Eva Johanna Kantelhardt

Ovarian cancer survival in sub‐Saharan Africa by human development index and histological subtypes: A population‐based registry study

AbstractOvarian cancer (OC) is the fourth most common cancer of women in sub‐Saharan Africa (SSA), although few data have been published on population‐level survival. We estimate ovarian cancer survival in SSA by human development index and histological subtype, using data from seven population‐based cancer registries in six countries: Kenya (Nairobi and Eldoret), Mauritius, Uganda (Kampala), Cote d'Ivoire (Abidjan), Ethiopia (Addis Ababa) and South Africa (Eastern Cape). A total of 644 cases diagnosed during 2008–2014 were included, with 77% being of epithelial subtypes (range 47% [Abidjan]—80% [Mauritius]). The overall observed survival in the study cohort was 73.4% (95% CI: 69.8, 77.0) at 1 year, 54.4% (95% CI: 50.4, 58.7) at 3 years and 45.0% (95% CI: 41.0, 49.4) at 5 years. Relative survival at Year 1 ranged from 44.4% in Kampala to 86.3% in Mauritius, with a mean for the seven series of 67.4%. Relative survival was highest in Mauritius at 72.2% and lowest in Kampala, Uganda at 19.5%, with a mean of 47.8%. There was no difference in survival by age at diagnosis. Patients from high and medium HDI countries had significantly better survival than those from low HDI countries. Women with cancers of epithelial cell origin had much lower survival compared to women with other histological subtypes (p = .02). Adjusted for the young age of the African patients with ovarian cancer (44% aged <50) survival is much lower than in USA or Europe, and underlines the need for improvements in the access to diagnosis and treatment of OC in SSA.

Prevalence and associated factors of persistent precancerous lesions among women treated for cervical lesions in Addis Ababa, Ethiopia

Abstract Background Cervical cancer is one of the leading causes of cancer-related deaths among Ethiopian women, despite being largely preventable. Women treated for precancerous cervical lesions remain at elevated risk of developing invasive cancer, yet little is known about the burden and predictors of persistent lesions following treatment in resource-limited settings. Materials and Methods We conducted a cross-sectional study among 242 women who underwent ablative or excisional therapy for precancerous cervical lesions at 3 clinics in Addis Ababa between November 2022 and December 2023. Data were collected using structured questionnaires and clinical records. Logistic regression analysis was used to identify factors associated with persistent lesions, reported as adjusted odds ratios (AORs) with 95% CIs. Results Of the 242 women treated, 104 (43.0%; 95% CI, 37.2-49.6%) experienced persistent lesions within 1 year. Persistent lesion rates were highest among women initially screened with a Pap smear (97.4%) compared to visual inspection with acetic acid (VIA) (21.9%) and HPV DNA testing (14.7%). Independent predictors of persistent lesions included an age of ≥50 years (AOR = 5.4; 95% CI, 1.56-18.93), being married (AOR = 2.5; 95% CI, 1.15-5.44), an HIV-positive status (AOR = 5.0; 95% CI, 1.41-20.3), and Pap smear as the initial screening modality (AOR = 4.9; 95% CI, 1.04-23.15). Conclusion Nearly half of the women treated for precancerous cervical lesions experienced persistent disease within 1 year, particularly those who were older, married, HIV-positive, or initially screened by Pap smear. These findings raise concerns about the effectiveness of current treatment and screening strategies.

Linking Microbiome Diversity and Immune Profiles in Ethiopian Patients With Cervical Cancer

PURPOSE This study investigates the interplay between T-cell receptor (TCR) immune characteristics and microbiome profiles to explore the relationship between immune diversity and microbial composition in cervical samples from Ethiopia. METHODS Cervical specimens were collected from patients at Tikur Anbessa Specialized Hospital in Addis Ababa, and rural Butajira, south-central Ethiopia. Patient data, including age, human papillomavirus status, pathology, and TCR immune characteristics, were analyzed with a focus on the interactions between TCR profiles and microbiome compositions in malignant samples. RESULTS Three distinct TCR profiles were identified: Group 1 (TCR active) exhibited features of active immune engagement, including high diversity, clonal expansion, and repertoire richness. Group 2 (TCR restricted) showed reduced TCR diversity and expansion, suggesting a restricted repertoire. Group 3 (TCR balanced) had moderate diversity and clonal activity. TCR repertoire groups were linked with microbial diversity, with Group 1 (TCR active) showing the highest number of microbes (high operational taxonomic units and microbial diversity). Maximum TCR clonal expansion positivity associated with microbial richness, while Group 3 (TCR balanced) was linked to reduced microbial alpha diversity. Taxonomic analysis revealed specific organisms enriched in TCR repertoire group. CONCLUSION Variations in TCR profiles are linked to distinct microbial environments in cervical cancer with greater microbial richness in patients with greater maximum productive frequency. These findings underscore the interplay between TCR diversity, microbiome composition, and malignancy, offering insights into the potential implications for microbiome-targeted therapies and prognostic biomarkers in cervical cancer.

