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Surgical candidacy and treatment initiation among women with cervical cancer at public referral hospitals in Kampala, Uganda: a descriptive cohort study

Objectives This study aimed to report the proportion of women with a new diagnosis of cervical cancer recommended for curative hysterectomy as well as associated factors. We also report recommended treatments by stage and patterns of treatment initiation. Design This was an observational cohort study. Inperson surveys were followed by a phone call. Setting Participants were recruited at the two public tertiary care referral hospitals in Kampala, Uganda. Participants Adult women with a new diagnosis of cervical cancer were eligible: 332 were invited to participate, 268 met the criteria and enrolled, and 255 completed both surveys. Primary and secondary outcomes measures The primary outcome of interest was surgical candidacy; a secondary outcome was treatment initiation. Descriptive and multivariate statistical analyses examined the associations between predictors and outcomes. Sensitivity analyses were performed to examine outcomes in subgroups, including stage and availability of radiation. Results Among 268 participants, 76% were diagnosed at an advanced stage (IIB–IVB). In total, 12% were recommended for hysterectomy. In adjusted analysis, living within 15 km of Kampala (OR 3.10, 95% CI 1.20 to 8.03) and prior screening (OR 2.89, 95% CI 1.22 to 6.83) were significantly associated with surgical candidacy. Radiotherapy availability was not significantly associated with treatment recommendations for early-stage disease (IA–IIA), but was associated with recommended treatment modality (chemoradiation vs primary chemotherapy) for locally advanced stage (IIB–IIIB). Most (67%) had started treatment. No demographic or health factor, treatment recommendation, or radiation availability was associated with treatment initiation. Among those recommended for hysterectomy, 55% underwent surgery. Among those who had initiated treatment, 82% started the modality that was recommended. Conclusion Women presented to public referral centres in Kampala with mostly advanced-stage cervical cancer and few were recommended for surgery. Most were able to initiate treatment. Lack of access to radiation did not significantly increase the proportion of early-stage cancers recommended for hysterectomy.

