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This study demonstrates that patients recognize barriers to understanding but value elements of consent. Further research is needed to develop approaches that meet patients' goals while recognizing the limitations inherent to this context.

PurposeChildren with acute lymphoblastic leukemia (ALL) in low-income countries have disproportionately lower cure rates than those in high-income countries. At Butaro Cancer Center of Excellence (BCCOE), physicians treated patients with ALL with the first arm of the Hunger Protocol, a graduated-intensity method tailored for resource-limited settings. This article provides the first published outcomes, to our knowledge, of patients with ALL treated with this protocol.MethodsThis is a retrospective descriptive study of patients with ALL enrolled at BCCOE from July 1, 2012 to June 30, 2014; data were collected through December 31, 2015. Descriptive statistics were used to calculate patient demographics, disease characteristics, and outcomes; event-free survival was assessed at 2 years using the Kaplan-Meier method.ResultsForty-two consecutive patients with ALL were included. At the end of the study period, 19% (eight) were alive without evidence of relapse: three completed treatment and five were continuing treatment. Among the remaining patients, 71% (30) had died and 10% (four) were lost to follow-up. A total of 83% (25) of the deaths were disease related, 3% (one) treatment-related, and 13% (four) unclear. Event-free survival was 22% (95% CI, 11% to 36%), considering lost to follow-up as an event, and 26% (95% CI, 13% to 41%) if lost to follow-up is censored.ConclusionAs expected, relapse was the major cause of failure with this low-intensity regimen. However, toxicity was acceptably low, and BCCOE has decided to advance to intensity level 2. These results reflect the necessity of a data-driven approach and a continual improvement process to care for complex patients in resource-constrained settings.

Purpose Low- and middle-income countries account for 86% of all cervical cancer cases and 88% of cervical cancer mortality globally. Successful management of cervical cancer requires resources that are scarce in sub-Saharan Africa, especially in rural settings. Here, we describe the early clinical outcomes and implementation lessons learned from the Rwanda Ministry of Health’s first national cancer referral center, the Butaro Cancer Center of Excellence (BCCOE). We hypothesize that those patients presenting at earlier stage and receiving treatment will have higher rates of being alive. Methods The implementation of cervical cancer services included developing partnerships, clinical protocols, pathology services, and tools for monitoring and evaluation. We conducted a retrospective study of patients with cervical cancer who presented at BCCOE between July 1, 2012, and June 30, 2015. Data were collected from the electronic medical record system and by manually reviewing medical records. Descriptive, bivariable and multivariable statistical analyses were conducted to describe patient demographics, disease profiles, treatment, and clinical outcomes. Results In all, 373 patients met the study inclusion criteria. The median age was 53 years (interquartile rage, 45 to 60 years), and 98% were residents of Rwanda. Eighty-nine percent of patients had a documented disease stage: 3% were stage I, 48% were stage II, 29% were stage III, and 8% were stage IV at presentation. Fifty percent of patients were planned to be treated with a curative intent, and 54% were referred to chemoradiotherapy in Uganda. Forty percent of patients who received chemoradiotherapy were in remission. Overall, 25% were lost to follow-up. Conclusion BCCOE illustrates the feasibility and challenges of implementing effective cervical cancer treatment services in a rural setting in a low-income country.

Background With a decline in malaria burden, innovative interventions and tools are required to reduce malaria transmission further. Mass drug administration (MDA) of artemisinin-based combination therapy (ACT) has been identified as a potential tool to further reduce malaria transmission, where coverage of vector control interventions is already high. However, the impact is limited in time. Combining an ACT with an endectocide treatment that is able to reduce vector survival, such as ivermectin (IVM), could increase the impact of MDA and offer a new tool to reduce malaria transmission. Objective The study objective is to evaluate the impact of MDA with IVM plus dihydroartemisinin-piperaquine (DP) on malaria transmission in an area with high coverage of malaria control interventions. Methods The study is a cluster randomized trial in the Upper River Region of The Gambia and included 32 villages (16 control and 16 intervention). A buffer zone of ~2 km was created around all intervention clusters. MDA with IVM plus DP was implemented in all intervention villages and the buffer zones; control villages received standard malaria interventions according to the Gambian National Malaria Control Program plans. Results The MDA campaigns were carried out from August to October 2018 for the first year and from July to September 2019 for the second year. Statistical analysis will commence once the database is completed, cleaned, and locked. Conclusions This is the first cluster randomized clinical trial of MDA with IVM plus DP. The results will provide evidence on the impact of MDA with IVM plus DP on malaria transmission. Trial Registration ClinicalTrials.gov NCT03576313; https://clinicaltrials.gov/ct2/show/NCT03576313 International Registered Report Identifier (IRRID) DERR1-10.2196/20904

