PURPOSEThe growing cancer burden in Botswana has been linked to aging, lifestyle factors, and high HIV infection prevalence. The government has designated four geographically distributed hospitals as public oncology centers (POCs). A needs assessment was undertaken to ascertain the characteristics of cancer care at these centers.METHODSA multisite cross-sectional survey study of cancer care was conducted with oncology staff at Princess Marina Hospital (PMH), Nyangabgwe Referral Hospital (NRH), Sekgoma Memorial Hospital (SMH), and Letsholathebe II Memorial Hospital (LMH) from February to April 2021. At each POC, a focal person (experienced nurse working in oncology) identified relevant oncology staff and confirmed service availability.RESULTSOnly PMH and NRH had a broad array of diagnostic, surgical, and treatment services. In addition, PMH was the only center with a a dedicated inpatient oncology service, a multidisciplinary committee to review patients, and a palliative care team. To support the only national cancer screening program, for cervical cancer, all POCs offered Pap tests. Mammography, available at PMH and NRH, was used solely for diagnosis. Patients from POCs requiring radiation therapy were referred to Gaborone Private Hospital at government expense. For perceived service availability, 51 staff, mainly oncologists, physicians, and nurses, were surveyed (66% based at PMH). Perceptions of services revealed a few concerns, for example, numerous staff considered hysterectomies for cervical cancer available when they were only performed at PMH.CONCLUSIONDespite Botswana's efforts to increase the proximity of cancer services to patients, there are marked gaps, particularly at the two district-level POCs, SMH and LMH. In the future, SMH and LMH could provide selected services for specific prevalent cancers on-site, as well as follow-up and palliative care.

PURPOSE High-level investment in cancer prevention and control in low- and middle-income countries is urgently needed to address the predicted surge in cancer incidence, yet few assessments of health systems have systematically identified gaps in infrastructure, training, and patient care in sub-Saharan Africa. In Botswana, we evaluated the current state of cancer care and prevention, to understand the strengths, weaknesses, and needs regarding the provision of comprehensive cancer services. METHODS The study evaluated four regional hospitals designated as cancer sites by the Botswana Ministry of Health and Wellness to decentralize cancer services. A multi-site, cross-sectional evaluation using qualitative and quantitative methods was conducted. Focus Group Discussions with cancer patients, cancer survivors, caregivers, the general population, and healthcare workers were analyzed for emergent themes. Quantitative surveys assessed knowledge, attitudes and practices of health workers and hospital management staff, and cancer service gaps at health facilities. RESULTS Knowledge gaps included low awareness of cancer signs and symptoms among the general population, poor knowledge of early detection and treatment among health workers, and caregivers lacked skills to support cancer patients. Cancer screening services, other than cervical screening, were limited in all sites. Diagnosis and treatment barriers included lack of specialized personnel, equipment, timely pathology services, and drug stockouts. There were low levels of confidence in cancer management, including chemotherapy, without support from oncologists. Providers reported low patient screening uptake due lack of access and patients reported fear of diagnosis. Health facilities did not routinely notify cancers to the national registry. Radiotherapy was limited to one private hospital in the capital. CONCLUSION Decentralization of cancer services to regions will require substantial capacity building at district hospitals to strengthen fragmented screening, early diagnosis and treatment services. Health provider training needs and infrastructure gaps were substantial, with low public awareness of cancer signs, symptoms and causes.

Purpose: Oncologic emergencies contribute to a large proportion of morbidity and mortality for oncology patients, who present unique medical challenges due to disease and treatment complexities. Emergencies training of medical staff is important, particularly if there is high turnover. We describe the development and implementation of a program to enhance timely recognition and treatment of oncologic emergencies. Due to the COVID19 pandemic, sessions were conducted virtually. Methods: Healthcare workers who normally care for oncology patients at Princess Marina Hospital (PMH) were invited to participate in a series of weekly virtual case-based lectures. Didactic content was developed between Botswana and Rutgers faculty and fellows to reflect specific management and resources available at PMH. Participation was through live chat case reviews and pre- and post- session questions. Feedback was elicited through Likert-scale surveys. Results: An average of 19 participants (range 13-29) attended the training sessions. Average make-up per session were as follows: 16% physicians, 26% Medical Officers, 4% Internal Medicine Residents, 32% nurses, 21% other. Healthcare workers from Botswana were invited to participate in content preparation and presentation to their peers; 3 of 8 presentations were by Botswana personnel. Average pre-session test score was 70% (range 40-89%); post-session score was 82% (range 55-97%). In post sessions surveys, average confidence in diagnosis and recognition across emergencies was 84% (range 71-100%); average confidence in management was 81% (range 57-100%). Conclusions: We describe the successful piloting of a case-based virtual training program in oncologic emergencies, which to our knowledge is the first of its kind. The program was adapted to the Botswana health care setting. Overall, confidence in diagnosis, recognition and management of oncologic emergencies appeared to increase after sessions. Plans are in place to expand the series to more sites within the country, most of which do not have dedicated oncology trained staff. Citation Format: Sharon Li, Sadaf Qureshi, Reena Antony, Kara Wilson, Robert Moumakwa, Refeletswe Lebelonyane, Tendani Gaolathe, Mansi Shah, Pallvi Popli, Ashwin Chandar, Sukhdeep Kaur, Richard Marlink, Tina Mayer, Peter Vuylsteke, Tlotlo Ralefala. Development and Implementation of a Case-based Virtual Training Program for Oncologic Emergencies in Botswana [abstract]. In: Proceedings of the 9th Annual Symposium on Global Cancer Research; Global Cancer Research and Control: Looking Back and Charting a Path Forward; 2021 Mar 10-11. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2021;30(7 Suppl):Abstract nr 84.

