Factors Associated with Loss to Follow-up among Cervical Cancer Patients in Rwanda

Placide Habinshuti; Marc Hagenimana; Cam Nguyen; Paul H. Park; Tharcisse Mpunga; Lawrence N. Shulman; Alexandra Fehr; Gilbert Rukundo; Jean Bosco Bigirimana; Stephanie Teeple; Catherine Kigonya; Gilles Francois Ndayisaba; Francois Uwinkindi; Thomas Randall; Ann C. Miller

doi:10.5334/aogh.2722

Factors Associated with Loss to Follow-up among Cervical Cancer Patients in Rwanda

Volume 86 (2020): Issue 1

By: Placide Habinshuti, Marc Hagenimana, Cam Nguyen, Paul H. Park, Tharcisse Mpunga, Lawrence N. Shulman, Alexandra Fehr, Gilbert Rukundo, Jean Bosco Bigirimana, Stephanie Teeple, Catherine Kigonya, Gilles Francois Ndayisaba, Francois Uwinkindi, Thomas Randall and Ann C. Miller

Open Access

|Sep 2020

Figures & Tables

Treatment flowchart for cervical cancer patients at Butaro Cancer Centre of Excellence (BCCOE). For curative treatment, pre-operative chemotherapy is provided at BCCOE and surgery at referral hospitals in Kigali while chemoradiation requires referrals to facilities outside of Rwanda. Palliative care can include chemotherapy and radiotherapy; however, only symptom control and chemotherapy are available for palliative care at BCCOE.

Flowchart of patients selected based on inclusion and exclusion criteria. Patients who had been enrolled at least one year at the time of data collection and were either alive and in care or lost-to follow-up (LTFU) one year after enrollment were included in the study. All percentages were calculated on the 652 patients enrolled at Butaro Cancer Center of Excellence (BCCOE) between 1 July 2012 and 30 June 2017.

Table 1

Demographic and clinical characteristics of cervical cancer patients at BCCOE enrolled between July 2012 and June 2017 who were early LTFU, late LTFU or alive and in care. N = 312 unless otherwise specified.

	Early LTFU N = 47		Late LTFU N = 78		Alive and in care N = 187
	n	%	n	%	n	%
Age
39 or younger	6	12.8	3	3.9	19	10.2
40–49	13	27.7	26	33.3	51	27.3
50–59	13	27.7	26	33.3	66	35.3
60–69	10	21.3	15	19.2	40	21.4
70 or older	5	10.6	8	10.3	11	5.9
Residence
Northern Province	19	40.4	16	20.5	58	31.0
Other	28	59.6	62	79.5	129	69.0
Province (n = 306)
Kigali	12	27.3	30	40.0	76	40.6
Eastern	3	6.8	6	8.0	21	11.2
Northern	19	43.2	16	21.3	58	31.0
Southern	3	6.8	13	17.3	9	4.8
Western	7	15.9	10	13.3	23	12.3
Type of insurance (n = 301)
National health insurance	39	90.7	70	92.1	169	92.9
Other	4	9.3	6	7.9	13	7.1
Referring health facility (n = 298)
No referral	5	11.9	6	7.9	20	11.1
Referral hospital	11	26.2	25	32.9	62	34.4
District hospital	24	57.2	42	55.3	93	51.7
Other	2	4.8	3	4.0	5	2.8
Smoking history (n = 300)
Current	0	0.0	0	0.0	1	0.6
Past	16	35.6	30	39.5	61	34.1
Never	29	64.4	46	60.5	117	65.4
Drinking history
Current	1	2.1	4	5.1	9	4.8
Past	16	34.0	27	34.6	58	31.0
Never	0	0.0	1	1.3	2	1.1
Missing	30	63.8	46	59.0	118	63.1
Ever used traditional medicine (n = 281)
No	26	60.5	42	57.5	100	60.6
Yes	17	39.5	31	42.5	65	39.4
Duration of chief complaint (n = 279)
Less than six months	13	32.5	27	37.0	58	34.9
6–11 months	8	20.0	18	24.7	38	22.9
12 months or more	19	47.5	28	38.4	70	42.2
ECOG
0–1	35	74.5	68	87.2	146	78.1
2+	6	12.8	6	7.7	18	9.6
Missing	6	12.8	4	5.1	23	12.3
HIV status
Positive	11	23.4	29	37.2	78	41.7
Negative	30	63.8	37	47.4	84	44.9
Missing	6	12.8	12	15.4	25	13.4
Has NCD comorbidities (n = 288)
No	38	88.4	66	94.3	165	94.3
Yes	5	11.6	4	5.7	10	5.7
Cancer stage at presentation
Stage 1 or 2	19	40.4	61	78.2	153	81.8
Stage 3 or 4	7	14.9	11	14.1	23	12.3
Unstaged	21	44.7	6	7.7	11	5.9
Type of treatment received
Curative chemotherapy and radiotherapy	0	0.0	28	35.9	121	64.7
Curative chemotherapy only	0	0.0	7	9.0	20	10.7
Curative radiotherapy only	0	0.0	10	12.8	25	13.4
Curative intent, no treatment recorded	12	25.5	16	20.5	10	5.4
Palliative treatment	7	14.9	10	12.8	8	4.3
Missing	28	59.6	7	9.0	3	1.6
Experienced chemotherapy toxicity (n = 178)
No	0	0.0	21	58.3	82	57.8
Yes	0	0.0	15	41.7	60	42.3
Experienced radiotherapy toxicity (n = 189)
No	0	0.0	17	43.6	84	56.0
Yes	0	0.0	22	56.4	66	44.0
Experienced adverse effect at follow up (n = 186)
No	1	2.2	14	41.2	30	19.9
Yes	0	0.0	20	58.8	121	80.1

