By D. Akrabor. Paul Quinn College.

The high cost of defensive medicine order alesse 0.18mg online, with an escalation in services solely to avoid malpractice litigation discount alesse 0.18mg amex. The availability and use of new medical technologies have contributed the most to increased health care spending cheap alesse 0.18mg without prescription, argue many analysts. The reasons government attempts to control health care costs have failed include: 1. Market incentive and profit-motive involvement in the financing and organization of health care, including private insurers, hospital systems, physicians, and the drug and medical-device industries. In addition to R&D, the medical industry spent 24% of total sales on promoting their products and 15% of total sales on development. If health care spending is perceived as a problem, a highly profitable drug industry exacerbates the problem. Many argue that reductions in the pre-approval testing of drugs open the possibility of significant undiscovered toxicities. Assessing risks and costs, as well as benefits, has been central to the exercise of good medical judgment for decades. Examples of Lack of Proper Management of HealthCare Treatments for Coronary Artery Disease 1. Both procedures increase in number every year as the patient population grows older and sicker. Rates of use are higher in white patients and private insurance patients, and vary greatly by geographic region, suggesting that use of these procedures is based on non-clinical factors. They reviewed 1,300 procedures and found 2% were inappropriate, 90% were appropriate, and 7% were uncertain. The New York numbers are in question because New York State limits the number of surgery centers, and the per-capita supply of cardiac surgeons in New York is about one-half of the national average. A definitive review published in 1994 found less than 30 studies of 5,000 that were prospective comparisons of diagnostic accuracy or therapeutic choice. Clinical evaluation, appropriate patient selection, and matching supply to legitimate demand might be viewed as secondary forces. Laparoscopic cholecystectomy was introduced at a professional surgical society meeting in late 1989. There was an associated increase of 30% in the number of cholecystectomies performed. Because of the increased volume of gall bladder operations, their total cost increased 11. The mortality rate for gall bladder surgeries did not decline as a result of the lower risk because so many more were performed. When studies were finally done on completed cases, the results showed that laparoscopic cholecystectomy was associated with reduced inpatient duration, decreased pain, and a shorter period of restricted activity. But rates of bile duct and major vessel injury increased and it was suggested that these rates were worse for people with acute cholecystitis. Patient demand, fueled by substantial media attention, was a major force in promoting rapid adoption of these procedures. The major manufacturer of laparoscopic equipment produced the video that introduced the procedure in 1989. Doctors were given two-day training seminars before performing the surgery on patients. In 1992, the Canadian National Breast Cancer Study of 50,000 women showed that mammography had no effect on mortality for women aged 40-50. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. Patient, provider and hospital characteristics associated with inappropriate hospitalization. The cost of inappropriate admissions: a study of health benefits and resource utilization in a department of internal medicine. Fourth Decennial International Conference on Nosocomial and Healthcare-Associated Infections. Malnutrition and dehydration in nursing homes: key issues in prevention and treatment. Nationwide poll on patient safety: 100 million Americans see medical mistakes directly touching them [press release]. Characteristics of medical school faculty members serving on institutional review boards: results of a national survey. Peer reporting of coworker wrongdoing: A qualitative analysis of observer attitudes in the decision to report versus not report unethical behavior.

