Dr. Ross Boyce Proves Climate Change Will Impact Malaria Control Programs

OIA Enriches International Medical Students’ Education

Ankita Ashoka of India is completed a cardiology research elective at UNC.

Ankita Ashoka of India is completing a cardiology research elective at UNC.

Ankita Ashoka excelled at badminton as a child in Bangalore, India. She was ranked India No.1 in the under – 13 age division and a part of the Sub-Junior Indian team. This allowed her to train in one of the best badminton academy in India, led by the former All-England Champion- Prakash Padukone. She entertained the idea of going pro, but another passion surfaced, causing her to set athletics aside.

“If it weren’t for medicine, I would be a professional badminton player,” Ashoka says sitting on the UNC School of Medicine campus where she has been completing a clinical, and now, a research rotation.

In her final year of medical school in India, Ashoka decided to apply to UNC’s International Visiting Student Program. The program is managed by the UNC School of Medicine’s Office of International Activities (OIA). Since 2009, more than 650 international visiting medical students from 19 countries have trained at UNC through the OIA. All students must be in their final year of medical school and in good standing with their home university. They also must express how studying at UNC will allow them to realize their educational goals and long-term career plans.

“The goal of the OIA is to provide not only the international medical students the opportunity to responsibly engage in U.S. clinical practices and see the difference in diagnoses and treatments, but it is as worthwhile for the UNC medical team who have the opportunity to share cross-cultural practices in a clinical environment and ideally learn from one another,” says Shay Slifko, OIA Program Manager. “Our hope is to keep building and improving our resources for UNC students and international medical students alike. We work towards providing resources and support in helping them adjust to the American medical system during their short time here in a way that is beneficial for their future careers as medical providers.”

Ashoka arrived in Chapel Hill in October 2015. She spent two months rotating through UNC’s Division of Nephrology and credits the faculty and fellows there with easing her transition into a U.S. clinical setting.

“Dr. Vimal Derebail, Dr. Randy Detwiler and the fellows took great interest in introducing me to different patient-care settings” Ashoka says. “They gave me valuable insight into the field of nephrology and helped me emerge as a confident student by the end of the elective. It was an amazing eight weeks of getting to the know the kidneys.”

Ashoka then shifted her focus from the kidneys to the heart. She wanted to work with Ross Simpson, Jr., MD, PhD, Professor of Medicine, Director of the Lipid Prevention Clinic at UNC and the principal investigator of the SUDDEN research group, which focuses on investigating the causes responsible for out of hospital sudden unexpected death. Ashoka approached Slifko about rotating through a cardiology research elective. Slifko was supportive and connected Ashoka with Simpson. Ashoka is now studying the link between mental and substance use disorders and sudden unexpected death.

“More often than we realize, mental disorders have a great impact on physical health and could be a potentially disabling condition.” Ashoka says. “Medicine is an ever-evolving field. Research gives us a better understanding of what we already know, and sometimes leads us to new findings or refutes old findings. It helps us get ahead of ourselves and modify the practice of medicine.”

Ashoka recently submitted two abstracts to the American Heart Association and is now working on writing a manuscript. Ashoka says “I owe this to Dr. Simpson and Shay, who have been very encouraging.” Simpson says he is impressed with Ashoka’s drive and diligence.

“Ankita is industrious and self-starting,” Simpson says. “She took a leadership role in developing this project on mental health issues and victims of sudden cardiac death. She has learned the basics of clinical research and the skills needed to write scientific papers. I hope to train more students like her.”

KenWideShot

Ken Langwani wants to be an OB/GYN in Malawi.

Seeing a Happy Mom and Child
Ken Langwani cannot remember a time when he wasn’t thinking about science. Growing up in Blantyre, Malawi, he attended secondary school on a scholarship. Grateful for this funding to further his education, Langwani knew he wanted to devote his life to a career that allowed him to give back to the community.

“I decided to go to medical school and I have found obstetrics and gynecology to be very satisfying,” Langwani says. “You see an instant result. It is so nice to see a happy mom with her child.”

While completing his family medicine rotation at the Malawi College of Medicine in Blantyre, Langwani received an email from the dean of faculty for the college about the opportunity to train at UNC through the Office of International Activities. Langwani relished the thought of learning how OB/GYN is practiced in another country. He applied to the International Visiting Students Program and flew to Chapel Hill in May to begin his OB/GYN rotation.

