Patient Factors Associated With Delays in Obtaining Cancer Care in Botswana

Sex Differences in the Survival of Patients with Neuroendocrine Neoplasms: A Comparative Study of Two National Databases

BACKGROUND

Neuroendocrine neoplasms (NENs) are increasing in incidence globally. Previous analysis of the UK cancer database (National Cancer Registration and Analysis Service (NCRAS)) showed a notable female survival advantage in most tumour sites. This study aims to compare NCRAS to the Surveillance, Epidemiology, and End Results Program (SEER) to validate these results using the same statistical methods.

METHODS

A total of 14,834 and 108,399 patients with NENs were extracted from NCRAS and SEER, respectively. Sixty-months survival for both males and females for each anatomical site of NENs were calculated using restricted mean survival time (RMST) and Kaplan-Meier Survival estimates. The sixty-month RMST female survival advantage (FSA) was calculated.

RESULTS

FSA was similar in NCRAS and SEER. The highest FSA occurred in lung and stomach NENs.

CONCLUSIONS

The data from SEER confirm the findings published by NCRAS. Female survival advantage remains unexplained.

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.

Patterns of care and outcomes for endometrial and ovarian cancers in botswana 2015-2021

Purpose

Endometrial and ovarian cancers are leading causes of cancer death among women. However, there is little data on these patients from low- and middle-income countries including Botswana, a country in sub-Saharan Africa. This study reports data on demographics, treatment, and outcomes for patients with endometrial and ovarian cancer in Botswana.

Methods

This prospective cohort study included all prospectively enrolled patients with endometrial or ovarian cancer who presented to Princess Marina or Gaborone Private Hospital between May 2015 and May 2021. Demographic, treatment, and survival data were analyzed.

Results

99 patients with endometrial and 38 patients with ovarian cancer were included. Median age at diagnosis was 64 for patients with endometrial cancer and 57 for patients with ovarian cancer. Just over half of patients with endometrial cancer (52.6%) presented with FIGO stages I and II, whereas most patients with ovarian cancer (65.8%) presented with stages III and IV. 24.2% of patients with endometrial cancer received chemotherapy, 32.3% received radiotherapy, 74.7% received surgical treatment, and 16.2% received no treatment; of patients with ovarian cancer, 42.1% received chemotherapy, 2.6% received radiotherapy, 52.6% received surgical treatment, and 31.6% of patients received no treatment. 1-and 2-year overall survival probabilities were 76.9% and 59.7% for patients with endometrial cancer and 62.8% and 43.7% for patients with ovarian cancer, respectively.

Conclusion

This study demonstrates that a large proportion of patients with ovarian and endometrial cancer in Botswana are diagnosed at an advanced stage, and many do not receive standard-of-care treatment. Further inquiry is required to characterize challenges to diagnosis and treatment of ovarian and endometrial cancers in Botswana.

Improving cervical cancer survival-A multifaceted strategy to sustain progress for this global problem

Cervical cancer is associated with profound socioeconomic and racial disparities in incidence, mortality, morbidity, and years of life lost. The last standard-of-care treatment innovation for locally advanced cervical cancer occurred in 1999, when cisplatin chemotherapy was added to pelvic radiation therapy (chemoradiation therapy). Chemoradiation therapy is associated with a 30%-50% failure rate, and there is currently no cure for recurrent or metastatic disease. The enormity of the worldwide clinical problem of cervical cancer morbidity and mortality as well as the egregiously unchanged mortality rate over the last several decades are recognized by the National Institutes of Health as urgent priorities. This is reflected within the Office of Research on Women's Health effort to advance National Institutes of Health research on the health of women, as highlighted in a recent symposium. In the current review, the authors address the state of the science and opportunities to improve cervical cancer survival with an emphasis on improving access, using technology in innovative and widely implementable ways, and improving current understanding of cervical cancer biology. LAY SUMMARY: Cervical cancer is associated with profound socioeconomic and racial disparities in incidence, mortality, morbidity, and years of life lost. In this review, the state of the science and opportunities to improve cervical cancer survival are presented with an emphasis on improving access, using technology in innovative and widely implementable ways, and improving current understanding of cervical cancer biology.

