Because most breast cancers cannot be attributed to modifiable risk factors, global breast cancer control efforts cannot rely solely on risk factor reduction,2 and will require systematic ...improvements in access to resource-appropriate, quality services to meet the Sustainable Development Goals for non-communicable diseases (target 3.4) and universal health coverage (target 3.8). For decades, there has been a steady escalation in the recognition of breast cancer as a public health priority through multiple political declarations, the most recent of which is the WHO 2017 Cancer Prevention and Control Resolution calling for broader investments in cancer, among other non-communicable diseases, as leading efforts to improve women's health. Breast cancer prevention through public education about risk-reduction strategies (eg, encouraging lactation, avoiding obesity, and limiting alcohol intake) is a foundational step for cancer control, but must be implemented alongside early-detection programmes.2 Late-stage presentation is unfortunately common throughout low-income and middle-income countries, where women are first diagnosed when their malignancy is already locally advanced (stage III) or metastatic (stage IV), at which point improving survival is both less likely and resource-intensive.
Background
Advanced stage presentation of patients with is common in low‐ and middle‐income countries (LMICs). A comprehensive analysis of existing delays and barriers in LMICs has not been ...previously reported. We conducted a systematic literature review to comprehensively outline delays and barriers to identify targets for future interventions and provide recommendations for future research in this field.
Materials and Methods
Multiple electronic databases were searched using a standardized search strategy. Eligible articles were of any language, from LMICs, and published between January 1, 2002, and November 27, 2017. Included studies reported cancer care intervals or barriers encountered. Intervals and associated barriers were summarized by cancer type and geographical region.
Results
This review included 316 study populations from 57 LMICs: 142 (44.9%) studies addressed time intervals, whereas 214 (67.7%) studies described barriers to cancer diagnosis. The median intervals were similar in the following three stages of early diagnosis: (a) access (1.2 months), (b) diagnostic (0.9 months), and (c) treatment (0.8 months). Studies from low‐income countries had significantly longer access intervals (median, 6.5 months) compared with other country income groups. Patients with breast cancer had longer delay intervals than patients with childhood cancer. No significant variation existed between geographic regions. Low health literacy was reported most frequently in studies describing barriers to cancer diagnosis and was associated with lower education level, no formal employment, lower income, and rural residence.
Conclusion
Early diagnosis strategies should address barriers during all three intervals contributing to late presentation in LMICs. Standardization in studying and reporting delay intervals in LMICs is needed to monitor progress and facilitate comparisons across settings.
Implications for Practice
This review draws the attention of cancer implementation scientists globally. The findings highlight the significant delays that occur throughout the cancer care continuum in low‐ and middle‐income countries and describe common barriers that cause them. This review will help shape the global research agenda by proposing metrics and implementation studies. By demonstrating the importance of standardized reporting metrics, this report sets forth additional research and evidence needed to inform cancer control policies.
摘要
背景。在中低收入国家 (LMIC)，晚期患者十分常见。以前，人们从未报告有关LMIC癌症治疗延误和障碍现状的综合分析。我们开展了一项系统的文献回顾工作，旨在全面地列述各种延误和障碍，以确定未来干预措施的目标并为该领域中的未来研究提供建议。
材料和方法。采用标准化检索策略在多个电子数据库中进行检索。符合条件的文章为在 2002 年 1 月 1 日至 2017 年 11 月 27 日期间以任何语言在LMIC发表的文章。纳入的研究报告了癌症治疗的时间间隔或遇到的障碍。按照癌症类型和地理区域，我们对时间间隔和相关的障碍进行了总结。
结果。本次回顾工作包含来自 57 个LMIC的 316 项研究人群:142 (44.9%) 项研究提到了时间间隔，而 214 (67.7%) 项研究描述了癌症诊断的障碍。在早期诊断的以下三个阶段中，中位时间间隔相似:(a) 就诊(1.2 个月)，(b) 诊断(0.9 个月)以及 (c) 治疗(0.8 个月)。与其他国家收入群体相比，低收入国家的就诊时间间隔明显更长(中位6.5 个月)。与儿童期癌症患者相比，乳腺癌患者的延误时间间隔更长。地理区域之间没有显著差异。在描述癌症诊断障碍的研究中，最常报告的是健康素养低，这一障碍与教育水平较低、无正式职业、收入较低以及在农村居住相关。
结论。早期诊断策略应该解决所有三个时间间隔中延误LMIC患者的诊断和治疗的障碍。对于LMIC的延误时间间隔，人们需要实现研究和报告的标准化，以监控进展情况并促进各种环境之间的对比。
实践意义:本次回顾工作引起了全球癌症一线科学家的关注。研究结果重点指出了在中低收入国家癌症连续治疗期间发生的重大延误问题并描述了导致此类问题的常见障碍。通过提出指标和实践研究，本次回顾工作将帮助制定全球研究议程。通过证实标准化报告指标的重要性，本报告提出了传达癌症控制政策所需的其他研究和证据。
This review outlines causes of delays in diagnosis and barriers to early diagnosis of cancer in patients in low‐ and middle‐income countries.