“I noticed differences immediately,” Langwani says. “In Malawi, your days as an OB/GYN are long and our medical records system is still paper-based. In the US, physicians can hand patients off to another doctor and all of that patient’s information is electronically accessible.”

Langwani said one of the most fascinating moments of his four-week clinical elective with UNC’s Department of Obstetrics and Gynecology was seeing a blood transfusion to combat fetal anemia. He trained with Tara Castellano, MD, who said the team learned as much from Langwani as he did from them.

“Ken not only contributed to the patients he cared for, but also enriched our team by providing such an interesting clinical perspective as a student from Malawi,” Castellano says. “Ken was able to gracefully assimilate to an entirely different medical culture and system compared to that in which he has received his education. Not only that, but Ken managed it all with such an incredibly positive attitude. All the faculty, house officers and other students who met Ken were very lucky to have the experience of working, learning and growing with Ken.”

Langwani also completed a four-week elective in trauma and emergency surgery at UNC before returning to Blantyre. While many of his peers in the OIA’s International Visiting Students Program hope to practice in the US, Langwani looks forward to finishing his fifth and final year of medical school in Malawi enriched by the lessons he has learned at UNC.

“I want to be an OB/GYN in Malawi,” says Langwani. “That’s my whole plan, and it is where I am needed.”

Apoorve Nayyar of India trained with Michelle Roughton, MD, Assistant Professor and Program Director in the Division of Plastic and Reconstructive Surgery at UNC.

Apoorve Nayyar of India trained with Michelle Roughton, MD, Assistant Professor and Program Director in the Division of Plastic and Reconstructive Surgery at UNC.

Cancer Doesn’t Discriminate
Apoorve Nayyar will never forget hearing one of his former patients calling out his name at UNC.

“He was a burn victim we had been treating and one week before he was to be discharged, his heart stopped,” Nayyar remembers. “We immediately started CPR. Then a few weeks later I am walking through the hospital and he shouts, ‘Hey AP’, he had given me that nickname. I was so happy to see him.”

Being able to improve the health of each patient he meets is what has propelled Nayyar through five and a half years of medical school in India and now several electives through the UNC School of Medicine’s OIA’s International Visiting Students Program. Since arriving in March, Nayyar has completed one-month long electives in plastic surgery, burn surgery and vascular surgery.

“Apoorve is a great student,” says Michelle Roughton, MD, Assistant Professor and Program Director in the Division of Plastic and Reconstructive Surgery. “He is eager to learn and appreciative of instruction. He is enthusiastic about surgery and should excel.”

Like Ashoka, Nayyar also decided to pursue a research elective while at UNC. But the rotation he wanted did not exist. He contacted Slifko.

“Shay was able to create the surgical oncology elective for me to match my interests,” Nayyar says. “She is so dedicated. The entire experience with the OIA has been wonderful. Being accepted was a very clear, fair process. UNC’s Office of International Activities is ranked highly by U.S. News & World Reports and in the online residency forums about studying in the US. Now, I know why.”

Nayyar, who would like to eventually complete his residency in the US in surgical oncology, is most excited about participating in this research elective. His current project focuses on pancreatic cancer, which only has a 4 percent survival rate.

“I really want to help people move from a cancer diagnosis to remission,” Nayyar says. “I especially want to focus on the underserved population, who may not have health insurance. Cancer doesn’t discriminate between the rich and poor. We have been blessed to have access to healthcare; not everyone has that. I believe in the dream of equitable healthcare and want everyone to have the opportunity to remain in good health. This gives me the drive to broaden my knowledge and skills, each day.”

Click here for more information about the Office of International Activities.

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Blog: International AIDS Conference Reveals Faces of HIV

Video: 2BeatHIV Engages Community


By Bradley Allf, Features Writer, UNC Institute for Global Health & Infectious Diseases

Our understanding of human immunodeficiency virus (HIV) has come a long way since it was first named in 1986. Yet little of this new information about the virus, which still infects 50,000 new people each year in the United States, seems to have made its way into the general public. A research project out of UNC called 2BeatHIV is trying to change that.

