollution. While patients with intestinal diseases are particularly vulnerable to acute weather events, the main long-term consequences of climate change are gastrointestinal cancer and liver disease. In addition to gastroenteritis, other infectious diseases such as vector-borne diseases and parasites are important in the context of global warming, heat waves and floods., Discussion: Adaptation strategies must be consistently developed and implemented for vulnerable groups. Patients at risk should be informed about measures that can be implemented individually, such as avoiding heat, ensuring appropriate hydration and following hygiene instructions. Recommendations for physical activity and a healthy and sustainable diet are essential for the prevention of liver diseases and carcinomas. Measures for prevention and the promotion of resilience can be supported by the physicians at various levels. In addition to efforts fostering sustainability in the immediate working environment, a system-oriented commitment to climate protection is important., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: Although non-Hodgkin lymphoma (NHL) is the 6th most common malignancy in Sub-Saharan Africa (SSA), little is known about its management and outcome. Herein, we examined treatment patterns and survival among NHL patients., Methods: We obtained a random sample of adult patients diagnosed between 2011 and 2015 from 11 population-based cancer registries in 10 SSA countries. Descriptive statistics for lymphoma-directed therapy (LDT) and degree of concordance with National Comprehensive Cancer Network (NCCN) guidelines were calculated, and survival rates were estimated., Findings: Of 516 patients included in the study, sub-classification was available for 42.1% (121 high-grade and 64 low-grade B-cell lymphoma, 15 T-cell lymphoma and 17 otherwise sub-classified NHL), whilst the remaining 57.9% were unclassified. Any LDT was identified for 195 of all patients (37.8%). NCCN guideline-recommended treatment was initiated in 21 patients. This corresponds to 4.1% of all 516 patients, and to 11.7% of 180 patients with sub-classified B-cell lymphoma and NCCN guidelines available. Deviations from guideline-recommended treatment were initiated in another 49 (9.5% of 516, 27.2% of 180). By registry, the proportion of all patients receiving guideline-concordant LDT ranged from 30.8% in Namibia to 0% in Maputo and Bamako. Concordance with treatment recommendations was not assessable in 75.1% of patients (records not traced (43.2%), traced but no sub-classification identified (27.8%), traced but no guidelines available (4.1%)). By registry, diagnostic work-up was in part importantly limited, thus impeding guideline evaluation significantly. Overall 1-year survival was 61.2% (95%CI 55.3%-67.1%). Poor ECOG performance status, advanced stage, less than 5 cycles and absence of chemo (immuno-) therapy were associated with unfavorable survival, while HIV status, age, and gender did not impact survival. In diffuse large B-cell lymphoma, initiation of guideline-concordant treatment was associated with favorable survival., Interpretation: This study shows that a majority of NHL patients in SSA are untreated or undertreated, resulting in unfavorable survival. Investments in enhanced diagnostic services, provision of chemo(immuno-)therapy and supportive care will likely improve outcomes in the region., (© The Author(s) 2023. Published by Oxford University Press.)

Background: The burden of colorectal cancer (CRC) is increasing in Sub-Saharan Africa (SSA). However, little is known about CRC treatment and survival in the region., Methods: A random sample of 653 patients with CRC diagnosed from 2011 to 2015 was obtained from 11 population-based cancer registries in SSA. Information on clinical characteristics, treatment, and/or vital status was obtained from medical records in treating hospitals for 356 (54%) of the patients ("traced cohort"). Concordance of CRC treatment with NCCN Harmonized Guidelines for SSA was assessed. A Cox proportional hazards model was used to examine the association between survival and human development index (HDI)., Results: Of the 356 traced patients with CRC, 51.7% were male, 52.8% were from countries with a low HDI, 55.1% had colon cancer, and 73.6% were diagnosed with nonmetastatic (M0) disease. Among the patients with M0 disease, however, only 3.1% received guideline-concordant treatment, 20.6% received treatment with minor deviations, 31.7% received treatment with major deviations, and 35.1% received no treatment. The risk of death in patients who received no cancer-directed therapy was 3.49 (95% CI, 1.83-6.66) times higher than in patients who received standard treatment or treatment with minor deviations. Similarly, the risk of death in patients from countries with a low HDI was 1.67 (95% CI, 1.07-2.62) times higher than in those from countries with a medium HDI. Overall survival at 1 and 3 years was 70.9% (95% CI, 65.5%-76.3%) and 45.3% (95% CI, 38.9%-51.7%), respectively., Conclusions: Fewer than 1 in 20 patients diagnosed with potentially curable CRC received standard of care in SSA, reinforcing the need to improve healthcare infrastructure, including the oncology and surgical workforce.

