Validity and Reliability of the Amharic Version of EORTC-QLQ-CR29 Among Colorectal Cancer Patients in Ethiopia.

BACKGROUND: The European Organization for Research and Treatment of Cancer - Quality of Life Questionnaire (EORTC-QLQ) developed to assess quality of life among colorectal cancer patients has not been translated into a local language or validated in the Ethiopian context. Therefore, this study aimed to examine the psychometric properties of the EORTC-QLQ-CR29 tool in Ethiopia among colorectal cancer patients. METHODS: A cross-sectional study was conducted in a major referral hospital in Addis Ababa, Ethiopia, from March to May, 2020. A total of 158 colorectal cancer patients were included. The validity of the tool was assessed using Multitrait Scale Analysis, Mann-Whitney test and Pearson correlation coefficient. The internal consistency was examined using Cronbach's alpha. RESULTS: Among the participants, 52.2% were men, with a median age of 46 years (IQR = 17.7 years). The item-total correlation alpha values ranged from 0.47 to 0.91. Multitrait Scale Analysis demonstrated convergent and divergent validity of the tool, except for the Blood and Mucus in Stool scale. All item correlations within their scales were greater than 0.4, except for the Blood and Mucus in Stool scale. The values of correlation coefficients between all items and their own domain were higher than other domains, except for the Blood and Mucus in Stool scale. The correlation between the core questionnaire and the colorectal tool ranged from -0.45 to 0.58. The tool showed a significant difference between stoma and non-stoma patients and between patients who had good physical function and those who did not. CONCLUSION: The Amharic version of the EORTC-QLQ-CR29 tool can be used to assess the health-related quality of life in Ethiopian colorectal cancer patients.

Catastrophic healthcare expenditure and coping strategies among patients attending cancer treatment services in Addis Ababa, Ethiopia.

BACKGROUND: With the rapid increase in magnitude and mortality of cancer, which is costly disease to manage, several patients particularly in developing countries are facing a huge financial burden. The study aimed to examine the incidence of catastrophic health expenditure (CHE), identify associated factors and coping strategies among patients attending cancer treatment services in Addis Ababa, Ethiopia. METHODS: A hospital-based cross-sectional survey of patients with cancer was conducted in public and private hospitals between January and March 2018. Data was collected using a structured questionnaire. All direct medical and nonmedical expenditures were measured and reported as expenditure (US$) per patient (1US$ equivalent to 23.41 Ethiopian Birr). The CHE was estimated using a threshold of 10% of annual household income. RESULTS: A total of 352 (response rate of 87.1%) participants were interviewed. Majority (73.3%) of the respondents were females; most (94%) from public hospitals and their mean (±SD) age was 48 ± 13.2 years. Vast majority (74.4%) of patients experienced CHE with mean overall expenditure of $2366 per patient (median: $1708). Medical expenditure shared the highest overall expenditure (83.6%) with mean medical and nonmedical costs of $1978 (median: $1394) and $388 (median: $222), respectively. Patients who took greater than six cycles of chemotherapy (AOR: 3.64; 95% CI: 1.11-11.92), and age (AOR: 1.03; 95% CI: 1.01-1.06) were significantly associated with CHE. Household saving (85.5%) followed by financial support received (43.0%) was the main coping strategy. CONCLUSION: A substantial number of patients with cancer were exposed to CHE with a considerable medical expenditure. Hence, in addition to the popularization of the already introduced health insurance scheme, other better prepayment or insurance mechanisms should also be considered to ensure financial risk protection and realize universal health coverage for patients with cancer.

Person and Family Centeredness in Ethiopian Cancer Care: Proposal for a Project for Improving Communication, Ethics, Decision Making, and Health.

