Engagement in HIV Care and Access to Cancer Treatment Among Patients With HIV-Associated Malignancies in Uganda

Low, Daniel; Phipps, Warren; Orem, Jackson; Casper, Corey; Ignacio, Rachel A. Bender

doi:10.1200/jgo.18.00187

Cited by 11 publications

(15 citation statements)

References 26 publications

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“…Prior studies on KS treatment with chemotherapy in sub-Saharan Africa have focused on outcomes of particular chemotherapy regimens, [17,18,[25][26][27] neither evaluated real-world delays in chemotherapy initiation, nor, perhaps most importantly, chemotherapy non-initiation in patients with chemotherapy indications. We know that there is often a significant delay between symptom recognition and successful initiation of cancer care in Africa [28]. Our results for KS echo data from other cancers in Africa, such as lymphoma and breast cancer, with similar delays [29] and non-initiation of chemotherapy [30].…”

Section: Discussionsupporting

confidence: 73%

Real-world use of chemotherapy for Kaposi’s sarcoma in a large community-based HIV primary care system in Kenya

et al. 2020

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Background: Kaposi's sarcoma (KS) is one of the most common HIV-associated malignancies in sub-Saharan Africa. Worldwide, the availability of antiretroviral therapy (ART) has improved KS survival. In resource-rich settings, survival has also benefited from chemotherapy, which is widely available. Little is known, however, about the epidemiology of chemotherapy use for HIV-associated KS in resource-limited regions such as sub-Saharan Africa. Methods: We identified all patients newly diagnosed with HIV-related KS from 2009 to 2012 in the 26-clinic AMPATH network, a large community-based care network in Kenya. We ascertained disease severity at diagnosis, frequency of initiation of chemotherapy, and distribution of chemotherapeutic regimens used. Indications for chemotherapy included AIDS Clinical Trial Group T1 stage and/or "severe" disease defined by WHO KS treatment guidelines. Results: Of 674 patients diagnosed with KS, charts were available for 588; 61% were men, median age was 35 years, and median CD4 at KS diagnosis was 185 cells/μl. At time of diagnosis, 58% had at least one chemotherapy indication, and 22% had more than one indication. For patients with a chemotherapy indication, cumulative incidence of chemotherapy initiation (with death as a competing event) was 37% by 1 month and 56% by 1 year. Median time from diagnosis to chemotherapy initiation was 25 days (IQR 1-50 days). In multivariable regression, patients with > 3 chemotherapy indications at time of diagnosis had a 2.30 (95% CI 1.46-3.60) increased risk of rapid chemotherapy initiation (within 30 days of diagnosis) compared to those with only one chemotherapy indication (p < 0.001). Initial regimens were bleomycin-vincristine (78%), adriamycin-bleomycin-vincristine (11%), etoposide (7%), and gemcitabine (4%). Conclusions: A substantial fraction of patients with KS in East Africa are diagnosed at advanced disease stage. For patients with chemotherapy indications, nearly half did not receive chemotherapy by one year. Liposomal anthracyclines, often used in resource-rich settings, were not first line. These findings emphasize challenges in East Africa cancer care, and highlight the need for further advocacy for improved access to higher quality chemotherapy in this setting.

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Section: Discussionsupporting

confidence: 73%

Real-world use of chemotherapy for Kaposi’s sarcoma in a large community-based HIV primary care system in Kenya

et al. 2020

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“…Delayed patient presentation for cancer treatment is common in low-resourced health systems across the globe. 6,[17][18][19][20] Studies have reported that the delays for patients with breast cancer in Africa range from 4 months to 17 months; our study falls in the middle of this range at nearly 10 months. 21 Delays in cancer diagnosis may lead to more advanced disease at presentation and increased mortality.…”

Section: Discussionmentioning

confidence: 88%

“…Other studies found that an association between lower levels of education and other measures associated with poverty are correlated with delayed presentation for patients with cancer. 6 , 17 , 19 , 20 , 25 Our results may suggest that most patients seeking care for cancer had less significant economic challenges, and measures should be taken to increase access to specialized care for all patients such as providing travel vouchers to those in rural communities.…”

Section: Discussionmentioning

confidence: 89%

Barriers to Cancer Care in Northern Tanzania: Patient and Health-System Predictors for Delayed Presentation

