Background. Understanding the cost of delivering breast cancer (BC) care in low-and middle-income countries (LMICs) is critical to guide effective care delivery strategies. This scoping review summarizes the scope of literature on the costs of BC care in LMICs and characterizes the methodological approaches of these economic evaluations. Materials and Methods. A systematic literature search was performed in five databases and gray literature up to March 2020. Studies were screened to identify original articles that included a cost outcome for BC diagnosis or treatment in an LMIC. Two independent reviewers assessed articles for eligibility. Data related to study characteristics and methodology were extracted. Study quality was assessed using the Drummond et al. checklist.Results. Ninety-one articles across 38 countries were included. The majority (73%) of studies were published between 2013 and 2020. Low-income countries (2%) and countries in Sub-Saharan Africa (9%) were grossly underrepresented. The majority of studies (60%) used a health care system perspective. Time horizon was not reported in 30 studies (33%). Of the 33 studies that estimated the cost of multiple steps in the BC care pathway, the majority (73%) were of high quality, but studies varied in their inclusion of nonmedical direct and indirect costs. Conclusion.There has been substantial growth in the number of BC economic evaluations in LMICs in the past decade, but there remain limited data from low-income countries, especially those in Sub-Saharan Africa. BC economic evaluations should be prioritized in these countries. Use of existing frameworks for economic evaluations may help achieve comparable, transparent costing analyses. The Oncologist 2021;26:1-12 Implications for Practice: There has been substantial growth in the number of breast cancer economic evaluations in lowand middle-income countries (LMICs) in the past decade, but there remain limited data from low-income countries. Breast cancer economic evaluations should be prioritized in low-income countries and in Sub-Saharan Africa. Researchers should strive to use and report a costing perspective and time horizon that captures all costs relevant to the study objective, including those such as direct nonmedical and indirect costs. Use of existing frameworks for economic evaluations in LMICs may help achieve comparable, transparent costing analyses in order to guide breast cancer control strategies.
PURPOSE There is limited evidence to guide incorporation of breast cancer early detection into resource-constrained health systems where mammography screening is not yet available. To inform such strategies, we sought to understand health care workers' perspectives on a breast cancer early detection initiative integrated into community, primary, and secondary levels of care in Rwanda. METHODS We conducted a qualitative study using semistructured interviews with 33 community health workers, clinicians, and administrators at health facilities participating in the Women's Cancer Early Detection Program (WCEDP), through which women received clinical breast examination if they were receiving cervical cancer screening, or had breast concerns. Through thematic analysis, we identified dynamics and patterns associated with successes and challenges of the program's breast health services. RESULTS Successes and challenges identified by participants corresponded with the community- and primary care–based steps of cancer early diagnosis identified by the WHO. Regarding step 1 (community awareness/access), participants noted increases in awareness and care-seeking. Challenges included difficulty overcoming stigma and engaging older women. Regarding step 2 (clinical evaluation), all participants described increased breast health knowledge, skills, and confidence. Integrating the WCEDP with other services was challenging because of inadequate staffing; offering WCEDP services on a designated day/week had advantages and disadvantages. Although participants appreciated WCEDP referral mechanisms, they desired more communication from referral facilities. Patients' poverty was the most consistently identified impediment to referral completion. CONCLUSION Rwandan health care workers identified real-world successes and challenges of implementing principles of early cancer diagnosis for breast cancer early detection. Future interventions should focus on engagement of older women, community awareness, patient socioeconomic support, and optimizing integration into primary care.
Purpose: As access to cancer care expands in sub-Saharan Africa, it is essential to develop strategies to examine and improve cancer care quality. We designed and implemented a quality improvement (QI) training and mentorship program for clinicians at Butaro Cancer Center of Excellence (BCCOE) in Rwanda to foster a culture of continual improvement. We report our early experience. Methods: The BCCOE QI curriculum was adapted from programs from Dana-Farber Cancer Institute and Partners In Health-Rwanda and included didactic training, mentored QI projects and leadership development. Prior to the program, staff QI needs, experiences and perspectives were assessed through two focus group discussions (FGDs) with 18 participants. Written surveys assessed staff QI self-efficacy and knowledge immediately before and after a one-day training. Three BCCOE clinicians selected as QI mentors received an additional 3-day intensive training and longitudinal coaching by Rwanda- and US-based QI coaches. Mentors worked with clinician colleagues and coaches to identify quality gaps and devise and implement metric-based QI projects. Results: FGD participants expressed eagerness to engage in QI efforts but identified challenges to QI implementation, including insufficient time, staff and financial resources. Forty oncology staff members (70% nurses) participated in one-day didactic trainings; 37 completed pre- and post-surveys. Perceived QI knowledge, confidence applying QI methods, and perception of adequate time for QI improved after the training (p<0.001 for all using paired t-tests). Mean performance on knowledge assessment items increased from 64% to 73% (p=0.001). Mentor-led teams designed and launched projects to: improve cancer staging/documentation before treatment; increase chemotherapy order double-checking; and reduce chemotherapy wait times. Conclusions: BCCOE's QI program has engaged oncology clinicians as QI leaders and participants, building a culture of team-based QI. Didactic training increased staff self-efficacy and knowledge, facilitating successful launch of projects. Future assessments will examine staff experience, attitudes and knowledge after project engagement. Citation Format: Fidele Sebahungu, David Tuyisenge, Lori Buswell, Olivier Habimana, Esperance Benemariya, Fred Mugabo, Aphrodis Ndayisaba, Cyprien Shyirambere, Hubert Tuyishime, Yeonsoo Sara Lee, Catherine Stauber, Jessica Cleveland, Sarah Kadish, Spyridon Potiris, Dan Gunderson, Temidayo Fadelu, Jean Bosco Bigirimana, Anatole Manzi, Lydia Pace. Building a Culture of Quality Improvement at Butaro Cancer Center of Excellence in Rwanda [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 49.
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