Changes in Cervical Cancer Stage at Diagnosis in Zambia over 15 years

doi:10.21203/rs.3.rs-5227892/v1

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Research Article

Changes in Cervical Cancer Stage at Diagnosis in Zambia over 15 years

https://doi.org/10.21203/rs.3.rs-5227892/v1

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Purpose

This study explored the trend for change in the proportion of late-stage cervical cancer at one cancer center in Zambia from 2008–2022.

Method

This study included data of 5,755 cervical cancer patients seen at the Cancer Diseases Hospital (CDH) in Lusaka, Zambia between 2008 and 2022. The data included information about patient age, year of diagnosis, FIGO stage at diagnosis, HIV status, marital status, employment status, region of residence, and cervical screening history. We evaluated the stage at diagnosis over three time periods (2008–2012, 2013–2017, 2018–2022). Regression analysis identified the predictors of late-stage presentation.

Results

The proportion of late-stage presentation (Stages III and IV) decreased during 2013–2017 compared to the late stages during 2008–2012 (OR: 0.70, 95% CI: 0.60–0.80). Subsequently, late-stage presentation increased during 2013–2017 compared to 2018–2022 (OR: 0.80, 95% CI: 0.71, 0.91). Women who were divorced or widowed, unemployed, and lived in provinces distant from Lusaka were more likely to present with late-stage diagnoses, irrespective of the time period.

Conclusion

Although there was an initial decrease in late-stage diagnoses during 2008–2012 compared to 2013–2017, the trend reversed from 2018–2022. The increase in the proportion of late-stage presentations in 2018–2022 is probably due to lack of treatment availability and low visual inspection of the cervix with acetic acid (VIA) screening sensitivity. Increasing the accessibility and availability of cervical cancer treatment and educating the vulnerable and risk-groups about the importance of screening may lead to early detection and downstaging in Zambia and other low-income countries.

Cervical cancer ranks as the fourth most common cancer for women in terms of incidence and mortality globally. Based on the estimates from the International Agency for Research on Cancer (IARC) in 2022, the incidence rate of cervical cancer was 18.7 per 100,000 women and the mortality rate was 8.9 per 100,000 women in 2022[1]. The burden of cervical cancer disproportionately affects women in sub-Saharan Africa. Of 25 countries where the most commonly diagnosed cancer for women is cervical cancer, 23 of them are from sub-Saharan Africa. The cervical cancer incidence rate in Zambia was 37.0 per 100,000 women, and the mortality rate was 23.3 per 100,000 women in 2022[1]. The country ranks fifth globally in incidence and eighth in mortality[2].

Late-stage cervical cancer diagnosis is associated with worse survival outcomes and higher mortality in Sub-Saharan Africa.[3] Early detection leads to better treatment outcomes and reduces deaths attributed to cervical cancer. Our previous research at the Cancer Diseases Hospital (CDH) in Lusaka, Zambia on cervical cancer from 2008–2012, showed a high proportion of patients presenting with late-stage diagnosis[4]. Patients in the Western and Southern provinces of Zambia had late-stage presentation than those in the Lusaka province. In addition, HIV status did not affect the progression of the stage[5, 6]. However, we did not explore these associations for patients seen after 2012 and how the presentation of late-stage diagnosis is relevant to sociodemographic factors.

The CDH was opened in 2007 in Lusaka as the only centralized treatment center for cancer patients in Zambia. In 2016 the first National Cancer Control Strategic Plan (NCCSP) was launched for 2016–2021. To continue the progress of the first plan, a second strategic plan was announced for 2022–2026. The strategic plans targeted multiple aspects of cancer control, including raising awareness of women, early detection, and improving the health care infrastructure for diagnosis and treatment. By 2021, cervical cancer screening has been available in 111 out of 118 districts in the country[7]. Zambia also expanded diagnostic services for cancer over the past decade; pathology laboratory units have been established in 5 out of the 10 provinces, and 6 provinces have imaging services[7]. Many district and provincial-level hospitals also offer diagnostic, surgery, and palliative services for cervical cancer [7, 8].

