Cancer In Low-resource Settings Research Articles

Expanding Access to Computed Tomographic Staging and Three-Dimensional Intensity Modulated Radiotherapy for Cervical Cancer in Ghana.

To build capacity for improved treatment of locally advanced cervical cancer in Ghana, including computed tomography (CT) staging and intensity modulated radiotherapy (IMRT). Patients 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. Of 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. It 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.

Abstract 56: Integrated Breast and Cervical Cancer Prevention: What is the Cost of Cost Reduction?

Abstract Purpose: coupling of breast and cervical cancer prevention has been proposed as a possible low hanging fruit to accelerate simultaneous reduction in burden of both cancers in low resource settings but unfortunately the evidence on effectiveness of such strategy is limited. We have therefore documented and compared the implementation processes of 2 intervention programs in low resource settings with the aim of catalyzing further research into the effectiveness of coupling prevention of breast and cervical cancer in low resource settings. Methods: Action research model was adopted in the implementation of coupling of breast cancer prevention strategies onto cervical cancer screening programs that End Cervical Cancer Nigeria Initiative (ECCNI) is involved in. This study compared the implementation processes and outcomes of leveraging two cervical cancer screening programs to prevent breast cancer in Kebbi State of Nigeria. Budget impact of the programs was projected and compared. Results: Two thousand four hundred and sixty-six (2,466) women were screened for cervical cancer across 10healthcare facilities under the WHO/CHAI/MCF supported pilot HPV screening in Kebbi State while the number of women who had clinical breast examination could not be ascertained. At the police cottage hospital, 125 women were screened for cervical cancer using VIA and 131 women had clinical breast examination within the reporting period. The estimated financial cost of implementation (excluding economic cost) per center was $4,550 for cervical cancer screening and $1,850 for clinical breast examination-based prevention program. The implementation cost for the integrated breast and cervical cancer screening at the police cottage hospital was $4,550, implying that no additional funding is required to leverage clinical breast examination on budgeted cervical cancer screening at the primary healthcare level. Conclusion: Integrated breast and cervical cancer prevention is a confirmed cost reducing strategy but further research is needed to determine cost effectiveness of the strategy. Citation Format: Ishak Lawal, Zainab Shinkafi-Bagudu, Nuhu Koko, Jamilu Mohammad, Abdullahi Bala Rano, Kabir Aliyu Suleiman. Integrated Breast and Cervical Cancer Prevention: What is the Cost of Cost Reduction? [abstract]. In: Proceedings of the 11th Annual Symposium on Global Cancer Research; Closing the Research-to-Implementation Gap; 2023 Apr 4-6. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(6_Suppl):Abstract nr 56.

Involving men in cervical cancer prevention; a qualitative enquiry into male perspectives on screening and HPV vaccination in Mid-Western Uganda.

Evidence-based preventive strategies for cervical cancer in low-resource setting have been developed, but implementation is challenged, and uptake remains low. Women and girls experience social and economic barriers to attend screening and human papillomavirus (HPV) vaccination programs. Male support has been proven successful in uptake of other reproductive healthcare services. This qualitative study with focus groups aimed to understand the perspectives of males on cervical cancer screening and HPV vaccination in Western-Uganda This knowledge could be integrated into awareness activities to increase the attendance of cervical cancer screening and HPV vaccination programs. Focus group discussions were conducted with men aged 25 to 60 years, who were married and/or had daughters, in Kagadi district, Mid-Western Uganda. All interviews were transcribed verbatim and thematically analyzed using an inductive approach. Eleven focus group discussions were conducted with 67 men. Men were willing to support their wives for screening and their daughters for HPV vaccination. Misperceptions such as family planning and poor personal hygiene leading to cervical cancer, and misperception of the preventative aspect of screening and vaccination were common. Women with cervical cancer suffer from stigmatization and family problems due to loss of fertility, less marital sexual activity, domestic violence and decreased economic productivity. Ugandan men were willing to support cervical cancer prevention for their wives and daughters after being informed about cervical cancer. Limited knowledge among men about the risk factors and causes of cervical cancer, and about the preventative aspect of HPV vaccination and screening and their respective target groups, can limit uptake of both services. Screening and vaccination programs should actively involve men in creating awareness to increase uptake and acceptance of prevention.

