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ABSTRACTBackground: Although cancer incidence and mortality are rising in Ethiopia, lay and healthprofessional perceptions of the disease remain limited.Objective: To explore perceptions of cancer, including its causes, signs and symptoms, andtransmission within a rural community in Ethiopia.Methods: We conducted a qualitative study in four rural neighbourhoods of Butajira incentral Ethiopia. Seven Focus Group Discussions (FGDs) and six In-Depth Interviews (IDIs)were held with community members, women representatives, religious leaders and keyinformants using two interview guides (divided by method). Behaviour change theories anda community research framework were used to summarize the findings.Results: Across respondent categories and data collection methods, respondents describedcancer or nekersa, which translates as ‘an illness that cannot be cured’, as serious and fatal.Cancer was further viewed as becoming more common and as underpinning more deathsparticularly among women. Causes of cancer largely focused on individual behaviours namelymitch (referring to exposure to sunlight), poor personal hygiene and urinating on the ground/dirty areas. Almost all participants strongly related cancer to a wound that does not heal andentails a foul-smelling discharge. Bleeding and weight loss were other commonly mentionedcomplaints of cancer.Conclusions: Although cancer is known among rural communities in this area, misconcep-tions about cancer aetiology and conflation of the signs and symptoms of cancer versus otherdiseases merit health messaging. Our study calls for design research to determine how toculturally tailor educational materials and deliver health campaigns regarding cancer causes,signs and symptoms within this context.

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Abstract:

Abstract
Background Cancer incidence is increasing in Ethiopia mainly due to increased life expectancy, while oncological
capacities remain limited. Strong referral linkages between different levels of the healthcare system are key to provide
timely access to cancer care. In this qualitative study, we assessed limitations and potential of cancer patient referral in
the rural Southwest of Ethiopia.
Methods We held four focus group discussions (FGD) with health professionals at one primary and three
secondary hospitals and conducted eight in-depth interviews (IDI) with the hospitals´ medical executives and local
health bureau representatives. Data was analysed inductively using thematic analysis and emerging themes were
categorized within the revised concept of access by Penchansky and Saurman.
Results The inevitable referral of patients with cancer in the rural Southwest of Ethiopia is characterized by the
absence of clear communication protocols and the lack of formal referral linkages. The newly implemented hubsystem
has improved emergency referrals and could be expanded to non-emergency referrals, sensitive to the needs
of advanced oncological care. Liaison officers can pave the way but need to be trained and equipped adequately.
Referred patients struggle with inadequate transportation systems, the lack of accommodation close to specialized
facilities as well as the inability to navigate at those sites due to language barriers, illiteracy, and stigmatization. Few
Non-Governmental Organizations (NGOs) help but cannot compensate the limited governmental support. The
shortage of medications at public hospitals leads to patients being directed to costly private pharmacies. In the light
of those challenges, cancer remains to be perceived as a “death sentence” within the rural communities.
Conclusions Standardized referral linkages and a multi-faceted support network throughout the cancer care
continuum are necessary to make oncology care accessible to Ethiopia´s large rural population.
Keywords Cancer, Healthcare system, Sub-Saharan Africa, Patient pathways

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Abstract
Background: In Ethiopia, both incidence and mortality of cervical cancer are relatively high. Screening services, which were implemented during the past few years, are currently being expanded. The World Health Organization recommends patients with a positive VIA (visual inspection with acetic acid) result should immediately receive treatment followed by rescreening after 1 year as precancerous lesions can reoccur or become residential despite treatment.
Materials and Methods: Screening logbooks dating between 2017 and 2020 were retrospectively reviewed in 14 health facilities of Addis Ababa and Oromia region. Data for 741 women with a VIA-positive result were extracted and those women were asked to participate in a questionnaire-based phone interview to gain insights about adherence to treatment and follow-up. Data were analyzed using descriptive methods and then fitted into 2 generalized linear models to test variables for an influence on adherence to follow up.
Results: Around 13 800 women had received a VIA screening, of which approximately 820 (5.9%) were VIA positive. While over 90% of women with a positive screen received treatment, only about half of the treated patients returned for a follow-up examination. After treatment, 31 women had a VIA-positive re-screen. We found that educational status, age over 40, no/incorrect follow-up appointment, health facility-related barriers, and use of reminders are important drivers of adherence to follow up.
Conclusion: Our results revealed that adherence to treatment after VIA positive screening is relatively high whereas adherence to follow up recommendations still needs improvement. Reminders like appointment cards and phone calls can effectively reduce the loss of follow-up.
Key words: cervical cancer screening; precancerous lesions; cryotherapy; follow-up; adherence; recurrence.