Advanced stage presentation and its determinant factors among colorectal cancer patients in Amhara regional state Referral Hospitals, Northwest Ethiopia

INTRODUCTION

Nowadays, the burden of colorectal cancer (CRC) has been increasing in the world, particularly in developing nations. This could be related to the poor prognosis of the disease due to late presentation at diagnosis and poor treatment outcomes. In Ethiopia, studies related to the stage of colorectal cancer at diagnosis and its determinants are limited. Therefore, the study was intended to assess advanced stage presentation and its associated factors among colorectal cancer patients in northwest Ethiopia.

METHODS

An institution-based retrospective study was conducted among 367 CRC patients at two oncologic centers (the University of Gondar and Felege Hiwot comprehensive specialized hospitals) from January 1, 2017, to December 31, 2020. Data were entered into EPi-data 4.2.0.0 and transferred to STATA version 14 statistical software for analysis. Binary logistic regression was used to identify factors associated with the outcome variable. All variables with P-value < 0.2 during bi-variable analysis were considered for multivariable logistic regression. The level of statistical significance was declared at P-value <0.05.

RESULTS

The magnitude of advanced stage presentation of colorectal cancer was 83.1%. Being rural dwellers (Adjusted odds ratio (AOR) = 3.6; 95% CI: 1.8,7.2), not medically insured (AOR = 3.9; 95% CI: 1.9,7.8), patients delay (AOR = 6.5; 95% CI:3.2, 13.3), recurrence of the disease (AOR = 2.3; 95% CI: 1.1,4.7), and no comorbidity illness (AOR = 4.4; 95% CI: 2.1, 9.1) were predictors of advanced stage presentation of CRC.

CONCLUSION

The current study revealed that the advanced-stage presentation of colorectal cancer patients was high. It is recommended that the community shall be aware of the signs and symptoms of the disease using different media, giving more emphasis to the rural community, expanding health insurance, and educating patients about the recurrence chance of the disease. Moreover, expansion of colorectal treatment centers and screening of colorectal cancer should be given emphasis.

Análise do Tempo para Início do Tratamento Oncológico no Brasil: Fatores Demográficos e Relacionados à Neoplasia

Introdução: E reservado a todo brasileiro com câncer, pela Lei dos 60 Dias, o direito de começar o tratamento em até dois meses. Todavia, estudos anteriores apontam a dificuldade dos pacientes em fazer valer essa normativa ao esbarrarem em problemáticas macroestruturais dos sistemas de saúde. Objetivo: Avaliar a influência de fatores demográficos e relacionados a neoplasia sobre o tempo para início do tratamento oncológico no Brasil. Método: Estudo seccional, desenvolvido com dados oriundos do PAINEL-Oncologia, uma base publica nacional, alimentada por diversas fontes de informação do Sistema Único de Saúde. Como variáveis de interesse, elegeram-se: a) tempo de tratamento; b) sexo; c) idade; d) diagnostico; e) estadiamento; f) modalidade terapêutica. Então, foi analisado o tempo transcorrido entre o diagnóstico e o início do tratamento oncológico. Resultados: Percebeu-se aumento exponencial, ao longo dos anos, da proporção de casos tratados oportunamente, isto e, em até 60 dias, como regulamenta a Lei. Entretanto, ainda e considerável a prevalência de atrasos no início do tratamento, sobretudo entre indivíduos idosos, do sexo masculino, com canceres em estádios menos avançados e que precisaram de radioterapia como primeira modalidade terapêutica. Além disso, o tempo de espera foi especialmente maior para os canceres de órgãos genitais masculinos, de cabeça e pescoço e de mama. Conclusão: Alguns fatores demográficos e relacionados a neoplasia estão envolvidos no atraso do início da terapia oncológica.

