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The enzyme ATE1 catalyzes eukaryotic post-translation arginylation, a key protein modification necessary for cellular homeostasis. Here, the authors show that ATE1s are previously unrealized iron-sulfur proteins that use this oxygen-sensitive inorganic cofactor to control cellular arginylation

Fc mediated effector functions of antibodies play important roles in immunotherapies and vaccine efficacy but assessing those functions in animal models can be challenging due to species differences. Rhesus macaques, Macaca mulatta (Mm) share approximately 93% sequence identity with humans but display important differences in their adaptive immune system that complicates their use in validating therapeutics and vaccines that rely on Fc effector functions. In contrast to humans, macaques only have one low affinity FcγRIII receptor, CD16, which shares a polymorphism at position 158 with human FcγRIIIa with Ile158 and Val158 variants. Here we describe structure-function relationships of the Ile/Val158 polymorphism in Mm FcγRIII. Our data indicate that the affinity of the allelic variants of Mm FcγRIII for the macaque IgG subclasses vary greatly with changes in glycan composition both on the Fc and the receptor. However, unlike the human Phe/Val158 polymorphism in FcγRIIIa, the higher affinity variant corresponds to the larger, more hydrophobic side chain, Ile, even though it is not directly involved in the binding interface. Instead, this side chain appears to modulate glycan-glycan interactions at the Fc/FcγRIII interface. Furthermore, changes in glycan composition on the receptor have a greater effect for the Val158 variant such that with oligomannose type glycans and with glycans only on Asn45 and Asn162, Val158 becomes the variant with higher affinity to Fc. These results have implications not only for the better interpretation of nonhuman primate studies but also for studies performed with human effector cells carrying different FcγRIIIa alleles.

ABSTRACT Antibodies (Abs) specific for CD4-induced envelope (Env) epitopes within constant region 1 and 2 (C1/C2) were induced in the RV144 vaccine trial, where antibody-dependent cellular cytotoxicity (ADCC) correlated with reduced risk of HIV-1 infection. We combined X-ray crystallography and fluorescence resonance energy transfer-fluorescence correlation spectroscopy to describe the molecular basis for epitopes of seven RV144 Abs and compared them to A32 and C11, C1/C2 Abs induced in HIV infection. Our data indicate that most vaccine Abs recognize the 7-stranded β-sandwich of gp120, a unique hybrid epitope bridging A32 and C11 binding sites. Although primarily directed at the 7-stranded β-sandwich, some accommodate the gp120 N terminus in C11-bound 8-stranded conformation and therefore recognize a broader range of CD4-triggered Env conformations. Our data also suggest that Abs of RV144 and RV305, the RV144 follow-up study, although likely initially induced by the ALVAC-HIV prime encoding full-length gp120, matured through boosting with truncated AIDSVAX gp120 variants. IMPORTANCE Antibody-dependent cellular cytotoxicity (ADCC) correlated with a reduced risk of infection from HIV-1 in the RV144 vaccine trial, the only HIV-1 vaccine trial to date to show any efficacy. Antibodies specific for CD4-induced envelope (Env) epitopes within constant region 1 and 2 (cluster A region) were induced in the RV144 trial and their ADCC activities were implicated in the vaccine efficacy. We present structural analyses of the antigen epitope targets of several RV144 antibodies specific for this region and C11, an antibody induced in natural infection, to show what the differences are in epitope specificities, mechanism of antigen recognition, and ADCC activities of antibodies induced by vaccination and during the course of HIV infection. Our data suggest that the truncated AIDSVAX gp120 variants used in the boost of the RV144 regimen may have shaped the vaccine response to this region, which could also have contributed to vaccine efficacy.

While a number of therapeutic options to control the progression of human immunodeficiency virus (HIV-1) now exist, a broadly effective preventive vaccine is still not available. Through detailed structural analysis of antibodies able to induce potent effector cell activity, a number of Env epitopes have been identified which have the potential to be considered vaccine candidates. These antibodies mainly target the gp120 Cluster A region which is only exposed upon viral binding to the target cell with epitopes becoming available for antibody binding during viral entry and fusion and, therefore, after the effective window for neutralizing antibody activity. This review will discuss recent advances in the structural characterization of these important targets with a special focus on epitopes that are involved in Fc-mediated effector function without direct viral neutralizing activities.

