Cervical cancer: the route from signs and symptoms to treatment in South Africa

Precarity and Hope at the Intersections of HIV and Cervical Cancer in a Johannesburg Clinic

In a tragically ironic twist, antiretroviral therapy (ART) that promised an end to AIDS ushered in a syndemic of viral cancers, transforming hope to despair. In this article we draw from the illness narratives of HIV positive women attending a cervical cancer screening clinic in Johannesburg, South Africa, and chart their pathways from HIV to cancer, and their quest for treatment. Our interlocutors described protracted struggles to access surgical procedures to prevent the onset of cervical cancer. Dealt a double blow of HIV and cervical cancer, women's narratives reveal the intersections of exposure to pathogens and the precarity of hope.

The effects of the LaSota strain of oncolytic Newcastle disease virus vaccine on cervical intraepithelial neoplasia Patients-Clinical cohort study

BACKGROUND

Cervical cancer is one of the most common malignancies in women, and its treatment has many side effects. Therefore, in this research, the effects of the LaSota strain of oncolytic Newcastle disease virus vaccine on cervical intraepithelial neoplasia (CIN) patients were investigated.

METHODS

15 patients who met the inclusion criteria and diagnosed as CIN II and CIN III were included in the study. The vaccine was injected inside the cervix (neoplasia site) at increasing doses during 21 days, and they were evaluated for adverse events. NDV antibody titer was measured in 90 days and the levels of ki-67 and p16 proteins were studied by immunohistochemistry. Also, the levels of some important inflammatory cytokines in the serum of CIN patients were measured and finally the patients were evaluated according to the final outcomes and the reduction of tumor lesions.

RESULTS

Only in the first dose of vaccine some patients showed flu-like symptoms. The accumulation of NDV antibodies started on the 7th day of the study and increased until the 90th day. Administration of LaSota vaccine had no significant effect on the expressions of Ki-67 and p16 proteins. Nevertheless, a decrease in the serum levels of Il-1β was observed in patients after the administration of the vaccine, but the serum levels of both Il-2 and INF-γ upregulated significantly. Also, vaccine administration had no significant effect in reducing CIN grades and lesions.

CONCLUSIONS

In general, we concluded that LaSota strain of NDV vaccine has no therapeutic effectiveness in CIN patients.

Diagnostic and pre-treatment intervals among patients with cervical cancer attending care at the Uganda Cancer Institute: a cross-sectional study

BACKGROUND

Majority of patients with cervical cancer in the low- and middle-income countries experience long diagnostic and pre-treatment intervals. This study sought to determine the factors associated with the diagnostic and pre-treatment intervals among patients with cervical cancer.

METHODS

This was a cross-sectional study conducted at the Uganda Cancer Institute (UCI) during October 2019 to January 2020. Patients aged ≥ 18 years with histological diagnosis of cervical cancer were consecutively sampled. Data were collected using a pre-tested semi-structured questionnaire and a data abstraction form. Diagnostic intervals, defined as the time between first visit of a patient to a primary healthcare provider to time of getting confirmed diagnosis, of ≤ 3 months was defined as early & >3 months as late. Pre-treatment intervals, which is the time from histological diagnosis to starting cancer chemo-radiotherapy of ≤ 1 month was defined as early and > 1 month as late. Data were analysed using STATA version 14.0. We used modified Poisson regression models with robust variance to determine socio-demographic and clinical factors associated with the intervals.

RESULTS

The mean age of the participants was 50.0 ± 11.7 years. The median diagnostic and pre-treatment intervals were 3.1 (IQR: 1.4-8.2) months and 2.4 (IQR: 1.2-4.1) months respectively. Half of the participants, 49.6% (200/403) were diagnosed early; one in 5 patients, 20.1% (81/403) promptly (within one month) initiated cancer chemo-radiotherapy. Participants more likely to be diagnosed early included those referred from district hospitals (level 5) (aPR = 2.29; 95%CI: 1.60-3.26) and with squamous cell carcinomas (aPR = 1.55; 95%CI: 1.07-2.23). Participants more likely to be diagnosed late included those who first discussed their symptoms with relatives, (aPR = 0.77; 95%CI: (0.60-0.98), had > 2 pre-referral visits (aPR = 0.75; 95%CI (0.61-0.92), and had advanced stage (stages 3 or 4) (aPR = 0.68; 95%CI: 0.55-0.85). Participants more likely to initiate cancer chemo-radiotherapy early included older patients (≥ 60 years) (aPR = 2.44; 95%CI: 1.18-5.03). Patients likely to start treatment late were those who had ≥2 pre-referral visits  (aPR = 0.63; 95%CI: 0.41-0.98) and those that took 3 - 6 months with symptoms before seeking healthcare (aPR = 0.52;95%CI: 0.29 - 0.95).

CONCLUSION

Interventions to promote prompt health-seeking and early diagnosis of cervical cancer need to target primary healthcare facilities and aim to enhance capacity of primary healthcare professionals to promptly initiate diagnostic investigations. Patients aged < 60 years require targeted interventions to promote prompt initiation of chemo-radiation therapy.

Access to palliative care in patients with advanced cancer of the uterine cervix in the low- and middle-income countries: a systematic review

BACKGROUND

Women with advanced uterine cervical cancer suffer from a combination of moderate to severe physical, psychological, social, and spiritual distress due to their disease and are in need of palliative care to improve their quality of life. Approximately 85% of the women live in the low- and middle-income countries. Whether these women and their families access palliative care is not known.

OBJECTIVES

To understand the geographic accessibility, availability, financial accessibility, and acceptability of palliative care by patients with advanced cervical cancer and their families.

METHODS

We conducted a Systematic review following PRISMA guidelines in CINAHL, Cochrane Central Register of Controlled Trials, MEDLINE, PsychINFO, PubMed and Scopus for the core concepts: palliative care, access, advanced uterine cervical cancer. Eligible articles were published in English, contained original data on experiences of patients and/or caregivers including symptoms management, and discussed available resources, communication, satisfaction, and healthcare utilization.

RESULTS

Overall there was limited access to palliative care with the few available facilities located in cities, far from the rural areas where most women lived. Pervasive poverty was common with poor affordability of healthcare, travelling, accommodation, and subsistence expenses. Misconceptions and poor knowledge of the disease, cultural beliefs and attitudes, and other health system insufficiencies also presented challenges for access.

CONCLUSION

Concerted effort should be made to improve availability of palliative care facilities. Health education to address misconceptions and other cognitive barriers that limit access among cervical cancer patients and their families should be urgently undertaken in the LMICs.

A qualitative exploration of the spiritual wellbeing of women with advanced cervical cancer in Ghana

BACKGROUND

Spiritual wellbeing is one of the most important aspects of human health, alongside physical, psychological and social factors. Religiosity/spirituality can play a critical role in the lives of people experiencing life-threatening illnesses, such as cervical cancer. Most women with cervical cancer in Africa, including Ghana, are diagnosed at the advanced stage. These women lean on their spiritual connections for strength during their illness. Despite the fact that numerous studies have been conducted on the relevance of religiosity/spirituality in the experience of cancer in other jurisdictions, the same cannot be said about Ghana. The study aims to fill this gap in the literature.

AIM

To explore the spiritual wellbeing of women diagnosed with advanced cervical cancer in Ghana.

METHOD

A qualitative explorative design was employed, with purposive sampling used to recruit 15 women with advanced cervical cancer from a cancer treatment centre of a teaching hospital in Ghana. Individual face-to-face interviews, lasting between 45-90 minutes, were used to gather information. Interviews were audio taped with participants' consent. Data were analysed using thematic content analysis.

FINDINGS

The following sub-themes were identified within one overarching theme of the spiritual wellbeing of women with advanced cervical cancer: the meaning of illness and acceptance; a sense of hope and religiosity; uncertainty; and the will to live.

CONCLUSION

Many participants believed they were bewitched, and the devil was responsible for their cervical cancer. Healthcare providers should adopt a multi-disciplinary approach and widen their care strategies to include spirituality, to enhance the treatment outcomes of women living with advanced cervical cancer.

A Narrative Synthesis of Literature on the Barriers to Timely Diagnosis and Treatment of Cancer in Sub-Saharan Africa

Poor cancer survival outcomes in sub-Saharan Africa (SSA) have been linked to delays in diagnosis and treatment. Here we present a detailed overview of the qualitative literature evaluating the barriers to receiving timely diagnosis and treatment of cancer in SSA. The PubMed, EMBASE, CINAHL, PsycINFO databases were searched to identify qualitative studies reporting on barriers to timely diagnosis of cancer in SSA published between 1995 and 2020. A systematic review methodology was applied, including quality assessment and narrative data synthesis. We identified 39 studies, of which 24 focused on breast or cervical cancer. Only one study focused on prostate cancer and one on lung cancer. When exploring factors contributing to delays, six key themes emerged from the data. The first theme was health service barriers, which included: (i) inadequate numbers of trained specialists; (ii) limited knowledge of cancer among healthcare providers; (iii) poor co-ordination of care; (iv) inadequately resourced health facilities; (v) negative attitudes of healthcare providers towards patients; (vi) high cost of diagnostic and treatment services. The second key theme was patient preference for complementary and alternative medicine; the third was the limited understanding of cancer among the population. The fourth barrier was a patient's personal and family obligations; the fifth was the perceived impact of cancer and its treatment on sexuality, body image and relationships. Finally, the sixth was the stigma and discrimination faced by patients following a diagnosis of cancer. In conclusion, health system, patient level and societal factors all influence the likelihood of timely diagnosis and treatment for cancer in SSA. The results provide a focus for targeting health system interventions, particular with regards to awareness and understanding of cancer in the region.