Background: Surgery is contributing to the climate crisis, not least in the outpatient sector. The present publication aims to identify the challenges this poses, and to provide clear, preferably evidence-based recommendations on environmental protection while simultaneously reducing costs., Method: Narrative review with a non-systematic search and selection in PubMed/MEDLINE and grey area literature as well as expert interviews., Results: Numerous primary articles, evidence syntheses, practical recommendations for action and checklists were identified and two experts were interviewed. Environmental issues were identified in the production and procurement, transport of people and goods, usage of materials, pharmaceuticals including anesthetic gases and energy consumption in the outpatient practice and also in disposal, recycling, and sterilization. High-quality publications do not describe a lack of knowledge on alternatives but on a lack of implementation in clinical practice. Therefore, the identified issues were classified in the 5‑R scheme (reduce, reuse, recycle, rethink, research) to present recommendations for action, which are synergetic in terms of cost reduction, patient and staff satisfaction. Furthermore, changes in regulatory frameworks are discussed., Conclusion: Outpatient surgery comes with relevant consumption of resources and carbon emissions. There are numerous opportunities for action that combine environmental protection with cost reduction as well as patient and staff satisfaction. Incentives, guidelines, and legal framework conditions are needed for comprehensive environmental protection in the private sector., (© The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2023.)

Physicians play an important role in adapting to and mitigating the adverse health effects of the unfolding climate and ecological crises. To fully harness this potential, future physicians need to acquire knowledge, values, skills, and leadership attributes to care for patients presenting with environmental change-related conditions and to initiate and propel transformative change in healthcare and other sectors of society including, but not limited to, the decarbonization of healthcare systems, the transition to renewable energies and the transformation of transport and food systems. Despite the potential of Planetary Health Education (PHE) to support medical students in becoming agents of change, best-practice examples of mainstreaming PHE in medical curricula remain scarce both in Germany and internationally. The process of revising and updating the Medical Licensing Regulations and the National Competency-based Catalog of Learning Objectives for Medical Education in Germany provided a window of opportunity to address this implementation challenge. In this article, we describe the development and content of national Planetary Health learning objectives for Germany. We anticipate that the learning objectives will stimulate the development and implementation of innovative Planetary Health teaching, learning and exam formats in medical schools and inform similar initiatives in other health professions. The availability of Planetary Health learning objectives in other countries will provide opportunities for cross-country and interdisciplinary exchange of experiences and validation of content, thus supporting the consolidation of Planetary Health learning objectives and the improvement of PHE for all health professionals globally., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Wabnitz, Schwienhorst-Stich, Asbeck, Fellmann, Gepp, Leberl, Mezger and Eichinger.)

