Quantifying cervical cancer radiotherapy care gap: Baseline assessment prior to implementation of a digital Health...

Sub-Saharan Africa accounts for over one-third of global cervical cancer deaths, despite representing only 14% of the world's female population. Radiotherapy (RT) services are essential in the treatment of cervical cancer, and the Uganda Cancer Institute (UCI) is the only oncology center with RT in a country of 50 million. Prior studies show most of the cervical cancer (CxCa) patients do not complete RT within the recommended timeframe of 6-8 weeks, and some miss their brachytherapy boost. This study analyzes care gaps to establish a baseline before implementing a digital health patient navigation app GLOCASSA.

We quantified radiotherapy care gaps among 104 cervical cancer patients (FIGO IB-IIIC) treated at the UCI between 2023 and 2024, representing 13% of the annual patient volume ethical approval was obtained. A mixed-methods approach was employed, combining retrospective review of radiotherapy charts with a custom mathematical framework for care gap assessment. Patient timelines were reconstructed from consultation through CT simulation, treatment initiation, completion, and follow-up, across three external beam radiotherapy regimens (45 Gy/15 fractions; 50 Gy/25 fractions; 50.4 Gy/28 fractions). We developed a Radiotherapy Care Gap (RCG) model incorporating professional benchmarks (ASTRO, ACR, ARS) to quantify delays, weighted by their clinical importance. Scores were normalized to reflect adherence (<1 expedited/incomplete; =1 standard; >1 delayed). Geospatial analyses were performed using ArcGIS Pro to measure travel distance from patient residence to UCI.

Among 104 cervical cancer patients treated with three EBRT regimens followed by brachytherapy, biologically equivalent doses were comparable across schedules (EQD2 ≈ 85-86 Gy). However, treatment completion within the recommended 6-8 weeks was rare, with on-time completion rates of 11% or lower at 6 weeks and ≤ 17% at 8 weeks. The majority of patients had Radiotherapy Care Gap Scores (RCGS) > 1, indicating significant delays, while only a small fraction achieved timely care (RCGS < 1). Extreme delays were observed, with some patients requiring over 30 weeks to complete therapy. Most patients (58%) were treated with 2D/3D techniques, though delays persisted across all modalities. Geospatial analysis showed a median travel time of 4 h to the radiotherapy center, and more than half of patients (53%) missed the recommended 6-week follow-up visit, highlighting substantial geographic and continuity-of-care barriers.

Our findings suggest that patient navigation and follow-up support are major unmet needs. Digital health platforms that provide real-time reminders, enable remote symptom reporting, and facilitate coordination between patients and care teams offer promising solutions. Future directions include the implementation of the GLOCASSA-App as a targeted intervention to mitigate identified care gaps.