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

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

Background. Cervical cancer (CC) is the most common female cancer in many countries of sub-Saharan Africa (SSA). We assessed treatment guideline adherence and its association with overall survival (OS). Methods. Our observational study covered nine populationbased cancer registries in eight countries: Benin, Ethiopia, Ivory Coast, Kenya, Mali, Mozambique, Uganda, and Zimbabwe. Random samples of 44-125 patients diagnosed from 2010 to 2016 were selected in each. Cancer-directed therapy (CDT) was evaluated for degree of adherence to National Comprehensive Cancer Network (U.S.) Guidelines. Results. Of 632 patients, 15.8% received CDT with curative potential: 5.2% guideline-adherent, 2.4% with minor deviations, and 8.2% with major deviations. CDT was not documented or was without curative potential in 22%; 15.7% were diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage IV disease. Adherence was not assessed in 46.9% (no stage or follow-up documented, 11.9%, or records not traced, 35.1%). The largest share of guideline-adherent CDT was observed in Nairobi (49%) and the smallest in Maputo (4%). In patients with FIGO stage I-III disease (n = 190), minor and major guideline deviations were associated with impaired OS (hazard rate ratio [HRR], 1.73; 95% confidence interval [CI], 0.36-8.37; HRR, 1.97; CI, 0.59-6.56, respectively). CDT without curative potential (HRR, 3.88; CI,) and no CDT (HRR, 9.43; CI, 3.03-29.33) showed substantially worse survival. Conclusion.We found that only one in six patients with cervical cancer in SSA received CDT with curative potential. At least one-fifth and possibly up to two-thirds of women never accessed CDT, despite curable disease, resulting in impaired OS. Investments into more radiotherapy, chemotherapy, and surgical training could change the fatal outcomes of many patients. The Oncologist 2021;25:1-10 Implications for Practice: Despite evidence-based interventions including guideline-adherent treatment for cervical cancer (CC), there is huge disparity in survival across the globe. This comprehensive multinational population-based registry study

Einleitung: Die Auswirkungen des Klimawandels auf die Gesundheit und die Notwendigkeit, die Treibhausgasemissionen des Gesundheitswesens zu reduzieren, werden zunehmend thematisiert. Über die Haltung ambulant tätiger Ärztinnen und Ärzte zum Klimaschutz in Praxen ist bisher wenig bekannt. Methodik: Zwischen Oktober 2020 und Februar 2021 wurden ambulant tätige Ärztinnen und Ärzte zu einer deutschlandweiten Online-Umfrage eingeladen. 1683 Teilnehmende beantworteten 39 Fragen zu den Bereichen Energie, Mobilität, Gebrauchsmaterialien, Finanzen und Patient*innenberatung. Dabei wurden Daten zu Ist-Zustand, Bereitschaft, Hürden und Wünschen hinsichtlich Klimaschutz in Praxen erhoben. Ergebnisse: 83% der Teilnehmenden sahen den Klimawandel als dringendes Problem, das sofortiges Handeln erfordere. Eine Mehrheit berichtete von klimawandelbedingten Folgen für die Gesundheit ihrer Patient*innen. Für Klimaschutz in ihren Praxen fühlten sich die meisten zuständig. Die Teilnehmenden zeigten große Bereitschaft zur Umsetzung klimafreundlicher Maßnahmen. Als Hindernisse wurden fehlende Information und Unterstützung durch Berufsverbände sowie finanzielle Mehrausgaben genannt. Der Großteil forderte die Entwicklung von klimafreundlichen Strategien durch Politik und Institutionen. Schlussfolgerung: Angesichts nationaler Klimaziele und Bereitschaft ambulant tätiger Ärztinnen und Ärzte zu Klimaschutz in Praxen ist berufspolitische Unterstützung z.B. durch Handlungsempfehlungen und finanzielle Förderungen zur klimafreundlichen Transformation des Gesundheitswesens im Einklang mit Planetary Health nötig. Für die Entwicklung effektiver Maßnahmen zur Einsparung von Treibhausgasemissionen in Arztpraxen sollten begleitende Studien zusätzliche Evidenz schaffen.

