Diagnostics play a critical role throughout the course of a person’s cancer journey. They are used to confirm cancer, stage a person’s disease, plan treatment and monitor response, with the net effect that people with cancer are expected to have shorter, more efficient journeys, likely with better outcomes and at lower cost.1 Yet with poor accessibility to quality, timely cancer diagnostics in most low-income countries impeding the quality of cancer care, how do we accelerate action to close the gap?
The World Health Organization’s recognition in 2018 of diagnostics as an essential component of an effective healthcare delivery system was a major step towards promoting investment in low-income settings.2 The recent Lancet Commission also points to the spotlight on diagnostics afforded by the COVID-19 pandemic as an opportunity to raise awareness of the scarcity of diagnostic capacity. The fact remains that 47% of the world’s population does not have adequate access to even basic diagnostics, dropping to a staggering estimated 19% in low-income and lower-middle-income countries.3
The reality is that quality-assured diagnosis is often a low priority in cancer control planning. This is despite documented delays in diagnosis in low- and middle- income countries where median time intervals between symptom discovery and the start of cancer treatment are reported to be three to eight months (compared to a median of 30 to 48 days in high-income countries).4 The example of breast cancer is striking—symptom misinterpretation, misdiagnosis and mismanagement as a result of health system gaps have been found to be frequent reasons for women in sub-Saharan Africa experiencing long diagnostic intervals and inappropriate treatment that in-turn result in poor outcomes. Addressing these health system barriers through quality improvements in services and infrastructure, health workforce and health technologies is therefore a critical step in ensuring patients receive the right treatment at the right time.5
There is often a misconception that diagnostics only come into play at the start of a patient's cancer journey. This can lead to a tendency to isolate diagnostics from treatment and care, thereby exacerbating existing siloes, and running the risk of widening the social equity gap.
Instead, building diagnostic capacity requires a systems lens—strengthening in parallel the service delivery, technologies, health workforce, information systems, governance and financing to support quality and timely diagnostics across the continuum of care. Through our work supporting cities to identify, design and develop cancer care solutions that respond to local needs, City Cancer Challenge (C/Can) is helping to build strong multi-stakeholder relations and collaborations across and between all of the elements of a health system so that cities are best placed to close the access gap to quality and timely cancer diagnosis.
The unique and long-standing challenges faced by many low-income countries requires a dedicated and contextualized approach to quality improvements.6,7 C/Can has been working with the American Society for Clinical Pathology (ASCP) in partnership since 2017, with their team lending technical expertise and experience to help assess existing diagnostic services, identify gaps and support implementation planning and execution in cities in low- and middle- income countries.
One of the first steps taken in a C/Can city is convening a City Executive Committee (CEC), bringing together representatives from the main public and private institutions providing cancer care, local and national government, academia, and civil society, to guide and oversee the C/Can process in the city. The Committee in turn appoints a multi-disciplinary Technical Committee of local experts to coordinate the collection of high quality, systems-level data to support local decision-making.
The robust situation analyses ensuing from this city-wide needs assessment has reinforced that diagnostic services are almost always lacking adequate quality and are significantly under-resourced.8 For example, the situation analysis in Kumasi, Ghana that incorporated contributions from 258 healthcare professionals from 38 institutions identified a critical need to strengthen the local health system capacity to reduce diagnostic and treatment intervals, and implement high-quality, integrated and effective cancer diagnostic services that are adapted to the local context.
Dr. Akosua Gyimah Omari-Sasu, Director of Health at the Kumasi Metropolitan Assembly and member of the CEC, is helping to lead the C/Can city initiative in Kumasi. “The City Needs Assessment was a first for Kumasi in bringing together such a diverse group of stakeholders around the table,” says Dr. Omari-Sasu. “Through identifying the gaps and opportunities together, we have been able to build consensus and collectively arrive at solutions that effectively meet shared goals.”
As an outcome of the assessment, the identified needs have been translated into 12 projects (eight of which are supported by technical assistance from C/Can), including projects focused on strengthening pathology and imaging in Kumasi.
With the support of the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) on behalf of the German Federal Ministry for Economic Cooperation and Development (BMZ), C/Can is working with local experts and suppliers in Kumasi and global partners like ASCP to strengthen the capacity across the city’s diagnostic ecosystem. This includes collaborating on improving the availability of priority technologies, for example, implementing solutions on the requirements for a city-wide Laboratory Networking System for pathology testing, as well as developing and implementing a standardised pathology reporting system in the city’s main laboratories.
