Mapping of Radiation Oncology and Gynecologic Oncology Services Available to Treat the Growing Burden of Cervical Cancer in Africa.

PURPOSE: To meet the demand for cervical cancer care in Africa, access to surgical and radiation therapy services needs to be understood. We thus mapped the availability of gynecologic and radiation therapy equipment and staffing for treating cervical cancer. METHODS AND MATERIALS: We collected data on gynecologic and radiation oncology staffing, equipment, and infrastructure capacities across Africa. Data was obtained from February to July 2021 through collaboration with international partners using Research Electronic Data Capture. Cancer incidence was taken from the International Agency for Research on Cancer's GLOBOCAN 2020 database. Treatment capacity, including the numbers of radiation oncologists, radiation therapists, physicists, gynecologic oncologists, and hospitals performing gynecologic surgeries, was calculated per 1000 cervical cancer cases. Adequate capacity was defined as 2 radiation oncologists and 2 gynecologic oncologists per 1000 cervical cancer cases. RESULTS: Forty-three of 54 African countries (79.6%) responded, and data were not reported for 11 countries (20.4%). Respondents from 31 countries (57.4%) reported access to specialist gynecologic oncology services, but staffing was adequate in only 11 countries (20.4%). Six countries (11%) reported that generalist obstetrician-gynecologists perform radical hysterectomies. Radiation oncologist access was available in 39 countries (72.2%), but staffing was adequate in only 16 countries (29.6%). Six countries (11%) had adequate staffing for both gynecologic and radiation oncology; 7 countries (13%) had no radiation or gynecologic oncologists. Access to external beam radiation therapy was available in 31 countries (57.4%), and access to brachytherapy was available in 25 countries (46.3%). The number of countries with training programs in gynecologic oncology, radiation oncology, medical physics, and radiation therapy were 14 (26%), 16 (30%), 11 (20%), and 17 (31%), respectively. CONCLUSIONS: We identified areas needing comprehensive cervical cancer care infrastructure, human resources, and training programs. There are major gaps in access to radiation oncologists and trained gynecologic oncologists in Africa.

Moving forward through consensus: a national Delphi approach to determine the top research priorities in prostate cancer in Uganda.

OBJECTIVE: To identify key areas for research in prostate cancer (PC) in the Ugandan context by establishing the major health system, socioeconomic and clinical barriers to seeking, reaching and receiving high-quality cancer care. DESIGN: Modified Delphi Technique. SETTING: Government and private-not-for-profit hospitals. METHODS: We applied a two-stage modified Delphi technique to identify the consensus view across cancer experts. In round 1, experts received a questionnaire containing 21 statements drawn from a systematic review identifying the reason for the delay in accessing cancer care. Each statement was scored out of 20. Statements scoring ≥15 from over 70% of participants were prioritised for inclusion while statements for which <30% of participants gave a score of ≥15 were excluded. Sixteen statements were included in round 2 as they did not receive consensus for inclusion or exclusion. RESULTS: We found that the top six research priority areas arise from challenges including: (1) lack of diagnostic services-ultrasound, laboratory tests and biopsy facilities; (2) high costs of services, for example, surgery, radiotherapy, hormone therapy are unaffordable to most patients, (3) lack of essential medicines, (4) limited radiotherapy capacity, (5) lack of awareness of cancer as a disease and low recognition of symptoms, (6) low healthcare literacy. The lack of critical surgical supplies, high diagnostic and treatment costs were ranked highest in order of importance in round 1. Round 2 also revealed lack of diagnostic services, unavailability of critical medicines, lack of radiotherapy options, high costs of treatments and lack of critical surgical supplies as the top priorities. CONCLUSION: These research priority areas ought to be addressed in future research to improve prompt PC diagnosis and care in Uganda. There is need to improve the supply of high-quality affordable anticancer medicines for PC patients so as to improve the survivorship from the cancer.

Delays in seeking, reaching and access to quality cancer care in sub-Saharan Africa: a systematic review.

