Research Article: Explaining disparities in oncology health systems delays and stage at diagnosis between men and women in Botswana: A cohort study

Date Published: June 6, 2019

Publisher: Public Library of Science

Author(s): Hari S. Iyer, Racquel E. Kohler, Doreen Ramogola-Masire, Carolyn Brown, Kesaobaka Molebatsi, Surbhi Grover, Irene Kablay, Memory Bvochora-Nsingo, Jason A. Efstathiou, Shahin Lockman, Neo Tapela, Scott L. Dryden-Peterson, Gita Suneja.


Men in Botswana present with more advanced cancer than women, leading to poorer outcomes. We sought to explain sex-specific differences in time to and stage at treatment initiation.

Cancer patients who initiated oncology treatment between October 2010 and June 2017 were recruited at four oncology centers in Botswana. Primary outcomes were time from first visit with cancer symptom to treatment initiation, and advanced cancer (stage III/IV). Sociodemographic and clinical covariates were obtained retrospectively through interviews and medical record review. We used accelerated failure time and logistic models to estimate standardized sex differences in treatment initiation time and risk differences for presentation with advanced stage. Results were stratified by cancer type (breast, cervix, non-Hodgkin’s lymphoma, anogenital, head and neck, esophageal, other).

1886 participants (70% female) were included. After covariate adjustment, men experienced longer excess time from first presentation to treatment initiation (8.4 months) than women (7.0 months) for all cancers combined (1.4 months, 95% CI: 0.30, 2.5). In analysis stratified by cancer type, we only found evidence of a sex disparity (Men: 8.2; Women: 6.8 months) among patients with other, non-common cancers (1.4 months, 95% CI: 0.01, 2.8). Men experienced an increased risk of advanced stage (Men: 67%; Women: 60%; aRD: 6.7%, 95% CI: -1.7%, 15.1%) for all cancers combined, but this disparity was only statistically significant among patients with anogenital cancers (Men: 72%; Women: 50%; aRD: 22.0%, 95% CI: 0.5%, 43.5%).

Accounting for the types of cancers experienced by men and women strongly attenuated disparities in time to treatment initiation and stage. Higher incidence of rarer cancers among men could explain these disparities.

Partial Text

Global cancer incidence is projected to increase from 17 to 22 million per year from 2015 to 2030, with most new cases and deaths expected to occur in low- and middle- income countries (LMIC) [1,2]. International Agency for Research in Cancer statistics from 2012 revealed that LMICs already experienced the majority of new cancer cases (57%) and deaths (65%) worldwide [3]. Health systems in LMICs are ill-equipped to face this burden due to limited numbers of oncology-trained staff, infrastructure for radiation and surgery, and affordable chemotherapy [4, 5]. In light of these resource constraints, efficient targeting of services is essential to ensure equitable delivery of cancer care [6].

After excluding cohort participants with missing covariate data (n = 73, 3%) and those whose time to treatment initiation was over the 90th percentile (n = 215, 10%), 1886/2174 (87%) cohort participants contributing 17,194.4 person-months of follow-up remained in our study, of whom 28% were male (Table 1). Participants were followed for a median of 6.4 months [IQR: 3.5–12.5]. Men were older, had lower educational attainment, and were more likely to be in a cohabiting couple than women. Men were more likely to report use of a traditional healer prior to diagnosis, severe cancer-related symptoms, and history of smoking. Men were also less likely to be HIV-infected compared to women in the study population.

Building on accumulating evidence from Botswana suggesting that men experience longer diagnostic and time-to-treatment and are diagnosed at more advanced stage than women, we were able to exploit a larger cohort study with detailed information on cancer types and sociodemographic factors to explore specific drivers of these disparities. On average, men were more likely than women to present with anogenital and other less common cancers, diseases which exhibited longer diagnostic and treatment appraisal times, as well as more advanced stage at presentation. When we estimated covariate-standardized associations between sex, appraisals, and advanced cancer stratified by cancer type, we found that disparities were strongly attenuated within most cancer types. Significant male-female disparities in time-to-treatment remained only among those patients with uncommon cancers (which tended to be specific to either men or women), and remained among patients with anogenital cancers with respect to stage.