Botswana Clinic Offers Lessons for Cervical Cancer Care With Limited Resources

Surbhi Grover, MD

In low- and middle-income countries, cervical cancer is one of the leading causes of death for women. For example, limited access to preventive screenings and the high rate of HIV has resulted in a high cervical cancer rate in Botswana.

Women with HIV have a higher risk of developing cervical cancer by 3- to 6-fold compared to women who are HIV-negative. Botswana has the second highest HIV rate in the world and more than two-thirds of all cervical cancer cases occur among women who also have HIV.

In Botswana, it can take a woman 5 months after diagnosis to receive the treatment she needs. Considering 75% of patients suffer from advanced forms of cervical cancer, the accessibility of treatment is crucial to a patient’s survival. The public clinics in Botswana do not offer radiation therapy and in private hospitals, it can be an inconvenient process, with the wait time being months.

The University of Pennsylvania took a multidisciplinary team (MDT) to Botswana to implement an approach to bring treatment to patients in a more efficient and conducive way. The primary objective is to streamline care and communication to providers to get treatments to facilities faster.

"With so many women suffering from advanced cervical cancer in Botswana, long delays between treatment and diagnosis can mean the difference between life and death," Surbhi Grover, MD, director of Global Radiation Oncology in the Perelman School of Medicine at the University of Pennsylvania and head of Oncology at Princess Marina Hospital in Botswana, said in a statement. "We saw an urgent need to develop a care program that gives cervical cancer patients the treatment they need as quickly as possible."

Weekly team meetings between radiation oncologists, clinical oncologists, gynecologists, nurse coordinators, and palliative care specialists, were established across providers to discuss patient cases and develop treatment plans. These meetings also helped increase the speed of documentation and paperwork, which further reduced the delay in treatments.

"While this type of model might seem common in the United States or other developed countries, it's actually quite a complicated process that lacks a global standard of guidelines," Grover said. "We saw many different models across the world, but no published outcomes on how to successfully implement an MDT approach for cervical cancer care."

During the weekly meetings, the team would examine patients and determine an appropriate care plan. If the patient requires radiation, the applicable documentation for sponsorship from the Botswana government was completed and submitted to the referral office. If a patient is HIV-positive or untested, they are referred to an HIV clinic to receive testing and antiretroviral treatment evaluation. The patients are then counseled on the treatment plan by the team and given a 2-week follow-up date to make sure all investigations and paperwork are completed.

Between May 2015 and December 2015, 135 patients were seen in the weekly gynecologic MDT clinic, with an average of 28 patients per month. A nurse coordinator was assigned to manage patient flow and information, gathering data from patients such as stage, date of biopsy, results of biopsy specimen assessment, and HIV status, ensuring the patient records were up-to-date before treatment.

Sixty percent of these patients were HIV-positive, 31% were HIV-negative, and the HIV status of the remaining 11 patients was unknown.

The most common diagnoses that were seen during this 6-month period was cervical cancer in 60% of patients, followed by high-grade cervical intraepithelial neoplastic lesions in 12%, and vulvar cancer in 11%. Among the patients with cervical cancer, 42% had locally advanced disease the required chemoradiation.

Due to the MDT clinic, 62% of patients needed only 1 visit for care coordination. Treatment delays were evaluated for both radiation therapy and surgery. The median delay from date of biopsy to the start of radiation treatment was 39 days after MDT initiation, which was an improvement from the 108 days before MDT initiation. The median delay from clinic visit to the start of radiation treatment was 24 days and the median delay from clinic visit to surgery was 31 days.

"With this model, we've shown that the MDT approach works in a resource-limited setting and actually helps address several challenges providers face," Grover said. "Many of our patients must travel long distances or face other barriers that prevent them from returning to the clinic for multiple visits. Offering patients a comprehensive treatment plan during 1 clinic visit is a game-changer."

The time from diagnosis to the start of radiation treatment was reduced by more than half following the initiation of these clinics. Due to the remaining 38.5% of patients needing more than 1 visit to the clinic, it suggests that 1 visit was generally sufficient in facilitating a patient’s navigation through the system.

Similar MDT clinic models are being observed for head and neck cancer, palliative care, and breast cancer in Botswana. There is a follow-up clinic being piloted where all patients treated with gynecologic cancer are seen after treatment or until signs of toxicities or recurrence appear. All patients treated in the MDT clinic will be linked to this new clinic and will receive regular communication about follow-up care.

"What this approach really shows is the importance of integrated care and treatment models," Grover said. "We hope our MDT model will be applied on a broad scale across many different illnesses and clinics in resource-limited settings worldwide."

Grover S, Chiyapo SP, Puri P, et al. Multidisciplinary Gynecologic Oncology Clinic in Botswana: A Model for Multidisciplinary Oncology Care in Low- and Middle-Income Settings [published online before print February 8, 2017]. J Glob. Oncol. doi:10.1200/JGO.2016.006353.