Cancer Prevention in Low- and middle-income Countries

Transcript

00:00 --> 00:03Funding for Yale Cancer Answers is
00:03 --> 00:06provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers
00:08 --> 00:10with Doctor Anees Chagpar.
00:10 --> 00:12Yale Cancer Answers features the
00:12 --> 00:13latest information on cancer care
00:14 --> 00:15by welcoming oncologists and
00:15 --> 00:17specialists who are on the forefront
00:17 --> 00:19of the battle to fight cancer.
00:19 --> 00:21This week it's a conversation
00:21 --> 00:23about cancer prevention in low
00:23 --> 00:25to middle income countries with
00:25 --> 00:27Doctor Raul Hernandez Ramirez. Dr.
00:27 --> 00:29Hernandez Ramirez is a research
00:29 --> 00:30scientist in Biostatistics at
00:30 --> 00:33the Yale School of Public Health.
00:33 --> 00:34Doctor Chagpar is a professor of
00:34 --> 00:36surgical oncology at Yale
00:36 --> 00:37School of Medicine.
00:38 --> 00:40Maybe we can start off
00:40 --> 00:42by you telling us a little bit more
00:42 --> 00:44about yourself and what it is you do.
00:44 --> 00:47Sure, I'm a research scientist,
00:47 --> 00:51I'm a chronic disease epidemiologist with training in
00:51 --> 00:53implementation science and
00:53 --> 00:54multi level interventions.
00:54 --> 00:57I have previous experience
00:57 --> 00:59working in Mexico before coming
00:59 --> 01:01to Yale to do my PhD and then
01:01 --> 01:05become a research faculty, I spent
01:05 --> 01:08several years working there in Mexico
01:08 --> 01:10at the Nationalist public health.
01:10 --> 01:13And regarding the focus of my research,
01:13 --> 01:16two of my main areas are cancer
01:16 --> 01:17and implementation science.
01:18 --> 01:21So talk a little bit more about your
01:21 --> 01:24research in terms of cancer prevention,
01:24 --> 01:27the intersection of that with
01:27 --> 01:31HIV and the work that you do in
01:31 --> 01:33low to middle income countries.
01:34 --> 01:38A large part of my work
01:38 --> 01:43on Cancer Research has been focused on
01:43 --> 01:46cancer risk in people living with
01:46 --> 01:49HIV in North America. And also on
01:49 --> 01:53breast and risk factors for breast and
01:53 --> 01:56cervical cancer and now implementation
01:56 --> 02:00science in Mexican women
02:00 --> 02:02and implementation sciences,
02:02 --> 02:05the study of methods to promote
02:05 --> 02:06the adoption of
02:06 --> 02:10an integration of evidence based practices,
02:10 --> 02:12interventions and policies into
02:12 --> 02:14routine health care and public health
02:14 --> 02:16settings to improve population health.
02:16 --> 02:18So it is used to improve the adoption,
02:18 --> 02:20appropriate adoption, adaptation,
02:20 --> 02:24delivery, and sustainment of effective
02:24 --> 02:26interventions by providing clinics,
02:26 --> 02:27organizations,
02:27 --> 02:29communities and the systems of care.
02:29 --> 02:31Regarding the field of
02:31 --> 02:33implementation science and cancer,
02:33 --> 02:35I'm interested in adopting,
02:35 --> 02:38developing, and applying interventions
02:38 --> 02:41to increase the uptake of
02:41 --> 02:42interventions and practices
02:42 --> 02:44for cancer prevention and care,
02:44 --> 02:47including prevention strategies to
02:47 --> 02:50enable the delivery of those
02:50 --> 02:52interventions and their sustainment.
02:55 --> 02:56That's pretty broad strokes.
02:56 --> 02:58I mean, one would think that
02:58 --> 03:01if we kind of break it down
03:01 --> 03:03and think about breast cancer,
03:03 --> 03:05so we know that breast
03:05 --> 03:07cancer is the leading cause
03:07 --> 03:11of cancer in women worldwide and one
03:11 --> 03:14of the leading cancer causes of cancer
03:14 --> 03:17related death in women worldwide,
03:17 --> 03:20often tying or competing for
03:20 --> 03:23first place with cervical cancer.