Background: Breast cancer (BC) is the most common cancer in sub-Saharan Africa (SSA). However, little is known about the actual therapy received by women with BC and their survival outcome at the population level in SSA. This study aims to describe the cancer-directed therapy received by patients with BC at the population level in SSA, compare these results with the NCCN Harmonized Guidelines for SSA (NCCN Harmonized Guidelines), and evaluate the impact on survival., Methods: Random samples of patients with BC (≥40 patients per registry), diagnosed from 2009 through 2015, were drawn from 11 urban population-based cancer registries from 10 countries (Benin, Congo, Cote d'Ivoire, Ethiopia, Kenya, Mali, Mozambique, Namibia, Uganda, and Zimbabwe). Active methods were used to update the therapy and outcome data of diagnosed patients ("traced patients"). Excess hazards of death by therapy use were modeled in a relative survival context., Results: A total of 809 patients were included. Additional information was traced for 517 patients (63.8%), and this proportion varied by registry. One in 5 traced patients met the minimum diagnostic criteria (cancer stage and hormone receptor status known) for use of the NCCN Harmonized Guidelines. The hormone receptor status was unknown for 72.5% of patients. Of the traced patients with stage I-III BC (n=320), 50.9% received inadequate or no cancer-directed therapy. Access to therapy differed by registry area. Initiation of adequate therapy and early-stage diagnosis were the most important determinants of survival., Conclusions: Downstaging BC and improving access to diagnostics and care are necessary steps to increase guideline adherence and improve survival for women in SSA. It will also be important to strengthen health systems and facilities for data management in SSA to facilitate patient follow-up and disease surveillance.

Background: Although prostate cancer (PCa) is the most commonly diagnosed cancer in men of sub-Saharan Africa (SSA), little is known about its management and survival. The objective of the current study was to describe the presentation, patterns of diagnosis, treatment, and survival of patients with PCa in 10 countries of SSA., Methods: In this observational registry study with data collection from 2010 to 2018, the authors drew a random sample of 738 patients with PCa who were registered in 11 population-based cancer registries. They described proportions of patients receiving recommended care and presented survival estimates. Multivariable Cox regression was used to calculate hazard ratios comparing the survival of patients with and without cancer-directed therapies (CDTs)., Results: The study included 693 patients, and tumor characteristics and treatment information were available for 365 patients, 37.3% of whom had metastatic disease. Only 11.2% had a complete diagnostic workup for risk stratification. Among the nonmetastatic patients, 17.5% received curative-intent therapy, and 27.5% received no CDT. Among the metastatic patients, 59.6% received androgen deprivation therapy. The 3- and 5-year age-standardized relative survival for 491 patients with survival time information was 58.8% (95% confidence interval [CI], 48.5%-67.7%) and 56.9% (95% CI, 39.8%-70.9%), respectively. In a multivariable analysis, survival was considerably poorer among patients without CDT versus those with therapy., Conclusions: This study shows that a large proportion of patients with PCa in SSA are not staged or are insufficiently staged and undertreated, and this results in unfavorable survival. These findings reemphasize the need for improving diagnostic workup and access to care in SSA in order to mitigate the heavy burden of the disease in the region., (© 2021 The Authors. Cancer published by Wiley Periodicals LLC on behalf of American Cancer Society.)

Introduction: The impact of climate change on health and the necessity to reduce emissions in the health sector is becoming an increasingly discussed topic. Little is known about medical doctors' (MDs) attitude towards climate protection measures in outpatient practices., Methods: Between October 2020 and February 2021, a survey was conducted among MDs in German practices. 1,683 participants answered 39 questions on energy use, transportation, disposable materials, budget and patient counselling. Data were collected on status, motivation, obstacles and needs regarding climate protection in practices., Results: 83% considered climate change an urgent problem requiring immediate action. A majority reported climate effects on their patients' health. Most MDs felt responsible for climate protection in their practices, showing a high degree of willingness to implement climate-friendly measures. Obstacles reported include lack of information and institutional support as well as the expected financial burden. A majority of MDs called on professional associations and politics to develop climate-friendly strategies., Conclusion: In view of national climate targets and the willingness of outpatient MDs to contribute to climate protection, support from medical associations is required, e. g. through practical recommendations and financial help, in order to transform the health sector in accordance with the idea of Planetary Health. Accompanying studies should provide further evidence on effective measures to reduce greenhouse gas emissions in practices., (Copyright © 2021. Published by Elsevier GmbH.)

