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Purpose Belize has among the highest cervical cancer incidence and mortality rates of Latin American and Caribbean countries. This study evaluates the perspectives of key stakeholders for cervical cancer screening in Belize and identifies the barriers and facilitators for providing equitable access to prevention services. Methods Semi-structured interviews discussing cervical cancer screening were conducted with key stakeholders across the six districts of Belize in 2018. Interviews were transcribed, coded, and analyzed thematically; themes were organized by levels of the social-ecological model. Results We conducted 47 interviews with health care providers (45%), administrators (17%), government officials (25%), and other stakeholders (13%). Majority (78%) of interviews were from the public sector. Perceived barriers to cervical cancer screening were identified across multiple levels: (1) Individual Patient: potential delays in Pap smear results and fear of a cancer diagnosis; (2) Provider: competing clinician responsibilities; (3) Organizational: insufficient space and training; (4) Community: reduced accessibility in rural areas; and (5) Policy: equipment and staffing budget limitations. The main facilitators we identified included the following: (1) at the Community level: resource-sharing between public and private sectors and dedicated rural outreach personnel; (2) at the Policy level: free public screening services and the establishment of population-based screening. Conclusion Despite free, publicly available cervical cancer screening in Belize, complex barriers affect access and completion of management when abnormal screening tests are identified. Provider workload, education outreach, and additional funding for training and facilities are potential areas for strengthening this program and increasing detection and management for cervical cancer control.

In resource-limited settings, augmenting primary care provider (PCP)-based referrals with data-derived algorithms could direct scarce resources towards those patients most likely to have a cancer diagnosis and benefit from early treatment. Using data from Botswana, we compared accuracy of predictions of probable cancer using different approaches for identifying symptomatic cancer at primary clinics. We followed cancer suspects until they entered specialized care for cancer treatment (following pathologically confirmed diagnosis), exited from the study following noncancer diagnosis, or died. Routine symptom and demographic data included baseline cancer probability assessed by the primary care provider (low, intermediate, high), age, sex, performance status, baseline cancer probability by study physician, predominant symptom (lump, bleeding, pain or other) and HIV status. Logistic regression with 10-fold cross-validation was used to evaluate classification by different sets of predictors: (1) PCPs, (2) Algorithm-only, (3) External specialist physician review and (4) Primary clinician augmented by algorithm. Classification accuracy was assessed using c-statistics, sensitivity and specificity. Six hundred and twenty-three adult cancer suspects with complete data were retained, of whom 166 (27%) were diagnosed with cancer. Models using PCP augmented by algorithm (c-statistic: 77.2%, 95% CI: 73.4%, 81.0%) and external study physician assessment (77.6%, 95% CI: 73.6%, 81.7%) performed better than algorithm-only (74.9%, 95% CI: 71.0%, 78.9%) and PCP initial assessment (62.8%, 95% CI: 57.9%, 67.7%) in correctly classifying suspected cancer patients. Sensitivity and specificity statistics from models combining PCP classifications and routine data were comparable to physicians, suggesting that incorporating data-driven algorithms into referral systems could improve efficiency.

Summary Background Cost-effectiveness data for cancer treatment are needed from sub-Saharan Africa, where diffuse large B-cell lymphoma (DLBCL) is a common, curable cancer. In high-income countries, the standard of care for DLBCL is R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) chemoimmunotherapy. Rituximab is often not available in sub-Saharan Africa due to perceived unaffordability, and treatment with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) is common. We aimed to evaluate the cost-effectiveness of treatment in Malawi, comparing best supportive care, CHOP, or R-CHOP in patients with DLBCL. Methods For this cost-effectiveness analysis, we used published Malawi microcosting data, clinical data from a prospective cohort treated with CHOP, and clinical trial data evaluating R-CHOP. We used a decision-tree model to calculate costs per disability-adjusted life-year (DALY) averted from the health system perspective for the treatment of patients with DLBCL with best supportive care, CHOP, or R-CHOP, running the model on a per-patient basis and a Malawi population-level basis. We used the WHO definitions of cost-effective (three times the GDP per capita of the country) and extremely cost-effective (equal to the GDP per capita of the country) as willingness-to-pay thresholds for Malawi. Findings On a per-patient level, compared with best supportive care, CHOP was estimated to avert a mean 7·4 DALYs at an incremental cost of US$1384, for an incremental cost-effectiveness ratio (ICER) of $189 per DALY averted, which is substantially lower than the willingness-to-pay threshold (extremely cost-effective). Compared with CHOP, R-CHOP was estimated to avert 2·8 DALYs at an incremental cost of $3324, resulting in an ICER of $1204 per DALY averted, which is slightly higher than the cost-effective willingness-to-pay threshold. In probabilistic sensitivity analyses, CHOP remained cost-effective for DLBCL treatment in more than 99% of simulations, whereas R-CHOP was lower than the threshold in 46% of simulations. Interpretation We estimated CHOP to be cost-effective for DLBCL treatment in Malawi, and that the addition of rituximab might be cost-effective. Despite upfront costs, DLBCL treatment is probably a prudent investment relative to other accepted health interventions in sub-Saharan Africa. Funding National Institutes of Health.

Female sex workers (FSW) in Malawi have among the highest HIV prevalence estimates worldwide. Daily oral pre-exposure prophylaxis (PrEP) is an effective HIV prevention method, yet preferences for PrEP delivery among FSW are lacking. Eight focus group discussions, a literature review, and cognitive interviews were conducted to identify modifiable PrEP delivery attributes and inform discrete-choice experiment (DCE) development for FSW in Lilongwe. Enrolled FSW received an interviewer-assisted DCE. Data were analyzed using mixed logit regression. Dispensing location was most preferred, followed by the provision of additional services. Women preferred receiving PrEP at family planning clinics or non-governmental organization run drop-in centers. Cervical cancer screening was the most preferred additional service, while pregnancy testing and partner risk reduction counseling were less valued. This study was the first study to examine PrEP delivery preferences in Malawi using DCE-a powerful elicitation tool to apply to other key populations at risk for HIV.