03:23 --> 03:25But the management of breast cancer
03:25 --> 03:28is very different and the screening
03:28 --> 03:30availability is very different and
03:30 --> 03:33the stage at which breast cancer is
03:33 --> 03:36picked up is very different in the US
03:36 --> 03:38as is in many low to middle income
03:38 --> 03:41countries where the ubiquity
03:41 --> 03:44of mammography is not the same as
03:44 --> 03:48it is in the US and it may not be
03:48 --> 03:49that mammography is necessarily
03:49 --> 03:53the be all and end all in low
03:53 --> 03:54to middle income countries.
03:54 --> 03:56Can you talk a little bit more
03:56 --> 03:58about kind of how you've analyzed
03:58 --> 04:00the problem of breast cancer in
04:00 --> 04:03low to middle income countries,
04:03 --> 04:05versus how it is in the United States
04:05 --> 04:08and what you think the key issues
04:08 --> 04:10are and perhaps some of the
04:10 --> 04:12strategies that you've used to address it.
04:13 --> 04:17Yeah, so most of my
04:19 --> 04:23research in middle income and lower
04:23 --> 04:26middle income countries in Mexico
04:26 --> 04:29in the terms of breast cancer
04:29 --> 04:31was focused on finding risk
04:31 --> 04:33factors for breast cancer,
04:33 --> 04:38but I would like to talk more given
04:38 --> 04:40the different points that you
04:40 --> 04:42mentioned in your question about
04:42 --> 04:44my work on cervical cancer.
04:45 --> 04:47In cervical cancer
04:47 --> 04:49like in other cancers as you
04:49 --> 04:51were mentioning there is
04:51 --> 04:52large variability.
04:53 --> 04:54Across the globe,
04:54 --> 04:56there is significant variability
04:56 --> 04:59in terms of implementing
04:59 --> 05:01cancer control programs.
05:03 --> 05:06In low and middle income countries
05:06 --> 05:08cancer is frequently
05:08 --> 05:10diagnosed at advanced stages and
05:10 --> 05:12that could be for breast cancer,
05:12 --> 05:15as well as for cervical cancer.
05:15 --> 05:20And the case of low income countries
05:22 --> 05:24there are common barriers
05:24 --> 05:26that are barriers that
05:26 --> 05:27are not necessarily generalizable
05:27 --> 05:30but they are kind of common that
05:30 --> 05:32they will be happening and depending
05:32 --> 05:33irregardless of whether it's breast cancer or cervical cancer.
05:37 --> 05:39And these include the lack of awareness
05:39 --> 05:42of the general populations and providers,
05:42 --> 05:44lack of access to diagnostic facilities,
05:44 --> 05:46long distance travel,
05:46 --> 05:50time to locations with cancer services.
05:50 --> 05:52And difficulties to implement conventional
05:52 --> 05:55screening and other cancer prevention
05:55 --> 05:57control methods due to the lack of
05:57 --> 05:58financial resources and expertise,
05:58 --> 06:01and there are also sociocultural factors
06:01 --> 06:04and stigma in the case of cervical cancer.
06:04 --> 06:06Despite being nearly fully preventable,
06:06 --> 06:08large disparities in incidence and
06:08 --> 06:11mortality exist globally and domestically.
06:11 --> 06:14It is the fourth most common cancer
06:16 --> 06:19and most common cause of
06:19 --> 06:22cancer death in the world.
06:22 --> 06:24But 85% of those deaths occur
06:24 --> 06:28in low and middle income countries.
06:28 --> 06:31Then regarding screening also,
06:31 --> 06:32they desire large variability,
06:32 --> 06:36with about 3 out of five women having
06:36 --> 06:38cervical cancer screening ever in
06:38 --> 06:41their lives in high income countries,
06:41 --> 06:43while it's only about 2 or less out of
06:43 --> 06:46five women that have ever been screened
06:46 --> 06:48in low and middle income countries,
06:48 --> 06:51with some countries like subsaharan
06:51 --> 06:53Africa presenting the lowest
06:53 --> 06:56coverage with a prevalence very low.
06:56 --> 07:00At a medium prevalence of 17%
07:00 --> 07:01coverage of screening.
