Multidisciplinary Model of Cervical Cancer Management in Botswana: Benchmarking the Care Cascade to Identify the Impact of Delays

Abstract

<h3>Purpose/Objective(s)</h3> Timely access to and completion of radiation therapy (RT) are crucial for optimizing clinical outcomes of patients with locally advanced cervical cancer. The cascade of cancer care comprises the steps between initial presentation and treatment initiation. It is unknown which of these steps if any contribute to delay and downstream survival. Multi-disciplinary management has been shown to enhance the likelihood of successful care coordination and delivery across this cascade, but when implemented in limited resource settings it is unknown if multi-disciplinary management initiatives can adequately identify care delivery gaps. This study sought to examine care delivery metrics and outcomes from a newly established multi-disciplinary team clinic (MDT) in a limited resource setting. The analysis benchmarked the timing of steps between diagnosis and RT initiation in patients with locally advanced cervical cancer in Botswana to determine if delay impacted survival. <h3>Materials/Methods</h3> Between January 2016 and July 2018, 230 patients with biopsy-proven cervical cancer were enrolled in Gaborone, Botswana and followed until November 2019. The number of days between biopsy, pathology, MDT consult, RT consult, simulation, and treatment start were calculated based on dates of care delivery. The association of delay with survival was evaluated using the Kaplan-Meier estimates and multivariable Cox proportional hazards models. <h3>Results</h3> After diagnosis, 187 (81.3%) patients ultimately received treatment. Times between various steps of the care cascade are detailed in Table 1. Untreated patients had a median of one-month additional delay between biopsy and pathology result (57 vs. 25 days, p=0.003). Univariate analysis showed patients treated with curative intent (EQD2 >65 Gy) had worse overall survival when delay between simulation and RT start was > 12 days (p=0.048). Median survival was 2 vs. 4.6 years for patients with and without delay >12 days, respectively. This association trended toward but did not meet statistical significance on multivariate analysis after controlling for HIV status and stage (HR 2.35, 95% CI 0.95 – 5.85, P=0.07). HIV status was not associated with delay at any point. <h3>Conclusion</h3> Treatment delay exists in all steps of the care cascade for patients with cervical cancer in Botswana. Delay of >12 days between radiation simulation and initiation was found to negatively impact survival in patients treated with curative intent. This study also demonstrates the feasibility of utilizing the resources of an MDT care model to quantify care delivery benchmarks in a low-resource setting, resulting in identification of actionable targets to improve care delivery and outcomes.