Themba G. Ginindza

Investigating Drug Treatment Costs and Patient Characteristics of Female Breast, Cervical, Colorectal, and Prostate Cancers in Antigua and Barbuda: A Retrospective Data Study (2017–2021)

Cancers are problematic for health systems globally, including in Antigua and Barbuda, where understanding the changing extent of common cancers is key to implementing effective prevention and control strategies. This study aimed to assess the relationship between treatment rates and drug treatment costs along with characteristics affecting these costs for patients with female breast, cervical, colorectal and prostate cancers in Antigua and Barbuda from 2017 to 2021. A retrospective observational study design was used. Estimates of age-standardized treatment rates and drug treatment costs were determined using direct standardization and a micro-costing approach, respectively. Linear regression was used to evaluate the relationship between age-standardized treatment rates and drug treatment costs. Model independent variables were assessed for multicollinearity and residuals examined for variance and normality. With a sum of 242 cases identified for this study, each cancer type showed evidence of strong positive correlations and significant associations between treatment costs and age-standardized treatment rates. The mean cost (USD) of drug treatment was highest for female breast (USD 25,009.63) and colorectal (USD 13,317.16) cancers and lowest for prostate (USD 12,528.10) and cervical (USD 5121.41) cancers, with several variables showing significance in the respective final models. An association existed between age-standardized treatment rates and drug treatment costs for the cancers studied. These results offer a basis for encouraging strategies in obtaining affordably priced cancer medicines in Antigua and Barbuda.

Overall Observed Survival of Female Breast, Cervical, Colorectal, and Prostate Cancers in Antigua and Barbuda, 2017–2021: Retrospective Data from Four Study Sites

Understanding cancer survival is important for countries such as Antigua and Barbuda, where female breast, cervical, colorectal, and prostate cancers are burdensome to the healthcare system. This study therefore aimed to estimate the survival probabilities of patients diagnosed with these cancers between 2017 and 2021. A retrospective analytical study design was used to evaluate cancer cases abstracted from medical records at key study sites. Estimates of observed survival probabilities were determined using a Kaplan–Meier analysis. Significant differences between survival curves were assessed using the log-rank test. Hazard ratios were calculated using Cox regression. A p-value < 0.05 indicated significance. A total of 391 diagnosed cases were included in this study (2017–2021): female breast cancer accounted for 42%, cervical cancer accounted for 10%, colorectal cancer accounted for 20%, and prostate cancer accounted for 28%. Overall, the mean age of the participants was 61.5 (±12.9) years; 62% were female, 73% were aged > 55 years, 56% were from St. John’s, and 82% were alive at the end of 2021. The median overall survival (years) was 4.8 for female breast cancer, 4.1 for cervical cancer, 4.5 for colorectal cancer, and not reached for prostate cancer. The cancer-specific overall observed 5-year survival probabilities were 44.9% for female breast cancer, 10.8% for cervical cancer, 19.6% for colorectal cancer, and 69.0% for prostate cancer. Significant associations between disease stage and overall survival were observed in female breast and colorectal cancers. This study provides important evidence for the 5-year observed survival probabilities of the studied cancers. Healthcare improvements that support cancer survival are required.

Cost Analysis Related to Diagnosis, Treatment and Management of Cervical Cancer in Antigua and Barbuda: A Prevalence-Based Cost-of-Illness Study

Cervical cancer remains a significant public health issue globally. In Antigua and Barbuda, cervical cancer is ranked among the top five most common cancers in terms of incidence and mortality among females. There is no evidence that the costs of diagnosing, treating, and managing this cancer have been studied before in Antigua and Barbuda. From the providers’ perspective, this study aimed to estimate costs associated with cervical cancer in Antigua and Barbuda. The prevalence-based cost-of-illness methodology was used to assess patient data abstracted from four study sites for the period 2017–2021, and to derive the annual prevalence. Top-down and bottom-up costing approaches were used to estimate direct medical costs. Costs were computed using the 2021 price level and converted to United States Dollars (USD). Total annual direct medical costs of cervical cancer were estimated at USD 0.24 million (ranging between USD 0.19 million and USD 0.30 million). Major cost drivers were treatment (USD 112,863.76), post-treatment side-effects care (USD 67,406.57), and the diagnostic process (USD 26,238.58). The overall direct medical unit costs for managing a case were estimated at USD 115,822.09. Our study reflects the current estimates for managing cervical cancer and provides evidence to complement cervical cancer prevention and cost containment measures in Antigua and Barbuda.