07:07 --> 07:09Women in Mexico are three times
07:09 --> 07:12more likely to die from cervical cancer
07:12 --> 07:15than in the US but even within the US,
07:15 --> 07:17US Hispanic women are more
07:17 --> 07:19likely to be diagnosed with
07:19 --> 07:22and die from cervical cancer
07:22 --> 07:25than US non Hispanic white women.
07:25 --> 07:28In fact, in Mexico cervical cancer is the
07:28 --> 07:31second most common cause of cancer mortality
07:31 --> 07:33among women, while in contrast,
07:33 --> 07:38is the 12th most common cause of cancer
07:38 --> 07:41mortality among women in the US.
07:41 --> 07:43And screening for cervical
07:43 --> 07:44cancer is effective.
07:44 --> 07:48The Pap smear and HPV are evidence
07:48 --> 07:51based HPV testing are evidence
07:51 --> 07:54based preventive interventions.
07:54 --> 07:56However, in the case of Pap smear,
07:56 --> 07:59unlike in high income countries
07:59 --> 08:01where cervical cancer screening
08:01 --> 08:03programs have resulted
08:03 --> 08:05in a dramatic decrease in incidence
08:05 --> 08:07of mortality in Mexico and other
08:07 --> 08:08low and middle income countries,
08:08 --> 08:10the impact of these programs
08:10 --> 08:12has thus far been limited.
08:14 --> 08:19Colposcopy as well
08:22 --> 08:24for cervical cancer screening
08:24 --> 08:27as I say is a pap smear and also
08:27 --> 08:29the HPV test.
08:30 --> 08:32And in other places in the
08:32 --> 08:35world there is also the visual
08:35 --> 08:36inspection with acetic acid.
08:36 --> 08:39So let me pause here for a moment
08:39 --> 08:41and just ask a question, which is,
08:41 --> 08:44you know, before we get into screening,
08:44 --> 08:45you had mentioned,
08:45 --> 08:47I mean certainly as an epidemiologist
08:47 --> 08:49you're interested in risk factors.
08:49 --> 08:51One of the interesting points that
08:51 --> 08:53you just raised is not only is
08:53 --> 08:55mortality of cervical cancer higher
08:55 --> 08:57in Mexico than it is in the US,
08:57 --> 08:58three times higher,
08:58 --> 09:00but Hispanic women in the US
09:00 --> 09:03also have a higher rate of
09:03 --> 09:05mortality from cervical cancer than
09:05 --> 09:08the rest of the American population.
09:08 --> 09:11So that raises the issue of
09:11 --> 09:14is there a genetic component
09:14 --> 09:18here in terms of race, slash,
09:18 --> 09:19ethnicity,
09:19 --> 09:24or is this really more grounded in
09:24 --> 09:28sociocultural and socioeconomic factors?
09:29 --> 09:32Yeah, I believe it will be more
09:32 --> 09:34grounded in those socio economical
09:34 --> 09:36and cultural factors as well,
09:36 --> 09:39and also related to cancer
09:39 --> 09:42disparities that exist and stigma.
09:42 --> 09:45From the perspective of these patients,
09:45 --> 09:47but also the services that are being
09:47 --> 09:50provided that may not reach the
09:50 --> 09:52populations that need those services
09:52 --> 09:55and in the case of risk factors,
09:55 --> 09:57for cervical cancer
09:59 --> 10:01one of the preventive interventions
10:01 --> 10:05is the vaccination with HPV, but
10:05 --> 10:07since that occurs at early ages,
10:07 --> 10:10you have older populations of
10:10 --> 10:13women that were not
10:13 --> 10:16vaccinated when they were younger
10:16 --> 10:20and that they still need to have
10:20 --> 10:23the basic prevention screening with
10:23 --> 10:27this cytology and follow-up care with
10:27 --> 10:31colposcopy to diagnose and treat.
10:33 --> 10:37And those are some of those services
10:37 --> 10:39we in the US and also when
10:39 --> 10:40comparing the US with Mexico,
10:40 --> 10:45the rates of those services are lower.
10:45 --> 10:48Which leads to a delay in
10:48 --> 10:52diagnosis and detecting cancers and
10:52 --> 10:55therefore detecting cancers at higher stages,
10:55 --> 10:56late stages,
10:56 --> 10:59in which they are more difficult to treat.
