ABSTRACT
Purpose: The global rise in cancer incidence has been accompanied by disproportionately high morbidity and mortality rates in low- and middle-income countries. Many patients who are offered potentially curative treatment for cervical cancer in low- and middle-income countries never return to start treatment for reasons that are poorly documented and little understood. We investigated the interplay of sociodemographic, financial, and geographic factors as barriers to care among such patients in Botswana and Zimbabwe. Methods and Materials: Patients seen in consultation between 2019 and 2021 who were >3 months late for an appointment to initiate definitive treatment were contacted via telephone and invited to complete a survey. Afterward, an intervention connected patients with resources and counseling to return for treatment. Follow-up data were collected 3 months later to ascertain the outcomes of the intervention. Fisher exact tests analyzed the relationship between the putative number and types of barriers and demographics. Results: We recruited 40 women who initially presented for oncology care but did not return for treatment at [Princess Marina Hospital] in Botswana (n = 20) and [Parirenyatwa General Hospital] in Zimbabwe (n = 20) to complete the survey. Overall, married women experienced more barriers than unmarried women (P < .001), and unemployed women were 10 times more likely to report a financial barrier than employed women (P = .02). In Zimbabwe, financial barriers and belief-associated barriers (eg, fear of treatment) were reported. In Botswana, many patients noted scheduling obstacles associated with administrative delays and COVID-19. At follow-up, 16 Botswana patients and 4 Zimbabwe patients had returned for treatment. Conclusions: Financial and belief barriers identified in Zimbabwe showcase the importance of targeting cost and health literacy to reduce apprehensions. In Botswana, administrative challenges could be addressed with patient navigation. Improving our understanding of the specific barriers to cancer care could enable us to help patients who might otherwise default.
ABSTRACT
PURPOSE: Advanced breast cancer (BC) at diagnosis is common in sub-Saharan Africa (SSA), including among women living with HIV (WLWH). In public hospitals across South Africa (SA), 10-15% of women present with stage IV BC, compared to < 5% in the United States (US); 20% of new BC diagnoses in SA are in WLWH. We evaluated the impact of HIV on overall survival (OS) among women with stage IV BC. METHODS: We conducted a prospective cohort study of women diagnosed with stage IV BC between February 2, 2015 and September 18, 2019 at six public hospitals in SA. Multivariate Cox regression models were used to estimate the association between HIV status and OS. RESULTS: Among 550 eligible women, 147 (26.7%) were WLWH. Compared to HIV-negative BC patients, WLWH were younger (median age 45 vs. 60 years, p < 0.001), predominantly black (95.9% vs. 77.9%, p < 0.001), and more likely to have hormone receptor-negative (hormone-negative) BC (32.7% vs. 22.6%, p = 0.016). Most women received systemic cancer-directed therapy (80.1%). HIV status was not associated with treatment or OS (Hazard Ratio (HR) 1.13 [95%CI 0.89-1.44]). On exploratory subgroup analysis, WLWH and hormone-negative BC had shorter OS compared to HIV-uninfected women (1-year OS: 27.1% vs. 48.8%, p = 0.003; HR 1.94 [95%CI 1.27-2.94]; p = 0.002), which was not observed for hormone receptor-positive BC. CONCLUSION: HIV status was not associated with worse OS in women with stage IV BC in SA and cannot account for the poor survival in this cohort. Subgroup analysis revealed that WLWH with hormone-negative BC had worse OS, which warrants further investigation.