A review of Kenya's cancer policies to improve access to cancer testing and treatment in the country

Background: Cancer is the third-leading cause of mortality in Kenya, resulting in unique challenges to the country’s health system. An increase in the number of cancer cases in Kenya over the past decade resulted in legislative actions and policies to guide delivery of cancer services. Kenya’s new national cancer control strategy and past policy efforts provide an opportunity to synergise information and enhance understanding to improve cancer diagnosis and treatment in the country. The objectives of this study are to (1) document policy-modifiable factors based on a review of policy documents and results of a key informant survey and (2) develop recommendations to improve policies affecting cancer testing and treatment services in Kenya. This study builds upon our previous study Improving Access to Cancer Testing and Treatment in Kenya (Makau Barasa et al. J Global Oncol 2(216), 2017). Methods: The study applied an in-depth systematic review of Kenya’s cancer policies and guidelines, a qualitative analysis of results from a section of a semi-structured key informant survey focused on the opinions of clinicians delivering cancer services as well as cancer support groups and advocacy leaders, and a stakeholder analysis identifying key policy-makers and implementers. Details of the complete key informant survey were published in our previous study. Results: Kenya’s cancer policies have guided progress made in providing the legal and implementation frameworks for the development and delivery of cancer services at the national and county levels. Some policy implementation gaps are noted. These include inadequate financing for cancer services, limited research and data to support policy formulation, and the concentration of cancer services in urban areas. The key informant survey identified policy-modifiable actions that can address some of the gaps and improve the delivery of and access to cancer testing and treatment services in the country. Some of these include addressing the financial barriers affecting cancer testing and treatment services; increasing stakeholder engagement in training health personnel to deliver cancer testing and treatment services; decentralising cancer services and improving cancer surveillance and research; and increasing education and awareness about cancer symptoms, screening procedures and treatment options. A set of priority policy actions were selected from the study findings and used to develop recommendations for Kenya’s policy-makers and stakeholders. Conclusions: Revisions to Kenya’s cancer policies are seeking to address gaps noted in past policies and to improve access to cancer testing and treatment in Kenya. However, based on study findings, additional actions can be taken to strengthen policy implementation. Considering the policy formulation and implementation process and costs, this study recommends focusing on three priority policy actions that can have significant impact on improving access to cancer testing and treatment services. These include addressing financing, insurance and human resources gaps; increasing stakeholder engagement; and decentralising health services for better surveillance and data to inform policies

Improving Access to Cancer Testing and Treatment in Kenya

Purpose: In response to the increasing cancer burden in Kenya, this study identified barriers to patients seeking access to cancer testing and treatment and to clinicians in delivering these services. Policy recommendations based on findings are presented. Methods: This qualitative study used semistructured key informant interviews. Purposive sampling was used to recruit 14 participants: seven oncology clinicians and seven support and advocacy leaders for patients with cancer. Qualitative analysis was used to identify themes. Results: Seven barriers to cancer testing and treatment were identified: high cost of testing and treatment, low level of knowledge about cancer among population and clinicians, poor health-seeking behaviors among population, long distances to access diagnostic and treatment services, lack of decentralized diagnostic and treatment facilities, poor communication, and lack of better cancer policy development and implementation. Conclusion: Kenyans seeking cancer services face significant barriers that result in late presentation, misdiagnosis, interrupted treatment, stigma, and fear. Four policy recommendations to improve access for patients with cancer are (1) improve health insurance for patients with cancer; (2) establish testing and treatment facilities in all counties; (3) acquire diagnosis and treatment equipment and train health personnel to screen, diagnose, and treat cancer; and (4) increase public health awareness and education about cancer to improve diagnoses and treatment. Effective cancer testing and treatment options can be developed to address cancer in a resource-constrained environment like Kenya. An in-depth look at effective interventions and policies being implemented in countries facing similar challenges would provide valuable lessons to Kenya’s health sector and policymakers

A non-experimental study of oral anticoagulation therapy initiation before and after national patient safety goals