The meaning of caring for patients with cancer among traditional medicine practitioners in Uganda: A grounded theory approach

Traditional medicine practitioners (TMPs) are a critical part of healthcare systems in many sub-Saharan African countries and play vital roles in caring for patients with cancer. Despite some progress in describing TMPs' caring experiences in abstract terms, literature about practice models in Africa remains limited. This study aimed to develop a substantive theory to clarify the care provided by TMPs to patients with cancer in Uganda. This study adhered to the principal features of the modified Straussian grounded theory design. Participants were 18 TMPs caring for patients with cancer from 10 districts in Uganda, selected by purposive and theoretical sampling methods. Researcher-administered in-depth interviews were conducted, along with three focus group discussions. Data were analyzed using constant comparative analysis. The core category that represented TMPs' meaning of caring for patients with cancer was "Restoring patients' hope in life through individualizing care." TMPs restored patients' hope through five main processes: 1) ensuring continuity in the predecessors' role; 2) having full knowledge of a patient's cancer disease; 3) restoring hope in life; 4) customizing or individualizing care, and 5) improving the patient's condition/health. Despite practice challenges, the substantive theory suggests that TMPs restore hope for patients with cancer in a culturally sensitive manner, which may partly explain why patients with cancer continue to seek their services. The findings of this study may guide research, education, and public health policy to advance traditional medicine in sub-Saharan Africa.

Experiences of women with advanced cervical cancer before starting the treatment: Systematic review of qualitative studies

BACKGROUND

Advanced stage and high mortality are characteristics of cervical cancer in developing countries. Comprehension of the diagnosis itinerary is one of the main strategies to control the disease impact.

OBJECTIVES

To identify reasons for the delay in diagnosing symptomatic cervical cancer according to the patient's perspectives reported in qualitative studies. We searched four databases (PubMed, Embase, CINAHL, and Web of Science).

SELECTION CRITERIA

We included qualitative studies of women with advanced cervical cancer that explored their experiences before treatment. We excluded unoriginal, non-qualitative, and duplicated studies.

DATA COLLECTION AND ANALYSIS

We selected 39 articles for a full-text reading and included 15 in the present review. We chose the Consolidated Criteria for Reporting Qualitative Research (COREQ) for quality assessment and The Model of Pathways to Treatment to guide the codifying process.

MAIN RESULTS

Four main themes emerged from the synthesis: (1) Health-seeking motivators; (2) Obstacles to seeking medical care; (3) Diagnosis delay; and (4) Coping with the disease. These themes were derived from patients' personal knowledge and beliefs, social relationships, socioeconomic status, and healthcare system characteristics.

CONCLUSIONS

Individual behavior, social factors, and healthcare organization contribute to the delay in diagnosing advanced cervical cancer.

Integrating network pharmacology approaches for the investigation of multi-target pharmacological mechanism of 6-shogaol against cervical cancer

Traditional treatment of cancer has been plagued by a number of obstacles, such as multiple drug resistance, toxicity and financial constraints. In contrast, phytochemicals that modulate a variety of molecular mechanisms are garnering increasing interest in complementary and alternative medicine. Therefore, an approach based on network pharmacology was used in the present study to explore possible regulatory mechanisms of 6-shogaol as a potential treatment for cervical cancer (CC). A number of public databases were screened to collect information on the target genes of 6-shogaol (SuperPred, Targetnet, Swiss target prediction and PharmMapper), while targets pertaining to CC were taken from disease databases (DisGeNet and Genecards) and gene expression omnibus (GEO) provided expression datasets. With STRING and Cytoscape, protein-protein interactions (PPI) were generated and topology analysis along with CytoNCA were used to identify the Hub genes. The Gene Ontology (GO) database Enrichr was used to annotate the target proteins, while, using the Kyoto Encyclopedia of Genes and Genomes (KEGG) database, signaling pathway enrichment analysis was conducted. Molecular docking and survival analysis for the Hub genes revealed four genes (HSP90AA1, HRAS, ESR1 and EGFR) with lowest binding energy and majority of the Hub genes (EGFR, SRC, CASP-3, HSP90AA1, MTOR, MAPK-1, MDM2 and ESR1) were linked with the overall survival of CC patients. In conclusion, the present study provides the scientific evidence which strongly supports the use of 6-shogoal as an inhibitor of cellular proliferation, growth, migration as well as inducer of apoptosis via targeting the hub genes involved in the growth of CC.Communicated by Ramaswamy H. Sarma.

Cancer signs and risk factors awareness in Addis Ababa, Ethiopia: a population-based survey

BACKGROUND

There is a paucity of data on public awareness of cancer in Ethiopia. This study assessed cancer signs, symptoms, and risk factors awareness among individuals aged 18 and older in Addis Ababa, Ethiopia.

METHOD

A population-based face-to-face interview was conducted applying a validated cancer awareness measure (CAM) tool. A total of 600 adults (315 males and 285 females) were recruited using a multistage sampling technique. One open-ended and ten closed-ended questions were used to assess awareness of cancer signs and symptoms. To assess awareness of cancer risk factors, one open-ended and twelve closed-ended questions were used. Logistic regression analysis was used to test the association between sociodemographic status and awareness of cancer signs, symptoms, and risk factors.

RESULTS

Based on the responses for the open-ended questions, unexplained bleeding (23.16%) and smoking (24.17%) were the most frequently recalled cancer sign and risk factor, respectively. Based on the responses for the closed questions, the majority of respondents identified tiredness all the time (80.7%) as a cancer symptom and alcohol use (82.5%) as a cancer risk factor.  The odds of cancer signs and symptoms awareness was higher in those with primary (AOR = 4.50, 95% CI, 1.72-11.79, p = 0.02), secondary (AOR = 4.62; 95% CI 1.86-11.43; p = 0.001), and tertiary (AOR = 7.51; 95% CI 3.04-18.56; p < 0.001) education than those who were illiterate. The odds of awareness about cancer signs and risk factors was 0.28 (95% CI 0.12-0.65; p = 0.003) and 0.22 (95% CI 0.83-0.58; p = 0.002) times lower, respectively, among individuals aged 60 and older than those aged 18 to 29.

CONCLUSIONS

Young adults who attended formal education of primary or higher level may have a better cancer signs and symptoms awareness. Future education interventions to increase awareness of the society in Addis Ababa may target illiterate and the elderly.

Sexual Dysfunction among Gynaecological Cancer Survivors: A Descriptive Cross-Sectional Study in Malaysia

BACKGROUND

Sexual dysfunction is a major issue among gynaecological cancer survivors. This study aimed to evaluate the prevalence of sexual dysfunction among survivors of gynaecological cancer in Malaysia and to determine its risk factors.

METHODS

A cross-sectional study was conducted of 116 married women with gynaecological cancer who attended the gynaeoncology and oncology clinics at Universiti Kebangsaan Malaysia Medical Centre (UKMMC). Sociodemographic and clinical data were collected. Sexual dysfunction was measured using the Malay Version Female Sexual Function Index (MVFSFI). Univariate and multivariate logistic regression analyses were used to determine the risk factors of female sexual dysfunction.

RESULTS

The prevalence of sexual dysfunction among gynaecological cancer survivors was 60% (70 out of 116). Sexual dissatisfaction was the most prevalent domain of sexual dysfunction at 68.1%. Sexual dysfunction was significantly associated with low education levels (Primary level, AOR = 4.92, 95% CI: 1.12-21.63; secondary level, AOR = 4.06, 95% CI: 1.14-14.44). Non-Malays were significantly more likely to have sexual dysfunction compared with Malays (AOR = 3.57, 95% CI: 1.16-11.06). In terms of treatment, combinations of surgery and radiotherapy (AOR = 4.66, 95% CI: 1.01-21.47) as well as surgery and chemoradiation (AOR = 5.77, 95% CI: 1.20-27.85) were considered.

CONCLUSIONS

Gynaecological cancer survivors with lower education levels, non-Malay ethnicity, and receiving treatment combinations of surgery and radiotherapy or surgery and chemoradiation have a higher risk of sexual dysfunction. A holistic approach in managing the various sociocultural and clinical issues is required to prevent sexual dysfunction among these patients.

Cervical cancer management in Zimbabwe (2019-2020)

BACKGROUND

Globally, cervical cancer is the fourth most commonly diagnosed cancer amongst women, and it is especially common in low- and middle-income countries (LMICs). The aim of the study was to determine the current patterns and characteristics of CC management in Zimbabwe in the HIV pandemic era, including the knowledge, attitude and practice of patience.

METHODS

The study was a mixed method which incorporated a cross-sectional survey of 408 CC patients which was conducted from October 2019 to September 2020 using an interviewer administered paper questionnaire. The study was conducted at Parirenyatwa hospital, the only cancer treating public health facility in Harare, Zimbabwe. Differences in study outcome by categorical variables were assessed using the Person Chi-square (χ2) test. Odds ratios (unadjusted and adjusted) and 95%CIs for potential risk factors associated with the outcome were estimated using logistic regression model.

