Title: Diagnostic and pre-treatment intervals among patients with cervical cancer attending care
at the Uganda Cancer Institute: A cross-sectional study
Version: 1 Date: 28 Oct 2023
Reviewer's report:
Title: "Factors associated with diagnostic and pre-treatment intervals among patients with
cervical cancer attending care at the Uganda Cancer Institute: A cross-sectional study"
Authors:
Amos Deogratius Mwaka, Jackie Lalam Lacika, Henry Wabinga, Joseph Kagaayi, Ronald
Opito, Christopher Garimoi Orach.
Summary of the research and overall impression
This manuscript aimed to identify factors associated with diagnostic and treatment delays among
women with cervical cancer in Uganda. It is therefore important if factors identified can add to
the interventions to improve cervical cancer outcomes in the region. Introduction, methodology
and results need some revision. Discussion needs to improve in terms of approach to discussion,
literature review and linked to the key findings including statistical measures of significance, etc.
Discussion on specific area of improvement
Abstract
Abstract is clear stating the purpose, study design and methodology, data analysis methods, key
findings of factors diagnostic and pre-treatment intervals among patients with cervical cancer.
No further comment for the abstract.
Introduction
The authors highlight the concern of growing cancer burden among women. It would had nice to
hear how programs like cervical cancer screening and immunization for the girl child have taken
shape in Uganda and how these programs have improved community awareness particularly
regarding cervical cancer. Throughout in the introduction, the authors have no mention of cancer
awareness programs, access to cervical cancer screening and levels of care where this service is
available, it’s availability throughout the country and, how these programs impact early cancer
detection among women.
Methods & Results
In the methods section, the authors mention data points such as disease factors (histology type,
tumour grade and stage). However, the results section reflects on histology type and tumour
stage. Was tumour grade score omitted in the final data collection tool?
In the results table 3, participants who responded to the question “Ever done PAP Smear” were
370. About 33 responses were not recorded. How did the authors deal with missing variables
in their statistical analysis?
In table3 of the results section, the authors chose to categorize participants into unemployed and
employed. Does ‘employed’ include participants whose livelihood may depend on business?
What about informal jobs?
In table 3 results section still, the authors state levels of referral as self, private clinics, level 4,
level 5, level 6, level 7. It is understood that before a health facility level 4, there are levels 3,2
etc. What happens to patients referred from those levels? Do they first have to go to level 4 or
5 or 6 before coming to level 7 or there is no specific referral criteria in this setting?
The opening paragraph of results section on page 16 says “Majority of participants (79.9%;
n=322) started cancer specific treatment after 1 months of reporting to the UCI”. The ‘1 months’
is not plural and should be corrected.
Discussion
In the introductory paragraph of the discussion, ensure the statement “Participants aged 50 – 59
years and with shorter diagnostic intervals (< 3 months) were more likely to be diagnosed in
early stages than those aged less than 40 years and with longer diagnostic intervals” is backed
by your statistic result (insert in parenthesis, statical test, p value or confidence intervals). Do
this for the rest of the statements in the discussions so that readers do not have to move back
and forth to look for results.
In the second paragraph of discussions, you state what you mean by middle age and early stage
and what was the median age for the Zambian study.
It would be nice to discuss each finding or question in a separate paragraph. What is significant
delay in diagnosis? As said before, can you insert your statistics in parenthesis?
The authors have not clearly stated factors that impede early initiation of treatment despite
mentioning older women having shorter treatment time intervals due to accelerated access to
cancer staging investigations. Are there generally impediments to accessing cancer diagnosis in
Uganda like the cost of the test? Is it generally available and free to anyone? Is there public or
private care preference among the study participants to seek cancer diagnosis?
Conclusion and recommendations
Conclusion needs to be based on the primary study outcome and its ramifications.
Recommendation
Revision required.