Most women diagnosed with cervical cancer by a visual screening program in Tanzania completed treatment: evidence from a retrospective cohort study

BMC Public Health, Sep 2014

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.

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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 - 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)


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Andrew C Gard, Amr S Soliman, Twalib Ngoma, Julius Mwaiselage, Crispin Kahesa, Robert M Chamberlain, Siobán D Harlow. Most women diagnosed with cervical cancer by a visual screening program in Tanzania completed treatment: evidence from a retrospective cohort study, BMC Public Health, 2014, pp. 910, 14, DOI: 10.1186/1471-2458-14-910