RESULTS

From a total of 408 CC patients recruited into the study no prevention mechanism was available or known to these patients and only 13% knew that CC is caused by Human papillomavirus. Only 87 (21%) had ever been screened for CC and 83 (97%) of those who had been screened had the visual inspection with acetic acid procedure done. Prevention (screening uptake) is statistically high among the educated (with secondary education OR = 9.497, 95%CI: 2.349-38.390; with tertiary OR = 59.381, 95%CI: 11.937-295.380). Late presentation varied statistically significantly with marital status (high among the divorced, OR = 2.866; 95% CI: 1.549-5.305 and widowed OR = 1.997; 95% CI: 1.112-3.587), was low among the educated (Tertiary OR = .393; 95% CI: .166-.934), low among those living in the rural (OR = .613; 95% CI: .375-.987), high among those with higher parity OR = 1.294; 95% CI: 1.163-1.439). Less than 1% of the patients had surgery done as a means of treatment. Radiotherapy was administered to 350 (86%) of the patients compared to chemotherapy administered to 155 (38%). A total of 350 (86%) have failed to take medication due to its unavailability, while 344 (85%) missed taking medication due to unaffordability. Complementary and alternative medicines were utilized by 235 (58%). Majority, 278 (68%) were HIV positive, mainly pronounced within age (36-49 years OR = 12.673; 95% CI: 2.110-76.137), among those with higher education (secondary education OR = 4.981; 95%CI: 1.394-17.802 and in those with no co-morbidities (893.956; 95%CI: 129.611-6165.810).

CONCLUSION

CC management was inadequate from prevention, screening, diagnosis, treatment and palliative care hence there is need to improve CC management in Zimbabwe if morbidity and mortality are to be reduced to acceptable levels. Education helped improve prevention, but reduces chances of diagnosis, working as a doubled edged sword in CC management Prevention was high among the educated. Those in rural areas experience poor CC management. It should be noted that general education is good; however it must be complimented by CC awareness to improve CC management outcomes holistically. Cervical cancer management services need to be decentralized so that those in rural areas have easy access. Given that those with co-morbidities and high parity have better CC management, CC services need to be tied to co-morbidity and antenatal/post-natal care and management services.

Mapping Evidence on Management of Cervical Cancer in Sub-Saharan Africa: Scoping Review

Cervical cancer (CC) is the most common viral infection of the reproductive tract and in Sub-Saharan Africa (SSA), its morbidity and mortality rates are high. The aim of this review was to map evidence on CC management in SSA. The scoping review was conducted in accordance with Arksey and O’Malley’s scoping review framework. The review included studies on different aspects of CC management. The review was also done following the steps and guidelines outlined in the PRISMA-Extension for Scoping Reviews (PRISMA-ScR) checklist. The following databases were searched: PubMed, EBSCOhost, Scopus and Cochrane Database of Systematic Review. A total of 1121 studies were retrieved and 49 which were eligible for data extraction were included in the review. The studies were classifiable in 5 groups: 14 (28.57%) were on barriers to CC screening, 10 (20.41%) on factors associated with late-stage presentation at diagnosis, 11 (22.45%) on status of radiotherapy, 4 (8.20%) on status of chemotherapy and 10 (20.41%) on factors associated with high HPV coverage. High HPV vaccine coverage can be achieved using the class school-based strategy with opt-out consent form process. Barriers to CC screening uptake included lack of knowledge and awareness and unavailability of screening services. The reasons for late-stage presentation at diagnosis were unavailability of screening services, delaying whilst using complementary and alternative medicines and poor referral systems. The challenges in chemotherapy included unavailability and affordability, low survival rates, treatment interruption due to stock-outs as well as late presentation. Major challenges on radiotherapy were unavailability of radiotherapy, treatment interruption due to financial constraints, and machine breakdown and low quality of life. A gap in understanding the status of CC management in SSA has been revealed by the study implying that, without full knowledge of the extent of CC management, the challenges and opportunities, it will be difficult to reduce infection, improve treatment and palliative care. Research projects assessing knowledge, attitude and practice of those in immediate care of girls at vaccination age, situational analysis with health professionals and views of patients themselves is important to guide CC management practice.

The Diagnostic Value of Circulating Cell-Free HPV DNA in Plasma from Cervical Cancer Patients

Circulating cell-free HPV DNA (ccfHPV DNA) may serve as a marker for cervical cancer. In this study, we used digital droplet PCR (ddPCR) to detect and quantify ccfHPV DNA in plasma from patients with HPV16- or HPV18-associated cervical cancer. Blood samples from 60 patients diagnosed with cervical cancer (FIGO IA1-IVA) at Aarhus or Odense University Hospital (June 2018 to March 2020) were collected prior to treatment, and patients were subdivided into an early stage (n = 30) and a late-stage subgroup (n = 30) according to disease stage. Furthermore, blood samples from eight women with HPV16- or 18-associated premalignant conditions (CIN3), and 15 healthy controls were collected. ddPCR was used to analyze plasma from all participants. ccfHPV DNA was detected in 19 late-stage patients (63.33%), 3 early stage patients (10.00%), and none of the CIN3 patients or controls. Quantitative evaluation showed significant correlations between ccfHPV DNA level and stage, tumor score, and tumor size. Thus, our results indicate that ccfHPV DNA may not be a useful marker for early detection of cervical cancer. However, for patients with advanced stage cervical cancer, ccfHPV DNA level represents a promising tool to establish tumor burden, making it useful for establishing treatment response and monitoring the disease.

Factors influencing symptom appraisal and help-seeking of older adults with possible cancer: a mixed-methods systematic review

BACKGROUND

The cancer burden falls predominantly on older (≥65 years) adults. Prompt presentation to primary care with cancer symptoms could result in earlier diagnosis. However, patient symptom appraisal and help-seeking decisions involving cancer symptoms are complex and may be further complicated in older adults.

AIM

To explore the effect of older age on patients' appraisal of possible cancer symptoms and their decision to seek help for these symptoms.

DESIGN AND SETTING

Mixed-methods systematic review.

METHOD

MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Library, Web of Science Core Collection, ASSIA, the ISRCTN registry, and the National Institute for Health and Care Excellence were searched for studies on symptom appraisal and help-seeking decisions for cancer symptoms by adults aged ≥65 years. Studies were analysed using thematic synthesis and according to the Synthesis Without Meta-Analysis guidelines.

RESULTS

Eighty studies were included with a total of 32 995 participants. Studies suggested a possible association between increasing age and prolonged symptom appraisal interval. Reduced knowledge of cancer symptoms and differences in symptom interpretation may contribute to this prolonged interval. In contrast, in the current study a possible association was found between increasing age and prompt help-seeking. Themes affecting help-seeking in older adults included the influence of family and carers, competing priorities, fear, embarrassment, fatalism, comorbidities, a desire to avoid doctors, a perceived need to not waste doctors' time, and patient self-management of symptoms.

CONCLUSION

This review suggests that increasing age is associated with delayed cancer symptom appraisal. When symptoms are recognised as potentially serious, increasing age was associated with prompt help-seeking although other factors could prolong this. Policymakers, charities, and GPs should aim to ensure older adults are able to recognise potential symptoms of cancer and seek help promptly.

Cost-Effectiveness of Bivalent, Quadrivalent, and Nonavalent HPV Vaccination in South Africa

BACKGROUND AND OBJECTIVES

In South Africa, the prevalence of human papillomavirus (HPV) and associated diseases, such as cervical cancer and genital warts, is among the highest in the world. This study evaluates the cost-effectiveness of bivalent, quadrivalent, and nonavalent HPV vaccination for 9- to 14-year-old girls from the South African healthcare system perspective.

METHODS

A Markov model portraying the natural HPV disease progression from high-risk infection to cervical intraepithelial neoplasia (CIN) I, CIN II/III, or cervical cancer and from low-risk infection to genital warts was built. Transition probability, utility, and efficacy data were sourced from peer-reviewed literature. Vaccination costs were calculated based on the World Health Organization (WHO) guidelines. The model was populated with a cohort of 520,000 9-year-old girls to calculate incremental cost-effectiveness ratios (ICER) in South African Rand (R) per quality-adjusted life-years (QALYs) gained for each vaccination strategy.

RESULTS

All HPV vaccination strategies dominate the no vaccine strategy. Compared with the bivalent vaccine, the nonavalent strategy increases QALYs by 0.14 and costs by R1793 (ICER: R13,013 per QALY) per person, while the quadrivalent vaccination provides -0.02 incremental QALYs and R1748 costs (ICER: -R116,397 per QALY). Consequently, at the South African willingness-to-pay threshold of R23,630 per QALY, nonavalent vaccination is the preferred strategy, with a probability of 90.2%. Scenario analysis demonstrated that results are influenced by vaccine coverage, efficacy, and duration of efficacy.

CONCLUSIONS

The introduction of nonavalent for bivalent HPV vaccination is a cost-effective intervention in South Africa. HPV vaccination should be part of a multifaceted public health strategy entailing screening, condoms, and education of all stakeholders to reduce the significant burden of sexual transmitted diseases in South Africa. Sex-neutral and catch-up vaccinations are subjects for further research.

Factors affecting the decision to investigate older adults with potential cancer symptoms: a systematic review

BACKGROUND

Older age and frailty increase the risk of morbidity and mortality from cancer surgery and intolerance of chemotherapy and radiotherapy. The effect of old age on diagnostic intervals is unknown; however, older adults need a balanced approach to the diagnosis and management of cancer symptoms, considering the benefits of early diagnosis, patient preferences, and the likely prognosis of a cancer.

AIM

To examine the association between older age and diagnostic processes for cancer, and the specific factors that affect diagnosis.

DESIGN AND SETTING

A systematic literature review.