Another similar study on the treatment of nephritis discount 0.18mg alesse overnight delivery, entitled generic alesse 0.18 mg with mastercard, Treatment Of Glomer-ulonephritis By Antigen purchase 0.18mg alesse fast delivery, published in the London Lancet, in Dec. Day, (London), also demonstrated the effectiveness of a simple, natural urine extract on several cases of both acute and chronic nephritis: "Treatment by injection of urine extract appeared of distinct value in acute glomerulonephritis and for exacerbations or relapses in chronic active forms of the disease. Garotescu, describes his experiences in treating cystitis, a painful inflammation, or infection of the bladder which commonly affects women and can lead to more serious conditions, such as kidney infections. The success of the treatment was verified by laboratory tests which showed a complete absence of colibaccilli (cystitis bacteria) in her urine. Laboratory analysis of urine sample revealed the presence of numerous colonies of colibacilli. Patient was given 4 injections of auto-urine, after which all symptoms and signs of the infection were completely ameliorated. Garotescu reported that he gave 220 urine injections to patients without any adverse side effects whatever, other than an occasional, temporary redness and swelling at the site of the injection which is commonly reported with urine injections, or injections of any kind. After experimenting with the effect of urea on the polio and rabies viruses, McKay and Schroeder report that: ". The effect of urea in strong concentration on these viruses (rabies and polio) proved interesting. Urea is such a relatively inactive substance and certainly not a 89 protoplasmic poison such as are most virucidal agents that it is in a way surprising that rabies and poliomyelitis are killed so easily by urea solutions. It is true that neutral and inactive as it is, urea, like alkalies, denatures protein when dissolving it and this reaction may be associated with the death of the virus. Because concentrated urea has been proven to destroy viruses without harming the body, oral urine therapy, which increases urea concentrations (see Dr. Symmers and Kirk (1915) reported on its bactericidal properties together with its use in the treatment of wounds. In spite of this article, the use of urea for wound therapy has apparently enjoyed little popularity in this country [England]. In America, however, it has recently been used for the treatment of various infected wounds by Robinson (1936) and by Holder and McKay (1937), who found it extremely efficient. Moreover, it is a substance that is readily obtainable in quantity and is both cheap and stable. For these reasons it was thought desirable to test its efficacy in the casualty 91 department of the Royal Free Hospital (London). No toxic effects have been recorded even though the urea has been applied in solid form. The procedure employed was as follows: The wounds were syringed free from pus and necrotic (dead) material with a saturated solution of urea, excessive moisture was removed and the urea crystals were then liberally applied. Waxed paper was placed next to the crystals to keep 85Your Own Perfect Medicine them in contact wit h the wound and to prevent the dressing becoming soaked. For a period of six months cases of the following types have been treated: (1) Abscesses–superficial and deep lesions, (2) Infected traumatic wounds of all descriptions, (3) infected hematomas (bruised areas), (4) Cellulitis, (inflamed subcutaneous tissue), (5) Septic wounds due to burns of 2nd, 3rd, and 4th degree, (6) varicose ulcers, (7) carbuncles (external staph infections), (8) Infected tenosynovitis (inflamed tendons) of the hand. With a view to comparing the efficiency of urea with that of other solutions, the cases at first selected for treatment were those which had either behaved sluggishly with other antiseptics or had actually retrogressed. During this time it had been treated with Eastoplast and various other substances. At the time the urea treatment was begun the ulcer was of oval irregular outline with everted swollen edges and a floor covered with a whitish, foul smelling slough. After 2 days the foul odor had disappeared and after 4 days the base of the ulcer was covered by a mass of bright red granulations (new tissue). By the 14th day the skin edges had grown in and the size of the ulcer was 3/4 by 1/2 in. The wound was opened again when it was found that the infection had entered the tendon sheath. Urea treatment was started and after 3 days the , slough was removed thus exposing the underlying tendon. The patient was discharged 22 days after the treatment was begun, the wound having healed completely. As will be seen from the above, we have used urea in a variety of casualty department cases. Owing to the extreme diffusibility of urea even the deepest wound can be treated effectively. A very definite response to urea treatment is nearly always obtained after two or three applications. Coupled with this is a considerable decrease of edema as the local circulatory conditions improve. For the carbuncles (external staph infections), treated, we found urea preferable to any other dressing after initial incision. In none of the cases of our series did we observe any skin 94 reaction which could be called a urea dermatitis (rash), nor have we evidence of any toxic effects.