Background: Cervical cancer (CC) is the most common female cancer in many countries of sub-Saharan Africa (SSA). We assessed treatment guideline adherence and its association with overall survival (OS)., Methods: Our observational study covered nine population-based cancer registries in eight countries: Benin, Ethiopia, Ivory Coast, Kenya, Mali, Mozambique, Uganda, and Zimbabwe. Random samples of 44-125 patients diagnosed from 2010 to 2016 were selected in each. Cancer-directed therapy (CDT) was evaluated for degree of adherence to National Comprehensive Cancer Network (U.S.) Guidelines., Results: Of 632 patients, 15.8% received CDT with curative potential: 5.2% guideline-adherent, 2.4% with minor deviations, and 8.2% with major deviations. CDT was not documented or was without curative potential in 22%; 15.7% were diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage IV disease. Adherence was not assessed in 46.9% (no stage or follow-up documented, 11.9%, or records not traced, 35.1%). The largest share of guideline-adherent CDT was observed in Nairobi (49%) and the smallest in Maputo (4%). In patients with FIGO stage I-III disease (n = 190), minor and major guideline deviations were associated with impaired OS (hazard rate ratio [HRR], 1.73; 95% confidence interval [CI], 0.36-8.37; HRR, 1.97; CI, 0.59-6.56, respectively). CDT without curative potential (HRR, 3.88; CI, 1.19-12.71) and no CDT (HRR, 9.43; CI, 3.03-29.33) showed substantially worse survival., Conclusion: We found that only one in six patients with cervical cancer in SSA received CDT with curative potential. At least one-fifth and possibly up to two-thirds of women never accessed CDT, despite curable disease, resulting in impaired OS. Investments into more radiotherapy, chemotherapy, and surgical training could change the fatal outcomes of many patients., Implications for Practice: Despite evidence-based interventions including guideline-adherent treatment for cervical cancer (CC), there is huge disparity in survival across the globe. This comprehensive multinational population-based registry study aimed to assess the status quo of presentation, treatment guideline adherence, and survival in eight countries. Patients across sub-Saharan Africa present in late stages, and treatment guideline adherence is remarkably low. Both factors were associated with unfavorable survival. This report warns about the inability of most women with cervical cancer in sub-Saharan Africa to access timely and high-quality diagnostic and treatment services, serving as guidance to institutions and policy makers. With regard to clinical practice, there might be cancer-directed treatment options that, although not fully guideline adherent, have relevant survival benefit. Others should perhaps not be chosen even under resource-constrained circumstances., (© 2021 The Authors. The Oncologist published by Wiley Periodicals LLC on behalf of AlphaMed Press.)

Non-Hodgkin lymphoma (NHL) is the sixth most common cancer in Sub-Saharan Africa (SSA). Comprehensive diagnostics of NHL are essential for effective treatment. Our objective was to assess the frequency of NHL subtypes, disease stage and further diagnostic aspects. Eleven population-based cancer registries in 10 countries participated in our observational study. A random sample of 516 patients was included. Histological confirmation of NHL was available for 76.2% and cytological confirmation for another 17.3%. NHL subclassification was determined in 42.1%. Of these, diffuse large B cell lymphoma, chronic lymphocytic leukaemia and Burkitt lymphoma were the most common subtypes identified (48.8%, 18.4% and 6.0%, respectively). We traced 293 patients, for whom recorded data were amended using clinical records. For these, information on stage, human immunodeficiency virus (HIV) status and Eastern Cooperative Oncology Group Performance Status (ECOG PS) was available for 60.8%, 52.6% and 45.1%, respectively. Stage at diagnosis was advanced for 130 of 178 (73.0%) patients, HIV status was positive for 97 of 154 (63.0%) and ECOG PS was ≥2 for 81 of 132 (61.4%). Knowledge about NHL subclassification and baseline clinical characteristics is crucial for guideline-recommended treatment. Hence, regionally adapted investments in pathological capacity, as well as standardised clinical diagnostics, will significantly improve the therapeutic precision for NHL in SSA., (© 2020 The Authors. British Journal of Haematology published by British Society for Haematology and John Wiley & Sons Ltd.)