Factors associated with length of time to diagnosis and initiation of treatment among cervical cancer participants attending care at the Uganda Cancer Institute, Kampala (Uganda)

Abstract

Background: Cervical cancer is still a major cause of morbidity and mortality among women in the low- and middle-income countries (LMICs). The majority of participants with cervical cancer in the LMICs are diagnosed after a long period from symptoms onset and when in advanced stages. However, in most LMICs including Uganda there is paucity of data on the diagnostic and pre-treatment intervals along the pathways to treatment. This study sought to determine the factors associated with the diagnostic and pre-treatment intervals among participants with cervical cancer at the UCI.

Methods & Analysis: This was a descriptive cross-sectional study conducted at the Uganda Cancer Institute from October 2019 to March 2020. 403 participants aged ≥18 years with confirmed histological diagnosis of cervical cancer were consecutively sampled. Data were collected using a pre-tested semi-structured questionnaire. Participants’ medical records were reviewed, and relevant data abstracted. The primary outcomes were diagnostic and pre-treatment intervals dichotomized as early and late. Diagnostic interval of ≤ 3 months was defined as early & >3 months as late, while pre-treatment interval of ≤ 1 month was defined as early and >1 month as late. STATA version 12 was used for data analysis. We used modified Poisson regression models with robust variance to determine socio-demographic, health systems and clinical factors associated with the intervals. Prevalence ratios with associated 95% confidence intervals (CI) were reported. Results: 403 of 427 participants had complete medical records and were included in the analysis. The mean age (±standard deviation) of the participants was 50.0±11.7 years. The median diagnostic and pre-treatment intervals were 3.1 (IQR: 1.4-8.2) months and 2.4 (IQR: 1.2-4.1) months respectively. Half (50.4%) of the participants (203/403) were diagnosed early, and less than a third, 20.1% (81/403, n=81) promptly initiated treatment. Participants more likely to be diagnosed early included those residing in urban areas (APR=1.27; 95%CI: 1.01-1.59), referral from secondary health facilities (APR=2.28; 95%CI: 1.61-3.23), formally employed (APR=1.27; 95%CI: 1.02-1.60) and participants with squamous cell carcinoma subtype (APR=1.53; 95%CI: 1.06-2.22). Participants more likely to be diagnosed late included those who first discussed their symptoms with relatives, (APR= 0.75; 95%CI: (0.59-0.96), had > 2 pre-referral visits (APR=0.75; 95%CI (0.61-0.93), had advanced stage (stage3/4) (APR=0.69; 95%CI: 0.56-0.85). Participants more likely to initiate cancer specific treatments early included those older >40-50years, (APR=1.89; 95%CI: 1.01-3.53), with knowledge of Pap smear (APR=8.6; 95%CI: 1.42-52.5), with positive family history of cervical cancer (APR=1.91; 95%CI: 1.04-3.53), & residing near the UCI (APR=2.34; 95%CI: 1.09-4.98). Participants who visited lower level health facilities > 2 times before referral (APR=0.61; 95%CI: 0.40 – 0.93) to UCI, and those who took 3 – 6 months to seek care after symptoms onset (APR=0.50; 95%CI: 0.28 – 0.90) were less likely to initiate cancer specific treatments within the one month of visit to the UCI. Conclusions and recommendations: Half of participants in this study were diagnosed early but less than one third promptly initiated cancer specific treatment. Women who first discussed symptoms with their relatives before visit to health facilities are diagnosed late. Inadequacies of primary healthcare professionals to diagnose and or refer cancer participants, and long distances to cancer specialized treatment center delay diagnosis and treatment initiation. Increasing awareness of cervical cancer symptoms and appropriate treatment among women in the population could guide appropriate help seeking when symptoms develop. Second there is need to empower primary healthcare professionals the lower level facilities so they promptly recognize and or refer participants with symptoms suggestive of cervical cancer to the tertiary health facilities.