
==== Front
JCO Glob Oncol
JCO Glob Oncol
go
GO
JCO Global Oncology
2687-8941
Wolters Kluwer Health

37738538
GO.22.00397
10.1200/GO.22.00397
ORIGINAL REPORTS
Gynecological Cancer
Benchmarking of the Cervical Cancer Care Cascade and Survival Outcomes After Radiation Treatment in a Low- and Middle-Income Country Setting
https://orcid.org/0000-0001-7443-5937
Grover Surbhi MD, MPH 1 2 3 4
https://orcid.org/0000-0001-8479-8512
MacDuffie Emily MD 1
Nsingo Memory MD 5
https://orcid.org/0000-0002-5346-2992
Lei Xiudong PhD 6
https://orcid.org/0000-0001-8280-2645
Mehta Priyanka MD, MPH 7
https://orcid.org/0000-0003-4907-9920
Davey Sonya MD 8
https://orcid.org/0000-0001-6843-0662
Urusaro Sandra BSN, MPHc 3 9 10
https://orcid.org/0000-0001-9800-1455
Chiyapo Sebathu MD 2
https://orcid.org/0000-0001-6401-3722
Vuylsteke Peter MD 4
Monare Barati RN, MPH 3
https://orcid.org/0000-0002-6170-1084
Bazzett-Matabele Lisa MD 2 11 12
Ralefala Tlotlo MD 2
https://orcid.org/0000-0002-1975-8837
Luckett Rebecca MD, MPH 2 11 13 14
https://orcid.org/0000-0001-9624-8366
Ramogola-Masire Doreen MD 11 15
https://orcid.org/0000-0002-3171-2911
Smith Grace L. MD, PhD, MPH 6 16
1 Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
2 Princess Marina Hospital, Gaborone, Botswana
3 Botswana-UPenn Partnership, Gaborone, Botswana
4 Department of Medicine, University of Botswana, Gaborone, Botswana
5 Department of Oncology, Gaborone Private Hospital, Gaborone, Botswana
6 Department of Health Services Research, MD Anderson Cancer Center, Houston, TX
7 Department of Gynecology & Obstetrics, Emory University, Atlanta, GA
8 Department of Medicine, Brigham and Women's Hospital, Boston, MA
9 School of Nursing, University of Pennsylvania, Philadelphia, PA
10 Department of Global Health, University of Washington, Seattle, WA
11 Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
12 Department of Obstetrics and Gynecology, Yale University, New Haven, CT
13 Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
14 Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA
15 Department of Obstetrics and Gynecology, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, PA
16 Department of Gastrointestinal Radiation Oncology, MD Anderson Cancer Center, Houston, TX
Surbhi Grover, MD, MPH, Department of Radiation Oncology, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104; e-mail: surbhi.grover@pennmedicine.upenn.edu.
2023
22 9 2023
22 9 2024
9 e220039728 11 2022
13 4 2023
28 7 2023
© 2023 by American Society of Clinical Oncology
2023
American Society of Clinical Oncology
https://creativecommons.org/licenses/by-nc-nd/4.0/ Creative Commons Attribution Non-Commercial No Derivatives 4.0 License: http://creativecommons.org/licenses/by-nc-nd/4.0/

Delays in care for patients with cervical cancer in Botswana can be benchmarked using a multidisciplinary clinic model.

PURPOSE

Timely radiation treatment (RT) is critical in cervical cancer treatment, but patients in low- and middle-income countries (LMICs) in sub-Saharan Africa often face barriers that delay care. Time to care was benchmarked in a multidisciplinary team (MDT) setting in Botswana.

METHODS

Time intervals between steps in care were recorded for 230 patients reviewed at MDT between January 2016 and July 2018. Associations between RT delay and overall survival (OS) were evaluated using Kaplan-Meier curves and multivariable Cox proportional hazards models.

RESULTS

For patients who received RT (n = 187; 81.3%), the median biopsy to pathology reporting interval was 25 (IQR, 19-36) days and was 57 (IQR, 28-68) days for patients who did not (P = .003). Intervals in care did not differ between patients who did and did not receive RT. Among treated patients, the uppermost quartile interval from pathology reporting to RT initiation was ≥111 days and that from RT simulation to initiation was ≥12 days. Among patients receiving a RT dose of ≥65 Gy (n = 100), the delay from RT simulation to initiation of >12 days was associated with worse median OS (2.0 v 4.6 years; P = .048); this association trended toward, although did not meet, statistical significance on multivariable analysis (hazard ratio, 2.35; 95% CI, 0.95 to 5.85; P = .07).

