Estimates of delays in diagnosis of cervical cancer in Nepal

Healthcare Provider-Related Factors in the Diagnostic Delay of Cervical Cancer: A Cross-Sectional Study

Background and objective Cervical cancer is the second most common malignancy among Indian women. In 2018, the World Health Organization (WHO) called for global action toward the elimination of cervical cancer through the triple-intervention strategy. One of its pillars is ensuring 70% screening coverage of eligible women with a high-performance test at least twice in their lifetime. Various factors contribute to the delayed diagnosis of cervical cancer, increasing the burden of the disease. In this study, we aimed to determine the healthcare provider (HCP)-related factors in the diagnostic delay of advanced cervical cancer. Methods This prospective cross-sectional study was conducted over two months in the cancer clinic of the Department of Obstetrics and Gynecology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India. We interviewed 384 women diagnosed with advanced cervical cancer [the International Federation of Gynecology and Obstetrics (FIGO) stage IB3-IVB] by using a questionnaire to capture data inputs regarding the various healthcare services they had received in the past 10 years along with details of HCPs. The collected data were analyzed using the software STATA version 17.0. Results Among 384 participants, 185 (48.1%) had interacted with an HCP in the past 10 years; 157 (40.8%) of them had visited a healthcare facility. Among these 185 women, only 22.16% had been advised to undergo screening, and only 15.18% had been tested despite several having access to primary health centers within 10 km of their residence. The lack of screening guidance by HCPs accounted for 78% of delayed diagnoses of cervical cancer. Conclusions Based on our findings, a deficiency in screening guidance in the asymptomatic period by healthcare providers across various levels of our healthcare system contributed significantly to the delayed diagnosis of cervical cancer.

The challenging journey of cervical cancer diagnosis and treatment at the second largest hospital in Indonesia

Objectives

Cervical cancer is a major health concern in developing countries. Access to preventive measures is limited in low- and middle-income countries, and cervical cancer is often identified at an advanced stage of the disease. In this study, we aimed to investigate when patients were first diagnosed and received treatment at a large hospital in Indonesia.

Methods

Data were collected using a questionnaire from outpatient visits and descriptively analyzed. Totally, 215 cervical cancer patients being treated at the Dr. Soetomo Academic Hospital's gynecological oncology outpatient clinic in Indonesia between August and October 2022 were included.

Results

Most patients were 51-60 years old (36.3 %), housewives (87 %), and had an elementary school education level (50 %). Most (88.4 %) admitted they were unaware about cervical cancer prevention, and 85.6 % never underwent screening. Most cervical biopsies were performed at primary hospitals (42.3 %). Fear of cancer treatment was the most frequent reason for patients arriving late at tertiary hospitals (50 %). Treatment delays occurred because patients had to visit two healthcare facilities before visiting a tertiary hospital (47.4 %). Most patients were diagnosed with stage III cancer (38.1 %), and chemotherapy was administered as the first-line therapy (96.3 %). Most patients (51.2 %) received their first therapy >12 months after initial symptom onset.

Conclusions

Most cervical cancer patients were diagnosed at a late stage owing to a lack of information regarding early symptoms and irregular screenings. Treatment was delayed owing to social barriers. Therefore, the government should have more strict policies to implement cervical cancer detection and prevention.

Health seeking behaviours and private sector delivery of care for non-communicable diseases in low- and middle-income countries: a systematic review

BACKGROUND

Globally, non-communicable diseases (NCDs) are the leading cause of mortality and morbidity placing a huge burden on individuals, families and health systems, especially in low- and middle-income countries (LMICs). This rising disease burden calls for policy responses that engage the entire health care system. This study aims to synthesize evidence on how people with NCDs choose their healthcare providers in LMICs, and the outcomes of these choices, with a focus on private sector delivery.

METHODS

A systematic search for literature following PRISMA guidelines was conducted. We extracted and synthesised data on the determinants and outcomes of private health care utilisation for NCDs in LMICs. A quality and risk of bias assessment was performed using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

We identified 115 studies for inclusion. Findings on determinants and outcomes were heterogenous, often based on a particular country context, disease, and provider. The most reported determinants of seeking private NCD care were patients having a higher socioeconomic status; greater availability of services, staff and medicines; convenience including proximity and opening hours; shorter waiting times and perceived quality. Transitioning between public and private facilities is common. Costs to patients were usually far higher in the private sector for both inpatient and outpatient settings. The quality of NCD care seems mixed depending on the disease, facility size and location, as well as the aspect of quality assessed.

CONCLUSION

Given the limited, mixed and context specific evidence currently available, adapting health service delivery models to respond to NCDs remains a challenge in LMICs. More robust research on health seeking behaviours and outcomes, especially through large multi-country surveys, is needed to inform the effective design of mixed health care systems that effectively engage both public and private providers.

TRIAL REGISTRATION

PROSPERO registration number CRD42022340059 .

A Qualitative Exploration of Barriers to Treatment Among HPV-Positive Women in a Cervical Cancer Screening Study in Western Kenya

BACKGROUND

Cervical cancer screening through self-collected high-risk human papillomavirus (HPV) testing has increased screening uptake, particularly in low-resource settings. Improvement ultimately depends, however, on women with positive results accessing follow-up treatment. Identifying the barriers to timely treatment is needed to tailor service delivery for maximum impact.

