Objective Colorectal cancer (CRC) is the second leading cause of cancer-related deaths worldwide, with incidence and mortality rising in low- and middle-income (LMICs) countries. Expanding the number of healthcare professionals trained in colonoscopy is crucial to addressing the increasing cancer burden. We developed a colonoscopy simulation-based training course and assessed whether training on locally developed low-fidelity (LF) simulation models resulted in skill acquisition and confidence comparable to training on high-fidelity (HF) models. Design A randomized crossover trial was conducted as part of a colonoscopy training program, which consisted of a 9-week online lecture series and a 4-day in-person colonoscopy training workshop, using HF and LF simulators. Performance was assessed using the Mayo Colonoscopy Skills Assessment Tool (MCSAT) and the Global Assessment of Gastrointestinal Endoscopic Skills (GAGES) tool. The primary outcome was the difference in median exam scores. Setting The study was conducted at the Obafemi Awolowo University Teaching Hospital in Ile-Ife, Nigeria, from January 4th, 2024, to May 3rd, 2024. Participants Participants were surgeons, surgical residents, and gastroenterologists of varying levels of experience from Nigeria. Results A total of twenty-one trainees enrolled in the online Zoom lectures, and 18 participants were randomized in the simulation course. Median MCSAT and GAGES scores improved over time in both HF and LF groups. For GAGES scores, only Exam 2 (after lectures and training on a simulation model) showed statistically significant differences for scope navigation (p = 0.046), use of strategies (p = 0.019), and the overall GAGES score (p = 0.041). No significant differences were observed at Exam 4 (the final exam of the course), suggesting that skills had converged by the end of training. Both HF and LF groups demonstrated significant increases in confidence. Conclusions This pilot trial suggests training on LF colonoscopy models results in similar colonoscopy skill acquisition and confidence compared to HF colonoscopy. LF colonoscopy training models can be used as cost-effective teaching tools in LMICs with limited resources and financial investments.

Background In Nigeria, cancer patients often pay for care out-of-pocket, leading to catastrophic health expenditure (CHE). However, data on the true costs and economic burden of cancer care are limited. This study prospectively analyzes direct and indirect out-of-pocket costs for colorectal cancer (CRC) care at a tertiary hospital in Southwest Nigeria. Methods Patients newly diagnosed with CRC between August 2019 and April 2024 were enrolled. Trained research assistants administered a context-specific questionnaire at admission and six months later. Patients reported household income and all cancer-related expenditures. CHE was defined using three standard thresholds: healthcare costs exceeding 40 % of capacity-to-pay or 10 % and 25 % of annual income. Results Data were collected from 50 patients with a mean age of 57.9 years (SD 14.3). Twelve percent of patients (6/50) presented with stage I disease. Forty-two percent (21/50) had stage II disease, while 46 % (23/50) had stage III or IV disease at presentation. 24 % (12/50) of patients had right-sided disease, while 38 % (19/50) had rectal cancer, 4 (21 %) of whom received neoadjuvant radiotherapy. Ninety percent (45/50) of patients received systemic chemotherapy. The mean annual capacity-to-pay for the cohort was $3930.71(SD $5108.10), while the mean cost of care was $5286.16(SD $2919.77). Indirect costs, including travel, lodging, and lost income, accounted for $2144.04(SD $2478.68) of the total cost of care. Between 95.2 % and 100 % of our cohort experienced a CHE. Only 20 % (10/50) of our cohort had health insurance. Conclusions More than 95 % of patients seeking care for CRC at a tertiary care facility in Southwest Nigeria experience a CHE because of out-of-pocket costs associated with accessing care. There is the need for more studies on interventions to reduce these cost barriers for patients. Policy Summary A more effective and accessible health insurance scheme is urgently needed in Nigeria to protect CRC patients from CHE.