PURPOSE Shortages in oncology-trained health care providers pose a major challenge in low- and middle-income countries (LMICs) and contribute to delays in the diagnosis and treatment of cancer. Presently, the sole oncologist in the public sector at Princess Marina Hospital, Botswana’s largest oncology referral center, is overextended, causing medical officers to be the primary providers for patients with cancer. Medical officers do not possess formal oncology training, which can potentially lead to imprecise management and suboptimal treatment. In addition, there is no standardized patient interview process in the hematology clinic, leading to inadequately captured patient records. These realities highlight the need for the dissemination and implementation of evidence-based guidelines and intake forms to standardize the delivery of cancer care for practitioners with varying degrees of training. METHODS To serve as a reference for medical officers and oncologists, we reviewed clinical guidelines for the most prevalent cancers in Botswana, namely breast, cervical, prostate, colorectal, and head and neck cancer. We incorporated American Joint Committee on Cancer 8th edition staging criteria into the preexisting guidelines approved by Ministry of Health and Wellness Botswana. We further customized them on the basis of radiology, pathology, and pharmaceutical resource availability in Botswana. Finally, to streamline patient visits, we created intake forms to capture comprehensive hematology-pertinent information. As a quality improvement project, we will record the use and impact of these forms as a tool to standardize the medical records. RESULTS Standardized cancer care guidelines were updated and are under review by the Ministry of Health and Wellness Botswana before circulation. In addition, feedback regarding the new intake forms and their use is currently being recorded. CONCLUSION In low- and middle-income countries, the development of cancer-specific treatment guidelines optimizes disease management through incorporation of evidence-based, resource-adjusted recommendations for clinicians and may aid in reducing global oncologic disparities. As the next phase in the implementation of guidelines, we plan to develop quick-reference cancer pathways for use in public institutions without existing oncologic expertise.

159 Background: With cancer accounting for 1 in every 7 deaths worldwide and 60-70% of cancer deaths occurring in low- and middle-income countries, any advancement in cancer care should include understanding to alleviate structural inequalities that produce these global oncological disparities. Rutgers-Cancer Institute of New Jersey (R-CINJ) Oncology Fellowship program, through partnerships with Rutgers Global Health and University of Botswana (UB), established a global oncology program in 2018 to provide young oncologists in training with this educational opportunity. Aims included understanding challenges faced by cancer patients in Botswana, evaluating opportunities to improve oncology care at Princess Marina Hospital (PMH), scholarly collaborations, and exchange knowledge. Methods: In partnership with PMH, UB, and Ministry of Health and Wellness (MOHW), R-CINJ created a global oncology program consisting of a 1 month rotation at PMH in Gaborone, Botswana, as well as longitudinal research/quality improvement (QI) projects. Two 3rd year oncology fellows rotated with house officers and oncologist at PMH. Weekly video conferences facilitated communication during the elective. Projects continued throughout 3rd year of fellowship, in conjunction with programmatic meetings. Results: Fellows gained exposure to cancer care using limited resources. In working with PMH staff, mentorship was provided, QI ideas were shared, and organizational changes were implemented. Scholarly activity was undertaken to examine trends in chemotherapy utilization at PMH over a 12-month period to assess patterns of malignancy and issues with stock outs. Relationship between pathology at PMH, UB, and Rutgers-CINJ and Rutgers Biomedical Engineering was established to expand digital pathology services in Botswana. Conclusions: Our global oncology program is a successful start to an ongoing partnership to help improve cancer care in Botswana. Future directions include development of cancer protocols in Botswana, helping limit medication shortages, and establishing telemedicine based collaboration to assist with diagnosis and improve pathology turnaround time.

e18309 Background: As a significant percentage of cancer deaths are occurring in low- and middle-income countries, there is an unmet need in facilitating cancer care delivery in these countries. Data on stock-outs and shortages of cancer medicines in Botswana have been reported as one of the roots hindering treatment and potentially increasing mortality, with at least 40% of essential drugs being out of stock for at least 30 days in 2015. A methodologic approach was published in 2018 to forecast chemotherapy (CT) volume, however, this was based on incidence and prevalence data, using multiple estimated assumptions. To obtain objective data, we examined trends in CT utilization at Princess Marina Hospital (PMH), largest referral hospital in Botswana, over a 12-month period evaluating indications for CT, dosages, and potential issues with stock outs of essential medications. Here we present the 21 injectable essential CT utilized during this period. Methods: This is a retrospective analysis, with data collected from October 2017 to September 2018 from the log book which is used daily by the pharmacy at PMH to record CT preparations. Data was organized to reflect dosage of CT, regimen used, and its indication. Results: Over 1 year period, 21 injectable CT agents were utilized for cancer therapy, with common treated diseases being Kaposi Sarcoma, Gyn cancer, Breast cancer, and Lymphomas. The 10 most utilized agents are listed with the monthly dosage used. Conclusions: We hope to analyze trends in CT utilization based on the available stocks of drugs at PMH to help optimize plans for purchasing and storing medications, with goal of reducing stock outs. In addition, we will analyze treatment regimens used at PMH and compare to current standard of care CT in the US and Sub-Saharan Africa to optimize cancer pathway protocols used in Botswana. [Table: see text]