Background: Childhood cancer rates in Africa are lower than in high-income countries but increasing, making pediatric cancers a significant public health concern. The purpose of this study was to provide an overview of the publication of pediatric cancer research in Africa, including publication types and citation trends over time. Methods: The Science Citation Index Expanded database within the Web of Science Core Collection was searched for articles published from 1991 to 2022 in the topic domain, using title, abstract, author keywords, and KeyWords Plus. Indicators used to assess publications performance of the countries included: total number of publications, single-country publications, collaborative publications with African countries, collaborative publications with non-African countries, first-author publications, corresponding-author publications, and single-author publications. Results: A total of 4461 relevant documents were retrieved, with 2770 original research articles. Annual number of articles rose from 13 articles in 1991 to 287 in 2022. Most articles were produced by Egypt (28 %) in North Africa, followed by South Africa (20 %) in sub-Saharan Africa. Collaboration between African countries remains low; however, international collaborations have enhanced the average number of citations per article. Most of the first authors (65 %) and corresponding authors (67 %) of these international collaborative articles were affiliated with non-African institutions. Conclusions: The number of publications sharply increased over the study period and diversely represents African countries. Collaborations with international partners increased citations; however, few of these publications had African first authors. Conversely, inter-institutional partnerships between African countries were relatively low, highlighting the need for better collaboration within Africa.

PURPOSECancer continues to be a significant public health concern. Sub-Saharan Africa (SSA) struggles with a lack of proper infrastructure and adequate cancer care workforce. This has led to some countries relying on referrals of cancer care to countries with higher income levels. In some instances, patients refer themselves. Some countries have made it their goal to attract patients from other countries, a term that has been referred to as medical tourism. In this article, we explore the current status of oncology-related medical tourism in SSA.METHODSThis was a cross-sectional study. The study participants included oncologists, surgeons, and any other physicians who take care of patients with cancer. A predesigned questionnaire was distributed through African Organization for Research and Training in Cancer member mailing list and through study team personal contacts and social media.RESULTSA total of 52 participants from 17 African countries with a 1.6:2 male to female ratio responded to the survey. Most (55.8%) of the respondents were from Eastern African countries. The majority (92%) of study participants reported that they knew patients who referred themselves abroad, whereas 75% referred patients abroad, and the most common (94%) referral destination was India. The most common (93%) reason for referral was perception of a higher quality of care in foreign health institutions.CONCLUSIONThe findings suggest the need to improve local health care systems including building trust of the system among general population. The study highlights potential financial toxicity, and it adds to the current emphasis on return of investment on homegrown workforce and cancer treatment infrastructure.

Introduction Research is an essential pillar of cancer control and key in shaping regional cancer control agendas. Imbalances in science and technology in terms of lack of female participation have been well documented. However, there is little evidence about country-level female participation in cancer research.Methodology Through a complex filter, cancer research papers were identified and grouped by countries and sex of the first and last authors of each paper and analysed by the percentage of females in these positions alongside other parameters.Results Our analysis of 56 countries’ outputs, in 2009, revealed that females were the first authors in 37.2% and last authors in 23.3% of papers. In 2019, females were the first author in 41.6% and last author in 29.4% of papers. Females increased as first authors by 26%, and as last authors by 12% between these two time periods. The top performing countries in terms female/male parity for first or last authorship were in Eastern and Southern Europe as well as Latin American countries.From 2009 to 2019, the highest proportion of females as first and last authors were from low-income and middle-income countries in Latin America and Eastern Europe.Females were more likely to publish in lower impact journals and were less likely to be cited compared to males.Conclusions Globally, progress in female’s authorship in oncology research has been uneven. More research is needed to understand the reasons behind this. Advancing diversity and equity in research leadership and authorship will be essential to address the complex challenges of cancer globally.

Objective Recent studies have identified challenges facing women oncologists in Western contexts. However, similar studies in Africa have yet to be conducted. This study sought to determine the most common and substantial challenges faced by women oncologists in Africa and identify potential solutions.Methods and analysis A panel of 29 women oncologists from 20 African countries was recruited through professional and personal networks. A Delphi consensus process identified challenges faced by women oncologists in Africa, and potential solutions. Following this, focus group discussions were held to discuss the results. Descriptive statistics were used to identify the most common challenges indicated by participants and thematic analysis was conducted on focus group transcripts.Results African women oncologists experienced challenges at individual, interpersonal, institutional and societal levels. The top-ranked challenge identified in the Delphi study was ‘pressure to maintain a work–family balance and meet social obligations’. Some of the challenges identified were similar to those in studies on women oncologists outside of Africa while others were unique to this African demographic. Solutions to improve the experience of women oncologists were identified and discussed, including greater work flexibility and mentorship opportunities.Conclusion Women oncologists in Africa experience many of the challenges that have been previously identified by studies in other regions. These challenges and potential solutions exist at all levels of the social-ecological framework. Women oncologists must be empowered in number and leadership, and gender-sensitive curricula and competencies must be implemented. A systems-level dialogue could bring light to these challenges and foster tangible action and policy-level changes.