Infection with HIV, which causes acquired immunodeficiency syndrome (AIDS) over time, was once a death sentence. But thanks to three decades of intensive study by researchers all over the world, HIV/AIDS has become a manageable chronic infection. With proper treatment, HIV-positive individuals enjoy a near normal life expectancy and researchers are hopeful that an effective vaccine could be developed in the coming years.

But no one, it seems, has told the general public. Despite landmark study results about treatment as prevention being released in 2011 and 2015 by UNC researchers, 44 percent of Americans believe that anti-HIV medications do not prevent the spread of HIV. The survey, conducted by The Washington Post and Kaiser Family Foundation, also found that more than a third of respondents (34 percent) incorrectly thought HIV could be transmitted by sharing a drinking glass, touching a toilet seat or swimming in a pool with someone living with HIV.

This has obvious repercussions for people living with the virus and the stigma that continues to be associated with it. The goal of 2BeatHIV is to get the public informed about HIV and invested in finding a cure for the disease.

The project, which is nested within UNC’s searcHIV working group, is headed up by Allison Mathews, PhD, a post-doc with a dual appointment in both the Institute for Global Health & Infectious Diseases and the Department of Social Medicine.

Mathews says the first step in the project was figuring out what 2BeatHIV’s target demographic would be. She and her team decided to focus on African-Americans from 18 to 35 years old in Durham, NC, a city where HIV infection is much more widespread that elsewhere in the state.

“We chose that group because they’re at the highest risk for HIV,” says Mathews. “But if you want to reach that demographic, you have to make the project relevant to them.”

Figuring out how to be relevant was one of the biggest concerns she and her team had when starting 2BeatHIV.

Allison Mathews, PhD, has been leading 2BeatHIV since the project took off last August.

Allison Mathews, PhD, has been leading 2BeatHIV since the project took off last August.

The Experiment
“How do you deliver information [about HIV research] in a way that you or anybody that doesn’t really care about HIV would still want to come and still want to learn that information?” says Mathews. “So I sought feedback from community members to ask them how they wanted to be engaged. The conversations started to center around ‘let’s do art events and music events and technology and use social media’—stuff people are already comfortable with.”

So the team started planning. They didn’t just want to host “HIV events”—they wanted to make events with broad public appeal, with community engagement around HIV cure research as one of the components of the event.

The first event, called “The Experiment,” was held in the Beyu Caffé in Durham. It was based around hip-hop.

“So hip-hop is kind of known for examining conspiracy theories. Like, they have conspiracy theories about the Illuminati, that kind of thing,” says Mathews. “So we decided to theme the event around that. We brought in hip-hop artists who came and participated in conversations with the community about conspiracy theories around HIV cure.”

These conversations examined some of the misconceptions people have about HIV cure, such as the idea that a cure already exists, but is being deliberately withheld by the government.

Participants then wrote down words and phrases based on the conversation and shouted them out to one of the hip-hop artists, who would freestyle rap using the words that were called out.

Angel Dozier, talent coordinator at Beyu Caffe and co-organizer of the event, thought that using hip-hop was a perfect vehicle for talking about HIV.

“I felt like bringing hip-hop into the conversation as another language was incredibly important,” says Dozier. “It was created by the marginalized to express their frustrations, express their inspirations, to pass along knowledge. And that’s how I see we communicated the HIV information in a way that was engaging to everyone.”

Actress Sheryl Lee Ralph signing autographs at 2BeatHIV’s “Red is the New Black Fashion Show” event in June.

Actress Sheryl Lee Ralph signing autographs at 2BeatHIV’s “Red is the New Black Fashion Show” event in June.

Star Power
2BeatHIV has also been effective in engaging with celebrities to spread the project’s message.

This summer, 2BeatHIV hosted actress Sheryl Lee Ralph at their event “Red is the New Black Fashion Show.” Ralph, also a prominent HIV/AIDS activist, was featured alongside musicians, fashion designers, and community health organizations at the event.

“She was so awesome. I loved her stage presence and how confident she was,” says Alexander Glenn, who participated in the event as a performer. Shantel Evans, who also attended the event, learned a lot from Ralph’s presentation. “I knew the AIDS situation was bad, but I didn’t know it was that bad,” says Evans.