Pattern of Care of Recurrent Cervical Cancer in Low-resource Settings: Challenges and Patient-initiated Follow-up as a Novel Opportunity.

The availability of optimum diagnostic strategies remains a major problem in resource-constraint countries. This technique of patient-initiated follow-up (PIFU) has been recently adopted in the UK for gynecological cancers and has proven cost benefits. However, no study from the Indian subcontinent has ever been reported. The primary objective was to study the pattern of care of recurrent cervical cancer in low-resource settings. The secondary objective was to compare the reliability of symptomatology/clinical evaluation and imaging methods on follow-up to detect recurrence and thus explore the feasibility of symptom-based PIFU. This was a single-institutional retrospective analysis of recurrent cervical cancer cases for a period of 3 years from January 2019 to January 2022. Patients who followed up for minimum of 6 months were included in the study. In 57 of the total 69 patients, symptoms alone were the index diagnostic method. Interestingly, neither of the methods of recurrence detection had impact on overall survival (OS). Cox regression analysis revealed adverse impact of erratic/lost to follow-up (hazard ratio [HR] = 3.8) and pelvic side wall disease (HR = 1.33) on survival. Patients with positive para-aortic nodes had significantly shorter disease-free interval of 11 months, so adding systemic therapy to adjuvant treatment in this cohort needs to be further investigated. Our analysis showed that patients with recurrence who were diagnosed with clinical manifestations alone vis-à-vis the ones who were diagnosed primarily on routine follow-up visit by some imaging or diagnostic test had comparable oncologic outcomes. PIFU can be a "practice changing modality" in patient management system, especially in low-resource settings. It will prove to be a simple cost-effective method to detect recurrence and prevent fallouts. Our study points to the feasibility of PIFU in Indian scenario.

Knowledge, practice and associated factors of breast self-examination among female university students of Bangladesh

BackgroundBreast cancer is the most common cancer and leading cause of death worldwide. Breast self-examination (BSE) is a cost-effective tool for self-assessment and for potential early detection of breast cancer in low-resource settings. This study aimed to explore knowledge, practice and associated factors of BSE among female university students of Bangladesh. MethodsA cross-sectional study was conducted among 400 conveniently selected female students aged ≥18 years from four universities. A pre-tested semi-structured self-administered questionnaire was used for data collection. Univariate and multivariable logistic regression and simple and multiple linear regression analysis was used to assess determinants of knowledge and practice regarding BSE. ResultsA total of 400 students participated from two private and two public universities (100 from each university). The average age of the participants was 20.89 ± 1.72 years (±SD). Of all, 60.5% had presence of knowledge (i.e., heard) about BSE. The average knowledge score was 7.41 ± 3.27 (in a scale of 0–15). Among those who had knowledge about BSE only 10.7% participants practiced it monthly. Being in public university (Adjusted Odds Ratio [aOR]: 3.42, 95% Confidence Interval [CI] 1.73–6.74) and years of education (aOR: 1.42, 95%CI: 1.02–1.97) were significant determinant of presence of knowledge regarding BSE. Moreover, studying in public university (β: 0.99, 95%CI 0.16–1.82) and education years passed (β: 0.51; 95%CI: 0.18–0.85) were associated with a higher knowledge score. Practice of BSE was negatively associated with students’ rural living prior to admission (aOR: 0.26, 95%CI: 0.08–0.79), and positively associated with level of knowledge regarding BSE (aOR: 1.48; 95%CI 0.08–0.79). ConclusionThis study revealed a general lack of knowledge and practice regarding BSE among female university students. As knowledge and practice of BSE would increase breast cancer awareness and screening acceptance, authorities should address the issue with properly planned strategies.

Anal Squamous Intraepithelial Lesions and Anal Cancer Management in Low Resource Settings.