Background:As with most Sub-Saharan African countries, Nigeria has a rising incidence of cancer, with disproportionate mortality rates. The financial burden of cancer care often results in catastrophic healthcare spending, leading to treatment refusal, disruption, and discontinuation. This is particularly significant in Nigeria, where nearly all patients are uninsured, and out-of-pocket costs often exceed households' ability to pay. Financial Navigation Programs (FNPs) have been shown to mitigate treatment-related financial toxicity in cancer care and reduce treatment abandonment, but there is a paucity of high-quality data on this intervention in resource-constrained settings. Here, we present a randomized controlled trial to evaluate the impact of a novel FNP in Nigeria. Methods:We designed the COST-FIN trial, a multi-site pragmatic single-blinded randomized controlled trial of newly diagnosed (<6 weeks from diagnosis) adults (≥18 years) with breast, colorectal, or prostate cancer at two tertiary cancer centers in Nigeria. Participants (n=200) will be randomized (1:1) to either the intervention (FNP) or the control arm and followed for 12 months. Data on key individual, treatment, and financial parameters will be collected via structured interviews and chart abstraction at baseline, 3, 6, and 12-month follow-up. In addition, participants randomized to the FNP will receive a tailored financial literacy assessment, financial planning support, and enhanced access to resources by trained financial navigators. Primary and secondary outcomes are Financial Catastrophe (FC) and Financial Distress (FD), respectively. Exploratory outcomes will include cost-related non-adherence and cost-effectiveness of the program. An interim analysis will be conducted when 50% of the estimated accruals reach 6 months of follow-up, with crossover if compelling evidence of benefit is demonstrated at that time point. All participants will be followed for 12 months from recruitment. Discussion:This first-of-its-kind study will provide evidence on the role of FNP in potentially eliminating financial barriers to cancer care in Nigeria. Given the country's renewed interest in cancer control through the passage of the National Cancer Control Plan, findings from this study have the potential to influence policy reform and set the stage for further studies to evaluate the scalability and implementation of similar interventions in resource-limited settings. Trial registration:ClinicalTrials.gov NCT06630962. Oct 8, 2024 (https://clinicaltrials.gov/study/NCT06630962).

PURPOSEThe global burden of cancer is growing rapidly, with a disproportionately higher increase in low- and middle-income countries. West Africa is particularly affected by this rise, where cancer control systems are woefully inadequate to meet the increasing needs of patients. Although many gaps exist across the continuum of cancer care, perhaps the most striking is the lack of surgical services, which plays a vital role in up to 80% of all patients with cancer. To address this critical gap in cancer care, the West African College of Surgeons established a bilateral partnership with Queen's University, Canada, to grow the surgical oncology workforce for the region by cocreating and implementing a general surgical oncology fellowship training program.METHODSTo inform the design of the curriculum tailored to the cancer care needs of West Africa, a narrative review of the literature was performed to identify the incidence and mortality associated with general surgical cancers in the region, as well as the health care resources available to address these malignancies.RESULTSThis comprehensive report provides a contemporary understanding of the landscape of cancer care with respect to the burden of disease, the existing resources, and the challenges in delivery of cancer services for West Africa.CONCLUSIONThe findings in this report quantify the unmet demand for cancer care in West Africa and highlight the scope for context-specific cancer training in this region.

