Introduction
The session on access to cancer care in lower middle-income countries was moderated by Dr. Aparna Parikh who is an Assistant Professor of Medicine at Harvard Medical School and an expert in the management of patients diagnosed with colorectal cancer and liquid biopsies. She also directs the Global Cancer Care Program at the Massachusetts General Cancer Center. The goal of the session was to highlight stories of equitable partnerships and the magnitude of impact that these partnerships can facilitate and focused on partnerships in nursing, clinical care and research. The first session was on global initiatives lead by nursing.
Developing on Oncology Care Model in an Ultra Low-Income Settings
The first set of speakers were Lori Buswell and Oliver Habimana. Lori Buswell Is the executive director for center for Global Cancer Medicine with Dana Farber Cancer institute and has worked extensively in global oncology but her more recent efforts has been focused on cancer care in Butaro, Rwanda with Partners in Health (PIH). Olivier Habimana, RN works in the Butaro Cancer Institute for nearly ten years and specializes in oncology education, training, and nursing quality improvement. He also leads the patient navigation program at Butaro Cancer Center of Excellence (BCCOE). They both shed light on nursing care globally, stating that there are 27 million nurses in the worldwide, making up more than 50% of the healthcare workforce. In 2030, the estimated shortage of between 9 and 13 million nurses and much of that shortage will be most palpable in the African and Asian continents.1
The global cancer medicine team at Dana Farber started working with Partners in Health in Rwanda and Haiti 11 years ago when there were no oncologists in the country. They started setting up an oncology task shifting model in Rwanda and utilized a task shifting model wherein physicians have not received specialty training in oncology receive focused oncology education through various educational courses, direct bedside teaching by US oncologists, observerships in the United States, the use of clinical pathways specifically developed for the resources available in the country.2 Nurses have been utilized to take on different roles where they can spearhead various initiatives such prevention and screening, survivorship, cancer treatment and palliative care. They have trained their nurses to be researchers, educators, policymakers, navigators, as well as direct care staff nurses.
Lori Buswell and their team’s approach to building this program was analogous to Maslow’s hierarchical needs. They built the cancer program ground up from setting up the right infrastructure to building the right foundation such as of preparation and mixing chemotherapy and making use of available resources. They built computerized chemotherapy templates and were then able to build on the program in terms of training and hiring in-house oncology nursing educators. They created oncology education booklets for patients with culturally appropriate illustrations to help convey health messages and have grown their research in quality improvement leading to a quality improvement grant. This work has led to presentations in international conferences and the nursing team at Butaro also serve as mentors to other oncology centers in East Africa.3 They have also been able to build their repository of traditional chemotherapeutic agents to include Rituximab and Trastuzumab.
Olivier Habimana focused his portion of the discussion on his roles in the Butaro Cancer Center of Excellence. He started off as a nurse in the Cancer Center and his role as become pivotal in the system as he specializes in capacity building for nurses and serves as an advocate for their nurses. He coordinates and organizes the training and education activities for the nursing staff. He highlighted some of the ongoing challenges they experience such as a constant need for more staffing and drug stock outs as the service at the BCCOE grows in demand. He also noted they have one radiotherapy department for the entire country and there is a clear need to further build infrastructure He also spoke of their steadfast work in addressing and overcoming stigma associated with being diagnosed with cancer and coping with adverse outcomes. He also noted they have one radiotherapy department for the entire country and there is a clear need to further build infrastructure He also spoke of their steadfast work in addressing and overcoming stigma associated with being diagnosed with cancer and coping with adverse outcomes. The long-term commitment with Dana Farber Cancer Institute has led to mutual and bidirectional collaboration as they continue to build and grow cancer care in Rwanda.
