GGEB Dissertation Defense - Tara Friebel-Klingner

In Botswana, cervical cancer is the most common cancer and leading cause of cancer death for females. The capital, Gaborone, houses the only gynecological cancer multi-disciplinary tumor (MDT) clinic in the country with the expertise and facilities able to provide standard of care for cervical cancer patients. Botswana, with a 20% prevalence of human immunodeficiency virus (HIV), is experiencing increasing morbidity and mortality from HIV/AIDS-related cancers, including cervical cancer). Data, resources, and interventions are needed to combat this growing cancer burden. For this dissertation, we abstracted social, biological, clinical, and geographic characteristics of cervical cancer patients presenting for treatment. First, we used logistic regression to investigate individual patient characteristics associated with tumor stage at presentation. We found the odds of having late-stage cervical cancer at presentation decreased with previous cervical cancer screening, whereas experiencing abnormal vaginal bleeding and never being married were associated with increased odds of late-stage cervical cancer. Second, we used geo-spatial methods to detect areas with high or low clustering of cervical cancer cases to identify sub-districts with disproportionate access to the MDT clinic. We identified five sub-districts with clustering, specifically highlighting sub-districts with disproportionately lower rates of cervical cancer cases presenting for care. Furthermore, we noted individual level predictors (HIV status and presence of abnormal vaginal bleeding) among patients living in areas with disproportionate rates. Third, we used multinomial logistic regression to study travel time from a patient's residence to the MDT clinic and tumor stage at presentation. We found that increased travel time was associated with later stages of cervical cancer at presentation. Additionally, women with increased travel time to the MDT clinic were more likely to be living with HIV, suggesting HIV status may influence referral to and receipt of cervical cancer care. In conclusion, identifying individual, community, and geographic factors associated with late-stage diagnosis and areas with low access to comprehensive cervical cancer care can guide future studies and national health programs in developing strategies that target underserved areas with interventions to improve early detection of cervical cancer. These strategies will be key in controlling the emerging cervical cancer burden in Botswana.