In Botswana, where human immunodeficiency virus (HIV) prevalence remains high, cervical cancer is the leading cause of cancer deaths in women. Multiple organizations recommend high-risk human papillomavirus (hr-HPV) testing as a screening tool; however, high coverage may not be feasible with provider-collected samples. We conducted the first assessment of self- versus provider-collected samples for hr-HPV testing in HIV-positive women in Botswana and report prevalence of hr-HPV and histological outcomes. We recruited HIV-positive women ≥25 years attending an HIV clinic in Gaborone. Self- and provider-collected samples from participants were tested for hr-HPV using Cepheid GeneXpert. Women testing positive for any hr-HPV returned for colposcopy. We used unweighted κ statistics to determine hr-HPV agreement. We report that 31 (30%) of 103 women tested positive for any hr-HPV. The most common genotypes were HPV 31/33/35/52/58. Overall agreement between self- and provider-collected samples for any hr-HPV was 92% with a κ of 0.80. Ten of the 30 hr-HPV-positive women attending colposcopy had CIN2+ (33%). In conclusion, in this HIV-positive population, there was excellent agreement between self and provider samples, and self-sampling may play an important role in screening programs in high HIV burden settings with limited resources like Botswana.

Objective: Women experiencing homelessness are at increased risk of cervical cancer and have disproportionately low Pap screening behaviors compared to the general population. Prevalence of Pap refusals and multiple kinds of trauma, specifically sexual trauma, are high among homeless women. This qualitative study explored how trauma affects Pap screening experiences, behaviors, and provider practices in the context of homelessness. Methods: We conducted 29 in-depth interviews with patients and providers from multiple sites of a Federally Qualified Health Center as part of a study on barriers and facilitators to cervical cancer screening among urban women experiencing homelessness. The Health Belief Model and trauma-informed frameworks guided the analysis. Results: Trauma histories were common among the 18 patients we interviewed. Many women also had strong physical and psychological reactions to screening, which influenced current behaviors and future intentions. Although most women had screened at least once in their lifetime, many patients experienced anticipated anxiety and retraumatization which pushed them to delay or refuse Paps. We recruited 11 providers who identified strategies they used to encourage screening, including emphasizing safety and shared decision-making before and during the exam, building strong patient–provider trust and communication, and individually tailoring education and counseling to patients’ needs. We outlined suggestions and implications from these findings as trauma-informed cervical cancer screening. Conclusion: Discomfort with Pap screening was common among women experiencing homelessness, especially those with histories of sexual trauma. Applying a trauma-informed approach to cervical cancer screening may help address complex barriers among women experiencing homelessness, with histories of sexual trauma, or others who avoid, delay, or refuse the exam.

PURPOSE: Underserved Black and Hispanic/Latinx women show low rates of follow-up care after an abnormal Pap test, despite the fact that cervical cancer is one of the few preventable cancers if detected early. However, extant literature falls short on efficacious interventions to increase follow-up for this population. A concurrent mixed methods study was completed to evaluate the acceptability of a text message-based intervention and identify perceived barriers and facilitators to follow-up after an abnormal Pap test among underserved predominantly Black and Hispanic/Latinx women. METHODS: Patients who completed follow-up for an abnormal Pap test were recruited to complete a cross-sectional survey, qualitative interview assessing barriers and facilitators to follow-up, and text message content evaluation (N=28). Descriptive statistics were performed to describe background variables and to evaluate the acceptability of text messages. A directed content analysis was completed for the qualitative interviews. RESULTS: Participants expressed interest in a text message-based intervention to increase abnormal Pap test follow-up. In the qualitative interviews, low knowledge about cervical risk and negative affect towards colposcopy/test results were identified as barriers to follow-up. Facilitators of follow-up included feeling relieved after the colposcopy and adequate social support. Participants rated the text messages as understandable, personally relevant, and culturally appropriate. CONCLUSIONS: The findings suggest that underserved Black and Hispanic/Latinx women experience cognitive and emotional barriers that undermine their ability to obtain follow-up care and a text message-based intervention may help women overcome these barriers. Future research should develop and evaluate text message-based interventions to enhance follow-up after an abnormal Pap test.

Background Cancer incidence is increasing in Africa, and the majority of patients are diagnosed with advanced disease, limiting treatment options and survival. We sought to understand care patterns and factors contributing to delayed diagnosis and treatment initiation among patients with cancer in Botswana. Patients and Methods We recruited 20 patients who were enrolled in a prospective cancer cohort in Botswana to a qualitative substudy that explored cancer care pathways and factors affecting cancer care access and quality. We conducted an in-depth interview with each participant between October 2014 and January 2015, using a a structured interview guide with questions about initial cancer symptoms, previous consultations, diagnosis, and care pathways. Medical records were used to confirm dates or treatment details when needed. Results Individual and interpersonal factors such as cancer awareness and social support facilitated care-seeking behaviors. However, patients experienced multiple delays in diagnosis and treatment because of provider and health system barriers. Health system factors, such as misdiagnosis, understaffed facilities, poor referral communication and scheduling, and inadequate laboratory reporting systems, affected access to and quality of cancer care. Conclusion These findings highlight the need for interventions at the patient, provider, and health system levels to improve cancer care quality and outcomes in Botswana. Results also suggest that widespread cancer education has potential to promote early diagnosis through family and community networks. Identified barriers and facilitators suggest that interventions to improve community education and access to diagnostic technologies could help improve cancer outcomes in this setting. Implications for Practice The majority (54%) of patients with cancer in Botswana present with advanced-stage cancer despite universal access to free health care, limiting the options for treatment and decreasing the likelihood of positive treatment outcomes. To reduce time from symptom onset to cancer treatment initiation, causes of delay in cancer care trajectories must be identified. The narratives of the patients interviewed for this study give insight into psychosocial factors, outlooks on disease, lower-level provider delays, and health system barriers that contribute to substantial delays for patients with cancer in Botswana. Identification of problems and barriers is essential for development of effective interventions to mitigate these factors, in order to improve cancer outcomes in this population.