The Nursing Experience in Botswana: Leading Patient Centered Care
The next speaker was Lorraine Drapek, DNP FNP-BC AOCNP who works in the department of Radiation Oncology and is a founding member of the Cancer Center’s Sexual Health Clinic team at Massachusetts General Hospital. She has been extensively involved in collaboration with cancer center in Botswana working on quality-of-life initiatives for women who received pelvic radiation. To set the stage, she focused on a survey study of 218 cancer patients in an oncology clinic in Botswana that showed cancer of the cervix to be the most common cancer (42.2%). Amongst those patients, 57% presented with advanced cancer (stage III or IV). Twenty-six percent of patients experienced delays in experiencing symptoms to deciding to seek professional help, 35.5% experienced delays in time from first symptom to their first appointment with a consultant, 63.1% experienced delays in diagnosis, and 50.4% experienced delays in treatment.4 She focusses her oncology outreach on improving the sexual health of women with cervical cancer via nursing education. She designed a quality improvement project funded by Botswana Oncology Global Outreach (BOTSOGO) wherein she spearheaded a clinic in Botswana focused on improving vaginal health for patients treated with pelvic radiation. She trained nurses on educating patients on long term effects of radiation and as a part of the project, they distributed lubricants and vaginal dilators to patients to maintain vaginal patency. The project was implemented in 2017 and conducted in the Gaborone Private Hospital, Gaborone, Botswana. Patients were also directed to the Gaborone private hospital from the Princess Marina Hospital for this initiative. The educational sessions were conducted by nursing staff on vagina health and sexuality after treatment, vaginal dilator use, cleaning and problem solving. Vaginal dilator use was assessed by follow up questionnaires resembling the structure of PROMIS focused on vaginal and sexual health. In the 2-year follow-up (n=110), 90% of patients were able to complete an in-person 6 week follow up and over 2 years, 10 patients were successfully discharged from the program.5 The program was well received amongst the patients. The oncology nurses played a key role in implementing the sexual survivorship amongst patients in Botswana. A major challenge faced during this initiative included loss to follow up due to many patients having transportation issues especially during the SARS-CoV2 pandemic.
Equitable Partnerships in Global Oncology: Best Practice Examples of a AMCs/LMICs partnership
Katherine Van Loon, MD MPH, an Associate Professor of Clinical Medicine at UCSF, a gastrointestinal oncologist, and the Director of Global Cancer Program at the Helen Diller Family Comprehensive Cancer Center, discussed her career path in global cancer control. She started her journey in 2001 when she spent time in South Africa and worked on the ethics of informed consent for participants in HIV clinical trials prior to the widespread availability of anti-retroviral therapies. She addressed the long history of abuse and power asymmetries in global health.6 She emphasized her own privilege of her own education, access to resources, and institutional support as she focuses on developing equitable collaborations in global health.
Three years after starting her career as faculty at UCSF, she was asked to establish a global oncology program at her institution. The shared vision for the Global Cancer Program at UCSF is to eradicate inequities in global cancer care and research. Their approach consists of three arms: (1) to perform innovative research in quality improvement to address the disparities in cancer care in lower- and middle-income countries; (2) to develop leaders in global cancer care and research; and (3) to foster collaborations to sustainably impact in cancer burden globally.
She shared the values framework for the Global Cancer Program at UCSF. She highlighted cultural humility and accompaniment as two values that are central to her program. She mentioned that cultural humility “requires a lifelong commitment to self-reflection and self-critique. It recognizes and acknowledges power imbalances. It realizes that individual experiences redefine what culture means in every single interaction.” She provided Paul Farmer’s definition of accompaniment: “To accompany someone is to go somewhere with him or her, to break bread together, to be present on a journey with a beginning and an end…There’s an element of mystery and openness…. I’ll share your fate for a while, and by ‘awhile’ I don’t mean ‘a little while.’ Accompaniment is much more often about sticking with a task until it’s deemed completed by the person or person being accompanied, rather than by the accompagnateur.” She emphasized the importance of non-paternalistic and bidirectional collaboration towards building global equity in cancer care.