Follow-up rescreening uptake and persistent positive rates among women after positive cervical cancer screening results in Ethiopia: a longitudinal cross-sectional study

Objective To assess cervical cancer screening positivity rates, follow-up rescreening uptake 1 year after treatment and persistent positivity among women with initial positive screening results in Ethiopia. The study also explored reasons for loss to follow-up and preferences for reminder strategies. Design Longitudinal cross-sectional study. Settings 10 primary healthcare facilities in Oromia and southern and central Ethiopia. Participants From November 2022 to April 2024, 17 586 women screened for cervical cancer. Of these 768 (4.4%) had positive screening results, and 515 women treated at the primary level were included to assess follow-up rescreening uptake. An additional 139 women who did not return for follow-up were interviewed to identify reasons for non-uptake and reminder preferences. Result Of the 515 women included in the analysis, 179 (34.8%, 95% CI: 30.6% to 38.8%) returned for follow-up rescreening. Among those re-screened, the persistent visual inspection with acetic acid (VIA) positivity rate was 16.1% (95% CI: 11.0% to 21.7%). Factors significantly associated with follow-up rescreening uptake included age over 40 (adjusted OR (AOR): 2.5; 95% CI: 1.34 to 5.00), urban residence (AOR: 1.7; 95% CI: 1.15 to 2.58), secondary or higher education (AOR: 2.0; 95% CI: 1.06 to 4.12) and HIV-positive status (AOR: 2.4; 95% CI: 1.27 to 4.87). Among the 139 women contacted, the main reasons for non-uptake were lack of time, forgetting appointments, visiting another facility and pregnancy. Regarding preferred reminders, 93% favoured text messages and all agreed to phone calls or home visits. Conclusion One-third of women adhered to follow-up rescreening after a positive cervical cancer screening in Ethiopia, revealing a considerable gap since those women had a three times higher chance of being VIA positive compared with the first screening. Older age, urban residence, higher education and HIV-positive status were significantly linked to follow-up rescreening uptake. Addressing barriers such as time constraints and forgotten appointments through tailored reminder strategies is essential for improving the follow-up rescreening uptake. Contextualised interventions can strengthen rescreening for finding those women at very high risk for cervical lesions and strengthen cervical cancer prevention in Ethiopia. Trial registration number NCT06515301 .

Barriers to adherence to cervical cancer screening care in Northern Tanzania

Abstract Background Cervical cancer disproportionately affects women in low- and middle-income countries compared to those in high-income countries because of the difference in quality and effectiveness of cervical cancer screening programs. An essential part of effective cervical cancer prevention is the continuum of care for a woman with a suspicious cervical lesion (SCL) consisting of appropriate treatment and, in Tanzania, a follow-up screening one year after treatment. This study aimed at identifying factors associated with non-adherence to the scheduled follow-up after treatment of a SCL. Additionally, the cervical cancer screening results one year after treatment were evaluated. Methods A total of 219 clients treated for a SCL between 2017 and 2021 from 8 centres in the Kilimanjaro region were interviewed. Contact and medical information of the clients was obtained at the facilities. Additionally, 11 in-depth interviews with healthcare providers were conducted. Results In the quantitative study, 143 (65.3%) clients treated for suspicious cervical lesions adhered to the recommended follow-up appointment. Significant factors associated with poor adherence were individual barriers such as failure to understand why they should return and access barriers to the health facility. The health workers mentioned a lack of awareness and financial challenges regarding transportation. Conclusion The complete journey of high-risk women needs attention, otherwise the primary screening will not be effective. Additional efforts are needed to address knowledge gaps and socio-economic problems during the follow-up.

