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Martei YM, Mokokwe L, Ngwako N, Kebuang K, Setlhako DI, Gabaatlhole G, Baaitse B, Segadimo T, Shulman LN, Barg F, Gaolebale BE. Development, acceptability and usability of culturally appropriate survivor narrative videos for breast cancer treatment in Botswana: a pilot study. BMJ Open 2024; 14:e073867. [PMID: 38296302 PMCID: PMC10828869 DOI: 10.1136/bmjopen-2023-073867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 12/14/2023] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVES Narrative communication has demonstrated effectiveness in promoting positive health behaviours, delivering support and coping with complex decision-making. Formal research evaluating this intervention for cancer treatment in Africa is lacking. We aimed to develop, and assess acceptability and usability of survivor video narrative interventions for breast cancer treatment in Botswana. DESIGN A pilot study design. SETTING Single-centre, tertiary hospital, sub-Saharan Africa. PARTICIPANTS Eight women, ≥18 years old, with stages I-III breast cancer were enrolled for the video intervention. 106 women, ≥18 years old, with stages I-IV breast cancer viewed the narrative videos and 98 completed the acceptability and usability surveys. INTERVENTION Survivor narrative videos were developed using the theory of planned behaviour and using a purposive sample of Batswana, Setswana-speaking, breast cancer survivors, who had completed systemic treatment and surgery with high rates of adherence to the prescribed treatment plan. PRIMARY OUTCOMES We assessed acceptability and usability among prospectively enrolled patients presenting for routine breast cancer care at Princess Marina Hospital in Botswana, using a 13-item survey. RESULTS Participants expressed high acceptability and usability of the videos, including 99% (97/98) who strongly agreed/agreed that the video presentations were easy to understand, 92% (90/98) who would recommend to other survivors and 94% (92/98) who wished there were more videos. Additionally, 89% (87/98) agreed or strongly agreed that the one-on-one instruction on how to use the tablet was helpful and 87% (85/98) that the video player was easy to use. CONCLUSION Culturally appropriate survivor video narratives have high acceptability and usability among patients with breast cancer in Botswana. There is an opportunity to leverage this intervention in routine breast cancer care for treatment support. Future studies will test the implementation and effectiveness of narrative videos on a wider scale, including for patients being treated for other cancers.
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Affiliation(s)
- Yehoda M Martei
- Department of Medicine (Hematology - Oncology Division), University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lebogang Mokokwe
- Botswana University of Pennsylvania Partnership, Gaborone, Botswana
- University of Botswana, Gaborone, Botswana
| | | | | | | | | | | | | | - Lawrence N Shulman
- Department of Medicine (Hematology - Oncology Division), University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Frances Barg
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Martei YM, Obasohan M, Mokokwe L, Ralefala T, Mosepele M, Gross R, Barg FK. Stigma and Social Determinants of Health Associated With Fidelity to Guideline-Concordant Therapy in Patients With Breast Cancer Living With and Without HIV in Botswana. Oncologist 2023; 28:e1230-e1238. [PMID: 37405697 PMCID: PMC10712728 DOI: 10.1093/oncolo/oyad183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 06/01/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Patients with breast cancer in sub-Saharan Africa (SSA) experience a disproportionate burden of mortality. Fidelity to treatment guidelines, defined as receiving optimal dose and frequency of prescribed treatments, improves survival. We sought to identify patient factors associated with treatment fidelity and how this may differ for people with HIV (PWH) and breast cancer. METHODS We conducted a qualitative study of women who initiated outpatient treatment for stages I-III breast cancer in Botswana, with deviance sampling of high- and low-fidelity patients. One-on-one interviews were conducted using semi-structured guides informed by the Theory of Planned Behavior. The sample size was determined by thematic saturation. Transcribed interviews were double coded with an integrated analytic approach. RESULTS We enrolled 15 high- and 15 low-fidelity participants from August 25, 2020 to December 15, 2020, including 10 PWH (4 high, 6 low fidelity). Ninety-three percent had stage III disease. Barriers to treatment fidelity included stigma, social determinants of health (SDOH), and health system barriers. Acceptance and de-stigmatization, peer and other social support, increased knowledge and self-efficacy were identified as facilitators. The COVID-19 pandemic amplified existing socioeconomic stressors. Unique barriers and facilitators identified by PWH included intersectional stigma, and HIV and cancer care integration, respectively. CONCLUSION We identified multilevel modifiable patient and health system factors associated with fidelity. The facilitators provide opportunities for leveraging existing strengths within the Botswana context to design implementation strategies to increase treatment fidelity to guideline-concordant breast cancer therapy. However, PWH experienced unique barriers, suggesting that interventions to address fidelity may need to be tailored to specific comorbidities.