There is a quick reference index at the end of a powerful tool for maintaining one’s own health order 0.18mg alesse amex. Medical educators Medical educators will fnd a resource on the principles of phy- sician health order 0.18mg alesse with visa. The cases are derived from evidence of patients’ needs alesse 0.18 mg visa, from practicing physicians’ perspectives, from content experts and from empirical research. This guide helps teachers ask effective educational questions that explore the variety of aspects that make up physician health and lead to sustainable practice. Societal expectations 8 Jordan Cohen Section 2 - The individual physician Introduction 11 Derek Puddester A. Leadership and leadership skills 18 Derek Puddester Section 3 - Balancing personal and professional life Introduction 21 Jordan Cohen A. Intimidation and harassment in training 54 Jordan Cohen Section 6 - Collegiality Introduction 57 Jordan Cohen A. Interdisciplinary relationships 66 Janet Wright Section 7 - Physician health and the doctor–patient relationship Introduction 68 Leslie Flynn A. Coping with an adverse event, complaint or litigation 70 Canadian Medical Protective Association B. Boundary issues 76 Michael Paré Section 8 - The physician life-cycle Introduction 79 Jordan Cohen A. Coping with and respecting the obligations of mandatory reporting 98 Canadian Medical Protective Association F. Physicians with an illness or a disability 104 Ashok Muzumdar Section 10 - Financial health Introduction 107 Jordan Cohen A. Puddester completed his undergraduate training in English/Russian Studies and Medicine at Memorial University of Newfoundland. He completed a Psychiatry Residency at McMaster University and a Fellowship in Child Psychiatry at uOttawa. He is the Medical Leader of the Behavioural Neurosciences and Consultation-Liaison Team at the Children’s Hospital of Eastern Ontario. Puddester is an Associate Professor at uOttawa’s Faculty of Medicine where he also serves as the Director of the Faculty Wellness Program. Puddester’s educational and research work focuses on physician health, healthy work environments, e-learning, and curriculum theory and development. The Canadian Association of Interns and Residents has recognized his leadership in physician health by creating the Dr. Derek Puddester Resident Well-Being Award which is given annually to a person or program that has made a signifcant contribution to the improvement of resident health and wellness. She became certifed as a Family Physician in 1988 and subsequently as a psychiatrist in 1995. She then began her professional ca- reer at Queen’s University when she was cross-appointed to the Departments of Family Medicine and Psychiatry in the role of Family Medicine Liaison Psychiatrist. She has held roles as Director of the Continuing Medical Education program, Postgraduate Program Director and the Director of Psychotherapy in the Department of Psychiatry. Flynn is currently an Associate Professor in the Departments of Psychiatry and Family Medicine and the Associate Dean of Postgraduate Medical Education at Queen’s University. Flynn has received departmental awards for Excellent Leadership in Education and Dedication to the Ideals of the Department as well as the Annual Staff Excellence in Teaching Award. She has conducted research in physician health, the Role of Health Advocate, interprofessional education and the scholarship of teaching and learning. Cohen is currently an Assistant Clinical Professor in the Department of Psychiatry of the Faculty of Medicine at the University of Calgary, where he completed both his residency and undergraduate medical training. He is also the Director of Student Affairs of Undergraduate Medical Education and Chair of The Physicianship Course for the Faculty of Medicine at the University of Calgary. His educational and research work focuses on balancing medicine, physician health and professionalism. He is also a board member of the Physician Health Monitoring Program for the Alberta College of Physicians and Surgeons. Derek Puddester Resident Well Being Award 2006 for his contributions to resident health; the Department of Psychiatry’s Postgraduate Clinical Education Award 2008 in recognition of outstanding contribution in the area of postgraduate clinical education; and the Department of Psychiatry’s Postgraduate Research Award for Part-time Faculty 2008 in recognition of outstanding research contributions in Psychiatry. Goals and objectives of this guide The vast majority of today’s physicians entered their profession This handbook is designed to help educators and learners after considerable refection, years of academic preparation, better understand the broad meaning of “physician health,” and in the face of signifcant competition and challenge. The to discover practical strategies to promote professional health intellectual, emotional, physical and social demands of medi- and to apply such knowledge to real-world situations. It is not cal training are rigorous, as are the professional and personal meant to be an academic exercise, but rather to form part of demands of practice. The good news is that most physicians a practical toolkit of resources that Canadian physicians can thrive in their work environments, are strong and healthy, access and apply as they see ft. Readers can use this handbook practise excellent strategies to safeguard their own well-being, to explore their own questions and needs, educators can draw and enjoy long and healthy lives. When physicians’ personal upon it as a resource for teaching and learning programs, and well-being and professional commitment are in balance, posi- investigators may fnd it helpful in identifying avenues for tive synergies result that sustain them in their healing role, to research in physician health.