2BeatHIV intern Samantha Farley thought it was “wonderful to see [Ralph] using her celebrity status to advocate for a cause that is so beneficial.” This advocacy likely attracted people to the event that otherwise might not have come.

Other celebrities have also gotten involved with 2BeatHIV. Actors Viola Davis and David and Tamala Mann, and gospel singer Shirley Caesar all contributed to a 2BeatHIV video back in April at the Women’s Empowerment Expo in Raleigh. Rapper Bun B, who has collaborated with Jay-Z, has also appeared in a 2BeatHIV video.

But 2BeatHIV isn’t just trying to connect with nationally famous people. Says Mathews:

“It’s not just the national celebrities, it’s local people. The local DJs and rappers, and even a friend of mine who’s called ‘The Sex Educator.’ Everyone in the community knows him and he goes into the community and does non-traditional HIV-testing.”

Instead of doing HIV-testing at a clinic, Paul Weaver (known in the community as the Sex Educator) goes to clubs and barber shops to test people. “I got him to do a video too because people in the local community, people that I can’t reach on my own— they know him,” says Mathews.

Alexander Glenn, right, performed at the “Red is the New Black Fashion Show.”

Alexander Glenn, right, performed at the “Red is the New Black Fashion Show.”

Crowdsourcing Ideas
One of the strengths of 2BeatHIV is its ability to utilize engagement around the project to further promote its message. Rather than existing as a static educational resource, 2BeatHIV encourages people to contribute to the project themselves.

“If you’re going into the community and telling someone, ‘you can shape the future of HIV cure research,’ they’ll say ‘I’m not a scientist, what can I do?’” says Mathews.

So the 2BeatHIV team tries to motivate people to use their own creative talents to contribute to the project. Almost every promotional aspect of 2BeatHIV, right down to its name and tagline, has been crowdsourced. The logo and many of the graphics were also designed by the public, often through contests.

Contests serve a double purpose. First, they help source engaging promotional content that the community cares about. And secondly, they make the project exciting for the people whose content gets featured by 2BeatHIV.

“Somebody submitted a poem—it was like a spoken word poem on ‘what does HIV cure mean to you?’ And then we pulled a quote from that poem and created a sticker,” says Mathews. “So that becomes promotional material and they’re like ‘wow that’s my poetry on something affiliated with UNC.’”

2BeatHIV also uses crowdsourcing for ideation through focus groups composed of community leaders in Durham.

Rita McDaniel, a leading HIV activist in the community, has participated in a number of these focus groups. She thinks that this community involvement is definitely one of the strengths of the project.

“I notice a lot of [HIV] events have the social workers, the doctors, the clinical trials people up on stage. And everybody else is down low,” says McDaniel. “You’re not really communicating at eye level with people that are actually experiencing the disease itself. Allison doesn’t do that. She puts us all on the same platform together. You’re not big ‘I,’ I’m not a little ’i’ and it works.”

McDaniel participates in the focus groups to voice her opinion on what’s going right and wrong with the project. She says having the opportunity for that open dialogue is what makes 2BeatHIV so unique.

“We haven’t had anything in this area like 2BeatHIV. So it’s new, it’s upbeat, it’s probably like me if I could ever wear some red bottomed shoes. It would be new for me, exciting.”

The 2BeatHIV table at the Red is the New Black Fashion Show.

The 2BeatHIV table at the Red is the New Black Fashion Show.

Local Focus, Global Reach
The ultimate goal of 2BeatHIV, however, is to use what the team learns about the community in Durham to build similar community engagement projects across SearcHIV’s field sites all over the world.

“I’m on regular calls with scholars in Guangzhou, China and Cape Town, South Africa about the project and the process of developing it and making it more popular and how they can implement it in their communities in those contexts,” says Mathews.

Although the specific projects implemented in these sites will manifest themselves differently, there are plenty of general lessons that 2BeatHIV hopes to learn from Durham.

“I think the broad impact is that we’re using this study as a prototype for how you can implement this in different contexts but using similar methods,” says Matthews. “I think that hopefully this is the beginning of turning this into an evidence-based practice. That would be the ultimate gold standard.”