Breast cancer screening in sub-Saharan Africa: a systematic review and ethical appraisal

Background

The aim of this systematic review was to evaluate the evidence and clinical outcomes of screening interventions and implementation trials in sub-Saharan Africa (SSA) and also appraise some ethical issues related to screening in the region through quantitative and qualitative narrative synthesis of the literature.

Methods

We searched Pubmed, OvidMEDLINE, Embase, and Web of Science to identify studies published on breast cancer screening interventions and outcomes in SSA. Descriptive statistics were used to summarize the frequency and proportions of extracted variables, and narrative syntheses was used to evaluate the clinical outcomes of the different screening modalities. The mixed methods appraisal tool was used to assess the quality of studies included in the review.

Results

Fifteen studies were included, which consisted of 72,572 women in ten countries in SSA. 63% (8/15) of the included publications evaluated Clinical Breast Examination (CBE), 47% (7/15) evaluated mammography and 7% (1/15) evaluated ultrasound screening. The cancer detection rate was < 1/1000 to 3.3/1000 and 3.3/100 to 56/1000 for CBE and mammography screening respectively. There was a lot of heterogeneity in CBE methods, target age for screening and no clear documentation of screening interval. Cost-effective analyses showed that CBE screening linked to comprehensive cancer care is most cost effective. There was limited discussion of the ethics of screening, including the possible harms of screening in the absence of linkage to care. The gap between conducting good screening program and the appropriate follow-up with diagnosis and treatment remains one of the major challenges of screening in SSA.

Discussion

There is insufficient real-world data to support the systematic implementation of national breast cancer screening in SSA. Further research is needed to answer important questions about screening, and national and international partnerships are needed to ensure that appropriate diagnostic and treatment modalities are available to patients who screen positive.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09299-5.

Perceived barriers to timely treatment initiation and social support status among women with breast cancer in Ethiopia

Timely care is essential to increase breast cancer survival. However, patients in Ethiopia still face multilevel barriers on their pathway to timely treatment initiation. This cross-sectional study at Tikur Anbessa Specialized Hospital Oncology Unit in Addis Ababa assessed systemic treatment initiation intervals of breast cancer patients and quantified the impact of socio-demographic and clinical factors, perceived barriers, and the patients´ perceived social support status on timely systemic treatment initiation (chemotherapy or hormonal therapy). A structured questionnaire was designed based on Pechansky´s "Concept of Access". Applying simple and multivariate logistic regression we analysed the influence of patients´ characteristics as well as their perceived barriers on timely treatment initiation. We measured social support with the Multidimensional Score of Perceived Social Support (MSPSS) and used the Wilcoxon Rank-Sum Test to assess its relationship with timely treatment initiation. Of 196 patients included into the study, 53% received systemic treatment within 90 days of their pathological diagnosis-the median treatment initiation interval was 85 days (IQR 123.5). Older women and patients diagnosed at late stages had higher odds of timely treatment initiation. Not being able to pay for services and lack of transport were most often perceived as barriers towards timely care. However, none of the perceived barriers showed a substantial influence on timely treatment initiation in the multivariate regression model. The patients´ perceived social support was found to be high, with an average MSPSS score of 73 out of 84 (SD 13,63). No impact of the perceived social support status on timely treatment initiation was found. The percentage of breast cancer patients waiting longer than 90 days from pathological diagnosis to systemic treatment initiation in Ethiopia remains unacceptably high. While women generally feel well supported by their social environment, costs and accessibility of treatment are perceived to be major barriers towards timely treatment initiation.