Spatiotemporal dynamics and prevention strategies of cervical cancer incidence in Addis Ababa, Ethiopia: an ecological study

Objective This study analysed the spatial and temporal patterns of cervical cancer incidence in Addis Ababa from 2012 to 2021. Design An ecological study was conducted from 1 September to 30 November 2023 to examine the spatiotemporal trends of cervical cancer incidence. Setting The research was conducted in Addis Ababa, the capital city of Ethiopia. Participants Included were all patients with clinically and/or histopathologically confirmed diagnoses of cervical cancer. Data analysis The study employed advanced analytical tools including R programming, Quantum Geographic Information System V.3.36.0, GeoDa V.1.2.2 and System for Automated Geoscientific Analyses GIS V.9.3.2. Techniques such as Bayesian empirical testing with a block weighting matrix for hotspot identification, Global Moran’s I for spatial autocorrelation, nearest neighbour imputation and universal Kriging interpolation were used to manage data gaps. Joinpoint trend analysis and direct age-standardised incidence rate (ASIR) using the Segi’s World standard population was applied to compare trends across subcities. A statistical significance threshold was set at p<0.05. Results Between 2012 and 2021, a total of 2435 new cervical cancer cases were recorded in the Addis Ababa City Population-based Cancer Registry, with significant spatial clustering observed in Nifas Silk Lafto, Bole, Kirkos as well as parts of Gulele and Yeka sub cities (z score>1.96) in 2018. The citywide age-standardised incidence rate varied from 19 to 26 cases per 100 000 women-years during 2013 and 2016, respectively. Subcity trends varied significantly, with increases and decreases noted in Akaki Kality and Kolfe Keraniyo over different periods while Bole subcity showed modest increase at 4.2% APC (95% CI: 0.6% to 7.9%; p=0.026). Conclusion The study highlights substantial fluctuations in ASIR and significant geographic disparities in cervical cancer throughout Addis Ababa. To address these challenges, the implementation of school-based human papillomavirus vaccination programmes, alongside targeted interventions, active campaigns and sustained surveillance, is critical. These strategies are essential to effectively reduce the cervical cancer burden and improve health outcomes in the community.

Barriers to early diagnosis and treatment of cervical cancer in Addis Ababa, Ethiopia: qualitative study

Objective Cervical cancer remains the most diagnosed and deadly cancer among women in low and middle income countries, including Ethiopia, although it can be controlled if detected and treated early. However, research on contextual barriers to early diagnosis and treatment of cervical cancer is limited in Ethiopia. This study aimed to describe the lived experience of the patients and to explore the barriers to early diagnosis and treatment of cervical cancer. Design We conducted a phenomenological qualitative study, which was part of a larger mixed-methods study. Setting Tikur Anbesa Specialised Comprehensive Hospital, Addis Ababa, Ethiopia. Participants 24 purposively selected patients with diagnostic delay and 16 patients with treatment delay were interviewed using an in-depth interview guide (IDI). Results Two broad themes and seven sub-themes to explain the barriers to early diagnosis and treatment of cervical cancer emerged. These themes and sub-themes include patient related barriers (inadequate knowledge, visits to traditional healers and practice of religious rituals as a solution for illness, poor adherence to the treatments and fear of side effects, and financial hardships) and provider related barriers (limited access to diagnostic and treatment infrastructure, inadequate training of healthcare providers and poor quality of care). Conclusions The findings of the study underscore the need to reinforce awareness among patients and the community, scale up the screening, diagnostic and treatment infrastructure, and advocate for quality of care in the healthcare facilities in Ethiopia to promote early diagnosis and treatment of cervical cancer.

Does Prior Experience Matter? Intention to Undergo Cervical Cancer Screening among Rural Women in South-Central Ethiopia

Early screening for cervical cancer has substantially reduced the morbidity and mortality attributed to it. This study aimed to assess factors that affect the intention to undergo cervical cancer screening among rural women attending primary healthcare facilities in south-central Ethiopia. A health-facility-based, cross-sectional study design was employed for which the calculated required sample size was 427. An interviewer-administered structured questionnaire was adapted from previously published research and used to collect data. Statistical Package for Social Sciences (SPSS) version 27 was used for the statistical analysis. A logistic regression model was used to determine the factors that influenced the women’s intention to undergo cervical cancer screening. A total of 420 women participated in this study, with a response rate of 98%. The mean score from the questionnaire that was used to assess the women’s intention to undergo cervical cancer screening was 10.25 (SD ± 2.34; min 3, max 15). The absence of previous screening experience (AOR: 0.498; 95% CI 0.27–0.92) and high degree of perceived behavioural control (AOR, 0.823; 95% CI 0.728–0.930) were significantly negatively associated with women’s intention to undergo cervical cancer screening. Previous screening experience and perceived behavioural control significantly influenced the intention to undergo cervical cancer screening. Women in rural areas could, therefore, benefit from awareness-creation programmes that focus on these factors.

