Improving continuity of care for cancer patients in LMICs

We designed a novel patient navigation program to reduce delays and improve adherence to care for cancer patients in low- and middle-income countries (LMICs). The program relies on a mobile data platform that allows for real-time tracking of patients across the care continuum from diagnosis to treatment and follow-up.

Franklin Huang, MD PhD
Assistant Professor of Medicine
University of California, San Francisco
Co-founder, Global Oncology

The central global health challenge of the future will be to design health systems that can provide standardized, high-quality care for patients with non-communicable diseases who require complex or non-linear treatment interventions. 

While infectious disease was once the leading cause of death in low- and middle-income countries (LMICs), cancer now kills more people in these areas than do HIV/AIDS, tuberculosis, and malaria combined. And despite the fact that 80% of global cancer deaths occur in LMICs, only 5% of total global spending on cancer care is expended in these regions. This means there is a growing tidal wave of non-communicable diseases that we as a global health community are largely unprepared to address.

The COVID-19 pandemic has exacerbated access issues for patients with non-communicable diseases like cancer, causing them to present to clinic later and with more advanced disease. In Belize, where we've piloted our innovative cancer patient navigation model, 40% of the population lives below the poverty line, patients face significant barriers to accessing and completing care in a timely manner. In order to retain them in care and improve their clinical outcomes, a holistic program that accounts for their psycho-emotional, educational, and socioeconomic needs is necessary. 

Our solution is designed to serve cancer patients in low- and middle-income countries who face significant barriers to accessing care. In the early stages of our partnership in Belize, we conducted a needs assessment to better understand the barriers that cancer patients faced in accessing care. By interviewing newly enrolled patients with a suspected or confirmed cancer diagnosis, we found that key types of barriers include educational, psycho-emotional, financial, and logistical. As 40% of the Belize population lives below the poverty line, many patients have difficulties with paying for medical services, traveling to clinic, securing child caretakers, and getting time off work. Additionally, there are no formal procurement channels for chemotherapy medication in-country, so patients have to acquire their medication across the border in neighboring Mexico or Guatemala, which presents other serious logistical challenges. 

Our patient navigation program has been designed and implemented in the context of a public oncology program which offers affordable, high-quality cancer care to all citizens of Belize. Before this program was launched, Belizeans were forced to navigate a fragmented, patchwork system of diagnostic and treatment services in the civil and private sectors. We believe that strengthening public health systems is key to achieving global health equity, rather than perpetuating the fragmentation and siloing of health systems. 

Additionally our solution provides a common good in that the CommCare application that is the technological core of the patient navigation program is built on an open-source platform. We aim to adapt this technical and programmatic framework to other emerging or established cancer programs in low- and middle-income countries. 

Our cancer patient navigation model has demonstrably improved the lives of cancer patients in Belize. Before the introduction of the patient navigation program, patients were left to navigate complex diagnostic and treatment pathways largely on their own. For instance, chemotherapy medications are unavailable in-country, which forces patients to procure the medications themselves over the border in neighboring Mexico or Guatemala. The administrative and logistical hurdles are enormous and patients risk serious delays in treatment without the support and guidance of patient navigators. Also, by counseling patients on where and how to access necessary services within and beyond the national hospital, patients are completing diagnostic studies in a more timely manner, which allows them to reach diagnostic resolution and begin treatment sooner. Lastly, the follow-up that patient navigators offer between hospital visits ensure that patients are aware of the next steps in their care journey, which reduces missed appointments and ensures better continuity of care.

Our goal for the next three years is to package the technical and programmatic framework of our cancer patient navigation model and adapt it for use in two new countries beyond Belize. We are currently reaching about 350 cancer patients per year (the total incident cases of cancer in Belize annually), but we aim to enroll 10,000 cancer patients into our patient navigation programs within the next 3 years. In order to do this, we need to grow our team by investing in personnel and subcontracting for software development services as needed. We also need to forge new partnerships with stakeholders in the Latin America and Caribbean region, which we've already begun to do.

Some key indicators for success are quality of care metrics including the average time from presentation to diagnostic resolution, average time from diagnostic resolution to treatment initiation, and number of missed appointments. We believe that our patient navigation model will be able to minimize these time intervals and reduce the number of missed appointments, which will translate into improved clinical outcomes for patients. 

A major barrier to success is resources. We've been able to accomplish an impressive amount with a small team and very limited resources, but in order to scale our cancer patient navigation model beyond Belize, we need a large investment of resources from funders who see the potential in our work. 

Another barrier will be ensuring that the technical solutions we develop and adapt for new settings are in alignment with the current data infrastructure in-country. There are existing data and documentation requirements of clinical providers and other personnel that we need to take into account, since there is a risk of creating redundancy and taking away from the already limited bandwidth of cancer care providers in low- and middle-income countries.

We will mitigate this barrier by doing a comprehensive assessment of the data landscape and ensuring that newly developed work flows and data flows streamline things to the extent possible.

Global Oncology (www.globalonc.org), San Francisco, CA, USA

Karl Heusner Memorial Hospital, Belize City, Belize

Through our on-the-ground partners in Belize, we have designed and implemented a promising model for cancer patient navigation that we believe has the potential to scale to other emerging or established cancer programs in low- and middle-income countries. A barrier that we are confident The Trinity Challenge can help us overcome is the need for more robust technological support. We've spent considerable time iterating on the workflows and dataflows that are necessary to ensure we can track cancer patients as they move through the clinical and social ecosystems, but we need to build an even more sophisticated tool in order to be able to scale our model further. With a team of software engineers from a Trinity Challenge member organization such as Google, we could translate the lessons learned from our time piloting the patient navigation program and develop a state-of-the-art system that would allow us to systematize cancer care delivery in such a way that it is as technically and logistically feasible as other much simpler health interventions like HIV/AIDS testing and treating which have revolutionized the global health field.

We would ideally like to partner with a tech company like Google, Microsoft, IBM, or Salesforce to build an even more sophisticated mobile data system for cancer patient navigation in low- and middle-income countries. The prototype we've designed in CommCare has been an excellent starting point for us and we've learned a tremendous amount about what features are key. We would be well-positioned to work with a team of software engineers to design a new tool that has even better functionality for tracking cancer patients in real-time and providing targeted support to shepherd them along their care journey.