ObjectivesThe Joint Commission revised its National Patient Safety Goals (NPSGs) to include oral anticoagulation therapy (OAT) in 2008. We sought to examine the effect of including OAT in The Joint Commission's NPSGs on historically low rates of OAT initiation for individuals with incident atrial fibrillation (AF).SettingSoutheastern state in the USA.ParticipantsNorth Carolina State Health Plan claims data from 944 500 individuals enrolled between 1 January 2006 and 31 December 2010, supplemented with data from the Area Resource File and Online Survey, Certification and Reporting data network. We evaluated OAT initiation before and after the 2008 NPSGs revisions in a retrospective cohort new user design with an AF intervention group and two control groups: a positive control—patients estimated to be at very high risk of thromboembolism (mechanical heart valve and pulmonary embolism); and a negative control—patients with very low perceived risk of thromboembolism (paroxysmal AF). We developed multivariable models using a difference-in-difference parameterisation. Effects were estimated with generalised estimating equations.Primary outcome measureOAT initiation, a binary outcome defined as having a prescription drug claim for warfarin within 30 days of the index claim.ResultsOAT initiation was low (26.8%) for eligible individuals with incident AF in 2006–2008 but increased after NPSGs implementation (31.7%, p=0.022). OAT initiation was high but decreased in the positive control group (67.5% vs 62.0%, p=0.003). Multivariate analysis resulted in a relative 11% (95% CI (4% to 18%), p<0.01) increase in OAT initiation for incident AF patients.ConclusionsWe document a substantial increase in guideline concordant OAT initiation in incident AF after the establishment of NPSGs, suggesting that regulatory healthcare agency initiatives can influence clinical practice

Research on HIV cure: Mapping the ethics landscape

According to current estimates, 36.7 million people are infected with HIV worldwide. Despite large-scale and growing programs to prevent and treat HIV infection, possible approaches to achieve a cure for HIV infection are of strong interest. In the development of candidate approaches to achieve an HIV cure, issues of future translation to human study participants, evidence-based practice, clinical care, diverse populations, and populations in low- and middle-income countries should all be considered. An HIV cure should be effective, safe, simple, affordable, and scalable. Acceptability research is a critical adjunct to ongoing biomedical HIV cure research efforts. Anticipating some of the ethical and implementation challenges related to HIV cure strategies is necessary before the availability of effective interventions. Ongoing engagement of stakeholders is needed to resolve ethical, logistical, social, cultural, policy, regulatory, and implementation challenges at all stages of the HIV cure research development process

'Well, It's the Risk of the Unknown… Right?': A Qualitative Study of Perceived Risks and Benefits of HIV Cure Research in the United States.

INTRODUCTION: Biomedical research towards an HIV cure is advancing in the United States and elsewhere, yet little is known about perceptions of risks and benefits among potential study participants and other stakeholders. We conducted a qualitative study to explore perceived risks and benefits of investigational HIV cure research among people living with HIV (PLWHIV), biomedical HIV cure researchers, policy-makers and bioethicists. METHODS: We conducted a qualitative research study using in-depth interviews with a purposive sample of PLWHIV, biomedical HIV cure researchers, policy-makers and bioethicists in 2015-2016. We analysed interview transcripts using thematic analysis anchored in grounded theory. RESULTS: We conducted and analyzed 36 key informant interviews. Qualitative analysis revealed four main findings. 1) Potential HIV cure study volunteers noted needing more information and education about the potential risks of HIV cure research. 2) Biomedical HIV cure researchers, policy-makers and bioethicists showed less awareness of social and financial risks of HIV cure research than PLWHIV. 3) Most respondents across the different categories of informants identified some risks that were too great to be acceptable in HIV cure research, although a subset of PLWHIV did not place an upper limit on acceptable risk. 4) PLWHIV showed a better awareness of potential psychological benefits of participating in HIV cure research than other groups of stakeholders. CONCLUSION: Our research suggests that PLWHIV have a variable understanding of the individual risks, sometimes substantial, associated with participating in biomedical HIV cure research studies. Community engagement and increased research literacy may help improve community understanding. Intensive informed consent procedures will be necessary for ethical study implementation. The current state of HIV cure research offers greater potential benefits to society than to participants. There is likely to be disagreement among regulators, researchers, clinicians, and potential participants about what constitutes acceptable risk for HIV cure studies