The project is certainly off to a good start, having already reached nearly 200,000 people online, and partnered with more than 25 community organizations, just since August. Joe Tucker, PhD, is one of the principal investigators of the SearcHIV working group. He says Mathews, who he described in an email as a “superstar,” has done a great job heading 2BeatHIV.

“It is quite impressive how she has brought together diverse community stakeholders and sought their input and feedback,” he says.

As 2BeatHIV expands its reach globally, this web of community engagement will only continue to grow.

Science: Understanding HIV Latency

David Margolis, MD, is the Principal Investigator of CARE.

David Margolis, MD, is the Principal Investigator of CARE.

A better understanding of HIV latency is the key to eradicating the virus researchers at the University of North Carolina and partner institutions write in a perspective in the journal Science. Worldwide, 37 million people are living with HIV. A cure has proved elusive due to viral latency – a period when the virus remains alive, but dormant in body thereby eluding the immune system.

Based at UNC, the National Institutes of Health-funded Collaboratory of AIDS Researchers for Eradication (CARE) seeks to validate and implement their “kick and kill” strategy to cure HIV infection. This approach involves waking up the latent or sleeping virus in the body, and at the same time boost the immune system to recognize and clear the virus. In the Science perspective, the researchers discuss the gains they have made in understanding latency over the past five years and the challenges that remain as the team of academic and industry investigators – from UNC, Duke University, Merck, GlaxoSmithKline, the University of California at San Diego, Emory University, MacroGenics, and other institutions – embark on the next steps in HIV cure research.

“We have learned a lot, and made advances, and we hope that we now have the tools to begin to chip away at the persistent virus that remains in patients, and requires them to maintain lifelong antiviral drug therapy,” said David Margolis, MD, Professor of Medicine at UNC and Principal Investigator of CARE.

The team has made tremendous strides in learning about latency reversing agents or LRAs. Four clinical studies have revealed that histone deacetylase (HDAC) inhibitors are the most effective LRA for inducing cell-associated HIV-1 RNA. The investigators have also studied cells from people living with HIV and found that serial dosing of LRAs is needed to reverse latency.

This figure demonstrates the potential obstacles HIV latency poses for viral eradication.

This figure demonstrates the potential obstacles HIV latency poses for viral eradication.

Questions the group hopes to answer over the next five years include if LRAs will promote the expression of viral protein on the surface of infected cells, and if pairing LRAs with immune interventions will lead to the clearance of persistent, latent infection.

The National Institute of Allergy and Infectious Diseases, part of the NIH, first funded CARE in 2011 through its Martin Delaney Collaboratory program for HIV cure research. The program was the first major funding initiative to focus on eradication of HIV from the body and was named in honor of internationally recognized HIV activist Martin Delaney. In July 2016, CARE was refunded by the NIH for another five-year period.

In this next project period, CARE will seek to 1) define next-generation therapies that reveal the latent reservoir of HIV infection, 2) develop novel reagents capable of depleting persistent infection, and 3) translate these advances in human clinical trials.

For more information about CARE, visit delaneycare.org.

Podcast: Bringing Breast Exams to Malawi

Maggie Zgambo, left, teaches a Malawian woman about self breast exams to screen for cancer.

Maggie Zgambo, left, teaches a Malawian woman about self breast exams to screen for cancer.

By Laura Oleniacz, Science Communications Manager, UNC Lineberger Comprehensive Cancer Center

As a 16-year breast cancer survivor, Maggie Zgambo was troubled by the barriers she saw preventing her fellow countrywomen in Malawi from being screened for breast cancer.

Some did not have permission from their husbands to be tested. Others went to the doctor with a breast health issue, such as a lump, but were not examined and given pain killers or antibiotics instead. Then there were the women who had abnormal clinical exam results, but who refused follow-up examinations because they were afraid of having cancer.

“It was so frustrating trying to phone them and plead with them to come, but they would not come,” Zgambo said.

Zgambo witnessed these challenges firsthand through her participation in a UNC Project-Malawi pilot study that trained lay women to conduct breast examinations. In all, study staff screened 1,000 women. By the researchers’ count, the project was a success: lay women without formal medical training could be taught to provide high-quality breast exams, and Malawian women were eager to receive screening when it was offered.