A low resource setting (LRS) is defined as a health care system which does not meet the criteria defined by the World Health Organization (WHO) or other national/international organizations in the following areas: infrastructure, materials, and human resources. 1 Patients encounter barriers which limit their access to care and services that are considered standard of care. While LRS is most commonly associated with developing countries, it is easy to overlook communities in developed countries which lack the financial resources to afford basic health care. This article describes the societal implications and barriers to care for both squamous intraepithelial lesions (SILs) and anal cancer in LRS, the existing screening/surveillance approaches, available treatment approaches to anal cancer, and it also discusses potential evidence-based approaches to bridge the gap for these disparities in anal cancer care.

Field validation of deep learning based Point-of-Care device for early detection of oral malignant and potentially malignant disorders

Early detection of oral cancer in low-resource settings necessitates a Point-of-Care screening tool that empowers Frontline-Health-Workers (FHW). This study was conducted to validate the accuracy of Convolutional-Neural-Network (CNN) enabled m(mobile)-Health device deployed with FHWs for delineation of suspicious oral lesions (malignant/potentially-malignant disorders). The effectiveness of the device was tested in tertiary-care hospitals and low-resource settings in India. The subjects were screened independently, either by FHWs alone or along with specialists. All the subjects were also remotely evaluated by oral cancer specialist/s. The program screened 5025 subjects (Images: 32,128) with 95% (n = 4728) having telediagnosis. Among the 16% (n = 752) assessed by onsite specialists, 20% (n = 102) underwent biopsy. Simple and complex CNN were integrated into the mobile phone and cloud respectively. The onsite specialist diagnosis showed a high sensitivity (94%), when compared to histology, while telediagnosis showed high accuracy in comparison with onsite specialists (sensitivity: 95%; specificity: 84%). FHWs, however, when compared with telediagnosis, identified suspicious lesions with less sensitivity (60%). Phone integrated, CNN (MobileNet) accurately delineated lesions (n = 1416; sensitivity: 82%) and Cloud-based CNN (VGG19) had higher accuracy (sensitivity: 87%) with tele-diagnosis as reference standard. The results of the study suggest that an automated mHealth-enabled, dual-image system is a useful triaging tool and empowers FHWs for oral cancer screening in low-resource settings.

ES13.05 The Ethics of International Research

ES13.05 The Ethics of International Research

MHealth-Based Point-Of-Care Diagnostic Tool for Early Detection of Oral Cancer and Pre-Cancer Lesions in a Low-Resource Setting

Background: Early detection of oral cancer in low-resource settings necessitates a robust, Point-of-Care screening tool that can empower Frontline-Health-Workers (FHW) for triaging high-risk populations. This study was conducted to validate the accuracy of Artificial-Neural-Network (ANN) enabled m(mobile)-Health device deployed with FHWs. Methods: The dual-imaging device enables white-light as well as auto-fluorescence imaging with both a wide and focused view. The effectiveness of the device was tested in tertiary-care/dental hospitals and low-resource settings of South/North-East India. Demographics and clinical details were documented in the device, and the subjects were screened independently, either by FHWs or along with specialists, in addition to a remote evaluation by oral cancer specialists. Simple and complex ANN were built using the images for classification of oral-potentially-malignant/malignant lesions and integrated into the mobile phone/cloud. The specialist diagnoses were compared with the histopathology, FHW, and ANN-based diagnosis to evaluate the efficacy of the oral cancer detection program. Findings: The program screened 5025 subjects with 95% (n=4728) having tele-diagnosis. Among the 16% (n=752) assessed by onsite specialists, biopsy was advised for 515, out of which 20% (n=102) underwent biopsy. The onsite specialist diagnosis showed high sensitivity (94%) and moderate specificity (72%) when compared to histology diagnosis, while tele-diagnosis showed high accuracy when compared with onsite specialists (sensitivity: 95%; specificity: 84%). FHWs, when compared with tele-diagnosis, identified suspicious lesions with less sensitivity (60%). Further, the efficacy of the FHWs in delineating suspicious lesions correlated (r= 0·80) with their prior experience in the project. The ANN (MobileNet) integrated with the phone for a real-time diagnosis could accurately delineate lesions (n=1416; sensitivity: 82%), while the cloud-based ANN (VGG19) had higher accuracy (sensitivity: 87%) when compared to tele-diagnosis. Interpretation: This study suggests that an automated mHealth-enabled dual-image system could prove a useful triaging tool, empowering FHWs towards accurate screening in low-resource settings. Clinical Trial: The study protocol was registered in the Clinical Trial Registry of the Indian Council of Medical Research (CTRI/2019/11/022167). Funding: This study is primarily funded by the National Institutes of Health (NIH), USA grants (UH2EB022623, UH3CA239682). This work is also supported by LAMMP NIH/NIBIB P41EB05890, Arnold and Mabel Beckman Foundation, California Tobacco-Related Diseases Program: T31IR1825. Declaration of Interest: We declare no competing interests. Ethical Approval: Institutional Ethics Committee approvals were obtained from the three nodal centers- The KLE Society’s Institute of Dental Sciences (KLE; ECR/887/Inst/KA/2016), Bengaluru, India, Christian Institute of Health Sciences and Research (CIHSR; EC/NEW/INST/2020/782), Dimapur, Nagaland, India, and Mazumdar Shaw Medical Center (MSMC; NNH/MEC-CL-2016-394), Bengaluru, India prior to the initiation of the clinical trial.