Background: HPV self-collection has been hampered by low adherence to triage to identify HPV-positive women needing diagnostic procedures. We investigated effectiveness of a multi-component mHealth intervention to increase adherence to triage among women with HPV-positive self-collected tests. Methods: We conducted a hybrid type I cluster randomized effectiveness-implementation trial in Jujuy, Argentina. Community health workers (CHWs) were eligible if actively offering HPV self-collection and served at least 26 eligible women. And women who performed self-collection and provided a mobile phone number were eligible for enrolment by the CHW. 260 CHWs were randomly allocated (3:2 ratio) to intervention (SMS messages sent to HPV-positive women and to CHWs informing them to visit non-adherent women) or the control group (usual care). The primary effectiveness outcome was percentage of HPV-positive women with triage 120 days after the test result. We evaluated the implementation of the intervention using the RE-AIM framework. Findings: 221 CHWs (132 intervention, 89 control group) contacted 5389 women; and 5351 agreed to participate (3241 intervention, 2110 control group). In total 314/445 (70·5%) HPV-positive women of the intervention group had triage at 120 days after the HPV result, compared to 163/292 (55·1%) in the control group (15·5% point improvement; 95%CI: 6·8–24·1). 97·2% of women accepted the intervention and 86·9% of CHWs agreed with adopting the intervention. Interpretation: The multicomponent mHealth intervention is highly effective in increasing adherence to triage, allowing for many more women at risk of cervical cancer to receive timely follow-up. Clinical Trial Registration Details: The trial is registered in ClinicalTrials.gov (NCT03478397). Funding Information: National Cancer Institute, National Institutes of Health, USA. Declaration of Interests: We declare no competing interests. Ethics Approval Statement: The study was approved by the Bioethics Review Committee of Jujuy’s Ministry of Health and Institutional Review Boards of CEMIC, Harvard T.H Chan School of Public Health and Rutgers University, and the Deakin University Human Research Ethics Committee. Women signed an informed consent, as well as CHWs participating in the CHW survey.

Rationale Graphic health warnings (GHWs) on cigarette packages present an important tobacco control opportunity, particularly for vulnerable populations suffering a disproportionate tobacco burden. One mechanism by which GHWs may influence smoking outcomes is by prompting interpersonal discussions within health discussion networks (the set of personal contacts with whom an individual discusses health issues). Objective The study examined the association between GHW-prompted conversations within health discussion networks and key tobacco-related outcomes, with attention to valence and content of the discussions. Method Between August 2013 and April 2014, we recruited 1200 individuals from three communities in Massachusetts, emphasizing recruitment of individuals of low socioeconomic position (SEP) and members of other selected vulnerable groups. Respondents were exposed to the nine GHWs proposed by the FDA in 2011, asked a series of questions, and assessed at follow-up a few weeks later. Results A total of 806 individuals were included in this analysis. About 51% of respondents reported having a health discussion network, with significantly lower reports among African-Americans and Hispanics compared to Whites. Around 70% of respondents (smokers and nonsmokers) with health discussion networks reported having one or more conversations about the GHWs with network members, the bulk of which were negative and focused on warning others about smoking. For smokers, we found a small but positive association between the percentage of network conversations that were negative and reports of quit attempts. Conclusion The results point to a potential mechanism by which GHWs may impact tobacco-related outcomes, prompting further inquiry into the role of health discussion networks (and discussion networks, more broadly) in tobacco control among low SEP individuals.

Objective: To assess the acceptability and preferences of HPV screening with self- sampling and mobile phone results delivery among women living with HIV (WLWH) in Botswana, as an alternative to traditional speculum screening.Methods: WLWH aged 25 years or older attending an infectious disease clinic in Gaborone were enrolled in a cross- sectional study between March and April 2017.Women self- sampled with a flocked swab, had a speculum exam, and completed an interviewer- administered questionnaire about screening acceptability, experiences,and preferences.Results: Of the 104 WLWH recruited, 98 (94%) had a history of traditional screening. Over 90% agreed self- sampling was easy and comfortable. Ninety- five percent were willing to self- sample again; however, only 19% preferred self- sampling over speculumexam for future screening. Preferences differed by education and residence with self- sampling being considered more convenient, easier, less embarrassing, and less painful. Speculum exams were preferred because of trust in providers’ skills and women's low self- efficacy to sample correctly. Almost half (47%) preferred to receive results via mobile phone call. Knowledge of cervical cancer did not affect preferences.Conclusion: HPV self- sampling is acceptable among WLWH in Botswana; however, preferences vary. Although self- sampling is an important alternative to traditional speculum screening, education and support will be critical to address women's low self- efficacy to self- sample correctly.

