Delayed diagnosis of cervical cancer in young women

Patient delay and related influencing factors in Chinese women under 35 years diagnosed with cervical cancer: A cross-sectional study

Objective

Patient delay was defined as an interval between the discovery of the initial symptoms and diagnosis, which was longer than 90 days. This study aimed to determine the patient delay rate and related factors in women with cervical cancer in Hunan province, South-Central China.

Methods

A cross-sectional study was conducted among 140 women with cervical cancer aged <35 years from October, 2019 to March, 2021. Assumptions in Andersen Behavioral Model of Health Services Utilization were used to measure the factors influencing patient delay. Logistic regression models were used to identify factors associated with patient delay. A P-value of <5% was considered significant.

Results

A total of 57 (40.71%) young women with cervical cancer had patient delay, with an average delay time of 178.70 (307.90) days. Predisposing factors, such as religion, unemployment, health beliefs related to cancer screening, and a history of cervical cancer screening within 2 years or more (P ​< ​0.05), were associated with patient delay. Enabling factors, such as distance to the nearest medical facility and type of the nearest medical facility, were associated with a reduced likelihood of patient delay. With the need-for-care factor, young women who experienced vaginal pain after or during intercourse had a higher risk (adjusted odds ratio, 33.48; 95% confidence interval, 3.22-348.68, P ​= ​0.003) of patient delay.

Conclusions

These findings reinforce the need for programs to enhance knowledge and awareness about cervical cancer screening and the importance of early diagnosis in women to help eliminate cervical cancer in China by 2050.

The Diagnostic Value of Circulating Cell-Free HPV DNA in Plasma from Cervical Cancer Patients

Circulating cell-free HPV DNA (ccfHPV DNA) may serve as a marker for cervical cancer. In this study, we used digital droplet PCR (ddPCR) to detect and quantify ccfHPV DNA in plasma from patients with HPV16- or HPV18-associated cervical cancer. Blood samples from 60 patients diagnosed with cervical cancer (FIGO IA1-IVA) at Aarhus or Odense University Hospital (June 2018 to March 2020) were collected prior to treatment, and patients were subdivided into an early stage (n = 30) and a late-stage subgroup (n = 30) according to disease stage. Furthermore, blood samples from eight women with HPV16- or 18-associated premalignant conditions (CIN3), and 15 healthy controls were collected. ddPCR was used to analyze plasma from all participants. ccfHPV DNA was detected in 19 late-stage patients (63.33%), 3 early stage patients (10.00%), and none of the CIN3 patients or controls. Quantitative evaluation showed significant correlations between ccfHPV DNA level and stage, tumor score, and tumor size. Thus, our results indicate that ccfHPV DNA may not be a useful marker for early detection of cervical cancer. However, for patients with advanced stage cervical cancer, ccfHPV DNA level represents a promising tool to establish tumor burden, making it useful for establishing treatment response and monitoring the disease.

Prevalence and determinants of late-stage presentation among cervical cancer patients, a systematic review and meta-analysis

Background

An estimated 570,000 women were diagnosed with cervical cancer worldwide, and about 311,000 women died from the disease. Cervical cancer is possibly the most curable human cancer; if detected at the precancerous stage. Additionally, early diagnosis and management other factors are essential to decrease mortality rate among those patients. So this review was aimed to identify the prevalence and determinants of late-stage presentation among cervical cancer patients.

Methods

A systematic search had carried out on PubMed, EMBASE, MEDLINE, Cochrane, Scopus, Web of Science CINAHL, and manually on Google Scholar. This meta-analysis follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The modified Newcastle-Ottawa Scale (NOS) was used to assess the quality of each study. A meta-analysis was done using a random-effects method using the STATA™ Version 14 software.

Result

Twenty-five studies from 3 world regions with 53,233 participants were enrolled in this meta-analysis. The overall estimated global pooled prevalence of late-stage presentation among cervical cancer patients with a random-effects model was 60.66% (95% CI: 56.27, 65.06). The subgroup analysis revealed that the prevalence of late-stage presentation was 62.60% in Africa, 69.30% in Asia, 46.51% in Europe, and 50.16% in North America. Educational status (p = 0.031) and place of residence (p = 0.004) are determinants of late-stage presentation.