I commend the authors for conceptualizing this study, however, there are some areas that are not clear making the interpretation of the results difficult and confusing. For instance, who are these 332 women screened from which the 268 eligible women were enrolled? This is cervical cancer, and the term "screening" should be made clear to readers. It could mean asymptomatic women screened for precancerous stages using one of the screening methods. Also, the statement 255 completed both surveys is not clear-what are these surveys? In addition to several grammatic errors requiring revisions, some of my specific comments for the authors to consider are briefly highlighted below: Comment #1: The title does not seem to reflect the message in this paper. I suggest that the title should be revised to reflect the nature of the study and the intended message-maybe "Clinical presentation and treatment options for women with cervical cancer at public referral hospitals in Kampala, Uganda". The word "uptake" is typically used for services that are known to be available to patients, but in this manuscript the authors have described the situation of women presenting with cervical cancer where close to 80% were diagnosed at advanced stages not amenable to surgical option. For those who presented at early stages, surgical option was recommended by the clinical team and a few declined for reasons enumerated in the paper.
Comment #2: The sample size assumptions are not clear. Since this was a "cohort study" to estimate the proportion of women with cervical cancer that received or were recommended for curative hysterectomy, it will be nice to know the hypothesized and postulated proportions of cases of early cervical cancer with hysterectomy to make such an intervention clinically or statistically significant. The sample of 265 included women with advanced stage cervical cancer but the final analytic sample for "surgical candidacy" should be the number of women with early cervical cancer. I strongly suggest that the authors should review this section with a biostatistician if sample size is of interest in a "convenience" sample. This limitation has already biased the sample and making it difficult to interpret the inferential statistics presented in the paper. Alternatively, the authors could provide a clear description of presentation of cervical cancer and challenges of treatment in Uganda. I made this suggestion earlier in comment #1 above.
Comment #3: in the result section under abstract, the actual numbers of women diagnosed at early stage should be specified rather than just stating that only 12% were recommended for hysterectomy. This is the primary outcome of this study and it will be nice to know the number of women who presented at early stages, then the proportion of that number that were recommended for hysterectomy. Also, it is unclear what is meant by "most (67%) had started treatment". The authors should situate these statements in the context of the study primary or secondary outcomes and should not leave the statements to the guess of the reader. I commend the authors for subgrouping early stages to IA1-IB1 and 1B2-IIA and providing the proportions of hysterectomy for each subgroup, but it will be nice to present a test of proportions for surgery between this 2 subgroups and provide a p-value. Comment #4: In Table 1, the numbers do not tally; 33 for surgical  candidates and 204 for late stages gives 237 not N=267 as shown in  the table. The numbers did not add up for almost all the variables  shown in the table. Also, the numbers for most of the variables in  table 3 do not add up. The authors should carefully check these up! Comment #5: Throughout the paper, the authors have used terminologies that are unclear and inconsistent-for instance, "treatment initiation", "treatment acquisition", etc. Although treatment initiation as an outcome has been defined as "patient-reported initiation of any form of treatment including hospice care", its use should be consistent, and as in comment #3 above, the authors should endeavor to specify the actual numbers and put the proportion in parenthesis for clarity. Some of the results are too vague! Comment #6: The authors made recommendation that hospice and palliative care are likely to be recommended treatments for patients for cervical cancer in Uganda on finding that 9 patients died before treatment. This recommendation is too presumptive and not backed by quality data. The central focus of this study is to estimate the proportion of "eligible" women who received recommendation for curative hysterectomy and the associated factors. I do not see the authors focusing on answering and discussing this problem. Who are these 9 patients that died without receiving treatment? At what stages were they diagnosed, and what treatment recommendations were offered to them? It is clear that cervical cancer screening leads to detection and treatment of precancer thereby preventing invasive cervical cancer in the population; it is also known that women who develop invasive cervical cancer in a screening setting are more likely to be diagnosed at early stages and have a chance for curative hysterectomy. Therefore, as mentioned in the discussion section the emphasis should be for screening rather than advocating for hospice and palliative care as treatment options. In addition, the authors rightly pointed out the problem of limited capacity for curative hysterectomy for early stages of cervical cancer in the introduction section of this manuscript but did not discuss its contribution to the current findings for example, can a structured training to improve surgical competency of non-gynecologic oncologic surgeons for modified radical hysterectomy lead to improve recommendation for surgery for early stage IB2-IIA?.
Comment #7: In the strength and limitation section, the authors stated that "this is one of the first studies in the region to report on "treatment acquisition" and the first to investigate association of treatment recommendations, availability of radiation as well as demographic and clinical factors on treatment initiation among women with cervical cancer". I see this as a deviation from the primary focus of this study-"estimate the proportion of women with early stage cervical cancer recommended for curative hysterectomy". The authors have also said that this was a convenience sample lacking statistical power to assess the impact of factors associated with the outcome. I suggest that the authors should refocus their narratives and provide a clearer message on the problem being investigated.

REVIEWER
Prof Sean Kehoe University of Birmingham, UK I am Chair of the FIGO Cancer Committee and cervical cancer in low resource countries is on my portfolio.

GENERAL COMMENTS
A very important topic and with cervical cancer mortality exceeding maternal mortality in low resource countries -it is important to have data such as that available in this study.

REVIEW RETURNED
12-Aug-2020 GENERAL COMMENTS Thanks for the opportunity to review this manuscript, examining the factors associated with recommendation for surgery, and subsequent uptake of treatment, among women diagnosed with cervical cancer in two hospitals in Kampala, Uganda. Cervical cancer rates are high in many countries in sub-Saharan Africa, and ensuring appropriate treatment following diagnosis, especially where there is the possibility of cure, is critical. Hence, I read the paper with interest.
Study findings are clearmost women in the study cohort were diagnosed with late stage disease; one third of women did not initiate recommended treatment; for only a small proportion of women was hysterectomy the Introduction In the first paragraph, the authors mention population-based cytologic screening in high-income countries. However, WHO guidance for many LMICs is HPV testing +/-VIA/ VILI screening. (WHO guidelines for screening and treatment of precancerous lesions for cervical cancer prevention. World Health Organization 2013. http://apps.who.int/iris/bitstream/10665/94830/1/9789241548694_eng.pdf). This should be mentioned: it does not detract from the point that a low percentage of women in Uganda have been screened (as an asideinterestingly reference 4 does not specify which modalities of cervical screening participants were being asked about, or were offered by the facilities participants were recruited at).
Minor typo -line 126 -'in January 2018.' Also line 126any information on what proportion of patients travelled to Kenya prior to the study?