MATERIALS AND METHODS

This qualitative study was conducted within a self-collected HPV screening trial in Migori County, Kenya. HPV-positive women were referred for no-cost cryotherapy treatment at the county hospital. Women not attending within 60 days of receiving HPV-positive results were randomly selected for in-depth interviews (IDIs). IDIs were coded and analyzed to develop an analytical framework and identify treatment barriers.

RESULTS

Eighty-one women were interviewed. IDIs showed a poor understanding of HPV and cervical cancer, impacting comprehension of screening results and treatment instructions. All 81 had not undergone treatment but reported intending to in the future. Eight reported seeking treatment unsuccessfully or not qualifying, primarily due to pregnancy. Transportation costs and long distances to the hospital were the most reported barriers to treatment. Other obstacles included work, household obligations, and fear of treatment. Impacts of social influences were mixed; some women reported their husbands prevented seeking treatment, others reported their husbands provided financial or emotional support. Few women experienced peer support.

CONCLUSIONS

Women faced many barriers to treatment following HPV screening in rural Kenya. Transportation barriers highlight a need for local treatment capacity or screen-and-treat approaches. Ensuring women understand their results and how to seek treatment is essential to improving cervical cancer screening in low-resource settings.

Experiences of women awaiting cervical CANCER screening results from selected hospitals in Accra, Ghana

Background

The rate at which cervical cancer is diagnosed among women worldwide is alarming, nevertheless, millions of women have never undergone cervical cancer screening, and many more with cervical cancer die prematurely without accessibility to quality healthcare or effective treatment. Women’s experiences following cervical cancer screening have not been extensively studied especially in advancing countries like Ghana. Hence, the researchers aim to explore the experiences of women awaiting cervical cancer results at selected hospitals in Accra.

Methods

An exploratory-descriptive qualitative design was adopted to purposively sample 48 participants engaged in face-face in-depth interviews, which were audio-taped and transcribed verbatim after. The interviews were guided by semi-structured interviews.

Findings

The findings revealed 3 themes and 10 subthemes. The themes were pre-screening experience, intra-screening experience, and post-screening experience. Participants narrated the challenges they face before the screening, during the screening, and as they waited for their results to get ready. Despite some challenges reported, most of the participants indicated that they were willing to come for a retesting if recommended.

Conclusion

In conclusion, participants who have undergone CCS have several experiences that may either motivate or discourage them from subsequent screening. Being aware of such experiences could help the nurses address them in order to increase the interest of the women in CCS.

Timeliness of diagnosis of breast and cervical cancers and associated factors in low-income and middle-income countries: a scoping review

OBJECTIVES

Addressing the barriers to early breast and cervical cancer diagnosis in low and middle-income countries (LMICs) requires a sound understanding and accurate assessment of diagnostic timeliness. This review aimed to map the current evidence on the time to breast and cervical cancer diagnosis and associated factors in LMICs.

DESIGN

Scoping review.

SOURCES

MEDLINE (via PubMed), Cochrane Library, Scopus and CINAHL.

ELIGIBILITY CRITERIA

Studies describing the time to diagnosis and associated factors in the context of breast and cervical cancer in LMICs published from 1 January 2010 to 20 May 2021.

STUDY SELECTION AND DATA SYNTHESIS

Two reviewers independently screened all abstracts and full texts using predefined inclusion criteria. The review was reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. Evidence was narratively synthesised using predefined themes.

RESULTS

Twenty-six studies conducted across 24 LMICs were included in the review, most (24/26) of which focused on breast cancer. Studies varied considerably in their conceptualisation and assessment of diagnostic time, events, intervals and delays, with a minority of the studies reporting the use of validated methods and tools. Patient-related intervals and delays were more frequently evaluated and reported than provider-related and health system-related intervals and delays. Across studies, there were variations in the estimated lengths of the appraisal, help-seeking, patient and diagnostic intervals for both cancers and the factors associated with them.

CONCLUSIONS

Despite the significant burden of breast and cervical cancer in LMICs, there is limited information on the timeliness of diagnosis of these cancers. Major limitations included variations in conceptualisation and assessment of diagnostic events and intervals. These underscore the need for the use of validated and standardised tools, to improve accuracy and translation of findings to better inform interventions for addressing diagnostic delays in LMICs.

Referral mechanism and beneficiary adherence in cervical cancer screening program in Tiruchirappalli district, Tamil Nadu state, India, 2012-2015

Background

A screening program for cervical cancer was established in 2011 in Tamil Nadu. Since the inception of the program, coverage, and dropout of screening has not been analyzed. We conducted a study to describe the referral mechanism in the cervical cancer screening program implemented in Tamil Nadu, to estimate the level of adherence to the referral process by the beneficiaries, and to identify strengths and weaknesses related to the referral mechanism in the program.

Methods

">This descriptive study was conducted during 2015-2016 in the Tiruchirappalli administrative district of Tamil Nadu. All women aged 30 years and above, who were screened in public health facilities, were the participants. Using a structured form, we collected the data maintained in the registers at the district health administration. We estimated the screening coverage, follow-up evaluation, and dropout rates at different stages of the referral mechanism. We used SPSS and Epi Info software for analysis.

