Health Barriers and Patterns of Gastric Cancer Care in Rural Central American Resource-Limited Settings

Cancer is a growing burden on low- and middle-income countries (LMICs).¹ By 2030, 70% of the cancer burden will occur in LMICs and be driven by 7 major cancers, including gastric cancer.² Gastric cancer is an appropriate model to assess barriers to cancer care because it is the third leading cause of global cancer mortality and the leading cause in regions such as the Central America-4 (CA-4): Honduras, Guatemala, Nicaragua, and El Salvador. The CA-4 is the largest LMIC region in the Western hemisphere with 36 million inhabitants, half of whom live in rural areas that lack regional treatment capacity.^2-6 We describe treatment patterns of gastric cancer care in rural Honduras, a high-incidence region.⁴

We analyzed factors associated with treatment and gastric cancer care in rural western Honduras in a cohort of patients with gastric cancer in an ongoing population-based, case-control study with an endoscopy and pathology registry from 2002 through 2015.⁴ The nascent population-based cancer registry data were used to assess completeness for 2013 through 2015.⁵ An active follow-up protocol was used in 2016 during household visits in rural and remote areas by interviewing the patient and/or relatives. Given the high mortality, most interviews were conducted with family members. Surveys were administered by trained interviewers with tablets using Research Electronic Data Capture. Treatment was defined as either receiving chemotherapy, undergoing surgical resection, or both. Data were obtained on alternative treatments. Socioeconomic status was estimated via unsatisfied basic needs assessment. Travel time (eg, walking, bus) was used as a surrogate for distance to treatment. Multivariable logistic regression was used to calculate odds ratios (OR) with 95% confidence intervals to identify factors (Figure) associated with treatment (STATA, version 14). Institutional review board approvals were obtained from Vanderbilt University and the Honduras Ministry of Health. Verbal informed consent was obtained from each participant.

The study identified 741 patients with gastric cancer (487 [65.7%] male) and a mean (SD) age of 63 (range, 20-97) years (Table). Of those patients, 738 (99.6%) had histologic confirmation (335 [45.2%] intestinal, 320 [43.2%] diffuse) and 580 (78.3%) received household visits. Of the patients who received household visits, 497 had complete treatment information: 123 of 497 (24.7%) received treatment; 113 of 496 (22.8%) underwent surgical resection; and 42 of 497 (8.5%) received chemotherapy. Patients who received treatment were more likely to be alive at follow-up (OR, 4.29; 95% CI, 1.57-11.73) (Figure). Patients with extreme poverty (OR, 0.49; 95% CI, 0.26-0.93) and those older than 55 years (OR, 0.34; 95% CI, 0.15-0.80) were less likely to receive treatment. The 79 patients (17.3%) who sought alternative therapies most commonly chose Aloe vera extract, herbs, and snakeskin powder. Patients with greater travel time to the regional treatment facility were less likely to undergo treatment.

Barriers to cancer care are substantial in the rural LMIC setting of Central America. Only 1 in 5 patients received curative or palliative surgical treatment. One in 12 patients received chemotherapy, which is not available in western Honduras. Living in households below the regional poverty standard was a barrier to treatment.

Limitations to our study include case ascertainment and the absence of certain clinical variables, which are a challenge in LMICs. Staging is not routine, and we used surrogate clinical assessments (eg, pyloric obstruction). Regardless, we were able to achieve follow-up of most cases in our cohort, and completeness was verified by correlation with population-based cancer registry data and the stability of incident cases per year.

To our knowledge, this is the first study in a rural and/or LMIC setting in Latin America. Our findings may be generalizable to rural communities in the CA-4 region and may have implications for the 5 million US immigrants from the CA-4 region. Health ministries are encouraged to develop national cancer control plans that prioritize access to cancer care and promote the establishment of cost-effective cancer prevention programs in high-risk areas.⁵

Corresponding Author: Douglas R. Morgan, MD, MPH, Vanderbilt Ingram Cancer Center, Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, 2525 West End Ave, Suite 750, Nashville, TN 37203 (douglas.morgan@vanderbilt.edu).

Accepted for Publication: May 3, 2018

Published Online: July 5, 2018. doi:10.1001/jamaoncol.2018.2570

Author Contributions: Drs Estevez-Ordonez and Morgan had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Estevez-Ordonez, E. Montalvan-Sanchez, Dominguez, Morgan.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Estevez-Ordonez, E. Montalvan-Sanchez, Wong, D. Montalvan-Sanchez, Rodriguez-Murillo, Morgan.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Estevez-Ordonez, Morgan.

Obtained funding: Estevez-Ordonez, Morgan.

Administrative, technical, or material support: Estevez-Ordonez, E. Montalvan-Sanchez, D. Montalvan-Sanchez, Rodriguez-Murillo, Dominguez, Morgan.

Study supervision: Estevez-Ordonez, E. Montalvan-Sanchez, Dominguez, Morgan.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was funded by the Fogarty International Center and National Institute of Mental Health (R25 TW009337), National Cancer Institute (P01 CA028842, P30 CA068485, K07 CA125588, PAR-15-155), Vanderbilt Medical Scholars Program, and National Center for Advancing Translational Sciences (UL1 TR000445).

Role of the Funder/Sponsor: The funders/sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We acknowledge the following individuals for their contribution to this study: Samuel A. Urrutia-Argueta, MD (Hospital de Occidente, Honduras Ministry of Health), Charlotte B. Cherry, MS, MPH (Vanderbilt Institute for Global Health). They received no compensation for their contributions.