PURPOSEThere is limited information on preferences for place of care and death among patients with cancer in low- and middle-income countries (LMICs). The aim was to report the prevalence and determinants of preferences for end-of-life place of care and death among patients with cancer in LMICs and identify concordance between the preferred and actual place of death.METHODSSystematic review and meta-analysis guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses was conducted. Four electronic databases were searched to identify studies of any design that reported on the preferred and actual place of care and death of patients with cancer in LMICs. A random-effects meta-analysis estimated pooled prevalences, with 95% CI, with subgroup analyses for region and risk of bias.RESULTSThirteen studies were included. Of 3,837 patients with cancer, 62% (95% CI, 49 to 75) preferred to die at home; however, the prevalence of actual home death was 37% (95% CI, 13 to 60). Subgroup analyses found that preferences for home as place of death varied from 55% (95% CI, 41 to 69) for Asia to 64% (95% CI, 57 to 71) for South America and 72% (95% CI, 48 to 97) for Africa. The concordance between the preferred and actual place of death was 48% (95% CI, 41 to 55) for South Africa and 92% (95% CI, 88 to 95) for Malaysia. Factors associated with an increased likelihood of preferred home death included performance status and patients with breast cancer.CONCLUSIONThere is very little literature from LMICs on the preferences for end-of-life place of care and death among patients with cancer. Rigorous research is needed to help understand how preferences of patients with cancer change during their journey through cancer.

Abstract Epidemiologic data on insecticide exposures and breast cancer risk are inconclusive and mostly from high-income countries. Using data from 1071 invasive pathologically confirmed breast cancer cases and 2096 controls from the Ghana Breast Health Study conducted from 2013 to 2015, we investigated associations with mosquito control products to reduce the spread of mosquito-borne diseases, such as malaria. These mosquito control products were insecticide-treated nets, mosquito coils, repellent room sprays, and skin creams for personal protection against mosquitos. Multivariable and polytomous logistic regression models were used to estimate odds ratios (ORadj) and 95% confidence intervals (CI) with breast cancer risk-adjusted for potential confounders and known risk factors. Among controls, the reported use of mosquito control products were mosquito coils (65%), followed by insecticide-treated nets (56%), repellent room sprays (53%), and repellent skin creams (15%). Compared to a referent group of participants unexposed to mosquito control products, there was no significant association between breast cancer risk and mosquito coils. There was an association in breast cancer risk with reported use of insecticide-treated nets; however, that association was weak and not statistically significant. Participants who reported using repellent sprays were at elevated risks compared to women who did not use any mosquito control products, even after adjustment for all other mosquito control products (OR = 1.42, 95% CI=1.15–1.75). We had limited power to detect an association with repellent skin creams. Although only a few participants reported using repellent room sprays weekly/daily or 0.25). Our analysis was limited when determining if an association existed with repellent skin creams; therefore, we cannot conclude an association. We found limited evidence of risk associations with widely used mosquito coils and insecticide-treated nets, which are reassuring given their importance for malaria prevention. Our findings regarding specific breast cancer risk associations, specifically those observed between repellent sprays, require further study.

ASCO is a global professional society representing more than 50,000 physicians, other health care professionals, and advocates in over 100 countries specializing in cancer treatment, diagnosis, prevention, and advocacy. ASCO strives, through research, education, and promotion of the highest quality of patient care, to create a world where cancer is prevented or cured, and every survivor is healthy. In this pursuit, health equity remains the guiding institutional principle that applies to all its activities across the cancer care continuum. This ASCO policy statement emphasizes the urgent need for global equity in clinical trials, aiming to enhance access and representation in cancer research as it not only improves cancer outcomes but also upholds principles of fairness and justice in health care.

PURPOSETo build capacity for improved treatment of locally advanced cervical cancer in Ghana, including computed tomography (CT) staging and intensity modulated radiotherapy (IMRT).MATERIALS AND METHODSPatients with histologically confirmed cervical cancer were prospectively staged with abdominopelvic CT and ultrasound and offered the opportunity to have IMRT instead of conventional two-dimensional radiotherapy. The development of an efficient, high-quality, and safe IMRT program was facilitated by investment in new technology and comprehensive training of the interdisciplinary radiotherapy team in collaboration with a North American center of excellence.RESULTSOf 215 patients with cervical cancer referred in 2022, 66% were able to afford CT scans and 26% were able to afford IMRT. Lymph node metastases were identified in 52% of patients by CT but in only 2% of patients by ultrasound. The use of CT resulted in 63% of patients being upstaged and changed treatment intent or radiation treatment volumes in 67% of patients. Patients who had IMRT experienced fewer acute side effects and were more likely to complete treatment as planned.CONCLUSIONIt is feasible to provide state-of the-art cancer treatment with CT staging and IMRT to patients with cervical cancer in low-resource settings and achieve meaningful improvements in outcomes. It requires a broad commitment by program leadership to invest in technology and staff training. Major challenges include balancing improved clinical care with reduced patient throughput when radiation treatment capacity is constrained, and with the additional cost in the absence of universal health coverage.