UNC researchers had to carefully design the study to overcome obstacles related to the country’s health care resources and infrastructure to make the project work. Despite the difficulties, they underscore the immense importance of screening for breast cancer as incidence of the disease increases in the country and in Africa overall.

“There are huge demographic transitions that are occurring in Africa, where populations are aging and lifestyles are becoming more westernized, all of which are associated with increased breast cancer risk,” said Satish Gopal, MD, MPH, a UNC Lineberger member and the cancer program director for UNC Project-Malawi. “Breast cancer is often occurring in very young women who would be cured in the U.S., but die because they’re in Malawi. That’s a disparity we’re trying to find solutions to.”

Click below to listen to Gopal discuss the breast cancer screening study.

Spared for a purpose
Zgambo knows the fear cancer can instill. Sixteen years ago, she discovered a lump in her breast that she thought was a simple infection. Her friends told her not to worry when it didn’t clear up on its own. They, too, thought it was likely an infection that could be easily treated with antibiotics. When her doctor told her he was 99 percent certain she had breast cancer, she was angry at herself for not recognizing the signs.

“I felt ignorant, and was furious at myself that despite my education, I did not think about breast cancer,” she said.

She also felt like the world was ending. That’s because for many people in her country, the odds of surviving cancer of any type are low.

There is currently no radiation treatment in Malawi. Cancer drugs that have dramatically improved survival for women with specific breast cancer types in the Unites States are often not available. There is no national breast cancer screening program, awareness of breast cancer is low, and women are often diagnosed at late stages.

“In Malawi, no one wants to talk about cancer because when someone has cancer, whatever type, it is like they are saying you are going to die,” Zgambo said. “Why? Because this is what was previously happening. If you had cancer, it meant you had to seek medical attention outside of the country. This involved a lot of money. There was no treatment for breast cancer apart from surgery until recently.”

But breast cancer was not a death sentence for Zgambo. While her surgery was unsuccessful, she was able to travel to South Africa to receive chemotherapy treatment, and she survived.

Zgambo believes God saved her for a reason: to spread awareness about breast cancer and the importance of early detection. She was passionate about joining the breast cancer screening project through UNC Project-Malawi, a clinical care and research collaboration between the University of North Carolina at Chapel Hill and the Malawi Ministry of Health, to do just that.

“When I was approached about the breast cancer screening project, I was very happy to be part of it,” Zgambo said. “I knew I would be able to reach out and teach a lot of women about breast cancer, and help others seek early medical attention.”

Breast cancer in Malawi occurs in very young women who would be cured in the US, says Satish Gopal, MD, MPH, UNC Lineberger member and Cancer Director of UNC Project-Malawi.

Breast cancer in Malawi occurs in very young women who would be cured in the US, says Satish Gopal, MD, MPH, UNC Lineberger member and Cancer Director of UNC Project-Malawi.

Using innovation and compassion
In designing the breast cancer screening project, UNC Project-Malawi researchers overcame health care resource limitations. Having experience working in a cancer clinic in the country’s capital of Lilongwe, Gopal and his colleagues knew how to optimize care despite resource constraints.

They work innovatively to provide care in a clinic where the beds, chairs and benches are often always full and people line up before the clinic opens, said Racquel Kohler, PhD, a former student at the UNC Gillings School of Global Public Health. Kohler, who is now a research fellow at the Harvard T.H. Chan School of Public Health, helped lead early research at UNC that laid the groundwork for the breast cancer screening pilot project.

“Some of the challenges to accessing breast cancer services in Malawi are similar to what low income women in the United States face,” Kohler said. “Structural barriers like distance to care and transportation costs as well as cultural norms prevent women from seeking care. Poverty and gender inequalities compound the problem in Malawi.”

One obstacle the researchers had to work around in designing the screening pilot was Malawi’s limited access to mammography and extreme scarcity of trained health care workers. They thought a physical breast exam by women who did not have formal medical training would be a good solution to that problem, analogous to task shifting approaches that have been successfully applied for HIV treatment in Malawi, said Gopal, who is also a member in the UNC Lineberger Global Oncology Program. They also arranged for the lay women they planned to train as breast health workers to conduct exams in clinics where women were already seeking care for other medical issues, thereby reducing barriers linked to transportation and low awareness of breast cancer.