11:00 --> 11:03You know, one of the interesting things,
11:03 --> 11:06one of the really wonderful things
11:06 --> 11:09that was reported by the American
11:09 --> 11:12Cancer Society just recently was a
11:12 --> 11:14dramatic fall in the mortality from
11:14 --> 11:17cervical cancer in this country,
11:17 --> 11:19which they felt was in large
11:19 --> 11:22part due to the vaccine.
11:22 --> 11:25One of the things that you mentioned was,
11:25 --> 11:27you know, financial considerations,
11:27 --> 11:28access considerations.
11:28 --> 11:31Certainly the health care
11:31 --> 11:34workforce in low to middle
11:34 --> 11:36income countries is substantially
11:36 --> 11:39reduced when compared to the US.
11:39 --> 11:42It may be more difficult
11:42 --> 11:45for people to access care.
11:45 --> 11:49But in the US, the vaccine is available.
11:49 --> 11:52In the US, Pap smears are available.
11:52 --> 11:56So why do you think it is that
11:56 --> 12:00Hispanic women in the US
12:00 --> 12:02still have higher rates?
12:02 --> 12:06Talk more about the
12:06 --> 12:07sociocultural factors that
12:07 --> 12:11you think may play in or do you
12:11 --> 12:13think that this is predicated also
12:13 --> 12:15on the fact that Hispanic women
12:15 --> 12:18there may be confounding by the
12:18 --> 12:21fact that they tend to be of lower
12:21 --> 12:22socioeconomic status and
12:22 --> 12:25may still even though there are
12:25 --> 12:28such services here in the US,
12:28 --> 12:30that they access them at a lower rate.
12:30 --> 12:33And perhaps you can talk a little bit
12:33 --> 12:35about the comparison between Hispanic
12:35 --> 12:39women in the US versus in Mexico.
12:40 --> 12:45I think that part of reduced access is
12:50 --> 12:53socioeconomical aspects as well as
12:53 --> 12:56other things related to
12:56 --> 12:58knowledge of cervical cancer
12:58 --> 13:01and this screening test and the
13:01 --> 13:03benefit of getting them performed
13:03 --> 13:05for preventing cervical cancer
13:05 --> 13:07and the fear of the test as well.
13:07 --> 13:10So those kinds of things may be
13:10 --> 13:12interrelated in some way with a
13:12 --> 13:14low literacy and in some cases
13:14 --> 13:16in women and Hispanic women in
13:16 --> 13:18the US and loss of economical
13:18 --> 13:24status and also others related to that.
13:24 --> 13:28Also it has been reported barriers such as
13:30 --> 13:33in low and middle income countries,
13:33 --> 13:37it happens too that barriers relate to the
13:37 --> 13:39distance or the travel time to get into
13:39 --> 13:42the colposcopy because of having to lose
13:42 --> 13:45time that women can be working or
13:45 --> 13:48taking care of children
13:48 --> 13:50if they support the family.
13:50 --> 13:53Which brings us to the really good point,
13:53 --> 13:55which we're going to pick up right after
13:55 --> 13:58the break on the implementation science.
13:58 --> 14:00We have a general idea of
14:00 --> 14:03some of the factors that might be at play,
14:03 --> 14:05but what can we really do about it?
14:05 --> 14:07Funding for Yale Cancer Answers
14:07 --> 14:09comes from Smilow Cancer Hospital,
14:09 --> 14:11where their Center for
14:11 --> 14:12Gastrointestinal Cancers provides
14:12 --> 14:14patients with a comprehensive,
14:14 --> 14:16multidisciplinary approach to
14:16 --> 14:18the treatment of GI cancers.
14:18 --> 14:22Learn more at smilowcancerhospital.org.
14:22 --> 14:24Breast cancer is one of the
14:24 --> 14:25most common cancers in women.
14:25 --> 14:27In Connecticut alone,
14:27 --> 14:29approximately 3500 women will be
14:29 --> 14:31diagnosed with breast cancer this year,
14:31 --> 14:33but there is hope thanks
14:33 --> 14:34to earlier detection,
14:34 --> 14:35non invasive treatments,
14:35 --> 14:37and the development of novel
14:37 --> 14:39therapies to fight breast cancer,
14:39 --> 14:41women should schedule a baseline
14:41 --> 14:43mammogram beginning at age 40 or
14:43 --> 14:45earlier if they have risk factors
14:45 --> 14:46associated with the disease.
