Delays Experienced by Patients With Pediatric Cancer During the Health Facility Referral Process: A Study in Northern Tanzania

Abstract

PURPOSE It is estimated that 50%-80% of patients with pediatric cancer in sub-Saharan Africa present at an advanced stage. Delays can occur at any time during the care-seeking process from symptom onset to treatment initiation. Referral delay, the time from first presentation at a health facility to oncologist evaluation, is a key component of total delay that has not been evaluated in sub-Saharan Africa. METHODS Over a 3-month period, caregivers of children diagnosed with cancer at a regional cancer center (Bugando Medical Centre [BMC]) in Tanzania were consecutively surveyed to determine the number and type of health facilities visited before presentation, interventions received, and transportation used to reach each facility. RESULTS Forty-nine caregivers were consented and included in the review. A total of 124 facilities were visited before BMC, with 31% of visits (n = 38) resulting in a referral. The median referral delay was 89 days (mean, 122 days), with a median of two facilities (mean, 2.5 facilities) visited before presentation to BMC. Visiting a traditional healer first significantly increased the time taken to reach BMC compared with starting at a health center/dispensary (103 v 236 days; P = .02). Facility visits in which a patient received a referral to a higher-level facility led to significantly decreased time to reach BMC ( P < .0001). Only 36% of visits to district hospitals and 20.6% of visits to health centers/dispensaries yielded a referral, however. CONCLUSION The majority of patients were delayed during the referral process, but receipt of a referral to a higher-level facility significantly shortened delay time. Referral delay for pediatric patients with cancer could be decreased by raising awareness of cancer and strengthening the referral process from lower-level to higher-level facilities.

A Study of Factors Influencing Delayed Diagnosis in Pediatric Cancers: A Step Towards Better Outcomes—A Cross-sectional Study

“…Inability of younger children to communicate effectively, together with vague symptoms of cancer in this age group may play a role in delay in seeking health care advice. Like many other studies, we did not find the sex of child as significant factor for patient, physician, or total diagnosis delay 1,4,14 …”

“…We found that higher parent's educational level was associated with shorter diagnosis delay 4,5 . Notably, many studies have consistently reported the mother’s education level as an important determinant affecting patient delay 10–12 .…”

Type of cancer and complementary and alternative medicine are determinant factors for the patient delay experienced by children with cancer: A study in West Java, Indonesia

“…[10][11][12] Patient pathways to presentation to healthcare professionals and initial management in primary care are critical determinants of outcomes in cancer. 13 Reducing diagnostic delays may improve prognosis by increasing the proportion of early-stage cancers being identified. 14 Patient delay is the period from the day the symptoms appear until the patient comes to the health facility for the first time.…”

“…Patient pathways to presentation to healthcare professionals and initial management in primary care are critical determinants of outcomes in cancer 13 . Reducing diagnostic delays may improve prognosis by increasing the proportion of early‐stage cancers being identified 14 .…”

Divergent clinical presentations and outcomes among children and adolescents with Kaposi sarcoma in Malawi and Tanzania

“…The 63% OS of the entire stage 2 cohort appears lower than historically reported outcomes (75% OS in a prior cohort from Lilongwe, Malawi [15]; 73% OS from Mbeya, Tanzania [13]). We observed that two main factors contributed to KS‐related mortality for children with lymphadenopathic KS: [1] risk of early death in critically ill patients with delayed presentation to tertiary care, as has been described among patients with other childhood malignancies in LMIC settings [33–35], and [2] higher risk of relapse in older children categorized as stage 2. Ultimately, the majority of younger children promptly initiated on BV chemotherapy achieve long‐term CR.…”