Methods
Overall, this is cleardata was collected in two stages, a questionnaire at the clinic, and a follow-up telephone survey. Loss to follow-up was low.
More information is needed on recruitment of women in the clinicswere sequential women approached, or more randomly e.g. every second woman? Were researchers in attendance on selected days or clinics of specific doctors that could have introduced bias?
Similarly, there is a need for greater clarity on informed consent and data collection. Was study information at the point of invitation to participate in the study provided verbally or in a written format? What proportion of women were literate? Lines 205/206 mentions 'Written informed consent documents' so implies all were literate. Line 176did women give specific consent for their medical records to be accessed by the research team? If so, please state this. In not, please explain why not. Line 167 -169were question asked verbally and the researchers recorded this directly into tablets or on a paper form, or did women complete a paper-based questionnaire? Please state how confidentiality of women was maintained during participation in the study.

Results
Results are clearly presented, in the text, tables, and figures.
Line 242 (also Figure 1, and Abstract) -'332 women were screened'do you mean invited to participate? For clarity, given the paper is about cervical cancer, it would be better not to use the word 'screening'.
Lines 281, and 285the word actually is not required

Discussion
Please expand on 'financial constraints' for readers less familiar with the public health system in Uganda and similar countries. As noted, clinical consultations are free of charge and there are nominal fees associated with radiation, surgery, labs and imaging. What is the nature of the financial constraints women face (are these nominal fees out of reach for most women, is it out of pocket health expenses, cost of travel to the hospital, or expenses for themselves and a guardian while they are in hospital, concerns about loss of income while receiving treatment, etc.?) It might be worth mentioning that there is a need for a parallel study to understand health providers' recommendations for treatment (do they make recommendations based on consideration of a woman's circumstances, concerns regarding availability of theatre /bloods etc., or skills (their own or that of surgical colleagues) for hysterectomy.
Also of note, prior screening was associated with candidacy for hysterectomy provides further indirect support for provision of cervical cancer screening, in that it detects lesions at an early and potentially curable stage.
Personal viewpoint -can I suggest the wording in the title is changed to treatment initiation (c.f. uptake)uptake (usually) has implicit in it some measure of choice, whereas I think many of the women in this study who did not go on to the recommended treatment modality had little choice In Methods, Participants and setting, we explain the eligibility criteria. Women potentially eligible were adult women with new diagnosis of cervical cancer at MNRH or UCI. Women were invited to participate and the research assistants "screened" the women to ensure they met eligibility criteria. Figure One shows that the 64 women were ineligible or declined to participate and enumerates the reasons.