BACKGROUND: Cancer is a major burden in Ethiopia. The Oncology Department of Tikur Anbessa (Black Lion) Specialized Hospital in Addis Ababa is the sole specialist unit for cancer care in the country. With only a handful of oncologists, a lack of resources, and a huge patient load, the work is challenging, especially in terms of achieving effective and ethical patient consultations. Patients, usually accompanied by family members, often wait for a long time to receive medical attention and frequently depart without treatment. Handling consultations effectively is essential to help patients as much as possible within such limitations. OBJECTIVE: The project has the following three main aims: (1) to enhance and expand the understanding of communicative and associated ethical challenges in Ethiopian cancer care; (2) to enhance and expand the understanding of the implications and use of person- and family-centered solutions to address such communicative challenges in practice; and (3) to plan and evaluate interventions in this area. METHODS: This project develops and consolidates a research collaboration to better understand and mitigate the communicative challenges in Ethiopian cancer care, with a focus on the handling and sharing of decision making and ethical tension among patients, staff, and family. Using theoretical models from linguistics, health communication, and health care ethics, multiple sources of data will be analyzed. Data sources currently include semistructured interviews with Ethiopian staff (n= 16), patients (n= 54), and family caregivers (n= 22); survey data on cancer awareness (n=150) and attitudes toward breaking bad news (n=450); and video recordings of medical consultations (n=45). In addition, we will develop clinical and methodological solutions to formulate educational interventions. RESULTS: The project was awarded funding by the Swedish Research Council in December 2017 for the period 2018 to 2021. The research ethics boards in Sweden and Ethiopia approved the project in May 2018. The results of the studies will be published in 2020 and 2021. CONCLUSIONS: The project is the first step toward providing unique and seminal knowledge for the specific context of Ethiopia in the areas of physician-patient communication research and ethics. It contributes to the understanding of the complexity of the role of family and ethical challenges in relation to patient involvement and decision making in Ethiopia. Improved knowledge in this area can provide a fundamental model for ways to improve cancer care in many other low-resource settings in Africa and the Middle East, which share central cultural prerequisites, such as a strong patriarchal family structure, along with strong and devout religiosity. The project will also serve to develop greater understanding about the current challenges in Western health systems associated with greater family and patient participation in decision making. In addition, the project will contribute to improving the education of Ethiopian health professionals working in cancer care by developing a training program to help them better understand and respond to identified challenges associated with communication. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/16493.

Nasopharyngeal Carcinoma: A Retrospective Study on Imaging Patterns at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

BACKGROUND: Nasopharyngeal carcinoma is one of the rare forms of cancer globally which has a high incidence in select geographic and ethnic populations. The current study aims to assess the clinical presentation, imaging patterns and radiology-pathology correlation of nasopharyngeal carcinoma. METHODS: This is a retrospective analysis of 80 patients with newly diagnosed nasopharyngeal carcinoma who came to Tikur Anbessa Specialized Hospital from January 2016 to August 2017. The patients' history, physical examination, abdominopelvic ultrasound, chest x-ray, computed tomography scan and biopsy reports were reviewed from their medical record. Patients who had previous history of treatment for nasopharyngeal carcinoma, those who did not have biopsy and those without imaging were excluded from the study. RESULTS: This study showed that 61(81.3%) patients had neck swelling as the initial clinical symptom, and the average time of presentation of symptoms was 6(IQR 8) months. On the other hand, 56(70.0%) were diagnosed with non-keratinizing undifferentiated nasopharyngeal carcinoma while 15(3.8%) had keratinizing nasopharyngeal carcinoma. Sixty-nine (86.3%) patients had nodal metastasis; 22.5% had invasion into the paranasal sinuses; 47.5% had T4 with T1, T2 and T3 being 18.8%, 17.5% and 7.5% stage respectively at time of diagnosis. Ninety percent of the cases had a diagnosis of nasopharyngeal carcinoma on imaging, but 10% were given alternative diagnosis. CONCLUSION: Non-keratinizing undifferentiated type was the commonest histologic subtype in this study which is also recognized as the commonest one in endemic countries. A significant number did not have a specific histologic WHO type on pathology report which could in turn affect the management and assessment of risk factors.

Definition of fields margins for the optimized 2D radiotherapy of prostate carcinoma.

