An evaluation of Population Services Zimbabwe’s mobile outreach model

This report documents a service evaluation of Population Services Zimbabwe’s (PSZ) mobile outreach program in four provinces of Zimbabwe. The evaluation was conducted by the Population Council between September and October 2013. It provides key findings on the quality of the PSZ outreach program in expanding choice and access to long-acting reversible contraceptives (LARCs) and permanent methods (PMs) of contraception, as well as recommendations for PSZ and other family planning programs to consider in scaling up and strengthening mobile outreach services. The evaluation, conducted by the Population Council, was designed to focus on various components of quality including adequate information and counseling on methods and services, good clinical procedure with minimal occurrence of adverse events, and client health-seeking behavior and client satisfaction. The level of integration of HIV and other SRH-related services into the family planning program was also evaluated

Profile and management of AIDS related lymphoma.

Doctoral Degree. University of KwaZulu-Natal, Durban.Worldwide, HIV-associated lymphoma (HAL) is a common HIV-related malignancy. Most are aggressive, high-grade B cell malignancies and are classified as AIDS Related Lymphomas (ARL). ARL include Diffuse large B cell lymphoma (DLBCL), Burkitt lymphoma (BL), and less commonly, plasmablastic lymphoma (PBL), primary effusion lymphomas (PEL) and primary central nervous system lymphoma (PCNSL). Prior to antiretroviral therapy (ART), the incidence of lymphoma was 60-200 fold higher than that seen in HIV-negative subjects, but this has decreased to 11-25 fold with the widespread use of ART. The prevalence of HIV in South Africa (SA) is estimated at 13.5% (8 million people), with the province of KwaZulu-Natal (KZN) leading other provinces at a seroprevalence rate of 18%. Most patients in SA access medical care through government health facilities. King Edward Vlll Hospital (KEH) is a government-funded, tertiary health care centre affiliated with the academic hospital of the Nelson R. Mandela School of Medicine of the University of KwaZulu located in Durban, KZN. Most ARL in the indigent population, other than BL, are treated at KEH. The aim of this original research was to describe the profile, outcome and prognostic variables of ARL treated in a government hospital at the epicentre of the HIV/AIDS pandemic in KZN, and compare this to data described elsewhere in South Africa and internationally. There is limited data from South Africa on ARL, and no data from KZN. Globally, conventional chemotherapy for ARL has been supplemented by rituximab, which is a monoclonal antibody targeting CD20. A shift in treatment midway through this study period, to include the use of rituximab locally for CD20-positive ARL, provided an opportunity to compare outcomes with and without rituximab. Plasmablastic lymphoma is a challenging ARL, in terms of diagnosis and management. As this is an unusual lymphoma, with a prevalence of 0.004% of all lymphomas, there viii are no large, prospective trials. We describe our experience with the profile and outcome of this cohort of ARL patients, treated with combination chemotherapy. Outcome in lymphoma is guided by prognostic scoring systems, the international prognostic index (IPI) or the age-adjusted IPI (aaIPI). As these prognostic scoring systems have not been validated in the local population in KZN, the utility of these scoring systems was assessed in this research

Asbestos and cancer: An overview of current trends in Europe.

This review assesses the contribution of occupational asbestos exposure to the occurrence of mesothelioma and lung cancer in Europe. Available information on national asbestos consumption, proportions of the population exposed, and exposure levels is summarized. Population-based studies from various European regions on occupational asbestos exposure, mesothelioma, and lung cancer are reviewed. Asbestos consumption in 1994 ranged, per capita, between 0. 004 kg in northern Europe and 2.4 kg in the former Soviet Union. Population surveys from northern Europe indicate that 15 to 30% of the male (and a few percent of the female) population has ever had occupational exposure to asbestos, mainly in construction (75% in Finland) or in shipyards. Studies on mesothelioma combining occupational history with biologic exposure indices indicate occupational asbestos exposure in 62 to 85% of the cases. Population attributable risks for lung cancer among males range between 2 and 50% for definite asbestos exposure. After exclusion of the most extreme values because of methodologic aspects, most of the remaining estimates are within the range of 10 to 20%. Estimates of women are lower. Extrapolation of the results to national figures would decrease the estimates. Norwegian estimates indicate that one-third of expected asbestos-related lung cancers might be avoided if former asbestos workers quit smoking. The combination of a current high asbestos consumption per capita, high exposure levels, and high underlying lung cancer rates in Central Europe and the former Soviet Union suggests that the lung cancers will arise from the smoking-asbestos interaction should be a major concern