OBJECTIVES: Late presentation and delays in diagnosis and treatment consistently translate into poor outcomes in sub-Saharan Africa (SSA). The aim of this study was to collate and appraise the factors influencing diagnostic and treatment delays of adult solid tumours in SSA. DESIGN: Systematic review with assessment of bias using Risk of Bias in Non-randomised Studies of Exposures (ROBINS-E) tool. DATA SOURCES: PubMed and Embase, for publications from January 1995 to March 2021. ELIGIBILITY CRITERIA: Inclusion criteria: quantitative or mixed-method research, publications in English, on solid cancers in SSA countries. EXCLUSION CRITERIA: paediatric populations, haematologic malignancies, and assessments of public perceptions and awareness of cancer (since the focus was on patients with a cancer diagnosis and treatment pathways). DATA EXTRACTION AND SYNTHESIS: Two reviewers extracted and validated the studies. Data included year of publication; country; demographic characteristics; country-level setting; disease subsite; study design; type of delay, reasons for delay and primary outcomes. RESULTS: 57 out of 193 full-text reviews were included. 40% were from Nigeria or Ethiopia. 70% focused on breast or cervical cancer. 43 studies had a high risk of bias at preliminary stages of quality assessment. 14 studies met the criteria for full assessment and all totaled to either high or very high risk of bias across seven domains. Reasons for delays included high costs of diagnostic and treatment services; lack of coordination between primary, secondary and tertiary healthcare sectors; inadequate staffing; and continued reliance on traditional healers and complimentary medicines. CONCLUSIONS: Robust research to inform policy on the barriers to quality cancer care in SSA is absent. The focus of most research is on breast and cervical cancers. Research outputs are from few countries. It is imperative that we investigate the complex interaction of these factors to build resilient and effective cancer control programmes.

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.

Cancer in sub-Saharan Africa: a Lancet Oncology Commission.

In sub-Saharan Africa (SSA), urgent action is needed to curb a growing crisis in cancer incidence and mortality. Without rapid interventions, data estimates show a major increase in cancer mortality from 520 348 in 2020 to about 1 million deaths per year by 2030. Here, we detail the state of cancer in SSA, recommend key actions on the basis of analysis, and highlight case studies and successful models that can be emulated, adapted, or improved across the region to reduce the growing cancer crises. Recommended actions begin with the need to develop or update national cancer control plans in each country. Plans must include childhood cancer plans, managing comorbidities such as HIV and malnutrition, a reliable and predictable supply of medication, and the provision of psychosocial, supportive, and palliative care. Plans should also engage traditional, complementary, and alternative medical practices employed by more than 80% of SSA populations and pathways to reduce missed diagnoses and late referrals. More substantial investment is needed in developing cancer registries and cancer diagnostics for core cancer tests. We show that investments in, and increased adoption of, some approaches used during the COVID-19 pandemic, such as hypofractionated radiotherapy and telehealth, can substantially increase access to cancer care in Africa, accelerate cancer prevention and control efforts, increase survival, and save billions of US dollars over the next decade. The involvement of African First Ladies in cancer prevention efforts represents one practical approach that should be amplified across SSA. Moreover, investments in workforce training are crucial to prevent millions of avoidable deaths by 2030. We present a framework that can be used to strategically plan cancer research enhancement in SSA, with investments in research that can produce a return on investment and help drive policy and effective collaborations. Expansion of universal health coverage to incorporate cancer into essential benefits packages is also vital. Implementation of the recommended actions in this Commission will be crucial for reducing the growing cancer crises in SSA and achieving political commitments to the UN Sustainable Development Goals to reduce premature mortality from non-communicable diseases by a third by 2030.

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.

Gynecological radiation oncology in sub-Saharan Africa: status, problems and considerations for the future.

Gynecological malignancies in Africa form a significant part of the burden of disease. The high prevalence of HIV in some countries creates a heightened risk for development of human papilloma virus related cancers such as cervical, vulval and vaginal cancers. Radiotherapy is an important modality of treatment for cancer and in Africa compensates for the lack of adequate surgical services for a large proportion of cancers as well as being a cornerstone of treatment for locally advanced cancers and palliation. In this review we look at the status of radiotherapy services in sub-Saharan Africa and critical factors that influence its delivery with a focus on gynecological malignancies. This unveils that radiotherapy for gynecological cancers in sub-Saharan Africa is a significant example of the need for a holistic development approach across different sectors of the economy and different disciplines of medicine. The complexity of its management continues to expose the underdevelopment of health and financial systems and the lack of universal health coverage and social systems as we continue to see unnecessary morbidity and mortality due to the lack of organization. More systematic and scientifically robust investigations tailored to the various sub-Saharan Africa countries need to be conducted to elicit disruptive local solutions to the status quo.