A 57-year-old woman comes to the physician 1 week after noticing a mass in her left breast during breast self-examination cheap 0.18 mg alesse visa. She was receiving estrogen therapy but discontinued it 6 weeks ago discount alesse 0.18mg with amex; she has had no menopausal symptoms cheap alesse 0.18mg on line. Examination shows a 2-cm, palpable, nontender, mobile mass in the upper outer quadrant of the left breast; no nipple discharge can be expressed. A 27-year-old nulligravid woman has had severe pain with menses that has caused her to miss at least 2 days of work during each menstrual cycle for the past year. A 22-year-old woman comes to the physician because of a 2-day history of pain with urination, intense vaginal itching, and a thick discharge. Genitourinary examination shows erythema of the vulva and vagina with an odorless curd-like discharge. A 27-year-old nulligravid woman and her husband have been unable to conceive for 12 months. She had a single episode of pelvic inflammatory disease 4 years ago and was treated with oral antibiotics. A 30-year-old woman, gravida 2, para 1, comes for her first prenatal visit at 26 weeks’ gestation. A 42-year-old woman, gravida 2, para 2, comes to the physician because of increasingly frequent loss of urine during the past year. She has loss of urine when she coughs, sneezes, exercises, or plays with her children. Her incontinence is never preceded by a sudden urge to void, and she does not have loss of urine at night. During a routine examination, a 25-year-old woman expresses concern about her risk for ovarian cancer because her mother died of the disease. At her 6-week postpartum visit, an 18-year-old woman, gravida 1, para 1, tells her physician that she has a pinkish vaginal discharge that has persisted since her delivery, although it is decreasing in amount. On physical examination, the uterus is fully involuted and there are no adnexal masses. A 32-year-old nulligravid woman comes to the physician because of a 6-week history of persistent foul-smelling vaginal discharge and vaginal itching. Her symptoms have not improved despite 2 weeks of treatment with over-the-counter antifungal medications and fluconazole. She has been sexually active and monogamous with her boyfriend during the past year, and they use condoms consistently. A wet mount preparation of the discharge shows numerous multi-flagellated organisms the size of erythrocytes. An asymptomatic 24-year-old primigravid woman at 36 weeks’ gestation comes for a routine prenatal visit. The S2 varies with inspiration, and the pulmonic component is soft; diastole is clear. A 42-year-old woman, gravida 3, para 3, comes to the physician because she has not had a menstrual period for 2 months. Pelvic examination shows a slightly enlarged uterus; there are no palpable adnexal masses. A 57-year-old woman comes to the physician for a routine health maintenance examination. The physician recommends that the patient increase her daily dose of the calcium supplement. The most appropriate next step in management is supplementation with which of the following? A 2778-g (6-lb 2-oz) male newborn is born at 37 weeks’ gestation to a 27-year-old woman, gravida 3, para 2, after an uncomplicated labor and delivery. She says she did not have any health problems during pregnancy, but she continued to consume two bottles of beer weekly during her pregnancy. Which of the following measures during the mother’s pregnancy is most likely to have prevented this child’s deformity? Two hours after vaginal delivery at term of a 3062-g (6-lb 12-oz) newborn, a 32-year-old woman, gravida 3, para 3, has the onset of heavy vaginal bleeding. Labor was augmented with oxytocin because of a prolonged first stage and required forceps delivery over a midline second-degree episiotomy. A 19-year-old primigravid woman at 8 weeks’ gestation is brought to the emergency department because of light vaginal bleeding and mild lower abdominal cramps during the past 8 hours. On pelvic examination, there is old blood in the vaginal vault and at the closed cervical os. A 16-year-old girl is brought to the emergency department 6 hours after the onset of moderate lower abdominal cramps and intermittent nausea. She says that her last menstrual period was 2 months ago, but she has had intermittent bleeding since then, including spotting for the past 2 days.