14:46 --> 14:48With screening, early detection,
14:48 --> 14:50and a healthy lifestyle,
14:50 --> 14:52breast cancer can be defeated.
14:52 --> 14:54Clinical trials are currently
14:54 --> 14:56underway at federally designated
14:56 --> 14:58Comprehensive cancer centers such
14:58 --> 15:00as Yale Cancer Center and Smilow
15:00 --> 15:02Cancer Hospital to make innovative
15:02 --> 15:04new treatments available to patients.
15:04 --> 15:06Digital breast tomosynthesis,
15:06 --> 15:07or 3D mammography,
15:07 --> 15:10is also transforming breast
15:10 --> 15:12cancer screening by significantly
15:12 --> 15:13reducing unnecessary procedures
15:13 --> 15:16while picking up more cancers.
15:16 --> 15:18More information is available
15:18 --> 15:19at yalecancercenter.org.
15:19 --> 15:22You're listening to Connecticut public radio.
15:22 --> 15:24Welcome back to Yale Cancer Answers.
15:24 --> 15:26This is doctor Anees Chagpar
15:26 --> 15:28and I'm joined tonight by my
15:28 --> 15:30guest doctor Hernandez Ramirez.
15:30 --> 15:32We're talking about cancer prevention
15:32 --> 15:34in low to middle income countries
15:34 --> 15:37and right before the break Raul was
15:37 --> 15:39telling us more about cervical cancer
15:39 --> 15:42which is a leading cause of cancer
15:42 --> 15:45related mortality around the world.
15:45 --> 15:48Interestingly, the rate of mortality
15:48 --> 15:51has dropped here in the US.
15:51 --> 15:54But one of the startling statistics
15:54 --> 15:57that he raised is that not only is
15:57 --> 16:00the mortality higher in Mexico
16:00 --> 16:03amongst women with cervical cancer,
16:03 --> 16:06but also among Hispanic women
16:06 --> 16:08right here in the US.
16:08 --> 16:10And there are a number of factors
16:10 --> 16:13that go into that whether it's a
16:13 --> 16:15distance to a treatment facility,
16:15 --> 16:18whether it's the availability of PAP smears,
16:18 --> 16:21whether it is low social
16:21 --> 16:22Health literacy,
16:22 --> 16:25whether it's low socioeconomic
16:25 --> 16:28status or whether it's cultural
16:28 --> 16:32factors that may impact the stigma
16:32 --> 16:35associated with cervical cancer,
16:35 --> 16:37whether it's lack of vaccines, many,
16:37 --> 16:39many factors could go into this.
16:39 --> 16:40So, Raul,
16:40 --> 16:42the other thing that you had mentioned
16:42 --> 16:45to us before the break is that you're
16:45 --> 16:47very involved in implementation science this
16:47 --> 16:48idea that
16:48 --> 16:51you actually try to make a difference,
16:51 --> 16:55and change some of the factors
16:55 --> 16:58that are going on in populations
16:58 --> 17:01to enhance prevention.
17:01 --> 17:03So can you talk about some of
17:03 --> 17:04the strategies that you've looked
17:04 --> 17:06at and some of your results?
17:08 --> 17:10Yeah, sure. So as you mentioned,
17:10 --> 17:13there are several common variants, right,
17:13 --> 17:17that have been reported in lower middle
17:17 --> 17:20income countries and other places and
17:20 --> 17:22what we have learned from
17:22 --> 17:24this work that we are doing in
17:24 --> 17:27low and middle income countries?
17:27 --> 17:29And this is related to the
17:29 --> 17:31implementation science part is
17:31 --> 17:33that there are promising health
17:33 --> 17:35interventions that have limited impact
17:35 --> 17:37in low and middle income countries,
17:37 --> 17:40because there are implementation problems,
17:40 --> 17:42so there are barriers to implement
17:42 --> 17:44these prevention and care practices,
17:44 --> 17:46even the basic ones.
17:46 --> 17:48And that's the key challenge
17:48 --> 17:50to reducing the cancer burden,
17:50 --> 17:51the cervical cancer burden in particular
17:51 --> 17:53in low and middle income countries.
17:53 --> 17:57So the barriers need to be identified
17:57 --> 18:00and addressed and that is where
18:00 --> 18:03implementation science plays a role.