Introduction Cancer care presents a huge financial burden to patients globally. This burden is particularly significant in low- and middle-income countries (LMICs) with high poverty rates and minimal sustainable funding models. In Nigeria, the most populous country in Africa with over 100,000 new cancer cases yearly, out-of-pocket costs for cancer care exceed the GDP per capita. The objective of this scoping review is to describe the available options for cancer financing for patients in Nigeria and to make recommendations for researchers and policy makers based on a review of the literature. Methods We conducted a comprehensive search of PUBMED, Economic Literature and African Medicus Index databases using a search strategy based on the core concepts of “healthcare financing”, “cancer patients” and “Nigeria”. There were no restrictions by publication timing or study design. However gray literature was excluded. Two independent reviewers conducted abstract screening and full-text review. Conflicts were reconciled by a third reviewer or by consensus where necessary. Data abstraction, synthesis, and analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. Results From 408 screened articles, 19 studies met the eligibility criteria, covering a time frame from 2008 to 2024. Most of the studies (14/19) were original research and based in urban (14/19) settings. The majority covered financing options for cancer treatment (16/19), while others covered screening and diagnosis. The available sources of cancer financing can be classified into out-of-pocket (OOP) insurance (public and private), family/relative support, loans, and non-governmental funding. Importantly, OOP was the predominant source of health care financing. Studies reported on the adverse impact of high OOP costs on catastrophic healthcare spending, delays in diagnosis as well as adherence to treatment. Studies unanimously recommended expanding private and public insurance coverage for improving financial risk protection against catastrophic health payments. Conclusion Evidence suggests that healthcare financing options are grossly limited for cancer patients in Nigeria with most patients paying OOP. We recommend the implementation of mandatory health insurance and expanded coverage for cancer care services. There is also a need for research into financing options available to patients across different settings, especially in rural and underserved regions. Furthermore, more rigorous study designs to capture financing options for both direct and indirect costs of cancer care are necessary.

Introduction: Breast cancer is the most common cancer and cause of cancer related mortality in Nigeria. The majority of women present with locally advanced disease. The current standard of care for these women is neoadjuvant chemotherapy (NAC) followed by modified radical mastectomy, including complete axillary lymph node dissection (ALND). Within the last decade, the de-escalation of axillary surgery has been extended to women who present with clinically node positive (cN1) disease who are converted to clinically node negative (cN0) after NAC. In this setting, a sentinel lymph node biopsy (SLNB) is performed using a dual-tracer localization technique with methylene blue and Tc-99 sulfur colloid. This is prohibitive to axillary de-escalation in many low- and middle-income countries (LMICs) where the nuclear medicine infrastructure, to support access to Tc-99 sulfur colloid lymphoscintigraphy, is limited. To overcome the challenge posed by the dearth of Tc-99 radiocolloid in Nigeria, this study seeks to evaluate the feasibility and efficacy of pre-operative axillary ultrasound (aUS) and a single agent (methylene blue) SLNB to stage the axilla in women converted from cN1 to cN0 disease after NAC. Methods: This is a phase II, single arm trial being conducted at Obafemi Awolowo University Teaching Hospital (OAUTH) Ile-Ife, Nigeria. Initial inclusion criteria include: women ≥ 18-70 years of age, biopsy confirmed invasive carcinoma of the breast and clinically palpable N1 disease (cN1). Eligible patients have an aUS and if abnormal nodes are present the most suspicious undergoes core biopsy and clip placement. Patients with pathology confirmed TanyN1M0 disease will undergo NAC with curative intent as per institutional standards at the discretion of the treating surgeon. Patients with a clinical complete response (cN0) at the completion of NAC will have a pre-op aUS. At the time of the operation, 5ml of 1% methylene blue is injected in an intra-parenchymal fashion with a 5-minute message. A sentinel lymph node will be classified as blue and/or suspicious by the operating surgeon. Surgeons performing the procedure have obtained additional training in the SLNB technique. Each sentinel lymph node will be removed and labelled separately and sequentially. A completion ALND (level 1-2) will be performed as per institutional practice and the contents labelled separately. Performance of the pre-operative clinical exam, aUS, SLNB and clipped node will be determined for each eligible patient. The study as research ethics board approval from OAUTH and was registered on clinicaltrials.gov prior to study initiation (NCT06039956). Results: As of June 2024, 37 patients have met initial inclusion criteria and have been consented and enrolled into the study. Nine of these have completed NAC and 6 have gone on to receive surgery as per the study protocol with a methylene blue only SLNB followed by completion axillary dissection. We expected to enrol 50 patients within the first year of the study. Target enrolment is 210 patients, which assumes a pCR of 30% and a FNR of 20% with 80% power to report on performance characteristics of the study intervention with 95% confidence intervals. Discussion: Tc-99 sulfur colloid is not readily available in many LMICs. We have designed and commenced the implementation of a protocol to study the de-escalation of axillary surgery for women who present with locally advanced, node positive breast cancer in a low-resource environment using readily available technology. Citation Format: Gregory Knapp, Olalekan Olasehinde, Rheann Brownstone, Omisore Oluwatosin, Adewale Aderounmu, Funmilola Wuraola, Toyosi Teniola Sotala, Omolade Betiku, Anya Romanoff, Folasade Adeyemi, Victoria Mango, Marcia Edelweiss, T. Peter Kingham, Olusegun Alatise. De-Escalating Axillary Surgery in Nigeria: a phase II Single Arm Trial Protocol [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2024; 2024 Dec 10-13; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2025;31(12 Suppl):Abstract nr P2-08-18.