Study protocol for key interventions to improve the follow-up adherence postcervical precancerous lesion treatment in Ethiopia: a pragmatic randomised controlled trial

Introduction The follow-up adherence after treatment for a positive screening test is critical for preventing the development of screen‐detected abnormalities in cervical cancer. Yet, this poses a major challenge in developing countries like Ethiopia, emphasising the urgency for intervention strategies. Our trial aims to assess which strategies would be effective in improving adherence to follow-up after suspicious cervical lesion treatment in Ethiopia. Thus, the objective of this study is to evaluate key interventions to improve the follow-up adherence rate among women treated for suspicious cervical lesions in primary healthcare settings in Ethiopia. Method and analysis We will employ a pragmatic randomised control trial study design, using Consolidated Standards of Reporting Trials guidelines for reporting and a Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist for developing the protocol, to evaluate intervention effectiveness. These interventions are: (a) structured nurses-led telephone call reminders, (b) home-visit reminders led by health extension workers and (c) application-based automated short message service text reminders. The standard care involves only receiving oral follow-up advice and a baseline follow-up card. The planned start date is 1 November 2024, with an anticipated end date of 1 November 2025. Our study will include women aged 30–49 who are HIV-negative and those over 25 who are HIV-positive, and who have been treated for suspicious cervical lesions after a positive visual inspection with acetic acid (VIA) screening, as per Ethiopian Ministry of Health guidelines for cervical cancer screening eligibility. The required sample size is 460, with 115 participants per arm. Study participants in the intervention group will receive the stated interventions plus the standard care, while the control group will receive only the standard care. The interventions will be delivered three times annually: 4 months from baseline, then at 8 months and finally at 12 months before the appointment due date. The primary outcome of our study is the proportion of adherence to follow-up recommendations, which will be measured by rescreening (VIA) after 1 year (11–13 months after the first screening). Descriptive statistics, χ2 test (Fisher’s exact test), binary logistic regression analysis and intention-to-treat will be used to describe and interpret the results. Ethics and dissemination The trial protocol has been approved by the institutional review board of Addis Ababa University with protocol number (008/24/SPH). Trial results will be disseminated to study participants, national and international audiences through workshops, conferences and publications in reputable journals. Trial registration number NCT06515301.

NCCN guideline–concordant cancer care in sub-Saharan Africa: a population-based multicountry study of 5 cancers

Abstract Background To assess population-based quality of cancer care in sub-Saharan Africa and to identify specific gaps and joint opportunities, we assessed concordance of diagnostics and treatments with National Comprehensive Cancer Network Harmonized Guidelines for leading cancer types in 10 countries. Methods Adult patients with female breast cancer, cervical cancer, colorectal cancer, non-Hodgkin lymphoma, and prostate cancer were randomly drawn from 11 population-based cancer registries. Guideline concordance of diagnostics and treatment was assessed using clinical records. In a subcohort of 906 patients with potentially curable cancer (stage I-III breast cancer, cervical cancer, colorectal cancer, prostate cancer, aggressive non-Hodgkin lymphoma [any stage]) and documentation for more than 1 month after diagnosis, we estimated factors associated with guideline-concordant treatment or minor deviations. Results Diagnostic information based on guidelines was complete for 1030 (31.7%) of a total of 3246 patients included. In the subcohort with curable cancer, guideline-concordant treatment was documented in 374 (41.3%, corresponding to 11.7% of 3246 patients included in the population-based cohort): aggressive non-Hodgkin lymphoma (59.8%/9.1% population based), breast cancer (54.5%/19.0%), prostate cancer (39.0%/6.1%), colorectal cancer (33.9%/9.5%), and cervical cancer (27.8%/11.6%). Guideline-concordant treatment was most frequent in Namibia (73.1% of the curable cancer subcohort/32.8% population based) and lowest in Kampala, Uganda (13.5%/3.1%). Guideline-concordant treatment was negatively associated with poor ECOG-ACRIN performance status, locally advanced disease stage, origin from low Human Development Index countries, and a diagnosis of colorectal cancer or cervical cancer. Conclusions The quality of diagnostic workup and treatment showed major deficits, with considerable disparities among countries and cancer types. Improved diagnostic services are necessary to increase the share of curable cancer in sub-Saharan Africa. Treatment components within National Comprehensive Cancer Network Guidelines for several cancers should be prioritized.

