Factors Related to Advanced Stage of Cancer Presentation in Botswana

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Botswana, an upper-middle income country in southern Africa, faces unique challenges in controlling cancer incidence and mortality. Despite universal access to free health care, the majority of Botswana cancer patients present at advanced stages. This study was designed to quantify cancer care-related delays and explore the patient-level and clinical factors related to advanced stage at presentation in Botswana. Two hundred and fourteen patients attending an oncology clinic between December 2015 and January 2017 at the Princess Marina Hospital in Gaborone, Botswana completed a questionnaire on sociodemographic and clinical factors, as well as the cancer-related fears, attitudes, beliefs, and stigmas. Odds ratios were calculated to identify factors significantly associated with advanced stage (stage III/IV) at diagnosis. Of the 214 patients, 40 (18.7%) were male and 174 (81.3%) were female. The median age of diagnosis was age 46, with a total of 146 (71.9%) patients older than 40 years. The most commonly represented cancers included cervical (42.3%), breast (16%), head and neck (15.5%), vulvar (7%), and Kaposi sarcoma (6.6%). Cancer stages represented in the study group included 17 (8.4%) Stage I, 39 (19.2%) Stage II, 49 (24.1%) Stage III, 24 (11.9%) Stage IV, and 74 (36.4%) with unknown stage. There were no significant differences in any of the cancer care delay intervals between early and advanced stage cancer patients. Most of the early and advanced stage patients held appropriate fears, attitudes, and beliefs regarding cancer and its treatment options. Patients who presented at advanced stages were significantly more likely to not be afraid of having cancer (OR=3.48; p<0.05), believe that their family would not care for them if they needed treatment (OR=6.35; p=0.05), and that they cannot afford to get cancer (OR=2.73; p<0.05). Male gender, non-female specific cancers, and the perception that symptoms were less serious were also significantly related to advanced stage diagnosis (p<0.05). Future cancer mortality reduction efforts should emphasize cancer symptom awareness and early detection through routine cancer screening, as well as increasing the acceptability of care seeking among male patients.