Background:Lymphedema is one of the most prevalent yet under-recognized complication of breast cancer treatment, with its prevalence largely unexplored in Nigeria and across much of sub-Saharan Africa. Methods:A cross-sectional study was conducted among breast cancer survivors at least 6 months post-mastectomy and axillary lymph node dissection. Lymphedema was diagnosed using multiple methods: patient-reported arm swelling, arm measurements (≥2 cm difference compared to the contralateral arm), a >10% difference in extracellular water (ECW) using bioimpedance analysis, and a lower threshold of 5% to capture subclinical lymphedema. Using patient report as the gold standard, the accuracy of the various diagnostic methods was assessed. The relationship between clinical variables and lymphedema was tested using univariate logistic regression analysis. Results:Fifty-one patients with a median age of 51 years and a median duration of 40 months post-surgery (10-62 months) were evaluated. The prevalence of lymphedema was 39.2% based on symptoms, 33% using arm measurements, 22.2% using bioimpedance analysis at a threshold of >10% difference in ECW, and 46.7% at a threshold of 5%. An ECW difference of >5% had the highest sensitivity (65%), while an ECW difference at 10% threshold had the best specificity (89%). Obesity was the only clinical variable associated with lymphedema in this cohort (p = 0.018). Conclusion:Breast cancer-related lymphedema (BCRL) appears common among Nigerian breast cancer patients. Its occurrence should be preempted, particularly in obese patients in whom preventive measures may be instituted. These findings highlight the potential value of incorporating BCRL awareness and management into breast cancer care in Nigeria.

Background/Objectives: Psychological distress is a significant concern among cancer patients, negatively affecting their quality of life and adherence to treatment. The Cancer Patient Empowerment Program (CancerPEP) was developed as a comprehensive, home-based intervention aimed at reducing psychological distress by incorporating physical activity, dietary guidance, and social support. This study aimed to evaluate the feasibility, accrual and attrition rates, safety, and effectiveness of the CancerPEP intervention, with and without the biofeedback device, on psychological distress from baseline to 6 months, specifically focusing on the effects of group randomization and the difference between pre- and post-intervention results. Methods: This single-site, crossover randomized clinical trial included 104 cancer patients who were randomized to receive the CancerPEP intervention, with or without a Heart Rate Variability (HRV) biofeedback monitor. At 6 months, participants who did not receive the device were allowed to use one until the end of the year, while those who did receive the device were followed up to 12 months. Randomization was stratified by the presence or absence of clinically significant psychological distress and metastatic status. Psychological distress was assessed using the Kessler Psychological Distress Scale (K10) at baseline, 6 months, and 12 months. The primary endpoint was the presence of nonspecific psychological distress, as measured by the K10 scale at 6 months from the trial start, based on group randomization. A secondary exploratory analysis assessed psychological distress at baseline, 6 months, and 12 months for both groups, while controlling for group randomization and prognostic covariates. Prognostic covariates included age; comorbidities; time between diagnosis and randomization; treatment modality; relationship status; and use of prescribed medications for anxiety, depression, or both. An exploratory sub-analysis was conducted for the breast cancer subgroup, based on the sample size available after recruitment. The trial is registered at ClinicalTrials.gov (NCT05508412). Results: The provision of the HRV biofeedback monitor in conjunction with the CancerPEP intervention did not significantly affect the primary outcome in either the full sample or the breast cancer subgroup, indicating that the HRV biofeedback provision was not beneficial in this trial. No self-reported or otherwise discovered adverse events at the 6-month mark were observed. About 10% of participants were lost to follow-up in both the early and late HRV monitor provision groups. Participation in the CancerPEP program led to a significant reduction in psychological distress over time. The odds of psychological distress were significantly higher at the start of the trial than at the end of the intervention (aOR = 2.64, 95% CI: 1.53–4.56) or 6 months after the intervention (aOR = 2.94, 95% CI: 1.62–5.30). Similarly, in the breast cancer subgroup, distress was higher at the trial’s start than at 6 months, i.e., after the intervention (aOR = 2.25, 95% CI: 1.24–4.08), or at the end of the trial at 12 months (aOR = 2.73, 95% CI: 1.35–5.52). Conclusions: CancerPEP significantly reduces psychological distress in cancer patients, with consistent improvements noted across various cancer types and stages, including benefits specifically for breast cancer patients. These findings build upon the success of the Prostate Cancer Patient Empowerment Program (PC-PEP), indicating that a similar comprehensive intervention can be advantageous for all cancer patients and may be further tailored to address specific needs. With its holistic approach—encompassing physical, dietary, and psychosocial support—CancerPEP shows promise as a vital component of survivorship care. Ongoing 24-month evaluations will yield critical data on its long-term benefits. Additionally, a randomized trial with a control group (usual care without intervention) for breast cancer patients is currently under way and could potentially guide the integration of CancerPEP into standard oncology care to enhance patient outcomes and quality of life.

