Establishing women's cancer care services in a fragile, conflict and violence affected ecosystem in Africa.

BACKGROUND: The majority of the world's poorest women (income < $1.90/day) reside in fragile, conflict and violence (FCV)-affected countries, like the Democratic Republic of the Congo. Health services in these settings have traditionally focused on immediate relief efforts, communicable diseases and malnutrition. Recent data suggests there is need to widen the focus to include cancer, as its incidence and mortality rates are rising. METHODS: Employing competency-based learning strategies, Congolese health professionals were trained to perform same-day cervical cancer screening and treatment of precancerous lesions of the cervix; same-day clinical breast examination and breast ultrasound diagnostics; surgical treatment of invasive cancers of the breast and cervix; and infusion of cytotoxic chemotherapy. Outpatient breast and cervical cancer care clinics, a chemotherapy suite and surgical theatres were outfitted with equipment and supplies. RESULTS: Combining local and regional hands-on training seminars with wise infrastructure investments, a team of US and Zambian oncology experts successfully implemented a clinical service platform for women's cancers in a private sector health facility in the Democratic Republic of the Congo. CONCLUSION: We forged a novel partnership between oncology health professionals from Africa and its Diaspora, international philanthropic organisations, a cancer medicine access initiative and an established African cancer centre to build women's cancer services in a FVC-affected African setting.

Building workforce capacity for the surgical management of cervical cancer in a fragile, low-income African nation-Democratic Republic of the Congo.

OBJECTIVES: Surgery is a cornerstone of the management of cervical cancer. Women diagnosed with cervical cancer in sub-Saharan Africa have very little access to specialised (gynaecologic oncology) surgical services. We describe our experiences and challenges of training local general gynaecologists to surgically treat early stage invasive cervical cancer at a private sector healthcare facility in a fragile, low-income African nation. METHODS: Implementation of the training curriculum began with assigned self-directed learning. It continued with on-site training which consisted of preoperative surgical video reviews, pre- and intra-operative assessment of disease status, deconstruction of the designated surgical procedure into its critical subcomponents and trainees orally communicating the steps of the surgical procedure with the master trainers. High-volume repetition of a single surgical procedure over a short time interval, intra-operative bedside mentoring, post-operative case review and mental narration were critical to the process of surgical skills transfer. RESULTS: Nineteen radical abdominal hysterectomies were successfully performed over four training visits; trainees were able to perform the procedure alone after eight cases; surgical complications decreased over time. The trainees have continued to perform the surgical procedures independently. CONCLUSION: Life-saving surgical capacity for the treatment of cervical cancer has been established and sustained at a private sector healthcare facility in a fragile, low-income African setting, through an innovative model of surgical training.

Leveraging a matrix of stakeholders to facilitate access to chemotherapy for women's cancers in the Democratic Republic of the Congo.

BACKGROUND: Cancer incidence is increasing worldwide. Over the next 20 years, the growing proportion of cases in low- and middle-income countries (LMICs) will account for an estimated 70% of all cancers diagnosed. The vast majority of cancer patients in LMICs will require chemotherapy, due to the advanced stage of their disease at the time of initial presentation. Unfortunately, the availability of cancer drugs in these environments is sparse, resulting in premature death and years of life lost. In an effort to lay a foundation for women's cancer control in the Democratic Republic of the Congo (DRC), we implemented a programme which combined workforce development, infrastructure creation and cancer drug access. This manuscript reports on our experience with the latter. METHODS: A private sector healthcare facility was selected as the programme implementation site. Workforce capacity was developed through a south-south partnership with an African national cancer centre. Cancer drugs were procured through a global cancer medicine access initiative. RESULTS: A new chemotherapy infusion unit was successfully established at the Biamba Marie Mutombo Hospital in Kinshasa, DRC. A team of Congolese healthcare providers was trained at the Cancer Disease Hospital in Zambia to safely and effectively administer chemotherapy for breast and cervical cancer. Over 100 breast and cervical cancer patients have been treated with 337 courses of chemotherapy, without any serious adverse events. CONCLUSION: Common barriers to cancer drug access and its administration can be eliminated using regional educational resources to build oncologic workforce capacity, private sector healthcare facilities for infrastructure support and pharmaceutical consortiums to procure low-cost cancer medicines. By leveraging a matrix of global, regional and local stakeholders, the prevailing status quo of very limited access to chemotherapy for women's cancers was creatively disrupted in DRC, Africa's largest fragile, conflict and violence-affected country.

Building a breast cancer detection and treatment platform in the Democratic Republic of the Congo by integrating training, service and infrastructure development.

BACKGROUND: Breast cancer is a leading cause of cancer-related morbidity and mortality in sub-Saharan Africa, a global region where opportunities for breast care of any type are extremely limited due to insufficient infrastructure, a paucity of clinical services and vast shortages of trained human resources. METHODS: A team of Zambian and US gynaecologic and breast oncology experts and nurse-specialists made multiple visits (each lasting 5 working days) to the Democratic Republic of the Congo (DRC), over a 2-year period. During each of five week-long site visits, hands-on training of local Congolese health providers was conducted during which time they were taught clinical breast exam (CBE), breast and axillary ultrasound, ultrasound-guided core needle biopsy/fine needle aspiration (FNA) and breast surgery. Simultaneous with the training exercises, a new breast care clinic was established and operationalised, and existing surgical theatres were upgraded. All activities were implemented in a private sector health care facility - Biamba Marie Mutombo Hospital - in the capital city of Kinshasa. RESULTS: From April 2017 to August 2020, a total of 5,211 women were identified as having breast abnormalities on CBE. Ages ranged from 26 to 86 years; median age: 42.0 (±14.1) years. Ultrasound abnormalities were noted in 1,420 (27%) clients, of which 516 (36%) met the criteria (indeterminate cystic lesion, solid or suspicious masses) for ultrasound-guided core needle biopsy or FNA. Pathology reports were available for 368 (71%) of the 516 clients who underwent biopsy, of which 164 were malignant and 204 benign. The majority (88%) of the cancers were advanced (TNM stages 3 and 4). Surgical procedures consisted of 183 lumpectomies, 58 modified radical mastectomies and 45 axillary lymph node dissections. Clinical competency for diagnostic and surgical procedures was reached early in the course of the training programme. CONCLUSION: By integrating onsite training with simultaneous investments in clinical service and infrastructure development, the barriers to breast cancer diagnosis and treatment were disrupted and a modern breast care service platform was established in a private sector health care facility in the DRC.