Results

Coverage of cervical cancer screening was 4,838(41.6%). We estimated 4,838(41.6%) of screened positives were lost to follow-up for a colposcopy examination. Biopsy samples were obtained from 3425(84%) of those who required a biopsy. Cervical cancer was diagnosed in 159(4.6%) and precancerous lesions in 528(15.4%) women.

Conclusion

More than half of the target population was screened in public health facilities. The dropout rate was less than half of those screened at the colposcopy evaluation level. Major pitfalls of the program were human resource issues at referral centers and poor maintenance of meaningful data.

Delay in Diagnosis of Cervical Cancer in Afghanistan: A Pilot Cross-Sectional Survey

Objectives: The present study aimed to investigate the potential delays in healthcare seeking and diagnosis of women with cervical cancer (CC) in Afghanistan.

Methods: Clinical records of three hospitals in Kabul were searched for CC cases, and the women identified were interviewed by a trained physician using a semi-structured questionnaire. The main outcomes were the prevalence of potential delays over 90 days (1) from symptoms onset to healthcare seeking (patient delay), and (2) from first healthcare visit to CC diagnosis (healthcare delay). Information was also collected on: type and stage of CC, diagnostic test utilized, familiarity for CC, signs and symptoms, treatment type, and potential reasons for delaying healthcare seeking.

Results: 31 women with CC were identified, however only 11 continued their treatment in the study hospitals or were reachable by telephone, and accepted the interview. The mean age was 51 ± 14 years, and only 18.2% had a previous history of seeking medical care. Patient delay was seen in 90.9% of the women (95% CI: 58.7–99.8), with a median of 304 ± 183 days. Instead, healthcare delay was found in 45.4% (95% CI: 16.7–76.6), with a median of 61 ± 152 days. The main reasons for patient delays were unawareness of the seriousness of the symptoms (70.0%) and unwillingness to consult a healthcare professional (30.0%). None of the women ever underwent cervical screening or heard of the HPV vaccination.

Conclusions: Given the global effort to provide quality health care to all CC patients, Afghanistan needs interventions to reduce the delays in the diagnosis of this cancer, for instance by improving all women's awareness of gynecological signs and symptoms.

Women's lived experiences of advanced cervical cancer: a descriptive qualitative study

AIM

To explore the lived experiences of women with advanced incurable cervical cancer attending a palliative care service in Uganda.

METHODS

This qualitative and exploratory study was conducted at Mobile Hospice Mbarara in South Western Uganda. The target population was a convenience sample of all patients with a confirmed histological diagnosis of advanced cervical cancer; stage 2B to 4B, and clinically advanced disease. Demographic data were collected prior to conducting semi-structured audio-taped interviews. Transcripts were read and re-read, coded and codes were then abstracted into emergent broad-based meaningful themes by consensus.

RESULTS

A total of 10 participants, average age of 53.4, age range 40-71, cancer staging 2B to 4 and average duration of illness 3.5 years were interviewed. Six themes emerged from the data: socio-demographic profiles of the women; road to cancer diagnosis; effects of disease on women's quality of life; experiences with main stream medicine; adapting to having cancer and needs of the women.

CONCLUSIONS

Living with advanced incurable cervical cancer is associated with significant disruptions in all domains of life. Good palliative care enables patients to achieve an optimal quality life. Poverty and a lack of knowledge about cervical cancer among women and health workers are the strongest predictors of a patient receiving a late advanced diagnosis.

Extent and Predictors of Delays in Diagnosis of Cervical Cancer in Addis Ababa, Ethiopia: A Population-Based Prospective Study

PURPOSE

A substantial proportion of cervical cancers are diagnosed at advanced stage in Ethiopia. Therefore, the aim of this study was to determine the extent and predictors of delays in cervical cancer diagnosis in Addis Ababa.

PATIENTS AND METHODS

We prospectively recruited 231 patients with cervical cancer diagnosed from January 1, 2017, to June 30, 2018, in 7 health facilities in Addis Ababa, representing 99% of all cervical cancers recorded in the Addis Ababa population-based cancer registry. A structured questionnaire on patients’ experience was administered face to face by trained interviewers. Health-seeking intervals > 90 days (date from recognition of symptoms to medical consultation) and diagnostic intervals > 30 days (dates from medical consultation to diagnostic confirmation) were categorized as delayed. Factors associated with these delays were assessed using multivariable binary logistic regression models.

RESULTS

The median health-seeking and diagnostic intervals for patients with cervical cancer in Addis Ababa were 10 and 97 days, respectively. Approximately one quarter of the patients were delayed in seeking medical consultation, and three fourths of the patients had delayed diagnostic confirmation. Factors associated with health-seeking delays included poor cervical cancer awareness, practicing of religious rituals, and waiting for additional symptoms before visiting a health facility. Factors associated with diagnostic delays included first contact with primary health care units and visits to ≥ 4 different health facilities before diagnosis.

CONCLUSION

A considerable proportion of patients with cervical cancer in Addis Ababa have delays in seeking medical care and diagnostic conformation. These findings reinforce the need for programs to enhance awareness about cervical cancer signs and symptoms and the importance of early diagnosis in the community and among health care providers.