A systematic review and meta-analysis of diagnostic accuracy of HPV tests for the screening of cervical cancer in low-resource settings.

HPV tests for the screening of cervical cancer in low-income countries (LICs) might improve early detection and preventive efforts. To determine the diagnostic accuracy of HPV tests for detecting cervical intraepithelial neoplasia grade 2 or worse (CIN 2+) in LICs. The Cochrane Library, MEDLINE, and CINAHL databases were searched on June 1, 2020. References of relevant studies were hand-searched. Diagnostic test accuracy studies were included if women had an HPV test for cervical cancer screening, followed by verification with colposcopy and colposcopy-directed biopsy. The primary target was CIN2+. Two authors independently screened studies, extracted data, and assessed methodological quality. Bivariate diagnostic random-effects meta-analysis was used. Eleven studies including 82 556 women were eligible, most of which were at low risk of bias. The pooled diagnostic odds ratio of hybrid capture test of samples collected from the cervix by healthcare providers for detecting CIN2+ and CIN3+ was 42.0 (95% confidence interval [CI] 20.7-76.3) and 97.1 (95% CI 35.3-215.0), respectively. Evidence indicates that hybrid capture tests can be used for screening of cervical cancer in LICs. Future studies are warranted for self-sampling and for low-cost HPV tests.

Plasmonic assay for amplification-free cancer biomarkers detection in clinical tissue samples

Developing countries have seen a rise in cancer incidence and are projected to harbor three-quarters of all cancer-related mortality by 2030. While disproportionally affected by the burden of cancer, these regions are ill-equipped to handle the diagnostic caseload. The low number of trained pathologists per capita results in delayed diagnosis and treatment, ultimately contributing to increased mortality rates. To address this issue, we developed a point-of-care (POC) plasmonic assay for direct detection of cancer as an alternative to pathological review. Whereas our assay has general applicability in many cancer diagnoses that involve tissue biopsies, we use head and neck cancer (HNC) as a model system because these tumors are increasingly prevalent in lower-income and underserved regions, due to risk factors such as smoking, drinking, and viral infection. Our method uses surface-enhanced Raman scattering (SERS) to detect unique RNA biomarkers from human biopsy samples without the need for complex target amplification machinery (e.g., PCR), making it time and resource-efficient. Unlike previous studies that required target amplification, this work represents a significant advance for HNC diagnosis directly in clinical samples, using only our SERS-based assay for RNA biomarkers. In this study, we tested our assay on 20 clinical samples, demonstrating the accuracy of the method in the diagnosis of head and neck squamous cell carcinoma. We reported sensitivity of 100% and specificity of 97%. Furthermore, we used a handheld Raman device to read the results in order to illustrate the applicability of our method for POC diagnosis of cancer in low-resource settings.

Scaling up cervical cancer prevention in Western Kenya: Treatment access following a community-based HPV testing approach.