Conclusion

The results of this meta-analysis indicated that the prevalence of late-stage presentation of cervical cancer is substantially high. Place of residence and educational status were significantly associated with late-stage presentation. Health care organizations should work on early screening, management, and on increasing community awareness to minimize late stage at presentation among those patients.

The use, quality and effectiveness of pelvic examination in primary care for the detection of gynaecological cancer: a systematic review

BACKGROUND

Urgent suspected cancer referral guidelines recommend that women with gynaecological cancer symptoms should have a pelvic examination (PE) prior to referral. We do not know to what extent GPs comply, their competency at PE, or if PE shortens the diagnostic interval.

OBJECTIVES

We conducted a systematic review of the use, quality and effectiveness of PE in primary care for women with suspected gynaecological cancer.

METHOD

PRISMA guidelines were followed. Three databases were searched using four terms: PE, primary care, competency and gynaecological cancer. Citation lists of all identified papers were screened independently for eligibility by two reviewers. Data extraction was performed in duplicate and independently. Paper quality was assessed using the relevant Critical Appraisal Skills Programme checklist. Emergent themes and contrasting issues were explored in a narrative ecological synthesis.

MAIN FINDINGS

Twenty papers met the inclusion criteria. 52% or less of women with suspicious symptoms had a PE. No papers directly explored GPs' competence at performing PE. Pre-referral PE was associated with reduced diagnostic delay and earlier stage diagnosis. Ecological synthesis demonstrated a complex interplay between patient and practitioner factors and the environment in which examination is performed. Presenting symptoms are commonly misattributed by patients and practitioners resulting in misdiagnosis and lack of PE.

CONCLUSION

We do not know if pre-referral PE leads to better outcomes for patients. PE is often not performed for women with gynaecological cancer symptoms, and evidence that it may result in earlier stage of diagnosis is weak. More research is needed.

Patient and primary care delays in the diagnostic pathway of gynaecological cancers: a systematic review of influencing factors

BACKGROUND

Gynaecological cancers are the second most common female cancer type, with survival rates in the UK lower than in many comparable countries. A potentially important factor in the UK's poorer cancer outcomes is diagnostic delay; gynaecological cancers are the cancer type most likely to be affected by less timely diagnosis.

AIM

To examine current evidence for factors that contribute to patient and primary care delays in the diagnostic pathway of gynaecological cancer.

DESIGN AND SETTING

A systematic review of the available literature.

METHOD

PRISMA guidelines were followed. MEDLINE and Embase databases and the Cochrane Library were searched using three terms: primary care; gynaecological cancer; and delay. Citation lists of all identified articles were searched. Two authors independently screened the titles, abstracts, and full texts of publications. Data extraction was performed by one author and quality assured by a second reviewer in a 20% sample of selected articles. Synthesis was narrative.

RESULTS

A total of 1253 references was identified, of which 37 met the inclusion criteria. Factors associated with delayed diagnosis were categorised as either patient factors (patient demographics, symptoms or knowledge, and presentation to the GP) or primary care factors (doctor factors: patient demographics, symptoms or knowledge, and referral process); and system factors (such as limited access to investigations).

CONCLUSION

Delayed diagnosis in the patient and primary care intervals of the diagnostic journey of gynaecological cancer is complex and multifactorial. This review identifies areas of future research that could lead to interventions to enable prompter diagnosis of gynaecological cancers.

Patient and disease characteristics associated with late tumour stage at presentation of cervical cancer in northwestern Tanzania

BACKGROUND

About two thirds of patients with cervical cancer in Tanzania present with advanced tumor stage, leading to significant morbidity and mortality. We designed a study to determine the factors associated with the late tumour stage at presentation among patients with cervical cancer in Mwanza.

METHODS

This cross-sectional study recruited women at Bugando Medical Centre (BMC) with histologically confirmed cervical cancer from November 2013 to April 2014. Patients were recruited serially until the sample size was reached.