In some countries, breast cancer age-standardised mortality rates have decreased by 2–4% per year since the 1990s, but others have yet to achieve this outcome. In this study, we aimed to characterise ...the associations between national health system characteristics and breast cancer age-standardised mortality rate, and the degree of breast cancer downstaging correlating with national age-standardised mortality rate reductions.
In this population-based study, national age-standardised mortality rate estimates for women aged 69 years or younger obtained from GLOBOCAN 2020 were correlated with a broad panel of standardised national health system data as reported in the WHO Cancer Country Profiles 2020. These health system characteristics include health expenditure, the Universal Health Coverage Service Coverage Index (UHC Index), dedicated funding for early detection programmes, breast cancer early detection guidelines, referral systems, cancer plans, number of dedicated public and private cancer centres per 10 000 patients with cancer, and pathology services. We tested for differences between continuous variables using the non-parametric Kruskal-Wallis test, and for categorical variables using the Pearson χ2 test. Simple and multiple linear regression analyses were fitted to identify associations between health system characteristics and age-standardised breast cancer mortality rates. Data on TNM stage at diagnosis were obtained from national or subnational cancer registries, supplemented by a literature review of PubMed from 2010 to 2020. Mortality trends from 1950 to 2016 were assessed using the WHO Cancer Mortality Database. The threshold for significance was set at a p value of 0·05 or less.
148 countries had complete health system data. The following variables were significantly higher in high-income countries than in low-income countries in unadjusted analyses: health expenditure (p=0·0002), UHC Index (p<0·0001), dedicated funding for early detection programmes (p=0·0020), breast cancer early detection guidelines (p<0·0001), breast cancer referral systems (p=0·0030), national cancer plans (p=0·014), cervical cancer early detection programmes (p=0·0010), number of dedicated public (p<0·0001) and private (p=0·027) cancer centres per 10 000 patients with cancer, and pathology services (p<0·0001). In adjusted multivariable regression analyses in 141 countries, two health system characteristics were significantly associated with lower age-standardised mortality rates: higher UHC Index levels (β=–0·12, 95% CI −0·16 to −0·08) and increasing numbers of public cancer centres (β=–0·23, −0·36 to −0·10). These findings indicate that each unit increase in the UHC Index was associated with a 0·12-unit decline in age-standardised mortality rates, and each additional public cancer centre per 10 000 patients with cancer was associated with a 0·23-unit decline in age-standardised mortality rate. Among 35 countries with available breast cancer TNM staging data, all 20 that achieved sustained mean reductions in age-standardised mortality rate of 2% or more per year for at least 3 consecutive years since 1990 had at least 60% of patients with invasive breast cancer presenting as stage I or II disease. Some countries achieved this reduction without most women having access to population-based mammographic screening.
Countries with low breast cancer mortality rates are characterised by increased levels of coverage of essential health services and higher numbers of public cancer centres. Among countries achieving sustained mortality reductions, the majority of breast cancers are diagnosed at an early stage, reinforcing the value of clinical early diagnosis programmes for improving breast cancer outcomes.
None.
To achieve an oncology workforce that is fit for purpose and sufficient in number, more holistic workforce planning is needed, focusing on educational sector and labor market dynamics. Oncology ...professionals must be trained and enabled to influence factors affecting their clinical practice including by developing competencies to redesign clinical practice, reduce burnout, and improve productivity and care.