To evaluate access to treatment after community-based HPV testing as testing within screen-and-treat programs has the potential to lower mortality from cervical cancer in low-resource settings. A prospective cohort study was conducted in western Kenya in 2018. Women aged 25-65years underwent HPV self-testing. HPV-positive women were referred for cryotherapy. Participant data were obtained from questionnaires during screening and treatment. The proportion successfully accessing treatment and variables associated with successful treatment was determined. Of the 750 women included, 140 (18.6%) tested positive for HPV. Of them, 135 were notified of their results, of whom 77 (59.2%) sought treatment and 73 (52.1%) received cryotherapy. Women who received treatment had a shorter time from screening to result notification (median 92days, interquartile range [IQR] 84-104) compared to those who did not (97days, IQR 89-106; P=0.061). In adjusted analyses, women with a history of cervical cancer screening (odds ratio [OR] 11, 95% confidence interval [CI] 1.42-85.20) and those electing result notification through a home visit (OR 4, 95% CI 1.23-14.17) were significantly more likely to acquire treatment at follow-up. Linkage to treatment after community-based HPV screening in this population was low, highlighting the need for strategies aimed at strengthening treatment linkage in similar settings.

African Head and Neck Society Clinical Practice guidelines for thyroid nodules and cancer in developing countries and limited resource settings.

International thyroid nodule and cancer management guidelines generally fail to take into account potential limitations in diagnostic and treatment resources. Thyroid cancer specialists from the African Head and Neck Society and American Head & Neck Society Endocrine Section developed guidelines for diagnosis and management of thyroid nodules and cancer in low resource settings. Recommendations were based on literature review and expert opinion, with level of evidence defined. Using the ADAPTE process, diagnostic and treatment algorithms were adapted from the National Comprehensive Cancer Network (NCCN). Low resource settings were simulated by systematically removing elements such as availability of laboratory testing, hormone replacement, imaging, and cytopathology from NCCN guidelines. Successful management of thyroid nodules and cancer in low resource settings requires adaptation of treatment methodologies. These guidelines define specific scenarios where either more or less aggressive intervention for thyroid pathology may be advisable based on limited available resources.

Abstract P1-01-06: Diagnostic accuracy of a novel palpation device to improve early detection of breast cancer in low-resource settings

Abstract Background and objectives: As the most commonly diagnosed cancer in women, breast cancer is projected to reach 1 million cases per year by 2020 in LMICs alone. Although incidence continues to increase in low- to middle-income countries, access to early detection in these high burden areas remain limited, in part due to lack of low-cost efficacious tools where mammography isn’t feasible. Therefore, the aim of this study is to evaluate the diagnostic accuracy of a lower cost, non-invasive, portable device called iBreastExam (iBE) in the detection of clinically relevant breast lesions. Methods: This study was a prospective non-randomized trial which enrolled women seeking routine screening or follow-up breast diagnostic evaluation from Nova Iguaçu and Rio de Janeiro, Brazil, respectively. Non-pregnant women aged 18 and older were eligible to enroll after providing informed consent. Each woman received an iBE palpation test and then mammography, ultrasound (US), or both, each by a different blinded clinician. For the sake of determining true lesion status, a positive mammogram was considered BIRADS 0, 3-6. A positive US was considered BIRADS 3-6. To assess accuracy of iBE to detect lesions, the sensitivity and specificity were calculated compared to mammography alone, ultrasound alone, or mammography plus ultrasound. For mammography plus US, the mammographic classification was considered the true status except for BIRADS 0, in which case the US classification was considered the truth. Each breast was considered an independent result for the sake of analysis. Results: The study enrolled and evaluated 226 women (449 breasts)with iBE, with a median age of 54 years old. Of the 434 breasts scanned by both iBE and mammography, 348 were normal by both and 17 lesions were detected by both. The sensitivity and specificity of iBE compared to mammography were 45.9% and 87.7%, respectively. Compared to the 324 US scans, where 258 normal by both and 20 lesions were detected by both, the sensitivity and specificity of iBE were 66.7% and 87.8%, respectively. Compared to mammography plus US, the sensitivity and specificity were 73.9% and 88.0%. Conclusions: Since iBE is being studied as a tool in resource-limited settings to facilitate early detection of suspicious breast lumps that warrant clinical follow-up, we chose other gold-standard diagnostic modalities and classifications, not detection of cancer, as our comparator. The relatively high specificity highlights the tools’ ability to reduce the pool of women warranting further evaluation but the sensitivity of iBE compared to mammography alone was relatively low. Notable, 15 of the 17 cases missed by iBE were classified as BIRADS 0. When these cases underwent US, the net sensitivity increased to 74%. These data highlight the potential for iBE to strengthen breast cancer early detection programs in LMIC’s and support the need for next generation sensors with improved sensitivity. Citation Format: Maurício M Costa, Anne F Rositch, Fernanda PA Pereira, Hildoberto C de Oliveira, Carolina F de Oliveira, Nilson Gomes, Flávia PPL Lopes. Diagnostic accuracy of a novel palpation device to improve early detection of breast cancer in low-resource settings [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-01-06.