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

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

Purpose Stage at diagnosis and receipt of therapy are the most important determinants of breast cancer (BC) survival in sub-Saharan Africa (SSA). Recently, the National Comprehensive Cancer Network therapy guidelines for SSA were published. Our study aimed to describe the cancer-directed therapy (CDT) received by patients with BC at the population level in SSA. Methods Random samples of patients with BC (≥ 40 cases per registry) who were diagnosed from 2009 to 2015 were drawn from 11 population-based cancer registries—Abidjan, Addis Ababa, Bamako, Brazzaville, Bulawayo, Cotonou, Eldoret, Kampala, Maputo, Namibia and Nairobi—which represented 10 countries in SSA. Active methods were used to update therapy and outcomes of patients with newly diagnosed invasive BC. Results A total of 834 patients were included, with median age at diagnosis of 48 years (range, 20 to 92 years; 16% diagnosed younger than age 35 years). Among patients with known stage (n = 434), 66% were diagnosed at stage III and IV. Eighty-one percent of all cases were morphologically verified. Detailed information on therapy and/or outcome was available for 533 patients (63.9%), and other files not found were assumed without therapy (worst-case scenario). Of the total cohort, 52% of patients had no record of CDT. Of patients without known metastasis (n = 747), 40.6% received surgery (83.1% mastectomy), 33.6% chemotherapy, and 15.5% radiotherapy. Hormone receptor status (HRS) was known for only 16.3%. Of patients with positive or unknown HRS (n = 714), 18.6% received endocrine therapy. Of 299 patients who received chemotherapy, 51.8% received an anthracycline-based regimen and 32.1% received an anthracycline regimen with an additional taxane. For patients in areas with radiotherapy facilities, use ranged from 26% in Addis to 67% in Namibia. Among patients with stage II and III disease (n = 334), 16.5% received surgery only, 8.4% chemotherapy only, 15% received both, 11.1% received both plus endocrine therapy, 5.7% received both plus radiotherapy, and 16.2% received all four modalities. The 5-year overall survival for all patients was 51.1% (95% CI, 44.9% to 56.9%). Conclusion More than one half of patients with BC in SSA had no record of CDT. Our finding of four of five patients without HRS testing suggests high underutilization of affordable and tolerable endocrine therapy. Improving access to care and HRS testing may facilitate adherence to resource-stratified guidelines. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . Eva Johanna Kantelhardt Travel, Accommodations, Expenses: Daiichi Sankyo Oncology Europe

Zusammenfassung Hintergrund Auch die ambulante Chirurgie trägt zur Klimakrise bei. Die Publikation soll die Herausforderungen identifizieren und klare, möglichst evidenzbasierte Empfehlungen für Umweltschutz bei gleichzeitiger Kostenreduktion geben. Methode Narratives Review mit nichtsystematischer umfangreicher Recherche in PubMed/MEDLINE und grauer Literatur sowie Befragung von Expert:innen. Ergebnisse Eine Vielzahl an Primärarbeiten, Evidenzsynthesen, praktischen Handlungsempfehlungen und Checklisten konnte identifiziert und zwei Expert:innen befragt werden. Umweltprobleme wurden erkannt in Produktion und Beschaffung, Verkehr, beim Verbrauch von Material, Pharmaka und Energie sowie bei Entsorgung, Wiederverwertung und Sterilisation. Hochwertige Publikationen beschreiben nicht einen Mangel an Wissen um Alternativen, sondern an praktischer Umsetzung. Deshalb wurden die Probleme in das 5‑R-Schema („reduce“, „reuse“, „recycle“, „rethink“, „research“) eingeordnet, um Handlungsempfehlungen mit Synergieeffekten bezüglich Kostenreduktion, Patient:innen- und Mitarbeiter:innenzufriedenheit zu präsentieren. Des Weiteren werden Veränderungen der Rahmenbedingungen diskutiert. Schlussfolgerung Ambulantes Operieren geht mit relevantem Ressourcenverbrauch einher. Es existieren zahlreiche Möglichkeiten, Umweltschutz mit Kostenreduktion sowie Zufriedenheit von Patient:innen und Mitarbeiter:innen zu verbinden. Für flächendeckenden Klimaschutz in der Niederlassung müssen Anreize und gesetzliche Rahmenbedingungen geschaffen werden.