Adherence to Treatment and Follow-Up of Precancerous Cervical Lesions in Ethiopia

Abstract Background In Ethiopia, both incidence and mortality of cervical cancer are relatively high. Screening services, which were implemented during the past few years, are currently being expanded. The World Health Organization recommends patients with a positive VIA (visual inspection with acetic acid) result should immediately receive treatment followed by rescreening after 1 year as precancerous lesions can reoccur or become residential despite treatment. Materials and Methods Screening logbooks dating between 2017 and 2020 were retrospectively reviewed in 14 health facilities of Addis Ababa and Oromia region. Data for 741 women with a VIA-positive result were extracted and those women were asked to participate in a questionnaire-based phone interview to gain insights about adherence to treatment and follow-up. Data were analyzed using descriptive methods and then fitted into 2 generalized linear models to test variables for an influence on adherence to follow up. Results Around 13 800 women had received a VIA screening, of which approximately 820 (5.9%) were VIA positive. While over 90% of women with a positive screen received treatment, only about half of the treated patients returned for a follow-up examination. After treatment, 31 women had a VIA-positive re-screen. We found that educational status, age over 40, no/incorrect follow-up appointment, health facility-related barriers, and use of reminders are important drivers of adherence to follow up. Conclusion Our results revealed that adherence to treatment after VIA positive screening is relatively high whereas adherence to follow up recommendations still needs improvement. Reminders like appointment cards and phone calls can effectively reduce the loss of follow-up.

Trends in the incidence of ovarian cancer in sub‐Saharan Africa

AbstractOvarian cancer (OC) is one of the commonest cancers of women in sub‐Saharan Africa (SSA), although to date no data have been available on time trends in incidence to better understand the disease pattern in the region. We estimate time trends by histological subtype from 12 population‐based cancer registries in 11 countries: Kenya (Nairobi), Mauritius, Seychelles, Uganda (Kampala), Congo (Brazzaville), Zimbabwe (Bulawayo and Harare), Cote d'Ivoire (Abidjan), The Gambia, Mali (Bamako), Nigeria (Ibadan) and South Africa (Eastern Cape). The selected registries were those that could provide consistent estimates of the incidence of ovarian cancer and with quality assessment for periods of 10 or more years. A total of 5423 cases of OC were included. Incidence rates have been increasing in all registries except Brazzaville, Congo, where a nonsignificant decline of 1% per year was seen. Statistically significant average annual increases were seen in Mauritius (2.5%), Bamako (5.3%), Ibadan (3.9%) and Eastern Cape (8%). Epithelial ovarian cancer was responsible for the increases observed in all registries. Statistically significant average annual percentage changes (AAPC) for epithelial OC were present in Bamako (AAPC = 5.9%), Ibadan (AAPC = 4.7%) and Eastern Cape (AAPC = 11.0%). Creating awareness among professionals of the growing importance of the disease is surely an important step to improving availability of, and access to, diagnosis and treatment of OC in SSA. Support must be given to the cancer registries to improve the availability of good‐quality data on this important cancer.

Factors associated with advanced stage at diagnosis of cervical cancer in Addis Ababa, Ethiopia: a population-based study

