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Abstract
Introduction Sub-Saharan Africa bears a disproportionate burden of cancer-related morbidity and mortality compared with high-resource settings. Although pathology services are essential to providing optimal oncological care, diagnostic capacity in sub-Saharan Africa is insufficient for the cancer burden. This scoping review will be conducted to summarise the current state of practices and evidence for interventions and implementation strategies to improve anatomic pathology services for cancer in the region. The objective of this scoping review is to describe efforts to strengthen capacity for anatomic pathology services in sub-Saharan Africa. The information gathered will be used to inform the design of future pathology capacity-building interventions. The primary aim of the scoping review is to comprehensively map the existing evidence on initiatives aimed at enhancing the capacity for pathology services.
Methods and analysis This study will follow Joanna Briggs Institute methodology for scoping reviews. MEDLINE, Embase, Cochrane Central and African Index Medicus will be searched for articles published in English and Portuguese with no limitations placed on date or publication type. A limited search for grey literature will be conducted using the WHO Institutional Repository for Information Sharing. Two independent reviewers will screen all articles, extract data and complete the descriptive analysis. All discrepancies will be resolved using a third reviewer. The results will be reported using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). This review will consider scientific literature from published primary studies as well as scoping and systematic reviews related to capacity-building efforts to strengthen anatomic pathology services in any sub-Saharan African country. All study designs will be considered, including quantitative, qualitative and/or mixed-methods studies.
Ethics and dissemination Ethical approval is not required for this study. Dissemination of findings from this work will include the publication of the results in a peer-reviewed journal and presentations at conferences.
Protocol registration number Open Science Framework, https://osf.io/6cmhg.
- Quality Improvement
- PATHOLOGY
- ONCOLOGY
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STRENGTHS AND LIMITATIONS OF THIS STUDY
A systematic and comprehensive search of electronic databases will ensure that all peer-reviewed evidence is identified.
Members of the research team include key stakeholders involved in capacity strengthening of pathology services in sub-Saharan Africa, which will help to strengthen the validity of the findings.
A formal assessment of the quality of evidence will not be performed and may lead to the inclusion of studies with a range of quality.
Decisions made to reduce the volume of results may omit relevant papers in the final review, including missing synonyms in the search, filtering for human studies, and including only articles written in English or Portuguese.
The search for grey literature will be limited to the WHO publications available in their Institutional Repository for Information Sharing database, which may also omit relevant papers in the final review.
Introduction
Sub-Saharan Africa (SSA) faces a growing burden of cancer with pathology services that are inadequately prepared to meet this public health challenge. High-quality pathology services are essential to cancer care and are required for accurate and timely diagnosis, prognosis and selection of optimal treatments.1 Although the World Health Organization’s ‘Model List of Essential In Vitro Diagnostics’ includes tests necessary for cancer diagnosis such as immunohistochemistry and flow cytometry, many of these recommended assays are not widely available in SSA.2–4 In fact, a recent survey of large, referral pathology laboratories in SSA found that only half provided onsite immunohistochemistry services.4 These disparities are in part attributable to an insufficient number of trained personnel, reagent and equipment shortages, and variable specimen processing protocols.4
Several groups, including the Lancet Commission on diagnostics and African Strategies for Advancing Pathology, have previously provided roadmaps or suggestions on how to best improve pathology services in SSA.3 5–7 Recommendations have included conducting situational analyses to determine the current state of pathology practices and to gain a better understanding of the existing capacity, resources and infrastructure.5 Additional proposals include interventions that introduce or bolster governance and regulatory frameworks to support quality, provide additional training to increase the number of skilled pathology personnel and increase investment in pathology infrastructure, including establishing reliable supply chains, specimen transport processes, specimen reporting and archiving.3 5–8 To help better inform future guidelines and interventions, a rigorous review of the literature is needed to give an overview of the extent and range of prior pathology capacity-building efforts across SSA. While the disparities in pathology services have been well described in the literature, there has not been a synthesis of attempted interventions that have been used to improve pathology services.5 9–12 Many of the published interventions to improve pathology services in low-resource settings have primarily involved intensive training, telepathology and greater access to new equipment and reagents.9 11–13 Assessment of clinical impact has also mainly been limited to effect on turnaround time and volume of cases diagnosed.10–12 Moreover, it is unknown what implementation strategies have been used to deploy these interventions. The implementation and service outcomes, as defined by the Outcomes for Implementation Research framework, are also often not well delineated.14 15 Elucidating contextual factors such as barriers and facilitators can provide insight into the design, deployment and success of an intervention. Furthermore, understanding how interventions were introduced, monitored and sustained will help to inform the design of future capacity strengthening initiatives. Therefore. the primary aim of the scoping review is to systematically map the existing evidence on initiatives aimed at enhancing the capacity for pathology services.
