Perspectives of Zambian Clinical Oncology Trainees in the MD Anderson and Zambia Virtual Clinical Research Training Program (MOZART).

BACKGROUND: African countries are underrepresented in cancer research, partly because of a lack of structured curricula on clinical research during medical education. To address this need, the MD Anderson and Zambia Virtual Clinical Research Training Program (MOZART) was developed jointly by MD Anderson Cancer Center (MDA) and the Cancer Diseases Hospital in Zambia (CDH) for Zambian clinical oncology trainees. We explored participant perspectives to provide insight for implementation of similar efforts. MATERIALS AND METHODS: The MD Anderson and Zambia Virtual Clinical Research Training Program consisted of weekly virtual lectures and support of Zambian-led research protocols through longitudinal mentorship groups that included CDH faculty and MDA peer and faculty mentors. Participants were contacted via email to take part in semi-structured interviews, which were conducted via teleconference and audio-recorded, transcribed, and coded. Emergent themes were extracted and are presented with representative verbatim quotations. RESULTS: Thirteen of the 14 (93%) trainees were interviewed. Emergent themes included (1) participants having diverse educational backgrounds but limited exposure to clinical research, (2) importance of cancer research specific to a resource-constrained setting, (3) complementary roles of peer mentors and local and international faculty mentors, (4) positive impact on clinical research skills but importance of a longitudinal program and early exposure to clinical research, and (5) challenges with executing research protocols. CONCLUSION: To our knowledge, this is the first qualitative study of African clinical oncology trainees participating in a virtual clinical research training program. The lessons learned from semi-structured interviews with participants in MOZART provided valuable insights that can inform the development of similar clinical research training efforts and scale-up.

Building Capacity for Cancer Research in the Era of COVID-19: Implementation and Results From an International Virtual Clinical Research Training Program in Zambia.

PURPOSE: The incidence of cancer in sub-Saharan Africa is increasing rapidly, yet cancer research in the region continues to lag. One contributing factor is limited exposure to clinical research among trainees. We describe implementation and results of a virtual clinical research training program for Zambian clinical oncology fellows developed jointly by the Cancer Diseases Hospital in Zambia and the MD Anderson Cancer Center to address this need. METHODS: The clinical research training program consisted of 14 weekly virtual lectures, development of research questions by Zambian clinical oncology fellows, assignment of faculty and peer mentors, longitudinal mentorship of research protocols, and anonymous precourse and postcourse surveys. The paired t-test was used to analyze the change in academic self-efficacy scores. RESULTS: Fourteen Zambian clinical oncology fellows participated. Senior fellows were paired with research mentors, leading to the development of eight research protocols. A total of 70 meetings and 126 hours of mentorship occurred with a median of seven meetings and 15 hours per pairing. The precourse and postcourse survey response rates were 86% and 79%, respectively. There were statistically significant increases in nine of 12 academic self-efficacy domains. The largest gains were in ability to independently perform research (P < .001) and research mentorship (P = .02) with an average increase of 1.5 points on a five-point scale in both domains. CONCLUSION: The Cancer Diseases Hospital MD Anderson Cancer Center clinical research training program for Zambian clinical oncology fellows led to increases in multiple academic self-efficacy domains among participants, formation of longitudinal mentorship groups with both faculty and peer mentors, and development of Zambian-led research protocols, demonstrating the feasibility of implementing a virtual model. This may be especially relevant because of shifting international collaboration paradigms after the COVID-19 pandemic.

Effects of HIV infection on metastatic cervical cancer and age at diagnosis among patients in Lusaka, Zambia.

OBJECTIVE: To examine the association between the duration of HIV infection and the stage of cervical cancer in Lusaka, Zambia. METHODS: This retrospective case-case study included 1583 cervical cancer patients from the Cancer Diseases Hospital in Lusaka, Zambia. A sub-population of HIV-positive patients with additional clinical HIV information was identified following linkage of cancer and HIV databases. Logistic regression models examined the relationship between HIV status and early-onset cervical cancer diagnosis, and between HIV infection duration and initial diagnosis of metastatic cervical cancer. RESULTS: The study population had an average age of 49 years and 40.9% had an initial diagnosis of metastatic cancer. HIV-positive women were more than twice as likely to be diagnosed at early-onset cervical cancer compared with HIV-negative women. Among the sub-population of HIV-positive patients, a longer duration of HIV infection was associated with 20% lowered odds of initial metastatic cancer diagnosis. CONCLUSION: The availability, accessibility, and impact of the cervical screening program in this population should be further examined to elucidate the relationship between cervical screening, age, and duration of HIV infection and the the stage of diagnosis of cervical cancer.

Radiation Sciences Education in Africa: An Assessment of Current Training Practices and Evaluation of a High-Yield Course in Radiation Biology and Radiation Physics.

