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 populationbased 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,) 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. The Oncologist 2021;25:1-10 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

Long-term follow-up on HIV infected and non-infected women with cervical cancer from Tanzania: staging, access to cancer-directed therapies and associated survival in a real-life remote setting

“…For most participants (71.5%) we had information about successful linkage for further care and treatment from the gynaecology department, however, only 42% received cancer-directed therapy (CDT) or palliative support. This again is in line with a recently published register study including nine population-based cancer registries from eight SAA countries reporting that only 15.8% of CC patients received CDT with curative potential and in addition 22% without curative potential [ 25 ]. There are only few centers in Tanzania where CDT is available, and during the period of our study only the Ocean Road Cancer Institute (ORCI) in Dar Es Salaam provided radio-chemotherapy.…”

Brachytherapy infrastructure in sub-Saharan Africa and quest for cervical cancer elimination

“…Only 20 of the 30 countries with external beam radiotherapy facilities have complementing brachytherapy facilities, and the Central African region lacks even a single-unit, implying that women with cervical cancer lack access to effective treatment. According to a recent study, two-thirds of women diagnosed with cervical cancer do not receive early and adequate treatment, and only around 22% receive treatment with the purpose of curing the disease [ 14 ].…”

Incidence, Treatment and Outcomes of Cervical Cancer in Low- and Middle-income Countries

“…Finally, the compliance to national/institutional treatment guidelines is poor. Griesel et al [19] reported the results of an observational study that evaluated adherence to NCCN treatment guidelines among eight countries in Africa. Only 16% of patients were treated with curative intent, of whom 8% had major deviations.…”