Objective: To identify and appraise mobile-based application (mAPP) interventions that have been used to support cancer control and care in low- and middle-income countries (LMICs).Methods: Four electronic databases were systematically searched for studies that reported primary research findings related to mAPP interventions applied in oncology settings in LMICs. A narrative synthesis was performed using the Mhealth Index and Navigation Database as an analytical framework.Results: Twenty studies reporting 18 cancer control and care mAPPs were included in this review. Among these mAPPs, ten focused on prevention, screening and early detection of cancer, five provided information to optimise supportive and palliative care, two provided support to assist treatment-shared decision-making and one covered information for follow-up and survivorship care.Conclusion: Cancer mAPP interventions are gradually gaining attention in LMICs as they provide unique resources for empowering and strengthening the role of people with cancer in their own care. To enhance cancer control, a focus on prevention and early detection is important; however, more mAPP interventions related to cancer treatment, follow-up and survivorship are also needed to enable more cost-effective cancer care.

PURPOSEThe post–COVID-19 funding landscape for cancer research globally has become increasingly challenging, particularly in resource-challenged regions (RCRs) lacking strong research ecosystems. We aimed to produce a list of priority areas for cancer research in countries with limited resources, informed by researchers and patients.METHODSCancer experts in lower-resource health care systems (as defined by the World Bank as low- and middle-income countries; N = 151) were contacted to participate in a modified consensus-seeking Delphi survey, comprising two rounds. In round 1, participants (n = 69) rated predetermined areas of potential research priority (ARPs) for importance and suggested missing ARPs. In round 2, the same participants (n = 49) rated an integrated list of predetermined and suggested ARPs from round 1, then undertook a forced choice priority ranking exercise. Composite voting scores (T-scores) were used to rank the ARPs. Importance ratings were summarized descriptively. Findings were discussed with international patient advocacy organization representatives.RESULTSThe top ARP was research into strategies adapting guidelines or treatment strategies in line with available resources (particularly systemic therapy) (T = 83). Others included cancer registries (T = 62); prevention (T = 52); end-of-life care (T = 53); and value-based and affordable care (T = 51). The top COVID-19/cancer ARP was strategies to incorporate what has been learned during the pandemic that can be maintained posteriorly (T = 36). Others included treatment schedule interruption (T = 24); cost-effective reduction of COVID-19 morbidity/mortality (T = 19); and pandemic preparedness (T = 18).CONCLUSIONAreas of strategic priority favored by cancer researchers in RCRs are related to adaptive treatment guidelines; sustainable implementation of cancer registries; prevention strategies; value-based and affordable cancer care; investments in research capacity building; epidemiologic work on local risk factors for cancer; and combatting inequities of prevention and care access.

ABSTRACT The human fecal and oral microbiome may play a role in the etiology of breast cancer through modulation of endogenous estrogen metabolism. This study aimed to investigate associations of circulating estrogens and estrogen metabolites with the fecal and oral microbiome in postmenopausal African women. A total of 117 women with fecal (N = 110) and oral (N = 114) microbiome data measured by 16S rRNA gene sequencing, and estrogens and estrogen metabolites data measured by liquid chromatography tandem mass spectrometry were included. The outcomes were measures of the microbiome and the independent variables were the estrogens and estrogen metabolites. Estrogens and estrogen metabolites were associated with the fecal microbial Shannon index (global P

Abstract Background The aim of this systematic review was to evaluate the evidence and clinical outcomes of screening interventions and implementation trials in sub-Saharan Africa (SSA) and also appraise some ethical issues related to screening in the region through quantitative and qualitative narrative synthesis of the literature. Methods We searched Pubmed, OvidMEDLINE, Embase, and Web of Science to identify studies published on breast cancer screening interventions and outcomes in SSA. Descriptive statistics were used to summarize the frequency and proportions of extracted variables, and narrative syntheses was used to evaluate the clinical outcomes of the different screening modalities. The mixed methods appraisal tool was used to assess the quality of studies included in the review. Results Fifteen studies were included, which consisted of 72,572 women in ten countries in SSA. 63% (8/15) of the included publications evaluated Clinical Breast Examination (CBE), 47% (7/15) evaluated mammography and 7% (1/15) evaluated ultrasound screening. The cancer detection rate was

