The study investigated the range of sociodemographic, clinical and histological factors associated with late stage presentation of cervical cancer cases who reported to Gynecological Oncology Care Unit at the Catholic Hospital, Battor from 2012 to 2016. The findings suggest that sociodemographic (no education) and clinical factors (absence of previous screening and age at menarche) influenced late presentation at the study site. Nearly two-thirds of patients with cervical cancer during the stated period reported with advanced stage disease, Similar results were found in studies conducted in Uganda, South India, Iran, Nepal, Tanzania [4,5,6, 13, 14] which make it evident that majority of women report with late stage disease, particularly in developing countries.
Other sociodemographic factors (age, marital status, educational level, NHIS, employment status, place of residence and distance) were not associated with late stage at presentation of cervical cancer cases. The influence of education was reported in similar studies conducted in Tanzania [5], Nepal [6] and Morocco [16]. This means that women who are educated will be more inclined to report early once they experience an unusual symptom. As most women with cervical cancer present at older ages, age was included to assess how it might affect other factors in the multivariable analysis. In this study, age was not a predictor of late presentation. This finding which contrasts with findings from earlier studies [8, 10, 16] agrees with a study in Uganda [4]. In terms of access to healthcare, active membership of the National Health Insurance Scheme was included in the present study. Nevertheless, being uninsured was not associated with late presentation. A potential explanation could be that National Health Insurance does not cover cost of diagnosis, but total abdominal hysterectomy as treatment for early cervical cancer. Moreover, women were dissuaded from seeking medical help related to gynecological issues based on the need to self-fund until symptoms become worse. In other studies, insurance covered the full management of cervical cancer [10,11,12].
The hospital is surrounded by rural communities, women who seek gynecological cancer care come from both rural and urban settings. Studies in the United States [15], Sudan [10] and Morocco [16] reported an association with rural urban residence, while studies in Uganda [4], and Nepal [6] did not report any association as in the present study. Being that the present study was conducted retrospectively, ascertaining average monthly income was not possible hence employment status was used as a proxy. Income generation can be used in determining the socioeconomic status of an individual as low socioeconomic status has been found to have a pronounced effect on late presentation [4, 14]. Employment status was used as a proxy measure to indicate income generation and suggests that a woman might have the capacity to care for her own health rather than relying on her partner or family relations, as in the case of unemployed women. Interestingly, this factor did not predict late stage at presentation with cervical cancer, compared to studies conducted in Uganda [4] and Iran [14]. It is expected that due to lack of money, women will not seek early care until symptoms becomes worse. Among all clinical variables (intermenstrual bleeding, previous screening history, smoking history, number of children and age at menarche) studied, only cases that did not undergo previous screening for cervical cancer and cases that reported older ages at menarche were independently associated with late presentation. A previous study in Iran [14] also reported a significant association with not having been screened previously. Women who have cervical lesions that are not detected early may progress to advanced disease without intervention. The older age at menarche was an unusual finding as it has not been reported previously in local studies or in the studies reviewed in this research. As the statistical association was not maintained in the results from the sensitivity analysis, this variable was omitted from the adjusted model. The authors have reconstructed the original conceptual framework to summarize the study results (Fig. 3).
Limitations
It is noteworthy that this study had some limitations. Firstly, the study being a retrospective study relied solely on the medical records. No additional information could be collected as the patients were not physically present. For example; although literature reports HIV status, contraceptive use and sexually transmitted infections as relevant clinical factors associated with cervical cancer, these were not documented in the records by the attending medical personnel in the period under study. Additionally, some missing data were observed for most of the variables investigated. This particularly affected age at menarche and the histopathology results. The missing data on age at menarche can be attributed to some sociocultural factors such as lack of education about menstruation by parents and guardians due to embarrassment in addressing the subject. There is also much emphasis placed on instilling fear about getting pregnant, rather than keeping personal record of gynaecological information such as menarche. The histopathology results often did not report on the tumour sub-type and characteristics of tumour. These omissions might have resulted from either the record personnel, the attending physician or the patient if she was unable or unwilling to supply the required information. Other cases that may not have reported at the facility in the time frame were excluded, so the actual prevalence could probably be higher.
A sensitivity analysis was conducted to assess the effect of the extent of missing values on the logistic regression model. In the first scenario, it was assumed that all missing records of age at menarche belonged to women who attained menarche in the age range 7–15 years. In the second scenario, it was assumed that all the missing records of age at menarche belonged to women who attained menarche in the age range 16–25 years. In both models, the absence of previous screening remained a significant factor associated with late stage at presentation of cervical cancer cases. However, age at menarche was not always associated with late presentation of cervical cancer. Therefore, the extent of missing values for age at menarche makes it difficult to conclude definitively that age at menarche is associated with late presentation of cervical cancer.
Future directions
In view of the findings, the following are recommended at community level:
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1.
The creation of an advocacy tool using a pictorial illustration to highlight study findings. This can be employed to create awareness and support cancer education at the Gynecological Oncology care unit. The tool should show the link between absence of screening and late stage at presentation. This would explain why women need to be screened early. Simple information should be included about places where women can get screened and time of availability of the service. The tool can be field tested and replicated for use during home visits made by community health workers and should target adult women. Further research will be required to assess the impact of the tool in improving screening rates in Battor, using the present study as a baseline.
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2.
Focus groups can be held with male and female groups to explore barriers to screening and find local solutions to address them. Engaging the support of male partners for increased uptake of preventive screening by women is a pro-active step. This is because male partners can provide funds to pay for the service and thereby influence health seeking behaviour.
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3.
The study findings should be disseminated. The media and local durbars offer the opportunity to increase awareness and advocate support from donor groups, civil society and private agencies to help equip additional service units so that services can have a wider reach. The provision of gift vouchers to facilitate screening and subsidize treatment costs by corporate organizations would be a meaningful addition.
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4.
The relationship with age at menarche can be explored further in future research if women are informed about the importance of keeping relevant information.
At the national level, the following are recommended:
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1.
Training of public health nurses, physician assistants and community health workers in preventive screening and supporting them with required logistics could be a way to decentralize services and make screening more accessible to women. This can be organized by Ghana Health Service in collaboration with local oncologists.
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2.
Consideration should be given to the inclusion of cancer screening and early treatment under the National Health Insurance Scheme. This is recommended as an adjunct measure to other recommendations as its merit lacked statistical support in the study, but it can offer potential benefits.
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3.
Standard guidelines for screening should be provided in consulting rooms and/or service units which should be supported with the necessary logistics.
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4.
Health education for in-school and out of school youth should provide information about keeping personal records of important developmental landmarks like menarche in the case of females. Physically challenged adolescent females can be assisted by teachers, guardians or a significant other person to maintain relevant health records, which should help attending physicians capture their data for analysis. Health workers can only record information that is provided by their patients voluntarily. Women will be encouraged to offer such information provided that they understand why it is relevant to keep account of it.