RESULTS

A total of 202 women with histologically confirmed cervical cancer were recruited. The mean age of the patients was 50.5 ± 13.3 years. The majority of patients (n = 129, 63.9%) were diagnosed with late stage disease (IIB-IVB). Patients also presented with severe anemia (n = 78, 38.6%), urinary tract infections (n = 74, 36.6%), hydronephrosis (n = 43, 21.2%), elevated serum creatinine levels (n = 33, 16.3%), vesicovaginal fistula (VVF), (n = 13, 6.4%), lung metastasis (n = 5, 2.4%), metastasis to the urinary bladder (n = 4, 1.9%), rectovaginal fistula (RVF) (n = 3, 1.4%), liver metastasis (n = 2, 0.9%) and hydroureter (n = 2, 0.9%). In multivariate logistic regression, factors associated with late stage at presentation were attending to alternative health practitioners and lack of personal initiative to seek care to formal health facilities (OR 2.3; 95% CI 1.2-4.2, p = 0.011 and OR 2.0; 95 % CI 1.0-3.8, p = 0.028) respectively.

CONCLUSION

Communities should be sensitized to women's empowerment, provide community education on early symptoms of cervical cancer, and the importance of early hospital attendance.

Factors associated with delayed diagnosis of cervical cancer in Iran--a survey in Isfahan City

BACKGROUND

In the absence of routine screening program for cervical cancer in Iran and high rate of diagnosed cancer in its advanced stage, recognition of sociodemographic factors related to delayed diagnosis of cancer in Iran could be helpful in reducing the burden of disease in our community. The aim of this study was to determine the stage of cervical cancer at diagnosis and factors related to delayed diagnosis of cervical cancer in Isfahan, Iran.

MATERIALS AND METHODS

In this cross sectional study women diagnosed with cervical cancer for the first time by histo-pathological examination were enrolled. According to the clinical and paraclinical findings and staging of the cancer, they were classified into early and delayed diagnosis of cervical cancer. Sociodemographic factors were compared in the two groups.

RESULTS

In this study of 55 women mean age was 48.3±12.0. According to our classification 6/55 (10.9%) and 49/55 (89.1%) of them had early and delayed diagnosis of cervical cancer. Delayed diagnosis of the cancer was significantly higher in patients with lower degree of education, lower socioeconomic status, having smoker and addict husband and those who did not have a history of Pap smear test (p<0.05).

CONCLUSIONS

The results of this study indicated risk factors related to delayed diagnosis of cervical cancer. The affected women should be targeted for implementation of specialized educational programmes for improving knowledge and screening test.

Delays in diagnosis of young females with symptomatic cervical cancer in England: an interview-based study

BACKGROUND

Diagnosis may be delayed in young females with cervical cancer because of a failure to recognise symptoms.

AIM

To examine the extent and determinants of delays in diagnosis of young females with symptomatic cervical cancer.

DESIGN AND SETTING

A national descriptive study of time from symptoms to diagnosis of cervical cancer and risk factors for delay in diagnosis at all hospitals diagnosing cervical cancer in England.

METHOD

One-hundred and twenty-eight patients <30 years with a recent diagnosis of cervical cancer were interviewed. Patient delay was defined as ≥3 months from symptom onset to first presentation and provider delay as ≥ 3 months from first presentation to diagnosis.

RESULTS

Forty (31%) patients had presented symptomatically: 11 (28%) delayed presentation. Patient delay was more common in patients <25 than patients aged 25-29 (40% versus 15%, P = 0.16). Vaginal discharge was more common among patients who delayed presentation than those who did not; many reported not recognising this as a possible cancer symptom. Provider delay was reported by 24/40 (60%); in some no report was found in primary care records of a visual inspection of the cervix and some did not re-attend after the first presentation for several months. Gynaecological symptoms were common (84%) among patients who presented via screening.

CONCLUSIONS

Young females with cervical cancer frequently delay presentation, and not recognising symptoms as serious may increase the risk of delay. Delay in diagnosis after first presentation is also common. There is some evidence that UK guidelines for managing young females with abnormal bleeding are not being followed.

Factors associated with late diagnosis of cervical cancer in Nepal

BACKGROUND

The majority of cervical cancers, the most prevalent cancer among Nepali women, are diagnosed in advanced stage leading to high mortality in Nepal. The present study explored factors associated with late diagnosis.