Healthcare provider challenges to early detection of cervical cancer at primary healthcare level in Rwanda

Our objective was to assess the health facility related factors that cause delays in cervical cancer diagnosis at a primary healthcare level in Rwanda. Healthcare providers in outpatient clinics at 10 health centers in Kigali city and the Eastern province of Rwanda were surveyed. Eighty-five healthcare providers participated; 83.5% were nurses and the remainder were midwives. Only 15 (17.6%) reported prior training on visual inspection with acetic acid (VIA) cervical cancer screening, and they were distributed among 6 of the 10 health centers surveyed. However, 76.5% of respondents reported that at least one person was trained in VIA at their health center. The basic equipment necessary for cervical cancer evaluation was reported to be generally available. Overall, only 31.8% of participants had good basic knowledge level on cervical cancer screening. No association was found between respondents' knowledge about cervical cancer screening and profession, education level, work experience or reported prior training on VIA. There is a gap in the number of primary healthcare providers with the skills to perform pelvic exam and VIA cervical cancer screening at health centers in Rwanda. As health centers are the first point of contact for patients with the healthcare system, there is a need to improve their knowledge and skills in performing cervical cancer screening and detection.

Effect of Waiting Time from Pathological Diagnosis to Definitive Concurrent Chemoradiation (CCRT) for Cervical Cancer on Overall Survival

Purpose

This study aimed to evaluate the effect of waiting time, from diagnosis to initiation of definitive concurrent chemoradiation (CCRT), on overall survival in cervical cancer patients.

Materials and Methods

Patients with cervical cancer who were treated with definitive CCRT between 2000 and 2017 were retrospectively reviewed. Time from initial pathological diagnosis to definitive CCRT was analyzed both as a continuous variable (per day) and as a categorical variable in two groups (group 1 ≤ median, group 2 > median). Patients with a waiting time of more than 60 days were excluded.

Results

The median waiting time was 14 days (0–60). There were differences between group 1 and group 2 in age and chemotherapy regimens. However, no significant difference was found in the International Federation of Gynecology and Obstetrics stage, cell type, or the number of cycles of chemotherapy received during CCRT. A longer waiting time was associated with poorer overall survival on the Kaplan-Meier curve (group 1 vs. group 2, p=0.042). On multivariate analysis, intervals as either a continuous variable (hazard ratio [HR], 1.023; 95% confidence interval [CI], 1.006 to 1.040; p=0.007) or a categorical variable (HR, 1.513; 95% CI, 1.073 to 2.134; p=0.018), FIGO stage, cell type, and the number of cycles of chemotherapy received during CCRT were significant independent prognostic factors for overall survival.

Conclusion

A shorter waiting time from pathological diagnosis to definitive CCRT showed benefit on overall survival. Our findings suggest that an effort to minimize waiting times should be recommended in cervical cancer patients who are candidates for CCRT.

Time from Self-Detection of Symptoms to Seeking Definitive Care among Cervical Cancer Patients

Background:

India had the burden of 97,000 new cases of cervical cancer with 60,000 deaths accounting nearly one-third of global cervical cancer deaths during the year 2018. Cervical cancer is the leading cause of cancer mortality in India. The present study aims to estimate the time interval between self-detection of cervical cancer symptoms and seeking care and different barriers for the possible time lag in seeking care.

Methods:

A cross-sectional study was undertaken from April 2017 to September 2017 in a regional cancer centre in the south of India. The centre has both a population and a hospital-based cancer registry. Cervical cancer cases (N= 210) with histological confirmation were interviewed at the hospital using a pre-tested semi-structured questionnaire.

Results:

The median time interval between the self-detection of cervical cancer symptoms and first contact with the general physician was 80 [IQR 45-150] days. The overall median time interval between the self-detection of symptoms to the initiation of primary treatment was 123[IQR 83-205] days. The major perceived reason for not seeking medical care was a lack of awareness in identifying cervical cancer symptoms in 183(92.9%) women.

Conclusion:

The median time of 80 days was observed from the self-detection of cervical cancer symptoms to the first contact with a general physician. Lack of awareness of patients pertaining to cancer symptoms was the major concern in seeking cancer care.

Factors associated with advanced stage at diagnosis of cervical cancer in Addis Ababa, Ethiopia: a population-based study

OBJECTIVE

To describe the patterns and factors associated with advanced stage at diagnosis of cervical cancer among Addis Ababa residents, Ethiopia.

DESIGN

A population-based cross-sectional study.

SETTING

Seven major hospitals or diagnostic facilities in Addis Ababa, Ethiopia.

PARTICIPANTS

All histopathology-confirmed patients with incident cervical cancer diagnosed from 1 January 2017 to 30 June 2018 among Addis Ababa residents.

OUTCOME MEASURES

The proportion of patients with cervical cancer diagnosed at early stage (stage I/II) and advanced stage (stage III/IV) of the disease according to International Federation of Gynaecology and Obstetrics staging criteria, and adjusted prevalence ratio (APR) for factors associated with advanced-stage diagnosis using a Poisson regression with robust variance model.