Abstract P6-11-20: Capacity-building for molecular analyses of formalin-fixed paraffin-embedded breast cancer samples from Rwanda

Abstract Background: The global burden of cancer is rising exponentially in countries with the least resources to manage it. Breast cancer mortality is higher in African women than European women, but neither race nor access to care completely account for this discrepancy. Molecular profiling and methylation analysis could be informative but is expensive and the feasibility of using archived samples from low-resource settings is not known. We present a retrospective tissue collection study of breast cancer patients diagnosed at the University of Rwanda to investigate the quality of DNA from FFPE. Methods IRB approval and Material Transfer Agreement were obtained. Fifty tumor blocks and eight sets of FFPE slides from 2014-2018 were transported from Rwanda to USA in 2 batches. Pathology was reviewed for concordance. DNA was extracted using the QIAamp DNA FFPE Tissue kit (Qiagen). Batch 1: DNA quality and quantity was assessed using the Qubit 3.0 fluorometer (Life Technologies). Batch 2: DNA quality was assessed using Kapa hgDNA pPCR QC Assay. Bisulfite conversion and array hybridization protocols for the Illumina EPIC methylation platform to detect 2.5% methylated DNA target were used. DNA methylation data generated using the Infinum MethylationEPIC BeadChip (Illumina, Inc.) were pre-processed using minfi (v1.30.0), prior to quality control using Enmix (v1.20.2). A detection P-value threshold of 1E-06 was used to identify poorly detected probes, and a maximum threshold of 5% low quality data was used to identify poorly performing samples and CpG loci. Outliers based on beta-value distributions were also flagged as poor-quality samples. Mean bisulfite intensity values were calculated using Infinium type I and II control probes. DNA methylation beta-values were calculated to assess the proportion of methylated alleles at each individual CpG locus. Results: Histology was 82% concordant. All samples in Batch 1 had >5% low quality CpG’s. FFPE processing was reviewed and buffered formalin was not used. For Batch 2 10% neutral buffered formalin was transported and delivered to Central University Hospital of Kigali in March 2019. Eight additional patient samples were obtained and 6 out of 8 had <5% low quality CpG’s. Conclusion: Complex molecular studies are feasible with international collaboration. Optimal reagents and processing are crucial for successful analysis. Quality checkpoints must be done early in the process to maximize the potential for interpretable results. Capacity-building to improve DNA quality is the first step toward optimizing cancer treatment and minimizing disparities as molecular profiling increasingly directs cost-effective treatment.These results confirm methods appropriate for future molecular research on breast cancer in low resource settings. Citation Format: Mary Dickinson Chamberlin, Victoria Forbes, Germaine Dushimimana, Arminja Kettenbach, Kristen Muller, Emile Musoni, Eric Rutaganda, Owen M. Wilkins, Fred W. Kolling, Brock Christensen. Capacity-building for molecular analyses of formalin-fixed paraffin-embedded breast cancer samples from Rwanda [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-11-20.