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Affiliation(s)
- Yehoda M Martei
- Department of Medicine (Hematology-Oncology), University of Pennsylvania, Philadelphia, PA, USA
| | - Modesty Obasohan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lebogang Mokokwe
- Botswana University of Pennsylvania Partnership, Gaborone, Botswana
- Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | | | | | - Robert Gross
- Department of Medicine (Infectious Diseases), University of Pennsylvania, Philadelphia, PA, USA
| | - Frances K Barg
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA, USA
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Toma A, O'Neil D, Joffe M, Ayeni O, Nel C, van den Berg E, Nayler S, Cubasch H, Phakathi B, Buccimazza I, Čačala S, Ruff P, Norris S, Nietz S. Quality of Histopathological Reporting in Breast Cancer: Results From Four South African Breast Units. JCO Glob Oncol 2021; 7:72-80. [PMID: 33434068 PMCID: PMC8081479 DOI: 10.1200/go.20.00402] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE High-quality histopathology reporting forms the basis for treatment decisions. The quality indicator for pathology reports from the European Society of Breast Cancer Specialists was applied to a cohort from four South African breast units. METHODS The study included 1,850 patients with invasive breast cancer and evaluated 1,850 core biopsies and 1,158 surgical specimen reports with cross-center comparisons. A core biopsy report required histologic type; tumor grade; and estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 (HER2) status, with a confirmatory test for equivocal HER2 results. Ki-67 was regarded as optional. Pathologic stage, tumor size, lymphovascular invasion, and distance to nearest invasive margin were mandatory for surgical specimens. Specimen turnaround time (TAT) was added as a locally relevant indicator. RESULTS Seventy-five percent of core biopsy and 74.3% of surgical specimen reports were complete but showed large variability across study sites. The most common reason for an incomplete core biopsy report was missing tumor grade (17.9%). Half of the equivocal HER2 results lacked confirmatory testing (50.6%). Ki-67 was reported in 89.3%. For surgical specimens, the closest surgical margin was reported in 78.1% and lymphovascular invasion in 84.8% of patients. Mean TAT was 11.9 days (standard deviation [SD], 10.8 days) for core biopsies and 16.1 days (SD, 11.3) for surgical specimens. CONCLUSION Histopathology reporting is at a high level but can be improved, especially for tumor grade, HER2, and Ki-67, as is reporting of margins and lymphovascular invasion. A South African pathology consensus will reduce variability among laboratories. Routine use of standardized data sheets with synoptic reports and ongoing audits will improve completeness of reports over time.
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Affiliation(s)
- Armand Toma
- Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Daniel O'Neil
- Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, FL
| | - Maureen Joffe
- Noncommunicable Diseases Research Division, Wits Health Consortium, Johannesburg, South Africa.,South African Medical Research Council/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Oluwatosin Ayeni
- Noncommunicable Diseases Research Division, Wits Health Consortium, Johannesburg, South Africa.,South African Medical Research Council/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Carolina Nel
- Department of Anatomical Pathology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg, South Africa
| | - Eunice van den Berg
- Department of Anatomical Pathology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg, South Africa
| | - Simon Nayler
- Wits Donald Gordon Medical Centre, Johannesburg, South Africa
| | - Herbert Cubasch
- Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Noncommunicable Diseases Research Division, Wits Health Consortium, Johannesburg, South Africa
| | - Boitumelo Phakathi
- Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ines Buccimazza
- Department of Surgery, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Sharon Čačala
- Department of Surgery, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Paul Ruff
- Noncommunicable Diseases Research Division, Wits Health Consortium, Johannesburg, South Africa.,Division of Medical Oncology, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shane Norris
- Noncommunicable Diseases Research Division, Wits Health Consortium, Johannesburg, South Africa.,South African Medical Research Council/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sarah Nietz
- Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Noncommunicable Diseases Research Division, Wits Health Consortium, Johannesburg, South Africa
