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The first Lancet Oncology Commission on Global Cancer Surgery was published in 2015 and serves as a landmark paper in the field of cancer surgery. The Commission highlighted the burden of cancer and the importance of cancer surgery, while documenting the many inadequacies in the ability to deliver safe, timely, and affordable cancer surgical care. This Commission builds on the first Commission by focusing on solutions and actions to improve access to cancer surgery globally, developed by drawing upon the expertise from cancer surgery leaders across the world. We present solution frameworks in nine domains that can improve access to cancer surgery. These nine domains were refined to identify solutions specific to the six WHO regions. On the basis of these solutions, we developed eight actions to propel essential improvements in the global capacity for cancer surgery. Our initiatives are broad in scope, pragmatic, affordable, and contextually applicable, and aimed at cancer surgeons as well as leaders, administrators, elected officials, and health policy advocates. We envision that the solutions and actions contained within the Commission will address inequities and promote safe, timely, and affordable cancer surgery for every patient, regardless of their socioeconomic status or geographic location.

Utilizing a large consortium data set of resident operative performance ratings, Abbott et al. evaluated the technical competency of U.S surgical trainees to perform certain procedures deemed critical in low resource settings (LRS).1 The authors demonstrated variability in practice-ready ratings among 17 defined procedures, noting insufficient experience to perform nearly half of the recommended essential surgical procedures in LRS, including two of the three bellwether procedures as cited by the Lancet Commission on Global Surgery.2 While some of these procedures may fall outside the scope of US general surgery training, the authors challenge the surgical education community to utilize the noted deficiencies to improve opportunities for trainees in global surgery. [...]one might argue that a US-trained surgeon is better prepared technically than culturally. [...]of the COVID-19 pandemic, some of this can now be more easily achieved due to the rapid uptake and success of various online educational platforms which improve access and bidirectional learning in the global surgery space.7 With growing concern about graduating residents’ preparedness, transition to practice from trainee to independent surgeon is a focus in the US and not just global surgery.8 Many academic institutions and healthcare systems have established onboarding programs that include mentorship, leadership training, monitoring surgical outcomes, and proctoring.9 These programs aim for increased surgeon autonomy, graded responsibility, practice management skills, and senior surgeon mentorship.

This study evaluates associations between patient distance traveled to surgical care and receipt of timely breast cancer surgery in Georgia. This retrospective cohort study included electronic health record data from women diagnosed with stage I-III breast cancer from 2004 to 2020 who received upfront surgery. Race was self-reported. Distance from patient home address to surgical treatment facility was measured as crow-fly distance. Multivariable logistic regression models estimated associations between time to surgery, race, and distance. Of 18,240 patients (White ​= ​61 ​% and Black ​= ​39 ​%) with a median distance to surgery of 11.4 miles (IQR: 5.9, 19.6), Black patients had approximately half the odds of receiving surgery within the recommended 60 days of diagnosis (OR: 0.52, 95 ​% CI: 0.47–0.56). Distance traveled was not associated with time to surgery. Understanding mechanisms driving surgical care delays and their effects on breast cancer outcomes is critical to reducing inequities in breast cancer care. •There are racial disparities in cancer care among patients in Georgia.•One-third of Black patients do not receive surgery within the recommended 60 days.•Black patients (compared to White) have half the odds of timely breast cancer surgery.•Patient distance traveled to surgery is not associated with surgical timeliness.•Understanding drivers of surgical delays is critical to reducing racial inequities.

BackgroundRetrospective studies have reported that breast cancer patients who perceived more personal responsibility for the surgery decision were more likely to undergo aggressive surgery. We examined this in a prospective study.Methods100 newly diagnosed breast cancer patients identified their decision- making role using the Patient Preference Scale. Chart review captured the initial surgery received. Patient decision role preference, role perception, role concordance, and provider role perception were compared with type of surgery to assess differences between mastectomy and lumpectomy groups and unilateral versus bilateral mastectomy. We compared type of surgery and patient role concordance. Satisfaction with Decision immediately after the visit, Decision Regret and FACT-B quality of life at 2 weeks and 6 months were assessed and compared with type of surgery.ResultsPatient decision role preference (p = 0.49) and perception (p = 0.16) were not associated with type of surgery. Provider perception of patient role was associated with type of surgery, with providers perceiving more passive patient roles in the mastectomy group (p = 0.026). Patient role preference varied significantly by stage of disease (= 0.024), with stage 0 (64%, N = 6) and stage III (60%, N = 6) patients preferring active roles and stage I (60%, N = 25) and stage II (52%, N = 16) patients preferring a collaborative role.ConclusionsPatient role preference and perception were not associated with type of surgery, while provider perception of patient role was. Patient role preference varied by stage of disease. Further study is warranted to better understand how disease factors and provider interactions affect decision role preferences and perceptions and surgical choice.Trial RegistrationThe study was registered with clinicaltrials.gov (NCT03350854). https://clinicaltrials.gov/ct2/show/NCT03350854.