Purpose Men in Botswana present with more advanced cancer than women, leading to poorer outcomes. We sought to explain sex-specific differences in time to and stage at treatment initiation. Methods Cancer patients who initiated oncology treatment between October 2010 and June 2017 were recruited at four oncology centers in Botswana. Primary outcomes were time from first visit with cancer symptom to treatment initiation, and advanced cancer (stage III/IV). Sociodemographic and clinical covariates were obtained retrospectively through interviews and medical record review. We used accelerated failure time and logistic models to estimate standardized sex differences in treatment initiation time and risk differences for presentation with advanced stage. Results were stratified by cancer type (breast, cervix, non-Hodgkin’s lymphoma, anogenital, head and neck, esophageal, other). Results 1886 participants (70% female) were included. After covariate adjustment, men experienced longer excess time from first presentation to treatment initiation (8.4 months) than women (7.0 months) for all cancers combined (1.4 months, 95% CI: 0.30, 2.5). In analysis stratified by cancer type, we only found evidence of a sex disparity (Men: 8.2; Women: 6.8 months) among patients with other, non-common cancers (1.4 months, 95% CI: 0.01, 2.8). Men experienced an increased risk of advanced stage (Men: 67%; Women: 60%; aRD: 6.7%, 95% CI: -1.7%, 15.1%) for all cancers combined, but this disparity was only statistically significant among patients with anogenital cancers (Men: 72%; Women: 50%; aRD: 22.0%, 95% CI: 0.5%, 43.5%). Conclusions Accounting for the types of cancers experienced by men and women strongly attenuated disparities in time to treatment initiation and stage. Higher incidence of rarer cancers among men could explain these disparities.

BACKGROUND SMS interventions are effective in promoting a variety of health behaviors; however, there is scarce information regarding SMS use for cervical cancer screening and follow-up care. The ATICA Study (Application of Communication and Information Technologies to Self-Collection, for its initials in Spanish) aims to evaluate a multi-component mHealth intervention to increase triage adherence among women with HPV-positive self-collected tests in Jujuy, Argentina. Here, we describe the formative results used to design the content of the SMS to be tested in the trial. OBJECTIVE To understand cultural and contextual elements, women’s beliefs and perceptions regarding the use of SMS by the health care system, and women’s preferences about the message content. METHODS We conducted five focus groups, stratified by rural/urban residence and age. All participants were aged 30 or older and had performed HPV self-collection. Participatory techniques, including brainstorming, card-based classification and discussions were used to debate the advantages and disadvantages of messages. We openly coded the discussions for agreements and preferences regarding SMS content. Messages for both HPV negative and positive women were validated through interviews with health authorities and 14 HPV-tested women. The final versions of the messages were pilot tested. RESULTS Forty-eight women participated in the FGs. Participant women rejected receiving both negative and positive HPV-results by SMS, as for them delivery of results should be done in a face-to-face encounter with health professionals. They stressed the importance of SMS content informing them that results were available to pick them up while highlighting the link they had with CHWs and the nearest health center. Women considered that a personalized SMS was important, as well as the use of a formal yet warm tone. Due to confidentiality issues, not using the word HPV was also a key component of the desired SMS content; therefore the final message included the term “self-collection” without mention of HPV infection. Results from the validation stage and pilot test showed high acceptability of the final version of the message. CONCLUSIONS Results suggest SMS is accepted when notifying women about HPV result availability, but it should not replace the delivery of results in face-to-face, doctor-patient encounters. Messages must be tailored and have a persuasive tone in order to motivate women to adhere to triage. CLINICALTRIAL ClinicalTrials.gov, NCT03478397. Registered on March 20th, 2018.

Background SMS interventions are effective in promoting a variety of health behaviors; however, there is limited information regarding the use of SMS for cervical cancer screening and follow-up care. The Application of Communication and Information Technologies to Self-Collection study aims to evaluate a multicomponent mobile health intervention to increase triage adherence among women with human papillomavirus (HPV)–positive self-collected tests in Jujuy, Argentina. Here, we describe the formative results used to design the content of the SMS to be tested in the trial. Objective This study aimed to understand the cultural and contextual elements, women’s beliefs, and perceptions regarding the use of SMS by the health care system and women’s preferences about the message content. Methods We conducted five focus groups (FGs), stratified by rural or urban residence and age. All participants were aged 30 years or older and had performed HPV self-collection. Participatory techniques, including brainstorming, card-based classification, and discussions were used to debate the advantages and disadvantages of messages. We openly coded the discussions for agreements and preferences regarding the SMS content. Messages for both HPV-negative and HPV-positive women were validated through interviews with health authorities and 14 HPV-tested women. The final versions of the messages were pilot-tested. Results A total of 48 women participated in the FGs. Participants rejected receiving both negative and positive HPV results by SMS because, for them, the delivery of results should be done in a face-to-face interaction with health professionals. They stressed the importance of the SMS content informing them that results were available for pick up and reflecting the kind of relationship that they have with the community health workers and the nearest health center. Women considered that a personalized SMS was important, as was the use of a formal yet warm tone. Owing to confidentiality issues, not using the word “HPV” was also a key component of the desired SMS content; therefore, the final message included the term “self-collection” without the mention of HPV infection. Results from the validation stage and pilot test showed high acceptability of the final version of the message. Conclusions The results suggest that SMS is accepted when notifying women about the availability of the HPV test result, but it should not replace the delivery of results in face-to-face, doctor-patient encounters. In addition, messages must be tailored and must have a persuasive tone to motivate women to adhere to the triage.

Background: Pharmacists play a vital role in recommending and providing vaccines to improve public health and are on the front line of mass immunization efforts. Aim: The objective of this study is to evaluate pharmacists’ perceptions on COVID-19 vaccines prior to emergency use authorization (EUA) amid a global pandemic. Methods: A voluntary, anonymous, cross-sectional survey was conducted between September and November 2020. Survey respondents included a convenience sample of licensed pharmacists in the United States. The primary outcomes were pharmacists’ willingness to receive and recommend hypothetical COVID-19 vaccines. Covariates assessed in the survey included COVID-19 exposure or personal experience, primary pharmacy practice setting, background in training, geographic region, and prioritization of clinical data. The data were analyzed using descriptive and inferential statistics. Results: This study surveyed 763 pharmacists and results from 632 participants were included in final analysis. Overall, 67.1% of the pharmacists were willing to receive a COVID-19 vaccine and 63.4% of the pharmacists were willing to recommend a COVID-19 vaccine at ≤1 year from the time of vaccine approval. At &gt, 1 year after vaccine approval, 78% of the pharmacists were willing to receive a COVID-19 vaccine and 81.2% of the pharmacists were willing to recommend a COVID-19 vaccine. Conclusions: Survey findings suggest that, while a majority of pharmacists surveyed indicate acceptance of hypothetical COVID-19 vaccines, there remains to be hesitancy among pharmacists to receive or recommend vaccination.