Introduction Cervical cancer is among the most common cancers and is the fourth most common cause of cancer death in women worldwide [1]. Women in low-and middle-income countries (LMICs) disproportionately bear the burden of cervical cancer; 85% of cervical cancer morbidity and 88% of cervical cancer mortality occur in this region [2-4]. In East Africa, among all types of cancers in women, cervical cancer is the leading cause of morbidity and mortality with 52,633 new cases and 37,017 deaths estimated in 2018 [5]. Without adequate investment in cervical cancer control, these rates are only expected to rise [2]. Treatment for cervical cancer is critical for control and secondary disease prevention in LMICs [2]. However, most LMICs have limited infrastructure and human resource capacity to support surgical screening and subsequent treatment with radiotherapy, evidenced by the lack of trained health personnel and inadequate availability of treatment equipment [2]. Where services are available, the cost of treatment often prohibits access [6, 7]. Further, issues such as late presentation at diagnosis, low pretreatment performance status, which indicates a patient's ability to tolerate chemotherapy, lack of adherence to treatment or post-treatment follow-up, and low quality of care worsen patient outcomes [2, 8-11]. Among important programmatic and patient-related aspects of cervical cancer treatment is post-treatment follow-up. Women receiving therapy for invasive cancer

Background Malaria transmission in The Gambia decreased substantially over the last 20 years thanks to the scale-up of control interventions. However, malaria prevalence is still relatively high in eastern Gambia and represents both a health and a financial burden for households. This study aims to quantify the out-of-pocket costs and productivity losses of seeking malaria treatment at household level. Methods A household survey was carried out through in-person interviews. Respondents were asked about malaria prevention methods, their treatment-seeking behaviour, and any costs incurred for transport, services, food, and/or overnight stays. A bottom-up costing approach was used to calculate the unit cost of treatment and a tobit regression approach to investigate cost drivers. Results The survey included 864 respondents, mainly subsistence farmers. Most respondents (87%) considered malaria to be a problem affecting their ability to perform their regular duties. Respondents preferred going to a health facility for treatment. The primary reason for not going was related to costs; 70% of respondents incurred costs for seeking health care, with a median of £3.62 (IQR: £1.73 to £6.10). The primary driver of cost was living in one of the villages that are off the main road and/or far from health facilities. 66% reported productivity loss of 5 working days on average during a malaria episode of them or their child. Conclusions Although malaria prevalence is decreasing and treatment is provided free of charge, households seeking treatment are confronted with out-of-pocket expenditures and lost working days; particularly in remote villages.

PurposeMinimal turnaround time for pathology results is crucial for highest-quality patient care in all settings, especially in low- and middle-income countries, where rural populations may have limited access to health care.MethodsWe retrospectively determined the turnaround times (TATs) for anatomic pathology specimens, comparing three different modes of operation that occurred throughout the development and implementation of our pathology laboratory at the Butaro Cancer Center of Excellence in Rwanda. Before opening this laboratory, TAT was measured in months because of inconsistent laboratory operations and a paucity of in-country pathologists.ResultsWe analyzed 2,514 individual patient samples across the three modes of study. Diagnostic mode 1 (samples sent out of the country for analysis) had the highest median TAT, with an overall time of 30 days (interquartile range [IQR], 22 to 43 days). For diagnostic mode 2 (static image telepathology), the median TAT was 14 days (IQR, 7 to 27 days), and for diagnostic mode 3 (onsite expert diagnosis), it was 5 days (IQR, 2 to 9 days).ConclusionOur results demonstrate that telepathology is a significant improvement over external expert review and can greatly assist sites in improving their TATs until pathologists are on site.