The economic burden of cervical cancer in Eswatini: Societal perspective

Background Cervical cancer imposes considerable economic burden on societies and individuals. There is lack of evidence regarding this from the developing world and particularly from sub-Saharan Africa. Therefore, the study aimed to estimate the societal costs of cervical cancer in Eswatini. Materials and methods The cost of illness study (CoI) was applied using national specific clinical and registry data from hospitals, registries and reports to determine the prevalence of cervical intraepithelial neoplasia (CIN) and cervical cancer in Eswatini in 2018. Cost data included direct medical costs (health care utilization in inpatient and outpatient care), direct non-medical costs (patient costs for traveling) and indirect costs based on productivity loss due to morbidity (patient time during diagnosis and treatment) and premature mortality. Results The estimated total annual cost for cervical cancer was $19 million (ranging between $14 million and $24 million estimated with lower and upper bounds). Direct cost represented the majority of the costs at 72% ($13.7 million) out of which total pre-cancerous treatment costs accounted for 0.7% ($94,161). The management of invasive cervical cancer was the main cost driver with costs attributable to treatment for FIGO III and FIGO IV representing $1.7 million and $8.7 million respectively. Indirect costs contributed 27% ($5.3 million) out of which productivity loss due to premature mortality represented the majority at 67% ($3.5 million). Conclusion The economic burden of cervical cancer in Eswatini is substantial. National public health prevention strategies with prophylactic HPV vaccine and screening for cervical lesions should therefore be prioritized to limit the extensive costs associated with cervical cancer.

Cervical cancer management in Zimbabwe (2019–2020)

Background Globally, cervical cancer is the fourth most commonly diagnosed cancer amongst women, and it is especially common in low- and middle-income countries (LMICs). The aim of the study was to determine the current patterns and characteristics of CC management in Zimbabwe in the HIV pandemic era, including the knowledge, attitude and practice of patience. Methods The study was a mixed method which incorporated a cross-sectional survey of 408 CC patients which was conducted from October 2019 to September 2020 using an interviewer administered paper questionnaire. The study was conducted at Parirenyatwa hospital, the only cancer treating public health facility in Harare, Zimbabwe. Differences in study outcome by categorical variables were assessed using the Person Chi-square (χ2) test. Odds ratios (unadjusted and adjusted) and 95%CIs for potential risk factors associated with the outcome were estimated using logistic regression model. Results From a total of 408 CC patients recruited into the study no prevention mechanism was available or known to these patients and only 13% knew that CC is caused by Human papillomavirus. Only 87 (21%) had ever been screened for CC and 83 (97%) of those who had been screened had the visual inspection with acetic acid procedure done. Prevention (screening uptake) is statistically high among the educated (with secondary education OR = 9.497, 95%CI: 2.349–38.390; with tertiary OR = 59.381, 95%CI: 11.937–295.380). Late presentation varied statistically significantly with marital status (high among the divorced, OR = 2.866; 95% CI: 1.549–5.305 and widowed OR = 1.997; 95% CI: 1.112–3.587), was low among the educated (Tertiary OR = .393; 95% CI: .166-.934), low among those living in the rural (OR = .613; 95% CI: .375-.987), high among those with higher parity OR = 1.294; 95% CI: 1.163–1.439). Less than 1% of the patients had surgery done as a means of treatment. Radiotherapy was administered to 350 (86%) of the patients compared to chemotherapy administered to 155 (38%). A total of 350 (86%) have failed to take medication due to its unavailability, while 344 (85%) missed taking medication due to unaffordability. Complementary and alternative medicines were utilized by 235 (58%). Majority, 278 (68%) were HIV positive, mainly pronounced within age (36–49 years OR = 12.673; 95% CI: 2.110–76.137), among those with higher education (secondary education OR = 4.981; 95%CI: 1.394–17.802 and in those with no co-morbidities (893.956; 95%CI: 129.611–6165.810). Conclusion CC management was inadequate from prevention, screening, diagnosis, treatment and palliative care hence there is need to improve CC management in Zimbabwe if morbidity and mortality are to be reduced to acceptable levels. Education helped improve prevention, but reduces chances of diagnosis, working as a doubled edged sword in CC management Prevention was high among the educated. Those in rural areas experience poor CC management. It should be noted that general education is good; however it must be complimented by CC awareness to improve CC management outcomes holistically. Cervical cancer management services need to be decentralized so that those in rural areas have easy access. Given that those with co-morbidities and high parity have better CC management, CC services need to be tied to co-morbidity and antenatal/post-natal care and management services.