Purpose: Cervical cancer is the fourth most common cancer among women worldwide. Belize has among the highest cervical cancer incidence and mortality rates of Latin American and Caribbean countries despite current programs to increase access to secondary prevention services. This study evaluates the perspectives of key stakeholders in the cervical cancer screening system in Belize to elucidate barriers and facilitators of cervical cancer screening services. Methods: In 2018, semi-structured interviews discussing challenges and successes in cervical cancer screening were conducted with key stakeholders across the 6 districts of Belize. Interviews were transcribed and coded using thematic content analysis to identify salient themes. Themes were organized by levels of the Tappan model. Results: A total of 47 interviews were conducted with healthcare providers (45%), administrators (17%), government officials (25%), and other stakeholders (13%). 78% of interviews were conducted in the public sector. Perceived barriers to cervical cancer screening were identified across 5 levels: (1) Individual (expectation of delay in Pap smear results and fear of a cancer diagnosis, reduces participation in screening); (2) Provider (responsibilities beyond the provision of screening service prevents clinics from offering services daily); (3) Organizational (insufficient space and training engenders diagnostic delays and possible misdiagnoses); (4) Community (screening limitations are more pronounced in rural vs. urban areas); and (5) Policy (limited budget allocated to equipment and staff restricts screening coverage). Salient facilitators were identified at the community and policy levels. At the community level, facilitators included resource-sharing between public and private sectors and the designation of personnel for rural outreach. Facilitators at the policy level included government coverage of screening costs and establishment of population-based screening targets. Conclusion: Despite no-cost cervical cancer screening in Belize, barriers still exist. Overloaded provider responsibilities, geographic inaccessibility, and insufficient funding are insights that serve as potential areas for system strengthening. Citation Format: Avni Mittal, Shane Neibart, Abha Kulkarni, Taylor Anderson, Jennifer Tsui, Shawna Hudson, Mark Einstein, Natalia Largaespada Beer, Racquel E. Kohler. Barriers and Facilitators of Cervical Cancer Screening Access in Belize: A Qualitative Analysis of Stakeholder Perspectives [abstract]. In: Proceedings of the 9th Annual Symposium on Global Cancer Research; Global Cancer Research and Control: Looking Back and Charting a Path Forward; 2021 Mar 10-11. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2021;30(7 Suppl):Abstract nr 63.

Purpose: Cost-effectiveness data for cancer treatment are needed from sub-Saharan Africa (SSA), where diffuse large B-cell lymphoma (DLBCL) is a common, curable cancer. In high-income countries, the standard of care for DLBCL is R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) chemoimmunotherapy. Rituximab is often not available in SSA due to cost, and treatment with CHOP is common. Methods: We evaluated the cost-effectiveness of DLBCL treatment using Malawi-specific data. Clinical data were from a prospective observational cohort treated with CHOP, as well as a clinical trial of R-CHOP. We used a decision-tree model to calculate costs per disability adjusted life year (DALY) averted from the health system perspective and estimated a willingness to pay (WTP) threshold of three times GDP per capita. Results: On a per-patient level, compared to no chemotherapy, CHOP is estimated to avert 7·9 DALYS, at an incremental cost of $1,500, for an incremental cost-effectiveness ratio (ICER) of $194 per DALY averted, which is well below WTP. In probabilistic sensitivity analysis, CHOP was cost-effective for DLBCL in >99% of simulations. Compared to CHOP, R-CHOP is estimated to avert 2·9 DALYs, at an incremental cost of $3,198 and ICER of $1,104 per DALY averted, which is at the WTP threshold and was below WTP in 45% of simulations. Conclusion: CHOP is cost-effective for DLBCL in Malawi, and the addition of rituximab may be cost-effective. Future studies in SSA and other LMIC settings should include rigorous economic evaluation to promote continued cancer treatment investments and prioritization. Citation Format: Matthew Painschab, Racquel Kohler, Stephen Kimani, Stephanie Wheeler, Satish Gopal. Cost-effectiveness Analysis of CHOP and R-CHOP Treatment of Diffuse Large B-cell Lymphoma in Malawi [abstract]. In: Proceedings of the 9th Annual Symposium on Global Cancer Research; Global Cancer Research and Control: Looking Back and Charting a Path Forward; 2021 Mar 10-11. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2021;30(7 Suppl):Abstract nr 75.

Despite the increasing burden, breast cancer control in sub-Saharan Africa is insufficient. Late diagnosis and lack of early detection and screening services contribute to high mortality. Clinical breast exam (CBE) screening can be valuable in low-income countries, including use of community health workers and non-health professionals to conduct exams. We assessed experiences of women who underwent CBE screening by trained laywomen in Lilongwe, Malawi, as part of a pilot program. The pilot study invited women attending urban health clinics to a breast cancer educational talk followed by CBE screening by trained laywomen. We purposively sampled participants from the pilot study and interviewed them about the screening experience and future cancer education programs and services. Overall participants had positive experiences and were willing to undergo CBE screening by trained laywomen. Participants were motivated by the educational talk, shared newly acquired cancer knowledge with their social networks, and encouraged others to seek screening. Screened women suggested strategies for future interventions including combining breast and cervical cancer screening, using female providers, partnering with community leaders to increase uptake, and expanding services into the community. Asymptomatic Malawian women accepted CBE screening by trained laywomen and considered breast cancer an important health issue. Women appreciated combined education and screening services and proposed further linkage of breast and cervical cancer screening. Based on our results, training laywomen to educate the public on breast cancer and conduct CBE is a feasible breast cancer control strategy in sub-Saharan Africa.