RESULTS

The mean age of the study participants was 52.9 (±13.3) years. Nearly two-thirds (60.4%, 95% CI: 53.8% to 66.5%) of patients with cervical cancer were diagnosed at an advanced stage. Advanced stage at diagnosis was significantly associated with paying medical bill out of pocket (APR=1.44, 95% CI: 1.08 to 1.91), diagnostic interval >90 days (APR=1.31, 95% CI: 1.04 to 1.71), practicing religion as a remedy or not taking immediate action following symptom recognition (APR=1.25, 95% CI: 1.08 to 1.91) and visiting more than three different health facilities prior to diagnostic confirmation (APR=1.24, 95% CI: 1.07 to 1.51).

CONCLUSIONS

Our findings of the high proportion of advanced-stage diagnosis of cervical cancer in Addis Ababa and its strong associations with out-of-pocket medical bill, seeking care out of conventional medicine settings and multiple visits to healthcare facilities before diagnostic confirmations underscore the need for public policies to improve the affordability of cancer care and enhance community awareness about the severity of the disease and referral system, in addition to expanding cervical cancer screening.

The Care Pathway Delays of Cervical Cancer Patient in Morocco

Introduction

The aim of this study is to document time intervals in cervical cancer care pathways, from symptom onset to disease detection and start of treatment, and evaluate how clinical, sociodemographic, and treatment factors influence delays throughout a patient's clinical pathway.

Methods

A retrospective study was conducted at the FEZ Oncology Hospital of the Hassan II University Hospital Center in Morocco.

Results

190 medical records of cervical cancer patients were collected. The dominant age group was 35–44, the median patient delay (PD) was 6 days, the median healthcare provider's delay (HCP) was 21 days, the median referral delay (RD) was 17 days, the median diagnostic delay (DD) was 9.5 days, the median total diagnostic delay (TDD) was 16 days, the median treatment delay (TD) was 67 days, and the median health system interval (HSI) was 92 days. Multivariate analysis revealed that age was associated with the patient delay, the healthcare provider's delay, the diagnosis delay, and the health system interval. The diagnosis year (the year in which the patient was diagnosed (either before 2012 or during 2012 as well as the other study years (from 2013 to 2017))), all investigations done prior to admission to the oncology hospital, and the age of first sexual activity were significantly associated with healthcare provider's delay.

Conclusion

The integration of a model and standard care pathway into the Moroccan health system is essential in order to unify cervical cancer care in the country.

Cervical Cancer Treatment Delays and Associated Factors in a Cohort of Women From a Developing Country

PURPOSE

To estimate treatment delays and associated factors among women diagnosed with cervical cancer who were treated at the main cancer center in Rio de Janeiro, Brazil.

MATERIALS AND METHODS

A retrospective cohort study was performed comprising 865 women newly diagnosed with cervical cancer between 2012 and 2014. Times from diagnosis to treatment initiation (less than or equal to 60 days) and from diagnosis to treatment ending (less than or equal to 120 days) were analyzed according to the Brazilian law for the treatment of patients with cancer. Associations between treatment delays and sociodemographic, economic, lifestyle, clinical, and treatment variables were estimated using logistic regression models, with 95% CIs.

RESULTS

The average age was 48 (± 13.7) years, and the median age was 47 years; 36.2% of patients had stage IIIB to IVA disease. The median time from diagnosis to treatment initiation was 114 days, which was statistically higher among women with stage IIB to IVA (105.5 days) compared with those with earlier stages (119 days). The delay in treatment initiation occurred in 92.8% of participants; the median time from diagnosis to treatment ending was 274 days, with a delay (more than 120 days) for 92.6% of patients. The median time interval from diagnosis to the first visit to the cancer center was 28 days, with a delay of more than 30 days for 46.6% of patients. Age (odds ratio [OR], 1.05; 95% CI,1.02 to 1.08), stage IIIB to IVA (OR, 0.38; 95% CI, 0.16 to 0.90), time to first visit to the cancer center (OR, 11.52; 95% CI, 4.32 to 30.66), chemoradiation treatment (OR, 4.56; 95% CI, 1.81 to 11.47), and adequate treatment (OR, 2.57; 95% CI, 1.26 to -5.40) were independently associated with delay of treatment initiation.

CONCLUSION

Significant delays in treatment initiation and ending were observed in this studied population. The treatment initiation delay was positively associated with age, time interval more than 30 days from diagnosis to first specialist assessment at the cancer center, treatment with chemoradiation, and adequate treatment.

Cervical cancer in Ethiopia - predictors of advanced stage and prolonged time to diagnosis

Introduction

In Ethiopia, most cervical cancer patients present at advanced cancer stages, long time after they experience first symptoms. We investigated possible predictors of long time spans between symptom onset and pathologic diagnosis (patient intervals). We also aimed to seek out predictors for advanced cancer stage diagnosis.

Methods

We conducted a retrospective cohort study among 1575 cervical cancer patients who were registered at Tikur Anbessa Specialized Hospital (TASH), Addis Ababa, Ethiopia between September 2008 and September 2012. Cox proportional hazards regression was used to find predictors of long patient intervals. Cumulative odds ordinal logistic regression was used to identify predictors of cancer stage at diagnosis.

