Cascade of care for people with positive symptoms of common cancers in selected primary health centres of Puducherry: An explanatory mixed-method study

Abstract

Background & objectives Cancer is a leading cause of death worldwide and constitutes a public health priority. Delays in diagnosis and treatment of cancer can adversely impact survival, recovery, and cost of treatment. The objective of this study was to estimate the proportion seeking timely care among those having early warning signals for oral, breast or cervical cancer and to explore the facilitators and barriers to early detection. Methods The study was conducted among 241 participants, including those having early signals for selected cancers and women who underwent opportunistic cervical cancer screening in the selected health facilities. Information regarding symptom appearance, presentation to any registered medical practitioner, confirmatory diagnosis, and treatment initiation were obtained from medical records. In-depth Interviews (IDIs) were conducted among six participants to explore facilitators and barriers to cancer detection. Results Among 7300 people screened using the Community Based Assessment Checklist (CBAC), 128 (1.7%) had warning signals for any one of the cancers. The percentage of people who sought medical care for oral, breast and cervical cancer symptoms were 80 per cent, 82 per cent and 57 per cent, respectively. Among those who underwent opportunistic cervical cancer screening in health centres (113), the screen positivity rate was 11 per cent, and adherence to referral for confirmation was 80 per cent. The median pre-diagnostic and diagnostic delays for the three cancers were 79 [Interquartile range (IQR): 44-126] and 27 (IQR: 13-73) days. One individual was diagnosed with oral cancer, and the treatment delay was 27 days. Facilitators identified for early seeking of care were encouragement by family and low-cost treatment at public facilities. Major barriers identified were neglect of symptoms by participants and their responsibilities towards family. Interpretation & conclusions Although very few people were identified to have early warning symptoms using CBAC, a substantial proportion of them sought medical care and underwent confirmatory diagnosis. Screen positivity rate and treatment-seeking behaviour were better among women undergoing opportunistic cervical cancer screening in the health centres. Measures need to be taken to improve health literacy among people to reduce diagnostic delay for cancers.

Keywords: Cascade of care; India; common cancer; delay; early detection; screening.