Prostate cancer (PCa) is one of the most common malignancies in men both in western and developing countries. Radiotherapy (RT) is an important therapeutic option. New technologies (including 3D, intensity modulated RT, image-guided RT and, volumetric modulated arc therapy) have been introduced in the last few decades with progressive improvement of clinical outcomes. However, in many developing countries, the only treatment option is the traditional two-dimensional (2D) technique based on standard simulation. The guidelines for 2D field definition are still based on expert's opinions. The aim of the present study was to propose new practical guidelines for 2D fields definition based on 3D simulation in PCa. A total of 20 patients were enrolled. Computed tomography-simulation and pelvic magnetic resonance images were merged to define the prostate volumes. Clinical Target Volume (CTV) was defined using the European Organisation for Research and Treatment of Cancer guidelines in consideration of the four risk categories: Low, intermediate, and high risk with or without seminal vesicles involvement, respectively. Planning Target Volume (PTV) was defined by adding 10 mm to the CTV. For each category, two treatment plans were calculated using a cobalt source or 10 MV photons. Progressive optimization was achieved by evaluating 3D dose distribution. Finally, the optimal distances between field margins and radiological landmarks (bones and rectum with contrast medium) were defined. The results were reported in tabular form. Both field margins (PTV D98% >95%) needed to adequately irradiate all patients and to achieve a similar result in 95% of the enrolled patients are reported. Using a group of patients with PCa and based on a 3D planning analysis, we propose new practical guidelines for PCa 2D-RT based on current criteria for risk category and CTV, and PTV definition.

Characteristics and follow-up of metastatic breast cancer in Ethiopia: A cohort study of 573 women.

OBJECTIVES: There is little information on characteristics, treatment and outcome of metastatic breast cancer (mBC) patients in low-income countries. This study aims to describe mBC in the setting of Ethiopia. MATERIALS AND METHODS: A retrospective cohort study was conducted among all female mBC patients from the only oncologic hospital in Addis Ababa 01/2006 to 12/2010. Time between first metastasis and known death or loss to follow-up for more than six months as surrogate for death were used for Cox proportional hazards model. RESULTS: A total of 573 patients were included; 188 (32.8%) women with de novo mBC (dnmBC) and 385 women with recurrent mBC (rmBC). The average age at time of first metastasis was 43.7 (standard deviation 11.9) years with an average survival probability of twelve months. Negative hormone receptor status, only present in 29% (Hazard ratio HR = 2.28 [95% confidence interval CI 1.56-3.32] p < 0.001), and grade 3 (HR = 1.72 [95% CI 1.15-2.55] p = 0.008) had significant influence on survival. Patients with initial bone metastasis (HR = 0.63 [95% CI 0.48-0.83] p = 0.001) had best chances of survival compared to more common initial visceral metastasis. About 35% of the patients received chemotherapy and 30.5% were on endocrine therapy. CONCLUSION: The lower survival for mBC in Addis Ababa compared to that from Western countries is presumably due to the later presentation at the hospital and lack of standard therapy. An unexpected high proportion of patients with hormone receptor positive mBC encourage consequent utilization of endocrine therapy to improve the quality of palliative care in this cohort.

First data from a population based cancer registry in Ethiopia.

BACKGROUND: The Addis Ababa City Cancer Registry, established in September 2011, is the only population-based cancer registry in Ethiopia, covering a catchment population of just over three million habitants. Herein, we report incidence data based on the first two years of registration, 2012-2013. METHODS: Newly-diagnosed cancer cases in the capital city were actively collected from 22 hospitals, clinics, and diagnostic facilities. RESULTS: During 2012-2013, a total of 4139 newly diagnosed cases were recorded, with the majority (67%) occurring in females. Cancers of the breast (31.5%) and cervix (14.1%) were the two most common cancers among females, while colorectal cancers (10.6%) and non-Hodgkin lymphomas (10.2%) were the most common cancers among males. The average annual age-standardized rate for all sites 2012-13 were 136.2 (per 100,000) and 70.7 in females and males, respectively. Female age-standardized rates were 40.6 for breast cancer and 21.5 for cervix, while equivalent rates in males were 7.6 per 100,000 for colorectal cancer and 6.8 per 100,000 for non-Hodgkin lymphoma. CONCLUSION: In general, these incidence patterns were similar to those reported in neighboring countries, which suggests that the majority of cancer cases occurring in Addis Ababa are captured within this starting phase of the registry. However, our finding of colorectal cancer as the most commonly-diagnosed cancer in males is novel and requires further investigation.