VERSION 1 -AUTHOR RESPONSE
This is cervical cancer, and the term "screening" should be made clear to readers. It could mean asymptomatic women screened for precancerous stages using one of the screening methods.
We thank the reviewer for this feedback. We have changed the wording to "invited to participate" in order to avoid confusion.
Also, the statement 255 completed both surveys is not clear-what are these surveys?
This line is in the abstract, under "Participants." Several lines prior, in "Design," we explain that the primary methodology was surveys.
In addition to several grammatic errors requiring revisions, some of my specific comments for the authors to consider are briefly highlighted below: Comment #1: The title does not seem to reflect the message in this paper. I suggest that the title should be revised to reflect the nature of the study and the intended message-maybe "Clinical presentation and treatment options for women with cervical cancer at public referral hospitals in Kampala, Uganda". The word "uptake" is typically used for services that are known to be available to patients, but in this manuscript the authors have described the situation of women presenting with cervical cancer where close to 80% were diagnosed at advanced stages not amenable to surgical option. For those who presented at early stages, surgical option was recommended by the clinical team and a few declined for reasons enumerated in the paper.
We appreciate the feedback on the title. We have replaced the word "uptake" with "initiation" to avoid confusion.
Comment #2: The sample size assumptions are not clear. Since this was a "cohort study" to estimate the proportion of women with cervical cancer that received or were recommended for curative hysterectomy, it will be nice to know the hypothesized and postulated proportions of cases of early cervical cancer with hysterectomy to make such an intervention clinically or statistically significant. The sample of 265 included women with advanced stage cervical cancer but the final analytic sample for "surgical candidacy" should be the number of women with early cervical cancer. I strongly suggest that the authors should review this section with a biostatistician if sample size is of interest in a "convenience" sample. This limitation has already biased the sample and making it difficult to interpret the inferential statistics presented in the paper. Alternatively, the authors could provide a clear description of presentation of cervical cancer and challenges of treatment in Uganda. I made this suggestion earlier in comment #1 above.
The reviewer has raised some important questions that we will address. As the study is largely descriptive, our power considerations focused on an acceptably precise estimate of proportion of those with early-stage disease, thus potential surgical candidates, as well as proportion of those recommended for surgery. The reviewer's comments encouraged us to be clearer about the nature of the study and the outcomes of interest. Secondarily, we sought to investigate factors associated with surgical candidacy, as well as treatment-initiation. Please see lines 237-247 where we have incorporated this feedback into the manuscript.
Comment #3: in the result section under abstract, the actual numbers of women diagnosed at early stage should be specified rather than just stating that only 12% were recommended for hysterectomy. This is the primary outcome of this study and it will be nice to know the number of women who presented at early stages, then the proportion of that number that were recommended for hysterectomy. Also, it is unclear what is meant by "most (67%) had started treatment". The authors should situate these statements in the context of the study primary or secondary outcomes and should not leave the statements to the guess of the reader. I commend the authors for subgrouping early stages to IA1-IB1 and 1B2-IIA and providing the proportions of hysterectomy for each subgroup, but it will be nice to present a test of proportions for surgery between this 2 subgroups and provide a p-value.
In an effort to stay within the word limits for the abstract, we chose to give percentages, rather than numbers and percentages.
The statement in Results in the abstract, "Most (67%) had started treatment" is describing the proportion of the living study participants who were reached for phone interview who had started treatment (170/255). This is explained in the Results section of the manuscript lines 317-320 We agree that it is important to sub-divide "early" into stage IA1-IB1 and IB2-IIA. Given that 92% of the former and just 3% of the latter were recommended for surgery and there were just 64 total "early stage" participants, the OR for recommendation for surgery for the stage IA1-IB1 is 299 with a 95% CI 29.37-3037. As the study was not powered to look at this difference and the numbers of those with "early stage" disease is small, we did not think it was relevant to report the test statistic or confidence interval. We present the findings descriptively.  (268); though, as explained in the Table footnote as well as in the text, we eliminated one woman with advanced stage disease who reported to have been recommended for surgery, leaving 267. As for the other variables, there were missing data, which is why the numbers do not add to 267. In Methods, Statistical analyses, we explain that listwise deletion was used to remove observations missing outcome or predictor variables.
Comment #5: Throughout the paper, the authors have used terminologies that are unclear and inconsistent-for instance, "treatment initiation", "treatment acquisition", etc. Although treatment initiation as an outcome has been defined as "patient-reported initiation of any form of treatment including hospice care", its use should be consistent, and as in comment #3 above, the authors should endeavor to specify the actual numbers and put the proportion in parenthesis for clarity. Some of the results are too vague! We have changed "acquisition" to "initiation" to avoid confusion.
Comment #6: The authors made recommendation that hospice and palliative care are likely to be recommended treatments for patients for cervical cancer in Uganda on finding that 9 patients died before treatment. This recommendation is too presumptive and not backed by quality data. The central focus of this study is to estimate the proportion of "eligible" women who received recommendation for curative hysterectomy and the associated factors. I do not see the authors focusing on answering and discussing this problem. Who are these 9 patients that died without receiving treatment? At what stages were they diagnosed, and what treatment recommendations were offered to them? It is clear that cervical cancer screening leads to detection and treatment of precancer thereby preventing invasive cervical cancer in the population; it is also known that women who develop invasive cervical cancer in a screening setting are more likely to be diagnosed at early stages and have a chance for curative hysterectomy. Therefore, as mentioned in the discussion section the emphasis should be for screening rather than advocating for hospice and palliative care as treatment options. In addition, the authors rightly pointed out the problem of limited capacity for curative hysterectomy for early stages of cervical cancer in the introduction section of this manuscript but did not discuss its contribution to the current findings for example, can a structured training to improve surgical competency of non-gynecologic oncologic surgeons for modified radical hysterectomy lead to improve recommendation for surgery for early stage IB2-IIA?.
We appreciate the feedback. As "surgical candidacy" was our outcome of interest, we begin the Discussion section with an analysis of those with stage IA1-IIA cervical cancer, focusing on factors that may or may not have contributed to the recommendation for hysterectomy lines 361-371. Later in the Discussion, lines 422-428, we discuss factors associated with a recommendation for surgery among the general study population and the implication of these associations.
The reviewer's suggestion of proposing a training program for radical hysterectomy is well-taken and is actually on-going. We have added 2 sentences to the Introduction explaining that there is a new local fellowship program designed for exactly this purpose, lines 126-131. We mention in the Discussion that these newly trained providers with limited surgical equipment (including hemostatic agents) and lack of access to sufficient cross-matched blood may be reticent to offer radical hysterectomy to stage IB2-IIA. We have made the connection to the new fellowship program explicit and commended our local colleagues (some of whom are co-authors) on this project.
While we were interested in reporting about surgical candidacy, given that most cervical cancer in Uganda is diagnosed at advanced stages, we felt we should address this trend in the context of treatment initiation patterns we observed in our sample. We were surprised that so few women were recommended for hospice, especially as hospice services are available in Uganda. Given that nearly a quarter of women did not start treatment, most were of advanced stage and some had even died before starting treatment, there seems to be a missed opportunity for the integration of palliative care and hospice treatment. This is a minor point in the discussion and we believe it is warranted. To address the reviewer's question regarding who the nine women were who had died, this is addressed in a footnote in Table 3: four had been recommended for chemotherapy, 4 for chemoradiation and 1 for hospice. In terms of stage, two of these women were stage IIB, four were IIIB, two were IVA and one was IVB; we have added a sentence to the footnote in Table III noting that all women who passed away were of advanced stage and enumerated the stage breakdown.
We agree that the point to underscore, as we do, is that expansion of vaccination and screening opportunities are the best way to decrease morbidity and mortality from cervical cancer. We do also advocate for efforts to improve earlier detection and diagnosis as well as to expand accessibility of curative surgery.
Comment #7: In the strength and limitation section, the authors stated that "this is one of the first studies in the region to report on "treatment acquisition" and the first to investigate association of treatment recommendations, availability of radiation as well as demographic and clinical factors on treatment initiation among women with cervical cancer". I see this as a deviation from the primary focus of this study-"estimate the proportion of women with early stage cervical cancer recommended for curative hysterectomy". The authors have also said that this was a convenience sample lacking statistical power to assess the impact of factors associated with the outcome. I suggest that the authors should refocus their narratives and provide a clearer message on the problem being investigated.
In addition to reporting the proportion of women recommended for hysterectomy, we also discuss treatment recommendations overall as well as treatment initiation, as described in Objectives. We have tried to make our power considerations clearer per this and previous feedback from the reviewer.

