title: Predictors of Timely Access of Oncology Services and Advanced-Stage Cancer in an HIV-Endemic Setting.
abstract: Three-quarters of cancer deaths occur in resource-limited countries, and delayed presentation contributes to poor outcome. In Botswana, where more than half of cancers arise in HIV-infected individuals, we sought to explore predictors of timely oncology care and evaluate the hypothesis that engagement in longitudinal HIV care improves access.
  
  
  
  Consenting patients presenting for oncology care from October 2010 to September 2014 were interviewed and their records were reviewed. Cox and logistic models were used to examine the effect of HIV and other predictors on time to oncology care and presentation with advanced cancer (stage III or IV).
  
  
  
  Of the 1,146 patients analyzed, 584 (51%) had HIV and 615 (54%) had advanced cancer. The initial clinic visit occurred a mean of 144 days (median 29, interquartile range 0-185) after symptom onset, but subsequent mean time to oncology care was 406 days (median 160, interquartile range 59-653). HIV status was not significantly associated with time to oncology care (adjusted hazard ratio [aHR] 0.91, 95% confidence interval [CI] 0.79-1.06). However, patients who reported using traditional medicine/healers engaged in oncology care significantly faster (aHR 1.23, 95% CI 1.09-1.40) and those with advanced cancer entered care earlier (aHR 1.48, 95% CI 1.30-1.70). Factors significantly associated with advanced cancer included income <$50 per month (adjusted odds ratio [aOR] 1.35, 95% CI 1.05-1.75), male sex (aOR 1.45, 95% CI 1.12-1.87), and pain as the presenting symptom (aOR 1.39, 95% CI 1.03-1.88).
  
  
  
  Longitudinal HIV care did not reduce the substantial delay to cancer treatment. Research focused on reducing health system delay through coordination and navigation is needed.
  
  
  
  The majority (54%) of patients in this large cohort from Botswana presented with advanced-stage cancer despite universal access to free health care. Median time from first symptom to specialized oncology care was 13 months. For HIV-infected patients (51% of total), regular longitudinal contact with the health system, through quarterly doctor visits for HIV management, was not successful in providing faster linkages into oncology care. However, patients who used traditional medicine/healers engaged in cancer care faster, indicating potential for leveraging traditional healers as partners in early cancer detection. New strategies are urgently needed to facilitate diagnosis and timely treatment of cancer in low- and middle-income countries.
authors.affiliation: Botswana Harvard AIDS Institute, Gaborone, Botswana Emory Rollins School of Public Health, Atlanta, Georgia, USA carolyn.brown.a@gmail.com.
authors.forename: Carolyn A
authors.initials: CA
authors.lastname: Brown
authors.affiliation: Department of Radiation Oncology, University of Utah, Salt Lake City, Utah, USA.
authors.forename: Gita
authors.initials: G
authors.lastname: Suneja
authors.affiliation: University of Botswana School of Medicine, Gaborone, Botswana Department of Oncology, Princess Marina Hospital, Gaborone, Botswana.
authors.forename: Neo
authors.initials: N
authors.lastname: Tapela
authors.affiliation: Botswana Harvard AIDS Institute, Gaborone, Botswana.
authors.forename: Abigail
authors.initials: A
authors.lastname: Mapes
authors.affiliation: Ministry of Health Botswana, Gaborone, Botswana.
authors.forename: Malebogo
authors.initials: M
authors.lastname: Pusoentsi
authors.affiliation: Botswana Harvard AIDS Institute, Gaborone, Botswana.
authors.forename: Mompati
authors.initials: M
authors.lastname: Mmalane
authors.affiliation: Botswana Harvard AIDS Institute, Gaborone, Botswana.
authors.forename: Ryan
authors.initials: R
authors.lastname: Hodgeman
authors.affiliation: Botswana Harvard AIDS Institute, Gaborone, Botswana Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, USA.
authors.forename: Matthew
authors.initials: M
authors.lastname: Boyer
authors.affiliation: Department of Oncology, Princess Marina Hospital, Gaborone, Botswana.
authors.forename: Zola
authors.initials: Z
authors.lastname: Musimar
authors.affiliation: Botswana-UPenn Partnership Health Program, Gaborone, Botswana.
authors.forename: Doreen
authors.initials: D
authors.lastname: Ramogola-Masire
authors.affiliation: Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Surbhi
authors.initials: S
authors.lastname: Grover
authors.affiliation: Department of Oncology, Gaborone Private Hospital, Gaborone, Botswana.
authors.forename: Memory
authors.initials: M
authors.lastname: Nsingo-Bvochora
authors.affiliation: Anatomic Pathology, National Health Laboratory, Gaborone, Botswana.
authors.forename: Mukendi
authors.initials: M
authors.lastname: Kayembe
authors.affiliation: Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Jason
authors.initials: J
authors.lastname: Efstathiou
authors.affiliation: Botswana Harvard AIDS Institute, Gaborone, Botswana Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, USA Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.
authors.forename: Shahin
authors.initials: S
authors.lastname: Lockman
authors.affiliation: Botswana Harvard AIDS Institute, Gaborone, Botswana Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, USA Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.
authors.forename: Scott
authors.initials: S
authors.lastname: Dryden-Peterson
mesh_terms: D000328:Adult; D001902:Botswana; D005260:Female; D015658:HIV Infections / Q000150:complications*; D006297:Health Services Accessibility; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D009369:Neoplasms / Q000473:pathology / Q000628:therapy*; D016016:Proportional Hazards Models
keywords: Advanced-stage cancer; Botswana; Cancer; HIV; Timely oncology care