The areas covered were the need for dose reduction as a result of standardized quality assurance procedures 0.18mg alesse visa, education and training safe alesse 0.18mg, and the development and implementation of a sustainable safety culture buy generic alesse 0.18mg on-line, research needs to improve the knowledge in individual radiosensitivity of patients, as well as the access to proper imaging techniques and training in diagnostic imaging and radiation protection in developing countries. Integration of radiation protection and safety It is important to include radiation protection and safety plans in management control systems in hospitals. This can best be achieved by involvement of key managers, authority given to radiation protection experts and transparent internal audits. Key challenges within such a process include effective communication within the organization and adoption of a graded approach towards radiation and safety. Dose assessment and national registries It is important to assess effective collective doses from diagnostic X ray and nuclear medicine examinations. This can be best achieved by establishing national registration systems to monitor frequency and doses, with the aim of identifying long term trends. The results can be used to select priorities for clinical audit and optimization actions. Experience shows that it is beneficial to engage stakeholders (professionals, institutional representatives, users) in developing methodology for clinical audits focusing on processes and outcomes. Of equal importance is the cooperation between authorities and professionals when establishing clinical audits. Quality assurance, education and training, and the development of a radiation safety culture Radiation protection is embedded in everyday clinical practice and is part of overall standard procedures. Radiographers have an important role in medical radiation protection; it is important that their education and training meets high standards. There is a strong need for increased cooperation between education and training organizations and employers. Adherence to dose reduction should be rewarded through accreditation and communication. Education to achieve a culture of radiation protection should go hand in hand with promoting justified use of radiation based examination. Risk management measures reduce the potential or even prevent unintended exposures and they are, therefore, a critical component of radiation protection culture. There is a need to demonstrate, through standard health technology assessment, that radiation protection measures, such as technological development, meet clinical cost– benefit requirements. The establishment of a safety culture is a focus area within the efforts of the International Radiation Protection Association to develop and enhance a strong radiation protection culture. The implementation of the Basic Safety Standards in health care at the global level Access to high quality and safe radiotherapy is particularly essential for developing countries. Specific attention should be given to developing countries, where access to proper imaging should be improved and training in diagnostic imaging and radiation protection should be a high priority. Individual sensitivity One of the key future impacts on medical radiation protection from advances in radiobiology is the specific consideration of the individual sensitivity of patients to ionizing radiation. There is an increasing opportunity to take into account the variability of the individual sensitivity of patients in diagnostic applications of ionizing radiation. Specific emphasis is on the most sensitive patients, the most sensitive tissues, the examinations with the highest dose and the most frequent examinations. Repeated medical exposures of young patients that are hypersensitive to ionizing radiation are a major concern for radiation protection. If fully established, the system of radiation protection may need to be revised to take into account individual sensitivity to ionizing radiation. In order to improve our knowledge of this important question, individual sensitivity and hypersensitivity to low doses of medical imaging and consequences for radiation protection systems and practices have to be explored further by targeted research activities. Moreover, the technical development in diagnosis and therapy has increased the capabilities for more targeted and individual approaches. Radiation protection and safety issues are closely linked to patient safety issues, and management control systems must include radiation protection and safety. Consideration should be give to make maximum dose reduction techniques mandatory in new acquisition techniques. It is recommended to replicate the best practices that have been applied to the nuclear industry and adjust them to the medical sector. As the ultimate goal is to arrive at a situation where medical radiation protection is evidence based, there is a need to narrow the gap between evidence and practice. For this purpose, more emphasis has to be devoted to risk assessment, long term follow-up and risk management. Concern has been raised about the fact that there is little to no access to imaging techniques in developing countries. Access to high quality and safe radiotherapy is particularly essential for countries with low and medium income. Low and medium income countries represent 85% of the world’s population but only one third of radiotherapy treatment facilities are operated in these countries. Owing to improvements in hygiene and life expectancy, it is assumed that over the next decade the increase in cancer incidence in low and medium income countries will be about twice as high as in high income countries. There is an urgent need to develop and provide these countries with equipment for basic imaging and treatment.

