Most women diagnosed with cervical cancer by a visual screening program in Tanzania completed treatment: evidence from a retrospective cohort study
BMC Public Health
Most women diagnosed with cervical cancer by a visual screening program in Tanzania completed treatment: evidence from a retrospective cohort study
Andrew C Gard
Amr S Soliman 0
Twalib Ngoma
Julius Mwaiselage
Crispin Kahesa
Robert M Chamberlain 0
Siobn D Harlow
0 University of Nebraska Medical Center College of Public Health , Omaha, NE , USA
Background: Visual inspection with acetic acid (VIA) to identify and treat pre-cancerous lesions is effective for cervical cancer prevention. Screening programs also facilitate screening and diagnosis of invasive cancers that must be referred for radiation therapy or chemotherapy. This study compared characteristics of women diagnosed with invasive cervical cancer by a VIA screening program who did and did not follow up for treatment and who did and did not complete treatment at the Ocean Road Cancer Institute (ORCI), Dar es Salaam, Tanzania. Methods: We conducted a retrospective cohort study of ORCI screening referrals from the period November 2002 to June 2011. Women referred for treatment of invasive disease (n = 980) were identified from an existing database of all women attending the screening clinic during this period (n = 20,131) and matched to a dataset of all cervical cancer patients attending ORCI in this period (n = 8,240). Treatment information was abstracted from patient records of women who followed up. Records of a random sample (n = 333) of unscreened patients were reviewed for disease stage. Results: Of the 980 women referred women, 829 (84.6%) sought treatment. Most of those women (82.8%) completed their prescribed radiation. Lower disease stage, having a skilled occupation, residence in Dar es Salaam, and younger age were independently associated with loss to follow-up. Higher disease stage, residence in Dar es Salaam, older age, and later year of first treatment appointment were independently associated with incomplete treatment among those who followed up. Significantly more screened women had stage 1 disease (14.0%) than unscreened women (7.8%). Conclusions: Most women referred from the screening clinic completed treatment for their cancer at ORCI. Some of those lost to follow-up may have sought treatment elsewhere. In most cases, the screening clinic appears to facilitate diagnosis and treatment, rather than screening, for women with invasive cervical cancer.
Cervical cancer; Screening; Visual inspection with acetic acid; Referral patterns; Radiation therapy; Tanzania
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Background
East Africa has the highest cervical cancer burden
worldwide [1]. In Tanzania, it is the most common
cancer in women, with an estimated annual incidence
of 50.9 cases per 100,000 and mortality of 37.5 women
per 100,000 in 2008 [1].
Although Pap smear is the most commonly used cervical
screening modality in the developed world, it requires
substantial medical infrastructure, training, and financial
resources to implement, and therefore is not feasible for
widespread application in most developing countries [2].
A simpler, more cost-effective [2] screening method is
visual inspection with acetic acid (VIA), which has been
shown to be accurate for detection of precancerous and
cancerous cervical lesions [3] and effective for cancer
prevention in large, randomized studies conducted in
developing countries [4,5].
The benefits of VIA are primarily from pre-clinical
detection of pre-cancerous lesions treatable with cryotherapy,
LEEP, or cold-knife conization, preventing these lesions
from progressing to invasive cancer [2,5]. However,
VIA screening programs also facilitate detection of
asymptomatic invasive cervical cancers and diagnosis
of symptomatic invasive cancers, through both VIA
itself and the provision of basic gynecological care by
competent health workers. These cancers must be
referred for surgery, radiation therapy, or chemotherapy.
We have identified no study to date that has provided a
comprehensive evaluation of the outcomes of women
with invasive cancer detected or diagnosed by a VIA
screening program.
Several studies have reported the percentage of women
diagnosed with invasive cervical cancer at screening [6-10],
with at least four studies offering some information about
the treatment received by women referred from screening
[11-14]. One study compared the stage of invasive cancer
diagnosed in screened and unscreened women [5]. In
Mali, 73.4% of 497 women referred from screening
received some treatment 35.0% radical hysterectomy,
34.4% cyclophosphamide chemotherapy, and 4.0%
radiation (none completed a full course) [11]. In Angola, 80.7%
of 57 women received some treatment 71.9% surgery or
radiation and 8.8% less-appropriate treatment [13].
In a randomized study in south India, 82.6% of 69
screening-detected invasive cancers were treated [15].
This is the only study to assess predictors of compliance
with treatment after VIA, although the analysis combined
cervical intraepithelial neoplasia and invasive cancer.
The authors foun (...truncated)