Results

Median patient interval was 30 weeks, with the interval substantially longer in patients residing in rural than urban areas. Longer patient intervals were associated with more advanced cancer stages at pathologic diagnosis. HIV-positive women had an almost 1.5 times increased risk of diagnosis at a more advanced stage.

Conclusion

Cervical cancer patients are diagnosed after long time periods leading to advanced stages at diagnosis. Measures to raise awareness about cervical cancer, to increase screening and to shorten the time interval from recognition of symptoms to diagnosis are urgently needed.

Effect of time interval from diagnosis to treatment for cervical cancer on survival: A nationwide cohort study

Objectives

Despite the ease of health care access and the waiver of copayments for cancer patients, treatment is delayed in a small proportion of Taiwanese patients diagnosed with cervical cancer. In this study, we explored the relationship between the time interval from diagnosis to treatment and survival in cervical cancer patients.

Material and methods

The study was a retrospective population-based observational study conducted between 2004 and 2010. In Taiwan, 12,020 patients were newly diagnosed with cervical cancer from 2004 to 2010, and 9,693 patients (80.6%) were enrolled in our final analysis.

Results

Most of the patients received treatment within 90 days of diagnosis (n = 9,341, 96.37%). After adjustment for other variables, patients who received treatment between 90 and 180 days and >180 days after diagnosis had a 1.33 (95% CI: 1.02–1.72, P < 0.05) and 1.36 (95% CI: 1.12–1.65, P < 0.05) times higher risk of death, respectively, than those who received treatment within 90 days. Kaplan–Meier analysis showed that the patients treated after 90 days from diagnosis had a lower overall survival rate than those treated within 90 days. In analysis stratifying the patients according to their initial tumor stage, namely stages I and II and stage III and IV, the time interval from diagnosis to treatment remained a significant prognosticator in those who received treatment >180 days after diagnosis.

Conclusion

A longer interval between diagnosis and treatment is associated with poorer prognosis among cervical cancer patients.

Cancer Control at the District Hospital Level in Sub-Saharan Africa: An Educational and Resource Needs Assessment of General Practitioners

PURPOSE

The WHO framework for early cancer diagnosis highlights the need to improve health care capacity among primary care providers. In Rwanda, general practitioners (GPs) at district hospitals (DHs) play key roles in diagnosing, initiating management, and referring suspected patients with cancer. We sought to ascertain educational and resource needs of GPs to provide a blueprint that can inform future early cancer diagnosis capacity–building efforts.

METHODS

We administered a cross-sectional survey study to GPs practicing in 42 Rwandan DHs to assess gaps in cancer-focused knowledge, skills, and resources, as well as delays in the referral process. Responses were aggregated and descriptive analysis was performed to identify trends.

RESULTS

Survey response rate was 76% (73 of 96 GPs). Most responders were 25 to 29 years of age (n = 64 [88%]) and 100% had been practicing between 3 and 12 months. Significant gaps in cancer knowledge and physical exam skills were identified—88% of respondents were comfortable performing breast exams, but less than 10 (15%) GPs reported confidence in performing pelvic exams. The main educational resource requested by responders (n = 59 [81%]) was algorithms to guide clinical decision-making. Gaps in resource availability were identified, with only 39% of responders reporting breast ultrasound availability and 5.8% reporting core needle biopsy availability in DHs. Radiology and pathology resources were limited, with 52 (71%) reporting no availability of pathology services at the DH level.

CONCLUSION

The current study reveals significant basic oncologic educational and resource gaps in Rwanda, such as physical examination skills and diagnostic tools. Capacity building for GPs in low- and middle-income countries should be a core component of national cancer control plans to improve accurate and timely diagnosis of cancer. Continuing professional development activities should address and focus on context-specific educational gaps, resource availability, and referral practice guidelines.

Influence of the time interval from diagnosis to treatment on survival for early-stage liver cancer

Objectives

Liver cancer is the fifth most common cancer in men and the ninth most common cancer in women, and the WHO expects that there will be 1,341,344 cases in 2034 worldwide. Liver cancer also has the second-highest cancer death rate, accounting for 7% of all cancers. The study is going to explore the relationship between time interval from diagnosis to treatment and survival status of early-stage liver cancer patients.

Materials and methods

This is a retrospective cohort study using the national database from Taiwan. The datasets include the Taiwan Cancer Registry Database (TCR), the National Health Insurance Research Database (NHIRD), and the National Registry of Deaths. The target population for the study was patients newly diagnosed with stage I and stage II liver cancer between the years 2004 and 2010. Total of 26,038 cases were included in the study. Except descriptive analysis, the relationship between patient characteristics and the time interval from diagnosis to treatment was examined by chi-square tests. In addition, modified Cox proportional hazard models were used to analyze the hazard ratio of patient death with various treatment delay durations.

Results

There were 20,430 patients (78.46%) who received treatment less than 30 days after diagnosis, while 2,674 patients (10.27%) received treatment between 31 and 60 days after diagnosis, and 2,068 patients (7.94%) received treatment between 61 and 180 days after diagnosis, and 866 patients (3.33%) who received treatment 181 days after diagnosis. Those treated more than 181 days and 61–180 days after diagnosis had a 1.68-fold increased risk of death (95% confidence interval: 1.50–1.88) and a 1.39-fold increased risk of death (95% confidence interval: 1.31–1.17), respectively. Being male, being elderly, having a higher CCI level, and being treated in a hospital with a low service volume were factors associated with a poorer prognosis.

