Symptomatic Presentation, Diagnostic Delays and Advanced Stage Among Cervical Cancer Patients in Mexico

Abstract

Background: Even though cancer of the cervix uteri is a preventable and highly curable disease, in Mexico it is the second cause of cancer mortality among women. According to the last National Survey of Health and Nutrition (2012) , Papanicolaou test screening coverage in Mexico is estimated at 45%. Additionally, studies have revealed quality problems in the taking and interpretation of Papanicolaou test tests and a lack of follow-up in ∼60% of women with positive Pap smears. To date there is no information on the time intervals of care for cervical cancer patients in Mexico. Aims: To quantify the intervals of care from the detection of a possible cervical cancer to the beginning of cancer treatment, describe the form of presentation and identify perceived barriers to timely care. Methods: We surveyed 427 patients that received a new cervical cancer diagnosis between 6.01.16 and 5.31.17 in the 2 largest public hospitals located in Mexico City available for uninsured cancer patients. Approximately 2/3 patients reside in Mexico City metropolitan area and 1/3 in surrounding states. All patients signed informed consent. Participants' medical files were reviewed. We gathered data on: dates necessary to estimate the intervals of care, sociodemographic characteristics, form of cancer identification (symptoms vs screening), perceived barriers of care and cancer clinical stage. Results: Clinical stages at diagnosis were: 9.5% in situ, 16.9% stage I, 25.2% stage II, 20.2% stage III, 17.8% stage IV and 10.5% not known. The median duration of the patient interval (time between symptom discovery and first medical consultation) was 24 days (IQR = 5.5-72), in comparison with 175 days (IQR = 101-272) for the health system interval (time between first medical consultation and treatment start). The diagnosis interval (first consultation to diagnosis) had a median duration of 99 days (IQR = 43-204) and the treatment interval (time between diagnosis and treatment start) a median of 57 days (IQR = 37-78). Only 15% (64/427) patients identified the problem through screening. The most common symptom of presentation was vaginal bleeding in 65.9% (236/363) cases. The main perceived barriers of diagnostic delay were: lack of information of available health services (63%), long waiting times between appointments (52%) and diagnostic medical errors in the first services consulted (38%). Conclusion: The vast majority of cervical cancer cases among uninsured women in the Mexico City metropolitan area have symptomatic presentations. Additionally, these patients face delays of ∼6 months between the first medical consultation and the confirmation of cancer. Low coverage of screening and diagnostic delays are the most likely explanations of the high mortality rates of cervical cancer that persist in Mexico despite the 30-year implementation of the national screening program.