“Often in medical clinics in Malawi, it’s first-come, first-serve, and the waiting rooms are packed to the gills,” Gopal said. “Women more or less wait for an entire day to get even relatively simple services. So we thought we’d try to take advantage of that time by giving standardized, educational talks about breast cancer and then offer screening immediately after.”

Maggie Zgambo, left, was inspired to participate in the study because she is a cancer survivor.

Maggie Zgambo, left, was inspired to participate in the study because she is a cancer survivor.

Implementing breast cancer screening in Malawi
UNC Project-Malawi researchers selected Zgambo and three other women to work as breast health workers. The women were taught about breast cancer prevention, detection, care and data collection in a four-week training course led by UNC surgeons, researchers, and Malawi Ministry of Health collaborators. They were trained to detect breast cancer tumors using a simulator with 27 different tumors and lymph nodes of varying shapes and sizes, as well as benign masses. These efforts were led by Lily Gutnik, MD, MPH, a surgery resident at University of Utah Hospital who lived in Malawi for a year through a post-doctoral research fellowship sponsored by the UNC Global Health Fellows Program and the Fulbright and Fogarty programs.

The training increased the women’s knowledge about breast cancer dramatically — from 49 percent to 91 percent of cancer-related questions answered correctly in surveys, according to an article on the study published in the journal PLOS One.

After their training, the women led 30-minute educational talks and conducted breast examinations. According to an article published about the project in the Journal of Surgical Research, of the 1,220 women eligible women, 82 percent agreed to receive a physical breast cancer exam. Researchers count that as a key hallmark of success for the pilot.

“In the absence of any screening efforts in Malawi, our study was focused on whether this would be accepted and whether it was feasible – and we demonstrated both of those things resoundingly,” Gopal said. “Uptake was really high. Most women who were offered this service, were really interested.”

Of the women who declined, the most common reason was that women were too tired or sick to participate. But women declined for other reasons, too, including needing their husbands’ approval, fear of cancer diagnosis, and lack of interest.

Researchers also had issues providing follow-up testing for women who had abnormal exam findings.

The breast health workers identified 67 women — out of 1,000 screened — with abnormal results. Physicians confirmed 29 of those cases, and recommended 19 of them for a biopsy. Thirteen women who had potential cancerous tumors in their breasts agreed to receive a biopsy, and two were abnormal. Neither of two women with abnormal test results had the masses removed surgically. One woman declined to return, and the other could not be contacted by phone. Four women of the 19 were recommended for biopsy because of enlarged axillary lymph nodes rather than because of suspicious breast lesions, and of those women, one was diagnosed with a type of HIV-linked cancer called Kaposi sarcoma.

“We tried to be comprehensive and thoughtful about how we put the program together, especially regarding downstream follow-up for women with detected abnormalities, and that was responsible for some of its successes,” Gopal said. “But even then, we had difficulty with some women, where despite calling them weekly and offering to reimburse them for transport or pick them up, we still had women who were difficult to get back in.”

Now that the pilot project is finished, Gopal said he hopes to eventually see breast cancer screening implemented on a larger scale, but that’s contingent on funding and interest. One of the important immediate next steps is to create a surveillance system so they can track breast cancer cases and outcomes in Malawi, said Stephanie Wheeler, PhD, a UNC Lineberger member and associate professor in the UNC Gillings School of Global Public Health. She also said that before screening can become routine, referral and treatment patterns need to be standardized.

“Otherwise, cancer screening in and of itself loses its value,” Wheeler said.

For Zgambo, her hope is that one day, early breast cancer detection will reduce the number of deaths. Although the pilot screening program is over, she said she’s continuing to spread awareness in a smaller way. She’s a member of a group of cancer survivors that has a mission to reach out to as many women as possible. Twice a year, they hold an event where they talk about their experiences, challenges they faced and the importance of early detection.

“I always educate women when the opportunity arises, say at church events or when I receive women visitors at home,” she said.

Just having her involved in the project, however, was extremely important, Gopal said.

“She provided a strong, living image that cancer can be overcome, and that women can go on to live healthy, productive lives even after a diagnosis of cancer,” Gopal said. “That message is very powerful in Malawi, just like it is in the US.”