Predicting the burden of cancer in Switzerland up to 2025

Predicting the short-term evolution of the number of cancers is essential for planning investments and allocating health resources. The objective of this study was to predict the numbers of cancer cases and of the 12 most frequent cancer sites, and their age-standardized incidence rates, for the years 2019–2025 in Switzerland. Projections of the number of malignant cancer cases were obtained by combining data from two sources: forecasts of national age-standardized cancer incidence rates and population projections from the Swiss Federal Statistical Office. Age-standardized cancer incidence rates, approximating the individual cancer risk, were predicted by a low-order Autoregressive Integrated Moving Average (ARIMA) model. The contributions of changes in cancer risk (epidemiological component) and population aging and growth (demographic components) to the projected number of new cancer cases were each quantified. Between 2018 and 2025, age-standardized cancer incidence rates are predicted to stabilize for men and women at around 426 and 328/100,000, respectively (<1% change). These projected trends are expected for most cancer sites. The annual number of cancers is expected to increase from 45,676 to 52,552 (+15%), more so for men (+18%) than for women (+11%). These increases are almost entirely due to projected changes in population age structure (+12% for men and +6% for women) and population growth (+6% for both sexes). The rise in numbers of expected cancers for each site is forecast to range from 4.15% (thyroid in men) to 26% (bladder in men). While ranking of the three most frequent cancers will remain unchanged for men (1st prostate, 2nd lung, 3rd colon-rectum), colorectal cancer will overtake by 2025 lung cancer as the second most common female cancer in Switzerland, behind breast cancer. Effective and sustained prevention measures, as well as infrastructural interventions, are required to counter the increase in cancer cases and prevent any potential shortage of professionals in cancer care delivery

Survival after bilateral breast cancer: results from a population-based study

Background: Controversy exists on the impact of bilaterality of breast cancer on survival. We used population-based data to compare survival of women with unilateral versus bilateral breast cancer. Patients and methods: At the Geneva cancer registry, we identified all 7,912 women diagnosed with invasive breast cancer between 1970 and 2002. Breast cancers were categorized as unilateral, synchronous bilateral (contralateral tumour diagnosed within six months after the first tumour) and metachronous bilateral (contralateral tumour diagnosed over six months after the first tumour). With multivariate modelling we compared characteristics and survival between women with unilateral and bilateral disease. Results: Patients with synchronous bilateral tumours (n=155, 2.0%) had more often lobular histology and less frequently stage I disease than women with unilateral disease. Women with metachronous breast cancer (n=219, 2.8%) received less often chemotherapy or hormone therapy for their first tumours. Ten-year disease-specific survival was similar (66%) after unilateral and metachronous bilateral breast cancer, but worse after synchronous bilateral cancer (51%). After adjustment, breast cancer mortality risks were not significantly increased for women with either synchronous or metachronous bilateral disease (Hazard ratios 1.1 (0.8-1.5) and 0.8 (0.5-1.4), respectively). Conclusion: This large population-based study indicates that bilaterality of breast cancer is not associated with impaired surviva

Patients' views about causes and preferences for the management of cancer-related fatigue—a case for non-congruence with the physicians?

Purpose: Cancer-related fatigue (CRF) is frequently overlooked. Adherence to treatment guidelines may be related to the patient's views about illness. This study aimed at exploring patients' views about CRF and determining whether they are congruent with best practice treatments. Methods: Data were collected in 160 consecutive patients hospitalized in a supportive care setting. Biological, clinical, and psychological variables were assessed using validated questionnaires. Patients were also asked to complete the Brief Fatigue Inventory (BFI) and a questionnaire investigating their main symptoms and views about CRF and its management. Results: Patients were mainly men (60%); median age was 66years. Various cancer diagnoses were represented; 17.5% had primary local diseases, 40% local recurrences, and 42.5% metastatic diseases. The majority of the patients experienced moderate or severe CRF (76.3%) on the BFI. Fatigue was the most frequently reported symptom (87.5%). Only anxiety, depression, and dimensions of quality of life were significantly related with CRF. Two thirds of the patients associated CRF with cancer-related morbidities. As for the best treatments, patients first stressed control of adverse effects. Over half of the patients were reluctant to report fatigue, mainly because they considered fatigue as an unavoidable side effect, but also because they feared a change towards less active/aggressive treatments. Conclusion: Patients mostly consider that CRF must be tolerated. Guidelines emphasize activity enhancement strategies as beneficial. The patients' preferences for rest rather than activity may be related to their high level of fatigue, which leads them to disregard activity as a possible treatmen