Table 2

Association between covariates and early LTFU for patients with cervical cancer presenting at BCCOE from July 2012 to June 2017. N = 234 unless otherwise specified. Late LTFU patients were excluded from this analysis.

Variable	Early LTFU		Alive and in care		p-value
Variable	n	%	n	%	p-value
Age
39 or younger	6	24.0	19	76.0	0.668
40–49	13	20.3	51	79.7
50–59	13	16.5	66	83.5
60–69	10	20.0	40	80.0
70 or older	5	31.3	11	68.7
Residence
Northern Province	19	24.7	58	75.3	0.220
Other	28	17.8	129	82.2
Type of insurance (n = 224)
National health insurance	39	18.8	169	81.2	0.517
Other insurance or no insurance	4	25.0	12	75.0
Referring health facility (n = 222)
No referral	5	20.0	20	80.0	0.630
Referral hospital	11	15.1	62	84.9
District hospital	24	20.5	93	79.5
Other	2	28.6	5	71.4
Smoking history (n = 224)
Current	0	0.0	1	100.0	0.890
Past	16	20.8	61	79.2
Never	29	19.8	117	80.1
Drinking history (n = 234)
Current	1	10.0	9	90.0	0.897
Past	16	21.6	58	78.4
Never	0	0.0	2	100.0
Missing	30	20.3	118	79.7
Uses/Used traditional medicine (n = 208)
No	26	20.6	100	79.4	>0.999
Yes	17	20.7	65	79.3
Duration of chief complaint (n = 206)
Less than six months	13	18.3	58	81.7	0.823
6–11 months	8	17.4	38	82.6
12 months or more	19	21.3	70	78.7
ECOG (n = 234)
0–1	35	19.3	146	80.7	0.806
2+	6	25.0	18	75.0
Missing	6	20.7	23	79.3
HIV status (n = 234)
Negative	30	26.3	84	73.7	0.048
Positive	11	12.4	78	87.6
Missing	6	19.4	25	80.6
Has NCD comorbidities (n = 218)
No	38	18.7	165	81.3	0.170
Yes	5	33.3	10	66.7
Cancer stage at presentation (n = 234)
Stage 1 or 2	19	11.1	153	88.9	<0.001
Stage 3 or 4	7	23.3	23	76.7
Unstaged	21	65.6	11	34.4
Type of treatment received (n = 234)
Curative chemotherapy and radiotherapy	0	0.0	146	100.0	<0.001
Curative chemotherapy only	0	0.0	20	100.0
Palliative treatment	7	46.7	8	53.3
Missing	40	75.5	13	24.5

Table 3

Association between different variables and late LTFU for patients with cervical cancer presenting at BCCOE from July 2012 to June 2017. N = 265 unless otherwise specified. Early LTFU patients were excluded from this analysis.

