Jennifer Moodley

Time to diagnosis for breast, cervical and colorectal cancer in Zimbabwe and South Africa: a cross-sectional study

Introduction Shorter time to diagnosis may lead to better cancer outcomes in Southern Africa. This study measured the time from symptoms to first healthcare visit (patient interval; PI) and diagnosis (diagnostic interval; DI) and associated factors for breast, cervical and colorectal cancer in Zimbabwe and South Africa (SA). Methods A cross-sectional survey collected data on socio-demographics, cancer awareness, barriers to seeking care, symptoms, healthcare visits and diagnosis after recent cancer diagnosis. Cox regression was used to determine factors associated with PI and DI. Results This study included 1021 participants (Zimbabwe 396, SA 625). Symptom and risk factor recall was low. Median PIs were shorter than DIs across cancers and regions. For breast cancer, those reporting more health-seeking barriers had longer PIs (Zimbabwe HR 0.801, 95% CI 0.703 to 0.913; SA HR 0.885, 95% CI 0.817 to 0.958), while greater emotional response to symptoms was associated with a shorter PI (Zimbabwe HR 1.194, 95% CI 1.101 to 1.295; SA HR 1.145, 95% CI 1.079 to 1.216). Interpreting a cervical symptom as serious (Zimbabwe) was associated with a shorter PI. DIs were longer in less-resourced regions and increased with number of healthcare visits before diagnosis. Significantly shorter DIs occurred when the first provider was a clinic doctor or specialist compared with a clinic nurse. Conclusions Efforts to improve timely cancer diagnosis in Zimbabwe and SA should focus on supporting primary healthcare providers in managing and referring symptomatic patients, enhancing cancer symptom awareness and interpretation, and addressing barriers to care.

Improving the Sensitivity-Specificity Balance of Human Papillomavirus Testing on Self- and Clinician-Collected Samples in South Africa

PURPOSE Human papillomavirus (HPV) testing on self-collected samples may increase coverage of cervical cancer screening, but previous studies have observed lower specificity of HPV testing in self- versus clinician-collected samples. Here we investigate strategies to improve the sensitivity-specificity balance of a round of HPV testing on self-collected samples. MATERIALS AND METHODS Women living with and without HIV, age 30-65 years, were recruited in South Africa. Self-collected vaginal samples and clinician-collected cervical samples were tested with Xpert HPV, an assay that detects the 14 high-risk HPV types in five separate channels: (P1) HPV 16; (P2) HPV 18, 45; (P3) HPV 31, 33, 35, 52, 58; (P4) HPV 51, 59; and (P5) HPV 39, 56, 66, 68. All women underwent colposcopy with histology sampling, and diagnosis of cervical intraepithelial neoplasia grade 2 or greater (CIN2+) was determined by adjudicated pathology. The AUC and related performance parameters were calculated using logistic regression with the cycle threshold (Ct) values of the channels as predictors. RESULTS HPV prevalence in women without and with HIV was higher in self-collected (25.1% v 61.5%) than in clinician-collected samples (16.2% v 48.4%). The optimal model to predict CIN2+ used Ct values from the three channels that detect HPV 16, 18, 45, 31, 33, 35, 52, and/or 58. AUC was superior for testing on clinician-collected (0.908) than on self-collected samples (0.878; P = .0261) in women without HIV, as well as for women living with HIV (0.868 v 0.819; clinician v self; P = .0002). Alternate approaches to handling multiple types and sequential testing approaches did not allow self-testing to achieve equivalent performance to testing on clinician-collected samples. CONCLUSION Using more stringent Ct cutoffs on the three channels that detect the eight highest-risk HPV types can improve the sensitivity-specificity balance of a round of screening in both self- and clinician-collected samples. Although performance of HPV testing on self-collected samples is excellent, performance parameters are better on clinician-collected samples.

Effectiveness of interventions for improving timely diagnosis of breast and cervical cancers in low and middle-income countries: a systematic review protocol

Introduction Breast and cervical cancers pose a major public health burden globally, with disproportionately high incidence, morbidity and mortality in low- and middle-income countries (LMICs). The majority of women diagnosed with cancer in LMICs present with late-stage disease, the treatment of which is often costlier and less effective. While interventions to improve the timely diagnosis of these cancers are increasingly being implemented in LMICs, there is uncertainty about their role and effectiveness. The aim of this review is to systematically synthesise available evidence on the nature and effectiveness of interventions for improving timely diagnosis of breast and cervical cancers in LMICs. Methods and analysis A comprehensive search of published and relevant grey literature will be conducted. The following electronic databases will be searched: MEDLINE (via PubMed), Cochrane Library, Scopus, CINAHL, Web of Science and the International Clinical Trials Registry Platform (ICTRP). Evidence will be synthesised in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). Two reviewers will independently screen the search outputs, select studies using predefined inclusion criteria and assess each included study for risk of bias. If sufficient data are available and studies are comparable in terms of interventions and outcomes, a meta-analysis will be conducted. Where studies are not comparable and a meta-analysis is not appropriate, a narrative synthesis of findings will be reported. Ethics and dissemination As this will be a systematic review of publicly available data, with no primary data collection, it will not require ethical approval. Findings will be disseminated widely through a peer-reviewed publication and forums such as conferences, workshops and community engagement sessions. This review will provide a user-friendly evidence summary for informing further efforts at developing and implementing interventions for addressing delays in breast and cervical cancer diagnosis in LMICs. PROSPERO registration number CRD42020177232.