High-burden Cancers in Middle-income Countries: A Review of Prevention and Early Detection Strategies Targeting At-risk Populations

Cancer incidence is rising in low- and especially middle-income countries (MIC), driven primarily by four high-burden cancers (breast, cervix, lung, colorectal). By 2030, more than two-thirds of all cancer deaths will occur in MICs. Prevention and early detection are required alongside efforts to improve access to cancer treatment. Successful strategies for decreasing cancer mortality in high-income countries are not always effective, feasible or affordable in other countries. In this review, we evaluate strategies for prevention and early detection of breast, cervix, lung, and colorectal cancers, focusing on modifiable risk factors and high-risk subpopulations. Tobacco taxation, human papilloma virus vaccination, cervical cancer screen-and-treat strategies, and efforts to reduce patient and health system-related delays in the early detection of breast and colorectal cancer represent the highest yield strategies for advancing cancer control in many MICs. An initial focus on high-risk populations is appropriate, with increasing population coverage as resources allow. These strategies can deliver significant cancer mortality gains, and serve as a foundation from which countries can develop comprehensive cancer control programs. Investment in national cancer surveillance infrastructure is needed; the absence of national cancer data to identify at-risk groups remains a barrier to the development of context-specific cancer control strategies.

Clinical and sociodemographic factors associated with late stage cervical cancer diagnosis in Botswana

BACKGROUND

Cervical cancer is the leading cause of female cancer mortality in Botswana with the majority of cervical cancer patients presenting with late-stage disease. The identification of factors associated with late-stage disease could reduce the cervical cancer burden. This study aims to identify potential patient level clinical and sociodemographic factors associated with a late-stage diagnosis of cervical cancer in Botswana in order to help inform future interventions at the community and individual levels to decrease cervical cancer morbidity and mortality.

RESULTS

There were 984 women diagnosed with cervical cancer from January 2015 to March 2020 at two tertiary hospitals in Gaborone, Botswana. Four hundred forty women (44.7%) presented with late-stage cervical cancer, and 674 women (69.7%) were living with HIV. The mean age at diagnosis was 50.5 years. The association between late-stage (III/IV) cervical cancer at diagnosis and patient clinical and sociodemographic factors was evaluated using multivariable logistic regression with multiple imputation. Women who reported undergoing cervical cancer screening had lower odds of late-stage disease at diagnosis (OR: 0.63, 95% CI 0.47-0.84) compared to those who did not report screening. Women who had never been married had increased odds of late-stage disease at diagnosis (OR: 1.35, 95% CI 1.02-1.86) compared to women who had been married. Women with abnormal vaginal bleeding had higher odds of late-stage disease at diagnosis (OR: 2.32, 95% CI 1.70-3.16) compared to those without abnormal vaginal bleeding. HIV was not associated with a diagnosis of late-stage cervical cancer. Rural women who consulted a traditional healer had increased odds of late-stage disease at diagnosis compared to rural women who had never consulted a traditional healer (OR: 1.61, 95% CI 1.02-2.55).

CONCLUSION

Increasing education and awareness among women, regardless of their HIV status, and among providers, including traditional healers, about the benefits of cervical cancer screening and about the importance of seeking prompt medical care for abnormal vaginal bleeding, while also developing support systems for unmarried women, may help reduce cervical cancer morbidity and mortality in Botswana.

Anticipated help seeking behaviour and barriers to seeking care for possible breast and cervical cancer symptoms in Uganda and South Africa

Objectives

Breast and cervical cancers are leading causes of cancer morbidity and mortality in sub-Saharan Africa. Most women present with advanced-stage disease and have poor outcomes. This study aimed to describe anticipated help-seeking behaviour for possible breast and cervical cancer symptoms, barriers to accessing health care and factors associated with less timely anticipated help-seeking in urban and rural settings in Uganda and South Africa (SA).

Methods

We conducted a cross-sectional community-based survey between August and December 2018. Data were collected from one randomly selected woman per household using the African Women Awareness of CANcer breast and cervical cancer tool. Anticipated help-seeking behaviour was dichotomised into waiting <1week or ≥1 week to seek care. Multivariable analysis identified factors associated with anticipated help-seeking behaviour.