Variable	Late LTFU		Alive and in care		p-value
Variable	n	%	n	%	p-value
Age
39 or younger	3	13.6	19	86.4	0.286
40–49	26	33.8	51	66.2
50–59	26	28.3	66	71.7
60–69	15	27.3	40	72.7
70 or older	8	42.1	11	57.9
Residence
Northern Province	62	32.5	129	67.5	0.082
Other	16	21.6	58	78.4
Type of insurance (n = 235)
National health insurance	70	29.3	169	70.7	0.790
Other insurance or no insurance	6	33.3	12	66.7
Referring health facility (n = 166)
No referral	6	23.1	20	76.9	0.812
Referral hospital	25	28.7	25	71.3
District hospital	42	31.1	42	68.9
Other	3	37.5	3	62.5
Smoking history (n = 255)
Current	0	0.0	1	100.0	0.632
Past	30	33.0	61	67.0
Never	46	28.2	117	71.8
Drinking history
Current	4	30.8	9	69.2	0.909
Past	27	31.8	58	68.2
Never	1	33.3	2	66.7
Missing	46	28.1	118	71.9
Uses/Used traditional medicine (n = 238)
No	42	29.58	100	70.4	0.670
Yes	31	32.29	65	67.7
Duration of chief complaint (n = 239)
Less than six months	27	31.76	58	68.2	0.888
6–11 months	18	32.14	38	67.9
12 months or more	28	28.57	70	71.4
ECOG
0–1	68	31.8	146	68.2	0.168
2+	6	25.0	18	75.0
Missing	4	14.8	23	85.2
HIV status
Negative	37	30.6	84	69.4	0.772
Positive	29	27.1	78	72.9
Missing	12	32.4	25	67.6
Has NCD comorbidities (n = 245)
No	66	28.6	165	71.4	>0.999
Yes	4	28.6	10	71.4
Cancer stage at presentation
Stage 1 or 2	61	28.5	153	71.5	0.730
Stage 3 or 4	11	32.4	23	67.6
Unstaged	6	35.3	11	64.7
Type of treatment received
Curative chemotherapy and radiotherapy	38	20.6	146	79.4	<0.001
Curative chemotherapy only	7	25.9	20	74.1
Palliative treatment	10	55.6	8	44.4
Missing	23	63.9	13	36.1

Table 4

Multivariable logistic regression for predictors of early LTFU presenting odds ratios, 95% confidence intervals and p-value for patients with cervical cancer presenting at BCCCOE from July 2012 to June 2017.

Variable	Unadjusted bivariate ORs			Final Model
Variable	OR	95% CI	p-value	OR	95% CI	p-value
NCD comorbidities
No Comorbidities	1
At least 1 NCD comorbidity	2.17	0.70–6.72	0.180
HIV status
Negative	1			1
Positive	0.39	0.18–0.84	0.020	0.46	0.20–1.06	0.071
Missing	0.67	0.25–1.79	0.430	0.51	0.25–1.80	0.430
Cancer stage at presentation
Stage 1 or 2	1			1
Stage 3 or 4	2.45	0.93–6.47	0.069	2.49	0.93–6.65	0.069
Unstaged	15.37	6.43–36.74	<0.001	14.93	6.12–36.43	<0.001

Table 5

Multivariable logistic regression for predictors of late LTFU presenting odds ratios, 95% confidence intervals and p-value for patients with cervical cancer presenting at BCCCOE from July 2012 to June 2017.

Variable	Unadjusted ORs			Final Model
Variable	OR	95% CI	p-value	OR	95% CI	p-value
Residence
Northern Province	1			1
Other Province	1.74	0.93–3.27	0.080	2.25	1.11–4.53	0.024
ECOG
0–1	1			1
2+	0.71	0.27–1.88	0.490	0.71	0.25–2.07	0.535
Missing	0.37	0.12–1.12	0.080	0.26	0.08–0.85	0.026
Type of treatment received
Curative chemotherapy and radiotherapy	1			1
Curative chemotherapy only	1.34	0.53–3.41	0.530	1.15	0.58–3.87	0.408
Palliative treatment	4.8	1.77–13.00	0.002	6.65	2.28–19.40	0.001
Missing	6.79	3.15–14.65	<0.001	7.99	3.56–17.97	<0.001

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DOI: https://doi.org/10.5334/aogh.2722 | Journal eISSN: 2214-9996

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Language: English

Published on: Sep 14, 2020

Published by: Ubiquity Press

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© 2020 Placide Habinshuti, Marc Hagenimana, Cam Nguyen, Paul H. Park, Tharcisse Mpunga, Lawrence N. Shulman, Alexandra Fehr, Gilbert Rukundo, Jean Bosco Bigirimana, Stephanie Teeple, Catherine Kigonya, Gilles Francois Ndayisaba, Francois Uwinkindi, Thomas Randall, Ann C. Miller, published by Ubiquity Press
This work is licensed under the Creative Commons Attribution 4.0 License.

Volume 86 (2020): Issue 1

Factors Associated with Loss to Follow-up among Cervical Cancer Patients in Rwanda

Figures & Tables

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Table 1

Table 2

Table 3

Table 4

Table 5

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