OBJECTIVE Inadequate access to essential medicines is a major contributor to poor childhood cancer survival in low- and middle-income countries (LMICs). We studied the availability and determinants of childhood cancer drug (CCD) access in Ghana to inform national health policy and facilitate public procurement efforts.
METHODS We employed a mixed-methods case study approach to analyse the determinants of CCD access in Ghana, comprised of a scoping literature review, in-depth qualitative interviews (n=21) with key health system stakeholders, and prospective collection and quantification of drug availability and price. Interviews were recorded, transcribed, coded deductively and inductively, and analysed to capture emergent themes. We determined alignment of cytotoxic and adjuvant medicines between the WHO Model List of Essential Medicines for Children (WHO EMLc) and Ghana’s Essential Medicines List (NEML), and compared national buyer prices against median international prices to assess procurement efficiency.
RESULTS Encouraging generic substitution, removing taxes on imported drugs and strategic national drug procurement are among the government cost-saving strategies that address the issue of affordability. The lack of public procurement of CCD renders Ghana reliant on the private sector and highly susceptible to stock-outs. Other barriers include drug quality concerns, low childhood cancer awareness and limited financing options for medicines.
Overall, there is a 65.2% alignment between the WHO EMLc and the NEML. However, the NEML only lists nine out of the 19 cytotoxic medicines on the WHO EMLc. Approximately 59.7% of the NEML drugs had a median price ratio greater than 3 which indicates inefficiency in procurement by the private sector, especially for adjuvant medicines.
CONCLUSION Rigorous evidence on health system determinants of CCD access in Ghana can inform policies to improve childhood cancer outcomes. Our findings yield transferable insights into drug access dynamics for children with cancer and other non-communicable diseases in comparable health system settings.

BACKGROUND Health promotion is important for childhood cancer survivors (CCS) given the many late effects that they face. Health behaviours of CCS are generally studied separately, despite the existing evidence suggesting that health risk behaviours are not independent. To our knowledge, there are few studies that examined the clustering of healthy risk behaviours among childhood cancer survivors.
METHODS The present study included 3149 patients treated in France for solid cancers in childhood before 2000. Health behaviours were reported using a questionnaire sent by mail. Latent class analysis was used to identify health behaviour patterns using data regarding physical activity, smoking, cannabis use, and alcohol consumption. Multinomial logistic regression analysis was used to examine the associations between these latent health behavior patterns and demographic, social, health, and treatment-related risk factors.
RESULTS Three health behaviour patterns emerged: ‘Low-risk’ (n = 1099, 34.90%), included the participants who exhibited the lowest probabilities for all risk behaviours; ‘Insufficiently active’ (n = 1459, 46.33%), and ‘High-risk’ (n = 591, 18.77%) for survivors who exhibited the highest probabilities for smoking (≤10 cigarettes per day, 11 to 20 cigarettes per day, or ≥ 21 cigarettes per day), cannabis use, and alcohol consumption (≥ 3 drinks per week). The multinomial logistic regression analysis revealed that male survivors, with a higher education (beyond high school), who were ≥ 12 years at diagnosis, and treated by radiation therapy alone or no radiotherapy and nor chemotherapy were significantly more likely to be in the high-risk group than the low-risk group.
CONCLUSIONS As childhood cancer survivors remain a vulnerable population, to characterize survivor groups according to their health risk behaviours and to identify its potential predictors are important to design public health interventions. Ours findings are important for clinicians supervising this long-term follow-up care of CCS, in order to propose targeted health interventions.