PURPOSE: Formal education in the radiation sciences is critical for the safe and effective delivery of radiotherapy. Practices and patterns of radiation sciences education and trainee performance in the radiation sciences are poorly described. This study assesses the current state of radiation sciences education in Africa and evaluates a high-yield, on-site educational program in radiation biology and radiation physics for oncology and radiation therapy trainees in Africa. METHODS: An anonymous survey was distributed to members of the African Organization for Research and Treatment in Cancer Training Interest Group to assess current attitudes and practices toward radiation sciences education. A 2-week, on-site educational course in radiation biology and radiation physics was conducted at the Cancer Diseases Hospital in Lusaka, Zambia. Pre- and postcourse assessments in both disciplines were administered to gauge the effectiveness of an intensive high-yield course in the radiation sciences. RESULTS: Significant deficiencies were identified in radiation sciences education, especially in radiation biology. Lack of expert instructors in radiation biology was reported by half of all respondents and was the major contributing factor to deficient education in the radiation sciences. The educational course resulted in marked improvements in radiation biology assessment scores (median pre- and posttest scores, 27% and 55%, respectively; P < .0001) and radiation physics assessment scores (median pre- and posttest scores, 30% and 57.5%, respectively; P < .0001). CONCLUSION: Radiation sciences education in African oncology training programs is inadequate. International collaboration between expert radiation biology and radiation physics instructors can address this educational deficiency and improve trainee competence in the foundational radiation sciences that is critical for the safe and effective delivery of radiotherapy.

Zambia's National Cancer Centre response to the COVID-19 pandemic-an opportunity for improved care.

The COVID-19 pandemic has overwhelmed health systems around the globe even in countries with strong economies. This is of particular concern for nations with weaker health systems. This article reports the response of a comprehensive cancer centre in a lower-middle income country to prevent COVID-19 transmission and how the implementation of pragmatic strategies have served as a springboard to improve cancer services beyond the COVID-19 pandemic. The strategies included establishment of a local taskforce, increased education and facilitation of good hygiene practices, staff training, patient triaging, improved patient scheduling, remote review of patients and establishing a virtual platform for meetings.

Effects of HIV status on non-metastatic cervical cancer progression among patients in Lusaka, Zambia.

INTRODUCTION: Sub-Saharan Africa has the highest global incidence of cervical cancer. Cervical cancer is the most common cause of cancer morbidity and mortality among women in Zambia. HIV increases the risk for cervical cancer and with a national Zambian adult HIV prevalence of 16%, it is important to investigate the impact of HIV on the progression of cervical cancer. We measured differences in cervical cancer progression between HIV-positive and HIV-negative patients in Zambia. METHODS: This study included 577 stage I and II cervical cancer patients seen between January 2008 and December 2012 at the Cancer Diseases Hospital in Lusaka, Zambia. The inclusion criteria for records during the study period included known HIV status and FIGO stage I and II cervical cancer at initial date of registration in the Cancer Diseases Hospital. Medical records were abstracted for clinical and epidemiological data. Cancer databases were linked to the national HIV database to assess HIV status among cervical cancer patients. Logistic regression examined the association between HIV and progression, which was defined as metastatic or residual tumor after 3 months of initial treatment. RESULTS: A total of 2451 cervical cancer cases were identified, and after exclusion criteria were performed the final analysis population totaled 537 patients with stage I and II cervical cancer with known HIV status (224 HIV-positive and 313 HIV-negative). HIV-positive women were, on average, 10 years younger than HIV-negative women who had a median age of 42, ranging between 25 and 72. A total of 416 (77.5%) patients received external beam radiation, and only 249 (46.4%) patients received the recommended treatment of chemotherapy, external beam radiation, and brachytherapy. Most patients were stage II (85.7%) and had squamous cell carcinoma (74.7%). HIV-positive patients were more likely to receive lower doses of external beam radiation than HIV-negative patients (47% vs 37%; P<0.05, respectively). The median total dose of external beam radiation for HIV-positive and HIV-negative patients was 46 Gy and 50 Gy, respectively. HIV positivity did not lead to tumor progression (25.4% in HIV-positive vs 23.9% in HIV-negative, OR 1.04, 95% CI [0.57, 1.92]). However, among a subset of HIV-positive patients, longer duration of infection was associated with lower odds of progression. CONCLUSION: There was no significant impact on non-metastatic cervical cancer progression by HIV status among patients in Lusaka, Zambia. The high prevalence of HIV among cervical cancer patients suggest that HIV-positive patients should be a primary target group for HPV vaccinations, screening, and early detection.

Demonstration of an algorithm to overcome health system-related barriers to timely diagnosis of breast diseases in rural Zambia.