Results

One thousand, seven hundred fifty-eight women participated (Uganda 873, SA 885, median age 34, interquartile ranges 26-47). Most would discuss symptoms with someone close to them (87.7% for breast, 83.0% for cervical symptoms). The majority anticipated seeking care from a health facility in <1 week: 86.1% and 88.0%, respectively, for breast and cervical symptoms. 38.7% of women expected to encounter at least 1 barrier when seeking care. Lack of money for transport or clinic costs was the most common barrier (24.6% of participants). For both cancers and in both countries, women who reported more barriers were significantly less likely to anticipate seeking timely care. In SA, rural location was also associated with longer anticipated time to seek care, adjusted prevalence ratio (aPR) 2.92, 95% confidence interval (CI) 1.48-5.76 and aPR 2.42, 95% CI 1.08-5.45 for breast and cervical cancer, respectively.

Conclusion

Interventions that improve community level cancer knowledge and highlight the importance of prompt help-seeking for possible symptoms are important to promote timely care seeking. In addition, addressing financial barriers by reducing transport and clinic costs and tackling geographical inequities in access to care could support women in seeking timely care for possible symptoms.

Radiotherapy waiting time in Northern Nigeria: experience from a resource-limited setting

Background

Access and availability of radiotherapy treatment is limited in most low- and middle-income countries, which leads to long waiting times and poor clinical outcomes. The aim of our study is to determine the magnitude of waiting times for radiotherapy in a resource-limited setting.

Methods

This is a retrospective cohort study of patients with the five most commonly treated cancers managed with radiotherapy between 2010 and 2014. Data includes diagnosis, patients’ demographics and treatment provided. The waiting time was categorised into intervals (1) between diagnosis and first radiation consultation (2) First consultation to radiotherapy treatment (3) Decision-to-treat to treatment and (4) Diagnosis to treatment.

Results

A total of 258 cases were involved, including cervical (50%; 129/258), breast (27.5%; 71/258), nasopharynx (12.8%; 33/258), colorectal (5%; 13/258) and prostate cancers (4.7%; 12/258). Mean age was 48 (±12.9) years. Treatment with radical intent comprised 67% (178/258) of cases, while 33% (80/258) had palliative treatment. The median time from diagnosis to first radiation consultation was 40 (IQR 17–157.75) days for all the patients, with prostate cancer having the longest time – 305 days (IQR 41–393.8). The median time between the first radiation oncology consultations and first radiotherapy treatment was 130.5 (IQR 14–211.5) days; cervical cancer patients waited a median of 139 (IQR 13–195.5) days. The median time between diagnosis and first radiotherapy for breast cancer patients was 329 (IQR 207–464) days, compared to 213 (IQR 101.5–353.5) days for all the patients.

Conclusion

The study shows that waiting time for radiotherapy in Nigeria was generally longer than what is recommended internationally. This reflects the need to improve access to radiotherapy in order to improve cancer treatment outcomes in resource-limited settings.

Addis Ababa population-based pattern of cancer therapy, Ethiopia

Cancer in Sub-Saharan Africa is becoming an important challenge for health services due to rising numbers of patients. In Addis Ababa with around 3.5 million inhabitants, more than 2000 cases are diagnosed annually. In this retrospective population-based cohort study we assessed completeness of and waiting time for cancer-therapy among patients registered in the Addis Ababa City Cancer Registry (AACCR), Ethiopia. Patient hospital files were retrieved to complete the data from AACCR. A total of 588 files were found (51% of those diagnosed from January to March 2012 and 2014). We analyzed completeness and waiting time of chemotherapy and radiotherapy; with completeness defined as ≥85% therapy received according to local guidelines. Analysis was done for the five most common cancer-types commonly treated with chemotherapy (breast, colorectal, non-Hodgkin`s lymphoma, lung and ovarian) and the four most common cancer-types commonly treated with radiotherapy (breast, cervical, head and neck and rectal). In our study, half of the patients (54.1%) received adequately dosed chemotherapy and 24.5% of patients received adequately dosed radiotherapy. The median waiting time was 2.1 months (Range: 0 to 20.72) for chemotherapy and 7 months (Range: 0.17 to 21.8) for radiotherapy. This study underscores the need for health system measures to improve cancer-directed therapy in Ethiopia, especially concerning radiotherapy.