OBJECTIVE Fever is one of the most common reasons for admission in paediatric oncology patients, yet its causes and optimal management are poorly established in low resource setttings where endemic infections are different. We aimed to evaluate the feasibility of developing a fever management algorithm (FMA) in a hospital in sub-Saharan Africa using an evidence-based approach that our group has previously used in Asia and Central America.
METHODS A four-part multidisciplinary approach was used to construct a locally adapted FMA at Parirenyatwa Hospital, Zimbabwe. First, we reviewed current antimicrobial and diagnostic study practices with the local oncology team. Next, we conducted a systematic review of existing literature and comparison of practices to published guidelines, while identifying discrepancies between recommended and current practice. Third, we gathered microbiology data through clinician interviews and audited culture results in the laboratory. Finally, we identified the information required to revise the FMA and designed interventions to prospectively obtain this data.
RESULTS By replicating a previously developed approach, we created a FMA for the initial seven days of fever. Due to costs and limited access to anti-pseudomonal monotherapy, imaging, and diagnostics, the unmodified use of published guidelines was not possible, necessitating local consensus on several trade-offs. The resultant algorithm stipulates mandatory and optional diagnostic studies, recommended treatment and duration of antimicrobial therapy. Management considerations include degree of neutropenia, presence of localizing signs/symptoms, persistence of fever, and development of vital sign instability. To support algorithm implementation and revision, process improvements such as blood culture collection retrainings and outcome monitoring tools were implemented.
CONCLUSIONS We demonstrated that our approach can generate an FMA tailored to institutional resources in a low-income country. Ongoing work includes improving the availability and quality of microbiology tests and standardizing data collection practices to inform further algorithm revisions.

BACKGROUND HIV-infected women are 8 times more likely to have invasive, rapidly progressing cervical cancer compared to HIV-uninfected. Early stage cervical cancer can be successfully treated by radical hysterectomy. There is a paucity of research on the complications of cervical cancer treatments in HIV-infected women.
OBJECTIVE To compare the outcomes of radical hysterectomy and pelvic lymphadenectomy among HIV infected and uninfected early operable cervical cancer.
METHODS The study included 53 women with operable early stage cervical cancer and who agreed to undergo radical hysterectomy and pelvic lymphadenectomy in Eldoret Kenya. Thirty-three (62%) were HIV-uninfected while 20 (38%) were HIV-infected.
RESULTS There was no statistically significant difference in age, education level, occupation or religion between the two groups. HIV-infected women were more likely to be widows compared to HIV-uninfected women (p=0.007). 55% had clinical stage 1B1/1B2,13% had stage 2A and 2% had stage 2B. Forty-seven (88%) had squamous cell carcinoma, adenocarcinoma 7.5% (n=4), adenosquamous 1.8% (n=1) and clear cell carcinoma 1.8% (n=1). There was no statistically significant difference in clinical variables (clinical stage, cervical length, cervical width, maximum tumour diameter, vaginal involvement, parametrial involvement, histology, and grade) between the HIV -infected and HIV-uninfected women. A majority of the women did not have any perioperative complications (n=47, 89%), had clear surgical margins (n=47, 89%) and were well healed (n=47, 89%) within 2 weeks. There was no statistical difference when complication type and rate were subdivided by HIV status.
CONCLUSION Radical Hysterectomy is well tolerated with no increase in complications in HIV-infected women. It is an appropriate treatment for early stage cervical cancer in HIV-infected women.

OBJECTIVE Endemic Burkitts Lymphoma (eBL) is an aggressive B-cell cancer that is only seen in children exposed to early Epstein-Barr virus infection and living in areas with stable and intense transmission of the malaria parasite Plasmodium falciparum. There, eBL can be the most common paediatric cancer. High frequencies (>5% of all circulating T cells) of Vδ1+ γδ T cells have been reported in various infectious and neoplastic diseases, but also among healthy individuals from areas with stable transmission of P. falciparum malaria. On the above basis, we set out to test the hypothesis that the Vδ1+ T-cell subset is expanded in patients with endemic Burkitts Lymphoma (eBL).
METHODS Cell samples were obtained from tumour fine-needle aspirates and peripheral blood of Ghanaian children with eBL, and from healthy age-matched control children (peripheral blood only). The phenotypes of tumour and peripheral blood cells were determined by multi-colour flow cytometry, using the following antibody markers: CD3, CD4, CD8, CD10, CD20, CD21, CD25, CD27, CD45RA, IgG, IgM, PD-1, TCR-γδ, and TCR-Vδ1. Surface marker expression pattern analysis included conventional hierarchical analysis of cell phenotypes, as well as t-distributed stochastic neighbour embedding (t-SNE) analysis.
RESULTS Our preliminary evidence documents high frequencies of Vδ1+ γδ T cells in both cell compartments (tumours and peripheral blood). We will present the complete results of our multi-parameter analysis of samples from all recruited participants, in the first detailed report of its kind in patients with this important tropical cancer.
CONCLUSIONS The function of the Vδ1+ T-cell subset is largely unknown, but it appears to be “adaptive-like” and quite distinct from that of the “innate-like” and largely complementary Vγ9Vδ2+ γδ T-cell subset. The data presented here support our hypothesis that the still quite enigmatic Vδ1+ T-cell subset serves an adaptive auto-regulatory function in conditions characterized by massive and/or chronic B-cell activation.

