An Ethical Approach to Routine Tragic Choices: Radiotherapy Allocation in Rwanda
UCSF Investigator: Rebecca DeBoer, MD, MA
Nearly every radiotherapy machine in sub-Saharan Africa and in low- and middle-income countries (LMICs) worldwide is over-burdened with more patients in need than can possibly be treated. Patients are generally treated based on ability to pay rather than clinical need, so those who can benefit most—whose lives are likely to be saved by radiotherapy—routinely lack access. This project aims to describe the experience of radiotherapy allocation at Butaro Hospital in rural Rwanda using mixed methods, to develop and implement fair deliberative process for radiotherapy priority setting at Butaro Hospital, and to revise radiotherapy prioritization guidelines using rigorous application of ethical theories. The prioritization guidelines that will be developed through this project can be directly applied in LMICs with similar disease burdens and healthcare barriers. The new protocol for fair deliberative process may be used broadly in other resource-limited settings, to refine the radiotherapy prioritization guidelines for a specific context or to set priorities for other limited resources, such as chemotherapy and biologic drugs. This project’s examination of explicit rationing may also inform priority setting in high-income countries in context such as drug shortages, intensive care unit beds, and waiting lists in socialized healthcare systems.
Implementation of Tanzania's National Cancer Treatment Guidelines at Ocean Road Cancer Institute
UCSF Investigators: Katherine Van Loon, MD, MPH, Rebecca DeBoer, MD, MA, Geoffrey Buckle, MD, MPH, and Tracy Kuo Lin, PhD
Tanzania Investigators: Jerry Ndumbalo, MD, MBA, and Stephen Meena, MD, MMed, Ocean Road Cancer Institute (ORCI)
Adherence to standard treatment guidelines is key to addressing global disparities in cancer mortality: in low-income countries, the overall case fatality from cancer is estimated to be 75%, compared with 46% in high-income countries. In 2017, leaders from Ocean Road Cancer Institute (ORCI) participated in the joint effort with the National Comprehensive Cancer Network (NCCN) and African Cancer Coalition to develop cancer treatment guidelines six cancers and two supportive care categories for Sub-Saharan Africa. Contemporaneously, ORCI also drafted Tanzania’s first edition of its National Treatment guidelines. In April 2018, leadership of the Committee for Tanzania’s National Cancer Treatment Guidelines visited UCSF to refine these guidelines with expert reviews by over 30 UCSF sub-specialist. This project supports the initial implementation phase of these guidelines at ORCI, with the overall objective of evaluating the feasibility and effectiveness of a theory-informed implementation strategy to facilitate adoption of guideline-based clinical practice at ORCI.
Validation of Estrogen Receptor Immunohistochemistry of Breast Cancer on Cell Block at Muhimbili National Hospital
Tanzania Investigator: Asteria H. Kimambo, MD, MUHAS
In Tanzania, breast cancer is the second leading cause of cancer mortality among women. The clinical management and prognosis of breast cancer depend critically on the hormone receptor status, including estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). At Muhimbili National Hospital (MNH), breast cancer biomarkers are determined by immunohistochemistry but are performed only on surgical specimens, requiring invasive and expensive procedures that are subject to suboptimal handling and long turnaround times. Fine needle aspiration biopsy is a minimally invasive and cost-effective procedure that can be performed at the bedside and can be used to collect material for cell block for ancillary studies, such as breast cancer biomarkers. Several past studies have shown comparable immunohistochemistry results for ER, PR, and HER2 between cell blocks and surgical specimens. In addition, performing immunohistochemistry on cell block can decrease turnaround time for breast cancer biomarker results, thus reducing delays in treatment and allowing patients to be eligible for life-prolonging and accessible hormone therapies more rapidly. This study hypothesizes that concordance for ER expression evaluated on cell block compared with corresponding histologic specimen will be greater than 90%.