Irrespective of the change in the availability of diagnosis and screening services, the change in cervical cancer stage at diagnosis over time in Zambia remains unexplored. Therefore, we conducted this study to evaluate the late-stage cervical cancer over 15-year period (2008 to 2022). We also aimed to identify sociodemographic factors associated with late-stage diagnosis.

Study Population

The study population included medical record data of 5755 cervical cancer patients seen at the CDH during 2008 to 2022. The CDH is the only specialized cancer diagnosis and treatment center in Zambia that offers comprehensive cancer management and the only hospital in Zambia that provides radiotherapy. Zambia adopted a centralized approach for the management of cancer patients, as all patients with confirmed cancer diagnoses are referred to the CDH for treatment. Therefore, the CDH is the hospital where the vast majority of cervical cancer patients are diagnosed and treated in the country.

The data for this study was assembled from four sources; a) the CDH electronic logbooks; b) the paper-based medical records of the CDH; c) the electronic databases of the CDH; d) and raw data from our previous study⁴. Linking the databases and determining the final study population that is included in this study is illustrated in Fig. 1. More details about the variables within the data source are described in the data collection section.

Inclusion and Exclusion Criteria

The patients in this study included women with confirmed cervical cancer who were referred to the CDH for further management. We excluded 55 patients whose age of diagnosis was less than 18 years or missing. Patients with medical records established at the CDH for cervical cancer treatment from January 1, 2008, to December 31, 2022, were included in the study. Patients with missing or undetermined cancer stage were excluded from the final analysis. Patients who were not Zambian citizens were excluded from the analysis.

Data Collection

Variables included in the final analysis included: a) age at diagnosis, b) HIV status, c) region of residence, d) employment status, e) marital status, f) FIGO stage, and g) cervical screening history. We first extracted all variables of interest from eligible patients from three sources: a) the cervical cancer research database; b) the data from the previous study⁴; and c) the electronic registry logbook of the CDH. Additionally, we found information on missing variables from paper medical records for patients from 2013 to 2022. For the year 2013, only 77 patients were included in the study as most of the medical records from the year were missing from the medical record room at the CDH.

Data Management

The primary outcome of interest for the study was the FIGO stage of cervical cancer diagnosis. Patients were classified into four stages: I, II, III, and IV. The FIGO stages were further classified into two categories where stages I and II were considered “early stage” and stages III and IV were considered “late stage”.

Marital status was classified as married, widowed or divorced, and single. Employment status was coded as “employed” if the woman had formal employment. Patients were coded as “screened” if the CDH record documented a history of screening before referral (e.g. a referral letter was found in the file) or if the patient had a record indicating cervical cancer screening within the SGKCDH database. The patients were coded as “not screened”, if the medical record indicated other sources of referral for management. The region of residence of the women was determined based on patient residential address and anyone from Luapula, Muchinga, Northern, North-western, and Western province was coded as “other province”. All the missing characteristics were categorized as unknown.

Statistical Analysis

We explored the differences in descriptive characteristics of the study population, comparing patients with early-stage versus late-stage diagnosis. Patient characteristics included age at diagnosis, HIV status, marital status, employment status,, cervical screening history, and region of residence. We performed a chi-square test for categorical variables and a t-test.

We analyzed the change in the proportion of late-stage cervical cancer by three time periods based on the patient date of registration: 2008–2012, 2013–2017, and 2018–2022. Logistics regression was performed to predict stage at diagnosis: a) used logistic regression model to predict late-stage versus early-stage across the three time periods; b) we analyzed the changes in the proportion of stages within the early-stage and late-stage categories (stage I versus stage II, stage III versus stage IV) based on the year of diagnosis. In both analyses, we calculated both the crude model and the adjusted model. The covariates of interest for the analysis included age at diagnosis, HIV status, marital status, employment status, and region of residence. In addition, a multivariate regression model was developed to explore sociodemographic factors associated with late-stage diagnosis. Sociodemographic factors in the model included age at diagnosis, HIV status, marital status, employment status, and region of residence. HIV-negative, married, employed, and having residence in Lusaka province were utilized as the reference categories. All statistical tests were two-sided and utilized a significance level of 0.05. Analyses were performed using the SAS statistical software package (release 9.4; SAS Institute, Inc., Cary, NC).

