Cervical Cancer Treatment Pathway in Botswana

BACKGROUND: The incidence and mortality of cervical cancer in Botswana are among the highest in the world. Despite availability of chemoradiation and government funding for cancer treatment, many patients referred for chemoradiation in Botswana do not receive treatment. OBJECTIVES: This study sought to determine the proportion of cervical cancer patients referred for chemoradiation who do not receive cancer treatment and identify factors associated with receipt or non-receipt of treatment. Time between key steps in the care cascade was quantified to identify points that contribute to delays in care. This study also examined the impact of Princess Marina Hospital's multidisciplinary gynecologic oncology (PMH MDT) clinic on treatment receipt. METHODS: 230 patients with biopsy-proven cervical cancer were enrolled from January 2015 to July 2018 at Princess Marina Hospital in Gaborone, Botswana and followed until November 2019. Patient demographics, clinical characteristics, treatment characteristics, and time between steps in the care cascade were compared between treated and untreated patients using Wilcoxon rank sum tests, chi-squared tests, student's t tests, and univariate binomial logistic regression. RESULTS: 43 (18.7%) patients did not receive cancer treatment. Higher FIGO stage at initial presentation (OR: 0.50, 95% CI: 0.31-0.83, p < 0.01) and presentation during MDT clinic's first year (OR: 0.30, 95% CI: 0.15-0.59, p < 0.001) were associated with significantly lower odds of receiving treatment. Age, residential distance from treatment site, and HIV status were not predictive of treatment receipt. The largest discrepancy in time between treated and untreated patients was median time between pathology report and first MDT clinic visit: 22 days for treated patients (IQR: 9-63; n = 162) vs. 44 days for untreated patients (IQR: 9-146; n = 33) (p > 0.05). CONCLUSION: The MDT model is an evidence-based strategy to improve care coordination and reduce treatment disparities, thus improving outcomes for cancer patients. While there are still gaps in Botswana's cervical cancer care cascade, the PMH MDT clinic has led to significant improvements in cancer care among this population. The PMH MDT clinic provides strong evidence that MDT clinics can and should be established in under-resourced settings.