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This paper brings together researchers, clinicians, technology developers and digital innovators to outline current applications of remote symptom monitoring being developed for palliative cancer care delivery in Africa. We outline three remote symptom monitoring approaches from three countries, highlighting their models of delivery and intended outcomes, and draw on their experiences of implementation to guide further developments and evaluations of this approach for palliative cancer care in the region. Through highlighting these experiences and priority areas for future research, we hope to steer efforts to develop and optimise remote symptom monitoring for palliative cancer care in Africa.

Purpose: This discussion paper outlines challenges and proposes solutions for successfully implementing prediction models that incorporate patient-reported outcomes (PROs) in cancer practice., Methods: We organized a full-day multidisciplinary meeting of people with expertise in cancer care delivery, PRO collection, PRO use in prediction modeling, computing, implementation, and decision science. The discussions presented here focused on identifying challenges to the development, implementation and use of prediction models incorporating PROs, and suggesting possible solutions., Results: Specific challenges and solutions were identified across three broad areas. (1) Understanding decision making and implementation: necessitating multidisciplinary collaboration in the early stages and throughout; early stakeholder engagement to define the decision problem and ensure acceptability of PROs in prediction; understanding patient/clinician interpretation of PRO predictions and uncertainty to optimize prediction impact; striving for model integration into existing electronic health records; and early regulatory alignment. (2) Recognizing the limitations to PRO collection and their impact on prediction: incorporating validated, clinically important PROs to maximize model generalizability and clinical engagement; and minimizing missing PRO data (resulting from both structural digital exclusion and time-varying factors) to avoid exacerbating existing inequalities. (3) Statistical and modeling challenges: incorporating statistical methods to address missing data; ensuring predictive modeling recognizes complex causal relationships; and considering temporal and geographic recalibration so that model predictions reflect the relevant population., Conclusion: Developing and implementing PRO-based prediction models in cancer care requires extensive multidisciplinary working from the earliest stages, recognition of implementation challenges because of PRO collection and model presentation, and robust statistical methods to manage missing data, causality, and calibration. Prediction models incorporating PROs should be viewed as complex interventions, with their development and impact assessment carried out to reflect this.

Introduction: inadequate pain control negatively impacts the quality of life of patients with cancer while potentially affecting the outcome. Proper pain evaluation and management are therefore considered an important treatment goal. This study assessed the prevalence of pain, the prescribing patterns, and the efficacy of pain control measures in cancer patients at the Radiation Oncology Unit of the Lagos University Teaching Hospital, Lagos., Methods: this was a longitudinal study design recruiting adults attending outpatient clinics. Participants were assessed at initial contact and again following six weeks using the Universal Pain Assessment Tool developed by the UCLA Department of Anaesthesiology., Results: among the patients reviewed, 34.0% (118 of 347) were at the clinic, referred for initial assessment following primary diagnosis. All respondents had solid tumours; the most common was breast cancer. The prevalence of pain at initial assessment was 85.9% (298 of 347), with over half of respondents, 74.5% (222 of 347) characterising their pain as moderate to severe. Over a quarter, 28.9% (100 of 347) of patients were not asked about their pain by attending physicians, and none of the patients had a pain assessment tool used during evaluation. In 14.4% (43 of 298) of patients, no intervention was received despite the presence of pain. At six weeks review, 31.5% (94 of 298) of patients had obtained no pain relief despite instituted measures., Conclusion: under-treatment of cancer pain remains a significant weak link in cancer care in (Low-to-middle-income country) LMICs like Nigeria, with a significant contributor being physician under-evaluation and under-treatment of pain. To ensure pain eradication, the treatment process must begin with a thorough evaluation of the patient's pain, an explicit pain control goal and regular reevaluation., Competing Interests: The authors declare no competing interests., (Copyright: Adedayo Olufemi Joseph et al.)