Public knowledge and understanding of health disparities is critical to generate support for programs and policies that address social determinants of health (SDH). Yet, public programs and policies are little informed by evidence or the link between SDH and health outcomes. This case study, using community-based participatory research principles, draws from the evidence of SDH and communication sciences. We describe Project IMPACT, an intervention to build capacity among community-based organizations (CBOs) to engage with media strategically, with the goal of influencing the information environment. The case offers an example of implementation science supporting an evidence-based approach, rather than a specific program or practice. We report how IMPACT leveraged the role community partners play in legitimizing issues so SDH and disparities are part of the public agenda. We assessed how strategic media engagement practices were implemented with the ultimate goal of changing public understanding of SDH and disparities to support SDH-related policies.

Partnerships between researchers and stakeholders offer an opportunity to bring scientific and practice-based knowledge and experience together to improve the quality, value, and relevance of implementation science efforts and increase the application of findings. The chapter covers (1) a continuum of engagement for research–practice partnerships, including the benefits and challenges of engaged implementation science; (2) challenges and opportunities for partnerships in implementation science in community, policy, public opinion, and public–private partnership domains; (3) implementation science partnership evaluation, with an emphasis on social network analysis; and (4) a series of questions for the field as increasing attention is paid to partnerships for implementation science.

BACKGROUNDThe patient-centered medical home (PCMH) is increasingly being implemented in an effort to improve and coordinate primary care, but its effect on health care utilization among breast cancer patients remains unclear. The objective of this study was to examine health care utilization and expenditures as a function of PCMH enrollment among breast cancer patients in North Carolina's Medicaid program. METHODSNorth Carolina Medicaid claims linked to North Carolina Central Cancer Registry records (2003-2007) were used to examine monthly patterns of health care use and expenditures. Controlling for a selection bias for time-invariant characteristics, fixed effects regression models analyzed associations between PCMH enrollment and utilization of outpatient, inpatient, and emergency department (ED) services and Medicaid expenditures during the 15 months after the diagnosis of breast cancer. RESULTSAmong 758 breast cancer patients, 381 (50%) were enrolled in a PCMH at some time in the 15 months after diagnosis. After controlling for individual fixed effects, PCMH enrollment was significantly associated with greater outpatient service use, but there was no difference in the probability of inpatient hospitalizations or ED visits. Enrollment in a PCMH was associated with increased average expenditures of $429 per month during the first 15 months. CONCLUSIONSGreater outpatient care utilization and increased average expenditures among breast cancer patients enrolled in a PCMH may suggest that these women have improved access to primary and specialty care. Expanding PCMHs may change patterns of service utilization for Medicaid breast cancer patients but may not be associated with lower costs. Cancer 2015;121:3975-3981. (c) 2015 American Cancer Society. Medical home enrollment is associated with greater outpatient service use and increased average expenditures among breast cancer patients. This may suggest that these women are more likely to be connected to primary and specialty care during the immediate postdiagnosis period.

Cervical cancer is the most common cancer among women in Malawi. National guidelines recommend screening women aged 30–45 years every five years; however, no specific recommendations exist for women with HIV. We aimed to assess the frequency of high-grade dysplasia (CIN 2 or CIN3) and cervical cancer among women in central Malawi and to examine associations with CIN2+ (CIN2/3 or cancer). We extracted cervical Pap smear, biopsy, loop electrosurgical excision procedure and uterine specimen reports from a hospital pathology database from November 2012 to November 2013. We used logistic regression to estimate associations with CIN2+. We reviewed specimens from 824 women; we excluded 194 with unknown HIV status, leaving 630 in the analytic sample. Twelve percent had high-grade dysplasia and 109 women (17%) had cancer. Twenty-five percent of high-grade dysplasia cases and 35% of cancers occurred among women outside recommended screening ages. The odds of having CIN2+ were 6.55 times (95% CI 4.44-9.67) greater for HIV+ women. High-grade dysplasia and cervical cancer are very common among Malawian women, especially HIV+ women. HIV infection was strongly associated with CIN2+. Expanding screening to women not covered by current guidelines could avert a substantial proportion of cervical cancer cases in Malawi.

Introduction: Smoking prevalence rates in Lebanon are among the highest in the Eastern Mediterranean region. Few smoking cessation programs are offered in Lebanon and little is known about the preferences of Lebanese smokers for cessation treatment programs. Objective: To establish which attributes of smoking cessation programs are most important to Lebanese smokers. Methods: Smokers at the American University of Beirut were surveyed to elicit their preferences for, and tradeoffs between the attributes of a hypothetical university-based smoking cessation program. Preferences for medication type/mechanism, risk of benign side effects, availability of support, distance traveled to obtain medication, and price of complete treatment were assessed using the discrete choice experiment method. Results: The smokers' responses (N = 191) to changes in attributes were statistically significant. Smokers were willing to make trade-offs between attributes. On average, smokers were willing to pay LBP 103,000 (USD 69) for cessation support. Respondents were willing to give up LBP 105,000 (USD 70) to avoid an additional 10% risk of minor side effects and LBP 18,000 (USD 12) to avoid an addition kilometer of travel to the nearest pharmacy. Heavy smokers were the least responsive group and had the lowest demand elasticities. Conclusions: Student smokers were willing to participate in a relatively complex exercise that weighs the advantages and disadvantages of a hypothetical smoking cessation program. Overall they were less interested in the pill form of smoking cessation treatment, but they were willing to make tradeoffs to be smoke-free.