Mapping awareness of breast and cervical cancer risk factors, symptoms and lay beliefs in Uganda and South Africa

Breast and cervical cancer are leading causes of cancer burden in Sub-Saharan Africa (SSA). We measured breast and cervical cancer symptom and risk factor awareness and lay beliefs in Uganda and South Africa (SA). Between August and December 2018 we conducted a cross-sectional survey of women ≥18 years in one urban and one rural site per country. Households were selected using systematic random sampling, then one woman per household randomly selected to participate. Data were collected by interviewers using electronic tablets customised with the locally validated African Women Awareness of Cancer (AWACAN) tool. This has unprompted questions (testing recall) followed by prompted questions (testing recognition) on risk factor, symptom awareness and lay beliefs for breast and cervical cancer. Mann Whitney and Kruskal Wallis tests were used to compare the association between socio-demographic variables and outcomes. Poisson regression with robust variance was conducted to identify independent socio-demographic predictors. Of the 1758 women interviewed, 90.8% had heard of breast and 89.4% of cervical cancer. 8.7% recalled at least one breast risk factor and 38.1% recalled at least one cervical cancer risk factor. 78.0% and 57.7% recalled at least one breast/cervical cancer symptom respectively. Recognition of risk factors and symptoms was higher than recall. Many women were unaware that HPV, HIV, and not being screened were cervical cancer risk factors (23.7%, 46.8%, 26.5% respectively). In SA, urban compared to rural women had significantly higher symptom and risk factor awareness for both cancers. In Uganda married women/living with a partner had higher awareness of breast cancer risk factors and cervical cancer symptoms compared to women not living with a partner. Women mentioned several lay beliefs (e.g. putting money in their bra as a breast cancer risk factor). We identified gaps in breast and cervical cancer symptom and risk factor awareness. Our results provide direction for locally targeted cancer awareness intervention programs and serve as a baseline measure against which to evaluate interventions in SSA.

Timeliness of diagnosis of breast and cervical cancers and associated factors in low-income and middle-income countries: a scoping review protocol

Introduction Breast and cervical cancer are leading causes of morbidity and mortality in women globally, with disproportionately high burdens in low-income and middle-income countries (LMICs). While the incidence of both cancers increases across LMICs, many cases continue to go undiagnosed or diagnosed late. The aim of this review is to comprehensively map the current evidence on the time to breast or cervical cancer diagnosis and its associated factors in LMICs. Methods and analysis This scoping review (ScR) will be informed by Arksey and O"Malley’s enhanced ScR methodology framework. It will be reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. We will conduct a comprehensive search of the following electronic databases: MEDLINE (via PubMed), Cochrane Library, Scopus and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). Two reviewers will independently screen all abstracts and full texts using predefined inclusion criteria. All publications describing the time to diagnosis and its associated factors in the contexts of breast or cervical cancer will be considered for inclusion. Evidence will be narratively synthesised and analysed using a predefined conceptual framework. Ethics and dissemination As this is a ScR of publicly available data, with no primary data collection, it will not require ethical approval. Findings will be disseminated widely through a peer-reviewed publication and forums such as conferences and community engagement sessions. This review will provide a user-friendly evidence summary for understanding the enormity of diagnostic delays and associated factors for breast and cervical cancers in LMICs, while helping to inform policy actions and implementation of interventions for addressing such delays.