METHOD

Electronic databases were searched for studies of patients aged >65 years presenting with cancer symptoms to primary care considering diagnostic decisions. Studies were analysed using thematic synthesis and according to the Synthesis Without Meta-analysis guidelines.

RESULTS

Data from 54 studies with 230 729 participants were included. The majority of studies suggested an association between increasing age and prolonged diagnostic interval or deferral of a decision to investigate cancer symptoms. Thematic synthesis highlighted three important factors that resulted in uncertainty in decisions involving older adults: presence of frailty, comorbidities, and cognitive impairment. Data suggested patients wished to be involved in decision making, but the presence of cognitive impairment and the need for additional time within a consultation were significant barriers.

CONCLUSION

This systematic review has highlighted uncertainty in the management of older adults with cancer symptoms. Patients and their family wished to be involved in these decisions. Given the uncertainty regarding optimum management of this group of patients, a shared decision-making approach is important.

Early detection of cervical cancer in western Kenya: determinants of healthcare providers performing a gynaecological examination for abnormal vaginal discharge or bleeding

BACKGROUND

In western Kenya, women often present with late-stage cervical cancer despite prior contact with the health care system. The aim of this study was to predict primary health care providers' behaviour in examining women who present with abnormal discharge or bleeding.

METHODS

This was a cross-sectional survey using the theory of planned behaviour (TPB). A sample of primary health care practitioners in western Kenya completed a 59-item questionnaire. Structural equation modelling was used to identify the determinants of providers' intention to perform a gynaecological examination. Bivariate analysis was conducted to investigate the relationship between the external variables and intention.

RESULTS

Direct measures of subjective norms (DMSN), direct measures of perceived behavioural control (DMPBC), and indirect measures of attitude predicted the intention to examine patients. Negative attitudes toward examining women had a suppressor effect on the prediction of health workers' intentions. However, the predictors of intention with the highest coefficients were the external variables being a nurse (β = 0.32) as opposed to a clinical officer and workload of attending less than 50 patients per day (β = 0.56). In bivariate analysis with intention to perform a gynaecological examination, there was no evidence that working experience, being female, having a lower workload, or being a private practitioner were associated with a higher intention to conduct vaginal examinations. Clinical officers and nurses were equally likely to examine women.

CONCLUSIONS

The TPB is a suitable theoretical basis to predict the intention to perform a gynaecological examination. Overall, the model predicted 47% of the variation in health care providers' intention to examine women who present with recurrent vaginal bleeding or discharge. Direct subjective norms (health provider's conformity with what their colleagues do or expect them to do), PBC (providers need to feel competent and confident in performing examinations in women), and negative attitudes toward conducting vaginal examination accounted for the most variance. External variables in this study also contributed to the overall variance. As the model in this study could not explain 53% of the variance, investigating other external variables that influence the intention to examine women should be undertaken.

Understanding health-seeking and adherence to treatment by patients with esophageal cancer at the Uganda cancer Institute: a qualitative study

BACKGROUND

In the low- and middle-income countries, most patients with esophageal cancer present with advanced stage disease and experience poor survival. There is inadequate understanding of the factors that influence decisions to and actual health-seeking, and adherence to treatment regimens among esophageal cancer patients in Uganda, yet this knowledge is critical in informing interventions to promote prompt health-seeking, diagnosis at early stage and access to appropriate cancer therapy to improve survival. We explored health-seeking experiences and adherence to treatment among esophageal cancer patients attending the Uganda Cancer Institute.

METHODS

We conducted an interview based qualitative study at the Uganda Cancer Institute (UCI). Participants included patients with established histology diagnosis of esophageal cancer and healthcare professionals involved in the care of these patients. We used purposive sampling approach to select study participants. In-depth and key informant interviews were used in data collection. Data collection was conducted till point of data saturation was reached. Thematic content analysis approach was used in data analyses and interpretations. Themes and subthemes were identified deductively.

RESULTS

Sixteen patients and 17 healthcare professionals were included in the study. Delayed health-seeking and poor adherence to treatment were related to (i) emotional and psychosocial factors including stress of cancer diagnosis, stigma related to esophageal cancer symptoms, and fear of loss of jobs and livelihood, (ii) limited knowledge and recognition of esophageal cancer symptoms by both patients and primary healthcare professionals, and (iii) limited access to specialized cancer care, mainly because of long distance to the facility and associated high transport cost. Patients were generally enthused with patient - provider relationships at the UCI. While inadequate communication and some degree of incivility were reported, majority of patients thought the healthcare professionals were empathetic and supportive.

CONCLUSION

Health system and individual patient factors influence health-seeking for symptoms of esophageal cancer and adherence to treatment schedule for the disease. Interventions to improve access to and acceptability of esophageal cancer services, as well as increase public awareness of esophageal cancer risk factors and symptoms could lead to earlier diagnosis and potentially better survival from the disease in Uganda.

Symptom appraisal, help-seeking and perceived barriers to healthcare seeking in Uganda: an exploratory study among women with potential symptoms of breast and cervical cancer

OBJECTIVE

We assessed the process of recognising abnormal bodily changes, interpretations and attributions, and help-seeking behaviour among community-based Ugandan women with possible symptoms of breast and cervical cancer, in order to inform health interventions aiming to promote timely detection and diagnosis of cancer.

DESIGN

Qualitative in-depth interviews.

SETTING

Rural and urban communities in Uganda.

PARTICIPANTS

Women who participated in the African Women Awareness of CANcer cross-sectional survey who disclosed potential breast and cervical cancer symptoms were eligible; recruitment was purposive. Interviews were conducted in women's homes, lasted between 40 and 90 min, were audio-recorded, transcribed verbatim and translated to English. Thematic analysis was used to identify themes and subthemes, underpinned by the conceptual framework of the Model of Pathways to Treatment.

RESULTS

23 women were interviewed: 10 had potential symptoms of breast cancer and 13 of cervical cancer. Themes regarding symptom appraisal and help-seeking included the: (1) detection and interpretation of abnormal bodily sensations; (2) lay consultations regarding bodily changes; (3) iterative process of inferring and attributing illnesses to the bodily changes; (4) restricted disclosure of symptoms to lay people due to concerns about privacy and fear of stigmatisation; (5) help-seeking from multiple sources including both traditional and biomedical health practitioners, and (6) multiple perceived barriers to help-seeking including long waiting times, lack of medicines, absenteeism of healthcare professionals, and lack of money for transport and medical bills.

CONCLUSION

Women with potential symptoms of breast and cervical cancer undergo complex processes of symptom interpretation, attributing symptoms or inferring illness, and lay consultations before undertaking help-seeking and management. Increasing community understanding of breast and cervical cancer symptoms, and tackling perceived barriers to health-seeking, could lead to prompt and appropriate symptom appraisal and help-seeking, and contribute to improving cancer outcomes.

Knowledge of cervical cancer risk factors and symptoms among women in a refugee settlement: a cross-sectional study in northern Uganda

BACKGROUND

There are limited data on awareness of cervical cancer risk factors and symptoms among refugee populations living in Uganda. In this study, we sought to determine the awareness and knowledge of cervical cancer risk factors and symptoms among women in Palabek refugee settlement, northern Uganda.

METHODS

We conducted a cross-sectional study. 815 women (aged 18-60 years) were randomly selected using multistage sampling in Palabek refugee settlement. Data were collected using pre-tested, structured questionnaires. Logistic regression models were used to determine magnitudes of association between socio-demographic and health system factors, and knowledge on cervical cancer risk factors and symptoms.

RESULTS

The majority of participants (53%, n = 433) were young (18-29 years), married (68%, n = 553), and did not have formal employment (93%, n = 759). Less than half (40%, n = 325) had heard of cervical cancer. Of those who had heard, most recognized multiple male sexual partners, early onset of sexual intercourse and HPV infections as risk factors for cervical cancer (93%, n = 295; 89%, n = 283; and 86%, n = 271 respectively). Median knowledge score for risk factor recognition = 7 (IQR: 3-9). Median knowledge score for symptoms recognition = 7 (IQR: 1-10). Half of women (50%, n = 409) correctly recognized 7 to 11 symptoms of cervical cancer, with vaginal bleeding between menstrual periods, pelvic pain, and vaginal bleeding during/after sexual intercourse recognized by 58, 52 and 54% respectively. Single women (OR = 0.59 (95%CI: 0.38-0.94), and women that lived farther than 1 kilo meter from nearest health facility in South Sudan (OR = 0.36-0.49 (95%CI: 0.26-0.84) were less likely to be knowledgeable of symptoms of cervical cancer.

CONCLUSION

A significant proportion of women in Palabek refugee settlement had not heard about cervical cancer. Refugee health services providers could increase awareness of cervical cancer risk factors and symptoms through health education in order to promote risk reduction behaviours and guide women during symptoms appraisal. Single women and those who lived more than one kilo metre from nearest health facility in home country could be a priority group for awareness intervention in the settlement.

Healthcare worker compliance with cervical cancer screening guidelines. An audit at district and regional level of care in the Pietermaritzburg Metropolitan area of KwaZulu-Natal

Background

In South Africa (SA) there are screening guidelines for cervical cancer in women living with HIV (WLWH). To our knowledge there is lack of data concerning the knowledge of health care workers (HCWs) about cervical cancer screening guidelines before the initiation of antiretroviral therapy (ART) in WLWH.

Objectives

To investigate the knowledge and familiarity of HCWs regarding cervical cancer screening guidelines in WLWH.