Ethical Considerations

The study was approved by the Institutional Review Board at Columbia University [IRB-AAAV1519] and the University of Zambia Biomedical Research Ethics Committee (UNZABREC) [Ref. No. 5411 − 2024]. Written permission to carry out the study was also obtained from the management of the Cancer Diseases Hospital.

Population Characteristics

A total of 6,626 cervical cancer patients diagnosed between 2008 to 2022 were identified, and 5,775 patients with known stage information were included in the final analysis. Eight hundred and fifty-one patients with unknown stage or recurring cervical cancer were excluded. Table 1 presents the descriptive statistics for the patients included in the final analysis. The total number of patients with early-stage diagnosis and late-stage diagnosis was almost even, with 2,899 (50.20%) patients with early-stage diagnosis and 2,876 (49.80%) patients with late-stage diagnosis. Most of the cervical cancer patients had either a stage II diagnosis (42.86%) or a stage III diagnosis (40.59%). The average age at diagnosis was 50.83, and the median age was 49, with a standard deviation of 21.14 years old. Lusaka province had the greatest number of patients (1,844). The information on the screening history of cervical cancer patients was very limited, with 11.84% of the patients not screened, 4.95% of the patients screened, and 83.2% of the patients’ screening history unknown. There was no significant difference in the age of diagnosis, HIV status, and screening history between the patients with early-stage diagnosis and patients with late-stage diagnosis. About 40.21% of the patients were HIV negative, and 38.18% of the patients were HIV positive, with 21.61% of the patient’s HIV status unknown. The total number of patients increased greatly in 2018–2022 to 2728 patients (47.88%) in comparison to 2008–2012(n = 1816) and 2013–2017(n = 1154).

Table 1

Descriptive Characteristics of Cervical Cancer Patients at CDH by Stage Diagnosis, 2008–2022(n = 5775)
	Early-stage (n = 2899,50.20%)		Late-stage (n = 2876, 49.80%)		Total (n = 5775)		P-value
Age at Diagnosis							0.160
Mean	50.44		51.22		50.83
SD	21.19		21.08		21.14
Median	49		49		49
	N	%	N	%	N	%	P-value^a
Year of Diagnosis							< 0.001*
2008–2012	830	28.63	986	34.28	1816	31.45
2013–2017	674	23.25	557	19.37	1231	21.32
2018–2022	1395	48.12	1333	46.35	2728	47.24
HIV (n = 4527)							0.462
Negative	1212	50.78	1110	51.87	2322	51.29
Positive	1175	49.22	1030	48.13	2205	48.71
Employment status (n = 5143)							< 0.001*
Unemployed	1875	72.12	1966	77.31	3841	74.68
Employed	725	27.88	577	22.69	1302	25.32
Marital Status (n = 5373)							< 0.001*
Married	1598	59.16	1415	52.96	3013	56.08
Single	297	11	327	12.24	624	11.61
Widowed/Divorced	806	29.84	930	34.81	1736	32.31
Region of Residence (n = 4876)							0.004*
Central	283	11.67	265	11.13	548	11.4
Copperbelt	442	18.22	397	16.68	839	17.46
Eastern	233	9.6	230	9.66	463	9.63
Lusaka	945	38.95	899	37.77	1844	38.37
Southern	262	10.8	273	11.47	535	11.13
Other	261	10.76	316	13.28	577	12.01
Screening (n = 970)							0.128
Not Screened	358	74.62	326	79.04	684	76.66
Screened	160	25.38	126	20.96	286	23.34
* p-value < 0.05
^a The chi-square test is run based on completed patients, removing patients within the unknown category, the total sample size is reported in superscripts next to the category title