ObjectiveTo describe the patterns and factors associated with advanced stage at diagnosis of cervical cancer among Addis Ababa residents, Ethiopia.DesignA population-based cross-sectional study.SettingSeven major hospitals or diagnostic facilities in Addis Ababa, Ethiopia.ParticipantsAll histopathology-confirmed patients with incident cervical cancer diagnosed from 1 January 2017 to 30 June 2018 among Addis Ababa residents.Outcome measuresThe proportion of patients with cervical cancer diagnosed at early stage (stage I/II) and advanced stage (stage III/IV) of the disease according to International Federation of Gynaecology and Obstetrics staging criteria, and adjusted prevalence ratio (APR) for factors associated with advanced-stage diagnosis using a Poisson regression with robust variance model.ResultsThe mean age of the study participants was 52.9 (±13.3) years. Nearly two-thirds (60.4%, 95% CI: 53.8% to 66.5%) of patients with cervical cancer were diagnosed at an advanced stage. Advanced stage at diagnosis was significantly associated with paying medical bill out of pocket (APR=1.44, 95% CI: 1.08 to 1.91), diagnostic interval >90 days (APR=1.31, 95% CI: 1.04 to 1.71), practicing religion as a remedy or not taking immediate action following symptom recognition (APR=1.25, 95% CI: 1.08 to 1.91) and visiting more than three different health facilities prior to diagnostic confirmation (APR=1.24, 95% CI: 1.07 to 1.51).ConclusionsOur findings of the high proportion of advanced-stage diagnosis of cervical cancer in Addis Ababa and its strong associations with out-of-pocket medical bill, seeking care out of conventional medicine settings and multiple visits to healthcare facilities before diagnostic confirmations underscore the need for public policies to improve the affordability of cancer care and enhance community awareness about the severity of the disease and referral system, in addition to expanding cervical cancer screening.

Cervical cancer screening in rural Ethiopia: a cross- sectional knowledge, attitude and practice study

Abstract Background Cervical cancer is the fourth most common cancer among women worldwide. Sub- Saharan Africa has a high incidence, prevalence and mortality due to shortage and underutilization of screening facilities. This study aims to assess knowledge and attitude towards cervical cancer and its prevention, as well as practice of cervical cancer screening. Methods This cross-sectional community- based study was conducted in Butajira, Ethiopia in February 2018. Systematic cluster randomized sampling was used to select households from which women in the targeted age group of 30–49 years were invited to participate. Data was collected using a quantitative door to door approach. The questionnaire included socio-demographic data, obstetric history, general knowledge, risk factors, attitude and practice. Logistic regression was used to assess factors associated with knowledge, attitude and practice after dichotomizing the scores using the median as cut off point. Results Three hundred forty-two out of 354 women completed the interviewer administered questionnaire making the response rate 96.3%. 125 women (36%) were aware of cervical cancer and 14 (4.7%) knew symptoms. None of the women named HPV as a risk factor. 61% thought it was a deadly disease, 13.5% felt at risk of developing cervical cancer and 60.7% said cervical cancer is treatable. Eight women (2.3%) had previously been screened. 48.1% had a source of information concerning cervical cancer, of which 66.5% named nurses. Better knowledge was associated with 1–8 years of education (OR = 2.4; CI: 2.4–1.3), having a source of information (OR = 9.1, CI:4.0–20.6), use of contraceptives (OR = 2.3, CI: 1.3–4.0) and a higher income (OR = 1.009, CI: 1.00–1.01). Naming nurses (OR:5.0, CI:2.4–10.3), another source of information (OR = 3.3, CI:1.2–9.0), use of contraceptives (OR = 2.2, CI:1.2–3.8) and living in an urban area (OR = 3.3, CI:1.2–9.0) were associated with a positive attitude. Naming nurses (OR = 21,0, CI:10.4–42.3) and another source of information (OR = 5.8, CI:2.4–13.5) were associated with participating in cervical cancer screening. Conclusion Most women were unaware of cervical cancer, HPV-infection as a risk factor and did not feel susceptible to cervical cancer. As Health workers were the most commonly mentioned source of information, focus should be put on their further education.

Cervical cancer survival in sub‐Saharan Africa by age, stage at diagnosis and Human Development Index: A population‐based registry study

AbstractCervical cancer is the leading cause of cancer death in African women. We sought to estimate population‐based survival and evaluate excess hazards for mortality in African women with cervical cancer, examining the effects of country‐level Human Development Index (HDI), age and stage at diagnosis. We selected a random sample of 2760 incident cervical cancer cases, diagnosed in 2005 to 2015 from 13 population‐based cancer registries in 11 countries (Benin, Cote d'Ivoire, Ethiopia, Kenya, Mauritius, Mozambique, Namibia, Seychelles, South Africa, Uganda and Zimbabwe) through the African Cancer Registry Network. Of these, 2735 were included for survival analyses. The 1‐, 3‐ and 5‐year observed and relative survival were estimated by registry, stage and country‐level HDI. We used flexible Poisson regression models to estimate the excess hazards for death adjusting for age, stage and HDI. Among patients with known stage, 65.8% were diagnosed with Stage III‐IV disease. The 5‐year relative survival for Stage I‐II cervical cancer in high HDI registry areas was 67.5% (42.1‐83.6) while it was much lower (42.2% [30.6‐53.2]) for low HDI registry areas. Independent predictors of mortality were Stage III‐IV disease, medium to low country‐level HDI and age >65 years at cervical cancer diagnosis. The average relative survival from cervix cancer in the 11 countries was 69.8%, 44.5% and 33.1% at 1, 3 and 5 years, respectively. Factors contributing to the HDI (such as education and a country's financial resources) are critical for cervical cancer control in SSA and there is need to strengthen health systems with timely and appropriate prevention and treatment programmes.