For an immunization buy alesse 0.18 mg overnight delivery, the germs from the illness are changed and then injected into the body generic alesse 0.18mg mastercard, which teaches the body’s own defense system to fght the disease best alesse 0.18 mg. Each kind of me changes the brain; Once the brain is changed, it’s never quite the same. Marijuana is one kind to smoke, And the white powder, cocaine, is also called coke. It also affects the cerebellum, the part of the brain responsible for balance and coordination. Both cocaine and marijuana turn on the pleasure center, part of the limbic system, making the body crave the substance. I can harden your teeth and make them strong; Dentists love me because I keep kids away from the drill for so long. Fluoride hardens and repairs enamel, the covering on teeth, and prevents cavities from forming. When you have strep throat and you feel really sick, I kill all the germs—I do the trick. Pretty soon, you feel okay; Then I’ve done my job, and the bacteria have gone away. Alcohol keeps people from thinking clearly, slows down the ability to respond to danger, makes people sleepy, and can kill neurons. That’s not all that I do; I also can make it harder to write words that are clear, fresh, and new. Caffeine makes people feel more awake but less able to write or draw well due to shaky hands. I don’t mean to make people smoke forever and ever, But I guess I’m just oh so clever. Nicotine takes away people’s appetite, speeds up the heart, and changes the brain so that it needs nicotine to work normally. Brain Teaser hasn’t been able to make it to the club for a couple of days because he sprained his ankle. In fact, the whole idea is to get you kids thinking about the difference between drugs used as medicines and drugs used for other purposes. Here goes: You can use me on waffes and pancakes, I’m brown, sweet, sticky, and with me a mess you can make. During the frst three modules, we introduced the parts of the brain and the process of neurotransmission so that now, by module 4, the children have some understanding of the complexity of the central nervous system. One group of drugs, with a benefcial effect on the body, includes medicines that they have probably taken—aspirin/Tylenol, antibiotics, immunizations, and fuoride. The other category, which can have harmful effects on the body, includes alcohol, nicotine, and illegal drugs, such as marijuana and cocaine. One of the points we emphasize in the module is that all these substances are powerful. Even helpful drugs must be taken under the right conditions and given by trusted individuals—parents or health care professionals, for example. If too much medicine is given, that can be just as dangerous as taking an illegal substance. Help provide your child with more knowledge so that when the time comes, he or she will make a solid, science-based decision not to take drugs. For example, if you have a glass of wine with dinner, explain that your choice is okay because you are an adult, are drinking in moderation, and are not doing anything dangerous, such as driving after drinking. Emphasize that adults can make these choices, while children are not yet old enough. By learning about how the brain works and about drugs, however, your child is getting a foundation to make thoughtful decisions in the future. Additional Resources The books and Web sites listed below have more information about drugs. This book provides a good abuse and a section designed specifcally for overview of the brain, neurotransmission, the parents, teachers, and students. Gives a good overview of nicotine This site is designed specifcally for young and caffeine and how each of these drugs people to learn about the effects of drug abuse affect the body and brain. I can be a gas, aspirin that makes a person better is from like air, or a liquid, like water. I am a pill or liquid mouthwash, and even in the water that makes headaches and fevers supply. People who use me might not be sick person fight germs and get able to stop taking me, even if they become very, very better. People who use me might not be sick person fight germs and get able to stop taking me, even if they become very, very better. They are administered by people who care about children like parents, doctors, dentists, and other care givers. Helpful medicines include aspirin/Tylenol, antibiotics, fluoride, and immunizations. Most of these drugs are illegal for children, and some are even illegal for adults.

In 2015 discount 0.18mg alesse with mastercard, approximately 35% of low- income countries reported that pathology services were generally available in the public sector compared to more than 95% of high-income countries (29) generic alesse 0.18mg otc. Poor coordination and loss to follow-up The facility where a clinical diagnosis is made may be different from where the biopsy is obtained buy 0.18 mg alesse with visa, pathology reviewed and/or staging performed. Delays in cancer diagno- sis may arise due to poor follow-up, lack of referral pathways and fragmented health services. Less than 50% of low- and lower-middle-income countries currently have clearly defned referral systems for suspected cancer from primary care to second- ary and tertiary care (29). As the number of providers involved and the number of diagnostic steps increase, there are greater risks of miscommunication and lack of follow-up of important results (6). The greater the number of facilities that patients need to visit for cancer diagnosis and treatment, the greater the burden placed on individuals and families to overcome fnancial and geographic barriers and the greater the risk of duplicated services. The absence of unique patient identifers or reli- able health information systems worsens communication among providers, facilities and patients (32). Step 3: Access to treatment Promoting early identifcation of cancer in the absence of appropriate access to treat- ment is not only ineffective, but is also unethical. A signifcant percentage of patients who receive a cancer diagnosis do not initiate or complete treatment due to various barriers that can include an inability to afford care or fear of fnancial catastrophe, geographic barriers and anxiety about cancer treatment (33–35). Guide to cancer early diaGnosis | 19 Financial, geographic and logistical barriers Basic cancer treatment consists of one or a combination of treatment modalities, including surgery, systemic therapy and radiotherapy. In a signifcant number of coun- tries, basic treatment services are