Mapping Evidence on Management of Cervical Cancer in Sub-Saharan Africa: Scoping Review

Cervical cancer (CC) is the most common viral infection of the reproductive tract and in Sub-Saharan Africa (SSA), its morbidity and mortality rates are high. The aim of this review was to map evidence on CC management in SSA. The scoping review was conducted in accordance with Arksey and O’Malley’s scoping review framework. The review included studies on different aspects of CC management. The review was also done following the steps and guidelines outlined in the PRISMA-Extension for Scoping Reviews (PRISMA-ScR) checklist. The following databases were searched: PubMed, EBSCOhost, Scopus and Cochrane Database of Systematic Review. A total of 1121 studies were retrieved and 49 which were eligible for data extraction were included in the review. The studies were classifiable in 5 groups: 14 (28.57%) were on barriers to CC screening, 10 (20.41%) on factors associated with late-stage presentation at diagnosis, 11 (22.45%) on status of radiotherapy, 4 (8.20%) on status of chemotherapy and 10 (20.41%) on factors associated with high HPV coverage. High HPV vaccine coverage can be achieved using the class school-based strategy with opt-out consent form process. Barriers to CC screening uptake included lack of knowledge and awareness and unavailability of screening services. The reasons for late-stage presentation at diagnosis were unavailability of screening services, delaying whilst using complementary and alternative medicines and poor referral systems. The challenges in chemotherapy included unavailability and affordability, low survival rates, treatment interruption due to stock-outs as well as late presentation. Major challenges on radiotherapy were unavailability of radiotherapy, treatment interruption due to financial constraints, and machine breakdown and low quality of life. A gap in understanding the status of CC management in SSA has been revealed by the study implying that, without full knowledge of the extent of CC management, the challenges and opportunities, it will be difficult to reduce infection, improve treatment and palliative care. Research projects assessing knowledge, attitude and practice of those in immediate care of girls at vaccination age, situational analysis with health professionals and views of patients themselves is important to guide CC management practice.

Effectiveness of Clinic-Based Patient-Led Human Papillomavirus DNA Self-Sampling among HIV-Infected Women in Uganda

In Uganda, the uptake of cervical cancer (CC) screening services is low, at 46.7%, among HIV-infected women, and only 9% of these women adhere to annual CC screening. Some studies have evaluated the possibility of community or home-based human papillomavirus (HPV) self-collected vaginal swabs, but not clinic-based HPV self-collected vaginal swabs. Therefore, we propose a study to determine the efficacy of clinic-based versus home-based HPV DNA self-sampling among HIV-infected women attending a rural HIV clinic in Uganda. We believe that a randomized, single-blinded trial would achieve this objective, and so we have chosen it to guide the study. Including a total of 382 participants from a rural HIV clinic, randomized into a ratio of 1:1 for clinic- and home-based HPV self-sampling, would allow us to appropriately ascertain the difference in the uptake of HPV self-sampling between the two arms. The Integrated Biorepository of H3 Africa Uganda Laboratory would be used as a reference laboratory for the HPV DNA extraction, typing, and sequencing. At baseline, modified Poisson regression models would be used to measure factors associated with the prevalence of HPV and uptake in both arms at baseline. Visual inspection under acetic acid (VIA), as a gold-standard test for CC to grade for CIN, would be performed at 0 and 6 months among a random sample of 75 women with a self-collected HPV sample. The difference in uptake could be determined using the intention-to-treat analysis. The difference in the groups by each variable would be summarized as the standardized mean difference (i.e., the mean difference divided by the pooled standard deviation). The predictors of the time for which participants would continue with HPV self-sampling in both arms, recovery, and Cox proportional hazards regression would be used. At the bivariate level, the associations between each independent variable and time, with the time of continuing HPV self-sampling, would be computed. Crude hazard ratios and their 95% confidence interval would be used in the presentation of the results, with p-values < 0.05 considered significant at the bivariate level. Incremental cost-effectiveness analysis (CEA) using a Markov model would be used to determine the cost of clinic-based HPV self-sampling. We believe that screening approaches to disease stratification could provide an insight into the merits and limitations of current approaches to the diagnosis of cervical cancer, and how these could eventually be implemented into HIV clinics in Uganda and other developing African countries. It is anticipated that the findings would guide the development of step-by-step guidelines for the HPV self-sampling approach.