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Twahir M, Oyesegun R, Yarney J, Gachii A, Edusa C, Nwogu C, Mangutha G, Anderson P, Benjamin E, Müller B, Ngoh C. Real-world challenges for patients with breast cancer in sub-Saharan Africa: a retrospective observational study of access to care in Ghana, Kenya and Nigeria. BMJ Open 2021; 11:e041900. [PMID: 33653746 PMCID: PMC7929861 DOI: 10.1136/bmjopen-2020-041900] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To evaluate medical resource utilisation and timeliness of access to specific aspects of a standard care pathway for breast cancer at tertiary centres in sub-Saharan Africa. DESIGN Data were retrospectively abstracted from records of patients with breast cancer treated within a prespecified 2-year period between 2014 and 2017. The study protocol was approved by local institutional review boards. SETTING Six tertiary care institutions in Ghana, Kenya and Nigeria were included. PARTICIPANTS Health records of 862 patients with breast cancer were analysed: 299 in Ghana; 314 in Kenya; and 249 in Nigeria. INTERVENTIONS As directed by the treating physician. OUTCOME MEASURES Parameters selected for evaluation included healthcare resource and use, medical procedure turnaround times and out-of-pocket (OOP) payment patterns. RESULTS Use of mammography or breast ultrasonography was <45% in all three countries. Across the three countries, 78%-88% of patients completed tests for hormone receptors and human epidermal growth factor receptor 2 (HER2). Most patients underwent mastectomy (64%-67%) or breast-conserving surgery (15%-26%). Turnaround times for key procedures, such as pathology, surgery and systemic therapy, ranged from 1 to 5 months. In Ghana and Nigeria, most patients (87%-93%) paid for diagnostic tests entirely OOP versus 30%-32% in Kenya. Similarly, proportions of patients paying OOP only for treatments were high: 45%-79% in Ghana, 8%-20% in Kenya and 72%-89% in Nigeria. Among patients receiving HER2-targeted therapy, the average number of cycles was five for those paying OOP only versus 14 for those with some insurance coverage. CONCLUSIONS Patients with breast cancer treated in tertiary facilities in sub-Saharan Africa lack access to timely diagnosis and modern systemic therapies. Most patients in Ghana and Nigeria bore the full cost of their healthcare and were more likely to be employed and have secondary or postsecondary education. Access to screening/diagnosis and appropriate care is likely to be substantively lower for the general population.
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Gebremariam A, Addissie A, Worku A, Assefa M, Pace LE, Kantelhardt EJ, Jemal A. Time intervals experienced between first symptom recognition and pathologic diagnosis of breast cancer in Addis Ababa, Ethiopia: a cross-sectional study. BMJ Open 2019; 9:e032228. [PMID: 31719089 PMCID: PMC6858206 DOI: 10.1136/bmjopen-2019-032228] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES This study aimed to estimate the magnitude of patient and diagnostic delays and associated factors among women with breast cancer in Addis Ababa. DESIGN This is a cross-sectional study. SETTINGS AND PARTICIPANTS All women newly diagnosed with breast cancer in seven major healthcare facilities in Addis Ababa (n=441) were included in the study. MAIN OUTCOMES AND MEASURES Patient interval (time from recognition of first symptom to medical consultation) and diagnostic interval (time from first consultation to diagnosis). Patient intervals >90 days and diagnostic intervals >30 days were considered delays, and associated factors were determined using multivariable Poisson regressions with robust variance. RESULTS Thirty-six percent (95% CI [31.1%, 40.3%]) of the patients had patient intervals of >90 days, and 69% (95% CI [64.6%, 73.3%]) of the patients had diagnostic intervals of >30 days. Diagnostic interval exceeded 1 year for 18% of patients. Ninety-five percent of the patients detected the first symptoms of breast cancer by themselves, with breast lump (78.0%) as the most common first symptom. Only 8.0% were concerned about cancer initially, with most attributing their symptoms to other factors. In the multivariable analysis, using traditional medicine before consultation was significantly associated with increased prevalence of patient delay (adjusted prevalence ratio (PR) = 2.13, 95% CI [1.68, 2.71]). First consultation at health centres (adjusted PR = 1.19, 95% CI [1.02, 1.39]) and visiting ≥4 facilities (adjusted PR = 1.24, 95% CI [1.10, 1.40]) were associated with higher prevalence of diagnostic delay. However, progression of symptoms before consultation (adjusted PR = 0.73, 95% CI [0.60, 0.90]) was associated with decreased prevalence of diagnostic delay. CONCLUSIONS Patients with breast cancer in Addis Ababa have prolonged patient and diagnostic intervals. These underscore the need for public health programme to increase knowledge about breast cancer symptoms and the importance of early presentation and early diagnosis among the general public and healthcare providers.