Methods

A cross-sectional questionnaire-based study exploring compliance with cervical cancer screening guidelines before initiating ART was conducted with 85 HCWs in the antiretroviral (ARV) clinics of a district and regional hospitals in KwaZulu-Natal, SA. Data were analysed using Stata V13 and a p-value of ≤ 0.05 was considered statistically significant.

Results

Eighty-five HCWs were included in the study. Health care workers’ responses to knowledge about cervical cancer screening in WLWH were suboptimal and revealed significant gaps. Most HCWs did not know the screening intervals of WLWH. Statistically significant associations were found between an HCW’s occupation and responses to the Likert scale questions.

Conclusion

Although the majority of HCWs were familiar with cervical cancer screening guidelines in WLWH, the study highlights that there are deficiencies in both knowledge and practice. Creating awareness among HCWs regarding the current methods of cervical cancer screening is a necessary to reduce morbidity and mortality from cervical cancer in WLWH.

Awareness of Cancer Risk Factors and Its Signs and Symptoms in Northern Tanzania: a Cross-Sectional Survey in the General Population and in People Living with HIV

An important component of cancer control programs for the growing burden in sub-Saharan Africa is a population's awareness of risk factors. Studies thereof have focused on single rather than multiple cancers and carcinogens. During March and April 2015, we undertook a survey to assess awareness of multiple cancer risk factors and symptoms in the Kilimanjaro Region, North Tanzania. General population (n = 620) and attendees at HIV care-and-treatment clinics (CTCs) were included (n = 207). Participants' mean age was 43.8 (interquartile range 30-52) years; 58% were female. Awareness of cancer risk was highest for tobacco (90%) and alcoholic spirits (67%), but tended to be lower for infections (41% for HIV (42.2% and 41.4% for CTC and community group, respectively) and 16% for HPV (16.0% and 16.6% for CTC and community group, respectively)), while that of moldy maize and peanuts was 35% for both. Awareness of specific cancer signs and symptoms ranged between 70% and 90%. Awareness of alcohol and tobacco was higher in men than women (odds ratio = 1.82 (1.38, 2.40) and 3.96 (2.14, 7.31), respectively). In relation to cancer treatment, 70% preferred modern medicine and 10% preferred traditional medicine alone. Sixty percent was not aware of any local cancer early detection services. Only 20% had ever been examined for cancer, and of those screened, CTC group was 1.5 times more likely to screen than community participants. Awareness did not differ by age or HIV status. There are good levels of cancer risk factor awareness for certain lifestyle-related carcinogens in Tanzania; however, increased awareness is needed especially for infections and cancer warning symptom both in the general and HIV-positive population, as well as some myths to be dispelled.

Quality of life among cervical cancer patients undergoing radiotherapy

Introduction

There has been an increasing rate of the incidence and mortality of cervical cancer in Ghana. Cancer and the treatment's side effects have adverse effects on the patients and this affects patient's well-being and lifestyle during and after radiotherapy. The study sought to assess the impact of demographic and clinical characteristics on Quality of Life (QoL) among cervical cancer patients undergoing radiotherapy in Ghana.

Methods

A cross sectional quantitative study design was carried out on 120 cervical cancer patients who were conveniently sampled from the study site. The data was collected between the months of December, 2017 and February, 2018. QoL was measured using the FACT-G questionnaire. The mean scores of QoL were determined, whiles the chi-square test was used to determine the impact of socio-demographic and clinical characteristics on the QoL of the patients.

Results

The mean age of the patients was 56.8 years. Majority of the patients reported stable QoL. The social well-being of the older patients was more affected than other patients. The unmarried, widows and patients who underwent surgery with radiotherapy were emotionally affected. Majority (56%) of the participants had stable QoL whiles 22% each had poor and good QoL. Significant association was found among 35-39 age group with physical well-being and overall QoL (p=0.017 and 0.029) respectively.

Conclusion

There is a need to embrace a QoL assessment instrument in the study site so as to help the oncology team in the identification and addressing of specific indicators that affect the QoL of cervical cancer patients.

The use, quality and effectiveness of pelvic examination in primary care for the detection of gynaecological cancer: a systematic review

BACKGROUND

Urgent suspected cancer referral guidelines recommend that women with gynaecological cancer symptoms should have a pelvic examination (PE) prior to referral. We do not know to what extent GPs comply, their competency at PE, or if PE shortens the diagnostic interval.

OBJECTIVES

We conducted a systematic review of the use, quality and effectiveness of PE in primary care for women with suspected gynaecological cancer.

METHOD

PRISMA guidelines were followed. Three databases were searched using four terms: PE, primary care, competency and gynaecological cancer. Citation lists of all identified papers were screened independently for eligibility by two reviewers. Data extraction was performed in duplicate and independently. Paper quality was assessed using the relevant Critical Appraisal Skills Programme checklist. Emergent themes and contrasting issues were explored in a narrative ecological synthesis.

MAIN FINDINGS

Twenty papers met the inclusion criteria. 52% or less of women with suspicious symptoms had a PE. No papers directly explored GPs' competence at performing PE. Pre-referral PE was associated with reduced diagnostic delay and earlier stage diagnosis. Ecological synthesis demonstrated a complex interplay between patient and practitioner factors and the environment in which examination is performed. Presenting symptoms are commonly misattributed by patients and practitioners resulting in misdiagnosis and lack of PE.

CONCLUSION

We do not know if pre-referral PE leads to better outcomes for patients. PE is often not performed for women with gynaecological cancer symptoms, and evidence that it may result in earlier stage of diagnosis is weak. More research is needed.

Cervical cancer knowledge, attitudes, beliefs and practices of women aged at least 25 years in Harare, Zimbabwe

BACKGROUND

Cervical cancer is the most common cancer and a major cause of morbidity and mortality among women in Zimbabwe yet it is preventable, early detectable and highly curable. The objective of this study was to investigate knowledge, attitudes, beliefs and practices towards cervical cancer, its prevention and treatment in Harare, Zimbabwe.

METHODS

Sequential explanatory mixed methods approach consisting of analytical cross sectional survey and a qualitative inquiry was used. Study population consisted of women with cervical cancer, health workers and other stakeholders who are involved in cancer control programmes. Patient survey data were collected using validated structured questionnaire in Surveytogo software in an android tablet. Qualitative study used key informant interviews to understand survey findings better. Data analyses for the survey involved univariate and multivariate analyses using STATA version 14. For qualitative study, themes in transcripts were coded and analyzed using Dedoose software to generate evidence for the study.

RESULTS

Participants reported different levels of knowledge of causes (23%), risk factors (71%), prevention (72%), screening (73%) and treatment (80%) of cervical cancer. Knowledge of causes of cervical cancer were negatively associated with: being aged 45 or more years (OR = 0.02; p = 0.004), having no household income (OR = 0.02;p = 0.007), household income <US$600 per month (OR = 0.02; p = 0.015), middle class wealth (OR = 0.01;p = 0.032), watching TV daily (OR = 0.01;p = 0.007) and 1-6 times per week (OR = 0.02; p = 0.045). Knowledge of causes of cervical cancer were also positively associated with listening to radio daily (OR = 394, CI: 11.02-1406) (p = 0.001) and 1-6 times a week (OR = 100, CI: 2.95-3364) (p = 0.010). Knowledge of prevention was only positively associated with listening to the radio daily (OR = 77, CI: 1.89-3114) (p = 0.022) and 1-6 times a week (OR = 174, CI: 2.42-1255) (p = 0.018). Major drivers of lack of knowledge for cervical cancer were: limited awareness programmes, lack of knowledge among health workers, donor prioritization of infectious diseases, infancy of cervical cancer interventions, negative attitudes towards cervical cancer and misconceptions.

CONCLUSIONS

This study revealed that knowledge of causes and prevention of cervical cancer was associated with frequent radio listenership. Strengthening of health education through the packaging of messages targeting the wider society using different delivery channels is thus recommended.

An exploration into the quality of life of women treated for cervical cancer

Background

Cervical cancer mainly occurs among women from the developing world, and women face unique challenges in terms of their disease and treatment. Most women present with advanced cervical cancer and receive the standard curative treatment with external beam radiotherapy and brachytherapy with or without chemotherapy.

Objectives

To describe the quality of life (QOL) of women treated for cervical cancer during treatment (M0), at 6 months after completing treatment (M6) and at 12 months after treatment (M12).

Methods

A cross-sectional design, calculated sample size (n = 153) and convenience sampling were used. Data were collected through structured interviews, and the EORTC QLQ-C30 and EORTC QLQ CX24 served as data collection instruments. Descriptive statistics were used to analyse the data, and the Kruskal–Wallis H test was used to compare the mean responses across the groups (p ≤ 0.05).

Results

The mean age of the respondents was 50.6 years (standard deviation [SD] 11.9). The global health status improved significantly in contrast with the functional scores. Financial difficulties were rampant, especially during the treatment phase. Insomnia and urinary frequency were the most cumbersome problems and remained so even after treatment.

Conclusions

Despite an improvement in the global health, cervical cancer and its treatment had a negative influence on the QOL in all domains of lives of these women. Assessing the QOL of patients during treatment and follow-up visits would allow nurses to develop interventions to address distressing problems timeously. In addition, Africa’s nurses should assess social functioning and develop programmes to prevent social dysfunction.

Human Papillomavirus Vaccine Introduction in South Africa: Implementation Lessons From an Evaluation of the National School-Based Vaccination Campaign

Evaluation of the campaign confirmed its feasibility in this setting: it achieved high coverage, few adverse events, and mostly positive media coverage. However, challenges occurred in data and cold chain management. Future implementation requires improved partnerships between government ministries, simplified informed consent, and closer monitoring of social media messaging.