BACKGROUND:Most patients pay out-of-pocket for cancer care in Nigeria, which can result in a catastrophic health care expenditure (CHE). There is a paucity of economic data on the cost of care and the impact this may have on the household. This study provides a prospective analysis of direct and indirect out-of-pocket costs for breast cancer care at a single tertiary care institution in South West Nigeria. METHODS:Consecutive patients undergoing curative intent treatment for a new diagnosis of breast cancer between August 2019 and September 2022 were approached for enrollment. A novel questionnaire was delivered to patients during hospital admission and again during six-month follow-up. Patients self-reported annual household income, capacity-to-pay, and all direct and indirect expenditures associated with access care. A CHE was defined using three commonly used definitions, including total healthcare expenditure that exceeds 40 % of a household's capacity-to-pay, or exceeds the proportion of annual income set at thresholds of 10 % and 25 %. RESULTS:Data were collected from 71 eligible patients with a mean age of 49.5 years (SD 11.26). Sixty-six percent (47/71, 66.2 %) of patients had ≥ Stage III disease at presentation, and 95.8 % received systemic chemotherapy. Only 23.9 % received adjuvant radiotherapy. The mean annual capacity-to-pay for the cohort was $2866.93 (SD $2749.74). The mean cost of care was $5192.77 (SD $4567.71). Out of the 71 patients enrolled in the study, between 56 (78.9 %) and 71 (100 %) experienced a CHE, depending on the included costs (direct +/- indirect) and threshold used. Sixty-six percent of patients had no form of health insurance. CONCLUSIONS:Over 70 % of breast cancer patients at a tertiary care facility in Nigeria experience a CHE because of out-of-pocket costs associated with accessing care. POLICY SUMMARY:A more effective and accessible health insurance mechanism is required in Nigeria to protect women with breast cancer from the cost of cancer care.