The extraordinary pace and scope of innovations in technology and informatics also promises transformation across all aspects of diagnostic capacity.9 As well as opening up opportunities to apply leapfrog high-quality diagnostics in low-income countries, including digital pathology,10 the adoption of digital health technologies to reduce fragmentation in services and improve the quality of reporting, for example, through standardization, is increasing.
At the end of the day, the solutions have to meet the local realities and needs of the individuals: for the people who are delivering, as well as receiving the diagnostics. Diagnostic solutions must be usable, they have to facilitate, rather than create additional barriers or siloes, and ultimately empower healthcare providers with the information they need, when they need it to make informed, and often life-saving decisions.
Photo Copyright: City Cancer Challenge. Photographer: Santiago Esteban
As the project coordinator for the C/Can city project aimed at improving the capacity and quality improvement of pathology diagnosis, and Head of the Laboratory Services Directorate at the Komfo Anokye Teaching Hospital (KATH), Dr. Ernest Kwasi Adjei champions the voice of local experts. “It is vital for local pathologists and technicians, the individuals working in the local labs and who understand the needs on the ground, to have real input into the development of local protocols and processes, “ says Dr. Kwasi Adjei. “Throughout this project, there has been a real sense of local ownership and it has been a huge source of reward in knowing that I have personally contributed to a policy or process that will have long-lasting impact.”
This needs driven approach is also good for providers. In their 2021 report on the state of global diagnostics,11 The World Economic Forum highlighted that better understanding of user input, contextual awareness, cultural and social concerns and the applicability of reference data were all key considerations in improving diagnostic performance in all markets.
Photo Copyright: City Cancer Challenge. Photographer: Santiago Esteban
Quality, accessible and affordable cancer diagnostic solutions exist, and they can and do work in resource-constrained settings. Traditionally, where we have often stumbled is the ability to convene the right people and bring the right partners to the table to identify those solutions and to support their planning and implementation. At the local level, impactful multisectoral action to adapt and apply innovations in infrastructure including digital, workforce and health financing, remain limited, and cancer diagnostics remain undervalued and inadequately resourced.
Through the city-wide collaboration approach, we are seeing a noticeable shift taking place where individuals and organizations are coming together and discussing collectively what needs to happen and having more substantive conversations about moving forward. And, as the gap between the private and public sectors are being bridged, and as we witness a groundswell of startups and emerging digital solutions, how do we leverage this moment and help connect the dots?
One way is through more inclusive, collective and targeted actions. C/Can, along with its partners, including ASCP, is helping to form a Global Coalition for Cancer Diagnostics, a public-private initiative of diagnostic organizations, civil society, local innovators, and advanced start-ups and healthcare professionals, dedicated to identifying, enabling and accelerating the development and implementation of cancer diagnostics and technologies in low-income countries, starting with Ghana in Kumasi.
Working alongside ASCP and its members, I am struck by the commitment of the pathology community to delivering high-quality diagnostics for patients. Though, as pathologists, laboratory professionals and researchers (my own background is in translational research, specifically identifying biomarkers of outcomes and drug response), we may not necessarily think about implementation in other settings. However, by sharing the lessons-learned and experiences from C/Can cities, it not only helps the transfer of knowledge, but can potentially lead to a deeper exploration of solutions and how they can be adapted, as well as to help to inspire leapfrog processes and technologies for low-income countries. And, by increasing transparency around preventable barriers such as long equipment downtimes—one of the three challenges to be tackled during the inaugural Diagnostics Co-Creation Sprint: Kumasi hosted by C/Can—and which is an all-too common frustration in LMICs, we have the opportunity to better address them.
There is remarkable innovation taking place, with diagnostics getting more efficient and more accurate. Processes can become more standardized. Although it may seem daunting, we're never starting from zero. And I would argue, we shouldn’t believe it’s too hard or too late to help improve the quality of life for a cancer patient.
As we come together on World Cancer Day, we invite ASCP members and the global pathology community to join us in our collective pursuit of ensuring every person has the opportunity to access timely and quality cancer diagnosis.