This review will focus on anatomic pathology services, which are defined as examinations of organs and tissues for the purpose of diagnosing cancer, and include tests such as histopathology, immunohistochemistry, molecular assays and flow cytometry, among others. While clinical pathology services are related and critical to cancer care, the challenges, gaps in practice and interventions to address those gaps may be markedly different than those seen in anatomic pathology and will therefore not be included in this scoping review. For example, clinical pathology services, which include the fields of blood banking, microbiology, haematology and clinical chemistry, primarily perform tests on bodily fluids, such as blood or urine. Overall, the data on successful capacity-strengthening interventions have not been well described. This review will identify the primary gaps in anatomic pathology services in SSA that the interventions intend to address as well as what interventions have been tested, along with details on their implementation and their impact.
Methods and analysis
The proposed scoping review will be conducted in accordance with Joanna Briggs Institute methodology for scoping reviews, including protocol development, screening, data extraction and presentation of results.16 The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) will be used to report the study.17 The protocol was registered on the Open Science Framework (https://osf.io/6cmhg). The study is planned to begin in January 2024 and is planned to end by June 2025.
Review questions
What interventions have been implemented to improve anatomic pathology services in SSA?
The following sub-questions will be addressed:
What are the primary gaps that reported interventions intend to target in anatomic pathology services in SSA?
What interventions have been tested in SSA? What are their implementation strategies and their outcomes?
What were the contexts, barriers, and facilitators of these interventions?
Inclusion and exclusion criteria
Participants
Inclusion criteria: The review will focus on interventions to improve anatomic pathology services, including interventions targeting individual-, organisational-, or system-level changes in SSA. Therefore, the range in participants may be broad and will include healthcare providers—including laboratory staff—hospital administrators and ministries of health, among others.
Exclusion criteria: Studies that focus on non-human populations will be excluded.
Concept
Inclusion criteria: Interventions explicitly targeting the improvement of tissue-based pathology services and laboratories in SSA will be included in the analysis.
Exclusion criteria: Efforts that include pathology services but do not specifically aim to improve diagnostic services for patient care, such as cancer control plans, screening programmes or the development of laboratories exclusively for research, will be excluded. Initiatives that focus on clinical pathology services will also be excluded.
Context
Inclusion criteria: Studies that focus on anatomic pathology services, such as infrastructure, workflows, diagnostic assays, personnel, supply chains and quality assurance/quality improvement initiatives, such as laboratory accreditation programmes, will be included. We will consider studies conducted in SSA as well as those that target capacity-building for anatomic pathology services in SSA.
Types of sources
Inclusion criteria: This scoping review will consider peer-reviewed articles with quantitative, qualitative and mixed methods study designs for inclusion. In addition, scoping reviews, systematic reviews and meta-analyses will be considered for inclusion. Because grey literature published by organisations and scholars from SSA is often not consistently digitised or curated into searchable databases and therefore difficult to access, only grey literature available on the WHO Institutional Repository for Information Sharing (IRIS) database will be considered. Results will be limited to items in English and Portuguese, which are the languages that members of the review team are fluent in. No limitations will be placed on date.
Exclusion criteria: Opinion pieces (eg, editorials, commentaries and letters to the editor) and critical reviews as defined by Grant and Booth will be excluded.18
Search strategy
A preliminary search of MEDLINE and PROSPERO was conducted in November 2023, and no other scoping reviews on the topic were identified as in progress or completed. The librarian continued to look for reviews related to the topic during the search building process, which ran from November 2023 to early January 2024.