OBJECTIVE To ascertain the experiences of parents as their children go through cancer treatment and understand their challenges in order to devise effective ways of supporting them.
METHODS This qualitative study was conducted between June and November 2017. Data were gathered through semi-structured interviews held with 27 parents whose children were being treated for various cancers at the Paediatric Oncology Unit of the University of Port Harcourt Teaching Hospital, Nigeria.
RESULTS Respondents were 19 mothers, 2 fathers and 3 couples. Their children were aged 11months to 15years. Majority of respondent knew the diagnosis of their children while few could only name the site of the tumour. While undergoing chemotherapy, symptoms parents perceived as most distressing included vomiting, fever, pain, refusal to eat and falling of hairs. Financial constraint was the major challenge to treatment compliance. Parents perceived that getting more information on the child's illness, specifically concerning nutrition, and having more contact with doctors will help them cope better with their child's treatment.
CONCLUSION Parents of children with cancer experience various stressors and expressed the need for support and information, while improving communication between physician and parents will also contribute in aiding parents cope with cancer treatment.

OBJECTIVE To explore the lived experiences of women with advanced cervical cancer. Most of cervical cancer research has concentrated on screening and knowledge about the disease, with little being known about what it's really like for women living with advanced, incurable disease. This study presents this under-researched area with the intent to unearth and explore women's lived experiences of advanced cervical cancer.
METHODS The study design was qualitative and exploratory using a descriptive approach. The study was conducted at a hospice; Mobile Hospice Mbarara in South Western Uganda. The target population was all patients with a working diagnosis of advanced cervical cancer; stage 2B to 4B. Convenience purposive sampling was employed. Demographic data were collected prior to conducting semi-structured audio taped
interviews. Interviews were conducted in native local language and data saturation utilized. Interviews were transcribed verbatim in English, transcripts read and re-read, and emergent themes got from participants' significant statements. Thematic data analysis was used.
RESULTS 10 participants were interviewed, with the average age of 53.4 and age range 41-71. Six themes emerged from the data; demographic profiles, receiving news of diagnosis, living with disease, its symptoms and effects, health care system experience, needs of women, and support structures and coping strategies.
CONCLUSIONS Living with advanced incurable cervical cancer is a challenging and suffering experience for women, with substantial disruptions in all domains of quality of life. Statements like " I've lost weight and it's too much, I've prayed to God to take me away but He hasn't, I started feeling pain since then till now,, above all if I can cure..., You think and fail to sleep, .... I fail to get money to here for medications .... I get pain, they would tell me go there, here, so they delayed me..." all exemplify suffering. Living with symptoms of disease, challenges and delays in getting health care, poverty and disrupted social relationships were commonly mentioned. To improve quality of life of patients, these issues have to be identified and addressed.

OBJECTIVES Kenyatta National Hospital (KNH), the only public hospital delivering comprehensive cancer care in the country, launched a new patient navigation program in June 2017 with support from the American Cancer Society. This study aimed to determine the extent to which identified patient barriers to care are addressed and to assess patient satisfaction with care received after two years of implementation.
METHODS Cross-sectional surveys were administered at baseline in the Cancer Treatment Centre (CTC) (n=453), after one year of implementation in the CTC (n=392), and after two years in the CTC and outpatient clinics (n=344) using quantitative and qualitative methods. Inclusion/exclusion criteria were developed to recruit eligible participants using random sampling methods. A standardized questionnaire was used to collect patient socio-demographic information, clinical, psychosocial, and physical barriers, and satisfaction with care. Quantitative data were analysed using descriptive analysis and correlations tested using Chi-square tests and logistic regression. Qualitative data were analysed thematically.
RESULTS Over half of patients surveyed at baseline had not received directions to the CTC or education about their disease and/or treatment plan. After one year, a third more patients found the CTC within 30 minutes of arriving to KNH, 19.3% more received directions from staff, and 89% reported that finding the CTC was very easy compared to 76.2% at baseline. A third more patients received written materials about their diagnosis. Eighty-eight percent of patients who received directions, and 93% of material recipients were highly satisfied with support provided.
The year two follow-up survey will be fielded in May-June 2019 and data analysed by August 2019.
CONCLUSIONS After one year, patients are better informed about their diagnosis, more able to access the CTC and other service points within the hospital and highly satisfied with support received. After two years, the program hopes to demonstrate further gains in these areas as well as improved psychosocial support.