CONCLUSION

The MDT-coordinated care model allows for systematic benchmarking of the patient treatment cascade. Barriers to timely treatment exist for this cohort in Botswana, and RT delay may be associated with OS of patients receiving curative treatment. Interventions to accelerate the timing of the radiation oncology care cascade may improve clinical outcomes in this LMIC setting.

OPEN-ACCESSTRUE
==== Body
pmcINTRODUCTION

With an estimated 604,000 new cases and 342,000 deaths in 2020, cervical cancer imposes a substantial and increasing global burden.1 Low- and middle-income countries (LMICs), particularly those in sub-Saharan Africa, bear a disproportionate share of the cervical cancer morbidity and mortality burden; 90% of the deaths because of cervical cancer that occurred in 2020 occurred in these countries.1

CONTEXT

Key Objective

Is it feasible to benchmark delays in care and evaluate the impact on survival after implementation of multidisciplinary team (MDT) clinics in a limited-resource setting?

Knowledge Generated

MDT coordination of care allows for data collection that comprehensively evaluates delays between key steps in the care cascade in Botswana. The median time between pathologic diagnosis and radiation initiation for patients with cervical cancer in Botswana was 83 days, and the delay between radiation simulation and initiation of >12 days is associated with poorer survival in this patient population.

Relevance

Coordination provided by MDT clinic allows for identification of barriers to efficient care delivery to target efforts toward improvement.

In Botswana, a middle-income country in sub-Saharan Africa, the incidence of cervical cancer remains among the highest in the world (34.4 per 100,000 women) and cervical cancer is the leading cause of cancer death among women.1-4 Factors contributing to Botswana's high cervical cancer burden include a high HIV prevalence (25.1% among women age 15-49 years), limited access to screening, and social barriers to treatment.5,6 As a result, the majority of patients in Botswana present with locally advanced cancer that requires radiation with or without chemotherapy6 as treatment with curative intent.

Currently, standard curative-intent therapy for locally invasive cervical cancer in Botswana consists of external beam radiation therapy (EBRT) with concurrent cisplatin-based chemotherapy and brachytherapy boost, consistent with the global standard of care.7-9 The government of Botswana provides free public health care, including cervical cancer treatment, to all citizens. In 2015, a multidisciplinary team (MDT) clinic was created at Princess Marina Hospital (PMH), Botswana's main public hospital.10 Studies conducted in high-income countries (HICs) have shown that MDT clinics can reduce patient delays, increase the accuracy of diagnosis, decrease treatment variability, and even improve patient survival.11-13 To our knowledge, PMH's MDT clinic is the first of its kind in an LMIC and is staffed by a radiation oncologist, a clinical oncologist, a gynecologist, a pathologist, a palliative care specialist, and a nurse coordinator. This integrated MDT clinic discusses the cases of all patients referred to the clinic and collaboratively determines appropriate care plans, which may involve referral to Gaborone Private Hospital (GPH), the country's only radiation oncology facility that houses a single linear accelerator.6 Despite these efforts, patients with cervical cancer remain at risk for delays in care because of barriers in coordinating and implementing the multiple and multidisciplinary care delivery steps in the care cascade. The delay of radiation treatment (RT) for cervical cancer has been associated with reduced survival in HICs14,15 and LMICs.16

This LMIC MDT clinic setting provides an opportunity to benchmark care delivery metrics for multidisciplinary and RT-specific management. The purposes of this study were to describe the overall multidisciplinary cervical cancer care cascade, from diagnosis through treatment, in this setting and to quantitatively benchmark the time to care delivery at key points in the cascade in a well-characterized patient sample. We also sought to identify delays in care that may affect survival in this MDT setting, with a specific focus on the outcomes of patients with locally advanced cervical cancer warranting RT. Our overall goal was to demonstrate that feasible, comprehensive benchmarking can be implemented in such LMIC MDT settings. Such benchmarking is critical for the identification of steps that can be taken to continuously improve clinical outcomes and care delivery in this high-risk patient population.

