Factors Associated with Loss to Follow-up among Cervical Cancer Patients in Rwanda

Placide Habinshuti,Tharcisse Mpunga,Gilles Francois Ndayisaba,Cam Nguyen,Catherine Kigonya,Lawrence N Shulman,Thomas Randall,Jean Bosco Bigirimana,Gilbert Rukundo,Ann C Miller,Francois Uwinkindi,Paul H Park,Marc Hagenimana,Stephanie Teeple,Alexandra Fehr

doi:10.5334/aogh.2722

Abstract

Background:Cervical cancer is among the most common cancers affecting women globally. Where treatment is available in low- and middle-income countries, many women become lost to follow-up (LTFU) at various points of care.Objective:This study assessed predictors of LTFU among cervical cancer patients in rural Rwanda.Methods:We conducted a retrospective study of cervical cancer patients enrolled at Butaro Cancer Center of Excellence (BCCOE) between 2012 and 2017 who were either alive and in care or LTFU at 12 months after enrollment. Patients are considered early LTFU if they did not return to clinic after the first visit and late LTFU if they did not return to clinic after the second visit. We conducted two multivariable logistic regressions to determine predictors of early and late LTFU.Findings:Of 652 patients in the program, 312 women met inclusion criteria, of whom 47 (15.1%) were early LTFU, 78 (25.0%) were late LTFU and 187 (59.9%) were alive and in care. In adjusted analyses, patients with no documented disease stage at presentation were more likely to be early LTFU vs. patients with stage 1 and 2 when controlling for other factors (aOR: 14.93, 95% CI 6.12–36.43). Patients who travel long distances (aOR: 2.25, 95% CI 1.11, 4.53), with palliative care as type of treatment received (aOR: 6.65, CI 2.28, 19.40) and patients with missing treatment (aOR: 7.99, CI 3.56, 17.97) were more likely to be late LTFU when controlling for other factors. Patients with ECOG status of 2 and higher were less likely to be late LTFU (aOR: 0.26, 95% CI 0.08, 0.85).Conclusion:Different factors were associated with early and later LTFU. Enhanced patient education, mechanisms to facilitate diagnosis at early stages of disease, and strategies that improve patient tracking and follow-up may reduce LTFU and improve patient retention.

Highlights

Cervical cancer is among the most common cancers and is the fourth most common cause of cancer death in women worldwide [1]
Among 652 cervical cancer patients registered at Butaro Cancer Center of Excellence (BCCOE) between July 2012 and June 2017, 65 (10.0%) were not enrolled for at least a year, 36 (5.5%) had died, 223 (34.2%) had been referred for hospice care, 7 (1.1%) had other outcomes, and 9 (1.4%) had no outcome data available (Figure 2)
Among the patients who were early lost to follow-up (LTFU), the largest proportion were from the Northern Province (19, 43.2%) and the majority had no stage documented at presentation (21, 44.7%)

Summary

Introduction

Cervical cancer is among the most common cancers and is the fourth most common cause of cancer death in women worldwide [1]. The cost of treatment often prohibits access [6, 7] Issues such as late presentation at diagnosis, low pretreatment performance status, which indicates a patient’s ability to tolerate chemotherapy, lack of adherence to treatment or post-treatment follow-up, and low quality of care worsen patient outcomes [2, 8,9,10,11]. Where treatment is available in low- and middle-income countries, many women become lost to follow-up (LTFU) at various points of care. Patients with no documented disease stage at presentation were more likely to be early LTFU vs patients with stage 1 and 2 when controlling for other factors (aOR: 14.93, 95% CI 6.12–36.43). Mechanisms to facilitate diagnosis at early stages of disease, and strategies that improve patient tracking and follow-up may reduce LTFU and improve patient retention

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Discussion

Conclusion