unavailable (Figure 7) (29). Fear of fnancial catastrophe is also a major cause of non-attendance for diagnosis, delay and abandonment of treatment among patients with early cancer symptoms. Impoverished or low socioeconomic status populations are at the highest risk of not receiving treatment for cancer. In some set- tings, as much as 50% of cancer patients forego treatment due to the inability to pay for care (36,37). Patients may have to travel long distances to access a facility capable of providing cancer treatment, and longer travel distance has been associated with late presen- tation (38). Indirect, out-of-pocket costs and the time required to seek and navigate care can be burdensome and function as disincentives to accessing timely, afforda- ble treatment. The morbidity of cancer treat- ment may trigger fears of alienation from a person’s family or community. This can be compounded by poor communication between patients and providers and inaccurate perceptions of cancer treatment. Misconceptions can be exacerbated by differences in religion, gender, class and belief systems between the patient and the health-care team (39). In addition, patients may not understand or not be given clear instructions on the recommended facility and time for evaluation at the treatment facility. Results from the situation analysis can assist with the development of strategic priorities to address the common barriers. Potential interventions to strengthen to early diagnosis Step 1 Step 2 Step 3 Awareness Clinical and evaluation, Access to accessing diagnosis and treatment care staging Diagnostic Awareness of symptoms, Accurate clinical Referral for Accessible, high-quality testing and seeking and accessing care diagnosis treatment treatment staging Interventions: Intervention: Intervention: Interventions: Intervention: • empower and engage people and • improve provider • strengthen • develop • improve access to treatment communities capacity at frst diagnostic referral by reducing fnancial, • improve health literacy and contact point and mechanisms geographic, logistical and reduce cancer stigma pathology and sociocultural barriers services integrated • Facilitate access to primary care care • Provide supportive counselling and people- centred care Leadership and governance to improve access to care Leadership and governance in cancer control involve development and implemen- tation of strategic frameworks combined with effective oversight, coalition-building and multisectoral engagement, regulation, resource allocation, attention to system design and accountability. Careful consideration should be made for how distribution of resources impacts access and equity (7). Accreditation and standards can improve the availability and readiness of key interventions at each level of the health system. Similarly, multisectoral action through effective partnership can facilitate early diagnosis and promote access to cancer care (40). Step 1: Awareness and access to care Empower and engage people and communities Empowering and engaging people and communities enable timely clinical presen- tation by improving health literacy, reducing stigma and facilitating access to care. Important objectives of engaging with communities are to improve knowledge and awareness of cancer, to listen to what they report as their major barriers to seeking earlier diagnosis for cancer symptoms and to use their knowledge to develop solu- tions. Feedback from the community can include the location of services, opening times of health facilities, costs of care, provider behaviour or addressing other prac- tical issues such as transport. Improve health literacy and reduce cancer stigma Specifc strategies to improve health literacy and reduce stigma depend on predom- inant sources of information and can include printed media, radio, television, social media and other online tools. Interventions used to promote public awareness about cancer should be culturally appropriate and consistent at all levels of the health sys- tem. Key messages include awareness of “alarm” or “red fag” symptoms that may represent cancer, how to seek evaluation for these symptoms and awareness that timely evaluation and treatment can increase the likelihood of a cure. Awareness of highly predictive cancer symptoms includes knowing how to self-identify changes and to understand that specifc symptoms may represent cancer without excessive fear or denial (Table 3). Guide to cancer early diaGnosis | 23 Table 3. Common symptoms and signs that may be due to cancera Site of cancer Common symptoms Breast lump in the breast, asymmetry, skin retraction, recent nipple retraction, blood stained nipple discharge, eczematous changes in areola Cervix Post-coital bleeding, excessive vaginal discharge Colon and rectum change in bowel habits, unexplained weight loss, anaemia, blood in the stool (rectal cancer) Oral cavity White lesions (leukoplakia) or red lesions (erythroplakia), growth or ulceration in mouth Naso-pharynx nosebleed, permanent blocked nose, deafness, nodes in upper part of the neck Larynx Persistent hoarseness of voice Stomach upper abdominal pain, recent onset of indigestion, weight loss Skin melanoma Brown lesion that is growing with irregular borders or areas of patchy colouration that may itch or bleed Other skin cancers lesion or sore on skin that does not heal Urinary bladder Pain, frequent and uneasy urination, blood in urine Prostate diffculty (long time) in urination, frequent nocturnal urination Retinoblastoma White spot in the pupil, convergent strabismus (in a child) Testis swelling of one testicle (asymmetry) a These common symptoms may be due to cancer or due to a different medical condition. Mass media are an important platform for awareness raising, although messaging strategies need to be carefully designed and tested to reach population groups most in need (17). Social networks can also be used to improve health-seeking behaviour and health literacy (41). Cancer survivors and advocates play an important role in reducing stigma and promoting public awareness that cancer can be a curable dis- ease, and can be paired with the professional community for further leveraging (12).