Explaining disparities in oncology health systems delays and stage at diagnosis between men and women in Botswana: A cohort study

Purpose

Men in Botswana present with more advanced cancer than women, leading to poorer outcomes. We sought to explain sex-specific differences in time to and stage at treatment initiation.

Methods

Cancer patients who initiated oncology treatment between October 2010 and June 2017 were recruited at four oncology centers in Botswana. Primary outcomes were time from first visit with cancer symptom to treatment initiation, and advanced cancer (stage III/IV). Sociodemographic and clinical covariates were obtained retrospectively through interviews and medical record review. We used accelerated failure time and logistic models to estimate standardized sex differences in treatment initiation time and risk differences for presentation with advanced stage. Results were stratified by cancer type (breast, cervix, non-Hodgkin’s lymphoma, anogenital, head and neck, esophageal, other).

Results

1886 participants (70% female) were included. After covariate adjustment, men experienced longer excess time from first presentation to treatment initiation (8.4 months) than women (7.0 months) for all cancers combined (1.4 months, 95% CI: 0.30, 2.5). In analysis stratified by cancer type, we only found evidence of a sex disparity (Men: 8.2; Women: 6.8 months) among patients with other, non-common cancers (1.4 months, 95% CI: 0.01, 2.8). Men experienced an increased risk of advanced stage (Men: 67%; Women: 60%; aRD: 6.7%, 95% CI: -1.7%, 15.1%) for all cancers combined, but this disparity was only statistically significant among patients with anogenital cancers (Men: 72%; Women: 50%; aRD: 22.0%, 95% CI: 0.5%, 43.5%).

Conclusions

Accounting for the types of cancers experienced by men and women strongly attenuated disparities in time to treatment initiation and stage. Higher incidence of rarer cancers among men could explain these disparities.

Time Intervals From Onset of Clinical Manifestations to Treatment in Patients With Cancer at Hospital General San Felipe, Tegucigalpa, Honduras

PURPOSE

In cancer, clinical staging is related to outcomes, and this is linked to the evolution of the disease over time. In Honduras, cancer mortality is high, and time intervals from onset of symptoms to treatment of cancer are not known. We conducted a cross-sectional study to determine these intervals.

PATIENTS AND METHODS

This investigation was carried out from April 25 to August 30, 2018, and included 202 patients at the main cancer referral center in Honduras. For the purposes of the study, information was obtained from patients, their caregiver, medical records, or treatment cards. Patients older than age 18 years were included after informed consent was signed.

RESULTS

The mean time interval from onset of symptoms to cancer treatment was 232 days. Different intervals of time were identified, and the mean of these intervals was calculated in days as follows: 68 days from onset of symptoms to first medical evaluation; 146 days from first evaluation to oncologist consultation; 26 days from cancer specialist to the pathology report; and 86 days from the histopathologic diagnosis to the beginning of treatment. Once diagnosis was established, the average elapsed times to chemotherapy, radiotherapy, surgery, and chemoradiotherapy were 88, 102, 76, and 154 days, respectively (P < .05, when surgery is compared against chemotherapy and radiotherapy).

CONCLUSION

The mean time interval from symptom presentation to treatment in patients with cancer is more than 7 months. This could explain the advanced stages of disease seen at the time of treatment in Honduras, which decrease chance of cure and increase the mortality rate of cancer). Appropriate intervention to decrease these intervals must be taken to reduce mortality.