Characteristics and outcome of prostate cancer with PSA <4 ng/ml at diagnosis: a population-based study

Introduction: This population-based study aims to assess prognosis of prostate cancer diagnosed with prostate-specific antigen (PSA) levels <4 ng/ml in routine care. Materials and methods: We compared prostate cancer patients with low PSA values (n=59) with other prostate cancer patients (n=1330) by logistic regression and the Cox model using data from the Geneva Cancer Registry. Results: Patients with low PSA values more frequently had early-stage and well differentiated tumours. Nevertheless, 35% presented with aggressive tumour characteristics or metastases. After adjustment for other prognostic factors, prostate cancer-specific mortality was similar for both groups (hazard ratio: 1.1; 95%CI: 0.6-2.2). Conclusion: We conclude that cancer with low PSA values at diagnosis is not indolen

Breast cancer management and outcome according to surgeon's affiliation: a population-based comparison adjusted for patient's selection bias

Background Studies have reported that breast cancer (BC) units could increase the quality of care but none has evaluated the efficacy of alternative options such as private BC networks, which is our study objective. Patients and methods We included all 1404 BC patients operated in the public unit or the private network and recorded at the Geneva Cancer Registry between 2000 and 2005. We compared quality indicators of care between the public BC unit and the private BC network by logistic regression and evaluated the effect of surgeon's affiliation on BC-specific mortality by the Cox model adjusting for the propensity score. Results Both the groups had high care quality scores. For invasive cancer, histological assessment before surgery and axillary lymph node dissection when indicated were less frequent in the public sector (adjusted odds ratio (OR): 0.4, 95% confidence interval (CI) 0.3-0.7, and OR: 0.4, 95% CI 0.2-0.8, respectively), while radiation therapy after breast-conserving surgery was more frequent (OR: 2.5, 95% CI 1.4-4.8). Surgeon affiliation had no substantial effect on BC-specific mortality (adjusted hazard ratio (HR): 0.8, 95% CI 0.5-1.4). Conclusions This study suggests that private BC networks could be an alternative to public BC units with both structures presenting high quality indicators of BC care and similar BC-specific mortalit

Tumor Location of the Lower-Inner Quadrant Is Associated with an Impaired Survival for Women With Early-Stage Breast Cancer

Background: There is growing evidence that tumors of the inner quadrants (especially the lower-inner quadrant) metastasize more often to the internal mammary chain (IMC). As these metastases are not investigated, patients with lower-inner quadrant tumors have an increased risk of being under-staged and under-treated and may therefore have a higher risk of death from breast cancer. Methods: We identified all 1522 women operated for stage I breast cancer between 1984 and 2002 recorded at the population-based Geneva Cancer Registry. We compared breast cancer mortality risk by tumor location with multivariate Cox regression analysis that accounted for all factors linked to tumor location and survival. Results: Ten-year disease-specific survival was 93% (95%CI: 91-94%). Patients with breast cancer of the lower-inner quadrant (n=118; 7.8%) had an importantly increased risk of dying of breast cancer compared to women with breast cancer of the upper-outer quadrant (multiadjusted Hazard Ratio: 2.3, 95%CI: 1.1-4.5, P=0.0206). The over-mortality associated with this quadrant was particularly evident for tumors >10 mm (multiadjusted HR: 3.6, 95%CI: 1.6-7.9, P=0.0016). There was no increased breast cancer mortality risk for tumors located in other quadrants. Conclusions: Tumor location in the lower-inner quadrant is an independent and important prognostic factor of stage I breast cancer. Further research is needed to evaluate if the over-mortality of patients with stage I cancer of the lower-inner quadrant is indeed a result of under-treatment due to undetected IMC metastases. If so, patients with stage I breast cancer of the lower-inner quadrant are good candidates for systematic IMC investigatio