The trend of Stage Diagnosis of Cervical Cancer over time

The proportion of late-stage diagnosis versus early-stage diagnosis for different years of diagnosis was presented in Fig. 2. In 2008–2012, 54.3% of the patients with confirmed cervical cancer had a late-stage diagnosis. We compared this proportion with those in 2013–2017 (45.25%) and in 2018–2022 (48.86%) by running a logistic regression model on the stage of diagnosis to the year of diagnosis, and the model output is described in Table 2. The odds of having a late-stage diagnosis were significantly higher in 2008–2012 when compared to the later two time periods. However, the odds of having late-stage diagnoses (OR: 1.16, 95% CI: 1.01–1.32) were significantly lower in 2013–2017 when compared to 2018–2022. The associations were still statistically significant in the adjusted model considering covariates including marital status, employment status, HIV status, region of residence, and age at diagnosis. This indicated that downstaging was achieved for cervical cancer diagnosis from 2008 to 2017, but in more recent years, we identified an upstaging trend in cervical cancer diagnosis at the hospital.

Table 2

Crude and Adjusted Regression of the Prediction of stage of diagnosis based on the year of diagnosis for women with cervical cancer at CDH (n = 5775)
Effect	Crude Model				Adjusted Model^c
Effect	OR Point Estimate	95% Confidence Limits		P-value	OR Point Estimate	95% Confidence Limits		P-value
2013–2017 vs 2008-2012^a	0.70	0.60	0.80	< 0.001*	0.60	0.48	0.74	< 0.001*
2018–2022 vs 2008-2012^b	0.80	0.71	0.91	< 0.001*	0.73	0.62	0.87	< 0.001*
2018–2022 vs 2013-2017^b	1.16	1.01	1.32	0.035*	1.23	1.02	1.48	0.034*

^a Using 2008–2012 as the reference period

^b Using 2013–2017 as the reference period

^c Adjusting for: HIV status, employment status, marital status, age at diagnosis, and region of residence (2723 observations are removed from the model due to missing value of HIV status, employment status, marital status or region of residence, final n = 3052)

*p-value < 0.05

Results for comparing the proportion of FIGO stage diagnosis within the early-stage category and late-stage category respectively are presented in Table 3. The proportion of patients with stage I diagnosis increased from 5.62% in 2008–2012 to 7.8% in 2013–2017 to 8.28% in 2018–2022. The change in the proportion of stage I diagnosis versus stage II diagnosis was significant when comparing the period of 2008–2012 with the period of 2018–2022. The association was significant in the adjusted model as well. A significant change in the proportion of patients presenting with stage III diagnosis compared to stage IV diagnosis was observed across years of diagnosis in the crude model while using 2013–2017 as the reference period. However, no significant association was found in the adjusted model.

Table 3

Crude and Adjusted Regression of the FIGO stage of diagnosis by Year of Diagnosis for women with cervical cancer at CDH within the early-stage diagnosis and late-stage diagnosis categories, 2008–2022 (n = 5775)
FIGO Stage	Year	Crude Model				Adjusted Model¹
FIGO Stage	Year	OR	95% Confidence Limits		P-value	OR	95% Confidence Limits		P-value
I versus II	2013–2017 vs 2008–2012¹	1.19	0.88	1.60	0.266	1.30	0.84	2.02	0.240
	2018–2022 vs 2008–2012¹	1.38	1.07	1.77	0.012*	1.75	1.20	2.54	0.004*
	2018–2022 vs 2013–2017²	1.16	0.90	1.51	0.250	1.34	0.95	1.89	0.092
III versus IV	2013–2017 vs 2008–2012¹	1.46	1.09	1.94	0.010*	1.11	0.72	1.69	0.640
	2018–2022 vs 2008–2012¹	0.96	0.78	1.18	0.669	0.88	0.64	1.21	0.419
	2018–2022 vs 2013–2017²	0.66	0.50	0.86	0.003*	0.79	0.54	1.17	0.238

