Fidelity and adaptation of breast cancer resource-stratified treatment guidelines in Botswana

项目摘要 乳腺癌是全球女性癌症死亡的主要原因， 2018年报告了626，000例死亡。尽管乳腺癌死亡率在2010年大幅下降， 发达国家、低收入和中等收入国家（LMICs）继续经历高增长， 死亡率这种差距在撒哈拉以南非洲和艾滋病毒感染者中更为明显 流行地区，其中艾滋病毒感染（艾滋病毒+）乳腺癌患者有显着 增加了全因死亡的风险。世界卫生组织-选择干预措施 “具有成本效益”的研究小组评估了乳腺癌的系统性治疗， SSA具有成本效益。随后，强有力的循证资源分层指南 旨在促进SSA的高质量乳腺癌治疗。无论多么关键 缺乏有关治疗保真度和基于指南的实施的真实数据 在乎这些数据对于理解较差的结果是否与 准则实施的质量或程度或其他无关因素。如果干预措施， 有针对性地实施最大化治疗保真度并最小化随机变异性 可能会取得成果。 长期目标是改善HIV+和HIV-乳腺癌患者的生存结局 通过设计有针对性的干预措施，以增加高质量的治疗提供。的 本申请的目的是让Martei博士正式培训成为一名独立的 研究人员在实施科学在癌症护理提供在SSA，并获得实际的 通过以下研究目标的技能：1）比较艾滋病毒+和艾滋病毒-之间的治疗保真度 接受治疗性治疗的乳腺癌患者，并确定保真度的HIV修饰剂; 2） 采用混合方法设计和高、低保真度患者的偏离样本 确定忠诚的社会经济和文化修饰符;和3）使用协作 制定干预规划框架，以确定适应指南的目标并制定菜单 实施战略和干预试验，以促进治疗的保真度。本研究 博茨瓦纳建立在博茨瓦纳和大学之间15年的合作研究基础上 宾夕法尼亚州，包括一个由美国和博茨瓦纳高级导师组成的多学科小组， 以及强大的公共资助的艾滋病和乳腺癌医疗保健系统。这与 国家癌症研究所全球健康优先领域中心“加强全球 癌症研究和资源适当的癌症控制策略"，以促进癌症 在中低收入国家开展循证和可持续的研究和控制工作。

Project Summary Breast cancer is the leading cause of cancer mortality among women globally with over 626,000 deaths reported in 2018. Despite substantial reductions in breast cancer mortality in developed countries, low- and middle- income countries (LMICs) continue to experience a high fatality rate. The disparity is more pronounced in Sub Saharan Africa (SSA) and in HIV prevalent regions, where HIV-infected (HIV+) breast cancer patients have a significantly increased risk of all-cause mortality. The “World Health Organization-Choosing Interventions that are Cost-Effective” team assessed systemic treatment for breast cancer at 95% coverage in SSA as cost-effective. Subsequently robust evidence-based resource-stratified guidelines have been developed to promote high quality breast cancer therapy delivery in SSA. However critical real-world data are lacking on the treatment fidelity and the implementation of guideline-based care. These data are critical to understanding whether inferior outcomes are related to the quality or extent of guideline implementation or other unrelated factors. If interventions that maximize treatment fidelity and minimize random variability are implemented, targeted outcomes will likely be achieved. The long-term goal is to improve survival outcomes in HIV+ and HIV- breast cancer patients in SSA by designing targeted interventions to increase high-quality therapy delivery. The objectives of this application are to allow Dr. Martei to formally train to become an independent investigator in implementation science in cancer care delivery in SSA, and to obtain practical skills through the following research aims: 1) compare treatment fidelity between HIV+ and HIV- breast cancer patients receiving curative intent therapy and identify HIV modifiers of fidelity; 2) using mixed methods design and a deviance sample of patients with high and low fidelity identify socioeconomic and cultural modifiers of fidelity; and 3) using the collaborative intervention planning framework to identify targets for guideline adaptation and develop a menu of implementation strategies and intervention trials to promote treatment fidelity. This study in Botswana builds upon 15 years of collaborative research between Botswana and the University of Pennsylvania, including a multidisciplinary group of US- and Botswana-based senior mentors, and the strong publicly-funded healthcare system for HIV and breast cancer. This is aligned with the National Cancer Institute Center for Global health priority areas of “Strengthening Global Cancer Research and Resource-Appropriate Cancer Control Strategies” to promote cancer research and control efforts that are evidence-based and sustainable in LMICs.