Abstract Background Several anthropometric measures have been associated with hormone-related cancers, and it has been shown that estrogen metabolism in postmenopausal women plays an important role in these relationships. However, little is known about circulating estrogen levels in African women, and the relevance to breast cancer or breast cancer risk factors. To shed further light on the relationship of anthropometric factors and estrogen levels in African women, we examined whether measured body mass index (BMI), waist-to-hip ratio (WHR), height, and self-reported body size were associated with serum estrogens/estrogen metabolites in a cross-sectional analysis among postmenopausal population-based controls of the Ghana Breast Health Study. Methods Fifteen estrogens/estrogen metabolites were quantified using liquid chromatography-tandem mass spectrometry in serum samples collected from postmenopausal female controls enrolled in the Ghana Breast Health Study, a population-based case–control study conducted in Accra and Kumasi. Geometric means (GMs) of estrogens/estrogen metabolites were estimated using linear regression, adjusting for potential confounders. Results Measured BMI (≥ 30 vs. 18.5–24.9 kg/m2) was positively associated with parent estrogens (multivariable adjusted GM for unconjugated estrone: 78.90 (66.57–93.53) vs. 50.89 (43.47–59.59), p-value

PURPOSEIt is established that addition of systemic therapy to locoregional treatment for breast cancer improves survival. However, reliable data are lacking about the outcomes of such treatment in women with breast cancer in low middle-income countries. We compared the outcomes of treatment in patients who had received neoadjuvant chemotherapy (NACT) or adjuvant chemotherapy and examined the factors associated with breast cancer recurrence and survival at the National Radiotherapy Oncology and Nuclear Medicine Centre, Korle Bu Teaching Hospital, Ghana.METHODSThis was a retrospective cohort study. The medical charts of women with breast cancer managed at the National Radiotherapy Oncology and Nuclear Medicine Centre from 2005 to 2014 were reviewed. A total of 388 patients with a median follow-up of 48 months were included in the study. Logistic regression was used to estimate the risk of recurrence. Survival was estimated using cox proportional hazards model. All models were adjusted with clinicopathologic variables. A P value of < .05 was considered statistically significant.RESULTSFifty-nine percent received adjuvant chemotherapy. In an adjusted logistic model, no difference was observed in locoregional recurrence between patients receiving NACT compared with those receiving adjuvant chemotherapy (odds ratio = 1.05; 95% CI, 0.44 to 2.47). However, NACT recipients had a higher likelihood of distant recurrence (odds ratio = 1.97; 95% CI, 1.24 to 3.15). In a multivariable analysis, no differences were observed in overall survival between the two chemotherapy groups (hazard ratio = 1.43; 95% CI, 0.91 to 2.26).CONCLUSIONNACT yields similar outcomes compared with adjuvant chemotherapy; however, recipients of NACT with advanced disease may have more distant failures. Early detection in a resource-limited setting is therefore crucial to optimal outcomes, significantly limiting recurrence and improving survival.

This report from ASCO's International Quality Steering Group summarizes early learnings on how the COVID-19 pandemic and its stresses have disproportionately affected cancer care delivery and its delivery systems across the world. This article shares perspectives from eight different countries, including Austria, Brazil, Ghana, Honduras, Ireland, the Philippines, South Africa, and the United Arab Emirates, which provide insight to their unique issues, challenges, and barriers to quality improvement in cancer care during the pandemic. These perspectives shed light on some key recommendations applicable on a global scale and focus on access to care, importance of expanding and developing new treatments for both COVID-19 and cancer, access to telemedicine, collecting and using COVID-19 and cancer registry data, establishing measures and guidelines to further enhance quality of care, and expanding communication among governments, health care systems, and health care providers. The impact of the COVID-19 pandemic on cancer care and quality improvement has been and will continue to be felt across the globe, but this report aims to share these experiences and learnings and to assist ASCO's international members and our global fight against the pandemic and cancer.