Reasons for Not Attending Cervical Cancer Screening and Associated Factors in Rural Ethiopia

Abstract Social, economic, and cultural factors have been associated with the level of participation in cervical cancer screening programs. This study identified factors associated with nonparticipation in cervical cancer screening, as well as reasons for not attending, in the context of a population-based, cluster-randomized trial in Ethiopia. A total of 2,356 women aged 30 to 49 years in 22 clusters were invited to receive one of two screening approaches, namely human papillomavirus (HPV) self-sampling or visual inspection with acetic acid (VIA). Participants and nonparticipants were analyzed according to their sociodemographic and economic characteristics. Reasons were determined for the refusal of women to participate in either screening method. More women in the VIA arm compared to the HPV arm declined participation in the screening [adjusted OR (AOR) 3.5; 95% confidence interval (CI), 2.6–4.8]. Women who declined attending screening were more often living in rural areas (AOR = 2.0; 95% CI, 1.1–3.5) and were engaged in informal occupations (AOR = 1.6; 95% CI, 1.1–2.4). The majority of nonattendants perceived themselves to be at no risk of cervical cancer (83.1%). The main reasons given for not attending screening for both screening approaches were lack of time to attend screening, self-assertion of being healthy, and fear of screening. We found that perceived time constraints and the perception of being at no risk of getting the disease were the most important barriers to screening. Living in rural settings and informal occupation were also associated with lower participation. Offering a swift and convenient screening service could increase the participation of women in cervical cancer screening at the community level.

Association between waiting time for radiotherapy initiation and disease progression among women with cervical cancer in Addis Ababa, Ethiopia

AbstractThere is shortage of radiotherapy machines in low‐income countries, including Ethiopia. Data on adverse effects of this on cancer outcomes are limited, however. Herein, we examined the extent of waiting time for radiotherapy and its association with disease progression based on a prospective cohort study of women diagnosed with stage IA‐IVA cervical cancer in Addis Ababa and who were scheduled to receive radiotherapy at Tikur Anbessa Specialized Hospital, the only hospital that provides radiotherapy services in the country. Association was examined using Multivariable mixed effects logistic regression model. Among the 178 women with cervical cancer scheduled for receipt of radiotherapy and with vital status information, 16 deceased (9.0%) while waiting for radiotherapy. For the remaining 162 women who initiated radiotherapy, the median treatment waiting period was 137 days (IQR = 60‐234 days), with 74.1% of women waiting for >60 days. Tumor progressed to higher stage for 44.4% of these women. Compared to those women who initiated radiotherapy ≤60 days after diagnostic confirmation, the odds of tumor progression to higher stage was three times higher in those women who initiated radiotherapy between 120‐179 days (aOR =3.30, 95%CI: 1.18‐9.27) and ≥180 days (aOR =3.06, 95%CI: 1.24‐7.52). Waiting period for receipt of radiotherapy among women with cervical cancer is exceedingly long in Addis Ababa, and it is associated with disease progression to higher stages. These findings reinforce the need to expand radiotherapy infrastructure in order to mitigate the undue high burden of the disease in Ethiopia and other parts of Africa.

Burden of Cancer and Utilization of Local Surgical Treatment Services in Rural Hospitals of Ethiopia: A Retrospective Assessment from 2014 to 2019