Background:

In April 2014, a national school-based human papillomavirus (HPV) vaccination program was rolled out in South Africa, targeting Grade 4 girls aged ≥9 years. A bivalent HPV vaccine with a 2-dose (6 months apart) schedule was used. At the request of the National Department of Health (NDoH), we conducted an external assessment of the first-dose phase of the vaccination program to evaluate program coverage and vaccine safety and identify factors that influenced implementation.

Methods:

We based our cross-sectional and mixed-methods approach on a process evaluation framework, which included a review of key planning and implementation documents and monitoring data; observation at vaccination sites; key informant interviews (N=34); and an assessment of media coverage and content related to the campaign.

Findings: There was overall success in key measures of coverage and safety. Over 350,000 Grade 4 girls were vaccinated in more than 16,000 public schools across South Africa, which translated to 94.6% of schools reached and 86.6% of age-eligible learners vaccinated. No major adverse events following immunization were detected. We attributed the campaign's successes to careful planning and coordination and strong leadership from the NDoH. The primary challenges we identified were related to obtaining informed consent, vulnerabilities in cold chain capacity, and onsite management of minor adverse events. While campaign planners anticipated and prepared for some negative media coverage, they did not expect the use of social media for spreading misinformation about HPV vaccination.

Conclusions:

The first phase of the national school-based HPV vaccination campaign was successfully implemented at scale in this setting. Future implementation will require improvement in the storage and monitoring of vaccine doses, better communication of role expectations to all stakeholders, and streamlined consent processes to ensure program sustainability.

Multilevel Factors Affecting Time to Cancer Diagnosis and Care Quality in Botswana

BACKGROUND

Cancer incidence is increasing in Africa, and the majority of patients are diagnosed with advanced disease, limiting treatment options and survival. We sought to understand care patterns and factors contributing to delayed diagnosis and treatment initiation among patients with cancer in Botswana.

PATIENTS AND METHODS

We recruited 20 patients who were enrolled in a prospective cancer cohort in Botswana to a qualitative substudy that explored cancer care pathways and factors affecting cancer care access and quality. We conducted an in-depth interview with each participant between October 2014 and January 2015, using a a structured interview guide with questions about initial cancer symptoms, previous consultations, diagnosis, and care pathways. Medical records were used to confirm dates or treatment details when needed.

RESULTS

Individual and interpersonal factors such as cancer awareness and social support facilitated care-seeking behaviors. However, patients experienced multiple delays in diagnosis and treatment because of provider and health system barriers. Health system factors, such as misdiagnosis, understaffed facilities, poor referral communication and scheduling, and inadequate laboratory reporting systems, affected access to and quality of cancer care.

CONCLUSION

These findings highlight the need for interventions at the patient, provider, and health system levels to improve cancer care quality and outcomes in Botswana. Results also suggest that widespread cancer education has potential to promote early diagnosis through family and community networks. Identified barriers and facilitators suggest that interventions to improve community education and access to diagnostic technologies could help improve cancer outcomes in this setting.

IMPLICATIONS FOR PRACTICE

The majority (54%) of patients with cancer in Botswana present with advanced-stage cancer despite universal access to free health care, limiting the options for treatment and decreasing the likelihood of positive treatment outcomes. To reduce time from symptom onset to cancer treatment initiation, causes of delay in cancer care trajectories must be identified. The narratives of the patients interviewed for this study give insight into psychosocial factors, outlooks on disease, lower-level provider delays, and health system barriers that contribute to substantial delays for patients with cancer in Botswana. Identification of problems and barriers is essential for development of effective interventions to mitigate these factors, in order to improve cancer outcomes in this population.

Perceptions and beliefs of lay people from northern Uganda regarding surgery for diagnosis and treatment of cervical cancer

OBJECTIVE

To explore perceptions and beliefs of people in a rural community in northern Uganda regarding surgery for the diagnosis and treatment of cervical cancer. The aim of the study was to inform interventions to reduce delay and improve timely diagnosis and prompt appropriate treatments for patients with symptoms of cervical cancer.

METHODS

A semi-structured study guide informed by Kleinman's explanatory model for illness was used to collect data during 24 focus group discussions involving 175 men and women aged 18 to 59 years in Gulu, northern Uganda. Using thematic analysis, themes and subthemes were identified from the data through an iterative process and consensus among the authors.

RESULTS

Surgery for diagnosis and management of cervical cancer was perceived as (1) appropriate when performed at early stage of cancer and by senior doctors, but (2) a potential catalyst for the spread of cancer and early death; and (3) a challenge to childbearing and motherhood as well as a source of distress to women and families if surgery involved removal of the uterus with subsequent permanent infertility.

CONCLUSIONS

There are some negative perceptions about surgery for cervical cancer that may deter prompt help-seeking for symptoms. However, targeted messages for public awareness interventions to promote help-seeking can be built on the positive perceptions and beliefs that surgery could be curative when undertaken for early-stage cancer and by skilled doctors.

Knowledge Adequacy on Cervical Cancer Among African Refugee and Non-Refugee Women in Brisbane, Australia

Cervical cancer is a significant public health issue, especially in the developing countries of sub-Saharan Africa. To examine knowledge adequacy on cervical cancer and screening test among African refugee and non-refugee women in Brisbane and further examine whether the level of knowledge vary between refugee and non-refugee women. A cross-sectional survey was conducted among 254 African-born women conveniently sampled from the Brisbane local government area. The outcome measures were knowledge on cervical cancer and Pap smear. In the multivariate logistic regression analysis non-refugees were more likely than refugees to have adequate knowledge about cervical cancer. Also, non-refugee women who were older and educated beyond secondary school, were more likely to have good knowledge about Pap smear test than refugee women. Overall, knowledge level about cervical cancer is limited among the participants and non-refugee women were more likely than refugee women to have good knowledge about cervical cancer and the screening test. These findings may inform the development of health education interventions for the targeted population to improve knowledge and awareness about cervical cancer and the screening guidelines in Australia.

The sociology of cancer: a decade of research

Biomedicine is often presented as the driving force behind improvements in cancer care, with genomics the latest innovation poised to change the meaning, diagnosis, treatment, prevention and lived experience of cancer. Reviewing sociological analyses of a diversity of patient and practitioner experiences and accounts of cancer during the last decade (2007-17), we explore the experiences of, approaches to and understandings of cancer in this period. We identify three key areas of focus: (i) cancer patient experiences and identities; (ii) cancer risk and responsibilities and (iii) bioclinical collectives. We explore these sociological studies of societal and biomedical developments and how sociologists have sought to influence developments in cancer identities, care and research. We end by suggesting that we extend our understanding of innovations in the fields of cancer research to take better account of these wider social and cultural innovations, together with patients, activists' and sociologists' contributions therein.

Population risk factors for late-stage presentation of cervical cancer in sub-Saharan Africa

BACKGROUND

Cervical cancer is the most prevalent malignancy in sub-Saharan Africa (SSA) with many women only seeking professional help when they are experiencing symptoms, implying late-stage malignancy and higher mortality rates. This ecological study assesses population-level exposures of SSA women to the numerous risk factors for HPV infection and cervical cancer, against late-stage presentation of cervical cancer.

MATERIALS AND METHOD

A literature review revealed the relevant risk factors in SSA. Open-access databases were mined for variables closely representing each risk factor. A proxy for late-stage presentation was used (ratio of incidence-to-mortality, IMR), and gathered from IARC's GLOBOCAN 2012 database. Variables showing significant correlation to the IMR were used in stepwise multiple regression to quantify their effect on the IMR.

RESULTS

Countries with high cervical cancer mortality rates relative to their incidence have an IMR nearer one, suggesting a larger proportion of late-stage presentation. Western Africa had the lowest median IMR (1.463), followed by Eastern Africa (IMR = 1.595) and Central Africa (IMR = 1.675), whereas Southern Africa had the highest median IMR (1.761). Variables selected for the final model explain 65.2% of changes seen in the IMR. Significant predictors of IMR were GDP (coefficient = 2.189 × 10^-6, p = 0.064), HIV infection (-1.936 × 10^-3, p = 0.095), not using a condom (-1.347 × 10^-3, p = 0.013), high parity (-1.744 × 10^-2, p = 0.008), and no formal education (-1.311 × 10^-3, p < 0.001).

CONCLUSION

Using an IMR enables identification of factors predicting late-stage cervical cancer in SSA including: GDP, HIV infection, not using a condom, high parity and no formal education.

Understanding stigma as a barrier to accessing cancer treatment in South Africa: implications for public health campaigns

Introduction

Cancer contributes to significant illness burden in South Africa, with delayed diagnosis resulting from limited knowledge of cancer, lack of biomedical treatment and stigma. This study examines ways in which people are identified as having cancer through perspectives of traditional healing or the biomedical model. Additionally, we sought to understand the stigma associated with cancer, including stereotypes, anticipated discrimination and coping styles.

Methods

Livestrong Foundation conducted 11 semi-structured focus groups with key community stakeholders in three South African townships. Interviews examined the negative consequences of being labeled with a cancer diagnosis as well as causes of, possible prevention of and barriers and methods to improve access to cancer treatment. Analyses were completed using directed content analysis.

