Factors Associated with Delay in Presentation of Symptomatic Cancers among HIV Infected Persons in Plateau State, Nigeria

There is increased incidence of cancer worldwide but much of the burden of morbidity and mortality will occur in the developing world because of cancer associated infectious diseases of which HIV infection carries a large proportion. Site-based studies show that proportion of late stage cancer presentation range between 60% 92% in the last 10 years. There is paucity of information on reasons for the late presentation. This study is aimed to find out the factors associated with delay in presentation of symptomatic cancers among HIV infected persons in Plateau State, Nigeria. A mixed method study consists of quantitative and qualitative component. Participants were sampled from HIV infected persons diagnosed with cancer and referred to the Oncology unit. Variables on Patient and health service factors associated with late presentation of cancers were collected. Quantitative data was analyzed using Epi info version 3.5.3 and Microsoft Excel while thematic analysis was done for qualitative data. There were 503 respondents and the mean age was 48.7 ± 13.5 years. Male sex OR 2.5, (P = 0.002); Farming occupation OR 1.7, (P = 0.0005) and Primary education OR 2.0, (P = 0.0005) were associated with delay. Majority of respondents 349(69%) presented more than six months after onset of symptom. Common symptoms were pain 462(45.70%), swelling 237(23.44%) and skin discoloration 210(20.77). Their Initial reaction was mainly the use of alternative remedies 234(46.5) CI 42.1 51.0. Up to 274(54.47%) of participants obtained diagnosis 3 months after presenting to a health facility. LaborHow to cite this paper: Isichei, M.W., Misauno, A.M., Ale, F.A., Isichei, C.O., Abubakar, A., Sabitu, K., Nguku, P. and Anyawu, P. (2017) Factors Associated with Delay in Presentation of Symptomatic Cancers among HIV Infected Persons in Plateau State, Nigeria. World Journal of AIDS, 7, 157-165. https://doi.org/10.4236/wja.2017.73013 Received: May 27, 2017 Accepted: July 16, 2017 Published: July 19, 2017 Copyright © 2017 by authors and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access M. W. Isichei et al. DOI: 10.4236/wja.2017.73013 158 World Journal of AIDS atory related issues 199(39.56%) and long booking time 163(32.40%) were the most common reasons for delay. Delay was found to be both patient and services related. The study also suggests that cancer symptom awareness is poor among the participants. There is no tangible cancer prevention program in the HIV/AIDs treatment program. A more in-depth knowledge of cancer is required for both the sufferer and the care giver.


Abstract
There is increased incidence of cancer worldwide but much of the burden of morbidity and mortality will occur in the developing world because of cancer associated infectious diseases of which HIV infection carries a large proportion. Site-based studies show that proportion of late stage cancer presentation range between 60% -92% in the last 10 years. There is paucity of information on reasons for the late presentation. This study is aimed to find out the factors associated with delay in presentation of symptomatic cancers among HIV infected persons in Plateau State, Nigeria. A mixed method study consists of quantitative and qualitative component. Participants were sampled from HIV infected persons diagnosed with cancer and referred to the Oncology unit. Variables on Patient and health service factors associated with late presentation of cancers were collected. Quantitative data was analyzed using Epi info version 3.5.3 and Microsoft Excel while thematic analysis was done for qualitative data. There were 503 respondents and the mean age was 48.7 ± 13.5 years. Male sex OR 2.5, (P = 0.002); Farming occupation OR 1.7, (P = 0.0005) and Primary education OR 2.0, (P = 0.0005) were associated with delay. Majority of respondents 349(69%) presented more than six months after onset of symptom. Common symptoms were pain 462(45.70%), swelling 237(23.44%) and skin discoloration 210(20.77). Their Initial reaction was mainly the use of alternative remedies 234(46.5) CI 42.1 -51.0. Up to 274(54.47%) of participants obtained diagnosis 3 months after presenting to a health facility. Labor-