Background Breast cancer is a leading cause of cancer related morbidity and mortality in Sub-Saharan Africa with women often being diagnosed at advanced stages of disease. Little is known about how the role of the husband impacts the diagnosis and treatment of women with breast cancer. In this study, we aimed to describe the role of the husband in the experiences of breast cancer patients in Tanzania. Methods We conducted semi-structured in-depth interviews with breast cancer patients ( n  = 20), physicians ( n  = 10), nurses ( n  = 10), and traditional healers ( n  = 18) exploring perceptions of breast cancer diagnosis and treatment in Tanzania. Interviews were recorded, transcribed, and subsequently coded by three independent reviewers. Emergent themes were identified using thematic analysis approach. Results We identified two distinct domains from responses: supportive husbands and unsupportive husbands. Within these domains, 5 supportive and 4 unsupportive themes were identified. Supportive husbands provided financial assistance, encouraged early treatment, adopted a caregiver role, displayed leadership in decision-making, and provided emotional support. Unsupportive husbands displayed stigma and shame, refused financial support, and resorted to rejection and abandonment which ultimately led to delays in diagnosis and treatment. Conclusions Majority of patients, providers, and traditional healers described unsupportive husbands as a component contributing to the delayed presentation and negative experiences of patients. We inferred that spousal financial concerns and societal stigma often drove husband rejection, which resulted in a lack of emotional and financial support for patients and contributed to delays in diagnosis and treatment. Improvements in husband education and communication may reduce stigma and misconceptions regarding breast cancer and may help increase the number of supportive husbands.

Background Breast cancer is the most common cancer-affecting women globally, with disproportionally high mortality rates in lower-income countries, including Ethiopia. The stage at diagnosis is a well-defined predictive system that determines the likelihood of breast cancer mortality. Early-stage breast cancer at diagnosis is associated with better treatment outcomes as compared with late stage. Although there are numerous primary studies on women with breast cancer with different proportions of early-stage breast cancer, there is currently no summary data on what proportion of breast cancer was diagnosed at early-stage in Ethiopia. This study focused on a pooled proportion of early-stage breast cancer at diagnosis in Ethiopia. Methods By using key terms, Medline through Pub-Med, Google Scholar, Science Direct, HINARI and Medley were searched about breast cancer in Ethiopia, and a total of 288 articles were retrieved. After screening the articles and quality of each article was assessed using Newcastle–Ottawa Scale. Finally, 41 articles were used for the final pooled proportion. A random effects model was used to estimate the pooled prevalence and heterogeneity of included studies that were then assessed by using prediction interval. Results Pooled proportion of early-stage breast cancer at diagnosis in Ethiopian hospitals was found to be 36% with a 95% confidence interval ranging from 31 to 41% and a 95% prediction interval ranging from 28 to 45%. Conclusion Most breast cancer patients (64%) in Ethiopia are diagnosed at a late-stage. This contributes to the high mortality rates of breast cancer among women in Ethiopia. Therefore, in line with recommendations by the World Health Organization, we recommend that there should be an emphasis in Ethiopia to focus on early detection of breast cancer.