Dataset evaluating the treatment timeliness of cervical cancer in Zambia.

Cervical cancer is the fourth most common cancer diagnosed among women globally. Effective screening routines and early detection are vital in reducing its disease burden and mortality. Several factors can influence the timely detection and treatment of cervical cancer, especially in low middle-income countries where the burden of this disease is highest. The data presented in this paper relates to the research article "Cervical cancer diagnosis and treatment delays in the developing world: Evidence from a hospital-based study in Zambia". The raw and analysed data include the studied patients' social demographic factors, clinical data concerning the stage and histological subtype of cancer, dates at which the various activities within the cancer treatment pathway occurred and delays to definitive treatment of cervical cancer at Zambia's only cancer treatment facility. Detailing delays to the treatment of cervical cancer allows recognition of specific points in the cancer treatment pathway requiring intervention to effectively improve cancer care and reduce the morbidity and mortality associated with the disease.

Immune correlates of therapy outcomes in women with cervical cancer treated with chemoradiotherapy: A systematic review.

BACKGROUND: Immune markers have been correlated with prognosis in a variety of solid tumors, including cervical cancer. OBJECTIVE: To review the literature on hematologic and immune markers and their association with recurrence and survival among patients with cervical cancer treated with chemoradiation. EVIDENCE REVIEW: This systematic review was conducted in accordance with PRISMA guidelines via searches of Ovid MEDLINE, Ovid Embase, and the Cochrane Library using keywords regarding cervical cancer, immune markers, and HIV. Studies involving patients treated with cisplatin-based chemoradiotherapy were selected and reviewed by at least two independent reviewers, with disagreements resolved by a third reviewer. FINDINGS: A total of 737 studies were identified, of which 314 assessed immune biomarkers in immunocompetent patients (30 included in the final analysis) and 327 studies in immunosuppressed patients (5 included in the final analysis). The strongest prognostic indicators were lymphopenia and elevated neutrophil-to-lymphocyte ratio. Other potential markers included HPV-specific lymphocyte response, cytokine profile, expression of immune-blocking antigens on cell surfaces, and tumor-associated lymphocyte, macrophage, and neutrophil infiltration. Studies of immunosuppressed patients described more severe cytopenic changes overall and concluded that viral suppression led to improved outcomes. CONCLUSIONS: The immunologic interplay at work in cervical cancer development, progression, and treatment is complex. Strong evidence was found in favor of lymphopenia and elevated neutrophil-to-lymphocyte ratio being prognostic for worse outcomes with other markers showing potential associations as well. Although the interpretation of immune status with regard to treatment approach remains unclear, future studies should aim to tailor treatment that minimizes possible detrimental immune effects.

Cervical cancer diagnosis and treatment delays in the developing world: Evidence from a hospital-based study in Zambia.

Expedited diagnostic processes for all suspected cervical cancer cases remain essential in the effort to improve clinical outcomes of the disease. However, in some developing countries like Zambia, there is paucity of data that assesses factors influencing diagnostic and treatment turnaround time (TAT) and other metrics vital for quality cancer care. We conducted a retrospective hospital-based study at the Cancer Diseases Hospital (CDH) for cervical cancer cases presenting to the facility between January 2014 and December 2018. Descriptive statistics were used to summarize demographic characteristics while a generalized linear model of the negative binomial was used to assess determinants of overall TAT. Our study included 2121 patient case files. The median age was 49 years (IQR: ±17) and most patients (n = 634, 31%) were aged between 41 and 50 years. The International Federation of Gynaecology and Obstetrics (FIGO) Cancer stage II (n = 941, 48%) was the most prevalent while stage IV (n = 103, 5.2%) was the least. The average diagnostic TAT in public laboratories was 1.48 (95%CI: 1.21-1.81) times longer than in private laboratories. Furthermore, referral delay was 55 days (IQR: 24-152) and the overall TAT (oTAT) was 110 days (IQR: 62-204). The age of the patient, HIV status, stage of cancer and histological subtype did not influence oTAT while marital status influenced oTAT. The observed longer oTAT may increase irreversible adverse health outcomes among cervical cancer patients. There is a need to improve cancer care in Zambia through improved health expenditure especially in public health facilities.