For the study, a medical librarian (JG) will design the scoping review search in Ovid Medline ALL. Subject headers and keywords reflecting three topics—pathology, SSA and capacity-building—will be combined using Boolean and adjacency operators. A second librarian will perform a PRESS review of the search, which will then translate to Embase (Elsevier) and Cochrane Central Register of Controlled Trials (Wiley) with the help of the Systematic Review Accelerator’s Polyglot Tool.19 20 In Medline and Embase, the Cochrane filter for human studies will be used.21 A simplified version of the search, using only keywords relating to pathology, will be developed in African Index Medicus (https://search.bvsalud.org/aimafro/). A limited search for grey literature will be developed in WHO IRIS (https://iris.who.int/). View the complete search strategies for all databases in online supplemental appendix 1. The reference list of all included sources of evidence will be screened for additional studies. To make up for any potential omissions, we will perform a forward and backward reference check of the items selected for inclusion in the review.
Supplemental material
Study/source of evidence selection
Following the search, all identified citations will be imported into the systematic review management tool Covidence (Veritas Health Innovation, Melbourne, Australia), which will remove duplicates. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant sources will be retrieved in full, with citation details imported into Covidence. The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of sources of evidence at full text that do not meet the inclusion criteria will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers at each stage of the selection process will be adjudicated by a third reviewer and/or further discussion among the review team. The results of the search and the study inclusion process will be reported in full in the final scoping review and presented in a PRISMA-ScR flow diagram.17
Data extraction
Two independent reviewers will extract data from relevant articles using a data extraction tool developed by the review team. A draft data extraction form is presented in online supplemental appendix 2. The initial draft of the data extraction tool is based on the tool developed by Ashoor et al and Proctor’s framework on implementation research outcomes.14 22 The data extraction tool will be modified and revised as needed during the data extraction process. Modifications will be detailed in the scoping review. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.
Data analysis and presentation
The data extracted from each included article will be presented in a tabular or diagrammatic format. Descriptive frequencies, counts and thematic analysis will be included along with the tabulated results and will describe how the results relate to the objectives of the review. Thematic analysis will be guided by the Outcomes for Implementation Research framework.14 Gaps in the literature, effective implementation strategies and areas of further research in how to effectively improve pathology services in SSA will be identified.
Patient and public involvement
There will be no patient or public involvement in this study.
Limitations
Limitations in this protocol include decisions made to reduce the number of results may omit relevant papers in the final review. For example, there may be missing synonyms for some of the search terms, the decision to filter for human-specific studies and selection of studies only in English and Portuguese based on the language proficiencies of the research team. It is also challenging to systematically search for grey literature on this subject. Therefore, we will focus only on grey literature available in the WHO IRIS database.
Discussion
Our scoping review will aim to provide insight into the existing evidence as well as gaps on interventions intended to improve pathology services in SSA. By exploring previous interventions, their targeted gaps, and outcomes, we can better understand which implementation strategies are the most effective in improving diagnostic capacity in resource-constrained settings. Therefore, this review will provide insights into how to best design and implement future interventions to reduce disparities in tissue-based diagnostics in SSA.
Ethics and dissemination
Ethical approval is not required for the planned scoping review. All data will be obtained from publicly available documents, and no primary data will be generated. The findings from this work includes publication of the results in a peer-reviewed journal and presentations at conferences.
Ethics statements
Patient consent for publication
References
Footnotes
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Contributors DLN conceptualised and designed the study. DLN and JG wrote the original draft of the protocol. JG provided methodological expertise. All the authors were involved in the review and editing of the manuscript. DLN is the guarantor. All the authors reviewed the manuscript, gave their approval for the final version of the work to be published and agreed to be accountable for the integrity of the work published.
Funding Members of the research team receive support from the Fogarty International Center and National Cancer Institute Award Number D43TW011598 (AHK, EJM, KVL), the NCI Award Number K08CA263299 (DLN); Cancer Center Support Grant (P30 CA008748) and from the University of California, San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center (BPM, ZI, PMI, KVL). The content is solely the responsibility of the authors and does not necessarily represent the official views of the U.S. National Institutes of Health.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.