Surgery waiting time and its associated factors among patients with early stage breast cancer at Mulago hospital: A retrospective study.

Abstract

Introduction. Breast cancer whose primary treatment is surgery is considered to be a cancer with a favorable prognosis (Walker, Walker et al. 1984) and this has been demonstrated in the high income countries (HICs) (SEER 1975-2002). However in the low and middle income countries (LMICs) cancer survival rates have remained low (Galukande, Wabinga et al. 2015, Ali-Gombe, Mustapha et al. 2021).The major factors attributable to this poor survival observed in Sub-Sahara Africa (SSA) are multifactorial and include the patient related characteristics and health system related characteristics (Tegegne, Chojenta et al. 2018) which ultimately result in late stage at diagnosis when treatment is often less effective and yet more expensive (Brand, Qu et al. 2019, Qu, Brand et al. 2020) and poor access to quality healthcare services (Fitzmaurice, Allen et al. 2017, Dalton, Holzman et al. 2019).Treatment of women with early stage breast cancer (ESBC) has a significantly higher survival rate as compared to those with metastatic disease and this has generally been observed even in the HICs (Swaminathan, Lucas et al. 2011). Because there are few effective primary prevention strategies for BC (Caplan and Helzlsouer 1992)timely diagnosis and treatment is therefore critical in optimizing the surgery waiting time and improving cancer survival and cancer care outcomes (Wells, Battaglia et al. 2008, World Health 2017, Moodley, Cairncross et al. 2018). The objective of this study therefore was to quantify the time interval between breast cancer diagnosis with decision to offer surgery as primary treatment and the actual day of surgery, identify the factors associated with surgery waiting time and determine the prevalence of surgery delay among patients with ESBC attending Mulago National Referral Hospital (MNRH). Methods: Four hundred and ninety three patients with a pathological diagnosis of early stage breast cancer were enrolled into this single institution retrospective descriptive study. The primary outcome measured was surgery waiting time and the secondary outcome variable measured was prevalence of surgery delay. The independent variables examined were the socio-demographics; age, occupation, education level, marital status, menopausal status, and family history of breast malignancy, personal health related behaviors and the clinico-pathological characteristics; breast symptoms, history of comorbidities, clinical stage, tumor size, tumor palpability, lymph node status, tumor histological type and histological grade and tumor receptor status and the health facility related factors; symptom evaluation methods, post diagnosis imaging techniques, biopsy techniques and the surgery techniques. Stata SE 14 version was used to analyze the data. Descriptive analysis of continuous data was done using median and frequencies to summarize the sociodemographic, clinico-pathological and health system related characteristics of the patients. Categorical variables were expressed in the form of absolute numbers and relative frequencies. The median (interquartile range) surgery waiting time in this study was determined. Prevalence of surgery delay was assessed as a surgery waiting time of more than 30 days. Non parametric statistical tests were used to analyze the relationship between the surgery waiting time and the different patient and health system characteristics. For two group independent variables the Mann Whitney-U test was used and for more than two group independent variables Kruskal Wallis rank sum test was used. Binary Logistic regression was used to analyze the relationship between the predictor variables and surgery delay and results reported in terms of odds ratio (OR), p-value and 95% Confidence interval. Surgery delay was set at a cut of >30 days. Results. The median age of study participants was 54 years (30, 49). The median (IQR) surgery waiting time was 44 (30, 49) days. Age was significantly associated with SWT (p<0.0001) with low median SWTs (27days) observed among the younger women (<40). Education status,occupation status, health related behavior and family history of breast cancer were also significantly associated with SWT (p<0.0001) with lower median SWTs observed among the educated (30days), employed (39days), those with positive HRBe (40days), and those with a positive family history of BC (30days). Clinicopathological characteristics; type of breast symptoms, tumour size, lymph node status, clinical stage, histological grade, and triple negative status were all significantly associated with SWT (p<0.0001). All the health facility related factors were significantly associated with SWT (p<0.0001) with low median SWT reported among those with breast conservation surgery (27.5 days), no axillary clearance (30days), clinical symptom evaluation (40.0 days). The prevalence of surgery delay was 71.8%. Conclusion. This study demonstrated a high prevalence of surgery delay (71.8%). The factors significantly associated with SWT included advanced age at diagnosis, lack of resources and lack of adequate knowledge about the importance of early diagnosis as well as due to delays in the health facility care pathways and so there is need to create public awareness about the importance of early diagnosis of the disease, and the health care providers and managers in the health facilities need to make an effort to reduce the health system related delays observed. Key words: early breast cancer, surgery waiting time, primary treatment, diagnosis.