Background Chemotherapy-related health care utilization by breast cancer patients can be expensive for payers and patients. This study evaluated the patient-centered medical home program Community Care of North Carolina (CCNC) in terms of its potential to reduce health care utilization associated with chemotherapy-related adverse events (AEs). Methods Early-stage breast cancer cases diagnosed during the 5-year period 2003-2007 were identified in the North Carolina Central Cancer Registry; these cases were then linked to North Carolina Medicaid claims data. We measured health care utilization associated with chemotherapy-related AEs by setting (inpatient, outpatient, or emergency department) during a 15-month postdiagnosis follow-up period. Descriptive and multivariate analyses were performed to examine associations between CCNC enrollment and health care utilization associated with chemotherapy-related AEs. Results A large proportion of breast cancer patients had at least 1 health care visit associated with a chemotherapy-related AE (n = 412 [72.3%]). The mean numbers of AE-related visits occurring in inpatient, outpatient, and emergency department settings were 0.30 (standard deviation [SD] = 0.83), 6.92 (SD = 10.94), and 0.46 (SD = 1.26), respectively. CCNC enrollment was associated with significantly fewer inpatient admissions (marginal effect, -0.1421; 95% confidence interval, -0.280 to -0.004). Limitations In this observational study, we were unable to draw conclusions about the causality of these associations. Conclusions Patients enrolled in CCNC had fewer inpatient health care visits associated with chemotherapy-related AEs. Future research should continue to explore the extent to which patient-centered medical homes can monitor and help manage the effects of cancer treatments.

Hormone receptor-positive (HR+) cancers account for most breast cancer diagnoses and deaths. Among survivors with HR + breast cancers, endocrine therapy (ET) reduces 5-year risk of recurrence by up to 40 %. Observational studies in Medicare- and privately-insured survivors suggest underutilization of ET. We sought to characterize ET use in a low-income Medicaid-insured population in North Carolina. Medicaid claims data were matched to state cancer registry records for survivors aging 18–64 diagnosed with stage 0–II HR + breast cancer from 2003 to 2007, eligible for ET, and enrolled in Medicaid for at least 12 of 15 months post-diagnosis. We used multivariable logistic regression to model receipt of any ET medication during 15 months post-diagnosis controlling for age, race, tumor characteristics, receipt of other treatments, comorbidity, residence, reason for Medicaid eligibility, involvement in the Breast and Cervical Cancer Control Program (BCCCP), and diagnosis year. Of 222 women meeting the inclusion criteria, only 50 % filled a prescription for ET. Involvement in the BCCCP and earlier year of diagnoses were associated with significantly higher odds of initiating guideline-recommended ET (adjusted odds ratio [AOR] for the BCCCP 3.76, 95 % confidence interval [CI] 1.67–8.48; AOR for 2004 relative to 2007 2.80, 95 % CI 1.03–7.62; AOR for 2005 relative to 2007 2.11, 95 % CI 0.92–4.85). Results suggest substantial underutilization of ET in this population. Interventions are needed to improve timely receipt of ET and to better support survivors taking ET. Low-income survivors should be counseled on the importance of ET and offered support services to promote initiation and long-term adherence.

Medicare covers several cancer screening tests not currently recommended by the U.S. Preventive Services Task Force (Task Force). In September 2002, the Task Force relaxed the upper age limit of 70 years for breast cancer screening recommendations, and in March 2003 an upper age limit of 65 years was introduced for cervical cancer screening recommendations. We assessed whether mammogram and Pap test utilization among women with Medicare coverage is influenced by changes in the Task Force's recommendations for screening.We identified female Medicare beneficiaries aged 66-80 years and used bivariate probit regression to examine the receipt of breast (mammogram) and cervical (Pap test) cancer screening reflecting changes in the Task Force recommendations. We analyzed 9,760 Medicare Current Beneficiary Survey responses from 2001 to 2007.More than two-thirds reported receiving a mammogram and more than one-third a Pap test in the previous 2 years. Lack of recommendation was given as a reason for not getting screened among the majority (51% for mammogram and 75% for Pap). After controlling for beneficiary-level socioeconomic characteristics and access to care factors, we did not observe a significant change in breast and cervical cancer screening patterns following the changes in Task Force recommendations.Although there is evidence that many Medicare beneficiaries adhere to screening guidelines, some women may be receiving non-recommended screening services covered by Medicare.

6644 Background: DLBCL is common in Africa, and often curable, but treatment costs and cost-effectiveness are key considerations. WHO defines extremely cost-effective interventions as having an incremental cost-effectiveness ratio (ICER) < GDP per capita. Methods: We used a decision tree model to conduct a cost-effectiveness and budget impact analysis from a health systems perspective in Malawi (2017 GDP per capita $340). Comparisons were made between CHOP vs. palliative care with diagnosis (PC+D), and palliative care without diagnosis (PC-D). Microcosting and clinical outcomes were derived from published prospective data. Costs reflect treatment and 2 years of follow-up. Outcomes reflect a lifetime time horizon. Life expectancies were derived from UNdata, and disability-adjusted life year (DALY) weights from the Global Burden of Disease Study. Costs were analyzed in 2017 US $, and costs and outcomes were discounted at 3% annually. Annual estimates for new DLBCL cases (n=161) were used as input incidence. Probablistic sensitivity analysis was conducted using Crystal Ball software over 1000 simulations. Results: For the base case, the ICER of CHOP versus PC+D is $150/DALY averted, and versus PC-D is $200/DALY averted (Table). The ICER was stable across a wide range of sensitivity analyses. The ICER varied most across the range of progression-free survival estimates ($117-209), and range of costs for CHOP plus follow-up ($71-308). CHOP was extremely cost-effective by the WHO definition in 99% of simulations versus PC+D, and 94% of simulations versus PC-D. In the base case, total annual cost of DLBCL treatment with CHOP in Malawi was $306,221. Conclusions: This is one of the first rigorous cost-effectiveness and budget impact analyses for cancer treatment in a low-income country. CHOP is extremely cost-effective compared to palliative care, with ~$300,000 needed annually to treat all DLBCL cases in Malawi. These findings merit external validation, and support continued regional investments in cancer care. [Table: see text]

Opportunities for collaboration on global noncommunicable disease (NCD) research across international borders and scientific disciplines are increasingly available, coinciding with globalization of science and an unprecedented interest in global health among U.S. students, clinicians, and early-career investigators (1). However, challenges to developing and funding a global NCD research agenda remain. In September 2014, researchers representing 41 institutes, including universities, government agencies, private companies, journals, and foundations in the United States met to discuss the challenges and identify opportunities for moving forward on a global NCD research agenda. Four action items emerged from this conference.