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Affiliation(s)
- Alem Gebremariam
- Public Health, Adigrat University College of Medicine and Health Sciences, Adigrat, Ethiopia
- Preventive Medicine, Addis Ababa University School of Public Health, Addis Ababa, Ethiopia
| | - Adamu Addissie
- Preventive Medicine, Addis Ababa University School of Public Health, Addis Ababa, Ethiopia
| | - Alemayehu Worku
- Preventive Medicine, Addis Ababa University School of Public Health, Addis Ababa, Ethiopia
| | - Mathewos Assefa
- Radiotherapy Center, Addis Ababa University School of Medicine, Addis Ababa, Ethiopia
| | - Lydia E Pace
- Medicine, Brigham and Women's Hospital, Boston, Massachuset, USA
| | - Eva Johanna Kantelhardt
- Institute for Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Ahmedin Jemal
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia, USA
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Williams VL, Narasimhamurthy M, Rodriguez O, Mosojane K, Bale T, Kesalopa K, Kayembe MA, Grover S. Dermatology-Driven Quality Improvement Interventions to Decrease Diagnostic Delays for Kaposi Sarcoma in Botswana. J Glob Oncol 2019; 5:1-7. [PMID: 31702944 PMCID: PMC6882519 DOI: 10.1200/jgo.19.00181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2019] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Kaposi sarcoma (KS) is an HIV-associated skin cancer that is highly prevalent in Botswana and associated with significant morbidity and mortality. Histopathology-confirmed diagnosis is required for chemotherapeutic interventions in Botswana, which creates barriers to care because of limited biopsy and pathology services. We sought to understand the role a dermatology specialist can play in improving KS care through quality improvement (QI) initiatives to reduce histologic turnaround times (TATs) for KS. METHODS Employment of a dermatology specialist within a public health care system that previously lacked a local dermatologist generated quality improvements in KS care. Retrospective review identified patients diagnosed with KS by skin biopsy in the predermatology QI interval (January 1, 2015, to December 31, 2015) versus the postdermatology QI interval (January 1, 2016, to November 31, 2017). Histology TATs and clinical characteristics were recorded. A t test compared the median histology TATs in the pre- and post-QI intervals. RESULTS A total of 192 cases of KS were diagnosed by skin biopsy. Nearly all (98.4%) were HIV-positive; and 52.8% of patients were male with a median age of 39 years. Median TAT in the postdermatology QI interval was 11 days (interquartile range, 12-23 days) compared with 32 days in the predermatology QI interval (interquartile range, 24-56 days; P < .00). CONCLUSION Dermatology-led QI initiatives to improve multispecialty care coordination can significantly decrease histology TATs for KS. The reduction of diagnostic delays is a key first step to decreasing the morbidity and mortality associated with this cancer in resource-limited settings.
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Affiliation(s)
- Victoria L. Williams
- University of Botswana, Gaborone, Botswana
- Princess Marina Hospital, Gaborone, Botswana
- Botswana-UPenn Partnership, Gaborone, Botswana
- University of Pennsylvania, Philadelphia, PA
| | | | | | | | | | | | - Mukendi A. Kayembe
- University of Botswana, Gaborone, Botswana
- National Health Laboratory, Gaborone, Botswana
| | - Surbhi Grover
- University of Botswana, Gaborone, Botswana
- Princess Marina Hospital, Gaborone, Botswana
- Botswana-UPenn Partnership, Gaborone, Botswana
- University of Pennsylvania, Philadelphia, PA
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Bhatia RK, Narasimhamurthy M, Martei YM, Prabhakar P, Hutson J, Chiyapo S, Makozhombwe I, Feldman M, Kayembe MKA, Cooper K, Grover S. Report of clinico-pathological features of breast cancer in HIV-infected and uninfected women in Botswana. Infect Agent Cancer 2019; 14:28. [PMID: 31649747 PMCID: PMC6805363 DOI: 10.1186/s13027-019-0245-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 09/12/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND To characterize the clinico-pathological features including estrogen receptor (ER), progesterone receptor (PR) and Her-2/neu (HER2) expression in breast cancers in Botswana, and to compare them by HIV status. METHODS This was a retrospective study using data from the National Health Laboratory and Diagnofirm Medical Laboratory in Gaborone from January 1, 2011 to December 31, 2015. Clinico-pathological details of patients were abstracted from electronic medical records. RESULTS A total of 384 unique breast cancer reports