Effectiveness of interventions for improving timely diagnosis of breast and cervical cancers in low-income and middle-income countries: a systematic review

Objectives To systematically synthesise available evidence on the nature and effectiveness of interventions for improving timely diagnosis of breast and cervical cancers in low and middle-income countries (LMICs). Design A systematic review of published evidence. The review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses. Data sources A comprehensive search of published literature was conducted. In addition, relevant grey literature sources and bibliographical references of included studies were searched for potentially eligible evidence. Study selection Studies published between January 2010 and November 2020 were eligible for inclusion. To be eligible, studies had to report on interventions/strategies targeted at women, the general public or healthcare workers, aimed at improving the timely diagnosis of breast and/or cervical cancers in LMIC settings. Data extraction and synthesis Literature search, screening, study selection, data extraction and quality appraisal were conducted by two independent reviewers. Evidence was synthesised and reported using a global taxonomy framework for early cancer diagnosis. Results From the total of 10 593 records identified, 21 studies conducted across 20 LMICs were included in this review. Most of the included studies (16/21) focused primarily on interventions addressing breast cancers; two focused on cervical cancer while the rest examined multiple cancer types. Reported interventions targeted healthcare workers (12); women and adolescent girls (7) and both women and healthcare workers (3). Eight studies reported on interventions addressing access delays; seven focused on interventions addressing diagnostic delays; two reported on interventions targeted at addressing both access and diagnostic delays, and four studies assessed interventions addressing access, diagnostic and treatment delays. While most interventions were demonstrated to be feasible and effective, many of the reported outcome measures are of limited clinical relevance to diagnostic timeliness. Conclusions Though limited, evidence suggests that interventions aimed at addressing barriers to timely diagnosis of breast and cervical cancer are feasible in resource-limited contexts. Future interventions need to address clinically relevant measures to better assess efficacy of interventions. PROSPERO registration number CRD42020177232.

Timeliness of diagnosis of breast and cervical cancers and associated factors in low-income and middle-income countries: a scoping review

Objectives Addressing the barriers to early breast and cervical cancer diagnosis in low and middle-income countries (LMICs) requires a sound understanding and accurate assessment of diagnostic timeliness. This review aimed to map the current evidence on the time to breast and cervical cancer diagnosis and associated factors in LMICs. Design Scoping review. Sources MEDLINE (via PubMed), Cochrane Library, Scopus and CINAHL. Eligibility criteria Studies describing the time to diagnosis and associated factors in the context of breast and cervical cancer in LMICs published from 1 January 2010 to 20 May 2021. Study selection and data synthesis Two reviewers independently screened all abstracts and full texts using predefined inclusion criteria. The review was reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. Evidence was narratively synthesised using predefined themes. Results Twenty-six studies conducted across 24 LMICs were included in the review, most (24/26) of which focused on breast cancer. Studies varied considerably in their conceptualisation and assessment of diagnostic time, events, intervals and delays, with a minority of the studies reporting the use of validated methods and tools. Patient-related intervals and delays were more frequently evaluated and reported than provider-related and health system-related intervals and delays. Across studies, there were variations in the estimated lengths of the appraisal, help-seeking, patient and diagnostic intervals for both cancers and the factors associated with them. Conclusions Despite the significant burden of breast and cervical cancer in LMICs, there is limited information on the timeliness of diagnosis of these cancers. Major limitations included variations in conceptualisation and assessment of diagnostic events and intervals. These underscore the need for the use of validated and standardised tools, to improve accuracy and translation of findings to better inform interventions for addressing diagnostic delays in LMICs.

Navigating cancer: Insights from patient journey mapping

Background Cancer is an increasing public health problem in South Africa, with breast cancer being the most diagnosed cancer and cervical cancer the leading cause of cancer deaths among women. Despite the complexity of breast and cervical cancer patients’ journeys through the healthcare system, patients’ voices are still predominantly missing from the body of literature. Patient journey mapping, as a qualitative research method, offers an opportunity for centring patients in their care journeys and reimagine healthcare provision for the potential improvement of health systems and patient outcomes. Aim The aim of this study was to map journeys of breast and cervical cancer patients across the cancer care continuum. Methods Using patient journey mapping, we conducted six focus group discussions with patients with breast and cervical cancer who had completed treatment in Gauteng, KwaZulu Natal and the Western Cape, South Africa. The process involved three steps: 1.) development of individual maps; 2.) narrative sharing; and 3.) development of a collective map. Results of the study were shared in feedback sessions. Findings A total of 31 people participated in the focus groups: 23 with breast cancer, 7 cervical cancer and one had both cancers during her lifetime. The participants’ ages ranged between 30 and 69 years old. A patient journey map was developed drawing on the individual and collective maps and participant narratives. The findings of the paper constellate around three themes. The first theme, (de)personalised care, offers an examination of how relational, institutional and structural factors shape and are reshaped through participants lived experiences across the cancer care continuum. The second theme, self-advocacy, explores how participants advocate for their healthcare needs throughout the cancer care continuum. The third theme, intersecting vulnerabilities, explores how intersecting social identities, such as socioeconomic factors, gender, comorbidities and mental health, shape their cancer care journeys. Conclusions By centring patient with breast and cervical cancer voices, patient journey mapping not only showed where services and systems fall short but also provided guidance for redesigning a more patient responsive health system.