Healthcare delivery interventions to reduce cancer disparities worldwide

Table 2 Patient-facing studies from low- and middle-income countries involving either a navigation or technology-based component of the intervention

	Ref.	Study design	Country	Cancer type	Intervention type	Time point	Outcome	Result (intervention vs control)	Location
Screening	Thomas et al[35] (2002)	Cluster randomized trial	China (n = 266064)	Breast	Classes teaching self-breast exam with supervised exams every 6 mo vs none	10 yr	Deaths attributable to breast cancer	0.1% vs 0.1% (P = 0.67)	Factory workers in Shanghai (urban)
	Mittra et al[34] (2010)	Cluster randomized trial	India (n = 151538)	Breast	Lay health care workers doing clinical breast examination vs social worker delivered education	3 rounds of screening at 2-yr intervals	Downstaging at diagnosis	1st round: ND (P = 1.00) | 2nd round: ND (P = 0.47) | 3rd round lower stage at diagnosis (P = 0.004)	Slums in Mumbai (urban)
	Sankaranarayanan et al[32] (2011)	Cluster randomized trial	India (n = 115652)	Breast	Lay worker clinical breast exam vs education only	3 yr	Stage at diagnosis	Early-stage diagnosis: 44% vs 25% (P = 0.023) | Advanced-stage diagnoses: 45% vs 68 (P = 0.005)	Thiruvananthapuram, Kerala (suburban)
	Ma et al[109] (2012)	Cluster randomized trial	China (n = 453)	Breast	Education + lay navigation vs printed materials	6 mo	Screening rate	73% vs 5% (P < 0.001)	Employees in Nanjing (urban)
	Shastri et al[110] (2014)	Cluster Randomized Trial	India (n = 151538)	Cervical	Lay health care workers doing cervical examination vs social worker delivered education	12 yr	Cervical cancer mortality (rate per 100000 person years of observation)	11% vs 16% (P = 0.003)	Slums in Mumbai (urban)
	Abiodun et al[111] (2014)	Cohort trial with control from neighboring area (quasi-experimental design)	Nigeria (n = 700)	Cervical	Patient education by medical students vs none	3.25 mo	Cervical cancer screening rate	8% vs 4% (P = 0.038)	Ogun state (rural)
	Rosser et al[112] (2015)	Randomized controlled trial	Kenya (n = 251)	Cervical	Lay health worker 30-minute educational talk vs none	3 mo	Screening rate	59% vs 61% (P = 0.60)	Homa Bay County (rural)
	Lima et al[113] (2017)	Randomized cohort trial	Brasil (n = 524)	Cervical	Behavioral telephone interview vs educational telephone call	NR	Screening rate	67% vs 58% (NR)	Women without up-to-date screens in Fortaleza (urban)
Diagnostic resolution	Pisani et al[33] (2006)	Single arm description of a cluster randomized trial	Philippines (n = 151168)	Breast	Lay health worker clinical breast exam	2 yr	Follow-up for abnormal screening exam	35% follow-up rate	Manila (urban)
	Ginsburg et al[36] (2014)	Cluster randomized trial	Bangladesh (n = 22337)	Breast	CHW with smartphone +/- additional CHW training to navigate	NR	Follow up care if abnormal CBE	63% vs 43% (no navigation) (P < 0.0001)	Khulna Division (rural)
	Mishra et al[114] (2017)	Retrospective descriptive study	India (n = 2610432)	Head and Neck	CHWs doing physical exams, counseling patients to stop smoking, and referring patients to an ENT practice if a positive exam	3 yr	Referral to tertiary care center	2610432 screened | 10522 (1.1%) quit smoking | 3309 (0.13%) referred to tertiary care center of which 1890 (57%) were positive for cancer | 1712 (91%) diagnosed were able to start treatment	Gujarat (rural)
	Riogi et al[38] (2017)	Cohort study with retrospective control group	Kenya (n = 75)	Breast	Cohort of patients cared for by nurses trained to navigate vs historic cohort	1 mo	Completion of follow-up testing	58% vs 24% (P = 0.0026)	Nairobi (urban)
	Vasconcelos et al[39] (2017)	Randomized cohort trial	Brasil (n = 775)	Cervical	Tying ribbon with appointment date on hand vs education session vs card reminder	2 mo	Return for pap test results	66% vs 82% (education) vs 77% (control) (P < 0.05)	Fortaleza (urban)
	Chavarri-Guerra et al[115] (2019)	Retrospective descriptive study	Mexico (n = 70)	All	Lay navigator	3 mo	Obtain appointment at cancer center	91% had appointment at 3-mo censor	Mexico City (urban)
	Mireles-Aguilar et al[116] (2018)	Retrospective descriptive study	Mexico (n = 656)	Breast	Media campaigns for navigation program followed by navigation by a nurse if alert activated	NR	Follow-up for self-reported symptomatic breast lesions	69% attendance to appointment | Median time from alert activation to treatment (n = 22): 33 days	Nuevo Leon state (urban and rural)
Treatment	Li et al[117] (2016)	Randomized controlled trial	China (n = 66)	Bladder	"Enhanced" nursing care including phone follow-ups vs usual nursing care	NR	Follow-up after tumor resection	86% vs 63% (P = 0.032)	Laiwu, Shandong province (NR)
	Alvarez et al[45] (2017)	Retrospective descriptive study	Guatemalan children (n = 1,789)	All	Multifaceted intervention including transportation, food, shelter, and education/guidance on the importance of completing treatment	N/A	Treatment abandonment (year 2001 vs 2008)	27% vs 7% (NR)	Guatemala City (urban and rural)
	Yeoh et al[46] (2018)	Cohort study with retrospective control group	Malaysia (n = 283)	Breast	Nurses who received additional education in patient navigation vs retrospective cohort	N/A	Treatment abandonment	4% vs 12% (P = 0.048)	Klang (suburban)
Palliative	Sajjad et al[118] (2016)	Parallel cohort trail	Pakistan (n = 50)	Breast	Nurse delivered education series + nurse delivered support during chemotherapy sessions + nurse phone follow-ups vs none	1.5 mo	Change in global quality of life score	Improvement for the intervention group (P = 0.020) | No change for historic cohort (P = 0.111)	Karachi (urban)
	Nejad et al[119] (2016)	Parallel cohort trail	Iranian caregivers of cancer patients (n = 60)	Breast	Nurse delivering 2 in-person education / training sessions + 4 telephone follow-up sessions vs none	NR	Change in caregiver strain index scores	Improved scores for the intervention group (P = 0.001)	Tabriz (urban)

Low- and middle- income countries status determined at time of study. If a study had comparisons at multiple points (i.e., three months and six months) only the final time point in each study is reported. NR: Not reported; N/A: Not applicable; CBE: Clinical breast exam; CHW: Community health worker; ENT: Otorhinolaryngology (Ears, Nose, Throat).