Results

Revealed three main labeling mechanisms: physical appearance of perceived signs/symptoms of cancer, diagnosis by a traditional healer, or a biomedical diagnosis by a Western physician. Being labeled led to anticipated discrimination in response to prevalent cancer stereotypes. This contributed to delayed treatment, use of traditional healers instead of biomedical treatment and secrecy of symptoms and/or diagnosis. Further, perceptions of cancer were commonly conflated with HIV/TB owing to prior educational campaigns.

Conclusion

Our study deepens the understanding of the cancer labeling process in South Africa and the resulting negative effects of stigma. Future anti-stigma interventions should partner with traditional healers due to their respected community status and consider how previous health interventions may significantly impact current understandings of illness.

Text messages to increase attendance to follow-up cervical cancer screening appointments among HPV-positive Tanzanian women (Connected2Care): study protocol for a randomised controlled trial

Background

Cervical cancer is a major health concern in Tanzania, caused by poor attendance for cervical cancer screening and follow-up of women at risk. Mobile telephone health interventions are proven effective tools to improve health behaviour in African countries. So far, no knowledge exists on how such interventions may perform in relation to cervical cancer screening in low-income settings. This study aims to assess the degree to which a Short Message Service (SMS) intervention can increase attendance at appointments among women who have tested positive for high-risk (HR) Human Papillomavirus (HPV) during cervical cancer screening.

Methods/design

Connected2Care is a non-blinded, multicentre, parallel-group, randomised controlled trial. Tanzanian women testing positive to HR HPV at inclusion are randomly assigned in an allocation ratio of 1:1 to the SMS intervention or the control group (standard care). In a period of 10 months, the intervention group will receive 15 one-directional health educative text messages and SMS reminders for their appointment. The total sample size will be 700 with 350 women in each study arm. Primary outcome is attendance rate for follow-up. Secondary objectives are cost-effectiveness, measured through incremental ratios, and knowledge of cervical cancer by a 16-item true/false scale questionnaire at baseline and follow-up. Barriers against implementing the intervention will be assessed in a mixed-methods sub-population study.

Discussion

This study may provide information on the potential effects, costs, and barriers in implementing an SMS intervention targeting a group of women who are followed up after testing positive for HR HPV and are, therefore, at increased risk of developing cervical cancer. This can guide decision-makers on the effective use of mobile technology in a low-income setting. Trial status: recruiting.

Trial registration

ClinicalTrials.gov, ID: NCT02509702. Registered on 15 June 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2215-x) contains supplementary material, which is available to authorized users.

Exploring grassroots feedback about cancer challenges in South Africa: a discussion of themes derived from content thematic analysis of 316 photo-narratives

INTRODUCTION

Cancer is an important health problem in Africa with projections that incidence could double by 2030. While sparse, the literature on cancer control in African low- and middle-income countries suggests poor cancer planning, overburdened services and poor outcomes. South Africa has established oncology health care services but also has low cancer awareness, poor cancer surveillance and widespread service challenges.

METHODS

Data for this study was derived from 316 photovoice interviews with cancer patients, families of cancer patients and oncology workers across South Africa. The objectives of the study were to collect first-hand feedback about cancer challenges and to develop recommendations for the improvement of cancer control strategies.

RESULTS

9 themes of cancer challenges were distinguished via thematic content analysis of the photo-narratives. The identified themes of cancer challenges were physical and treatment challenges, emotional, poor services, transport, finances, information, powerlessness, stigma, and schooling challenges.

CONCLUSION

The findings of this study offer the patient and family perspective of cancer challenges as a valid contribution to our body of cancer knowledge. The 9 themes of cancer challenges profile the emotional, physical and social impact of cancer on patients and families, and offer detailed subjective information about problem occurrence in the trajectory of care. Recommendations following from the 9 themes of cancer challenges include training for improved patient-centred care standards, the need for cancer surveillance, innovative and locally appropriate cancer awareness campaigns, private and government health care partnerships and the development of psychosocial services. The advocating of findings and recommendations to influence cancer control strategies in South Africa, is indicated.

Barriers and facilitators of cervical cancer screening practices among African immigrant women living in Brisbane, Australia

PURPOSE

To describe barriers and facilitators of cervical screening practices among African immigrant women living in Brisbane, Australia.

METHOD

Nineteen African immigrant women (10 refugee and 9 non-refugee) were recruited using convenience sampling. The interviews were conducted with a semi-structured and open-ended questionnaire guide. All the interviews were audio recorded and transcribed verbatim. The data was manually analysed using interpretative thematic analysis. Thematic categories were identified and organised into coherent broader areas.

RESULTS

Lack of knowledge about cervical cancer and Pap smear, the absence of warning signs, embarrassment, fear, concern about the gender of the service provider, lack of privacy, cultural and religious beliefs, and healthcare system factors were identified as barriers to screening. The results did not show any major differences between refugee and non-refugee women. Recommendation of the test by health professionals, provision of standardised information on the test, and preferences for female service providers were identified as facilitators of cervical screening.

CONCLUSION

There is a need to provide culturally appropriate approaches to cervical screening practices and to enhance cultural competence among health professionals to apply service delivery models that honour group cultures.

Barriers and Challenges to Treatment Alternatives for Early-Stage Cervical Cancer in Lower-Resource Settings

Cervical cancer is one of the most common cancers among women worldwide, and approximately 85% of new diagnoses occur in less-developed regions of the world. Global efforts in cervical cancer to date have focused on primary and secondary prevention strategies of human papillomavirus vaccination and cervical cancer screening. Cervical cancer screening is effective to reduce the incidence of cervical cancer and can result in diagnosis at earlier stages, but it will take time to realize its full impact. With expansion of screening programs, there is now a greater imperative to increase access to treatment for women who have cervical cancer, particularly in earlier stages of disease, when it is still curable. Resources for multimodality treatment can be limited-or even absent-in many less-developed regions of the world and may be associated with geographic, social, and financial barriers for the patient. However, there is evidence that, in many cases, less-invasive and less-resource-intensive treatment options are still effective. To this end, the National Comprehensive Cancer Network and American Society of Clinical Oncology have published guideline adaptations for specific resource constraints, and research about more conservative approaches to the treatment of cervical cancer continues. This review focuses on potential barriers and challenges to provision of safe and effective treatment of early-stage cervical cancer in lower-resource settings, and it suggests future directions for expansion of access to cervical cancer treatment around the world.

Women's experiences with cervical cancer screening in a colposcopy referral clinic in Cape Town, South Africa: a qualitative analysis

OBJECTIVE

The aim of this study was to explore and understand women's experience with cervical cancer screening and with the referral pathways for abnormal Papanicolau (Pap) smears.

DESIGN AND SETTING

Focus group discussions were conducted with first time colposcopy clinic attendees at a tertiary hospital colposcopy clinic in Cape Town, South Africa during November 2014. A thematic analysis was conducted to identify key themes. Initial coding categories were drawn from the interview guide.

PARTICIPANTS

27 women participated in 4 focus group discussions.

RESULTS

Participants mean age was 34 years, most did not complete secondary level education and were unemployed. Negative community opinions relating to Pap smears and colposcopy referral might deter women from seeking treatment. Having a gynaecological symptom was the most commonly cited reason for having a Pap smear. Fear of having a HIV test performed at the same time as Pap smear and low encouragement from peers, were factors identified as potential access barriers. Participants commented on insufficient or lack of information from primary providers on referral to the colposcopy clinic and concerns and apprehension during waiting periods between receiving results and the colposcopy appointment were discussed.

CONCLUSIONS

There is a strong and urgent need to improve current knowledge about cervical cancer and Pap smears and the necessity and benefits of timely access to screening programmes, results and treatment. Strategies such as community health education programmes and mass media interventions could be employed to disseminate cervical cancer information and address negative community perceptions. Better training and support mechanisms to equip healthcare providers with the skills to convey cervical cancer information to women are needed. The use of short message service (SMS) to deliver Pap smear results and provide patients with more information should be considered to improve waiting times for results and alleviate apprehension during waiting periods.

Awareness of cervical cancer risk factors and symptoms: cross-sectional community survey in post-conflict northern Uganda

BACKGROUND

Lack of awareness of risk factors and symptoms for cancer may lead to late diagnosis and poor prognosis.

OBJECTIVE

We assessed community awareness about cervical cancer risk factors and symptoms and perceptions about prevention and cure of cervical cancer in order to contribute data to inform interventions to improve cervical cancer survival.

DESIGN

Cross-sectional population-based survey.

SETTING AND PARTICIPANTS

We conducted this study in Gulu, a post-conflict district in Uganda in 2012. The sample included 448 persons aged 18 years and above, selected through a multi-stage stratified cluster sampling process.

DATA COLLECTION METHODS AND ANALYSIS

We collected data using a pretested structured questionnaire. Logistic regressions were used to determine magnitudes of associations between socio-demographic and outcome variables.

RESULTS

Most participants (444/448) had heard about cervical cancer. Known risk factors including multiple sexual partners, human papillomavirus infection, and early onset of sexual activity, were recognized by 88%, 82%, and 78% of respondents respectively. 63% of participants believed that prolonged use of family planning pills and injections caused cervical cancer. The majority of participants recognized symptoms of cervical cancer including inter-menstrual bleeding (85%), post-menopausal bleeding (84%), and offensive vaginal discharge (83%). 70% of participants believed that cervical cancer is preventable and 92% believed that it could be cured if diagnosed at an early stage.

DISCUSSION AND CONCLUSIONS

Recognition of cervical cancer risk factors and symptoms was high among study participants. Targeted interventions including increasing availability of HPV vaccination, population-based cervical screening and diagnostic services can translate high awareness into actual benefits.