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Abstract
Ovarian cancer (OC) is the fourth most common cancer of women in sub-Saharan Africa (SSA), although few data have been published on population-level survival. We estimate ovarian cancer survival in SSA by human development index and histological subtype, using data from seven population-based cancer registries in six countries: Kenya (Nairobi and Eldoret), Mauritius, Uganda (Kampala), Cote d'Ivoire (Abidjan), Ethiopia (Addis Ababa) and South Africa (Eastern Cape). A total of 644 cases diagnosed during 2008–2014 were included, with 77% being of epithelial subtypes (range 47% [Abidjan]—80% [Mauritius]). The overall observed survival in the study cohort was 73.4% (95% CI: 69.8, 77.0) at 1 year, 54.4% (95% CI: 50.4, 58.7) at 3 years and 45.0% (95% CI: 41.0, 49.4) at 5 years. Relative survival at Year 1 ranged from 44.4% in Kampala to 86.3% in Mauritius, with a mean for the seven series of 67.4%. Relative survival was highest in Mauritius at 72.2% and lowest in Kampala, Uganda at 19.5%, with a mean of 47.8%. There was no difference in survival by age at diagnosis. Patients from high and medium HDI countries had significantly better survival than those from low HDI countries. Women with cancers of epithelial cell origin had much lower survival compared to women with other histological subtypes (p = .02). Adjusted for the young age of the African patients with ovarian cancer (44% aged <50) survival is much lower than in USA or Europe, and underlines the need for improvements in the access to diagnosis and treatment of OC in SSA.
KEYWORDS: epithelial, HDI, ovarian cancer, sub-Saharan Africa, survival

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Abstract
Background: Out-of-pocket (OOP) health expenditures for cancer care expose households to unanticipated economic consequences. When the available health services are mainly dependent on OOP expenditure, the household faces catastrophic health expenditure (CHE). This study aimed to estimate the incidence and intensity of CHE in hospitalized cancer patients and identify coping strategies and associated factors.

Method and material: Hospital-based cross-sectional study design was conducted on 305 cancer inpatients in Addis Ababa between November 2021 and February 2022. All patients with cancer who were hospitalized during the data collection period were included in the study. The incidence of CHE was estimated at the 40% threshold of households' non-food expenditure and the intensity of CHE was captured based on the amount by which household expenditure exceeded the threshold and mean positive overshoot, the mean level by which CHE exceeds the threshold used. Multivariate logistic regression was used to assess the relationship between CHE levels and the independent variables.

Results: The incidence of CHE at the 40% threshold of households' non-food expenditure was 77.7%, while the O and MPO were 36.2% and 46.6%, respectively. CHE for cancer care was significantly associated with patient residence, increased number of chemotherapy cycles, increased duration of hospital admission, lack of insurance enrolment, and lower-income quintiles. Saving and selling assets were identified as the primary coping mechanisms.

Conclusion: The incidence and intensity of CHE among inpatients with cancer were high and which could lead to impoverishment of households. Improved quality and coverage of health insurance and decentralizing cancer care to regions standards similar to Addis Ababa will save households from incurring CHE.
Keywords: Ethiopia; cancer; catastrophic out-of-pocket health expenditure; coping mechanisms.

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Abstract
Cancer diagnosis and treatment can be physically arduous, disrupting patients’ social and work lives. Understanding the extent of these problems is key to addressing patients’ needs, but specific psychosocial challenges have not yet been well studied in resource-limited settings. A qualitative study was conducted in the capital and two regions of Ethiopia with the aim of exploring psychosocial challenges among cancer patients. A total of 14 in-depth interviews (IDIs) and 16 focus group discussions (FGDs) were done with cancer patients, health professionals, community representatives, and religious leaders. Four separate interview guides were used to facilitate the interviews and discussions. All transcribed documents, field notes, and reflexive memos were entered into NVivo 12 software, and deductive thematic analysis using the social-ecological model was applied to summarize the main findings. At an individual level, emotional distress, suicidal risk, denial, and refusal of treatment were identified immediately after diagnosis while hopelessness, feeling depressed, and fear of death were commonly reported psychosocial challenges during the course of treatment. Involvement of family members in major treatment decisions was recognized at an interpersonal level. Our result also revealed that cancer patients had strong social support from family members and close friends. In the community, traditional medicine and religious rituals were considered an alternative treatment for cancer. The findings indicate that counselling and psychoeducation are crucial for cancer patients, family members, and close friends. Awareness creation programmes should be delivered through collaboration with religious leaders and traditional healers.

