Experiences of women receiving high dose rate brachytherapy for cervical cancer at ocean road cancer institute Dar-es-salaam Tanzania

Cervical cancer is a health problem of the developing world, as approximately 84% of all women diagnosed with this disease live in developing regions. According to Denny, it is estimated that 78 897 women living in Africa will be diagnosed with cervical cancer annually, whilst 61 671 (78%) will die from this disease [1,2]. Late presentation and lack of treatment facilities contribute to the high death rate. In the global south, cervical cancer remains the second most common cancer (after breast cancer) among women of reproductive age. Worldwide, it is the third most common carcinoma after breast cancer and colorectal cancer. Unlike other cancers, cervical cancer is almost 100% preventable by ensuring that women receive quality screening and treatment of precancerous lesions [3]. The impact of secondary prevention efforts for cervical cancer prevention in high resource settings is impressive. Despite this, the World Health Organization (WHO) estimates of global cervical cancer rates remain sobering, with more than 500,000 new cases diagnosed each year. Of those cases, more than 85% of women hail from developing countries where access to primary and secondary prevention is far from universal [4]. Abstract

In these settings, most women diagnosed with cervical cancer in developing countries present at late stages when curative treatments are often no longer possible. East Africa has the highest rate of cervical cancer in the world. In this region, the Age-Standardized Incidence Rate (ASR) is estimated at 42.7 new cases per 100,000 women ASR rates range from Malawi at 75.9/100,000 to Kenya at 40.1/100.000. Tanzania ranks second in the region with an ASR of 54.9/100,000 women. Similar to other East African countries, cervical cancer is the leading cause of cancer and cancer-related death among Tanzanian women.
Each year more than 7,300 Tanzanian women are diagnosed with cervical cancer. More than half of these women die as they are diagnosed at a late stage of the disease [5].

Setting and sample
The setting was an academic and only cancer treatment hospital in Dar-es-salaam city Tanzania. The hospital offers specialist inpatient and outpatient services and serves as referral hospital for cancer patients from a number of regional

Social demographic characteristics
A total of fi fty women receiving high dose rate brachytherapy for cervical cancer at Ocean Road Cancer Institute participated in this study in fi lling of interviewer administered questionnaires.
The mean age was 47.5 years and majority of women were married 48 (96%). 40 (80% ) of participants were peasant by occupation and 24 out of 50 women (48%) were Christians and 26 (52&) were Muslims Figure 1.
Three themes arose from the study which are patient perception, expectation and impressions, informational need and psychological experiences [11].

Patient perception, expectation and impressions
Many patients had good perception about brachytherapy treatment before treatment 48 (96%) because they believed it cures their disease although the fi rst impression on brachytherapy was bad for most of patients because of stories about the procedures from other patients who already had brachytherapy. After fi rst treatment many patients had good impression on brachytherapy 38 (76%). Majority of patient expectations was less than expected because they expected brachytherapy to be bad but they found it good after fi rst treatment 40 (80%) Figure 2 [12].

Informational needs
Being provided with information about brachytherapy procedures was another them which arose during the study. Many participants had very few information about the procedure. Regarding the awareness of the procedure, all participants were aware. 39 participants (78%) were slightly satisfi ed with the information about treatment procedures since they had no enough information. The frequency of being given information about the treatment procedure was once for majority of patients 45 (95%). The information source for most patients were from healthcare workers 44(88%) Figure 3.

Psychological experiences
The psychological experiences experienced by the participants in the study were pain, distress, fear humiliation and anxiety. Pain was the major complain especially during the insertion of uterine and vaginal applicators in the cervix. The participants explained that the painful medication given to them was not enough for pain relief. Receiving brachytherapy also caused fear to women due to stories which they were told by their fellow who already had brachytherapy treatment. It was a negative experience to most participants because they experienced emotional distress before, during and after having brachytherapy. Presence of many people in a preparatory room made the participants to consider brachytherapy as humiliating procedure Figure 4.

