Multi-pronged approach needed to speed up cancer diagnosis

By 2050, researchers predict that Africa will have the highest number of new cancer cases compared to any other continent in the world; and the death toll is expected to skyrocket by an estimated 147%.

These eye-opening statistics demonstrate the high burden of disease cancer has on African populations; and came to light during the African Awareness of Cancer and Early Diagnosis (AWACAN-ED) Programme event on Wednesday, 13 May. The event took place at the University of Cape Town Graduate School of Business (UCT GSB) Academic Conference Centre. It was organised to spotlight the programme’s South African findings. AWACAN-ED is a global health research group funded by the National Institute for Health and Care Research. The programme focuses on advancing early diagnosis of cancer in Southern Africa. The team comprises researchers from UCT, the University of Zimbabwe and Queen Mary University of London in the United Kingdom.

“Our work is really informed by this current and projected cancer burden. It [the burden of disease] grounds our work because we want to address it. [The burden of disease and estimated death toll] doesn’t have to be that way if we can affect some change,” said UCT’s Professor Jennifer Moodley, the co-director of the AWACAN-ED programme.

Cancer in Africa

Moodley said cancer in Africa has a unique set of features. As a start, 57% of the cancer burden is carried by women, which is very different in many other countries where men bear the brunt of the disease. In addition, she told the audience, an alarming number of cancers affecting African populations are caused by infections, and these are preventable when they are caught in time.

“Cervical, breast and colorectal cancers are common in our setting,” she said. “Most of our patients are diagnosed when they present with a symptom. But that’s true even for high income countries, not just [lower income countries].”

“We as researchers, as clinicians, as people working in the field know very little about the levels of public awareness of these cancers.”

What’s different (to low-income countries), she pointed out, is that most of AWACAN-ED’s research participants (three quarters) were diagnosed at an advanced stage. This ultimately affects their outcome.

“We as researchers, as clinicians, as people working in the field know very little about the levels of public awareness about these cancers. Do people know about symptoms and risk factors? We also know very little about the journey that people follow and the time it takes them to get to a diagnosis and the factors that impact that,” she said.

Where it started – the first, four-year study

These sentiments informed the programme’s first study (funded through a Newton Funding Programme) – a four-year project that focused specifically on breast and cervical cancer awareness at community level. What researchers wanted to know was what people understood about these cancers. They interviewed symptomatic women to understand how they interpreted their symptoms, as well as primary healthcare providers to get a sense of their challenges with managing their symptomatic patients.

Their research found huge gaps in community knowledge of both breast and cervical cancer symptoms and risk factors. Participants also indicated that their journeys to care were particularly difficult and was impacted by intersecting challenges including finances, competing priorities, clinic locations and safety concerns.

“The journey was really hard for our participants. And primary care providers actually asked us to be better supported in terms of managing patients who could possibly have cancer [with] training, referrals and feedback,” she said.

This work, set the foundation for a revised programme (under same name), which kicked off in October 2021 and focused on patients and healthcare workers in South Africa and Zimbabwe. It built on past collaborations and partnerships from the initial four-year project. Moodley said one question led researchers throughout the project: “Can we use innovative approaches in primary healthcare to advance early diagnosis of breast, cervical and colorectal cancers?”

Three workstreams

The programme comprised three workstreams.

• Workstream one assessed the current time intervals of breast, cervical and colorectal cancers symptom awareness to referral and diagnosis and the factors that influenced these intervals. A large cross-sectional survey formed part of this workstream. It included interviews with patients recently diagnosed with cancer and was conducted at secondary and tertiary level health facilities.
• Workstream two developed two toolkits that promoted a timely presentation and referral process for people with cervical, breast and colorectal cancers in Southern Africa. The toolkits were designed to help public symptom appraisal and help-seeking behaviour and assist primary healthcare providers manage the referral process to ensure efficient referrals and diagnosis.
• Workstream three evaluated the public and provider toolkit’s effectiveness.

Results in brief

Moodley said their research for South Africa (patients were surveyed in the Eastern Cape and Western Cape) revealed that people don’t understand the risk factors of cancer, and their understanding of cancer symptoms are not where it should be either.

In addition, she said, participants also faced major barriers to accessing health care, and those in the Eastern Cape are worse off compared to their Western Cape counterparts. Financial barriers were uppermost on the list and generally prevented participants from diligently attending appointments. Not far behind, she added, was the distance patients needed to travel to a clinic, with Eastern Cape patients needing to travel further than those in the Western Cape.

“Clearly, to improve timely diagnosis and downscale cancer, we need a multipronged approach.”

Another glaring result that emerged from this programme, is that 19% of patients in the Eastern Cape presented with early-stage cancer, versus 63% in the Western Cape. For cervical cancer, she said, participants with higher education levels and who experienced less deprivation were diagnosed through screening programmes rather than symptoms and had lower odds of advanced stage disease. For colorectal cancer, results indicated that if the primary symptom was something other than bleeding, participants had higher odds of presenting with advanced stage disease.

“Clearly, to improve timely diagnosis and downscale cancer, we need a multipronged approach that combines guidance to our providers as well as the public. We need to improve cancer symptom and risk factor awareness, address barriers to care, support our primary healthcare providers and address some of the health system issues we picked up,” Moodley said.

Other presentations focused on public and provider toolkits, health facility preparedness for timely diagnosis and barriers and facilitators to timely diagnosis. For more on the AWACAN-ED programme visit the website.