MATERIALS AND METHODS

A cross-sectional study was carried out in two specialized cancer hospitals of Nepal from August 12 to October 12, 2012. Randomly selected 110 cervical cancer patients were interviewed and their medical records were reviewed. Multivariate logistic regression analysis was performed to predict associations.

RESULTS

Mean age of patients was 52.7years (SD=10.6), 66% were illiterate and 77% were rural inhabitants. Medical shops (33.6%) and private hospitals (31%) were major first contact points of patients with health care providers (HCP). There was no cervical/per-speculum examination (78.2%) and symptoms misinterpretation (90%) of patients occurred in initial consultation with HCP. Four in every five cases (80.9%) of cervical cancer had late diagnosis. Literate women (adjusted OR=0.121, CI: 0.030-0.482) and women having abnormal vaginal bleeding as early symptom (adjusted OR=0.160, CI: 0.035-0.741) were less likely to suffer late diagnosis. Women who shared their symptoms late (adjusted OR=4.272, CI: 1.110-16.440) and did so with people other than their husband (adjusted OR=12.701, CI: 1.132-142.55) were more likely for late diagnosis.

CONCLUSIONS

High level of illiteracy among women and their problematic health seeking behavior for gynecological symptoms are responsible for late diagnosis of cervical cancer in Nepal. In the absence of a routine screening program, prevention interventions should be focused on raising awareness of gynecological symptoms and improving health seeking behavior of women for such symptoms.

Estimates of delays in diagnosis of cervical cancer in Nepal

BACKGROUND

Cervical cancer is the leading cause of cancer related deaths among women in Nepal. The long symptom to diagnosis interval means that women have advanced disease at presentation. The aim of this study was to identify, estimate and describe the extent of different delays in diagnosis of cervical cancer in Nepal.

METHODS

A cross-sectional descriptive study was conducted in two tertiary cancer hospitals of Nepal. Face to face interview and medical records review were carried out among 110 cervical cancer patients. Total diagnostic delay was categorized into component delays: patient delay, health care providers delay, referral delay and diagnostic waiting time.

RESULTS

Total 110 patients recruited in the study represented 40 districts from all three ecological regions of the country. Median total diagnostic delay was 157 days with more than three fourth (77.3%) of the patients having longer total diagnostic delay of >90 days. Out of the total diagnostic delay, median patient delay, median health care provider delay, median referral delay and median diagnostic waiting time were 68.5 days, 40 days, 5 days and 9 days respectively. Majority of the patients had experienced longer delay of each type except referral delay. Fifty seven percent of the patients had experienced longer patient delay of >60 days, 90% had suffered longer health care provider delay of >1 week, 31.8% had longer referral delay of >1 week and 66.2% had waited >1 week at diagnostic center for final diagnosis. Variation in each type of delay was observed among women with different attributes and in context of health care service delivery.

CONCLUSIONS

Longer delays were observed in all the diagnostic pathways except for referral delay and diagnostic waiting time. Among the delays, patient delay is of crucial importance because of its longer span, although health care provider delay is equally important. In the context of limited screening services in Nepal, the efforts should be to reduce the diagnostic delay especially patient and health care provider delay for early detection and reduction of mortality rate of cervical cancer.

Measuring the nature and duration of symptoms of cervical cancer in young women: developing an interview-based approach

BACKGROUND

Some young women experience delays in diagnosis of cervical cancer, but little research about ways of studying these delays has been published. A major challenge is that gynaecological symptoms are common in young women, but cervical cancer is rare. This study describes the development and testing of a measure for studying delays in diagnosis in young women with cervical cancer.

METHODS

Prospective development of an interview measure and testing of its ability to reliably and systematically collect relevant data in two large hospitals in London, UK using 27 women aged 18-40 diagnosed with cervical cancer in the previous two years. We developed a semi-structured interview schedule and data extraction form to systematically collect data on symptoms (including nature and duration) and risk factors for delayed diagnosis from young women with cervical cancer. We piloted the measure among young women with cervical cancer (audiorecording it with their permission), refining it iteratively. To complete the measure, we developed a database for managing the data and a manual for using the schedule. Two researchers extracted data from the recorded interviews to assess inter-rater reliability.