Cervical cancer prevention and treatment research in Africa: a systematic review from a public health perspective

BACKGROUND

Women living in Africa experience the highest burden of cervical cancer. Research and investment to improve vaccination, screening, and treatment efforts are critically needed. We systematically reviewed and characterized recent research within a broader public health framework to organize and assess the range of cervical cancer research in Africa.

METHODS

We searched online databases and the Internet for published articles and cervical cancer reports in African countries. Inclusion criteria included publication between 2004 and 2014, cervical cancer-related content pertinent to one of the four public health categories (primary, secondary, tertiary prevention or quality of life), and conducted in or specifically relevant to countries or regions within the African continent. The study design, geographic region/country, focus of research, and key findings were documented for each eligible article and summarized to illustrate the weight and research coverage in each area. Publications with more than one focus (e.g. secondary and tertiary prevention) were categorized by the primary emphasis of the paper. Research specific to HIV-infected women or focused on feasibility issues was delineated within each of the four public health categories.

RESULTS

A total of 380 research articles/reports were included. The majority (54.6 %) of cervical cancer research in Africa focused on secondary prevention (i.e., screening). The number of publication focusing on primary prevention (23.4 %), particularly HPV vaccination, increased significantly in the past decade. Research regarding the treatment of precancerous lesions and invasive cervical cancer is emerging (17.6 %), but infrastructure and feasibility challenges in many countries have impeded efforts to provide and evaluate treatment. Studies assessing aspects of quality of life among women living with cervical cancer are severely limited (4.1 %). Across all categories, 11.3 % of publications focused on cervical cancer among HIV-infected women, while 17.1 % focused on aspects of feasibility for cervical cancer control efforts.

CONCLUSIONS

Cervical cancer research in African countries has increased steadily over the past decade, but more is needed. Tertiary prevention (i.e. treatment of disease with effective medicine) and quality of life of cervical cancer survivors are two severely under-researched areas. Similarly, there are several countries in Africa with little to no research ever conducted on cervical cancer.

Social, demographic and healthcare factors associated with stage at diagnosis of cervical cancer: cross-sectional study in a tertiary hospital in Northern Uganda

OBJECTIVE

To examine patient and primary healthcare factors and stage at diagnosis in women with cervical cancer in Northern Uganda with the intention to identify factors that are associated with advanced stages in order to inform policies to improve survival from cervical cancer in low income and middle income countries.

DESIGN

Cross-sectional hospital-based study.

SETTING

Tertiary, not-for-profit private hospital in postconflict region.

PARTICIPANTS

Consecutive tissue-diagnosed symptomatic patients with cervical attending care. Of 166 patients, 149 were enrolled and analysed.

PRIMARY OUTCOME

Cervical cancer stage at diagnosis.

RESULTS

Most women were diagnosed at stages III (45%) or IV (21%). After controlling for age, marital status, educational attainment and number of biological children, there was evidence for association between advanced stage at diagnosis and pre-referral diagnosis of cancer by primary healthcare professionals (adjusted OR (AOR)=13.04:95% CI 3.59 to 47.3), and financial difficulties precluding prompt help seeking (AOR=5.5:95% CI 1.58 to 20.64). After adjusting for age, marital status and educational attainment, women with 5-9 biological children (AOR=0.27:95% CI 0.08 to 0.96) were less likely to be diagnosed with advanced stage (defined as stages III/IV) cancer. In this pilot study, there was no statistical evidence for associations between stage at diagnosis, and factors such as age at diagnosis and marital status.

CONCLUSIONS

This study is a first attempt to understand the descriptive epidemiology of cervical cancer in rural Ugandan settings. Understanding individual patient factors, patients' behavioural characteristics and healthcare factors associated with advanced stage at diagnosis is essential for targeted effective public health interventions to promote prompt health seeking, diagnosis at early stage and improved survival from cervical cancer.

Barriers to biomedical care and use of traditional medicines for treatment of cervical cancer: an exploratory qualitative study in northern Uganda

Use of traditional medicines for treatment of cancers has increased worldwide. We used a qualitative approach to explore barriers to biomedical care and reasons for use of traditional medicines for the treatment of cervical cancer in Gulu, northern Uganda. We carried out 24 focus group discussions involving men and women aged 18-59 years. We employed content analyses technique in data analysis. Traditional medicines were used mainly due to barriers to biomedical care for cervical cancer. The barriers included health system factors, for example long distances to health facilities and unavailability of medicines; health workers' factors, for example negative attitudes towards patients and demands for bribes; individual patient's factors, for example inability to pay for medical care; and socio-cultural beliefs about superiority of traditional medicines and perceived greater privacy in accessing traditional healers. Barriers to biomedical care and community beliefs in the effectiveness of traditional medicines encourage use of traditional medicines for treatment of cervical cancer but might hinder help-seeking at biomedical facilities. There is need for targeted culturally sensitive awareness campaign to promote effectiveness of modern medicine and to encourage cautious use of traditional medicines in the treatment of cervical cancer.

Symptomatic presentation with cervical cancer in Uganda: a qualitative study assessing the pathways to diagnosis in a low-income country

Background

Symptomatic cervical cancer patients in low- and middle-income countries usually present with late stage disease and have poor survival. We explored the views of cervical cancer patients on their symptom appraisal and interpretations, and their help-seeking including lay consultations.

Methods

We conducted an in-depth interview study in two northern Ugandan hospitals. Theoretical models underpinned the study guide for data collection and analysis. We used thematic analysis techniques, informed by the theoretical concepts in the Model of Pathways to Treatment. Sub-themes and themes were identified through consensus among investigators.

Results

Eighteen women aged 35–56 years, recently diagnosed with cervical cancer were interviewed. Their first symptoms included abnormal vaginal bleeding, offensive vaginal discharge and lower abdominal pain. Most participants did not perceive themselves to be at risk for cervical cancer and they usually attributed the initial symptoms to normal bodily changes or common illnesses such as sexually transmitted diseases. Lay consultations with husbands, relatives and friends were common and often influenced decisions and timing for seeking care. Prompt help-seeking was frequently triggered by perceived life threatening symptoms such as heavy vaginal bleeding or lower abdominal pain; symptom burden sufficient to interfere with patients’ work routines; and persistence of symptoms in spite of home-based treatments. Participants did not promptly seek care when they perceived symptoms as mild; interpreted symptoms as due to normal bodily changes e.g. menopause; and attributed symptoms to common illnesses they could self-manage. Their cancer diagnosis was often further delayed by long help-seeking processes including repeated consultations. Some healthcare professionals at private clinics and lower level health facilities failed to recognize symptoms of cervical cancer promptly therefore delayed referring women to the tertiary hospitals for diagnosis and treatment.

Conclusion

Ugandan patients with symptomatic cervical cancer often misattribute their gynaecological symptoms, and experience long appraisal and help-seeking intervals. These findings can inform targeted interventions including community awareness campaigns about cervical cancer symptoms, and promote prompt help-seeking in Uganda and other low- and middle-income countries with high incidence and mortality from cervical cancer.

Integrating cervical cancer prevention initiatives with HIV care in resource-constrained settings: A formative study in Durban, South Africa

Cervical cancer screening rates remain suboptimal among women in South Africa (SA), where cervical cancer prevalence is high. The rollout of HIV-related services across SA may provide a means to deliver cervical cancer screening to populations with limited access to health care systems. In this mixed methods study, psychosocial factors influencing cervical cancer prevention and perceptions of the provision of Pap smears in HIV care settings were examined. Structured interviews were conducted with women (n = 67) from a municipal housing estate in Durban, SA. Key informants (n = 12) also participated in semi-structured interviews. Findings revealed that participants had low cervical cancer knowledge, but desired more information. Relevant themes included the normalisation of HIV and beliefs that cervical cancer might be worse than HIV. A comprehensive community clinic was desired by most, even if HIV-positive patients were treated there. This study provides important insight into integrating cervical cancer screening with HIV clinics, which may increase cancer screening among South African women.

Delays in diagnosis of young females with symptomatic cervical cancer in England: an interview-based study

BACKGROUND

Diagnosis may be delayed in young females with cervical cancer because of a failure to recognise symptoms.

AIM

To examine the extent and determinants of delays in diagnosis of young females with symptomatic cervical cancer.

DESIGN AND SETTING

A national descriptive study of time from symptoms to diagnosis of cervical cancer and risk factors for delay in diagnosis at all hospitals diagnosing cervical cancer in England.

METHOD

One-hundred and twenty-eight patients <30 years with a recent diagnosis of cervical cancer were interviewed. Patient delay was defined as ≥3 months from symptom onset to first presentation and provider delay as ≥ 3 months from first presentation to diagnosis.

RESULTS

Forty (31%) patients had presented symptomatically: 11 (28%) delayed presentation. Patient delay was more common in patients <25 than patients aged 25-29 (40% versus 15%, P = 0.16). Vaginal discharge was more common among patients who delayed presentation than those who did not; many reported not recognising this as a possible cancer symptom. Provider delay was reported by 24/40 (60%); in some no report was found in primary care records of a visual inspection of the cervix and some did not re-attend after the first presentation for several months. Gynaecological symptoms were common (84%) among patients who presented via screening.

CONCLUSIONS

Young females with cervical cancer frequently delay presentation, and not recognising symptoms as serious may increase the risk of delay. Delay in diagnosis after first presentation is also common. There is some evidence that UK guidelines for managing young females with abnormal bleeding are not being followed.