University of Birmingham, UK
A very important topic and with cervical cancer mortality exceeding maternal mortality in low resource countries -it is important to have data such as that available in this study.

Introduction
In the first paragraph, the authors mention population-based cytologic screening in high-income countries. However, WHO guidance for many LMICs is HPV testing +/-VIA/ VILI screening. (WHO guidelines for screening and treatment of precancerous lesions for cervical cancer prevention. World Health Organization 2013. http://apps.who.int/iris/bitstream/10665/94830/1/9789241548694_eng.pdf). This should be mentioned: it does not detract from the point that a low percentage of women in Uganda have been screened (as an aside -interestingly reference 4 does not specify which modalities of cervical screening participants were being asked about, or were offered by the facilities participants were recruited at).
We thank the reviewer for pointing out that cytologic screening is not recommended for LMICs, we agree. Instead of discussing recommended screening modalities for LMICs (especially in comparison to high-income countries), we removed "cytologic" from the description of population-based screening in high-income countries. Our intention was to posit that the disparity in screening uptake in LMICs compared to high-income countries results in the disparity in incidence and mortality from cervical cancer. While screening is of upmost importance, we address this in our conclusion, recommendations for particular modes of screening warrants a longer discussion that we felt was beyond the scope of this paper.
Minor typo -line 126 -'in January 2018.' We have fixed the typo.
Also line 126any information on what proportion of patients travelled to Kenya prior to the study?
Thanks for this question; we agree the option needs clarification. The Ugandan Ministry of Health and Aga Khan, a private hospital in Nairobi, worked out an MOU to offer subsidized treatment for 400 of the estimated 17,000 Ugandan patients needing radiation at the time the machine was taken out of commission. Out-of-pocket expenses for a woman obtaining five weeks of radiation treatments for cervical cancer, including transportation, accommodation and living expenses in Nairobi, would have totaled approximately $5000, which would have been unaffordable for most Ugandans. It is unclear how many patients benefitted from this program (though anecdotally, we are aware of very few overall, no cervical cancer patients), nor how the Ministry of Health ultimately selected the patients. None of the patients in this study went to Kenya for treatment, though some were recommended for radiation during the time the machine was out of commission and presumably the intention would have been for treatment abroad. We added two sentences to the introduction to expand on the Kenyan radiation option, lines 137-141.

