Cervical cancer in southern Malawi: A prospective analysis of presentation, management, and outcomes

Background
Malawi has the highest age-standardised rate of cervical cancer in the world. This study describes the presentation, management, and short-term outcomes of newly diagnosed cervical cancer patients at Queen Elizabeth Central Hospital (QECH), in southern Malawi.
Methods
All patients with a new diagnosis of cervical cancer presenting to QECH between 1st January and 1st July 2015 had demographic data, referral pathway, stage, histology, and management prospectively recorded at presentation and 2 months after enrolment.
Results
There were 310 women who presented with cervical cancer to QECH during the study period and 300 were included (mean age 44.9 years; HIV prevalence 47%), representing 8% of the estimated annual number of new presentations in Malawi. The mean age of patients with HIV was 6.9 years younger than those without HIV (P < 0.05). Forty-four percent of patients (n = 132) had stage I cervical cancer and 168 (56%) presented with more advanced disease (stage II-IV). There was a mean delay of 23.1 weeks between symptom onset and first clinical assessment, and a further 19 weeks before attending QECH. The most common management plans at initial QECH consultation were: same-day biopsy (n = 112; 37.3%), booking for curative surgery (n = 76; 25.3%), and referral to palliative care (n = 93; 31%). At 2 months, 64 biopsies (57%) were reported, 31 operations (40.8%) were completed, and 27 patients (29%) had attended palliative clinic.
Conclusions
Patients presenting with cervical cancer to QECH were young, with a high prevalence of HIV and late stage of disease. The lack of pathological and surgical capacity and the absence of radiotherapy severely limited the possibility of curative treatment. Access to quality palliative care remains an important component of management in low-resource settings. Improving awareness of cervical cancer in the community, and better recognition and management within the health service, are important in reducing the cancer burden for women in Malawi.