Discussion
Treatment of cervical cancer patients by brachytherapy is a mandatory procedure if the intent of patient is curative. Despite of it being a signifi cant treatment for cervical cancer patients with stage II to stage IV, it can be a worst experience due to the complexity nature of the procedure. In this study participants were associated with pain, distress, fear, anxiety and considered as humiliation. The study categorized the experiences into four parts as patients' perceptions, expectations and impression, informational needs, and psychological experiences. Pain was a major negative experience for most women in this study as compared to the study done by AD Dzaka and JE Maree (2016) in south Africa which showed that pain is a major problem for   women receiving high dose rate brachytherapy for cervical cancer. The study by AD Dzaka and JE Maree also explained the informational need by patients that they should be provided with enough information regarding their treatment which can help to improve their experiences. This study also revealed distress, humiliation and fear as the psychological experiences which were also found in the study by AD Dzaka and JE Maree in south Africa. Some participants felt unprepared and uninformed and experienced the health professionals as uncaring. In addition, having more than the essential staff present when they were at their most vulnerable, lying on their backs with their legs 'wide open', added to their emotional distress. Velji and Fitch [13] who investigated the experiences of Canadian women who received brachytherapy, found the information that women received prior to the treatment and the care they received from nurses during the procedure shaped their experience positively or negatively. In addition, Brand [14] found a signifi cant relationship between the fear and anxiety women experience before brachytherapy and hence information needs. Considering these factors, it is not surprising that the women in the study feared brachytherapy and considered it a negative experience. However, to conclude that the negative experiences of the participants were caused by their information needs and the lack of care they expected would be over-simplifying a complex issue and should be investigated before defi nite deductions can be made. In contrast with the fi ndings of Velji and Fitch [13,14], who found that the treatment modality itself did not play an important role in how women experience this treatment, the nature of the procedure expressed as 'shoving stuff in your vagina' played a major role in how our participants experienced brachytherapy. The participants experienced both physical and emotional pain. Participants feared the procedure before they had been treated and even the follow-up treatments. Andersen, Karlsson, Anderson and Tewfi k [15,16], when exploring survivorship issues in women diagnosed with gynaecological cancer, found levels of anxiety and distress in women remained high before, during and after brachytherapy. Kwekkeboom, Dendaas, Straub and collegues16 found that pre-treatment distress was signifi cantly higher than that experienced before the second brachytherapy. It is unclear whether the distress levels of women in the current study decreased after the fi rst treatment as the number of treatments was not taken into consideration and distress levels were not measured. However, distress after the fi rst treatment was still a reality for the women in our study. The severe pain participants experienced, described as 'cutting' and 'I could not take the pain', added to their suffering. According to Arnold, Lee and Stuart [17] and Chapman [18] pain is a common symptom amongst persons receiving any form of cancer treatment and is a reality for about 50-53% of patients at all disease stages and about 62-88% of patients with advanced disease. Nail [19] found most women diagnosed with gynaecological cancer experience varying degrees of pain during brachytherapy, which, according to Kwekkeboom, Dendaas, Straub, et al. [16], ranges from mild to moderate. In addition, Rollison and Strang [20] found more than half (13 of 20) of the patients in their study experienced moderate to severe pain during this procedure. Although the current study did not assess the levels of pain, it provides evidence of the experience of severe pain during brachytherapy procedures. As evident by 'that pill and injection didn't drug me', the conscious sedation participants received did not prevent them from experiencing pain. The way pain is managed does not seem to be best practice as, according to Puntillo, Wild, Morris, et al. [21] and Gordon, Dahl, Miaskowski and colleagues [22], unlike other forms of cancer pain, procedural pain can be anticipated and prevented. As described by 'I couldn't sleep, I'm thinking of the agony I'm gonna go through', women experienced high levels of anxiety. Warnock [23], on investigating experiences of gynaecological cancer patients treated with brachytherapy, found a relationship between pain and anxiety and diffi culty coping during the procedure. However, it was unclear whether the pain was raised by the anxiety or the anxiety resulted in pain. The emotional pain of having to lie in the lithotomy position with your legs wide open adds to the complexity of the pain experience. In addition, it was interesting to fi nd the participants preferred childbirth, described by Simkin [24], as the ultimate painful, emotionally distressing, vulnerable and exhausting event in a woman's life, to having to undergo brachytherapy. It can only be concluded, as supported by Velji and Fitch [14] and Kwekkeboom Dendaas, Straub and colleagues [16], that brachytherapy is a very unpleasant and the study also had similar fi ndings as the study done by Deirdre Long, Hester Sophia Friedrich-Nel and Georgina Joubert in 2012 South Africa that explained the importance of provision of information regarding treatment procedures and overall treatment to patients. The study showed the importance of providing information to patients regarding disease, treatment and possible side effects that reduce the feeling of fear and anxiety toward their treatment. Patient expectations, perception and impression were found to be negative before treatment but after the fi rst treatment the negativity changed and patient considered brachytherapy as a excellent and necessary treatment [25].
This was similar as the study done by Alicia Ehlers and Chandra Rekha Makanjee in 2017 about Exploration of gynaecological cancer high dose rate brachytherapy treatment which fi ndings showed that brachytherapy was considered as a sensitive procedure which requires better preparation and treatment procedures information to patients.
The study also found that the effi ciency of drug used for pain relief during insertion of uterine and vaginal applicators is very low. This fi nding is similar to the study done by Theresa N Elumela and Abbas A.Abdus -Salam on the topical anaesthesia