met our inclusion criteria. Of the patients with known HIV status, 42.7% (50/117) were HIV-infected. Median age at the time of breast cancer diagnosis was 54 years (IQR 44-66 years). HIV-infected individuals were more likely to be diagnosed before age 50 years compared to HIV-uninfected individuals (68.2% vs 23.8%, p < 0.001). The majority of patients (68.6%, 35/51) presented with stage III at diagnosis. Stage IV disease was not presented because of the lack of data in pathology records surveyed, and additionally these patients may not present to clinic if the disease is advanced. Overall, 68.9% (151/219) of tumors were ER+ or PR+ and 16.0% (35/219) were HER2+. ER+ or PR+ or both, and HER2- was the most prevalent profile (62.6%, 132/211), followed by triple negative (ER-/PR-/HER2-, 21.3%, 45/211), ER+ or PR+ or both, and HER2+, (9.0%, 19/211) and ER-/PR-/HER2+ (7.1%, 15/211). There was no significant difference in receptor status noted between HIV-infected and HIV-uninfected individuals. CONCLUSIONS Majority of breast cancer patients in Botswana present with advanced disease (stage III) at diagnosis and hormone receptor positive disease. HIV-infected breast cancer patients tended to present at a younger age compared to HIV-uninfected patients. HIV status does not appear to be associated with the distribution of receptor status in breast cancers in Botswana.
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Affiliation(s)
- Rohini K. Bhatia
- University of Rochester School of Medicine and Dentistry, Rochester, NY USA
| | - Mohan Narasimhamurthy
- Department of Pathology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Yehoda M. Martei
- Division of Hematology – Oncology, University of Pennsylvania, Philadelphia, PA USA
| | - Pooja Prabhakar
- University of Texas Southwestern Medical Center, TX, Dallas, USA
| | - Jeré Hutson
- University of Pennsylvania, Philadelphia, PA USA
| | | | | | - Michael Feldman
- Department of Pathology, University of Pennsylvania, Philadelphia, PA USA
| | | | - Kum Cooper
- Department of Pathology, University of Pennsylvania, Philadelphia, PA USA
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104 USA
- Princess Marina Hospital, Gaborone, Botswana
- Botswana University of Pennsylvania Partnership, Gaborone, Botswana
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Bhatia RK, Rayne S, Rate W, Bakwenabatsile L, Monare B, Anakwenze C, Dhillon P, Narasimhamurthy M, Dryden-Peterson S, Grover S. Patient Factors Associated With Delays in Obtaining Cancer Care in Botswana. J Glob Oncol 2018; 4:1-13. [PMID: 30199305 PMCID: PMC6223504 DOI: 10.1200/jgo.18.00088] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Purpose Delays in diagnosis and treatment of cancers can lead to poor survival. These delays represent a multifaceted problem attributable to patient, provider, and systemic factors. We aim to quantify intervals from symptom onset to treatment start among patients with cancer in Botswana and to understand potential risk factors for delay. Patients and Methods From December 2015 to January 2017, we surveyed patients seen in an oncology clinic in Botswana. We calculated proportions of patients who experienced delays in appraisal (between detecting symptoms and perceiving a reason to discuss them with provider, defined as > 1 month), help seeking (between discussing symptoms and first consultation with provider, defined as > 1 month), diagnosis (between first consultation and receiving a diagnosis, defined as > 3 months), and treatment (between diagnosis and starting treatment, defined as > 3 months). Results Among 214 patients with cancer who completed the survey, median age at diagnosis was 46 years, and the most common cancer was cancer of the cervix (42.2%). Eighty-one percent of patients were women, 60.7% were HIV infected, and 56.6% presented with advanced cancer (stage III or IV). Twenty-six percent of patients experienced delays in appraisal, 35.5% experienced delays help seeking, 63.1% experienced delays in diagnosis, and 50.4% experienced delays in treatment. Patient income, education, and age were not associated with delays. In univariable analysis, patients living with larger families were less likely to experience a help-seeking delay (odds ratio [OR], 0.31; P = .03), women and patients with perceived very serious symptoms were less likely to experience an appraisal delay (OR, 0.45; P = .032 and OR, 0.14; P = .02, respectively). Conclusion Nearly all patients surveyed experienced a delay in obtaining cancer care. In a setting where care is provided without charge, cancer type and male sex were more important predictors of delays than socioeconomic factors.