Equitable Partnerships in Global Oncology: Best Practice Examples of a AMCs/LMICs partnership
Over the past five years, her team has established three regional hubs in Vietnam, Tanzania, and Mexico. She reflected on the partnership she established between UCSF and the Instituto Nacional de Cancerologia (INCan) and the Instituto Nacional de Salud Publica (INSP) in Mexico.7 In an early stakeholder meeting, they identified potential areas for collaboration based upon local priorities. UCSF’s Cancer Center and Institute for Global Health Sciences each contributed $50,000 to fund the pilot collaborations, and projects were selected based upon priority as well as demonstrated bilateral leadership. As an example, they decided that since colorectal cancer related mortality is the highest cause of cancer-related mortality in Mexico City and is also a rising issue amongst the Latino community in California, they would focus one pilot project on colorectal cancer screening. This area of research was found to be of mutual interest in both institutions.
Dr. Van Loon also spoke on challenges related to research in global oncology. Making strides in global oncology is challenging in academia as seeking funding via grants and generating publications remain measures of academic success; however, direct impacts on patient outcomes are ultimately the true measures of success in this area. The funding available for cancer research globally is not nearly enough to address the emerging issues, and the magnitude of problems related to global cancer control far exceeds the available funding opportunities. Often funding from sponsoring agencies originates in the United States of America reflects the goals of the sponsor and may not align with local needs. She also reminded us that research and improvements in clinical care are not always synonymous but can be intertwined with an enhanced focus on implementation science and quality improvement research methods.
The last speaker of this session was Dr. Erika Ruiz-Garcia who is a Professor in the Department of Gastrointestinal Medical Oncology and Chief of the Translational Medicine Laboratory at the Instituto Nacional de Cancerologia in Mexico City and collaborator of Dr. Van Loon. Her talk was focused on ongoing equitable projects between institutions in global oncology. Instituto Nacional de Cancerologia (INCan) in Mexico City is one the largest hospitals and the institution focused on caring for patients who belong to the lower socioeconomic status. Per Dr. Ruiz-Garcia, INCan has greater than 200,000 patient visits yearly amongst which 5,000 are new cases and one-fifth of all new consultations are for gastrointestinal cancers. She first spoke of the prospective Legacy study focused on studying the tumor biology and risk factors associated with gastric cancers in Latin America and European countries belonging to the consortium.8 She also is working on an exploratory analysis of gut microbiome, diet and lifestyle of Latinx patients residing in Mexico and California. Challenges related to this study include transportation of stool samples related to tighter restrictions over the USA- Mexico border. She is also working on collaborative efforts in studying patients with SARS-CoV2 and cancer. She has been able to contribute samples from 400 patients adding to diversity of representation from Latinx patients to their joint consortium with other European and Latin American countries. She strives for higher representation of minorities in clinical trials and other research initiatives. Dr. Ruiz-Garcia concluded her presentation by reiterating the need for equitable partnerships which are quite like “marriages”; mutually beneficial and trusting relationships that can result in a great global impact.
Conflict of Interest
AP: Equity in C2i Genomics XGenomes Cadex and Parithera and in the last 36 months, has served as an advisor/consultant for Eli Lilly, Pfizer, Inivata, Biofidelity, Checkmate Pharmaceuticals, FMI, Guardant , Abbvie, Bayer, Delcath, Taiho ,CVS, Value Analytics Lab, Seagen, Saga, AZ, Scare Inc, Illumina, Taiho, Hookipa and Science For America. She receives fees from Up to Date. She has received travel fees from Karkinos Healthcare. She has been on the DSMC for a Roche study and on Steering Committee for Exilixis. She has received research funding to the Institution from PureTech, PMV Pharmaceuticals, Plexxicon, Takeda, BMS, Mirati, Novartis, Erasca, Genentech, Daiichi Sankyo and Syndax. AS, OH, LB, LD, KVL, ER have no conflict of interest to disclose regarding financial, honoraria, activities, relationships, and affiliations, or any other interests regarding this work.
Acknowledgement
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Funding information
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Ethical statements
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Author contributions
i. AS, AP: conception and design
ii. AS: data collection and assembly
iii. AS: data analysis, manuscript writing
iv. AS, LB, OH, LD, KVL, ERZ, AP: critically reviewing and revising the manuscript for relevant information
All authors have approved the publication of this manuscript.