Purpose Breast cancer related lymphedema (BCRL) is a common complication of breast cancer treatment. Despite patients in sub-Saharan Africa being significantly at risk, very limited data exist on the subject in this context. Hence this study. Methods A crossectional study of survivors, at least 6 months post-mastectomy and axillary lymph node dissection (ALND). Lymphedema was diagnosed using multiple techniques: self-report of arm swelling, arm measurement (≥ 2cm difference from contralateral arm), > 10% difference in extracellular water (ECW) using bioimpedance analysis and a lower threshold of 5% to include patients with subclinical lymphedema. With self-report as the reference, the accuracy of the various diagnostic methods was assessed. The relationship between lymphedema and clinical variables was tested using univariate logistic regression analysis. Results Fifty one patients with a median age of 51years and a median duration of 40 months post-surgery (10–62 months) were evaluated. The prevalence of lymphedema was 39.2% based on symptoms, 33% using arm measurements, 22.2% using bioimpedance analysis at a threshold of > 10% difference in ECW and 46.7% at a threshold of 5%. ECW difference of > 5% had the highest sensitivity (65%) while ECW difference at 10% threshold had the highest specificity (89%). Obesity was the only variable associated with lymphedema in this cohort (p = 0.018). Conclusion This is the first series on BCRL among survivors using conventional and contemporary detection techniques in the Nigerian context. The high rate reported in this cohort provides a strong justification to preemptively adopt interventions to either mitigate its occurrence or limit its progression.

Background and ObjectivesProspective data on presentation and outcomes of colorectal cancer (CRC) in Nigeria are limited; however, emergency presentation with advanced disease is thought common. MethodsConsecutive CRC patients presenting at six sites over 6 years were included. Risk factors for emergency presentation were evaluated using logistic regression methods. Overall survival (OS) was compared between emergent and elective patients using Kaplan-Meier methods and the log-rank test. ResultsOf 535 patients, 30.7% presented emergently. Median age was 56 years, 55% were men, and 5.0% reported a cancer family history. Emergency patients had more proximal cancers (42.1% vs. 24.0%), Stage IV disease (61.6% vs. 40.2%; p < 0.001), lower household income ((sic)35 000/month vs. (sic)50 000/month), lower education levels (p = 0.008) and accessed care with nonmotorized transport (50.6% vs. 37.2%; p = 0.005). Median OS was shorter in the emergency group (6.4 vs. 17.4 months; p < 0.001). Across clinical stages, emergency presentation was associated with worse OS (Stage IV median OS 4.8 vs. 9.4 months; p = 0.002). Surgery improved survival in both groups, although emergency patients had higher 30-day postoperative mortality (23.2% vs. 9.1%; p < 0.001). ConclusionsEmergent Nigerian CRC patients have worse OS than elective patients. Cancer control efforts should focus on faster cancer detection, early presentation, diagnosis, and treatment.

Introduction: The incidence of triple negative breast cancer (TNBC) in West Africa appears to mirror the higher incidence of the disease among African American women in the United States. However, there remains a paucity of molecular data on TNBC from sub-Saharan Africa, despite the emergence of effective immunotherapies. Methods: Consecutive patients diagnosed with invasive breast cancer between March 2018-Jan 2020 were identified from a prospective clinical database and paired biobank at Obafemi Awolowo University Teaching Hospital (OAUTH). All specimens were processed and fixed in formalin within 60 minutes of excision by a trained pathologist. Tissue sections (4μm thick) representative of tumor were selected for routine evaluation of estrogen, progesterone and human epidermal growth factor receptor-2 expression by immunohistochemistry. This was performed at OAUTH with adequate controls according to the ASCO/CAP guidelines and verified at an outside institution for quality assurance. Additional sections from the FFPE blocks of TNBC specimens were further stained using the Dako PharmDx 22C3 PD-L1 commercial assay according to manufacturer protocols at Dalhousie University. External on-slide controls included tonsil, PD-L1 negative TNBC, and PD-L1 positive TNBC. PD-L1 expression was scored using the combined positive score (CPS), which is the number of 22C3 staining tumour cells, lymphocytes, and macrophages divided by the number of viable tumour cells, multiplied by 100. The threshold for a positive result was a CPS of ≥10 as per manufacturer instructions and institutional protocol. Research ethics board approval as well as data and material transfer agreements between institutions was obtained for this study. Results: From 85 cases, 32 were TNBC (37.6%). The mean age and BMI were 49.6±SD 7.7 and 26.2±5.7, respectively. The majority of patients presented with locally advanced disease (64.2% Stage III, 14.2% Stage IV). Seventy-nine percent (78.5%) of patients received an average of five cycles of neoadjuvant chemotherapy (SD 2.3). From 32 TNBC specimens, 27 had available FFPE tissue blocks, and of those, 24 had interpretable PD-L1 IHC for inclusion in the analysis. A total of 37.5% (9/24) of cases demonstrated a CPS ≥10. Conclusions: Over a third of breast cancer specimens in this Nigerian cohort were triple negative, 37.5% of which had PD-L1 CPS scores of ≥10. These results suggest a large proportion of patients in Nigeria may benefit from access to immunotherapy. This is the first reported incidence of PD-L1 expression in breast cancer from sub-Saharan Africa. Citation Format: Olalekan Olasehinde, Funmilola Wuraola, Aleksandra Kajetanowicz, Gilllian Bethune, Marcia Edelweiss, Peter Ntiamoah, Oluwole Odujoko, Avinash Sharma, Victoria Mango, Peter Kingham, Olusegun Alatise, Gregory Knapp. Programmed death ligand-1 expression in triple-negative breast cancer from Nigeria [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-23-17.