WOMEN’S INTENTIONS TO RECEIVE CERVICAL CANCER SCREENING WITH PRIMARY HUMAN PAPILLOMAVIRUS TESTING

We explored the potential impact of HPV testing on women’s intentions to be screened for cervical cancer in a cohort of Canadian women. Participants aged 25-65 from an ongoing trial were sent a questionnaire to assess women’s intentions to be screened for cervical cancer with HPV testing instead of Pap smears and to be screened every 4 years or after 25 years of age. We created scales for attitudes about HPV testing, perceived behavioural control and direct and indirect subjective norms. Demographic data and scales that were significantly different (p<0.1) between women who intended to be screened with HPV and those who did not intend were included in a stepwise logistic regression model. Of the 2016 invitations emailed, 1538 were received, and 981 completed surveys for a response rate of 63% (981/1538). Eighty-four percent of women (826/981) responded that they intended to attend for HPV-based cervical cancer screening, which decreased to 54.2% when the screening interval was extended, and decreased further to 51.4% when screening start was delayed to age 25. Predictors of intentions to undergo screening were attitudes (OR 1.22; 95%CI 1.15, 1.30), indirect subjective norms (OR 1.02; 95%CI 1.01, 1.03) and perceived behavioural control (OR 1.16; 95% CI 1.10; 1.22). Intentions to be screened for cervical cancer with HPV testing decreased substantially when the screening interval was extended and screening started at age 25. Use of primary HPV testing may optimize the screening paradigm, but programs should ensure robust planning and education to mitigate any negative impact on screening attendance rates

Exercise for health: a randomized, controlled trial evaluating the impact of a pragmatic, translational exercise intervention on the quality of life, function and treatment-related side effects following breast cancer

Exercise for Health was a randomized, controlled trial designed to evaluate two modes of delivering (face-to-face [FtF] and over-the-telephone [Tel]) an 8-month translational exercise intervention, commencing 6-weeks post-breast cancer surgery (PS). Outcomes included quality of life (QoL), function (fitness and upper body) and treatment-related side effects (fatigue, lymphoedema, body mass index, menopausal symptoms, anxiety, depression and pain). Generalised estimating equation modelling determined time (baseline [5 weeks PS], mid-intervention [6 months PS], post-intervention [12 months PS]), group (FtF, Tel, Usual Care [UC]) and time-by-group effects. 194 women representative of the breast cancer population were randomised to the FtF (n = 67), Tel (n = 67) and UC (n = 60) groups. There were significant (p < 0.05) interaction effects on QoL, fitness and fatigue with differences being observed between the treatment groups and the UC group. Trends observed for the treatment groups were similar. The treatment groups reported improved QoL, fitness and fatigue over time and changes observed between baseline and post-intervention were clinically relevant. In contrast, the UC group experienced no change, or worsening QoL, fitness and fatigue, mid-intervention. Although improvements in the UC group occurred by 12-months post-surgery, the change did not meet the clinically relevant threshold. There were no differences in other treatment-related side effects between groups. This translational intervention trial, delivered either FtF or Tel, supports exercise as a form of adjuvant breast cancer therapy that can prevent declines in fitness and function during treatment and optimise recovery post-treatment

Combined search for the quarks of a sequential fourth generation

Results are presented from a search for a fourth generation of quarks produced singly or in pairs in a data set corresponding to an integrated luminosity of 5 inverse femtobarns recorded by the CMS experiment at the LHC in 2011. A novel strategy has been developed for a combined search for quarks of the up and down type in decay channels with at least one isolated muon or electron. Limits on the mass of the fourth-generation quarks and the relevant Cabibbo-Kobayashi-Maskawa matrix elements are derived in the context of a simple extension of the standard model with a sequential fourth generation of fermions. The existence of mass-degenerate fourth-generation quarks with masses below 685 GeV is excluded at 95% confidence level for minimal off-diagonal mixing between the third- and the fourth-generation quarks. With a mass difference of 25 GeV between the quark masses, the obtained limit on the masses of the fourth-generation quarks shifts by about +/- 20 GeV. These results significantly reduce the allowed parameter space for a fourth generation of fermions.Comment: Replaced with published version. Added journal reference and DO

Constraints on the χ_(c1) versus χ_(c2) polarizations in proton-proton collisions at √s = 8 TeV

The polarizations of promptly produced χ_(c1) and χ_(c2) mesons are studied using data collected by the CMS experiment at the LHC, in proton-proton collisions at √s=8  TeV. The χ_c states are reconstructed via their radiative decays χ_c → J/ψγ, with the photons being measured through conversions to e⁺e⁻, which allows the two states to be well resolved. The polarizations are measured in the helicity frame, through the analysis of the χ_(c2) to χ_(c1) yield ratio as a function of the polar or azimuthal angle of the positive muon emitted in the J/ψ → μ⁺μ⁻ decay, in three bins of J/ψ transverse momentum. While no differences are seen between the two states in terms of azimuthal decay angle distributions, they are observed to have significantly different polar anisotropies. The measurement favors a scenario where at least one of the two states is strongly polarized along the helicity quantization axis, in agreement with nonrelativistic quantum chromodynamics predictions. This is the first measurement of significantly polarized quarkonia produced at high transverse momentum