Rick

Aagard

Erwin

et al. 2021

JCO Global Oncology

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PURPOSE Cancer is a growing problem in Africa, and delays in receiving timely cancer care often results in poorer outcomes. The purpose of this study was to identify the patient and health-system factors associated with delayed cancer care in adults living in the Northern Zone of Tanzania. PATIENTS AND METHODS Between July 2018 and July 2019, we surveyed adult patients presenting to an oncology clinic in Northern Tanzania. Delayed presentation was defined as 12 weeks or longer from initial symptoms to presentation for cancer care. Multivariate logistic regression and adjusted relative risk (aRR) were used to identify factors predicting delayed presentation. RESULTS Among 244 adult patients with cancer who completed the survey, 78% (n = 191) had delayed presentation. Patient-related factors associated with delayed presentation included lower educational attainment ( P = .03), increased travel time ( P = .05), lack of cancer knowledge ( P < .05), and fear of cancer and cancer treatments ( P < .05) on multivariate analysis. On analysis of aRR, patients without private car and those with health insurance had higher risk of delayed presentation (aRR: 1.27; 95% CI, 1.02 to 1.32 and aRR: 1.15; 95% CI, 1.01 to 1.32). There was a strong association with increased number of visits before presentation at the cancer center and delayed presentation ( P = .0009). CONCLUSION Cancer awareness and prevention efforts targeting patients and community-level health care workers are key to reduce delays in cancer care in Northern Tanzania.

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“…Our findings corroborate closely with two earlier studies at UCI albeit centred on access to chemotherapy. Buckle et al 11 investigated turnaround time to chemotherapy among children with endemic Burkitt's lymphoma and the median duration was 14 days, while Low et al 14 reported a median turnaround time of 15 days among adults with epidemic Kaposi's sarcoma. Notably, our cohort was heterogeneous with cervix cancer as the most frequent dignosis which requires a unique set of pre-treatment evaluation, as well as concurrent radiotherapy.…”

Section: Discussionmentioning

confidence: 99%

Turnaround time and barriers to treatment of newly diagnosed cancer in Uganda: a mixed-methods longitudinal study

Kibudde¹,

Namisango²,

Nakaganda³

et al. 2022

Afr H. Sci.

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Introduction: Cancer represents a growing public health concern. Late-stage at diagnosis, limited access to effective treatment, and loss to follow-up are responsible for dismal outcomes. Objective: To describe care pathways, turnaround times, and identify barriers to timely initiation of cancer treatment Methods: Using a sequential mixed-methods design involving focus group discussions, we followed up 50 participants between January, and June 2018. We computed the median observed turnaround time to treatment (TTT) at each care step and reported delay as deviations from the proposed ideal turnaround times. Results: The ideal TTT with either chemotherapy, or radiotherapy, or surgery was 8, 14, and 21 days respectively. At a median follow-up time of 35.5 days (IQR 17-66), only 29 of the 50 study participants had completed all steps between registration and initiation of treatment, and the observed median TTT was 16 days (9 – 22 days) for chemotherapy, and 30 days (17 – 49 days) for radiotherapy, reflecting a significant delay (p-value = 0.017). Reported barriers were; shortage ofspecialists, patients required visits to outside facilities for staging investigations, prohibitive costs, poor navigation system and time wastage. Conclusions: When compared to the recommended ideal turnaround time, there was significant institutional delay in access to chemotherapy and radiotherapy attributed to multiple external and internal healthcare system barriers. Keywords: Turnaround time; steps; barriers; waiting time; cancer; Uganda.

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Engagement in HIV Care and Access to Cancer Treatment Among Patients With HIV-Associated Malignancies in Uganda

Cited by 11 publications

References 26 publications

Real-world use of chemotherapy for Kaposi’s sarcoma in a large community-based HIV primary care system in Kenya

Real-world use of chemotherapy for Kaposi’s sarcoma in a large community-based HIV primary care system in Kenya

Barriers to Cancer Care in Northern Tanzania: Patient and Health-System Predictors for Delayed Presentation

Turnaround time and barriers to treatment of newly diagnosed cancer in Uganda: a mixed-methods longitudinal study

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