Background: Despite recent international efforts to develop resource-stratified clinical practice guidelines for cancer, there has been little research to evaluate the best strategies for dissemination and implementation in lowand middle-income countries (LMICs). Guideline publication alone is insufficient. Extensive research has shown that structured, multifaceted implementation strategies that target barriers to guideline use are most likely to improve adherence; however, most of this research has been conducted in high-income countries. There is a pressing need to develop and evaluate guideline implementation strategies for cancer management in LMICs in order to address stark disparities in cancer outcomes. Methods: In preparation for the launch of Tanzania's first National Cancer Treatment Guidelines, we developed a theory-driven implementation strategy for guideline-based practice at Ocean Road Cancer Institute (ORCI). Here, we use the Intervention Mapping framework to provide a detailed stepwise description of our process. First, we conducted a needs assessment to identify barriers and facilitators to guideline-based practice at ORCI. Second, we defined both proximal and performance objectives for our implementation strategy. Third, we used the Capability, Opportunity, Motivation and Behavior/Behavior Change Wheel (COM-B/BCW) framework to categorize the barriers and facilitators, choose behavior change techniques most likely to overcome targeted barriers and leverage facilitators, and select a feasible mode of delivery for each technique. Fourth, we organized these modes of delivery into a phased implementation strategy. Fifth, we operationalized each component of the strategy. Sixth, we identified the indicators of the process, outcome, and impact of our intervention and developed an evaluation plan to measure them using a mixed methods approach.

PURPOSE Tanzania and other low-income countries face a growing burden of cancer and a pressing need to strengthen cancer care delivery systems. The overall case fatality from cancer is disproportionately higher in low-income countries, and adherence to standard treatment guidelines is a critical component of addressing disparities in outcomes. In 2017, Tanzania’s Ministry of Health, Community Development, Gender, Elderly, and Children (MOHCDGEC) commissioned leaders at Ocean Road Cancer Institute to develop Tanzania’s first National Cancer Treatment Guidelines. METHODS In 2017, we convened 90 stakeholders from 15 institutions in Tanzania to form 10 different technical working groups (TWGs). TWGs were organized according to disease-specific categories and were composed of representatives from relevant disciplines, including surgeons, gynecologists, pediatricians, radiologists, pathologists, oncologists, social workers, dieticians, and nurses. Each TWG conducted a review of the current literature and prepared a summary of the epidemiology, diagnostic, and staging procedures; options for management; and essential medicines currently available in Tanzania. In 2018, after multiple revisions and meetings of each TWG, the guidelines underwent an external review with 2 oncologists from Tanzania participating in consultations with approximately 30 disease-specific experts at the University of California, San Francisco. RESULTS Guidelines were developed for a total of 70 diseases. The guidelines are intended to be facilitative, enabling, and providing the basis for the attainment of high standards in the management of cancers in a resource-constrained setting. Guidelines were formatted for dissemination in both hard copy and soft copy using the AgileMD platform. CONCLUSION In February 2020, Tanzania’s MOHCDGEC disseminated its first-ever National Cancer Treatment Guidelines. After dissemination, MOHCDGEC will implement a monitoring and evaluation strategy that ensures and promotes the use of the guidelines. We have developed a theory-informed implementation strategy that focuses on education, workflow modifications, and behavior change that will be piloted at Ocean Road Cancer Institute.

Background. In response to the increasing burden of cancer in Tanzania, the Ministry of Health Community Development, Gender, Elderly and Children launched National Cancer Treatment Guidelines (TNCTG) in February 2020. The guidelines aimed to improve and standardize oncology care in the country. At Ocean Road Cancer Institute (ORCI), we developed a theory-informed implementation strategy to promote guideline-concordant care. As part of the situation analysis for implementation strategy development, we conducted focus group discussions to evaluate clinical systems and contextual factors that influence guideline-based practice prior to launching of TNCTG. Methods. In June 2019, three focus group discussions were conducted with a total of 21 oncology clinicians at ORCI, stratified by profession. A discussion guide was used to stimulate dialogue about facilitators and barriers to delivery of guideline concordant care. Discussions were audio recorded, transcribed, translated, and analyzed using thematic framework analysis. Results. Participants identified factors both within the inner context of ORCI clinical systems and outside of ORCI. Themes within the clinical systems included: capacity and infrastructure, information technology, communication, efficiency and quality of services provided. Contextual factors external to ORCI included: inter-institutional coordination, oncology capacity in peripheral hospitals, public awareness and beliefs, and financial barriers. Participants provided pragmatic suggestions for strengthening cancer care delivery in Tanzania. Conclusion.Our results highlight several barriers and facilitators within and outside of the clinical systems at ORCI that may affect uptake of the TNCTG. Our findings were used to inform a broader guideline implementation strategy, in effort to improve uptake of the TNCTGs at ORCI. Implications for practice. This study provides an assessment of cancer care delivery systems in a low resource setting from the unique perspectives of local multidisciplinary oncology clinicians. Situational analysis of contextual factors that are likely to influence guideline implementation outcomes is the first step of developing an implementation strategy for cancer treatment guidelines. Many of the barriers identified in this study represent actionable targets that will inform the next phases of our implementation strategy for guideline-concordant cancer care in Tanzania and comparable settings. The Oncologist ;9999:• •

Purpose Low-income countries (LICs) face a growing cancer burden and a pressing need to strengthen cancer care delivery systems. Overall case fatality from cancer is estimated to be 30% higher in LICs than in high-income countries, and adherence to standard treatment guidelines is a critical component of addressing this disparity. Despite several recent international efforts to develop resource-stratified cancer treatment guidelines, little research has been done on their implementation. In 2018, Tanzania’s Ministry of Health will publish a new set of national cancer treatment guidelines for all cancers. The objective of this work is to evaluate the feasibility, adoption, and effectiveness of a theory-informed implementation strategy to facilitate the uptake of guideline-based clinical practice at the national referral center, Ocean Road Cancer Institute (ORCI). Our central hypothesis is that this implementation strategy will be undertaken with fidelity and context-appropriate adaptations and will effectively increase guideline-concordant treatment at ORCI. Methods Qualitative data demonstrate that major barriers to guideline-based practice at ORCI include a lack of familiarity with standard treatment guidelines and a culture that prioritizes experience-based expertise over guidelines. We developed a multifaceted intervention to target these barriers using the Capability, Opportunity, Motivation and Behavior/Behavior Change Wheel framework. Our intervention has three phases: distribution of national cancer treatment guidelines in hard and soft copy, with an accompanying publicity campaign; dedicated multidisciplinary trainings for oncology providers and implementation champions; and reinforcement strategies, such as environmental restructuring and point-of-care clinical forms, to promote guideline-based practice. We will use a pre–post design that uses a mixed-methods approach to measure process and outcomes, including clinical data collection, survey administration, and qualitative interviews, focus groups, and field observation. Conclusion In Tanzania and other LICs, shifting to guideline-based practice entails a change in clinical culture and behavior, and guideline publication alone is unlikely to result in meaningful change. A theory-informed implementation strategy is the optimal way to ensure the adoption and sustained use of guideline-based practice. Systematic evaluation will allow us to make necessary modifications, disseminate findings, and advance knowledge in the field of cancer treatment guideline implementation in LICs. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . Li Zhang Consulting or Advisory Role: Dendreon, Unity