Participant Evaluation of a Multi-disciplinary Oncology Preceptorship Training Program for Oncology Health Professionals from Kumasi, Ghana.

A critical shortage of skilled healthcare workers is a primary cause of disparate global cancer outcomes. We report participant evaluation of a multidisciplinary preceptorship program. In collaboration with the city of Kumasi, Ghana, Mayo Clinic and the City Cancer Challenge hosted a preceptorship program for comprehensive multidisciplinary breast and cervix cancer training. A total of 14 healthcare workers from Kumasi received two weeks of training at Mayo Clinic in November and December 2021. Each participant and preceptor were requested to complete an anonymous post-participation survey. Of the 14 trainee participants, 10 (71%) completed the survey. All respondents found the program "valuable and applicable to their clinical practice." Ninety percent reported they were able to "review effective and critical elements in the development and expansion of the multidisciplinary team" and able to "solve practical clinical cases as a team". General themes of satisfaction included: (1) organization and administration, (2) clinical observations and demonstrations, (3) guidelines development, and (4) recognizing the central importance of cultivating a team-based approach. Of the 40 preceptors, 16 (40%) completed the survey. All respondents reported they felt the training would meaningfully "influence patient care in Ghana", that participation "added value or joy to their clinical practice," and all wished to "participate in future preceptorship programs". After a focused two-week program, trainees reported high satisfaction, usefulness from observing specialized cancer care, and value in closely observing a multidisciplinary oncology team. Preceptors reported the experience added joy and perspective to their clinical practice and wished to participate in future programs.

Diversity of cervicovaginal human papillomavirus (HPV) genotypes and naturally occurring E6/E7 DNA polymorphisms of HPV-16 in Ghana.

Human papillomavirus (HPV) E6 and E7 oncogene expression is essential for cervical carcinogenesis. Evidence exists that E6/E7 variants may have different transforming activities while the risk of HPV-16 variants (A/D) differs by race/ethnicity. We determined the type-specific diversity of HPV infection in women with high grade cervical disease or cervical cancer in Ghana and investigated naturally occurring E6/E7 DNA variants in this population. HPV genotyping was carried out on 207 cervical swab samples collected from women referred to a gynaecology clinic at two teaching hospitals in Ghana. HPV-16, HPV-18 and HPV-45 were detected in 41.9%, 23.3% and 16.3% of cases respectively. HPV-16 E6/E7 DNA sequencing was performed in 36 samples. Thirty samples contained E6/E7 variants of the HPV-16-B/C lineage. 21/36 samples were of the HPV-16C1 sublineage variant and all contained the E7 A647G(N29S) single nucleotide polymorphism (SNP). This study reveals the diversity of E6/E7 DNA and the dominance of HPV16 B/C variants in cervicovaginal HPV infection in Ghana. Type-specific HPV diversity analysis indicates that most Ghanaian cervical disease cases are vaccine preventable. The study provides an important baseline from which for the impact of vaccine and antivirals on clinically relevant HPV infection and associated disease can be measured.

Assessment of Adult Women With Ovarian Masses and Treatment of Epithelial Ovarian Cancer: ASCO Resource-Stratified Guideline.

PURPOSE: To provide expert guidance to clinicians and policymakers in three resource-constrained settings on diagnosis and staging of adult women with ovarian masses and treatment of patients with epithelial ovarian (including fallopian tube and primary peritoneal) cancer. METHODS: A multidisciplinary, multinational ASCO Expert Panel reviewed existing guidelines, conducted a modified ADAPTE process, and conducted a formal consensus process with additional experts. RESULTS: Existing sets of guidelines from eight guideline developers were found and reviewed for resource-constrained settings; adapted recommendations from nine guidelines form the evidence base, informing two rounds of formal consensus; and all recommendations received ≥ 75% agreement. RECOMMENDATIONS: Evaluation of adult symptomatic women in all settings includes symptom assessment, family history, and ultrasound and cancer antigen 125 serum tumor marker levels where feasible. In limited and enhanced settings, additional imaging may be requested. Diagnosis, staging, and/or treatment involves surgery. Presurgical workup of every suspected ovarian cancer requires a metastatic workup. Only trained clinicians with logistical support should perform surgical staging; treatment requires histologic confirmation; surgical goal is staging disease and performing complete cytoreduction to no gross residual disease. In first-line therapy, platinum-based chemotherapy is recommended; in advanced stages, patients may receive neoadjuvant chemotherapy. After neoadjuvant chemotherapy, all patients should be evaluated for interval debulking surgery. Targeted therapy is not recommended in basic or limited settings. Specialized interventions are resource-dependent, for example, laparoscopy, fertility-sparing surgery, genetic testing, and targeted therapy. Multidisciplinary cancer care and palliative care should be offered.Additional information can be found at www.asco.org/resource-stratified-guidelines. It is ASCO's view that health care providers and health care system decision makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement but not replace local guidelines.

Two rare presentations of embryonal rhabdomyosarcoma of the cervix in teenagers at a low-resource teaching hospital in Ghana: A case series.