Zambia cervical cancer control program resource mapping - Leveraging support to achieve the 90-70-90 elimination target.

BACKGROUND: Zambia has one of the highest incidence and mortality rates of cervical cancer at 65.5 and 43.4 per 100 000 respectively. In line with efforts of the cervical cancer elimination strategy the Zambia national cervical cancer sub-committee undertook a resource mapping exercise of projected spending on the prevention and control program. The aim was to elicit the available resources over a prospective 4-year period and compare it to the projected costs. MATERIALS AND METHODS: A 4-step approach was used for this activity. This included creation of tool adapted for the local program, orientation of stakeholders to the tool, population of the tool by stakeholders and collation, comparison and reporting of submitted data. Comparative analysis to the cervical cancer control costing report 2019-2023 was conducted. RESULTS: Fifty-nine percent of resources in the stipulated period were allocated to prevention efforts. Isolated with diagnostic, treatment and palliation (14 %) the prevention allocation increased to 81 %. Community and stakeholder engagement was 5 % whilst technical assistance and health information were 12 % and 9 % respectively. The dispensation to research was the lowest at 0.7 %. For health system levels, secondary and primary levels were projected at 40 % and 12 % respectively following the central allotment of 45 %. Community and stakeholder engagement took up 3 %. The secondary prevention to tertiary intervention ratio was 4:1 in the projection compared to approximately 2:1 in the actual budgeted costs for the same period, showing a two-fold discordance. CONCLUSION: To achieve the accelerated elimination of cervical cancer as a public health problem policy cohesiveness is necessary. This can be facilitated with continuous stakeholder involvement in planning, implementation and review. POLICY SUMMARY: In order to accelerate the elimination of cervical cancer as a public health problem policy cohesiveness is vital and this can be achieved by continuous stakeholder involvement in planning, implementation and review.

The use a virtual interactive system to enhance gynecologic oncology multi-disciplinary care in Zambia.

BACKGROUND: Gynecologic malignancies represent a significant proportion of the increasing cancer burden in Zambia. The care and outcomes of cancer patients improves in a multidisciplinary team but insufficient coordination in weak health systems is a barrier to this model of care. The World Health Organization (WHO) identifies digital health interventions as tools to bridge the gap between challenges and health systems' goals in low resource environments. A low-cost innovative virtual interaction system (VIS) was integrated into the gynecologic oncology multidisciplinary tumor board to enhance patient navigation and management. METHODS: Paper-based forms used by each specialist group participating in the tumor board were collected and placed on a digital platform. Tumor board members were interviewed to assess their acceptability of the new digital modules and ensure correct nomenclature was being used for data entry. This was followed by an orientation and launch of VIS. RESULTS: For a 12-week period following the launch, 197 gynecologic oncology patients were registered at the Zambian national cancer center (Cancer Diseases Hospital), of which 130 were entered in the VIS, and of those less than half had management decisions recorded. The median time from first visit to simulation for radiotherapy was 52 days; from simulation to start of treatment 102.5 days. Eighteen (14 %) of the 130 patients entered into the VIS were recorded as lost to follow up. CONCLUSION: The introduction and implementation of a digital intervention for navigation and management of gynecologic patients in a low resource environment proved both feasible and acceptable. It provides an instant easily accessible platform for important information on time intervals and delays in the patient pathway. End user orientation and support is an integral part to its successful integration and consistent management of the data is required to maximize its impact on efficiency, effectiveness and patient care.

Choosing Wisely Africa: Ten Low-Value or Harmful Practices That Should Be Avoided in Cancer Care.

