Cervical Cancer in Sub-Saharan Africa: A Multinational Population-Based Cohort Study of Care and Guideline Adherence

Abstract

Background: Cervical cancer (CC) is the most common female cancer in many countries of sub-Saharan Africa (SSA). We assessed treatment guideline adherence and its association with overall survival (OS).

Methods: Our observational study covered nine population-based cancer registries in eight countries: Benin, Ethiopia, Ivory Coast, Kenya, Mali, Mozambique, Uganda, and Zimbabwe. Random samples of 44-125 patients diagnosed from 2010 to 2016 were selected in each. Cancer-directed therapy (CDT) was evaluated for degree of adherence to National Comprehensive Cancer Network (U.S.) Guidelines.

Results: Of 632 patients, 15.8% received CDT with curative potential: 5.2% guideline-adherent, 2.4% with minor deviations, and 8.2% with major deviations. CDT was not documented or was without curative potential in 22%; 15.7% were diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage IV disease. Adherence was not assessed in 46.9% (no stage or follow-up documented, 11.9%, or records not traced, 35.1%). The largest share of guideline-adherent CDT was observed in Nairobi (49%) and the smallest in Maputo (4%). In patients with FIGO stage I-III disease (n = 190), minor and major guideline deviations were associated with impaired OS (hazard rate ratio [HRR], 1.73; 95% confidence interval [CI], 0.36-8.37; HRR, 1.97; CI, 0.59-6.56, respectively). CDT without curative potential (HRR, 3.88; CI, 1.19-12.71) and no CDT (HRR, 9.43; CI, 3.03-29.33) showed substantially worse survival.

Conclusion: We found that only one in six patients with cervical cancer in SSA received CDT with curative potential. At least one-fifth and possibly up to two-thirds of women never accessed CDT, despite curable disease, resulting in impaired OS. Investments into more radiotherapy, chemotherapy, and surgical training could change the fatal outcomes of many patients.

Implications for practice: Despite evidence-based interventions including guideline-adherent treatment for cervical cancer (CC), there is huge disparity in survival across the globe. This comprehensive multinational population-based registry study aimed to assess the status quo of presentation, treatment guideline adherence, and survival in eight countries. Patients across sub-Saharan Africa present in late stages, and treatment guideline adherence is remarkably low. Both factors were associated with unfavorable survival. This report warns about the inability of most women with cervical cancer in sub-Saharan Africa to access timely and high-quality diagnostic and treatment services, serving as guidance to institutions and policy makers. With regard to clinical practice, there might be cancer-directed treatment options that, although not fully guideline adherent, have relevant survival benefit. Others should perhaps not be chosen even under resource-constrained circumstances.

Keywords: Access to care; Cervical cancer; Population-based; Radiotherapy; Sub-Saharan Africa; Survival.

Figure 1

Trial flow diagram. Patients with hospital files found or successful telephone contact were considered to be traced.Abbreviation: FIGO, International Federation of Gynecology and Obstetrics.

Figure 2

Therapy evaluation in the population‐based cohort (n = 632). Evaluations refer to the therapy evaluation scheme in Table 1. Colors depict the degree of adherence: green indicates optimal, light green minor deviation, yellow major deviation, orange CDT without curative potential, and red no CDT. Light gray indicates patients with FIGO stage IV, middle and darker gray indicates missing stage or observation time, and no color indicates untraced patients. Patients with hospital files found or successful telephone contact were considered to be traced.Abbreviations: CDT, cancer‐directed therapy; FIGO, International Federation of Gynecology and Obstetrics; FU, follow‐up (time of observation since diagnosis).

Figure 3

Therapy evaluation in the population‐based cohort (n = 632) stratified by registry. Evaluations refer to the therapy evaluation scheme in Table 1. Colors depict the degree of adherence: green indicates optimal, light green minor deviation, yellow major deviation, orange CDT without curative potential, and red no CDT. Light gray indicates patients with FIGO stage IV, middle and darker gray indicates missing stage or observation time, and white indicates the proportion of untraced patients. *, Principal EBRT availability at the study site did not exclude overstrain or temporary breakdown of machines. EBRT in Bulawayo was nonfunctional during the whole study period.Abbreviations: CDT, cancer‐directed therapy; EBRT, external beam radiotherapy; FIGO, International Federation of Gynecology and Obstetrics; FU, follow‐up (time of observation since diagnosis).

Figure 4

Overall survival in the traced cohort (n = 410). Median overall survival was 23 months. Patients with hospital files found or successful telephone contact were considered to be traced.Abbreviations: CI, confidence interval; OS, overall survival.

Figure 5

Results of multiple Cox regression for risk of early death in the therapy association cohort (n = 190) are shown: through inclusion criteria (FIGO stages I–III and follow‐up ≥3 months), bias was reduced. Therapy evaluation refers to Table 1.Abbreviations: CDT, cancer‐directed therapy; CI, confidence interval; ECOG, Eastern Cooperative Oncology Group; FIGO, International Federation of Gynecology and Obstetrics; HRR, hazard rate ratio.