METHODS

Study Participants and Data Collection

Consecutive patients with biopsy-proven, locally advanced cervical cancer who were potentially eligible for RT or chemoradiation treatment (CRT) were enrolled between January 2016 and July 2018 at PMH's MDT clinic in Gaborone, Botswana. Because Gaborone houses the country's sole linear accelerator, this sample represents a majority of patients with cervical cancer referred and seen for curative treatment in the country over this period. Patients were staged clinically according to the International Federation of Gynaecology and Obstetrics staging criteria.17 Basic laboratory studies including complete blood count and renal function test, chest x-ray, and abdominal ultrasound were performed before treatment. All patients were followed prospectively for the collection of data on survival until November 2019. Patient and clinical characteristics, including demographic information, International Federation of Gynecology and Obstetrics (FIGO) 2009 stage (I-III and IV), dates of care delivery, receipt of EBRT and/or brachytherapy, receipt and number of chemotherapy cycles, and HIV status, were abstracted from patient interviews and electronic and paper medical records. Overall survival (OS) was calculated from the date of care (eg, pathology reporting, RT referral, or RT simulation) to the date of death as determined by telephone calls to patients and their next of kin and/or medical records (event) or last follow-up examination (censored).

Assessment of Cervical Cancer Care Delivery Timing and RT Delay

The steps required for diagnosis and treatment of patients with cervical cancer were delineated by the clinical team. Patients who underwent workup outside PMH did not have records available to delineate the clinical timeline between presentation and biopsy, and therefore, treatment timeline for this study started from the date of biopsy. The intervals between biopsy and pathology reporting, pathology reporting and MDT consultation, MDT consultation and GPH consultation, GPH consultation and RT simulation, RT simulation and RT initiation, MDT consultation and RT initiation, pathology reporting and RT initiation, and RT initiation and the end were calculated on the basis of dates of care delivery. RT planning after simulation typically takes 1 week at GPH. A delay in RT initiation was defined as an interval of >12 days after simulation to represent at least 1 week's delay including intervening weekends.

Statistical Analyses

Descriptive statistics (medians and IQRs) were calculated for the intervals between care cascade steps. We compared these time intervals by the receipt of treatment, HIV status, and FIGO 2009 stage using the Wilcoxon rank-sum test. Additional analyses of the times to treatment were conducted with data from the subset of 175 patients who received treatment, excluding patients with missing treatment dates (n = 12). Predictors of RT delay were identified using the chi-squared test and a multivariable linear regression model that included age (younger than 50 and 50 years and older), FIGO stage (I-III and IV), HIV status (yes/no), brachytherapy (yes/no), number of chemotherapy cycles (0, 1-3, 4-6), and distance from hometown to treatment facility (<60 and ≥60 km). The total equivalent dose in 2-Gy fractions (EQD2) of radiation was calculated for each patient on the basis of the standard reporting guidelines of the American Brachytherapy Society.18 In stratified analyses, an EQD2 threshold of 65 Gy to differentiate definitive and palliative doses was tested. In a sensitivity analysis, the threshold of 70 Gy was also tested. Calculation of estimated risk ratios (RRs) and 95% CIs was performed using the SAS GENMOD procedure and log link.

OS was evaluated using the Kaplan-Meier product limit method and compared between patients with and without RT delay using the log-rank statistic. Multivariable Cox proportional hazards models adjusted for baseline covariates were established, with parsimonious final models selected on the basis of clinical and statistical significance. HIV positivity was included because of its clinical significance. The results are expressed as hazard ratios (HRs) with 95% CIs.

For all analyses, statistical tests were two-sided and P values ≤ .05 were considered to be significant. SAS version 9.4 (version 9.4; SAS Institute, Cary, NC) and R (version 4.0.5, R Foundation for Statistical Computing, Vienna, Austria) were used.

Ethical Considerations

All participants provided written informed consent in their language of choice (English or Setswana). The Health Research Development Committee of the Botswana Ministry of Health (Institutional Review Board [IRB] #821167 and #1584) and the IRB of the University of Pennsylvania (IRB #820905) approved the study conduct and data collection. The IRB of the University of Texas MD Anderson Cancer Center (IRB #PA18-0395) approved the data analysis.

RESULTS

Patient Characteristics

Of the cohort of 230 patients with cervical cancer, 64.8% (n = 149) were women living with HIV. The median age of the cohort was 49 (IQR, 42-61) years, and in patients who received RT (n = 187 [81.3%]), it was 49 (IQR, 42-61) years. The proportions of patients presenting with FIGO stages I-IV were 8.3% (n = 19), 28.3% (n = 65), 34.3% (n = 79), and 22.2% (n = 51), respectively. In total, 81.3% (n = 187) received RT. Additional characteristics are presented in Table 1. Of the patients who received RT, 53.4% (n = 100) received total EQD2 ≥65 Gy. Brachytherapy was administered to 54.0% (n = 101) of patients, of whom 81.2% received doses of ≥20 Gy. Chemotherapy was prescribed to 43.3% (n = 81) of patients, of whom 95.1% (n = 77) received at least one cycle.