PURPOSE: Choosing Wisely Africa (CWA) builds on Choosing Wisely (CW) in the United States, Canada, and India and aims to identify low-value, unnecessary, or harmful cancer practices that are frequently used on the African continent. The aim of this work was to use physicians and patient advocates to identify a short list of low-value practices that are frequently used in African low- and middle-income countries. METHODS: The CWA Task Force was convened by the African Organization for Research and Training in Cancer and included representatives from surgical, medical, and radiation oncology, the private and public sectors, and patient advocacy groups. Consensus was built through a modified Delphi process, shortening a long list of practices to a short list, and then to a final list. A voting threshold of ≥ 60% was used to include an individual practice on the short list. A consensus was reached after a series of teleconferences and voting processes. RESULTS: Of the 10 practices on the final list, one is a new suggestion and 9 are revisions or adaptations of practices from previous CW campaign lists. One item relates to palliative care, 8 concern treatment, and one relates to surveillance. CONCLUSION: The CWA initiative has identified 10 low-value, common interventions in Africa's cancer practice. The success of this campaign will be measured by how the recommendations are implemented across sub-Saharan Africa and whether this improves the delivery of high-quality cancer care.

Negative impact of the COVID-19 pandemic on the management of cervical cancer patients in Zambia.

International travel has largely been suspended due to the COVID-19 pandemic. Due to this situation, Zambia has not been able to import radioactive isotopes for High Dose Rate (HDR) brachytherapy, Iridium 192 (I192) and this has led to suspension of treatment for patients. Cancer of the cervix is the most common cancer in Zambia and brachytherapy is a core component of the treatment armamentarium. Mitigation strategies may include external beam radiotherapy boost or hysterectomy but both systems are overburdened and fragile.

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.

Challenges, Opportunities, and Priorities for Advancing Breast Cancer Control in Zambia: A Consultative Meeting on Breast Cancer Control.

In 2016, the Zambian government made cancer control a national priority and released a National Cancer Control Strategic Plan for 2016 to 2021, which focuses on malignancies of the breast, cervix, and prostate, and retinoblastoma. The plan calls for a collective reduction in the cancer burden by 50%. In support of this vision, Susan G. Komen sponsored a consultative meeting in Lusaka, Zambia, in September 2017 to bring together the country's main breast cancer stakeholders and identify opportunities to improve breast cancer control. The recommendations generated during the discussions are presented. There was general agreement that the first step toward breast cancer mortality reduction should consist of implementation of early detection service platforms focused on women who are symptomatic. Participants also agreed that the management of all components of the national breast cancer control program should be integrated and led by the Ministry of Health. As much as possible, early detection and treatment services presently offered by the Cervical Cancer Prevention Program of Zambia and Cancer Diseases Hospital should be leveraged. Efforts are under way through multiple stakeholders to implement the following recommendations: development of national guidelines for the early diagnosis of breast cancer, training of breast surgeons, implementation of early detection and surgical treatment service platforms at the district-hospital level, and epidemiologic research, including the improvement of electronic recording mechanisms.

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.

The Effect of Cryotherapy on Human Papillomavirus Clearance Among HIV-Positive Women in Lusaka, Zambia.

OBJECTIVE: We sought to investigate the progression of human papillomaviruses (HPV) infection in HIV-positive women after cryotherapy. METHODS: We examined changes in detection of high-risk HPV (hrHPV) cervical infections among HIV-infected women over a 12-week period after cryotherapy using stored specimens from a cohort study conducted between June 2009 and March 2011 in Lusaka, Zambia. Samples from visits at baseline and weeks 4, 8, and 12 were tested using the Roche Linear Array assay. RESULTS: A total of 89 women were included in the analysis. The median age was 32 years (interquartile range [IQR], 28-36 years). The median CD4+ cell count was 350 cells/µL (IQR, 214-470 cells/µL), and 66% of women were receiving antiretroviral therapy. At baseline, the prevalence of hrHPV was 91% (95% confidence interval [CI], 83%-95%). HPV45 was the most common HPV type, present in (30%) women, followed by HPV16 (27%), HPV18 (27%), HPV51 (20%), and HPV58 (22%). Among women with valid results both at baseline and 12 weeks, 25% (17/67) cleared their initial hrHPV infection within 12 weeks of treatment, although 65% (11/17) had new hrHPV types detected. CONCLUSIONS: Cryotherapy led to clearance of 25% of hrHPV infections within 12 weeks of treatment. However, hrHPV infection remained persistent in most women, and new hrHPV types were detected often, explaining the high rate of persistence and recurrence of cervical disease in this population. Continued efforts to scale up HPV vaccination and cervical screening should remain a priority in high HIV burden settings such as Zambia.