Background Traditional healers play a significant role in Sub-Saharan Africa's healthcare system, but little is known about their role across the cancer care continuum in this context. Given the prevalence of patients consulting healers, we aimed to elucidate their role and impact on cancer care delivery in Sub-Saharan Africa. Methods Following the PRISMA reporting standards, all research focused on the role of traditional healers in the cancer care continuum in sub-Saharan Africa was included in this scoping review. Data sources assessed include PubMed, Cochrane Library, Embase, and CINAHL Plus with Full Text, Scopus, Sociological Abstracts, African Journals Online, African Index Medicus, and Google Scholar. Studies that lacked perspectives on the healers’ role, focused solely on the actual herbal medicines, were written in non-English language, were not primary research, or the full-text was unavailable were excluded. Two reviewers performed screening and data extraction for each article, confirmed by a third reviewer. Results One thousand four hundred seventy-one studies were identified, with 1437 screened and 191 full-texts reviewed. Of those, 158 were excluded, and 33 (comprising of 1564 healers) were included for final data extraction and analysis. Five studies (64 healers) showed their role in prevention, eleven (454 healers) in diagnosis, twenty-seven (1524 healers) in treatment, and two (25 healers) in palliative care in Sub-Saharan Africa. While some desired increased collaboration with the biomedical system and referred patients, others lacked trust and remained hesitant to provide referrals. Conclusion Results showed that traditional healers play an important role in cancer treatment. This provides an opportunity to leverage the skills of traditional healers to improve cancer outcomes, in a way that recognizes and respects local culture. Future research focused on improving the collaboration between traditional healers and the biomedical healthcare system may lead to strengthening the referral system and early detection and treatment of cancer. Registration  This study was registered on PROSPERO, CRD42022293055.

Breast cancer burden is high in low-income countries. Inadequate early detection contributes to late diagnosis and increased mortality. We describe the training program for Malawi's first clinical breast exam (CBE) screening effort. Laywomen were recruited as Breast Health Workers (BHWs) with the help of local staff and breast cancer advocates. The four-week training consisted of lectures, online modules, role-playing, case discussions, CBE using simulators and patients, and practice presentations. Ministry of Health trainers taught health communication, promotion, and education skills. Breast cancer survivors shared their experiences. Clinicians taught breast cancer epidemiology, prevention, detection, and clinical care. Clinicians and research staff taught research ethics, informed consent, data collection, and professionalism. Breast cancer knowledge was measured using pre- and post-training surveys. Concordance between BHW and clinician CBE was assessed. Breast cancer talks by BHW were evaluated on a 5-point scale in 22 areas by 3 judges. We interviewed 12 women, and 4 were selected as BHWs including 1 breast cancer survivor. Training was dynamic with modification based on trainee response and progress. A higher-than-anticipated level of comprehension and interest led to inclusion of additional topics like breast reconstruction. Pre-training knowledge increased from 49% to 91% correct (p<0.0001). Clinician and BHW CBE had 88% concordance (kappa 0.43). The mean rating of BHW educational talks was 4.4 (standard deviation 0.7). Malawian laywomen successfully completed training and demonstrated competency to conduct CBE and deliver breast cancer educational talks. Knowledge increased after training, and concordance was high between BHW and clinician CBE.

Background Breast cancer (BC) is the most common cancer among women in Tanzania and has one of the highest mortality rates worldwide due to late-stage diagnosis and suboptimal treatment. The role of traditional healers in late-stage diagnosis has not been widely studied. We aimed to identify the barriers to early BC diagnosis in Tanzania and possible solutions by interviewing healthcare providers (HCPs), traditional healers (THs), and other key informants (KIs). Methods We used phenomenological qualitative study design. We administered six open-ended qualitative questions to 20 HCPs (including 10 doctors and 10 nurses), 10 THs, and 9 KIs in rural and urban community settings in the Kilimanjaro region. A focus group discussion with 8 THs was also conducted. The questions explored perceived reasons for late diagnosis of BC, the initial reaction of patients who presented with a noticeable breast changes and reasons for visiting a health facility after the disease had advanced. Participants were recruited after their working hours. Data were analyzed using thematic approach and NVIvo 12 software. Results The findings were synthesized into five themes to explain late diagnosis: (1) HCPs and THs have limited knowledge and misconceptions about the causes, signs, and symptoms of breast cancer; (2) patients experience stigma (3) treatment is expensive and difficult to access; (4) patients perceive barriers based on myths, misperceptions and spiritual beliefs; and (5) HCPs and THs often blame each other for ineffective treatment and delays in effective treatment. The participants also provided suggestions to reduce delays in diagnosis and treatment, including enhancing knowledge and awareness among THs and HCPs to help them recognize the signs and symptoms of BC through education campaigns, addressing the cost of access to care and treatment, addressing stigma associated with BC, and developing collaborative efforts between HCPs and THs. Conclusion In this study, limited knowledge, misconceptions, stigma, access and cost was observed as barriers across all groups.Raising community awareness and improving understanding of BC is crucial in reducing misconceptions and stigma. Future collaboration between healthcare providers and traditional healers could be beneficial in the development of strategies to recognize the early signs and symptoms of BC and promote pathway referral to care.