OBJECTIVE Palliative care growth in Africa is dynamically evolving but various factors militate against it. This was a preliminary study that aimed at comparing treatment outcomes (symptom reduction, loss to follow-up and satisfaction with care) among cancer patients utilizing telehealth applications, such as a web-based app.
METHODS Following ethical approval, adult cancer outpatients (n = 120) were randomized to one of three groups to receive palliative care over a 3-month period (A = daily mobile application use [EPAC© app] and monthly clinic visits; B = daily phone calls and monthly clinic visits; C = monthly clinic visits only). At each visit, symptom burden, satisfaction with care and caregiver burden were assessed. Time to loss to follow-up was analyzed using Kaplan-Maier survival analysis.
RESULTS Participants (65% females) were mostly middle aged (mean age 53.5±14.8 years), employed (78.3%), and cared for by a nuclear family member (90.8%). Attrition rate at month 3 for groups A, B, and C were 92.5%, 90.0% and 100%, respectively. Mean time to loss to follow-up for groups A, B, and C were 1.4 (95% C.I. = 1.2-1.6), 1.3 (95% C.I. = 1.1-1.6) and 1.0 (C.I. = 1.0-1.0), respectively with EPAC© app group having longest retention in follow-up (1.4-month). Group B participants were better satisfied with care received but it was not significant (p>0.05). There were no significant differences among the three study groups with regards to patients’ satisfaction with care, quality of life, symptoms report and caregiver burden (p>0.05).
CONCLUSION Use of mobile application did not seem to promote increased follow-up visits for this cohort of palliative care patients, possibly because of the high attrition rates. However, findings support earlier reports of positive influence of mobile device use in improving certain outcome parameters in cancer patients. This study also highlights some pertinent issues that may hamper use of mobile phone apps in similar environments as this research environment. Future RCTs with well-structured retention strategies and taking present study limitations into consideration are warranted to further assess the EPAC© app’s effectiveness.

INTRODUCTION Zambia, had an estimated 136.2 per 100,000 age-standardized incidence rate for all cancers, in both sexes and all ages. This is translated to about 12,052 new cases of cancer per year. Cervical cancer remains the most common cancer in Zambia with an estimated 3000 cases annually. Unfortunately, most of our patients present late, hence the need to improve and integrate cancer screening and palliative care (PC) services at all levels of health care delivery. Zambia has in recent years made significant strides in the integration of PC within the existing health system. She is committed to achieving universal health coverage across all spectra of health care.
AIM To create a policy environment that encourages the development of cancer and palliative care in Zambia.
METHODS The government through the MOH held a series of meetings with key stakeholders, including professionals, cancer & PC specialists that formed the technical working group.
RESULTS The Cancer Disease Hospital (CDH) was opened in 2007 and further expanded to 252 bed capacity in 2016. The first draft of the National Palliative Care Strategic Framework (NPCSF) was developed in 2012. Zambia developed the 2016-2021 National Cancer Control Strategic Plan prioritizing 4 cancers (cervical, prostate & breast cancers and retinoblastoma) and palliative care. On PC, the strategy aims to; develop an effective PC service at all levels of the health care system & complete and implement the NPCSF. Hospices were saved from closure as a result of inadequate funding from international donors, as the MOH provided direct funding to support hospices and placed medical personnel on the government payroll to provide care. Government with support from partners expanded the cervical cancer screening programme. The government continued to support the training of health care workers in radiation-oncology and palliative care. In 2015, Zambia hosted the Malawi-Zambia-Finland (MaZaFi) Nursing, Cancer and Palliative Care Conference. The First Lady of the Republic of Zambia was Guest of Honour. The Zambian government has continued to create funded PC specialist positions for medical doctors and nurses within its establishment. To improve health care financing, in an attempt to reach universal health coverage, Zambia signed into law the National Health Insurance Act in 2018
CONCLUSION It is possible to integrate cancer care and palliative care services within the health systems in a country like Zambia due to the strong government will and institutional frameworks and policies that support its integration.