PURPOSETo document progress and bottlenecks in breast cancer management in sub-Saharan Africa, subsequent to a 2013 pilot survey conducted through the African Organization for Research and Treatment in Cancer (AORTIC) network.METHODSAn anonymous survey of breast cancer management was conducted in 2018 among AORTIC members. Results concerning respondent specialty, access to tumor boards, treatment accessibility, diagnostic services, and factors influencing treatment outcomes were compared with the 2013 findings.RESULTSThirty-seven respondents from 30 facilities in 21 sub-Saharan Africa countries responded. The majority (92%) were clinical oncologists. Radiotherapy facilities were available in 70% of facilities. Seventy-eight percent of these had linear accelerators, and 42% had cobalt60 machines. Eighty percent of facilities had multidisciplinary tumor boards. Immunohistochemistry was routinely performed in 74% of facilities, computed tomography scan in 90%, bone scan in 16%, and positron emission tomography scans in 5%. Anthracyclines, taxanes, tamoxifen, letrozole, anastrozole, and zoledronic acid were available in the majority; trastuzumab, fertility, and genetic counseling were available in 66%, 58%, and 16%, respectively. There were a 50% increase in oncologist respondents over 2013 and a > 50% increase in radiotherapy facilities, particularly linear accelerators. Availability of trastuzumab, aromatase inhibitors, and taxanes increased. Immunohistochemistry capacity remained the same, whereas facilities harvesting at least 10 axillary lymph nodes increased. Bone scan facilities decreased. Responses suggested improved diagnostic services, systemic therapies, and radiotherapy. Sociocultural and economic barriers, system delays, and advanced stage at presentation remain.CONCLUSIONClinicians in sub-Saharan Africa have basic tools to improve breast cancer outcomes, recording positive strides in domains such as radiotherapy and systemic therapy. Socioeconomic and cultural barriers and system delays persist. Workforce expansion must be prioritized to improve quality of care to improve outcomes.

PURPOSEThe COVID-19 pandemic significantly disrupted cancer care in Africa, further exposing major health disparities. This paper compares and contrasts the experiences of 15 clinicians in six different African cancer centers to highlight the positive aspects (silver linings) in an otherwise negative situation.METHODSData are from personal experience of the clinicians working at the six cancer centers blended with what is available in the literature.RESULTSThe impact of COVID-19 on cancer care appeared to vary not only across the continent but also over cancer centers. Different factors such as clinic location, services offered, available resources, and level of restrictions imposed because of COVID-19 were associated with these variations. Collectively, delays in treatment and limited access to cancer care were commonly reported in the different regions.CONCLUSIONThere is a lack of data on cancer patients with COVID-19 and online COVID-19 and cancer registries for Africa. Analysis of the available data, however, suggests a higher mortality rate for cancer patients with COVID-19 compared with those without cancer. Positive or silver linings coming out of the pandemic include the adoption of hypofractionated radiation therapy and teleoncology to enhance access to care while protecting patients and staff members. Increasing collaborations using online technology with oncology health professionals across the world are also being seen as a silver lining, with valuable sharing of experiences and expertise to improve care, enhance learning, and reduce disparities. Advanced information and communication technologies are seen as vital for such collaborations and could avail efforts in dealing with the ongoing pandemic and potential future crises.

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

Abstract Circulating tumor DNA (ctDNA) sequencing studies could provide novel insights into the molecular pathology of cancer in sub-Saharan Africa. In 15 patient plasma samples collected at the time of diagnosis as part of the Ghana Breast Health Study and unselected for tumor grade and subtype, ctDNA was detected in a majority of patients based on whole- genome sequencing at high (30×) and low (0.1×) depths. Breast cancer driver copy number alterations were observed in the majority of patients.

Introduction Research is a critical pillar in national cancer control planning. However, there is a dearth of evidence for countries to implement affordable strategies. The WHO and various Commissions have recommended developing stakeholder-based needs assessments based on objective data to generate evidence to inform national and regional prioritisation of cancer research needs and goals.Methodology Bibliometric algorithms (macros) were developed and validated to assess cancer research outputs of all 54 African countries over a 12-year period (2009–2020). Subanalysis included collaboration patterns, site and domain-specific focus of research and understanding authorship dynamics by both position and sex. Detailed subanalysis was performed to understand multiple impact metrics and context relative outputs in comparison with the disease burden as well as the application of a funding thesaurus to determine funding resources.Results African countries in total published 23 679 cancer research papers over the 12-year period (2009–2020) with the fractional African contribution totalling 16 201 papers and the remaining 7478 from authors from out with the continent. The total number of papers increased rapidly with time, with an annual growth rate of 15%. The 49 sub-Saharan African (SSA) countries together published just 5281 papers, of which South Africa’s contribution was 2206 (42% of the SSA total, 14% of all Africa) and Nigeria’s contribution was 997 (19% of the SSA total, 4% of all Africa). Cancer research accounted for 7.9% of all African biomedical research outputs (African research in infectious diseases was 5.1 times than that of cancer research). Research outputs that are proportionally low relative to their burden across Africa are paediatric, cervical, oesophageal and prostate cancer. African research mirrored that of Western countries in terms of its focus on discovery science and pharmaceutical research. The percentages of female researchers in Africa were comparable with those elsewhere, but only in North African and some Anglophone countries.Conclusions There is an imbalance in relevant local research generation on the continent and cancer control efforts. The recommendations articulated in our five-point plan arising from these data are broadly focused on structural changes, for example, overt inclusion of research into national cancer control planning and financial, for example, for countries to spend 10% of a notional 1% gross domestic expenditure on research and development on cancer.