Impact of neoadjuvant chemotherapy in improving operative intervention in the management of cervical cancer in low resource setting: a preliminary report

There is paucity of data on interventions to improve cancer outcome in the low-resource setting. This study aims to determine the effect of Neoadjuvant Chemotherapy (NACT) in improving operative outcomes of cervical cancer. This was a longitudinal intervention study of patients diagnosed with FIGO stage IIB - IIIA cervical cancer that had NACT. Patients were re-evaluated after treatment with 4 cycles of chemotherapy for operability. McNemar test was used to determine changes in operability of the tumour. There was a significant difference in the number of patients that converted from inoperable to operable tumor post-chemotherapy. This study shows some promise for NACT for FIGO stage IIB - IIIA cancer of the cervix, especially in low-resource settings, where radiotherapy is scarce.

Breast cancer subtypes: implications for the treatment and survival of patients in Africa—a prospective cohort study from Mozambique

BackgroundData regarding breast cancer epidemiology, treatment and survival in Africa are scarce. We aimed to assess the distribution of breast cancer subtypes in Mozambique and its impact on patients’ treatment and survival. The concordance of biomarker assessment between cytological and histological samples was also evaluated.MethodsProspective cohort study including 210 patients diagnosed between January 2015 and August 2017, followed to November 2019. Clinicopathological characteristics, treatment, 3-year overall survival (OS) and disease-free survival (DFS) were compared across classic tumour subtypes (oestrogen receptor (ER)-positive/human epidermal growth factor receptor 2 (HER2)-negative, HER2-positive and triple-negative breast cancer (TNBC)) and surrogate intrinsic subtypes (St. Gallen classification). Concordance was measured using Cohen’s κ statistics.ResultsA total of 51% of patients had ER-positive/HER2-negative tumours, 24% HER2-positive and 25% TNBC. Concordance between cytological and histological samples regarding ER and HER2 status was substantial (κ=0.762 and κ=0.603, respectively). There were no significant differences across subtypes regarding clinical characteristics and treatment, except for HIV positivity and high histological grade (more prevalent among TNBC) or endocrine therapy (higher use among ER-positive/HER2-negative and HER2-positive patients). Three-year OS was 52.5% (95% CI, 44.3% to 60.0%), being higher in ER-positive/HER2-negative (61.1%) compared with HER2-positive (53.2%) and TNBC (31.9%) patients. Adjusted HRs were 1.96 (95% CI, 1.13 to 3.39) among HER2-positive and 3.10 (95% CI, 1.81 to 5.31) among TNBC versus ER-positive/HER2-negative patients. Three-year DFS was 46.6% (95% CI, 38.0% to 54.8%), being lower among TNBC versus ER-positive/HER2-negative patients (HR 2.91; 95% CI, 1.64 to 5.16). Results were similar between surrogate intrinsic subtypes.ConclusionThere was a high proportion of HER2-positive and TNBC among Mozambican patients and their survival was poor compared with ER-positive/HER2-negative patients, partly due to the limited treatment options. A systematic assessment of ER, PR and HER2 status is feasible and may help tailoring and optimise the treatment of patients with breast cancer in low-resource settings, potentially leading to survival gains in this underserved population.

CERVICAL CANCER SCREENING USING ACETIC ACID AMONG HIGH RISK WOMEN AND PLAN OF NURSING ACTION

Background: Screening for cervical cancer using visual inspection with acetic acid (VIA) has been advocated by WHO as a suitable, low cost and feasible alternative modality for control of cervical cancer in low resource setting. The aim of the study was to assess cervical cancer screening for high risk women using acetic acid and implement the plan of nursing action. A cross-sectional design was carried out in the Gynecological OPD at Zagazig University Hospitals. A purposive sample of 100 females was required to estimate sensitivity and specificity of acetic acid in identifying pre malignant epithelial cell changes of the cervix. The tools used for data collection were; a structured interview sheet, clinical assessment sheet and the plan for nursing action. The results revealed that, women at risk for cervical cancer were more likely to be >30 years and more, their age of marriage was <20 years, had positive family history of cancer. They were also multipara, had repeated cervical laceration, exposed to STIs especially chlamydia and menorrhagia was present in 29.0% of them. Meanwhile post-coital bleeding was reported by 19.0% of the participants. Positive result for premalignant cervical lesion was 26.0% for VIA. Sensitivity and specificity of VIA were found to be 100% and 89.16% respectively. The accuracy of VIA was 91.0% which means that VIA test was more accurate. It can be concluded that VIA can effectively identify more cases of cervical intraepithelial neoplasia. It has been proven to achieve high sensitivity with an acceptable specificity. VIA test offers hope for universal screening as an alternate method for low resource setting. It is recommended that; VIA should be actively advocated to improve detection rate of cervical lesions so that it should be performed in all the women attending outpatient gynecological clinics.