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Affiliation(s)
- Rohini K. Bhatia
- Rohini K. Bhatia, University of Rochester School of Medicine and Dentistry, Rochester, NY; Sarah Rayne, University of the Witwatersrand, Johannesburg, South Africa; William Rate, Georgetown University School of Medicine, Washington, DC; Lame Bakwenabatsile and Barati Monare, Botswana-University of Pennsylvania Partnership; Mohan Narasimhamurthy, University of Botswana; Surbhi Grover, Princess Marina Hospital, Gaborone, Botswana; Surbhi Grover, University of Pennsylvania, Philadelphia, PA; Chidinma Anakwenze, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX; Preet Dhillon, Public Health Foundation of India, Gurgaon, India; Scott Dryden-Peterson, Brigham and Women’s Hospital and Botswana Harvard AIDS Institute, Harvard TH Chan School of Public Health, Boston, MA
| | - Sarah Rayne
- Rohini K. Bhatia, University of Rochester School of Medicine and Dentistry, Rochester, NY; Sarah Rayne, University of the Witwatersrand, Johannesburg, South Africa; William Rate, Georgetown University School of Medicine, Washington, DC; Lame Bakwenabatsile and Barati Monare, Botswana-University of Pennsylvania Partnership; Mohan Narasimhamurthy, University of Botswana; Surbhi Grover, Princess Marina Hospital, Gaborone, Botswana; Surbhi Grover, University of Pennsylvania, Philadelphia, PA; Chidinma Anakwenze, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX; Preet Dhillon, Public Health Foundation of India, Gurgaon, India; Scott Dryden-Peterson, Brigham and Women’s Hospital and Botswana Harvard AIDS Institute, Harvard TH Chan School of Public Health, Boston, MA
| | - William Rate
- Rohini K. Bhatia, University of Rochester School of Medicine and Dentistry, Rochester, NY; Sarah Rayne, University of the Witwatersrand, Johannesburg, South Africa; William Rate, Georgetown University School of Medicine, Washington, DC; Lame Bakwenabatsile and Barati Monare, Botswana-University of Pennsylvania Partnership; Mohan Narasimhamurthy, University of Botswana; Surbhi Grover, Princess Marina Hospital, Gaborone, Botswana; Surbhi Grover, University of Pennsylvania, Philadelphia, PA; Chidinma Anakwenze, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX; Preet Dhillon, Public Health Foundation of India, Gurgaon, India; Scott Dryden-Peterson, Brigham and Women’s Hospital and Botswana Harvard AIDS Institute, Harvard TH Chan School of Public Health, Boston, MA
| | - Lame Bakwenabatsile
- Rohini K. Bhatia, University of Rochester School of Medicine and Dentistry, Rochester, NY; Sarah Rayne, University of the Witwatersrand, Johannesburg, South Africa; William Rate, Georgetown University School of Medicine, Washington, DC; Lame Bakwenabatsile and Barati Monare, Botswana-University of Pennsylvania Partnership; Mohan Narasimhamurthy, University of Botswana; Surbhi Grover, Princess Marina Hospital, Gaborone, Botswana; Surbhi Grover, University of Pennsylvania, Philadelphia, PA; Chidinma Anakwenze, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX; Preet Dhillon, Public Health Foundation of India, Gurgaon, India; Scott Dryden-Peterson, Brigham and Women’s Hospital and Botswana Harvard AIDS Institute, Harvard TH Chan School of Public Health, Boston, MA
| | - Barati Monare
- Rohini K. Bhatia, University of Rochester School of Medicine and Dentistry, Rochester, NY; Sarah Rayne, University of the Witwatersrand, Johannesburg, South Africa; William Rate, Georgetown University School of Medicine, Washington, DC; Lame Bakwenabatsile and Barati Monare, Botswana-University of Pennsylvania Partnership; Mohan Narasimhamurthy, University of Botswana; Surbhi Grover, Princess Marina Hospital, Gaborone, Botswana; Surbhi Grover, University of Pennsylvania, Philadelphia, PA; Chidinma Anakwenze, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX; Preet Dhillon, Public Health Foundation of India, Gurgaon, India; Scott Dryden-Peterson, Brigham and Women’s Hospital and Botswana Harvard AIDS Institute, Harvard TH Chan School of Public Health, Boston, MA