Methods
Overall, this is cleardata was collected in two stages, a questionnaire at the clinic, and a follow-up telephone survey. Loss to follow-up was low.
More information is needed on recruitment of women in the clinicswere sequential women approached, or more randomly e.g. every second woman? Were researchers in attendance on selected days or clinics of specific doctors that could have introduced bias?
Women were approached sequentially (added clarification, line 179) on the days when the research assistants were able to be in clinic. This is thus a convenience sample. The research assistants were in clinic approximately 50% of the time during the study period. This was a half-time job for the research assistants, who were trained RNs and unable to work fulltime on the study. We do not believe there was specific bias related to specific days of the week or clinics as the research assistants schedules did vary; however, the convenience sample is limited in generalizability, which we address in Discussion, lines 430-431.
Similarly, there is a need for greater clarity on informed consent and data collection. Was study information at the point of invitation to participate in the study provided verbally or in a written format? What proportion of women were literate? Lines 205/206 mentions 'Written informed consent documents' so implies all were literate.
We thank the reviewer for this important feedback. The study information was provided verbally and patients were also given a written copy in either Luganda or English. Consent forms were signed by participants. If participants were unable to sign for whatever reason, illiteracy included, a thumbprint was accepted as signature. As is the convention per IRB in Uganda, if a thumbprint was given in place of a signature, a third-party witness (usually the participant's care-giver) was required to sign the consent form as evidence that an informed consenting process had transpired. We did not specifically collect data on literacy, limited literacy and/or illiteracy, though we did inquired about education level, which is described in the manuscript. We have amended lines 228-229 to make the informed consenting process clearer.
Line 176did women give specific consent for their medical records to be accessed by the research team? If so, please state this. In not, please explain why not.
The data were collected verbally, we have added clarification in line 188. Researchers directly recorded the information onto tablets.
Please state how confidentiality of women was maintained during participation in the study.
Maintaining confidentiality was important to us. Participants were assigned a unique identification number for all data collected over the course of the study. Although no data was ultimately saved on the tablets used to collect data, the tablets were kept in locked cabinet in an access-limited room at the study sites. All project staff were trained on procedures for maintaining confidentiality. Survey data, including some clinical data, was electronically captured (directly onto tablets) using ODK software, which, once form data are finalized, encrypts the files. The database will be saved on a secure encrypted database at the research site. Excel files generated from the data were deidentified. No participant identifying information will be disclosed in any publication arising from the study. We have added lines 231-234 to Methods, Ethics statement in order to address this important question.

Results
Results are clearly presented, in the text, tables, and figures.
Line 242 (also Figure 1, and Abstract) -'332 women were screened'do you mean invited to participate? For clarity, given the paper is about cervical cancer, it would be better not to use the word 'screening'.
We have made this change to avoid confusion Lines 281, and 285the word actually is not required Agree, we have removed the word "actually."

Discussion
Please expand on 'financial constraints' for readers less familiar with the public health system in Uganda and similar countries. As noted, clinical consultations are free of charge and there are nominal fees associated with radiation, surgery, labs and imaging. What is the nature of the financial constraints women face (are these nominal fees out of reach for most women, is it out of pocket health expenses, cost of travel to the hospital, or expenses for themselves and a guardian while they are in hospital, concerns about loss of income while receiving treatment, etc.?) We have added lines 334-336 to expand on what was meant by "financial constraints." As this study is part of a larger project to report about various reasons for delay along the process of obtaining care (data forthcoming), we had asked about lack of funds for travel and the nominal fees associated with treatment and diagnostic studies -we lumped these together as "financial constraints." We have expanded the correlate part of the Discussion: see added lines 401-407 for explanation of underfunded healthcare system as well as the reality of Uganda's average monthly income (approx. $80 USD) and a rural population required to travel for cancer care.
It might be worth mentioning that there is a need for a parallel study to understand health providers' recommendations for treatment (do they make recommendations based on consideration of a woman's circumstances, concerns regarding availability of theatre /bloods etc., or skills (their own or that of surgical colleagues) for hysterectomy.