Conclusion

Overall, this study utilized a national cohort to conclude that for early-stage liver cancer patients, a longer the time interval from diagnosis to treatment results in a lower survival rate.

Knowledge, attitude, practice and barriers of cervical cancer screening among women living in mid-western rural, Nepal

Objective

To find out the knowledge, attitude, practice, and barriers of cervical cancer screening in mid-western rural, Nepal.

Methods

A hospital-based cross-sectional study was conducted. Women aged 20 or more were interviewed using a structured questionnaire regarding the socio-demographic information, knowledge, attitude, practice, and barriers to the cervical cancer screening.

Results

Total of 360 participants were recruited for this study, mean age was 30.13±10.4 years. More than 87% of participants had inadequate knowledge, but around 72% had a favorable attitude towards cervical cancer screening. There was a significant portion of women (86.4%) had never done any cervical cancer screening test. Despite being higher literacy rate of Brahmin and Chhetri ethnic group, they were less likely to attend the cervical cancer screening than Dalit and Janajati (p<0.001); and those who had a positive family history of cancer were more likely to attend the cervical cancer screening (p<0.001). Similarly, married women, who had adequate knowledge and or favorable attitude, were more likely to practice cervical cancer screening, though statistically not significant. Factors such as “No symptoms,” “Lack of awareness,” “Embarrassment,” etc. were the most common barriers for the cervical cancer screening.

Conclusion

The adequate knowledge and practice of cervical cancer screening were meager among rural Nepalese women, but most of them had a favorable attitude. There is an imperative need for related awareness programs to promote the uptake of cervical cancer screening tests.

Malignant Neoplasm Burden in Nepal - Data from the Seven Major Cancer Service Hospitals for 2012

In Nepal, while no population based cancer registry program exists to assess the incidence, prevalence, morbidity and mortality of cancer, at the national level a number of hospital based cancer registries are cooperating to provide relevant data. Seven major cancer diagnosis and treatment hospitals are involved, including the BP Koirala Memorial Cancer hospital, supported by WHO-Nepal since 2003. The present retrospective analysis of cancer patients of all age groups was conducted to assess the frequencies of different types of cancer presenting from January 1st to December 31st 2012. A total of 7,212 cancer cases were registered, the mean age of the patients being 51.9 years. The most prevalent age group in males was 60-64 yrs (13.6%), while in females it was 50-54 yrs (12.8%). The commonest forms of cancer in males were bronchus and lung (17.6%) followed by stomach (7.3%), larynx (5.2%) and non Hodgkins lymphoma (4.5%). In females, cervix uteri (19.1%) and breast (16.3%), were the top ranking cancer sites followed by bronchus and lung (10.2%), ovary (6.1%) and stomach (3.8%). The present data provide an update of the cancer burden in Nepal and highlight the relatively young age of breast and cervical cancer patients.

Community-Based Health Education has Positive Influence on the Attitude to Cervical Cancer Screening among Women in Rural Nepal

The main purpose of this study was to assess the knowledge of cervical cancer among women in rural Nepal and explore the feasibility and impact of a community-based awareness program on cervical cancer. Community-based educational meetings on cervical cancer and its prevention were conducted among women's groups in rural Nepal. Through a questionnaire, the women's baseline knowledge of risk factors, symptoms, and perceived risk of cervical cancer were identified. The willingness to participate in cervical cancer screening was compared before and after the educational meeting. The meetings were followed by a cervical cancer screening program. Among the 122 participants at the educational meeting, only 6 % had heard of cervical cancer. Their baseline knowledge of risk factors and symptoms was poor. The proportion of women willing to participate in cervical screening increased from 15.6 to 100 % after attending the educational meeting. All the study subjects participated in the screening program. Additionally, the study participants recruited a further 222 of their peers for screening. Poor knowledge of cervical cancer among women in rural Nepal highlights the urgency of public awareness programs for cervical cancer at a national level. A community-based awareness program can change women's attitude to cervical screening, and women's groups can play a major role in promoting participation in cervical cancer screening programs.

[Effect of waiting time for radiotherapy on five-year overall survival in women with cervical cancer, 1995-2010]

Overall 5-year survival and factors associated with death were evaluated in a cohort of 342 women with cervical cancer referred to radiotherapy in the Baixada Fluminense, in Greater Metropolitan Rio de Janeiro State, Brazil. Overall 5-year survival was 25.3%, reaching 60.8% in women with stage IIA or less. The model adjusted by extended Cox proportional regression showed an increase in mortality risk for patients with stages IIB-IIIB (HR = 1.89; 95%CI: 1.214; 2.957) and IVA-IVB (HR = 5.78; 95%CI: 2.973; 11.265). Cytology in asymptomatic women (HR = 0.58; 95%CI: 0.362; 0.961) and referral for first consultation in an oncology service in the Baixada Fluminense (HR = 0.60; 95%CI: 0.418; 0.875) were the main protective factors identified by the study. Waiting time (> 60 versus ≤ 60 days) was not statistically significant, but a delay of 4 days worsened the outcome. The 60-day limit for initiating radiotherapy should be respected, because delay greater than 64 days showed a significant association between all waiting time cut-off points and 5-year mortality risk.