Introduction
Cancer is becoming the leading cause of death worldwide, with about 16.1% of these cancers found to have been linked to certain infection [1] [2]. The mechanism through which infections cause cancer vary. Some have been found to occur as a result of damage to cells due to long-term inflammation by bacterial, parasitic or fungal infection which can eventually transform to cancer in the presence of other factors such as smoking, alcohol, diet and hazardous exposures [3]. In viral infections, the pathogenesis is somewhat different, and the virus directly affects the genes inside the cells by inserting its own gene into the human cell nucleus taking control of the entire cell and redirecting its growth pattern causing the cell to grow out of control [4].
HIV is one of the viral infections implicated in "infection induced cancers" and a person infected with HIV has higher risk of developing cancer and dying from it compared to non infected persons [5]. Although cancer incidence was low in the developing world, it is now rapidly on the increase attributed to the high HIV infection rates [6]. This has made these same countries worst hit in terms of the burden of cancer morbidity and mortality [7]. Nigeria has the second highest world HIV burden and the prevalence of the disease vary across the 36 states of the country [8]. The HIV infected persons in Nigeria are therefore at high risk of developing cancer and even dying from it. Plateau State with an estimated population of about three million people had a HIV prevalence of 7.7% in 2010, ranking 6 th in the country and remained steady until its decline to 3.6% in the year 2013 [9]. These HIV infected persons on the Plateau are therefore at risk of developing cancer [10]. Routine cancer screening among this group will help in early diagnoses of cancers thereby reducing mortality [11].
Cancer occurring in an individual with background HIV infection has been reported to be very aggressively compounded by the low immunity. Granted that the introduction of the Highly Active Antiretroviral Therapy (HAART) for HIV treatment can rise the immune system to normal levels following appropriate and consistent use, the immune system still remains damaged in its molecular components rendering the individual susceptible to developing cancer [12]. There is also increased risk of cancer in individuals with low immunity when  [13]. Despite the aggressive nature of cancer in these groups of persons, cancer treatment remains the same as in non HIV infected individual. The outcome in the HIV-Infected persons however has been reported to be very poor compared to the non HIV infected resulting in high morbidity and mortality [14].
Treatment of cancer in the general population even in the best hospitals until recently has remained difficult and associated with high mortality all over the world. A multidisciplinary and multimodal approach to cancer treatment using a combination of "Early Detection" through various screening techniques and "Targeted Evidence Based Treatment" has improved the outcome [14]. Cancer when detected early even in the HIV infected is easier to treat, cheaper in terms of cost, has better prognosis, and cure can be achieved, there is increased survival rates, lower morbidity and mortality.
Report on the pattern of cancer presentation in Nigeria however reviled that about 80% -85% of common malignancies in Nigeria presented late with a mortality of about 90% associated with the late stage disease presentation in the patients. Reasons for the late presentation ranged from Ignorance, lack of awareness of cancer, low socioeconomic status, myths about cancer compounded by lack of trained personnel in the field of cancer and inadequate hospitals equipped for cancer management lead to the delay in diagnosis [15]. Other factors are competing use of alternative medicine such as Traditional/Herbal medicines as first line of treatment instead of orthodox medicine. This usually is cheaper, easily accessible and may relieve some symptoms but in the long run cancer continue to progress to late stage [16]. To reduce the high mortality due to late presentation of cancer in the HIV infected persons in our setting, we need to improve on early diagnosis.
Although HIV infection is known to increase the risk of cancer in infected persons, little is known about cancers among our HIV infected patients, if they present late and the reasons for the delay. We analyzed the length of time it takes to initiation definitive cancer treatment for HIV infected persons with cancer in Plateau State from the time symptom was first noticed.

Materials and Methods
A mixed method study design, consisting of qualitative and a quantitative com- Consenting participants were sampled from HIV infected persons who were already diagnosed with cancer and those with symptoms suggestive of cancer referred from the various HIV treatment facilities to the Jos University Teaching Hospital. Cancer patients presenting to the Oncology unit for treatment who were diagnosed HIV positive during routine work up investigations were also enrolled. Histological diagnosis was done for suspected cases. Case files at referral centers were consulted to confirm diagnosis for participants with multiple cancers who could not give correct information about the primary cancer they had.
Informed consent was obtained from all participants. Data was analyzed using Excel version 6.0 and Epi info version 3.4.5.
Analysis of the type of cancers found among HIV respondents indicated that Kaposi sarcoma 173(31.63%) was the commonest occurring cancer among the respondents, however 44(8.04%) respondents had multiple cancers (Table 1).

Health facility visit on account of cancer related symptoms Patient mediated treatment actions
Laboratory related issues 199(39.56%) and Long booking time 163(32.40%) were the most common reasons for delay in initiating treatment ( Table 2).

Discussion
The main founding in this research is there was delay in presentation of cancers among the study population. Using a modified Andersen's model, Phase one delay was due to "Patient mediated factors"; Phase two and three delay was "ser-   In phase one, majority of the respondents experienced their symptoms for more than 3 months before seeking medical attention at a health facility. This could be due to the way individual interpret symptoms which leaded to taking appropriate action. In this study, some of the symptoms participants experienced were vague, not unusual in HIV infection and therefore might not have been regarded as a sign of a more serious health problem. This agrees with Whitaker, Katriina L who reported in their study that symptoms that occur in daily life are not usually regarded to be related to cancer [17]. Cromme, Susanne K and colleagues had a contrary finding, "worrying about wasting GP time rather than non recognition of symptom was a more cogent reason for delay in help seeking among their cancer patients" [18].
Pain and swelling were however strong reasons for seeking medical attention among the participants. Increasing intensity of pain, increasing size of a mass among others were strong reasons to abandon alternative measure and to seek medical help. This finding is supported by a study reported by Whitaker KL where they found pain (72%) and lump (70%) were associated with highest level of help seeking [19]. Pain however is a symptom that can be present at early or late stage of the disease depending on the type of cancer. In this study, worsening pain especially when it become incapacitating prompted participants to seek help. Increasing size of lump being visible on the other hand could also have been interpreted as a more serious problem prompting presentation to a health facility.
Majority of respondents delayed due to preference for alternative methods of treatment first.  [21].
Another important factor is that the first doctor patient came in contact with at the primary or even secondary health care did know what to do. Macleod and his colleagues also reported in their study that significant factor for system delay was failure of the practitioner to recognize symptoms and to act appropriately which also supports our findings [22].

Limitations
1) There is no standard definition of late presentation of cancer therefore "Patient and Provider delay of three months from the time patient first noticed a symptom to first presentation at a health facility" was adopted for this study.
2) Stage of the disease was not used in this study because there was lack of required instruments for accurately staging the disease.
3) There was possibility of recall bias and some patients were not sure of the type of cancers they had. Case notes were then used to extract information and sometimes inconclusive due to lose sheets.

Conclusion
The factors for delay in our study are intricately inter-related. The study also suggests that cancer symptom awareness is poor among the participants. There is no tangible cancer prevention program in the HIV/AIDs treatment program.
A more in-depth knowledge of cancer is required for both the sufferer and the care giver.