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Abstract
Background Although mastectomy is the standard treatment modality for breast cancer patients in Ethiopia, our
previous study revealed that one in five patients do not receive the recommended procedure, half due to patient
refusal or lack of returning to the hospital. Therefore, this study aimed to explore reasons for refusing mastectomy and
identify challenges among breast cancer patients in Ethiopia.
Methods An explorative qualitative study was conducted in four hospitals located in the towns of Woliso, Butajira,
Hossana, and Assela. A total of 14 in-depth interviews (IDIs) and eight focus group discussions (FGDs) were held with
breast cancer patients, patient relatives, and health professionals. Four semi-structured interview guides were used to
facilitate the IDIs and FDGs. All recorded IDIs and FGDs were transcribed and translated verbatim and entered in NVivo
12 software. Emerging ideas were categorised and explained using an inductive content analysis approach.
Results Our participants reported that particularly elderly and very young women refuse to have mastectomy. The
main reasons identified in this study were summarised into six themes: (i) fear of the surgical procedure, (ii) religious
beliefs and practice, (iii) utilisation of traditional treatments, (iv) in relation to having a baby and breastfeeding
their children (young patients often request to remove only the lump, leaving their breast tissue intact), (v) lack of
awareness about the disease, and (vi) sociocultural factors and advice from the community that influence women,
since breasts are considered an attribute of femininity, beauty, and motherhood. In addition, knowing someone who
died after mastectomy emerged as a main reason for not having breast cancer surgery.
Conclusions High refusal rate for mastectomy has direct implication on increased breast cancer mortality. Hence,
expansion of radiotherapy service is instrumental to initiate breast-conserving surgery as an alternative surgical
procedure, especially for young women with early-stage breast cancer. Involving religious leaders, traditional healers,
and breast cancer survivors could be an effective strategy to persuade newly diagnosed breast cancer patients.
Addressing individual patient psychosocial needs and preferences may substantially improve retention of breast
cancer patients in the health system.
Keywords Breast cancer, Breast surgery, Mastectomy, Refusal, Reasons, Ethiopia

Abstract:

Background
Although prostate cancer (Pca) screening plays important role in early diagnosis and reduction of mortality, Tanzanian men are relatively unscreened. We aimed to investigate Pca knowledge level and barriers to screening among at-risk men in northern Tanzania.
Methods
This community-based survey was conducted in northern Tanzania from May to September 2022, involving men age ≥40 years. Participants were invited by announcing in local churches, mosques, brochures, and social media groups. Participants attended a nearby health facility where survey questionnaires were administered. Knowledge level was measured on the Likert scale and scored as poor (<50 %) or good (≥50 %).
Results
A total of 6205 men with a mean age of 60.23 ± 10.98 years were enrolled in the study. Of these, 586 (9.5 %) had ever been screened for Pca. Overall, 1263 men (20.4 %) had good knowledge of Pca. Having health insurance, knowing at least 1 risk factor or symptoms of Pca, and hospital as the source of Pca information were significantly associated with ever being screened. The most common reasons for not being screened were a belief that they are healthy (n = 2983; 53.1 %), that Pca is not a serious disease (n = 3908; 69.6 %), and that digital rectal examination (DRE) as an embarrassing (n = 3634; 64.7 %) or harmful (n = 3047; 54.3 %) procedure.
Conclusion
Having Pca knowledge, health insurance and hospital source of information were correlated with increased screening. False beliefs about DRE and the seriousness of Pca had negative effects on screening. Increasing community knowledge and universal health coverage would improve uptake of Pca screening.

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Abstract
Background: To assess population-based quality of cancer care in sub-Saharan Africa and to identify specific gaps and joint opportunities, we assessed concordance of diagnostics and treatments with National Comprehensive Cancer Network Harmonized Guidelines for leading cancer types in 10 countries.
Methods: Adult patients with female breast cancer, cervical cancer, colorectal cancer, non-Hodgkin lymphoma, and prostate cancer were randomly drawn from 11 population-based cancer registries. Guideline concordance of diagnostics and treatment was assessed using clinical records. In a subcohort of 906 patients with potentially curable cancer (stage I-III breast cancer, cervical cancer, colorectal cancer, prostate cancer, aggressive non-Hodgkin lymphoma [any stage]) and documentation for more than 1month after diagnosis, we estimated factors associated with guideline-concordant treatment or minor deviations.
Results: Diagnostic information based on guidelines was complete for 1030 (31.7%) of a total of 3246 patients included. In the subcohort with curable cancer, guideline-concordant treatment was documented in 374 (41.3%, corresponding to 11.7% of 3246 patients included in the population-based cohort): aggressive non-Hodgkin lymphoma (59.8%/9.1% population based), breast cancer (54.5%/ 19.0%), prostate cancer (39.0%/6.1%), colorectal cancer (33.9%/9.5%), and cervical cancer (27.8%/11.6%). Guideline-concordant treatment was most frequent in Namibia (73.1% of the curable cancer subcohort/32.8% population based) and lowest in Kampala, Uganda (13.5%/3.1%). Guideline-concordant treatment was negatively associated with poor ECOG-ACRIN performance status, locallyadvanced disease stage, origin from low Human Development Index countries, and a diagnosis of colorectal cancer or cervical
cancer.
Conclusions: The quality of diagnostic workup and treatment showed major deficits, with considerable disparities among countries and cancer types. Improved diagnostic services are necessary to increase the share of curable cancer in sub-Saharan Africa. Treatment components within National Comprehensive Cancer Network Guidelines for several cancers should be prioritized.