We report two cases of embryonal rhabdomyosarcoma (ERMS) of the cervix in teenagers presenting to Komfo Anokye Teaching Hospital in Kumasi, Ghana within one month of each other. Between October and November 2019, two patients presented with ERMS of the cervix. They both underwent fertility-sparing surgery followed by chemotherapy with vincristine, actinomycin-D, and cyclophosphamide. Preoperative workup for the two patients was minimal due to limited availability and high cost of imaging in a low-resource setting. Both patients were discussed at a multidisciplinary tumor board meeting to guide best management practices. Both patients had local surgical resection with histological confirmation of ERMS and negative margins, followed by six cycles of vincristine, actinomycin-D, and cyclophosphamide. Neither of the patients had perioperative complications or received radiation therapy. At the time of publication, both patients are currently alive and without evidence of recurrence. Fertility-sparing surgery followed by chemotherapy for patients with ERMS of the cervix is accessible in low-income countries.

Gynecologic Oncology Sub-Specialty Training in Ghana: A Model for Sustainable Impact on Gynecologic Cancer Care in Sub-Saharan Africa.

African women have double the risk of dying from cancer than women in high-income countries. In Ghana, most women with gynecological malignancies present with advanced-stage disease when treatment is less effective. Barriers to improved cancer outcomes include the availability of cancer screening, affordability of treatment, and access to gynecologic oncology specialists. In response to a paucity of gynecologic oncology providers, an in-country fellowship training program was established at Komfo Anokye Teaching Hospital (KATH) in 2013. Historically, Ghanaian resident physicians were sent to other countries for fellowship training and were unlikely to repatriate. The establishment of an in-country training program not only addresses the challenge of "brain drain," but also builds local capacity in gynecologic oncology education and emphasizes culturally relevant and accessible healthcare. The four-years gynecologic oncology fellowship program at KATH was developed as part of a longitudinal multi-decade partnership between the University of Michigan and academic medical centers in Ghana. The fellowship trains obstetricians and gynecologists to provide subspecialist clinical and surgical care to patients with gynecologic malignancies. Fellows collaborate with the radiation, oncology and pathology departments, participate in monthly inter-institutional tumor board meetings, conduct research, advise on health policy issues, and train subsequent cohorts. This fellowship is representative of emerging twenty-first-century trends in which subspecialty training programs in low-income countries are strengthened by international collaborations. Providing specialized training in gynecologic oncology can help develop and maintain resources that will improve clinical outcomes for women in low-resources settings.

Use of Magnetic Resonance Imaging (MRI) in the Management of Diagnostic Uncertainty in Low-Resource Settings: A Case Report of Cesarean Ectopic Pregnancy in a Tertiary Hospital in Ghana.

BACKGROUND Low- and middle-income countries (LMICs) account for the overwhelming majority of maternal deaths worldwide. Cesarean section rates have increased globally over the last 10 years, including in LMICs, and are an important intervention to decrease neonatal and maternal mortality. However, cesarean sections also contribute to increased complications in subsequent pregnancies, including invasive placentation and cesarean scar ectopic pregnancies (CSEP). Potential CSEP complications include rupture of the uterus, bladder invasion, and maternal mortality. CASE REPORT We present the case of a 35-year-old Ghanaian woman (gravidity 5, parity 3) with a positive urine pregnancy test and 2 months of amenorrhea. Ultrasound scanning demonstrated a gestational sac with a fetal pole and absent cardiac activity located in the lower uterine segment. Myometrium infiltration was present, with only 2 mm of anterior myometrium between the gestational sac and the urinary bladder. Owing to concern for CSEP with uncertain bladder invasion, a pelvic MRI was obtained for preoperative planning. Following the MRI, which demonstrated an intact bladder, the patient underwent an uncomplicated exploratory laparotomy and excision of the CSEP. CONCLUSIONS In LMICs, pelvic ultrasound continues to be the diagnostic tool of choice for CSEP. However, in cases with diagnostic uncertainty or possible bladder invasion, MRI is an additional imaging tool that can optimize preoperative planning and minimize the risk of maternal mortality and potential post-surgical complications.

Familial adenomatous polyposis: a case study.

Familial adenomatous polyposis (FAP) is an inherited syndrome characterized by several adenomatous polyps of the gastrointestinal (GI) mucosa. If treatment is not provided, an average individual with classic FAP will develop colorectal carcinoma around the age of 40 years. The incidence rate of FAP in developing countries like Ghana is unknown compared to advanced countries. We present the first FAP case of a 22-year-old Ghanaian female who presented with massive lower GI bleeding and underwent surgical management after a thorough investigation. The initial assumption that colonic polyps are scarce in native Africans may be more than what is perceived. This highlights the need for the availability of endoscopic services in Ghana.

Acute Gastric Necrosis in a Teenager.

Gastric infarction is a rare condition often associated with high mortality due to a delay in diagnosis. The stomach which has a rich supply of blood is a rare site for such a condition. Gastric infarction has a long list of etiological factors. We report a case of a patient who was managed successfully following gastric infarction from gastric dilatation. An 18-year-old female student presented with a three-day history of abdominal pain associated with abdominal distension of two days. The abdomen was distended with generalized tenderness, rebound tenderness, and guarding. Bowel sounds were absent. Digital rectal examination was unremarkable, and a pregnancy test was negative. Biochemical tests were all normal. Intraoperatively, two litres of serosanguinous fluid was suctioned from the abdomen. About 300 mL of pus was suctioned from the pelvis. The gangrenous portion was resected, and repair was done in two layers using Conell and Lambert suture techniques. Acute gastric necrosis is a rare surgical condition that requires a high index of suspicion and prompts aggressive resuscitation and surgical intervention to obviate the high mortality rate associated with the condition.