Purpose To assess the cost-effectiveness of intensity modulated radiation therapy (IMRT) versus 3-dimensional conformal radiation therapy (3D-CRT) in the treatment of head-and neck-cancer (HNC). Methods and Materials We used a Markov model to simulate radiation therapy-induced xerostomia and dysphagia in a hypothetical cohort of 65-year-old HNC patients. Model input parameters were derived from PARSPORT (CRUK/03/005) patient-level trial data and quality-of-life and Medicare cost data from published literature. We calculated average incremental cost-effectiveness ratios (ICERs) from the US health care perspective as cost per quality-adjusted life-year (QALY) gained and compared our ICERs with current cost-effectiveness standards whereby treatment comparators less than $50,000 per QALY gained are considered cost-effective. Results In the first 2 years after initial treatment, IMRT is not cost-effective compared with 3D-CRT, given an average ICER of $101,100 per QALY gained. However, over 15 years (remaining lifetime on the basis of average life expectancy of a 65-year-old), IMRT is more cost-effective at $34,523 per QALY gained. Conclusion Although HNC patients receiving IMRT will likely experience reduced xerostomia and dysphagia symptoms, the small quality-of-life benefit associated with IMRT is not cost-effective in the short term but may be cost-effective over a patient's lifetime, assuming benefits persist over time and patients are healthy and likely to live for a sustained period. Additional data quantifying the long-term benefits of IMRT, however, are needed.

Background Community Care of North Carolina (CCNC) initiated an innovative medical home program in the 1990 s to improve primary care in Medicaid-insured populations. CCNC has been successful in improving asthma, diabetes, and cardiovascular outcomes but has not been evaluated in the context of cancer care. We explored whether CCNC enrollment was associated with guideline-concordant follow-up care among breast cancer survivors. Methods Using state cancer registry records matched to Medicaid claims, we identified women 18 to 64 years old who were diagnosed with stage 0, I, II, or unstaged breast cancer from 2003 to 2007 and tracked their monthly CCNC enrollment. Using published American Society for Clinical Oncology guidelines to define our outcomes, we employed multivariate logistic regressions to examine, as a function of CCNC enrollment, receipt of mammogram and at least 2 physical examinations/history-taking visits within observational windows consistent with the guidelines. Results Of the 840 women, approximately half were enrolled into the CCNC for some time during the study period. Between 40% and 85% received follow-up mammogram in accordance with guidelines, with significant variation by CCNC status, and 95% of women received at least 2 physical examinations/history-taking visits. In multivariate models, increasing months of CCNC enrollment was significantly positively associated with receipt of follow-up mammogram but not with physical examinations/history-taking visits. Conclusions Results suggest that CCNC enrollment is associated with guideline-concordant follow-up care for Medicaid-insured survivors. Given the growing population of cancer survivors and increased emphasis on primary care medical homes, future studies should explore what factors are associated with medical home participation and whether similar findings are observed with extended follow-up.

Young adulthood represents a time of myriad transitions, which leave young adults (YAs) more susceptible to the influences of cancer risk-promoting information. The tobacco, alcohol, indoor tanning, and food and beverage industries engage in aggressive marketing strategies through both traditional and social media to target this age group to consume their products, which have known links to cancer. Despite this barrage of messaging, detailed data are lacking on the communication behaviors of subgroups of this diverse age group, particularly those from low SES. This paper explores the available data on media usage among YAs and describes the cancer risk-promoting information environment, with a focus on communication inequalities and their implications for cancer research and control. Nationally representative data on media consumption patterns indicate that the majority of YAs access a diverse range of traditional and social media platforms, but these data do not fully describe differences at the intersection of age and important factors such as SES, gender, race/ethnicity, or urban/rural residence. Meanwhile, risk-promoting information is heavily marketed to YAs across media, with an increasing focus on using social media sites to normalize products and evade marketing restrictions. Gaps in the available data on YAs' media consumption behaviors, coupled with aggressive risk-promoting marketing strategies toward YAs, may impede cancer control efforts. Relationships between exposure to various cancer risk-promoting information, concurrent risk behaviors, SES disparities, and communication inequalities should be investigated to develop innovative and effective control programs and policies to promote cancer control in this important group.

Objective Many women in Africa are diagnosed with advanced breast cancer. We explored Malawian breast cancer patients’ perspectives about their diagnosis and ability to access care to identify help-seeking behaviors and to describe factors influencing delay. Methods We purposively sampled 20 Malawian breast cancer patients to conduct in-depth interviews. Transcripts were double coded to identify major themes of breast cancer help-seeking behaviors and what delayed or facilitated access to care. Results We outlined a breast cancer help-seeking pathway describing decisions, behaviors, and interactions from symptom presentation to receipt of cancer care. Patients were largely unaware of breast cancer and did not immediately notice or interpret symptoms. As symptoms progressed, women inferred illness and sought help from social networks, traditional remedies, and medical care. Economic hardship, distance to the facility, provider knowledge, health system factors, and social norms often delayed reaching the facility, referrals, diagnosis, and receipt of care. Conclusions Social-contextual factors at the individual, interpersonal, health system, and societal levels delay decisions, behaviors, and access to breast cancer detection and appropriate care. Practice implications A comprehensive approach to improving breast cancer early detection must address public awareness and misconceptions, provider knowledge and communication, and cancer care delivery.