Title: NIHR Global Research Group on Advancing Early Diagnosis of Cancer in Southern Africa- AWACAN-ED
Funder: Department of Health and Social Care

Abstract: Research question: Can we use innovative approaches with digital technologies in primary care and public health to advance early diagnosis of breast, cervical and colorectal cancer in Southern Africa?_x000D_ _x000D_ Background: By 2030 an estimated 24 million people worldwide will develop cancer and 13 million people will die annually from cancer, with 75% of deaths in low-and middle-income countries (LMICs). Cervical, breast and colorectal cancer are common in LMICs. In Southern Africa, people with symptoms of these cancers are diagnosed when they self-present to a health facility, usually at an advanced stage with associated poor outcomes. A key goal of comprehensive cancer control is a shift to earlier stage at diagnosis._x000D_ _x000D_ Aims and objectives: To advance early diagnosis of these cancers we will:_x000D_ • Assess the time intervals from symptom awareness to referral and diagnosis and factors influencing these intervals in Zimbabwe (low-income country) and South Africa (SA) (upper middle-income country) (Workstream 1)._x000D_ • Develop two e-Tools that promote more timely presentation and referral: a symptom assessment and management e-Tool for primary care providers and a symptom appraisal and help-seeking e-Tool for the public (Workstream 2)_x000D_ • Evaluate the e-Tools to ensure that they are operationally and economically feasible and equitable, socio-culturally acceptable and support timely referral (Workstream 3)._x000D_ _x000D_ Methods: The Model of Pathways to Treatment and the MRC complex intervention framework underpin the research. Data will be collected from public sector facilities in two provinces in each country:_x000D_ Workstream 1: in-depth interviews with health facility managers, providers, and health facility assessments, and cross-sectional survey of patients with breast, cervical or colorectal symptoms or those recently diagnosed. Data on pathways to diagnosis and health expenditure will be collected._x000D_ Workstream 2: e-Tool content developed by expert advisory groups, and software development for the tools with iterative prototype usability testing._x000D_ Workstream 3: (A) Primary care provider e-Tool: a pragmatic, type 2 hybrid effectiveness-implementation pilot study, with a ‘before-and-after’ study design, to evaluate whether its use impacts the primary care, pre-diagnostic and total diagnostic intervals; a process evaluation of implementing the e-Tool; in-depth interviews with primary care providers to assess usability, subjective experiences and challenges with the e-Tool; a cross-sectional survey to measure provider knowledge before and after intervention implementation; (B) Public e-Tool: focus group discussions with community participants to evaluate usefulness of the public e-Tool and barriers to use; a cost-effectiveness analysis of the provider e-Tool._x000D_ _x000D_ Timelines: Workstream 1: months 1–24; Workstream 2: months 13-48; Workstream 3: months 25-48._x000D_ _x000D_ Anticipated impact and dissemination: Results will be disseminated through peer-reviewed publications in high-impact journals and conference presentations, as well as local stakeholder meetings, press and media. Impact will include: baseline data on key time intervals in the pathway to breast, cervical and colorectal cancer diagnosis in each country, the key factors influencing these intervals and patient health costs; an e-Tool for primary care providers to support assessment and referral patients presenting with possible cancer; an e-Tool for public use to promote symptom appraisal and help-seeking.

Lay abstract: By 2030, about 24 million people worldwide will develop cancer each year. Most cases will occur in low- and middle-income (LMIC) countries because people in these countries are living longer. While more people are getting cancer, services to diagnose and to treat cancer are often not widely available, and there are huge differences in care-seeking and quality of care. Cancer outcomes can be improved by early detection and timely diagnosis. We aim to advance the early diagnosis of cancer in Southern Africa by developing and evaluating e-Tools to improve care-seeking and reduce healthcare delays in two countries: Zimbabwe and South Africa. We will focus on cervical and breast cancer in women and colorectal cancer in men and women as these are common cancers and have relatively easy methods for detecting and treating the cancers, especially in the early stages._x000D_ _x000D_ The research aims to answer important questions about how to encourage appropriate help-seeking among people with possible cancer symptoms and how to deliver high-quality, accessible and equitable cancer referral and diagnosis services in lower level facilities. It will be undertaken mainly in local clinics and secondary health facilities that are the first place that people go for health services in these countries. Studies will include materials in local languages to increase awareness and access to the services. We will also have a major focus on quality training for junior researchers._x000D_ _x000D_ The questions to be answered include: Can we improve timely symptom appraisal and help-seeking among people with possible symptoms of cancer? Can we develop and evaluate an effective digital e-Tool for local primary care workers which will support their service, including patient management and referrals? Can we provide an acceptable and user-friendly e-Tool for patients to promote early diagnosis of breast, cervical and colorectal cancer?_x000D_ _x000D_ To answer these questions we will map current primary care and hospital services for breast, cervical and colorectal cancer in the two Southern African countries. We will then identify key factors influencing patient pathways, from symptom awareness through to referral and diagnosis, and develop two interventions. One will be a symptom assessment and management e-Tool for primary care providers and the other a symptom appraisal and help-seeking e-Tool for the public. We will evaluate the feasibility, acceptability and effectiveness (including cost-effectiveness) of these e-interventions. Importantly, we will draw on community engagement and involvement at all stages of the research, and emphasize interventions that are affordable and socioculturally acceptable to African women and men and local healthcare providers._x000D_ _x000D_ This research will help health authorities plan how new approaches can be integrated into existing health services in countries like Zimbabwe and South Africa. It will demonstrate which resources are needed to provide accessible, good quality, cost effective services that successfully help people to have a more timely diagnosis of breast, cervical and colorectal cancer. This is urgently needed as the number of people getting cancer and needing treatment in LMICs will increase over the next few years.

Research activity codes: 4.3 INFLUENCES AND IMPACT;7.1 INDIVIDUAL CARE NEEDS;7.3 MANAGEMENT AND DECISION MAKING
Health categories: CANCER AND NEOPLASMS