Competing Interests: Murallitharan MunisamyStock and Other Ownership Interests: Sanofi/Aventis, MMPKV HEALTHCARE SDN BHDHonoraria: AstraZenecaSpeakers' Bureau: MSDResearch Funding: Pfizer Kingsley NdohStock and Other Ownership Interests: Geron Omolola SalakoConsulting or Advisory Role: Stack DiagnosticsSpeakers' Bureau: Janssen and JanssenPatents, Royalties, Other Intellectual Property: I have intellectual property rights to Oncopadi Digital Cancer Clinic Felipe RoitbergHonoraria: Boehringer Ingelheim, Sanofi, Roche, MSD Oncology, AstraZeneca, Nestle Health Science, Dr. Reddy's, Oncologia BrasilConsulting or Advisory Role: MSD OncologyResearch Funding: Roche, Boehringer Ingelheim, MSD, Bayer, AstraZeneca, TakedaNo other potential conflicts of interest were reported.

Introduction: Coverage of palliative care in low and middle-income countries is very limited, and global projections suggest large increases in need. Novel approaches are needed to achieve the palliative care goals of Universal Health Coverage. This study aimed to identify stakeholders' data and information needs and the role of digital technologies to improve access to and delivery of palliative care for people with advanced cancer in Nigeria, Uganda and Zimbabwe., Methods: We conducted a multi-country cross-sectional qualitative study in sub-Saharan Africa. In-depth qualitative stakeholder interviews were conducted with N = 195 participants across Nigeria, Uganda and Zimbabwe (advanced cancer patients n = 62, informal caregivers n = 48, health care professionals n = 59, policymakers n = 26). Verbatim transcripts were subjected to deductive and inductive framework analysis to identify stakeholders needs and their preferences for digital technology in supporting the capture, transfer and use of patient-level data to improve delivery of palliative care., Results: Our coding framework identified four main themes: i) acceptability of digital technology; ii) current context of technology use; iii) current vision for digital technology to support health and palliative care, and; iv) digital technologies for the generation, reporting and receipt of data. Digital heath is an acceptable approach, stakeholders support the use of secure data systems, and patients welcome improved communication with providers. There are varying preferences for how and when digital technologies should be utilised as part of palliative cancer care provision, including for increasing timely patient access to trained palliative care providers and the triaging of contact from patients., Conclusion: We identified design and practical challenges to optimise potential for success in developing digital health approaches to improve access to and enhance the delivery of palliative cancer care in Nigeria, Uganda and Zimbabwe. Synthesis of findings identified 15 requirements to guide the development of digital health approaches that can support the attainment of global health palliative care policy goals.

Since the first case of COVID-19 and its progression to a pandemic, healthcare systems the world over have experienced severe difficulties coping with patient care for both COVID-19 and other diseases most especially non communicable diseases like cancer. These difficulties in Low- and middle-income countries (LMICs), especially in Sub-Saharan Africa including Nigeria, are myriad. These LMICs are already bedeviled weak health systems, ill equipped cancer treatment centers, with outdated machines and grossly inadequate numbers of oncologists required to treat patients with cancer. As a result of these challenges coupled with unclear guidelines on how to manage cancer patients in the wake of the COVID-19 pandemic, 11 key Nigerian opinion leaders had a consensus meeting to identify challenges and possible workable solutions on continuing cancer care during the COVID-19 pandemic. The discussion highlighted ethical issues, barriers to continuing cancer care (such as lockdown, fear of contracting disease, downscaled health services) and resource constraints such unavailable personal protective equipment. Yet, practical solutions were proffered such as necessary protective measures, case by case prioritization or de-prioritization, telemedicine and other achievable means in the Nigerian setting., Competing Interests: The authors declare no competing interests., (Copyright: Adeniyi Adedayo Olabumuyi et al.)

