Prevalence and factors associated with delayed surgery among children with Wilms tumor at Mulago Hospital: a mixed-method study

Lule Daniel, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London
Shamim Nabidda, The Aga Khan University
Abraham Muhwezi, Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
Ronald Naitala, Joint Clinical Research Center, Kampala, Uganda
Anne Akullo, Joint Clinical Research Center, Kampala, Uganda
Enid Kawala Kagoya, Department of Clinical Epidemiology and Biostatistics, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
Ruth Namazzi, College of Health Sciences, Makerere University, Uganda
Nasser Kakembo, Department of Surgery, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
Joan N. Kalyango, Makerere University, Uganda

Abstract

Introduction Wilms tumor (WT) is a highly treatable form of childhood cancer, with five-year survival rates greater than 90% in high-income countries. In low- and middle-income countries, survival is still low. Delayed surgery is one of the leading factors for poor survival, as it leads to tumor complications, making subsequent treatment more complex. However, there is a paucity of information in Uganda on the prevalence and factors associated with delayed surgery. This study aimed to determine the prevalence and factors associated with delayed surgery, and to explore the barriers and facilitators of timely surgery among children with WT at Mulago Hospital.

Methods The study employed a convergent concurrent mixed-methods design. The quantitative component involved a retrospective cross-sectional design using 261 patient records selected through consecutive sampling and reviewed via a data abstraction tool. Modified Poisson regression was used to assess associated factors. The qualitative component included in-depth interviews with 10 healthcare workers and 10 caregivers selected purposively and was analyzed via inductive thematic analysis.

Results The prevalence of delayed surgery was 63.6% (95% confidence interval (CI) 57.0-68.7). The year of diagnosis (2021: adjusted prevalence ratio (aPR) 2.26, 95% CI 1.40–3.65, p value 0.001; 2022: aPR 1.78, 95% CI 1.07–2.99, p value 0.026; and 2023: aPR 2.01, 95% CI 1.24–3.25, p value 0.004), tumor laterality (aPR 1.41, 95% CI 1.07–1.85, p value 0.014), hemoglobin level after preoperative chemotherapy (POPC; aPR 1.22, 95% CI 1.05–1.51, p value 0.032), and chemotherapy regimen (VAD: aPR 1.32, 95% CI 1.11–1.57, p value 0.02; and AV/CE: aPR 1.46, 95% CI 1.07–1.99) were associated with delayed surgery. Qualitative findings revealed systemic, patient-level, chemotherapy, and tumor-related barriers to and facilitators of timely surgery.

Conclusion The prevalence of delayed surgery was high among children with WT. Delayed surgery results from a complex interplay of clinical, systemic, and patient-related factors. Addressing barriers at both the institutional and patient levels may help reduce surgical delays and improve outcomes.