The African Research Group for Oncology (ARGO) was formed in 2013 to undertake methodologically rigorous cancer research in Nigeria, and to strengthen cancer research capacity in the country through training and mentorship of physicians, scientists, and other healthcare workers. Here, we describe how ARGO's work in colorectal cancer (CRC) has evolved over the past decade. This includes the consortium's scientific contributions to the understanding of CRC in Nigeria and globally and its research capacity‐building program.

PURPOSEMammography, breast ultrasound (US), and US-guided breast biopsy are essential services for breast cancer early detection and diagnosis. This study undertook a comprehensive evaluation to determine population-level access to these services for breast cancer early detection and diagnosis in Nigeria using a previously validated geographic information system (GIS) model.METHODSA comprehensive list of public and private facilities offering mammography, breast US, and US-guided breast biopsy was compiled using publicly available facility data and a survey administered nationally to Nigerian radiologists. All facilities were geolocated. A cost-distance model using open-source population density (GeoData Institute) and road network data (OpenStreetMap) was used to estimate population-level travel time to the nearest facility for mammography, breast US, and US-guided biopsy using GIS software (ArcMAP).RESULTSIn total, 1,336 facilities in Nigeria provide breast US, of which 47.8% (639 of 1,336) are public facilities, and 218 provide mammography, of which 45.4% (99 of 218) are public facilities. Of the facilities that provide breast US, only 2.5% (33 of 1,336) also provide US-guided breast biopsy. At the national level, 83.1% have access to either US or mammography and 61.7% have access to US-guided breast biopsy within 120 minutes of a continuous one-way travel. There are differences in access to mammography (64.8% v 80.6% with access at 120 minutes) and US-guided breast biopsy (49.0% v 77.1% with access at 120 minutes) between the northern and southern Nigeria and between geopolitical zones.CONCLUSIONTo our knowledge, this is the first comprehensive evaluation of breast cancer detection and diagnostic services in Nigeria, which demonstrates geospatial inequalities in access to mammography and US-guided biopsy. Targeted investment is needed to improve access to these essential cancer care services in the northern region and the North East geopolitical zone.

Peritoneal mesothelioma (PM) is a rare malignancy originating from the peritoneal lining. Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) is the standard‐of‐care for patients with isolated PM. Due to a paucity of prospective data there are several different HIPEC protocols. The aims of this study are to describe the CRS and HIPEC protocols for PM and patient outcomes across Canada.