18:03 --> 18:05Implementation science can help
18:05 --> 18:08to identify what are those
18:08 --> 18:10factors that influence implementation
18:10 --> 18:14and then to try to
18:14 --> 18:17select and develop intervention
18:17 --> 18:21strategies to address those factors
18:21 --> 18:24and enable implementation.
18:24 --> 18:27My work in Mexico,
18:27 --> 18:29we have seen that there are
18:29 --> 18:32frequent gaps in screening and follow
18:32 --> 18:34up care after abnormal screens.
18:34 --> 18:37And the reason for those
18:37 --> 18:39gaps may be addressable so
18:39 --> 18:42to investigate the reasons for poor
18:42 --> 18:44follow up of abnormal screen in Mexico,
18:44 --> 18:46we have established a research group
18:46 --> 18:49between a group of researchers at Yale and
18:49 --> 18:51Mexico's National Autonomous University,
18:51 --> 18:55UNAM and the National Institute of
18:55 --> 18:57Public Health in Spain and Mexico.
18:57 --> 18:59And we started by looking at data
18:59 --> 19:01from a group of patients that were
19:01 --> 19:03recommended to get a colposcopy
19:03 --> 19:05after testing positive for HPV.
19:07 --> 19:09In some screening demonstration
19:09 --> 19:12studies in Mexico Clinic that
19:12 --> 19:14was among uninsured populations.
19:14 --> 19:17And we have identified factors positively
19:17 --> 19:20linked to follow-up of positive HPV results.
19:20 --> 19:23And those include having a history
19:23 --> 19:25of PAP and providing contact data.
19:25 --> 19:28Those were associated with greater
19:28 --> 19:31adherence to obtaining screening test
19:31 --> 19:33results before getting a
19:33 --> 19:36colposcopy appointment we may need
19:36 --> 19:39to get their test results.
19:39 --> 19:41Then also the availability of
19:41 --> 19:43family medicine service and
19:43 --> 19:46being attended by nurses with
19:46 --> 19:48a good amount of experience was
19:48 --> 19:51associated with greater adherence to
19:51 --> 19:52obtaining those screened results.
19:52 --> 19:53In contrast,
19:53 --> 19:55as mentioned before also observing
19:55 --> 19:57in other places,
19:57 --> 19:59the longer travel time to colposcopy
19:59 --> 20:01clinic were linked to decreased attendance.
20:01 --> 20:05So interventions to improve follow
20:05 --> 20:08up for those with abnormal results can
20:08 --> 20:10be developed based on this information.
20:10 --> 20:13Such as strategies that can be
20:13 --> 20:15used to secure contact data.
20:15 --> 20:16Also,
20:16 --> 20:19there could be educational interventions,
20:21 --> 20:23skills relative to the cervical
20:23 --> 20:25cancer program recommendations,
20:25 --> 20:27especially emphasizing the importance
20:27 --> 20:30of encouraging patients to promptly
20:30 --> 20:32collect their screening results
20:32 --> 20:34and get follow-up care if needed.
20:34 --> 20:34And also,
20:34 --> 20:36in the case of the travel or
20:36 --> 20:38the long distance barrier,
20:38 --> 20:40to provide travel support for
20:40 --> 20:41patients that need a colposcopy
20:42 --> 20:44or even taking the clinic to the
20:44 --> 20:45communities with a mobile
20:45 --> 20:46Scope clinic.
20:46 --> 20:48Those sound like
20:48 --> 20:51good strategies, but you know,
20:51 --> 20:54as I've found with global oncology,
20:54 --> 20:56there's always multiple layers to
20:56 --> 20:59the onion and the puzzle always seems
20:59 --> 21:02to be a little bit more complicated
21:02 --> 21:04than you would initially anticipate.
21:04 --> 21:08So for example, the idea of,
21:08 --> 21:10you know, providing education for
21:10 --> 21:13nurses so that they may understand
21:13 --> 21:16cervical cancer and its prevention
21:16 --> 21:19and treatment in a greater detail sounds
21:19 --> 21:22like that's a great idea, and it is,
21:22 --> 21:25but for many low to middle income countries
21:25 --> 21:28the problem is not only the
21:28 --> 21:29lack of knowledge,
21:29 --> 21:32it's the lack of nurses.
