Patterns of Treatment Noninitiation and Early Loss to Follow-Up in Breast Cancer Care in Haiti
Authors: Fadelu T. , Damuse R. , Pecan L. , Greenberg L. , Danjoue S. , Lormil J. , Shulman L. 
Published: September 2018

Background: Loss to follow-up after treatment initiation is a recognized and well-studied problem in cancer care programs in low- and low-middle income countries (LMIC). However, there is less literature on causes of treatment noninitiation in LMIC breast cancer programs. Hôpital Universitaire de Mirebalais (HUM) in Haiti established the main public comprehensive cancer center in the country in 2013. The facility is located in the Centre Department but serves patients from all the other nine departments (regions) of the country. Care provided within the facility is free after an initial nominal deposit, as a result of a multi-institutional collaboration with Zanmi Lasante, a local arm of Partners In Health, an international nonprofit organization, and US academic institutions. Aim: To determine the causes of treatment noninitiation and early loss to follow-up (LTFU) among a retrospective cohort of patients seen in the HUM breast cancer program. Methods: We evaluated 1371 women who had their first visit between July 1, 2013 and December 31, 2016. The list of breast cancer patients was generated from electronic medical record diagnosis codes. We identified individuals who were followed for less than 90 days (Under-90). We reviewed the patient's record to determine reason for care noninitiation and early losses. We used logistic regression analysis to determine if distance from HUM contributed to being Under-90, while controlling for demographic factors. Results: 339 (24.6%) patients in the breast cancer program were seen for less than 90-days. The two most common periods of early LTFU were prior to obtaining diagnostic biopsy (113 patients- 33%), and after referral for staging diagnostic imaging (83 patients- 24%). 49 patients (14%) had confirmed diagnosis and completed staging but never initiated treatment, while only 23 (7%) did not initiate treatment due to confirmed advanced metastatic disease or death. Majority of the patients 1254 (91.5%) came from outside the Centre region; early LTFU was more common among these patients (25.6%) compared with Centre region patients (16.2%). Using logistic regression analysis, controlling for age and rural/urban home classification, we found that the odds of Under-90 was 2.05 (95% CI: 1.22-3.45), P = 0.007, for those living outside the Centre region, compared with living in hospital's region. We repeated the analysis comparing the Centre region to the immediately adjacent regions, and more distant regions; we found the odds of Under-90 was 1.88 (95% CI: 1.12-3.18) for the adjacent regions, and 2.92 (95% CI: 1.61-5.31) for the distant regions. Conclusion: Treatment noninitiation and early losses are a significant problem in the HUM breast cancer program. As anticipated, living farther from HUM increased the odds of early LTFU. Effective interventions are needed to reduce the number of patients failing to initiate therapy, and these interventions must begin at the first contact with the oncology program.