TABLE 1 Patient Characteristics by Treatment Receipt

Cervical Cancer Care Cascade

Patients presented directly to PMH or on referral from a local health clinic. New patients and referred patients without recent biopsy underwent biopsy at PMH. The pathologist reviewed biopsies and made the tissue diagnoses. Patient cases were then presented for review by the radiation oncologist, clinical oncologist, gynecologist, and pathologist at the MDT clinic. Patients who required RT were referred to GPH for initial consultation with a radiation oncologist and scheduling for simulation. After simulation, the radiation oncologist, the dosimetrist, and the physicist created and reviewed radiation plans. Patients then presented for their first RT session (Fig 1).

FIG 1 The multidisciplinary cervical cancer care cascade in Botswana. GPH, Gaborone Private Hospital; MDT, multidisciplinary team; PMH, Princess Marina Hospital.

The intervals between key steps in the care cascade are shown in Table 2. The interval with the least amount of data collected was biopsy to pathology reporting, for which 30% of the cohort had dates available for collection. For all other intervals, dates were successfully collected in ≥70% of the cohort.

TABLE 2 Time to Care Delivery for Each Care Cascade Step in All Patients

Median interval length between biopsy and pathology reporting was longer among patients who did not receive RT than for those who did (median interval, 57 [IQR, 28-68] v 25 [IQR, 19-36] days; P = .003; Table 3). Among patients who initiated RT, those with stage IV disease had a shorter median interval from MDT visit to RT initiation than stage I-III patients (median interval, 38 [IQR, 5-56] v 47 [IQR, 41-69] days; P = .02; Table 4). No difference in care interval according to HIV status was detected (Table 5).

TABLE 3 Time to Care Delivery for Each Care Cascade Step in All Patients Stratified by RT Receipt

TABLE 4 Time to Care Delivery for Each Care Cascade Step in Patients Who Received RT Stratified by Stage

TABLE 5 Time to Care Delivery for Each Care Cascade Step in Treated Patients, Stratified by HIV Status

Associations Between the RT Dose, RT Delay, and OS

Relative to patients who received EQD2 <65 Gy, those who received EQD2 ≥65 Gy had better adjusted OS (adjusted HR, 0.36; 95% CI, 0.20 to 0.64; P < .001; Table 6) but trended toward greater delay in starting RT, although this did not meet statistical significance (adjusted RR, 1.73; 95% CI, 0.94 to 3.16; P = .08; Table 7). Among patients who received EQD2 ≥65 Gy, the RT delay of >12 days was associated with worse OS (2 v 4.6 years; P = .048). No other time intervals were associated with differential survival outcomes: biopsy to pathology reporting (log-rank P = .63), pathology reporting to MDT visit (log-rank P = .23), and RT referral to simulation (log-rank P = .08). In this curative group of patients with and without a >12-day delay, 1-year Kaplan-Meier survival estimates were 0.85 (95% CI, 0.64 to 0.94) and 0.91 (95% CI, 0.82 to 0.96); 2-year estimates were 0.59 (95% CI, 0.32 to 0.78) and 0.76 (95 CI, 0.62 to 0.85), respectively (Figs 2A-2C). After adjustment for potentially confounding covariates, this association trended toward, but did not meet, statistical significance at a threshold of P < .05 (HR, 2.35; 95% CI, 0.95 to 5.85; P = .07; Table 8). The trend toward but not meeting statistical significance was consistent in the sensitivity multivariate analysis for patients receiving EQD2 ≥70 Gy (HR, 2.51; 95% CI, 0.98 to 6.40; P = .054; Appendix Table A1). Among patients who received EQD2 <65 Gy, RT delay did not significantly affect OS (HR, 0.85; 95% CI, 0.35 to 2.08; P = .72; Table 8).

TABLE 6 HRs for the Association of RT Delay (>12 days after RT simulation) With Overall Survival Among Patients With Cervical Cancer (n = 175)

TABLE 7 Univariate and Multivariate Results for Predictors of RT Delay (>12 days from RT simulation)

FIG 2 Kaplan-Meier curves and OS for patients with cervical cancer with versus without RT delay (>12 days v 0-12 days) for (A) all patients treated with RT (n = 175), (B) among those who received EQD2 ≥65 Gy (n = 100), and (C) among those who received EQD2 <65 Gy (n = 75). EQD2, total equivalent dose in 2-Gy fractions; OS, overall survival; RT, radiation treatment.