RESULTS

The final interview schedule yielded quantitative data on the nature and duration of symptoms and risk factors for delayed diagnosis. Inter-rater reliability was high. In the pilot, 12 of the 27 women were diagnosed via symptomatic presentation. Median time from the symptom triggering presentation to presentation was one month (interquartile range 0-4 months). Median time from presentation to diagnosis was three months (interquartile range 1-8.5 months).

CONCLUSIONS

We have developed a reliable tool for measuring the nature and duration of symptoms in young women with cervical cancer. Pilot data suggest that a substantial proportion of women experience delay between first presentation and diagnosis.

Timeliness of cervical cancer diagnosis and initiation of treatment in the National Breast and Cervical Cancer Early Detection Program

OBJECTIVES

To examine time intervals from cervical cancer screening to diagnosis and treatment initiation among low-income and uninsured women in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) during two consecutive time periods.

METHODS

We analyzed NBCCEDP data for women with abnormal Pap tests (n=100,167), from which 1,417 invasive cervical cancers were diagnosed. We examined two time intervals for this study: diagnostic interval (time from abnormal Pap test to the date of definitive diagnosis) and treatment initiation interval (time from definitive diagnosis to treatment initiation) for two time periods: 1996-2002 and 2003-2009. We compared median time intervals for diagnostic and treatment initiation using the Kruskal-Wallis test. Adjusted proportions (predicted marginals) were calculated using logistic regression to examine diagnosis and treatment within program benchmarks (≤60 days).

RESULTS

Median diagnostic intervals decreased overall by 6 days (54 vs. 48 days, p<0.001). This decrease in the median diagnostic interval was noted for all variables examined. The median treatment initiation intervals remained stable over the two time periods.

CONCLUSIONS

Women screened by the NBCCEDP receive diagnostic follow-up and initiate treatment within preestablished program guidelines.

Reasons for diagnostic delay in gynecological malignancies

INTRODUCTION

To describe the different delay types in women with gynecological cancer and to analyze the relationship between diagnostic delay and a number of characteristics for patients, cancers, and the health care system.

METHOD

Data were obtained from 4 different questionnaires, the Electronic Patient Journal (EPJ), and the Danish Gynecological Cancer Database (DGCD). A total of 161 women with ovarian cancer (63), endometrial cancer (50), cervical cancer (34), and vulvar cancer (14) were included. Outcome measures were different delay types counted in days and 4 clinically important variables' impact on the diagnostic delay: presence of alarm symptoms, age (divided into 2 groups: ≤60 or >60 years), performance of gynecological examination by the general practitioner (GP), and notification of cancer suspicion on first referral from GP.

RESULTS

Across cancer types, median total delay was 101 days. Some 10% of women experienced the longest delay with a total delay of 436 days or more. Vulva cancer had the longest delay, whereas women with ovarian cancer had the shortest delay. More than one third (39%) of the women consulted their GP for reasons other than the predefined alarm symptoms. Gynecological examination by the GP was less likely to be performed if the woman did not present with vaginal bleeding. The length of the delay was shortened by performance of a gynecological examination by the GP and a primary referral from the GP raising the receiver's suspicion of cancer.

CONCLUSION

Reducing diagnostic delays should be achievable, particularly for those most delayed, and interventions aimed at reducing delays need to be developed. Creation of new valid instruments for measuring delay is essential in future research.

Human papillomavirus type 16 e6 gene variations in young Chinese women with cervical squamous cell carcinoma

Human papillomavirus (HPV) 16 E6 gene mutation is considered an important genetic change in cervical lesion progression. To explore the possible association of specific HPV16 E6 sequence variations with the development of invasive cervical squamous cell carcinoma (SCC) in young women, we examined the distribution of HPV16 E6 variants in a Chinese cervical SCC population and analyzed the difference between younger patients (≤35 years, n = 50) and older ones (>35ys, n = 71). Human papillomavirus type 16 E6 DNA was amplified by polymerase chain reaction and sequenced by Sanger fluorescent dye dideoxy-termination method. Analysis revealed that the most frequently found variation in this Chinese population was the EV (As) lineage (65.45%). In addition, the EV (As) lineage seems more common and uniform in younger patients than other lineages, and it may be associated with early age at diagnosis of cervical SCC in young women.