¹Adjusting for Age at diagnosis, HIV status, Employment status, Marital Status, and Region of Residence

*p-value < 0.05

Sociodemographic Factors Associated with Late-Stage Cervical Cancer at Diagnosis

Table 4 demonstrates the output of the multivariate model regarding sociodemographic factors associated with late-stage cervical cancer at diagnosis. Screening history was excluded from the multivariate model since a significant proportion of the patients’ screening history was undetermined. A total of 3,052 patients were utilized for complete case analysis. Women who were divorced or widowed were found to have higher odds of late-stage diagnosis (OR: 1.31, 95% CI: 1.12–1.54) in comparison to women who were married. Women who are employed were found to have decreased odds of late-stage diagnosis (OR: 0.72, 95% CI: 0.61–0.85) compared to unemployed women. People who lived in Luapula, Muchinga, Northwestern, Northern, and Western provinces also had higher odds of presenting with late-stage cervical cancer at diagnosis (OR: 1.30, 95% CI: 1.02–1.66) compared to people who lived in the Lusaka province. HIV status and age at diagnosis were not significantly associated with late-stage diagnosis in the multivariate model.

Table 4

Social Demographic Factors Associated with Late-stage Diagnosis (n = 3052)
Late Stage at Diagnosis	Adjusted OR¹	95% CI		P-value
Age At Diagnosis	1.00	1.00	1.00	0.557
HIV Positive versus HIV Negative	0.99	0.85	1.15	0.883
Single versus Married	1.18	0.93	1.49	0.174
Widowed/Divorced versus Married	1.31	1.12	1.54	0.001*
Unemployed versus Employed	1.391	1.17	1.64	< 0.001*
Central province versus Lusaka province	0.95	0.74	1.21	0.657
Copperbelt province versus Lusaka province	0.95	0.77	1.17	0.634
Eastern province versus Lusaka province	0.97	0.75	1.26	0.832
Other provinces versus Lusaka province	1.30	1.02	1.66	0.034*
Southern province versus Lusaka province	1.14	0.90	1.45	0.294

¹ Adjusted for age at diagnosis, HIV status, marital status, employment status, and region of residence

*p-value < 0.05

Notes: 2723 patients are removed due to incomplete information

This study revealed the following interesting findings. First, the proportion of late-stage diagnoses decreased from 2008–2012 in comparison to 2013–2017. Subsequently, the proportion of late-stage diagnoses increased in 2018–2022 compared to 2013–2017. Secondly, women who were divorced/widowed had higher odds of presenting with late-stage cervical cancer than women who were married. Thirdly, unemployed women were more likely to have a late-stage diagnosis than employed women. Lastly, women who came from regions that were more distant from Lusaka province were more likely to present with late stage.