Facilitators and Barriers to HPV Self-Sampling as a Cervical Cancer Screening Option among Women Living with HIV in Rural Uganda

Background: There is a paucity of studies exploring women living with HIV’s (WLWH) experiences relating to human papillomavirus (HPV) self-sampling as cervical cancer (CC) screening approach, either at the clinic or at the home setting, using qualitative methods. Our study explored facilitators and barriers to HPV self-sampling as a CC screening approach among human immunodeficiency virus (HIV)-infected women, as supported by the new WHO guidelines of using the HPV test as a screening modality. Methods: The study was guided by the health promotion model (HPM), which helps individuals achieve higher levels of well-being. The phenomenology design was used to explore the deeper facilitators and barriers of women regarding self-sampling, either at home or in clinical settings, at Luweero District Hospital, Uganda. The in-depth interview (IDI) guide was translated from English to Luganda. Qualitative data analysis was guided by content analysis techniques. The transcripts were coded in   NVivo 20.7.0. The coded text was used to generate categories of analytically meaningful data that guided the formation of themes, the interpretation of results, and the final write-up. Results: WLWH were motivated to screen for HPV using the clinic-based approach because of perceived early diagnosis and treatment, visualization of the cervix, and free service, while reduced distance, privacy and the smooth sample collection kit were motivators for the home-based approach. A barrier that cut across the two HPV self-sampling approaches was a lack of knowledge about HPV. The barriers to clinic-based HPV self-sampling screening included lack of privacy, perceived painful procedures for visual inception under acetic acid (VIA), and fear of finding the disease. Stigma and discrimination were reported as the major barriers to the home-based HPV self-sampling approach. The major reasons why some WLWH refused to screen were fear of finding the disease, stress, and financial disruptions related to being diagnosed with CC disease. Conclusions: Therefore, early diagnosis for HPV and CC enhances clinic-based HPV self-sampling, while privacy enhances the home-based HPV self-sampling approach. However, fear of finding a disease and the lack of knowledge of HPV and CC hinders HPV self-sampling. Finally, designing pre- and post-testing counselling programs in HIV care is likely to increase the demand for HPV self-sampling.

Cervical Cancer Screening and Treatment Algorithms Using Human Papillomavirus Testing—Lessons Learnt from a South African Pilot Randomized Controlled Trial

Abstract Background: To report quantitative and qualitative results on cervical cancer human papillomavirus (HPV)-based screening and treatment algorithms, with/out triage with visual inspection after acetic acid (VIA), followed by ablative treatment (AT). Methods: Women 30 to 54 years old from Durban, South Africa were recruited, regardless of human immunodeficiency virus (HIV) status, randomized into one of two study arms and screened for HPV. VIA triage arm: HPV-positive women were triaged using VIA, biopsied and received AT if VIA positive and eligible; no triage arm: eligible HPV-positive women received AT. Women ineligible for AT were referred to colposcopy. Women were asked about side effects immediately and 1 week after AT. Retention to screening and treatment algorithms was compared between arms. Results: A total of 350 women [275 HIV-uninfected and 75 women living with HIV, (WLWH)] were allocated to receive HPV testing with VIA triage (n = 175) or no triage (n = 175). HPV prevalence was 28% [95% confidence interval (CI) = 23–33]; WLWH: 52% (95% CI = 40–64) versus HIV-uninfected: 21% (95% CI = 17–27; P < 0.05). Among women who underwent VIA triage with histologic diagnosis, 3/17 were VIA negative with cervical intraepithelial neoplasia (CIN)2+; 14/18 were VIA positive with <CIN2. Retention to screening and treatment algorithms was high (92%). Conclusions: This pilot demonstrated the feasibility of implementing screening and treatment algorithms, including performing triage and treatment in one visit; however, VIA triage did not reduce overtreatment and missed some precancerous lesions. Impact: This study reports on implementation feasibility of two World Health Organization screening and treatment algorithms (with/out VIA triage). Although the retention to screening and treatment algorithms was high in both arms, the question of how best triaging HPV-positive women deserves further consideration, particularly for WLWH. See related In the Spotlight, p. 763