National cancer control plans: a global analysis Romero, Yannick; Trapani, Dario; Johnson, Sonali ...
The lancet oncology,
October 2018, 2018-10-00, 20181001, Letnik:
19, Številka:
10
Journal Article
Recenzirano
There is increasing global recognition that national cancer plans are crucial to effectively address the cancer burden and to prioritise and coordinate programmes. We did a global analysis of ...available national cancer-related health plans using a standardised assessment questionnaire to assess their inclusion of elements that characterise an effective cancer plan and, thereby, improve understanding of the strengths and limitations of existing plans. The results show progress in the development of cancer plans, as well as in the inclusion of stakeholders in plan development, but little evidence of their implementation. Areas of continued unmet need include setting of realistic priorities, specification of programmes for cancer management, allocation of appropriate budgets, monitoring and evaluation of plan implementation, promotion of research, and strengthening of information systems. We found that countries with a non-communicable disease (NCD) plan but no national cancer control plan (NCCP) were less likely than countries with an NCCP and NCP plan or an NCCP only to have comprehensive, coherent, or consistent plans. As countries move towards universal health coverage, greater emphasis is needed on developing NCCPs that are evidence based, financed, and implemented to ensure translation into action.
Summary Surgery is essential for global cancer care in all resource settings. Of the 15·2 million new cases of cancer in 2015, over 80% of cases will need surgery, some several times. By 2030, we ...estimate that annually 45 million surgical procedures will be needed worldwide. Yet, less than 25% of patients with cancer worldwide actually get safe, affordable, or timely surgery. This Commission on global cancer surgery, building on Global Surgery 2030, has examined the state of global cancer surgery through an analysis of the burden of surgical disease and breadth of cancer surgery, economics and financing, factors for strengthening surgical systems for cancer with multiple-country studies, the research agenda, and the political factors that frame policy making in this area. We found wide equity and economic gaps in global cancer surgery. Many patients throughout the world do not have access to cancer surgery, and the failure to train more cancer surgeons and strengthen systems could result in as much as US$6·2 trillion in lost cumulative gross domestic product by 2030. Many of the key adjunct treatment modalities for cancer surgery—eg, pathology and imaging—are also inadequate. Our analysis identified substantial issues, but also highlights solutions and innovations. Issues of access, a paucity of investment in public surgical systems, low investment in research, and training and education gaps are remarkably widespread. Solutions include better regulated public systems, international partnerships, super-centralisation of surgical services, novel surgical clinical trials, and new approaches to improve quality and scale up cancer surgical systems through education and training. Our key messages are directed at many global stakeholders, but the central message is that to deliver safe, affordable, and timely cancer surgery to all, surgery must be at the heart of global and national cancer control planning.
To curb the rising global burden of non-communicable diseases (NCDs), the UN Sustainable Development Goals (SDGs) include a target to reduce premature mortality from NCDs by a third by 2030. A ...quantitative assessment of the effect on longevity of meeting this target is one of the many important measures needed to advocate and inform national disease control policies. We did a global analysis to estimate improvements in average expected years lived between 30 and 70 years of age that would result from meeting the SDG target.
We estimated age-specific mortality in 183 countries in 2015, for the four major NCDs (cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes) and all NCDs combined, using data from WHO Global Health Estimates. We then estimated the potential gains in average expected years lived between 30 and 70 years of age (LE30–70)) by eliminating all or a third of premature mortality from specific causes of death in countries grouped by World Bank income groups. The feasibility of reducing mortality to the targeted level over 15 years was also assessed on the basis of historical mortality trends from 2000 to 2015.
Reducing a third of premature mortality from NCDs over 15 years is feasible in high-income and upper-middle-income countries, but remains challenging in countries with lower income levels. National longevity will improve if this target is met, corresponding to an average gain in LE30–70) of 0·64 years worldwide from reduced premature mortality for the four major NCDs and 0·80 years for all NCDs. According to major NCD type, the largest gains attributable to cardiovascular diseases would be in lower-middle-income countries (a gain of 0·45 years), whereas gains attributable to cancer would be in low-income countries (0·33 years).
A one-third reduction in premature mortality from the major NCDs in 2015–30 would have substantial effects on longevity. High-level political commitments to effective and equitable national surveillance and prioritised prevention, early detection, and treatment programmes tailored to the major NCD types are needed urgently in lower-resourced settings if this SDG target is to be met by 2030.