Challenges in Prevention and Care Delivery for Women with Cervical Cancer in Sub-Saharan Africa

Virtually all cases of invasive cervical cancer are associated with infection by high-risk strains of human papilloma virus. Effective primary and secondary prevention programs, as well as effective treatment for early-stage invasive cancer have dramatically reduced the burden of cervical cancer in high-income countries; 85% of the mortality from cervical cancer now occurs in low- and middle-income countries. This article provides an overview of challenges to cervical cancer care in sub-Saharan Africa (SSA) and identifies areas for programmatic development to meet the global development goal to reduce cancer-related mortality. Advanced stage at presentation and gaps in prevention, screening, diagnostic, and treatment capacities contribute to reduced cervical cancer survival. Cost-effective cervical cancer screening strategies implemented in low resource settings can reduce cervical cancer mortality. Patient- and system-based barriers need to be addressed as part of any cervical cancer control program. Limited human capacity and infrastructure in SSA are major barriers to comprehensive cervical cancer care. Management of early-stage, locally advanced or metastatic cervical cancer involves multispecialty care, including gynecology oncology, medical oncology, radiology, pathology, radiation oncology, and palliative care. Investment in cervical cancer care programs in low- and middle-income countries will need to include effective recruitment programs to engage women in the community to access cancer screening and diagnosis services. Though cervical cancer is a preventable and treatable cancer, the challenges to cervical control in SSA are great and will require a broadly integrated and sustained effort by multiple stakeholders before meaningful progress can be achieved.

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.

Identifying the Factors Causing Delayed Presentation of Cancer Patients to a Government Medical College of Central India

BACKGROUND

The incidence of cancer is increasing throughout the world. One of the prime aims of its management is early diagnosis and therapeutic intervention. Factors causing delay to either of these goals should be identified and rectified.

AIM

To identify the factors causing delayed initial diagnosis and subsequent management in patients presenting to the Oncology department.

MATERIALS AND METHODS

Three hundred proven cancer patients were prospectively evaluated for the pattern of presentation to the outpatient Department of Radiation Oncology of a Government Medical College (MC) in Central India.

RESULTS

The mean age of presentation was 51.05 years (range 7 months-77 years). The number of male patients was 168 while females were 132. The duration of symptoms ranged from 20 days to 3 years. The number of patients with little/no education presented mainly in advanced stages as compared to their educated counterpart and this difference was statistically significant (p<0.001). The number of patients presenting directly to the department was 108, those diagnosed outside and referred to us was 84 while those diagnosed and received some form of oncologic treatment outside and referred thereafter was 108. The difference in the primary delay between patients presenting directly to the MC versus those diagnosed outside was significant (p=0.0126). The mean duration of starting definitive treatment after presentation to the outpatient was 4.68 days (range 0-22 days) and was very significantly (p< 0.001) less than the secondary delays caused to the other two subsets of patients.

CONCLUSION

Factors causing delayed presentation are both patient and system related. It is imperative to educate the common people regarding the early signs and symptoms of cancer. At the same time, the system needs to overhaul its efficiency to avoid secondary delays that adversely affect the treatment outcome. An upgradation of the existing oncology facilities in the public sector can achieve this target efficiently.

Knowledge and awareness of human papillomavirus (HPV), cervical cancer and HPV vaccine among women in two distinct Nepali communities

BACKGROUND

This study assessed human papillomavirus (HPV), cervical cancer, and HPV vaccine knowledge and awareness among women in two sub-populations in Nepal - Khokana, a traditional Newari village in the Lalitpur District about eight kilometers south of Kathmandu, and Sanphebagar, a village development committee within Achham District in rural Far-Western Nepal.

METHODS

Study participants were recruited during health camps conducted by Nepal Fertility Care Center, a Nepali non-governmental organization. Experienced staff administered a Nepali language survey instrument that included questions on socio-demographics, reproductive health and knowledge on HPV, cervical cancer, and the HPV vaccine.

RESULTS

Of the 749 participants, 387 (51.7%) were from Khokana and 362 (48.3%) were from Sanphebagar. Overall, 53.3% (n=372) of women were aware of cervical cancer with a significant difference between Khokana and Sanphebagar (63.3% vs 43.0%; p=0.001). Overall, 15.4% (n=107) of women had heard of HPV and 32% (n=34) of these women reported having heard of the HPV vaccine. If freely available, 77.5% of the women reported willingness to have their children vaccinated against HPV. Factors associated with cervical cancer awareness included knowledge of HPV (Khokana: Odds Ratio (OR)=24.5; (95% Confidence Interval (CI): 3.1-190.2, Sanphebagar: OR=14.8; 95% CI: 3.7-58.4)) and sexually transmitted infections (Khokana: OR=6.18; 95% CI: 3.1-12.4; Sanphebagar: OR=17.0; 95% CI: 7.3- 39.7) among other risk factors.

CONCLUSIONS

Knowledge and awareness of HPV, cervical cancer, and the HPV vaccine remains low among women in Khokana and Sanphebagar. Acceptance of a freely available HPV vaccine for children was high, indicating potentially high uptake rates in these communities.