The role of right ventricular function in mitral valve surgery.

BACKGROUND: An impaired right ventricular function is associated with a poor survival rate in patients with heart failure. Few investigations have analyzed the prognostic value of right ventricular function on the outcomes of mitral valve (MV) surgery. The objectives of this study were to define the effect of right ventricular function on postoperative outcomes after MV repair (MVP) or replacement (MVR). METHODS: From September 2007 to February 2012, 335 consecutive patients underwent MVP or MVR at our institution. Preoperative transthoracic and transesophageal echocardiography (TEE) and postoperative TEE were used to define right ventricular function and MV performance. Preoperative right ventricular function was graded as normal to mild (grade 1-2) or as moderate to severe (grade 3-4). MV or tricuspid valve regurgitation was graded as non-trivial to mild (grade 0-2) or as moderate to severe (grade 3-4) preoperatively and postoperatively. Survival rate was evaluated at 1 year after surgery. RESULTS: Of the 334 patients in the study, 280 patients showed a normal to a mildly impaired right ventricular function preoperatively (group 1). Fifty-four patients presented with moderate to severe right ventricular dysfunction (group 2). Patients with a compromised right ventricular function were more likely to undergo MVR (28.6% versus 53.7%, P <.001). The mean pulmonary artery pressure was 23.6 mm Hg in group 1 and 34 mm Hg in group 2 (P <.001). The left atrial diameter was 4.6 cm in group 1 and 5.3 cm in group 2 (P <.001). The 2 groups were not different with respect to operative mortality, but the patients in group 2 experienced more transfusion of blood products (588.4 mL versus 1180.6 mL, P <.001), longer intensive care unit stays (83.9 versus 149.6 hours, P <.001), and hospital stays (8.9 versus 12.8 days, P = .005). The rate of postoperative MV regurgitation was significantly higher in group 2 (1.8 versus 14.8%, P <.001). The overall 1-year survival rate was 92.5% in group 1 and 94.5% in group 2 (P = .59). CONCLUSIONS: This study has shown that a dysfunctional preoperative right ventricular function uses more resources and is associated with postoperative MV regurgitation, but it is not associated short- and mid-term mortality after MV surgery.

Traumatic partial avulsion of a single right subclavian artery from the aortic arch and definitive repair.

Blunt injury to the right subclavian artery is a rare complication of severe deceleration trauma often associated with significant morbidity and mortality. We describe an atypical presentation in a patient who sustained a traumatic avulsion of his right subclavian artery arising off the aortic arch. An interposition graft was used to restore the continuity of the artery to the ascending thoracic aorta.

Prospective study of mitral valve repair with the CarboMedics AnnuloFlex annuloplasty system: effectiveness and safety after one year.

BACKGROUND AND AIM OF THE STUDY: The CarboMedics AnnuloFlex annuloplasty system includes a flexible ring that may be implanted as a complete or partial ring to correct mitral annular dilatation by reinforcement of the entire annulus, or only the posterior portion of the annulus. The study aim was to evaluate clinical and functional results during the first year in patients receiving this flexible annuloplasty system. METHODS: Between February 2001 and August 2002, 69 patients (mean age 55 years; range: 27-81 years) underwent mitral valve repair that included implant of the AnnuloFlex annuloplasty ring. Mitral regurgitation (MR) was the predominant lesion, with 98.6% of patients exhibiting grade 3/4 insufficiency. Functional classification of valve pathology was normal leaflet motion (type I) in 4% of patients, leaflet prolapse (type II) in 93%, and restricted leaflet motion (type III) in 3%. Valve disease was degenerative in 90%, ischemic in 4%, infectious in 3%, and other in 3%. RESULTS: There was one hospital death. Late follow up was obtained for 62 patients; cumulative follow up was 61 patient-years. One-year actuarial survival was 99%, freedom from thromboembolism was 94%, from endocarditis 98%, and from reoperation 98%. Echocardiographic evaluations performed at 3-6 months after repair (mean 4.7 months) showed MR to be grade 0/1+ in 90% of patients and grade 2+ in 8%. Mitral valve area was 3.4+/-1.7 cm2, within normal limits (mitral valve area > or =1.5 cm2) in 95% of patients. Average peak and mean pressure gradients were 5.9+/-3.0 and 2.8+/-1.7 mmHg, respectively. Left ventricular end-diastolic diameter decreased postoperatively, which may reflect successful correction of MR after mitral valve repair. CONCLUSION: These early results show that the AnnuloFlex annuloplasty system is safe and effective when used with other techniques for repair of MR, and preserves mitral annular flexibility and function at one-year follow up.