Accelerating Radiation Oncology at Ocean Road Cancer Institute using Machine learning-based Assistance - Cervix (AROMA-C)
UCSF Investigator: Melody Xu, MD
Evaluation of Factors Related to Delay in Imaging Presentation of Women with Breast Cancer in Tanzania
Tanzania Investigator: Lulu L. Sakafu, MD, MMed RAD, MUHAS
Breast cancer is the second leading cause of cancer death in women worldwide. While breast cancer is widely prevalent in both developed and developing regions, the prognosis is far worse in low- and middle-income countries, where women are typically diagnpsed at more advanced stages. In Tanzania, approximately 80% of women are diagnosed at stage III or IV, when treatments are much less effective and mortality is high. In wealthy countries, like the United States, the standard of care is to immediately refer patients for diagnistic breast imaging evaluations as soon as signs and symptoms of breast cancer, such as a palpable lump, are recognized. It is well know that delay between onset of breast symptoms and the diagnosis and treatment of breast cancer is detrimental to survival. The aim of this study is to evaluate the extent and factors involved in the delay between symptom onset and diagnostic imaging evaluation of breast cancer in Tanzania. Specifically, this study will: 1) Assess the psychosocial factors associated with late presentation of imaging services in Tanzania; 2) Determin how breast cancer information and perception contributes to late imaging; 3) Assess how health seeking behavior, preference for alternative treatment, culture, and norms contribute to late breast cancer imaging; and 4) Assess knowledge and skills in breast cancer imaging among medical doctors attending breast cancer patients.
Efficacy of an Intensive, Ultrasound-Guided Fine-Needle Aspiration Biopsy Training Workshop in Tanzania
UCSF Investigator: Dianna Ng, MD
Tanzania Investigator: Edda Vuhahula, DDS, PhD, MUHAS
In January 2019, faculty from the UCSF and Muhimbili University of Health and Allied Sciences (MUHAS) Departments of Pathology and Radiology collaboratively organized and led an ultrasound-guided fine-needle aspiration biopsy (FNAB) short course at MUHAS. This workshop was the second FNAB short course facilitated by UCSF at MUHAS, and it was designed for pathologists, radiologists, and residents in Tanzania to improve their technical skills in ultrasound-guided FNAB . The course consisted of case-based presentations and hands-on practice, focusing on sampling technique and basic ultrasounds skills. Course attendees included many individuals who had taken part in the previous course, held in Fall 2017, as well as many new attendees.
Implementing and Evaluating a Palliative Wound Care and Palliative Care Nursing Educational Program at Ocean Road Cancer Institute
UCSF Investigators: Stella Bialous, Stephanie Kennell-Heiling, Kim Baltzel, Linda Abramovitz
Tanzania Investigators: Nazima Dharsee, MD PhD; Mary Haule, CN
Nurses at Ocean Road Cancer Institute (ORCI) manage primarily malignant fungating and post-surgical wounds, caring for 30-45 wounds daily. With 270 inpatient beds and multiple outpatient departments, palliative wound management is a large component of the daily nurses’ activities at ORCI. Similarly, many patients arrive at ORCI in advanced stages and require a palliative care plan.
This nursing capacity building project has a two-fold purpose: 1) to deliver a 2-module training (one in palliative wound care and one in palliative care) to 40 nurses caring for cancer patients in Dar es Salaam, Tanzania; and 2) to support the development of local oncology nurse mentors at ORCI to sustain practices learned in the training, including implementation of a palliative wound management nursing assessment & management tools.
The education will be sustained through the implementation and evaluation of a nursing protocol on palliative wound care and palliative care that will be supported by the identification of local nurse mentors, who will become a local resource in the long term. With support from the UCSF team, nurse mentors will be responsible for implementation, monitoring and evaluation of the program impact, using two key indicators: 1) wound care charting, using the wound assessment and management tools developed by ORCI nurses in partnership with UCSF nurses; and 2) medication administration to assess pain management in palliative wound care and palliative care.