Comparing patients from 2008–2012 with patients from 2013–2017, the proportion of patients presenting with late-stage cervical cancer decreased. The proportion of patients presenting with stage I diagnoses increased steadily across the three periods. The proportion of stage I diagnoses in comparison to stage II diagnoses significantly increased between 2008–2012 and 2018–2022. In July 2007, CDH opened as a centralized treatment center for cancer. In 10 years, the awareness of the availability of cancer treatment at CDH gradually increased, and treatment through radiotherapy and chemotherapy was available consistently. However, there was an increase in the proportion of patients presenting with late stage from 2018–2022 compared to patients from 2013–2017. There are three possible reasons for the increase in late-stage presentations in 2018–2022: a) the expansion of diagnostic service due to NCCSP; b) disruption in radiotherapy treatment in 2022; and c) the low detection rate of the cervical screening program. Implementation of the first NCCSP in 2016 led to the expansion of histopathology and diagnostic facilities, so more patients were referred to CDH for 2018–2022 than in the first two periods. A low level of awareness and knowledge of cervical cancer led most patients to present for diagnosis at a later stage. Despite diagnostic services becoming more accessible, the overall turnaround time from biopsy to confirmed stage diagnosis for cervical cancer patients remained long[9]. When patients reached CDH, they were more likely already presenting with advanced stage due to delays in diagnosis. Additionally, the disruption of radiotherapy in 2022 was due to machine depletion[10] may also impacted patient referrals. Women with confirmed histopathology results may have decided to delay their first assessment as they believed that they would not receive treatment, even if they came to CDH. Last but not least, Visual Inspection with Acetic Acid(VIA) screening for cervical cancer had a sensitivity of only 22.8%[11], and a large proportion of women presented for cervical cancer screening only when they experienced physical pain or illness[12]. Therefore, screening mostly captured invasive cervical cancer rather than pre-cancer. Given the recommendation to be screened every 3–5 years depending on HIV status[13], women with pre-cancerous lesions may subsequently developed advanced cervical cancer during this period between screenings. As of December 2022, about 1.5 million Zambian women enrolled in the screening program, which is about 32% of the eligible population[14]. A study in Tanzania found a trend of downstaging from 2002–2018[15], but the study was conducted at the Ocean Road Cancer Institute (ORCI), the main cancer center of Tanzania that includes that main and largest cervical screening center in the country¹⁵. Downstaging in Tanzania was also due to the establishment of an in-house histopathology unit at ORCI, that led to rapid treatment after histopathologic confirmation of cancer[15, 16]. CDH does not have a pathology unit, women had to complete the biopsy examination at other hospitals or community-level clinics before they were referred to CDH for treatment. Also, the CDH does not have a large screening center and the referral system in Zambia prolong the time period from diagnosis to treatment for cervical cancer patients.

Being widowed or divorced was significantly associated with late-stage cervical cancer at diagnosis. Previous studies in Zimbabwe found that widowed or divorced women were at an elevated risk of being diagnosed with late-stage cervical cancer, and women who were unmarried (single, widowed, or divorced) in Morocco were more likely to present with late-stage compared to married women [17, 18]. This finding was consistent with our result, as the changes in lifestyle following divorce and widowhood is likely to impose a higher risk for cervical cancer[19]. In addition, divorced or widowed women in sub-Saharan countries are especially vulnerable since they may lose their source of income or assets following divorce or widowhood[20]. Also, these women are less likely to be able to afford the cost of medical services[21]. A study in Nepal found that husbands would encourage their wives to seek treatment for symptoms like bleeding, subsequently leading to early detection of cervical cancer among married women[22]. Without spousal support, it is possible that women may not feel encouraged to seek medical care for symptoms related to cervical diseases.

Employment was a protective factor against advanced-stage diagnosis of cervical cancer. A study from Kenya did not identify any significant association between employment status and late-stage diagnosis[23], which is inconsistent with the findings from our study. The Kenyan study had a relatively small sample size (n = 152) and all the patients were recruited in a very short period in 2014. Employment status was still an important socio-economic factor to consider in Zambia. While treatment is provided for free, unemployed women may not be able to afford transportation costs to access screening and treatment which delays their first appointment at CDH. This correlation between late-stage presentation and employment status may also be attributed to different levels of knowledge and awareness about cervical cancer. Among South African women who attended gynecology clinics, employed women have more knowledge about cervical cancer causes and risk factors compared to unemployed women[24]. Employed women had a higher likelihood of learning about cervical cancer given they tend to have a broader social network and higher level of education compared to unemployed women.

Women who lived in Luapula, Muchinga, Northern, Northwestern, and Western provinces were more likely to present with late-stage diagnoses than women who lived in Lusaka. Our previous study on patients seen during 2008–2012, revealed that patients from the Western and Southern provinces had a higher proportion of late-stage presentation compared to patients from Lusaka[4]. Our previous study was partially consistent with our results since the previous study only had patients from three provinces while our study contained patients from all 10 provinces in Zambia. Our finding was consistent with the observations of previous literature in Tanzania since women who lived in regions further from the cancer treatment center had the highest proportion of late-stage cervical cancer patients[15]. Additionally, women who lived in rural areas in Ghana and Sudan were more likely to present with late-stage diagnosis compared to women who lived in urban areas[25, 26]. Our study outcome explained how the accessibility of the treatment center contributed to early diagnosis. The five provinces identified are more distant from the Lusaka province, where CDH is located, which imposes more transportation barriers for patients living in those provinces to come for treatment.

