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

Abstract

There 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.

Access to Radiation Therapy and Related Clinical Outcomes in Patients With Cervical and Breast Cancer Across Sub-Saharan Africa: A Systematic Review

“… 33 Factors that decrease survival include late-stage presentations, treatment breaks, loss to follow-up, poor performance status, undifferentiated tumors, older age, poor nutrition, and long wait times. 24 , 34 , 36 , 41 , 43 , 61 , 79 - 83 In one series, compared with wait times of < 60 days, all-cause mortality was three times higher for waits between 120 and 179 days and 5.8 times higher if > 180 days. 24 Some patients with CC were given chemotherapy while awaiting RT availability; within this cohort, survival was similar to those given upfront chemoradiation.…”

“… 22 , 23 Furthermore, Ethiopia developed a mixed model with government, private, and NGO contributions; 70% of patients may still require OOP payments. 23 , 24 In Gabon, patient costs decreased from 51% to 22% of health spending from 2008 to 2020 because of increased government healthcare allocations, improving access for low-income patients. 25 Similarly, in Botswana, government subsidies comprise a significant portion of low-income patient coverage.…”

“… 23 , 58 - 60 Having single national centers leads to delays; while awaiting RT for CC, an Ethiopian cohort noted 16 deaths and 44.4% progression to a higher stage if waiting for more than 60 days. 24 Ethiopia, however, is actively working to expand RT access to six regional centers. 23 Ghana and Sudan have two centers each, and, within Ghana, 78% of patients live within 45 km of a RT center.…”

“… 71 Staffing concerns extend beyond providers and lead to struggles with managing a vast referral network and recordkeeping, limiting provision adequate survivorship care with incomplete documentation. 24 , 42 , 67 , 72 …”

Cervical cancer treatment in Rwanda: Resource-driven adaptations, quality indicators, and patient outcomes

“…The median time from cervical cancer diagnosis to CRT initiation was 106 days in Zambia [28], 25 weeks (175 days) in Northern Nigeria [29], and 114-116.5 days in Botswana [16] (though this center subsequently reduced time to treatment from 108 to 39 days after implementation of a multidisciplinary clinic [30]). Two studies from Ethiopia, reporting median time to treatment of 3.8 months (116 days) and 137 days, demonstrated disease progression to higher stages during the waiting period [18,31]. These figures contrast starkly with a median time to treatment initiation of 21-22 days [26] or 36.3-43.9 days [32] reported in two large U.S. cohorts.…”