Background: Testicular germ cell tumours (GCTs) are rare malignancies most prevalent in 15–40-year-old men. Incidence rates of testicular cancer on a global level show marked geographic variation with higher incidence rates reported in predominantly Caucasian populations. African data on GCT management show low incidence rates but an advanced stage at presentation and high mortality rates. Aim: The aim of the study was to explore patterns of practice in the management of testicual GCTs. Setting: The study was conducted in an African oncology care setting. Methods: A cross-sectional web-based survey was distributed to doctors or nurses providing oncology care for patients with testicular GCT in Africa. Data on staging procedures, chemotherapy and radiotherapy (RT) treatment schedules across institutions are reported and discussed in the context of international treatment guidelines and local resources. Results: Eleven African countries contributed data. Epidemiological estimates were received from 20 institutions and management and outcome data from 18 institutions. The estimated ratio of seminoma to non-seminoma was 1:1.3. The stage at presentation was tumour-node-metastases-serum marker (TNM-S) Stage III at half of the institutions surveyed. Chemotherapy regimens mostly followed international guidelines, but certain essential drugs were not consistently accessible at all centres. Radiotherapy services were available to all but one respondent, with three-dimensional planning being widely used. There was marked variation in RT doses and treatment fields. Conclusion: The resources to effectively manage testicular GCT appear to be accessible to most institutions surveyed. Regional management guidelines, sharing of clinical expertise within Africa through online platforms and centralised data collection on epidemiology, management and treatment efficacy are advocated to better allocate resources and improve the outcomes reported in this rare but potentially curable condition.

Abstract Background Improving access to radiotherapy services in low and middle-income countries (LMICs) is challenging. Many LMICs’ radiotherapy initiatives fail because of multi-faceted barriers leading to significant wastage of scarce resources. Supporting LMICs to self-assess their readiness for establishing radiotherapy services will help to improve cancer outcomes by ensuring safe, effective and sustainable evidenced-based cancer care. The aim of the study was to develop practical guidance for LMICs on self-assessing their readiness to establish safe and sustainable radiotherapy services. Methods The Access to Radiotherapy for Cancer treatment (ARC) Project was a pragmatic sequential mixed qualitative methods design underpinned by the World Health Organisation’s ‘Innovative Care for Chronic Conditions Framework’ and ‘Health System Building Blocks Framework for Action’ conceptual frameworks. This paper reports on the process of overall data integration and meta-inference from previously published components comprising a systematic review and two-part qualitative study (semi-structured interviews and a participant validation process). The meta-inferences enabled a series of radiotherapy readiness self-assessment requirements to be generated, formalised as a REadiness SElf-Assessment (RESEA) Guide’ for use by LMICs. Findings The meta-inferences identified a large number of factors that acted as facilitators and/or barriers, depending on the situation, which include: awareness and advocacy; political leadership; epidemiological data; financial resources; basic physical infrastructure; radiation safety legislative and regulatory framework; project management; and radiotherapy workforce training and education. ‘Commitment’, ‘cooperation’, ‘capacity’ and ‘catalyst’ were identified as the key domains enabling development of radiotherapy services. Across these four domains, the RESEA Guide included 37 requirements and 120 readiness questions that LMICs need to consider and answer as part of establishing a new radiotherapy service. Conclusions The RESEA Guide provides a new resource for LMICs to self-assess their capacity to establish safe and sustainable radiotherapy services. Future evaluation of the acceptability and feasibility of the RESEA Guide is needed to inform its validity. Further work, including field study, is needed to inform further refinements. Exploratory and confirmatory factor analyses are required to reduce the data set and test the fit of the four-factor structure (commitment, cooperation, capacity and catalyst) found in the current study.