CERVICAL CANCER SCREENING USING ACETIC ACID AMONG HIGH RISK WOMEN AND PLAN OF NURSING ACTION

Background: Screening for cervical cancer using visual inspection with acetic acid (VIA) has been advocated by WHO as a suitable, low cost and feasible alternative modality for control of cervical cancer in low resource setting. The aim of the study was to assess cervical cancer screening for high risk women using acetic acid and implement the plan of nursing action. A cross-sectional design was carried out in the Gynecological OPD at Zagazig University Hospitals. A purposive sample of 100 females was required to estimate sensitivity and specificity of acetic acid in identifying pre malignant epithelial cell changes of the cervix. The tools used for data collection were; a structured interview sheet, clinical assessment sheet and the plan for nursing action. The results revealed that, women at risk for cervical cancer were more likely to be >30 years and more, their age of marriage was <20 years, had positive family history of cancer. They were also multipara, had repeated cervical laceration, exposed to STIs especially chlamydia and menorrhagia was present in 29.0% of them. Meanwhile post-coital bleeding was reported by 19.0% of the participants. Positive result for premalignant cervical lesion was 26.0% for VIA. Sensitivity and specificity of VIA were found to be 100% and 89.16% respectively. The accuracy of VIA was 91.0% which means that VIA test was more accurate. It can be concluded that VIA can effectively identify more cases of cervical intraepithelial neoplasia. It has been proven to achieve high sensitivity with an acceptable specificity. VIA test offers hope for universal screening as an alternate method for low resource setting. It is recommended that; VIA should be actively advocated to improve detection rate of cervical lesions so that it should be performed in all the women attending outpatient gynecological clinics.

Training to Improve the Quality of Early Detection of Breast Cancer in Low-Resource Settings

Purpose Breast cancer (BC) is the most common cancer among women in Latin America, yet many countries lack the capacity to provide early detection and diagnostic services. In Peru, mammograms are not readily available in secondary cities, and 57% of women who are diagnosed with BC are diagnosed with stage III and IV disease. To bring services to women in a northern region of Peru, PATH collaborated with Peruvian health institutions at the local, regional, and national levels to design and implement a strategic algorithm with which to increase the early detection of BC in the absence of mammography. Here, we evaluate the impact of training on the quality of clinical breast exam (CBE), ultrasound triage, and fine-needle aspiration (FNA) sampling and the reading of FNA biopsy for triage-positive women. Methods Two hundred twenty-four midwives and 15 doctors were included in two-step training in Trujillo, Peru. CBE trainings were performed using anatomic models and patient exams in 2-day sessions. Team discussion with trainers was used to improve skills. Doctors’ trainings for FNA sampling were led by two international expert pathologists in 2014 and by a Peruvian expert pathologist in 2016. Then in 2017, 43 pretraining and 50 post-training FNA biopsy samples were evaluated for adequacy and quality of diagnosis. Results Since the trainings, 14,223 women have received CBE on an opportunistic basis. Midwives refer abnormal cases (n = 281) for follow-up. All doctors felt well trained for CBE and FNA, whereas five of 15 doctors perceived the need for additional ultrasound training. Quality assessment revealed that the adequacy of FNA samples improved from 26% pretraining to 37% post-training. Of the 43 FNA samples, a low concordance with reviewers was observed in the detection of suspicious/carcinoma (6.9% v 13.9%), whereas full concordance was observed after the training, although the numbers were small. Conclusion In Peru, CBE remains an acceptable and feasible approach if complemented with ultrasound triage and FNA biopsy. Additional efforts are needed to increase coverage through a structured program. Training and continuous monitoring are essential for quality assurance. 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 . Ronald Balassanian Stock or Other Ownership: Cerus Corp ($400.00)