Abstract Background Global cancer estimations for Ethiopia announced 77 352 new cases in 2020 based on the only population-based registry in Addis Ababa. This study characterizes cancer patients in rural Ethiopia at 8 primary and secondary hospitals between 2014 and 2019. Patients and Methods All clinically or pathologically confirmed cancer cases that were diagnosed between 1 May 2014 and 29 April 2019 were included. A structured data extraction tool was used to retrospectively review patients’ charts and descriptive analysis was done. Results A total of 1298 cancer cases were identified, of which three-fourths were females with a median age of 42 years. Breast (38%) and cervical (29%) cancers were the most common among females, while prostate (19%) and oesophageal cancers (16%) were the most common among males. Only 39% of tumors were pathologically confirmed. Nearly two-thirds of the cases were diagnosed at an advanced stage. Surgery was the only accessible treatment option for more than half of the cancer patients, and systemic treatment (except endocrine) was rarely available. One in 5 patients did not receive the recommended surgical procedure, half due to patient refusal or lack of the patient returning to the hospital. Conclusion The pattern of cancer diagnoses in rural hospitals shows an exceptionally high burden in women in their middle-ages due to breast and cervical cancers. Advanced stage presentation, lack of pathology services, and unavailability of most systemic treatment options were common. The surgery was offered to nearly 60% of the patients, showing the significant efforts of health workers to reduce sufferings.

Characteristics of Women Seeking Cervical Cancer Cytology Screening in a Private Health Facility

Background and Objectives: Over 80% of cervical cancer cases in sub-Saharan Africa are detected at late stages, predominantly due to the lack or inaccessibility of prevention services. Public health facilities in Ethiopia offer free cervical cancer screening for eligible women. Besides the public health facilities, private providers also offer a variety of screening services at the patients’ expense. As the overall cervical cancer screening uptake in Ethiopia is still far below the 90% WHO target, coordination between all actors of the health system is key. This includes a close cooperation between the public and private sectors to combine the advantages of both to the benefit of all patients as well as media campaigns and community involvement to promote the self-initiation of screening. Materials and Methods: To gain insights into the utilization of cervical cancer screening in the private health sector, we conducted an institution-based cross-sectional study at Arsho medical laboratories in Addis Ababa. Every woman who came there for cervical cancer screening between 1 May and 30 June 2020 was asked to participate in a questionnaire-based, face-to-face interview about their socio-demographic background, cervical cancer screening experience and self-initiation of screening. A total of 274 women participated in the interviews. We further assessed the reproductive status of the patients, their risk factors for cervical cancer, source of information about the screening and barriers to cervical cancer screening. Results: The ages of the participants ranged between 20–49 years. The majority (over 70%) were married. A total of 37.6% reported self-initiating the screening. More than three-quarters of all interviewed women reported mostly using the private health care sector for all kinds of health services. Conclusions: While the Ethiopian government efforts on scaling up cervical cancer screening focus mainly on public health facilities, the private sector often does not get as much attention from policy makers. Efforts should be made to extend the government’s interest in cervical cancer screening and implementation research to the private healthcare sector.

Key Interventions to Improve the Follow-up Adherence Post Cervical Precancerous Lesion Treatment in Ethiopia

The goal of this pragmatic randomized control trial is to evaluate the effectiveness of three interventions in improving follow-up adherence among women treated for suspicious cervical lesions in primary healthcare settings in Ethiopia. The interventions include structured nurse-led telephone call reminders, home-visit reminders led by health extension workers, and application-based automated SMS text reminders. The main questions it aims to answer are: * Does structured nurse-led telephone call reminders improve follow-up adherence among women treated for suspicious cervical lesions compared to standard care? * Does home-reminder visits led by a Health Extension Worker (HEW) improve follow-up adherence among women treated for suspicious cervical lesions compared to standard care? * Does app-based automated SMS reminders improve follow-up adherence among women treated for suspicious cervical lesions compared to standard care? Structured Nurse-Led Telephone Call Reminders * Participants will receive proactive phone call reminders for scheduled follow-up visits. * The intervention includes three rounds: initially at 4 months post-recruitment, then every 4 months for HIV-negative women over a year, and every 2 months for 6 months for women living with HIV. Home-Reminder Visits Led by HEW Health Extension Workers (HEWs) will conduct door-to-door visits to remind participants of their scheduled follow-up appointments. • Door-to-door Visits will occur initially at 4 months (for HIV-negative women) and 2 months (for HIV-positive women) post-recruitment, then every 2 months for 6 months for HIV-positive and every 4 months for 12 months for HIV-negative participants. App-Based Automated SMS Reminders * Participants will receive SMS-based reminders for their follow-up visits. * The intervention consists of three rounds: initial texts at 4 months and 2 months post-recruitment for HIV-negative and HIV-positive women, respectively, followed by reminders every 2 months for 6 months for HIV-positive women and every 4 months for 12 months for HIV-negative women.