Evaluation of the Factors Associated with Delay in Initiation of Treatment of Advanced Stage Cervical Cancer Patients in Bangladesh

Abstract

Research Background: Cervical cancer is the second most common cancer in women and the third leading cause of female cancer death in Bangladesh. Delay in initiation of treatment in advanced stage cervical cancer patients is an important modifiable risk factor for cancer-related mortality. Identifying elements associated with delay of diagnosis will help reduce barriers to timely treatment of cervical cancer. Research Objectives: The objective of this study was to analyze the factors leading to delay in diagnosis and treatment of women with advanced stage cervical cancer. Methods: A cross-sectional observational study analyzed the factors associated with delay in initiation of treatment for 138 patients with advanced-stage cervical cancer from November 2019 to October 2020 at the National Institute of Cancer Research and Hospital (NICRH) in Dhaka, Bangladesh. Advanced-stage cervical cancer patients between the ages of 30 to 70 years were included in this study. Face-to-face interviews with the participants used a predesigned data collection sheet. In this study, three components of delay were identified: primary delay due to patient factors, healthcare provider delay, and healthcare-system infrastructure delay. Factors associated with delay were the independent variables and durations of delay were the outcome variables. Descriptive statistics were expressed as mean + standard deviation, median, percentage, and frequency. Results: One hundred and thirty-eight patients with advanced stage cervical cancer were included in the study. The mean age of the patients was 48.74 (±9.57) years. Thirty-four percent of patients were illiterate. More than half (57.25%) of the patients were from lower middle-class families. Delays were categorized as patient-related, healthcare provider delay, and healthcare-system infrastructure related. Patient-related factors included low monthly income, residence in a rural area, embarrassment, fear, lack of knowledge regarding cervical cancer, delay in contacting a spouse, family member or friend prior to the first medical encounter. These elements predicted a primary delay of more than 60 days (P value < 0.05) for 70.29% of patients. Healthcare providers’ delay-related factors included not performing a speculum examination at initial consultation, misdiagnosis, and consultation more than three times in different health facilities prior to referral to tertiary care center hospital and were associated with a delay of more than 30 days (P value < 0.05) and were experienced by 83.33% of patients. The major healthcare-system infrastructure delay-related factor was a long distance between the primary healthcare facility and the tertiary care center hospital from the patients’ residences (P value < 0.05). Overall, the median duration of patient-related delay was 75.51 days, healthcare provider delay was 44.03 days and healthcare-system infrastructure delay was 47 days to the initiation of treatment. Conclusion: Three broad categories of delay in diagnosis and treatment of cervical cancer: patient-related factors, healthcare provider-related factors, and healthcare-system infrastructure factors were analyzed. Illiteracy, lack of awareness regarding cervical cancer, lack of health-seeking behavior, and poor income status were associated with patient-related primary delay. Nonperformance of speculum examination in the initial consultation, misdiagnosis, inappropriate management, and delay in referral to the cancer treatment center by primary healthcare providers were the contributing factors for healthcare provider delay. Lack of availability and accessibility of health services and limitation of radiotherapy resources led to healthcare-system infrastructure delays. All three categories of delay must be addressed through the education of communities, the gynecologic training of community healthcare providers, the improvement of medical infrastructure, and the increase of medical resources.