HIV was not found to be associated with a late-stage diagnosis within this study. A previous study at CDH for patients in 2008–2012 did not find HIV status to be associated with the stage of diagnosis[5] and a study in South Africa presented similar results[27].Our finding was consistent with current literature since a previous study at CDH did not find HIV status to impact the progression of cervical cancer among non-metastatic patients significantly[6]. Zambian women strongly associated cervical cancer with HIV-positivity[28]. This stigma was compounded by the fact that cervical cancer screening clinics are located in the anti-retroviral treatment (ART) wards in public hospitals. It probably affected the willingness of women living without HIV to go for screening as they fear being regarded as women living with HIV(WLHIV). In addition, WLHIV were more likely to be screened as they were frequently encouraged to attend cervical cancer screening when they came for ART treatment.

Our study has several strengths. Our data came from the only cancer treatment center in Zambia. We are confident that all our patients were confirmed cervical cancer as histopathology confirmation was necessary for patient registration at the CDH. We explored multiple data sources (the electronic research database, CDH electronic register, and paper-based medical records) to best capture data of all cervical cancer patients the variables of interest and ensure the completeness of our data. The large sample size of our study with patients over 15 years and the comprehensiveness of our data allowed us to explore the trend in changes of cervical cancer stages over time. This study was the first to explore cervical cancer in Zambia over a long time period.

The study has a few limitations. Missing data was a challenge. However, the proportion of patients in which the stage information is unknown was relatively small (15%). The screening data within the medical records was not routinely recorded in the medical records and therefore a large proportion (> 80%) of the patients’ screening history was unknown. The missing screeing data did not affect our analysis significantly since screening was not a key variable of interest in our original research question in the study.

In summary, our study provided insights into the trends of change in the stage of cervical cancer diagnosis at the CDH in Zambia, from 2008 to 2022. The study also identified demographic risk factors associated with late-stage diagnosis. The high proportion of late-stage diagnoses of cervical cancer underscored the need to ensure the availability of treatment to avoid treatment delays. Expediting the transition from VIA inspection to HPV testing may increase the sensitivity of cervical cancer screening to capture cancer at an earlier stage. Future studies may also link the cervical cancer patients at CDH with the data from the national screening program to explore the association between screening history and cervical cancer. In addition, vulnerable groups, like widowed or divorced women and women who are unemployed, should be the target of future prevention programs, research, and educational programs. The findings of this study and the recommended future directions may be applicable to other low-income countries.

Acknowledgment:

Rongyi Wu was supported by the Cancer Epidemiology Education in Special Populations (CEESP) Program through funding from the National Cancer Institute’s grant # R25 CA112383.

Conflict of Interest Statement:

I declare that the authors have no competing interests as defined by Springer, or other interests that might be perceived to influence the results and/or discussion reported in this paper.

Data Availability Statement:

This study's data were collected through patient medical records. The data may not be openly shared to protect the privacy of the study participants. The data are available from the corresponding author upon reasonable request.

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Changes in Cervical Cancer Stage at Diagnosis in Zambia over 15 years

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Abstract

Purpose

Method

Results

Conclusion

Figures

Introduction

Methods

Study Population

Inclusion and Exclusion Criteria

Data Collection

Data Management

Statistical Analysis

Ethical Considerations

Result

Population Characteristics

The trend of Stage Diagnosis of Cervical Cancer over time

Sociodemographic Factors Associated with Late-Stage Cervical Cancer at Diagnosis

Discussion

Declarations

References

Additional Declarations

Status:

Version 1