Brown Carolyn A, Suneja Gita, Tapela Neo, Mapes Abigail, Pusoentsi Malebogo, Mmalane Mompati, Hodgeman Ryan, Boyer Matthew, Musimar Zola, Ramogola-Masire Doreen, Grover Surbhi, Nsingo-Bvochora Memory, Kayembe Mukendi, Efstathiou Jason, Lockman Shahin, Dryden-Peterson Scott
Botswana Harvard AIDS Institute, Gaborone, Botswana Emory Rollins School of Public Health, Atlanta, Georgia, USA
Department of Radiation Oncology, University of Utah, Salt Lake City, Utah, USA.
Oncologist. 2016 Jun;21(6):731-8. doi: 10.1634/theoncologist.2015-0387. Epub 2016 Apr 6.
Three-quarters of cancer deaths occur in resource-limited countries, and delayed presentation contributes to poor outcome. In Botswana, where more than half of cancers arise in HIV-infected individuals, we sought to explore predictors of timely oncology care and evaluate the hypothesis that engagement in longitudinal HIV care improves access.
Consenting patients presenting for oncology care from October 2010 to September 2014 were interviewed and their records were reviewed. Cox and logistic models were used to examine the effect of HIV and other predictors on time to oncology care and presentation with advanced cancer (stage III or IV).
Of the 1,146 patients analyzed, 584 (51%) had HIV and 615 (54%) had advanced cancer. The initial clinic visit occurred a mean of 144 days (median 29, interquartile range 0-185) after symptom onset, but subsequent mean time to oncology care was 406 days (median 160, interquartile range 59-653). HIV status was not significantly associated with time to oncology care (adjusted hazard ratio [aHR] 0.91, 95% confidence interval [CI] 0.79-1.06). However, patients who reported using traditional medicine/healers engaged in oncology care significantly faster (aHR 1.23, 95% CI 1.09-1.40) and those with advanced cancer entered care earlier (aHR 1.48, 95% CI 1.30-1.70). Factors significantly associated with advanced cancer included income <$50 per month (adjusted odds ratio [aOR] 1.35, 95% CI 1.05-1.75), male sex (aOR 1.45, 95% CI 1.12-1.87), and pain as the presenting symptom (aOR 1.39, 95% CI 1.03-1.88).
Longitudinal HIV care did not reduce the substantial delay to cancer treatment. Research focused on reducing health system delay through coordination and navigation is needed.
The majority (54%) of patients in this large cohort from Botswana presented with advanced-stage cancer despite universal access to free health care. Median time from first symptom to specialized oncology care was 13 months. For HIV-infected patients (51% of total), regular longitudinal contact with the health system, through quarterly doctor visits for HIV management, was not successful in providing faster linkages into oncology care. However, patients who used traditional medicine/healers engaged in cancer care faster, indicating potential for leveraging traditional healers as partners in early cancer detection. New strategies are urgently needed to facilitate diagnosis and timely treatment of cancer in low- and middle-income countries.
四分之三的癌症死亡发生在资源有限的国家，就诊延迟导致预后不良。在博茨瓦纳，超过一半的癌症发生在感染艾滋病毒的个体中，我们试图探索及时获得肿瘤治疗的预测因素，并评估参与长期艾滋病毒护理可改善就医机会这一假设。
对2010年10月至2014年9月前来接受肿瘤治疗的同意参与研究的患者进行访谈并查阅其记录。采用Cox模型和逻辑模型来检验艾滋病毒及其他预测因素对获得肿瘤治疗时间以及晚期癌症（III期或IV期）就诊的影响。
在分析的1146例患者中，584例（51%）感染艾滋病毒，615例（54%）患有晚期癌症。症状出现后首次门诊就诊的平均时间为144天（中位数29天，四分位间距0 - 185天），但随后获得肿瘤治疗的平均时间为406天（中位数160天，四分位间距59 - 653天）。艾滋病毒感染状况与获得肿瘤治疗的时间无显著关联（调整后风险比[aHR]为0.91，95%置信区间[CI]为0.79 - 1.06）。然而，报告使用传统药物/治疗师的患者接受肿瘤治疗的速度明显更快（aHR为1.23，95%CI为1.09 - 1.40），晚期癌症患者更早接受治疗（aHR为1.48，95%CI为1.30 - 1.70）。与晚期癌症显著相关的因素包括月收入低于50美元（调整后优势比[aOR]为1.35，95%CI为1.05 - 1.75）、男性（aOR为1.45，95%CI为1.12 - 1.87）以及以疼痛作为首发症状（aOR为1.39，95%CI为1.03 - 1.88）。
长期艾滋病毒护理并未减少癌症治疗的严重延迟。需要开展侧重于通过协调和引导来减少卫生系统延迟的研究。
在这个来自博茨瓦纳的大型队列中，尽管可普遍获得免费医疗保健，但大多数（54%）患者就诊时已处于癌症晚期。从首次出现症状到接受专科肿瘤治疗的中位时间为13个月。对于感染艾滋病毒的患者（占总数的51%），通过每季度进行一次艾滋病毒管理的医生就诊与卫生系统进行定期长期接触，未能成功实现更快地转入肿瘤治疗。然而，使用传统药物/治疗师的患者接受癌症治疗的速度更快，这表明有潜力将传统治疗师作为早期癌症检测的合作伙伴。迫切需要新的策略来促进低收入和中等收入国家的癌症诊断和及时治疗。