Utilization of clinical technology and mobile health (mHealth) is expanding globally. It is important to reflect on how their usage and application could translate in low- and middle-income country (LMIC) settings. With the exponential growth and advancements of mobile and wireless technologies, LMICs are prime to adapt such technologies to potentially democratize and create solutions to health-related challenges. The role of these technologies in oncology clinical trials continues to expand. The lure of mHealth promises disruptive technology that may change the way clinical trials are designed and conducted in many settings. Its applicability in the African context is currently under consideration. Although potentially of expanding benefit, the role of these technologies requires careful and nuanced evaluation of the context in which they might be applied to harness their full potential, while mitigating possible harms or preventing further deepening of disparities within populations. Moreover, technology and digital innovations are no substitute for poor referral pathways and dysfunctional health systems and can only complement or enhance definite strategies aimed at strengthening these health systems.

Introduction: Palliative care is a clinically and cost-effective component of cancer services in sub-Saharan Africa (SSA). Despite the significant need for palliative cancer care in SSA, coverage remains inadequate. The exploration of digital health approaches could support increases in the quality and reach of palliative cancer care services in SSA. However, there is currently a lack of any theoretical underpinning or data to understand stakeholder drivers for digital health components in this context. This project addresses this gap through engaging with key stakeholders to determine data and information needs that could be supported through digital health interventions., Methods and Analysis: This is a multicountry, cross-sectional, qualitative study conducted in Nigeria, Uganda and Zimbabwe. In-depth interviews will be conducted in patients with advanced cancer (n=20), caregivers (n=15), health professionals (n=20) and policy-makers (n=10) in each of the three participating countries. Data from a total of 195 interviews will transcribed verbatim and translated into English before being imported into NVivo software for deductive framework analysis. The analysis will seek to understand the acceptability and define mechanisms of patient-level data capture and usage via digital technologies., Ethics and Dissemination: Ethics approvals have been obtained from the Institutional Review Boards of University of Leeds (Ref: MREC 18-032), Research Council of Zimbabwe (Ref: 03507), Medical Research Council of Zimbabwe (Ref: MRCZ/A/2421), Uganda Cancer Institute (Ref: 19-2018), Uganda National Council of Science and Technology (Ref: HS325ES) and College of Medicine University of Lagos (Ref: HREC/15/04/2015). The project seeks to determine optimal mechanisms for the design and development of subsequent digital health interventions to support development, access to, and delivery of palliative cancer care in SSA. Dissemination of these findings will occur through newsletters and press releases, conference presentations, peer-reviewed journals and social media., Trial Registration Number: ISRCTN15727711., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Purpose: There is a paucity of data about current usage of oncology guidelines in low- and middle-income countries (LMICs), specifically in terms of the availability and quality of those guidelines. Our objective was to determine usage of oncology guidelines and the barriers and facilitators to their usage among radiation oncologists in LMICs., Methods: An online cross-sectional survey was conducted among practicing radiation oncologists in Nigeria via e-mail and the social media database of the Association of Radiation and Clinical Oncologists of Nigeria. In addition, paper questionnaires were administered at regional clinical meetings., Results: The survey response rate was 53.4% in a sample of 101 radiation oncologists from the database. Sixty-nine percent of respondents were consultants and 30% were residents. Approximately 43% had < 5 years' experience. All of the respondents were involved in administering chemotherapy during the treatment of patients with cancer, whereas approximately half were involved in diagnosing cancer. Ninety-three percent reported using guidelines in treating patients, the top two guidelines being those from the National Comprehensive Cancer Network (90%) and the American Society of Clinical Oncology (50%). The two major barriers to guideline usage were that facilities were inadequate for proper guideline implementation and that the information in guidelines were too complex to understand. Potential facilitators included providing adequate facilities, developing local guidelines, and increasing awareness of guideline usage., Conclusion: Our study shows that clinicians involved in the treatment of patients with cancer in LMICs are aware of cancer treatment guidelines. However, implementation of these guidelines hinders their usage because the facilities are inadequate, guidelines are not applicable to the local setting, and the information in the guidelines is too complex.