None.
Predominant reasons are misperceptions of cancer as being too complex and too expensive to treat, a lack of consensus on cost-effective interventions, an inability of host health systems to expand ...cancer services, and chronically underfunded humanitarian responses.3 The consequence is thousands of potentially avoidable deaths from cancer among the refugee population living in Jordan, Lebanon, and Turkey.4 What needs to be done? External development assistance must thus initially focus on early diagnosis and treatment of curable cancers (such as childhood cancer or early-stage breast, cervix, or colorectal cancers) to optimise expenditure. Current registries in Jordan, Lebanon, and Turkey are population-based, but data about refugee status are generally not captured or reported.2 Since the onset of the Syrian refugee crisis in 2013, the number of Syrian refugees in all countries reached more than 5 million in April, 2017, and continues to increase.1 Time will not resolve the cancer care needs of refugees and thousands will continue to be diagnosed each year.2 Abdul-Khalek and colleagues have rightly drawn attention to the economic requirements of providing cancer care for refugees.2 This paper is only the beginning of the research and political agendas; to deliver on the potential of universal health coverage, greater health service and implementation research is needed, focusing on how services are organised and delivered, and also documenting best practices in financing.
Cancer control planning has become a core aspect of global health, as rising rates of noncommunicable diseases in low‐resource settings have fittingly propelled it into the spotlight. Comprehensive ...strategies for cancer control are needed to effectively manage the disease burden. As the most common cancer among women and the most likely reason a woman will die from cancer globally, breast cancer management is a necessary aspect of any comprehensive cancer control plan. Major improvements in breast cancer outcomes in high‐income countries have not yet been mirrored in low‐resource settings, making it a targeted priority for global health planning. Resource‐stratified guidelines provide a framework and vehicle for designing programs to promote early detection, diagnosis, and treatment using existing infrastructure and renewable resources. Strategies for evaluating the current state and projecting future burden is a central aspect of developing national strategies for improving breast cancer outcomes at the national and international levels.
Background
Delays to cancer diagnosis exist, resulting in worse survival outcomes for many cancers. Interventions targeting delays and barriers to cancer diagnosis and treatment have been ...investigated, but mostly in high‐income countries. We conducted a systematic literature review to identify and characterize the interventions studied across cancers, within low‐ and middle‐income countries (LMICs).
Methods
This systematic review forms part two of a wider study examining solutions to delays and barriers in cancer early diagnosis in LMICs. A comprehensive literature search was conducted on November 27, 2017, encompassing published studies from the preceding 15 years. We extracted study design, population, and intervention, and reported outcome measures from each study. Results were presented by target of interventions (general vs. health care professionals). A narrative synthesis was used to summarize intervention efficacy.
Results
Of 10,193 s returned, 25 were included, consisting of studies across World Health Organization geographical regions, examining breast, cervix, childhood, prostate, head and neck, and gastric cancers. Altogether, 11 intervention studies targeted the general population, 12 targeted health care professionals, and 2 targeted both. The majority (17/25) of studies reported interventions focusing on patient and diagnosis‐related barriers early in the cancer care pathway. Most studies reported knowledge score as primary outcome measure (17/25); few (6/25) reported on clinically relevant measures such as reducing disease stage at presentation or diagnostic time interval. Effectiveness of interventions was demonstrated for some cancers only.
Conclusion
More interventions reporting clinically relevant measures and using standardized methods and outcomes are required to improve our ability to effectively improve cancer early diagnosis in LMICs.
Implications for Practice
Prior to this study, the extent of intervention literature in cancer early diagnosis in low‐ and middle‐income countries had not been characterized. This study aimed to outline and characterize interventions across all cancer types and across all countries. This systematic review demonstrated that interventions have been investigated targeting both the general population and health care professionals. Furthermore, this review demonstrates that the majority of studies report knowledge as an outcome measure, rather than clinically significant measures that improve cancer‐related outcomes, such as delay intervals or downstaging of disease. Future interventions should address clinically relevant measures to better assess efficacy of interventions.
This review reports on interventions that address delays and barriers in diagnosis and treatment of cancer, summarizing published studies from low‐ and middle‐income countries.
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