TABLE 8 HRs for Association of RT Delay (>12 days) With Overall Survival, Stratified by Total Equivalent Doses (EQD2) of ≥65 and <65 Gy

DISCUSSION

This study of the cervical cancer treatment cascade in an MDT clinic led to the identification of RT delays that may be modifiable and the elimination of which could improve clinical outcomes. This study also demonstrates the feasibility of data collection in a low-resource MDT clinic setting for the quantification of care delivery benchmarks, with data for all but one interval available in ≥70% of patient charts. Our findings highlight the strength of this benchmarking approach for the identification of actionable targets to improve radiation oncology care delivery and outcomes. Among patients who received treatment with curative intent, on unadjusted Kaplan-Meier survival analysis, an RT delay between simulation and RT start was associated with worse OS. Although multivariate models suggested that potential confounding by advanced cancer stage (but not HIV status) was detected, the adjusted model results also suggested that a trend toward worse OS remained among patients with RT delay.

Treatment delays have been studied at many cancer sites in HICs and LMICs.19,20 Ideally, CRT for cervical cancer including both EBRT and brachytherapy should be completed within 8 weeks of its initiation.21,22 Failure to do so can compromise local control and cancer-specific survival, with an estimated 0.5%-1% decrease in these metrics for every additional day of treatment time.23-25 Thus, the overall treatment time is an important metric for the characterization of care quality.

In this study population, delays were identified in almost every step of the treatment cascade. The longest interval was observed between the MDT consultation and initial radiation oncology consultation at GPH. Given the limitations of treating a large population of patients with cancer with a single linear accelerator, these delays may be due primarily to patient volume and challenges in care coordination. Pathology processing was the second most delayed step, and it took much longer for patients who did not receive RT than for those who ultimately did. This finding may reflect that some patients do not initiate treatment because of attrition or death while awaiting pathology results although the exact causes were not examined in this analysis. Patients with stage I-III disease were more likely to have longer delays between MDT consultation and RT initiation than patients with stage IV disease, likely because of the necessity of expedited palliative treatment for patients with metastatic disease requiring pain control and/or hemostasis. This may also explain why patients who received a palliative dose of RT had less delay from simulation to RT as compared with patients who received curative dose yet experienced worse OS. Overall, this timeline suggests that patients with metastatic disease requiring palliative RT received expedited treatment; however, reduced delays in this population did not affect survival, as expected, given their advanced disease.

In the present study, the median time between diagnosis and RT initiation was just under 12 weeks. Any measure that could be undertaken to reduce this duration could contribute to the improvement of clinical outcomes. The interval between RT simulation and initiation is dependent on both the health system and patient factors, and therefore, the impact of delay of >12 days on survival is likely multifactorial. Patients in Botswana are typically scheduled for RT initiation 7 days after simulation or plan completion. Given the high volume of patients treated, this initiation may be delayed until a treatment timeslot on the single linear accelerator becomes available. Delays in treatment plan creation can also cause initiation delay. RT delays for new patients and those on treatment also occur during machine failure, which necessitates the transport of experts and/or parts from neighboring South Africa or even far as other continents. Although the majority of these delays do not have simple solutions, the data from this study may suggest that time could be of importance when initiating RT for new patients and that the identification of opportunities to reduce delays at each step particularly from simulation to the start of RT is a potentially intervenable step to improve care delivery and outcomes.

Although the radiation team can attempt to minimize the time to RT initiation, many patient factors that are beyond its control also contribute to RT delay. For example, patients may return to their homes after RT simulation and encounter social, logistical, or financial barriers to returning in a timely manner. A previous study of allcomers to PMH showed that patient-centered delays occurred more often for patients with limited symptoms or symptoms attributable to comorbid conditions, those without supportive families, those with religious conviction in healing by a higher power, and those with financial concerns regarding travel costs and/or lost income.26 Although we did not investigate factors underlying RT delay in this study, this previous evidence supports the fact that a myriad of social determinants prevent timely receipt of care. Additional qualitative studies are needed to identify the reasons underlying patient-centered delays and, ultimately, to offer solutions that enable patients to receive timely, unfragmented cancer care.