| | - Chidinma Anakwenze
- Rohini K. Bhatia, University of Rochester School of Medicine and Dentistry, Rochester, NY; Sarah Rayne, University of the Witwatersrand, Johannesburg, South Africa; William Rate, Georgetown University School of Medicine, Washington, DC; Lame Bakwenabatsile and Barati Monare, Botswana-University of Pennsylvania Partnership; Mohan Narasimhamurthy, University of Botswana; Surbhi Grover, Princess Marina Hospital, Gaborone, Botswana; Surbhi Grover, University of Pennsylvania, Philadelphia, PA; Chidinma Anakwenze, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX; Preet Dhillon, Public Health Foundation of India, Gurgaon, India; Scott Dryden-Peterson, Brigham and Women’s Hospital and Botswana Harvard AIDS Institute, Harvard TH Chan School of Public Health, Boston, MA
| | - Preet Dhillon
- Rohini K. Bhatia, University of Rochester School of Medicine and Dentistry, Rochester, NY; Sarah Rayne, University of the Witwatersrand, Johannesburg, South Africa; William Rate, Georgetown University School of Medicine, Washington, DC; Lame Bakwenabatsile and Barati Monare, Botswana-University of Pennsylvania Partnership; Mohan Narasimhamurthy, University of Botswana; Surbhi Grover, Princess Marina Hospital, Gaborone, Botswana; Surbhi Grover, University of Pennsylvania, Philadelphia, PA; Chidinma Anakwenze, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX; Preet Dhillon, Public Health Foundation of India, Gurgaon, India; Scott Dryden-Peterson, Brigham and Women’s Hospital and Botswana Harvard AIDS Institute, Harvard TH Chan School of Public Health, Boston, MA
| | - Mohan Narasimhamurthy
- Rohini K. Bhatia, University of Rochester School of Medicine and Dentistry, Rochester, NY; Sarah Rayne, University of the Witwatersrand, Johannesburg, South Africa; William Rate, Georgetown University School of Medicine, Washington, DC; Lame Bakwenabatsile and Barati Monare, Botswana-University of Pennsylvania Partnership; Mohan Narasimhamurthy, University of Botswana; Surbhi Grover, Princess Marina Hospital, Gaborone, Botswana; Surbhi Grover, University of Pennsylvania, Philadelphia, PA; Chidinma Anakwenze, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX; Preet Dhillon, Public Health Foundation of India, Gurgaon, India; Scott Dryden-Peterson, Brigham and Women’s Hospital and Botswana Harvard AIDS Institute, Harvard TH Chan School of Public Health, Boston, MA
| | - Scott Dryden-Peterson
- Rohini K. Bhatia, University of Rochester School of Medicine and Dentistry, Rochester, NY; Sarah Rayne, University of the Witwatersrand, Johannesburg, South Africa; William Rate, Georgetown University School of Medicine, Washington, DC; Lame Bakwenabatsile and Barati Monare, Botswana-University of Pennsylvania Partnership; Mohan Narasimhamurthy, University of Botswana; Surbhi Grover, Princess Marina Hospital, Gaborone, Botswana; Surbhi Grover, University of Pennsylvania, Philadelphia, PA; Chidinma Anakwenze, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX; Preet Dhillon, Public Health Foundation of India, Gurgaon, India; Scott Dryden-Peterson, Brigham and Women’s Hospital and Botswana Harvard AIDS Institute, Harvard TH Chan School of Public Health, Boston, MA
| | - Surbhi Grover
- Rohini K. Bhatia, University of Rochester School of Medicine and Dentistry, Rochester, NY; Sarah Rayne, University of the Witwatersrand, Johannesburg, South Africa; William Rate, Georgetown University School of Medicine, Washington, DC; Lame Bakwenabatsile and Barati Monare, Botswana-University of Pennsylvania Partnership; Mohan Narasimhamurthy, University of Botswana; Surbhi Grover, Princess Marina Hospital, Gaborone, Botswana; Surbhi Grover, University of Pennsylvania, Philadelphia, PA; Chidinma Anakwenze, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX; Preet Dhillon, Public Health Foundation of India, Gurgaon, India; Scott Dryden-Peterson, Brigham and Women’s Hospital and Botswana Harvard AIDS Institute, Harvard TH Chan School of Public Health, Boston, MA
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