21:32 --> 21:36So how do you get around issues like a
21:36 --> 21:39lack of a workforce or a workforce that
21:39 --> 21:43is so constrained because it is so small
21:43 --> 21:45it doesn't meet World Health Organization
21:45 --> 21:48guidelines for the number of nurses that
21:48 --> 21:50are recommended for their population,
21:50 --> 21:53and so these nurses are working so
21:53 --> 21:56many hours that they may not have
21:56 --> 22:00time to attend educational activities,
22:00 --> 22:02on top of which, even if they did,
22:02 --> 22:05they still are very limited in their numbers.
22:05 --> 22:08How do you get around the fact that
22:08 --> 22:10even if you provide transportation
22:10 --> 22:13to patients to get to the clinic,
22:13 --> 22:15that many of them,
22:15 --> 22:18as you mentioned before the break,
22:18 --> 22:20may be working maybe two or three
22:20 --> 22:23jobs and maybe getting off from work,
22:23 --> 22:24maybe another barrier.
22:24 --> 22:27So how do you deal with all of these
22:27 --> 22:29layers of the onion?
22:29 --> 22:31Very good question.
22:31 --> 22:33There are multiple different
22:33 --> 22:35layers and because of that reason,
22:35 --> 22:37we are now preparing to conduct
22:37 --> 22:39research consisting of interviews and
22:39 --> 22:41surveys with patients and providers
22:41 --> 22:44to try to identify and understand
22:44 --> 22:47how those different factors at
22:47 --> 22:49different levels work
22:49 --> 22:52that affects the individuals.
22:52 --> 22:53In this case,
22:53 --> 22:54the patients receive the services,
22:54 --> 22:57but also what are those factors
22:57 --> 22:59related to the providers
22:59 --> 23:02that may be affecting implementation,
23:02 --> 23:05such as the lack of human resources,
23:05 --> 23:08but also the lack of time
23:08 --> 23:12to get to attend the
23:12 --> 23:13patients but also of course
23:14 --> 23:16time to see the patients,
23:16 --> 00:-01they will have time to
23:18 --> 23:19get additional trainings, right.
23:19 --> 23:22So we also need to see what
23:22 --> 23:24are kind of the barriers and
23:24 --> 23:27your level like organizational
23:27 --> 23:31levels that can also influence
23:31 --> 23:34the factors.
23:34 --> 23:36Going down to the patient
23:36 --> 23:38if there are things that can be
23:38 --> 23:39changed at the organization
23:39 --> 23:41level that it may be more
23:41 --> 23:43challenging but that may affect all
23:43 --> 23:47the other different levels and
23:47 --> 23:49the way is challenging because there
23:49 --> 23:51are things that are more modifiable
23:51 --> 23:53or easily modifiable than others.
23:53 --> 23:55But I think the first step is trying
23:55 --> 23:57to generate the evidence about
23:57 --> 23:59what is driving the problem in
23:59 --> 24:01this particular setting,
24:01 --> 24:05and with that evidence, try to
24:05 --> 24:08make changes at the higher level to
24:08 --> 24:10influence some program and
24:10 --> 24:14policies changes based on that and
24:14 --> 24:16hopefully with that information
24:16 --> 24:18in the case of things that are
24:18 --> 24:19harder to modify,
24:19 --> 24:22try to generate that evidence that can help.
24:22 --> 24:26Also get additional funding for
24:26 --> 24:29the clinics to have
24:29 --> 24:31in some cases where they have been
24:31 --> 24:34done in some places to have
24:34 --> 24:36community health workers that are
24:36 --> 24:39not patient navigators that dedicate
24:39 --> 24:42themselves to the patient
24:42 --> 24:44from the beginning of screening to
24:44 --> 24:47treatment through all the different steps.
24:50 --> 24:52An important part there is,
24:52 --> 24:55this part of getting the financial
24:55 --> 24:57resources needed to implement
24:57 --> 24:59these kind of strategies
24:59 --> 25:01that are more complex and that may
25:01 --> 25:04influence and may need to influence
25:04 --> 25:06different levels at different factors.
25:06 --> 25:07And I agree with you,
25:07 --> 25:11I think that ultimately many things,
25:11 --> 25:13not all, but many things,
25:13 --> 25:16come down to money in terms
25:16 --> 25:19of who's going to fund the bus,
25:19 --> 25:21who's going to hire
25:21 --> 25:23more health care workers.