BACKGROUND: Long delays to diagnosis is a major cause of late presentation of breast diseases in sub-Saharan Africa. AIMS: We designed and implemented a single-visit breast care algorithm that overcomes health system-related barriers to timely diagnosis of breast diseases. METHODS: A multidisciplinary team of Zambian healthcare experts trained a team of mid- and high-level Zambian healthcare practitioners how to evaluate women for breast diseases, and train trainers to do likewise. Working collaboratively, the two teams then designed a clinical platform that provides multiple breast care services within a single visit. The service platform was implemented using a breast outreach camp format, during which breast self-awareness, psychosocial counseling, clinical breast examination, breast ultrasound, ultrasound-guided biopsy, imprint cytology of biopsy specimens and surgical treatment or referral, were offered within a single visit. RESULTS: Eleven hundred and twenty-nine (1129) women attended the camps for breast care. Mean age was 35.9 years. The majority were multiparous (79.4%), breast-fed (76.0%), and reported hormone use (50.4%). Abnormalities were detected on clinical breast examination in 122 (10.8%) women, 114 of whom required ultrasound. Of the 114 who underwent ultrasound, 48 had identifiable lesions and were evaluated with ultrasound-guided core needle biopsy (39) or fine-needle aspiration (9). The concordance between imprint cytology and histopathology was 100%, when breast specimens were classified as either benign or malignant. However, when specimens were classified by histopathologic subtype, the concordance between imprint cytology and histology was 85.7% for benign and 100% for malignant lesions. Six (6) women were diagnosed with invasive cancer. Eighteen (18) women with symptomatic breast lesions had next-day surgery. SIGNIFICANCE: Similar to its impact on cervical cancer prevention services, a single visit breast care algorithm has the potential to overcome health system-related barriers to timely diagnosis of breast diseases, including cancer, in rural African settings.

Project ECHO: A Telementoring Program for Cervical Cancer Prevention and Treatment in Low-Resource Settings.

Cervical cancer incidence and mortality rates are significantly higher in low- and middle-income countries compared with the United States and other developed countries. This disparity is caused by decreased access to screening, often coupled with low numbers of trained providers offering cancer prevention and treatment services. However, similar disparities are also found in underserved areas of the United States, such as the Texas-Mexico border, where cervical cancer mortality rates are 30% higher than in the rest of Texas. To address these issues, we have adopted the Project ECHO (Extension for Community Healthcare Outcomes) program, a low-cost telementoring model previously proven to be successful in increasing local capacity, improving patient management skills, and ultimately improving patient outcomes in rural and underserved areas. We use the Project ECHO model to educate local providers in the management of cervical dysplasia in a low-resource region of Texas and have adapted it to inform strategies for the management of advanced cervical and breast cancer in Latin America and sub-Saharan Africa. This innovative approach, using ECHO, is part of a larger strategy to enhance clinical skills and develop collaborative projects between academic centers and partners in low-resource regions.

Complete Remission in Locally Advanced Breast Cancer: What Comprehensive Multi-Modality Treatment Has to Offer in Sub-Saharan Africa.

Locally advanced breast cancer presents as a heterogeneous disease, but it is often best treated with aggressive combined modality therapy.  Commonly, it carries a more guarded prognosis. Given the above, it can be a particularly challenging entity to treat in resource-limited settings. We identify one such case with a relative lack of hormone receptor positivity in the sub-Saharan country of Zambia. Management of the disease was hampered by the challenges of resource constraints and communication gaps that are especially acute in low- to middle-income nations as compared to Western societies. However, with skilled interdisciplinary advice and the means available at a tertiary care facility, our patient was able to afford a superior clinical outcome in the form of a pathologic complete response via the use of surgical, systemic, and radiotherapy modalities. Additionally, the ensuing remission was corroborated by a careful follow-up regime. We thus reinforce the feasibility and value of a team-based approach in the management of this disease regardless of the setting.

Observed and expected incidence of cervical cancer in lusaka and the southern and Western provinces of Zambia, 2007 to 2012.

OBJECTIVES: Cervical cancer is increasing but underestimated in developing countries. We calculated the observed and expected incidence of cervical cancer in Lusaka and Southern and Western provinces of Zambia. METHODS/MATERIALS: Data for 2007 to 2012 were obtained for the 3 provinces. Data included age, residence, year of diagnosis, marital status, occupation, human immunodeficiency virus (HIV), stage, radiotherapy, and chemotherapy. Expected incidence in Southern and Western provinces was calculated based on observed incidence for Lusaka province, adjusting for HIV. RESULTS: Crude and age-standardized incidence rates (ASRs) in Lusaka were 2 to 4 times higher than incidence in the other 2 provinces. Lusaka had a rate of 54.1 per 10(5) and ASR of 82.1 per 10(5) in the age group of 15 to 49 years. The Southern province had a rate of 17.1 per 10(5) and ASR of 25.5 per 10(5); the Western province had a rate of 12.3 per 10(5) and ASR rate of 17.2 per 10(5). The observed cervical cancer incidence rates in the Southern and Western provinces were lower than the rate in Lusaka, possibly because of the uncertainty of underreporting/underdiagnosis or actual lower risk for reasons yet unclear. The HIV seroprevalence rates in patients from the 3 provinces were 46% to 93% higher than seroprevalence in the respective general populations. CONCLUSIONS: Cervical cancer is significantly underestimated in Zambia, and HIV has a significant role in pathogenesis. Future studies should establish methods for case ascertainment and better utilization of hospital- and population-based registries in Zambia and other similar developing countries.