Several methods for the improvement of treatment uptake and completion in LMICs have been demonstrated to successfully increase completion rates. Programs such as nurse navigation and the implementation of a smartphone navigation application (eg, OP Care) have been shown to improve access to resources and mitigate patient attrition in these settings.27-31 A randomized study performed in the Ivory Coast showed that nurse navigation significantly improved treatment acceptance and completion in patients with lymphoma, primarily because of the reduction in patients' financial concerns and on-treatment discouragement.32 Although a knowledge gap regarding patient-specific treatment delays remains, support for care navigation may be one approach to their minimization via the provision of patient-specific support and gathering of data to support the implementation of larger interventions that encourage timely treatment.

Botswana's MDT clinic, established in 2015, was shown early in its implementation to enhance care coordination, standardize treatment of women with HIV infection, and improve clinical outcomes.10 The successful collection of clinical data and patient tracking through the care cascade in this study underscore the success and utility of this MDT clinic. Grover et al3,33 demonstrated that the survival outcomes of patients in Botswana with HIV infection and cervical cancer treated with curative intent do not differ from those of patients without HIV infection. This study further revealed no difference in care delays between these groups in the MDT clinic setting. The centralization of care provides more opportunities to gather insight into care pathways and to enhance care delivery.

The main limitation of this analysis is that it was retrospective. Thus, the association between RT delay and OS may not be causal, or there could be other residual confounders of the association, and therefore, this finding requires additional validation in prospective studies. In addition, the underlying causes of delays in the care cascade, including RT delay, are unknown for this patient cohort. A qualitative and systematic prospective study is needed to identify facility-level, physician-level, and clinical and social patient-level factors that lead to care delays, particularly between RT simulation and initiation, which can affect OS.

In conclusion, the establishment of efficient treatment pathways is particularly challenging in under-resourced settings. Here, we demonstrate the ability to use a newly established MDT clinic for systematic benchmarking of the steps in a care cascade as the pathway for future improvement of patient outcomes. This model of MDT-guided care coordination has the potential to improve our understanding of the barriers in the pathway from diagnosis to treatment, contributing to the collective knowledge and development of evidence-based approaches to systematically improve care delivery in low-resource settings.

PRIOR PRESENTATION

SUPPORT

AUTHOR CONTRIBUTIONS

Conception and design: Surbhi Grover, Memory Nsingo, Sebathu Chiyapo, Barati Monare, Doreen Ramogola-Masire, Grace L. Smith

Administrative support: Barati Monare

Provision of study materials or patients: Sebathu Chiyapo, Barati Monare

Collection and assembly of data: Surbhi Grover, Memory Nsingo, Sandra Urusaro, Barati Monare, Lisa Bazzett-Matabele, Grace L. Smith

Data analysis and interpretation: Surbhi Grover, Emily MacDuffie, Xiudong Lei, Priyanka Mehta, Sonya Davey, Sebathu Chiyapo, Peter Vuylsteke, Barati Monare, Rebecca Luckett, Doreen Ramogola-Masire, Grace L. Smith

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/go/authors/author-center.

Open Payments is a public database containing information reported by companies about payments made to US-licensed physicians (Open Payments).

APPENDIX

TABLE A1 HRs for Association of RT Delay (>12 days) With Overall Survival, Stratified by Total Equivalent Doses (EQD2) of ≥70 and <70 Gy

Presented at the ASTRO 2022 Annual Meeting, San Antonio, TX, October 26, 2022.

S. Grover: Mentored Patient-Oriented Career Research Development Award (1-K08CA230170-01A1), Department of Radiation Oncology, University of Pennsylvania, Sub-Saharan African Collaborative HIV and Cancer Consortia-U54 (1U54 CA190158-01), MD Anderson Cancer Center (P30 CA016672). G.L. Smith: National Cancer Institute (NIH/NCI K07CA211804).

Surbhi Grover

Honoraria: Varian Medical Systems

Consulting or Advisory Role: GenesisCare

Research Funding: Varian Medical Systems

Memory Nsingo

Employment: Gaborone Private Hospital

Stock and Other Ownership Interests: Gaborone Private Hospital

Sandra Urusaro

Other Relationship: Partners in Health

Peter Vuylsteke

Honoraria: Roche/Genentech, Novartis, MSD Oncology

Travel, Accommodations, Expenses: Roche

Lisa Bazzett-Matabele

Honoraria: Merck Sharp and Dhome

Travel, Accommodations, Expenses: Merck Sharp and Dhome

Doreen Ramogola-Masire

Travel, Accommodations, Expenses: MSD

Other Relationship: MSD

Grace L. Smith

Consulting or Advisory Role: AstraZeneca

Research Funding: Varian Medical Systems

Other Relationship: Oncora Medical

No other potential conflicts of interest were reported.
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