25:23 --> 25:25And I think, you know,
25:25 --> 25:27when we think about low to
25:27 --> 25:28middle income countries,
25:28 --> 25:31these countries developmentally are
25:33 --> 25:37just at the beginning
25:37 --> 25:40of their trajectory in terms
25:40 --> 25:43of national development and
25:43 --> 25:46oftentimes don't have a very strong
25:46 --> 25:49or stable GDP oftentimes
25:49 --> 25:52have governments that have
25:52 --> 25:55varying degrees of corruption.
25:55 --> 25:59And so trying to obtain funding
25:59 --> 26:03that is sustainable and that
26:03 --> 26:07can be funneled into healthcare
26:07 --> 26:09it is really difficult.
26:09 --> 26:11Now one of
26:11 --> 26:13the other things that you had mentioned
26:13 --> 26:17before the break is that you also have
26:17 --> 26:20been involved in work in HIV and
26:20 --> 26:22we know that around the world
26:22 --> 26:25we've actually seen a great deal
26:25 --> 26:29of progress in terms of HIV and
26:29 --> 26:33its control in large part mediated
26:33 --> 26:36by philanthropy and
26:36 --> 26:37the millennial development
26:37 --> 26:40goals of really reducing HIV,
26:40 --> 26:42malaria and TB.
26:42 --> 26:44And so the next question is,
26:44 --> 26:47is this one strategy that you may have
26:47 --> 26:51looked at or thought about in terms of
26:51 --> 26:56increasing infrastructure.
26:56 --> 26:58Getting out into cancer,
26:58 --> 27:01whether it's cervical cancer or others,
27:01 --> 27:04is building upon the infrastructure
27:04 --> 27:07that might already exist in terms of HIV.
27:07 --> 27:10And how would that work,
27:10 --> 27:12how does that look and is that something
27:12 --> 27:14that various countries are trying?
27:16 --> 27:17Yeah, very good point,
27:17 --> 27:19very good question.
27:19 --> 27:22And the integration of
27:22 --> 27:25services is something that
27:25 --> 27:26depends on the kind of services.
27:26 --> 27:27But integration specifically with
27:27 --> 27:31HIV services is a kind of a strategy
27:31 --> 27:33that is being used for different
27:33 --> 27:35purposes in different countries but
27:35 --> 27:38especially those
27:38 --> 27:41in which there are
27:41 --> 27:44high incidence or prevalence of HIV
27:44 --> 27:46especially in subsaharan Africa.
27:46 --> 27:50And there are efforts to integrate
27:50 --> 27:53chronic disease as well as cervical
27:53 --> 27:56cancer and cancer for other
27:56 --> 28:00care for other cancers into the
28:00 --> 28:02HIV programs since those have in
28:02 --> 28:04some way already figured out and
28:04 --> 28:06have the personnel have the support
28:06 --> 28:08or the infrastructure,
28:08 --> 28:10although they still have challenges
28:10 --> 28:12and barriers to implementing the
28:12 --> 28:13evidence based interventions.
28:13 --> 28:14But yeah,
28:14 --> 28:16there are some efforts that are being made to
28:16 --> 28:19try to integrate hypertension and
28:19 --> 28:21chronic disease, for example, management,
28:21 --> 28:24into HIV services as well as
28:24 --> 28:25cancer control services,
28:25 --> 28:27especially in the case of cervical
28:27 --> 28:29cancer, a cancer that is
28:29 --> 28:31elevated among those with HIV.
28:32 --> 28:34Doctor Raul Hernandez Ramirez is a
28:34 --> 28:36research scientist in Biostatistics
28:36 --> 28:39at the Yale School of Public Health.
28:39 --> 28:41If you have questions,
28:41 --> 28:43the address is canceranswers@yale.edu,
28:43 --> 28:45and past editions of the program
28:45 --> 28:48are available in audio and written
28:48 --> 28:49form at yalecancercenter.org.
28:49 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public Radio.
28:55 --> 28:57Funding for Yale Cancer Answers is
28:57 --> 29:00provided by Smilow Cancer Hospital.

Information

Cancer Prevention in Low- and middle-income Countries with guest Dr. Raul U. Hernandez-Ramirez February 19, 2023 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095