Aldehyde dehydrogenase 1A3 (ALDH1A3) is a cancer stem cell marker that promotes metastasis. Triple-negative breast cancer (TNBC) progression has been linked to ALDH1A3-induced gene expression changes. To investigate the mechanism of ALDH1A3-mediated breast cancer metastasis, we assessed the effect of ALDH1A3 on the expression of proteases and the regulators of proteases that degrade the extracellular matrix, a process that is essential for invasion and metastasis. This revealed that ALDH1A3 regulates the plasminogen activation pathway; it increased the levels and activity of tissue plasminogen activator (tPA) and urokinase plasminogen activator (uPA). This resulted in a corresponding increase in the activity of serine protease plasmin, the enzymatic product of tPA and uPA. The ALDH1A3 product all-trans-retinoic acid similarly increased tPA and plasmin activity. The increased invasion of TNBC cells by ALDH1A3 was plasminogen-dependent. In patient tumours, ALDH1A3 and tPA are co-expressed and their combined expression correlated with the TNBC subtype, high tumour grade and recurrent metastatic disease. Knockdown of tPA in TNBC cells inhibited plasmin generation and lymph node metastasis. These results identify the ALDH1A3-tPA-plasmin axis as a key contributor to breast cancer progression.

Abstract Introduction A major barrier to timely breast cancer diagnosis and care in Nigeria is attributable to the out-of-pocket cost of accessing healthcare services, despite the presence of a National Health Insurance Scheme (NHIS). Excessive out-of-pocket payments are often associated with a catastrophic health care expenditure (CHE). Despite the rising incidence of breast cancer in Nigeria, there is a paucity of economic data on the cost of care and the impact healthcare expenditure may have on a household. This study provides a comprehensive, prospective analysis of out-of-pocket spending for breast cancer care at a single tertiary care institution in South West Nigeria. Methods Consecutive patients undergoing curative intent surgery for a new diagnosis of breast cancer at Obafemi Awolowo University Teaching Hospital (OAUTH) between August 2019-April 2022 were approached for enrolment. A novel, context specific questionnaire was developed for this study and administered by trained personnel. The questionnaire was delivered to patients and caregivers during hospital admission and again during six-month follow-up. Participants were asked to estimate monthly household income and expenditures. Out-of-pocket direct and indirect expenses for breast cancer diagnosis and care were elicited. Where feasible, hospital accounting records and individual receipts were used to minimize recall bias. Sequelae of the out-of-pocket costs were also elicited, such as the use of debt financing and important forgone expenditures, such as childhood education. Capacity-to-pay was calculated for each household from the provided data as the sum of annual non-food expenditures. A CHE was defined as an aggregate healthcare expenditure that exceeded 40% of a household’s capacity-to-pay. All monetary figures were collected in the local currency (Naira) and converted to USD using the Nigerian Central Bank conversion rate of 415.83N to 1USD. Research ethics board approval was obtained for this study from OAUTH. Results Data were collected from 57 eligible patients with a mean age of 49.8 years (SD 12). The median household size was five (range 1-10) and the majority (75.4%) had completed at least secondary education. Seventy four percent (73.6%) of patients had ≥ Stage III disease at presentation and 89.5% received systemic chemotherapy. Only seven percent (4/received adjuvant radiotherapy. The mean annual capacity-to-pay for the cohort was $2,840.8 ($2,913.6). The mean cost of care, including direct and indirect expenditure was $3,379.7 (SD $3032.2). Excluding indirect costs, such as the cost of travel and self-reported lost income, the mean cost of direct expenditures associated with diagnosis and treatment was $1,705.3 (SD $1,236.6). Out of the 57 patients enrolled in the study 52 (91.2%) experienced a CHE as a result of their breast cancer treatment. As a result, 56% of households had to borrow money and seven percent withdrew children from school. Sixty-three percent of patients had no form of health insurance. Conclusions Over 90% of breast cancer patients at a tertiary care facility in Nigeria experience a CHE as a result of out-of-pocket costs associated with accessing care. This limits access to costly evidence-based adjuncts (i.e. radiotherapy) and has a negative impact on the wellbeing of the broader household. There is a need for national and global initiatives to ensure financial protection from the cost of breast cancer care. Citation Format: Funmilola Wuraola, Chloe Blackman, Israel Adeyemi Owoade, Adeoluwa Oluwaseyi Adeleye, Peter Kingham, Olusegun Alatise, Gregory Knapp. The Out-of-Pocket Cost of Breast Cancer Care in Nigeria: A Prospective Analysis [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-07-46.