PURPOSE For many oncology training programs in low- and middle-income countries, dedicated time for research education and mentorship of trainees is limited. Here, we report a 1-year–long collaboration between a cancer center in Canada and one in Ghana with the aim of imparting clinical research skills and mentoring the research of radiation oncology residents. METHODS On the basis of a needs assessment conducted in Ghana, we designed a curriculum consisting of 13 weekly seminars delivered via videoconference, followed by a 1-year–long mentorship program to support research projects. The primary outcome was the feasibility of the program from seminars to manuscript preparation. We used multiple secondary outcomes to capture the learning experience with study-specific questionnaires. We evaluated critical thinking ability using the Berlin questionnaire. Funding was made available for research and travel to international conferences. RESULTS Five Ghanaian trainees submitted research proposals. Nine Canadian faculty members delivered the seminars and two served as methodology mentors, and two Ghanaian faculty acted as local supervisors. Feedback questionnaires from all participants showed that they agreed strongly that they would recommend the sessions to another resident (75%), that the objectives were clear (71%), and that the topics were useful for their training (73%). At the end of the program, two Ghanaian trainees finalized their manuscripts and one was published. CONCLUSION Here, we report on the implementation of a mentorship program focused on research methods and evidence-based medicine in sub-Saharan Africa. The program was successful in the drafting and publication of abstracts and manuscripts by local trainees.

PURPOSEChoosing Wisely Africa (CWA) builds on Choosing Wisely (CW) in the United States, Canada, and India and aims to identify low-value, unnecessary, or harmful cancer practices that are frequently used on the African continent. The aim of this work was to use physicians and patient advocates to identify a short list of low-value practices that are frequently used in African low- and middle-income countries.METHODSThe CWA Task Force was convened by the African Organization for Research and Training in Cancer and included representatives from surgical, medical, and radiation oncology, the private and public sectors, and patient advocacy groups. Consensus was built through a modified Delphi process, shortening a long list of practices to a short list, and then to a final list. A voting threshold of ≥ 60% was used to include an individual practice on the short list. A consensus was reached after a series of teleconferences and voting processes.RESULTSOf the 10 practices on the final list, one is a new suggestion and 9 are revisions or adaptations of practices from previous CW campaign lists. One item relates to palliative care, 8 concern treatment, and one relates to surveillance.CONCLUSIONThe CWA initiative has identified 10 low-value, common interventions in Africa’s cancer practice. The success of this campaign will be measured by how the recommendations are implemented across sub-Saharan Africa and whether this improves the delivery of high-quality cancer care.

Africa attracts < 1% of all trials conducted around the world. The implication is that proof of safety and efficacy in Africans is lacking for a lot of new therapies. The sizeable proportion of approximately 20% of the global population that Africa represents largely does not have empiric data to support use of new therapies in a population with a distinct genetic and racial profile. Beyond the imperative of evidence-based interventions, Africans carry a disproportionately heavy burden of certain diseases, including prostate cancer, sickle cell anemia, and malaria. It therefore provides opportunity for efficient recruitment of participants for trials for such diseases. However, this advantage has not convinced sponsors to carry out clinical trials in Africa. India and China each have roughly the same population size as Africa, but each presents just one regulatory jurisdiction for clinical trials. Africa has 54 countries, and a sponsor would theoretically need to file 54 different applications to cover the entire continent. Collaboration and partnership among all stakeholders in the clinical trial ecosystem will reduce the burden on sponsors and make Africa competitive as a destination for clinical trials. Collaboration among national regulatory agencies will enable Africa to be treated as one regulatory jurisdiction and reduce administrative burden. Sites and researchers can partner to improve quality, attain necessary certifications, and increase overall efficiency. Central to all of these are clinical research organizations that can coordinate and work across borders to make clinical trial projects seamless. Ultimately, patients will benefit as quality of clinical practice improves and access to new therapies is enhanced.

PURPOSECervical cancer remains a major health challenge in low- to middle-income countries. We present the experiences of two centers practicing in variable resource environments to determine predictors of improved radiochemotherapy treatment.METHODS AND MATERIALSThis comparative review describes cervical cancer presentation and treatment with concurrent chemoradiotherapy with high-dose-rate brachytherapy between 2014 and 2017 at the National Radiotherapy Oncology and Nuclear Medicine Center (NRONMC) in Korle-Bu Teaching Hospital, Accra, Ghana, and Moffitt Cancer Center (MCC), Tampa, FL.RESULTSMedian follow-up for this study was 16.9 months. NRONMC patients presented with predominantly stage III disease (42% v 16%; P = .002). MCC patients received para-aortic node irradiation (16%) and interstitial brachytherapy implants (19%). Median treatment duration was longer for NRONMC patients compared with MCC patients (59 v 52 days; P < .0001), and treatment duration ≥ 55 days predicted worse survival on multivariable analysis (MVA; P = .02). Stage ≥ III disease predicted poorer local control on MVA. There was a difference in local control among patients with stage III disease (58% v 91%; P = .03) but not in survival between MCC and NRONMC. No significant difference in local control was observed for stage IB, IIA, and IIB disease.CONCLUSIONAlthough there were significant differences in disease presentation between the two centers, treatment outcomes were similar for patients with early-stage disease. Longer treatment duration and stage ≥ III disease predicted poor outcomes.