Gynecological cancers represent a significant global health challenge, with increasing documentation of cases, particularly in developing countries [1]. Recent global statistics from the International Agency for Research on Cancer have revealed that gynecological cancers account for 25% of all new cancers diagnosed in women aged up to 65 years in developing regions, compared to 16% in the developed world [2]. This marked disparity highlights the growing burden of gynecological malignancies in resource-limited settings.

The global burden of gynecological cancers shows a concerning trend, with developing countries accounting for 820,265 cases (77.7%) of all new cases of common gynecological cancers, including cervical, uterine, and ovarian cancers [3]. This observed pattern in developing nations has been attributed to multiple factors, including the adoption of Western lifestyle behaviors, increasing prevalence of immunosuppressing conditions, and high rates of oncogenic infections [4]. Additionally, socioeconomic factors, limited healthcare access, and inadequate screening programs contribute significantly to late presentation and poor outcomes [5].

In India, the management of gynecological cancers faces unique challenges. Limited healthcare resources, cultural barriers, and socioeconomic constraints often result in delayed diagnosis and suboptimal treatment adherence [6]. The situation is further complicated by variations in healthcare delivery systems across different regions and socioeconomic strata. Despite these challenges, there is limited literature specifically addressing the obstacles faced by clinicians in managing these cases in tertiary care settings.

Understanding these challenges is crucial for developing effective strategies to improve outcomes. Previous studies have suggested that factors such as late presentation, limited treatment accessibility, and poor compliance significantly impact treatment outcomes [7]. However, there is a notable gap in comprehensive data analyzing these challenges in the Indian context, particularly in government tertiary care facilities serving diverse socioeconomic populations.

This study aims to evaluate the various challenges faced by clinicians in managing gynecological cancers at a tertiary care facility, focusing on factors such as late presentation, noncompliance with treatment regimens, outcomes of radical surgeries, and availability of treatment facilities. Additionally, it seeks to understand the pattern and relative frequencies of gynecological malignancies among women admitted to the department of gynecology. The findings of this study will contribute to the development of more effective management strategies and help address the specific needs of this patient population.

This retrospective observational study was conducted at the Department of Obstetrics and Gynecology, ESIC Medical College & PGIMSR, Chennai, India, between January 2019 and December 2023. The study protocol received approval from the Institutional Ethics Committee of ESIC Medical College & PGIMSR 

The study population comprised all patients diagnosed with gynecological malignancies and treated at our institution during the study period. We included histopathologically confirmed cases of gynecological malignancies in patients aged ≥18 years who received treatment at our institution and had complete medical records available for analysis. Cases of non-gynecological cancers, those with incomplete medical records, without histopathological confirmation, and patients who received primary treatment elsewhere were excluded. A total of 159 cases meeting these criteria were analyzed.

Data collection was performed through systematic review of medical records retrieved from the hospital's Medical Records Department after obtaining necessary permissions. A structured proforma was used to collect comprehensive information including demographic data, clinical parameters, disease characteristics, management details, and outcome measures. Management details were documented, including screening methods used, diagnostic procedures, treatment modalities, treatment availability, adherence patterns, and follow-up information. Outcome measures included treatment completion status, quality of life assessment, follow-up compliance, and treatment-related complications. Late presentation was defined as presentation with stage III/IV disease. Treatment adherence was categorized as full, partial, or dropped out based on completion of prescribed treatment. Quality of life was assessed using a standardized questionnaire and categorized as good, fair, or poor. Regular follow-up was defined as attendance at ≥80% of scheduled follow-up visits.

To ensure data quality, extraction was performed by two independent researchers, with random verification of 10% of cases by a senior consultant. Discrepancies were resolved through consensus, and missing data were handled through multiple imputation techniques. Statistical analysis was performed using SPSS software version 29.02. Descriptive statistics were presented as mean ± standard deviation or median with interquartile range for continuous variables, and frequencies with percentages for categorical variables. Analytical statistics included chi-square tests for categorical variables. A p-value <0.05 was considered statistically significant.

Study limitations included the single-center design, retrospective nature of data collection, potential recall bias in symptom duration, missing data in some variables, and limited follow-up duration for some cases. Despite these limitations, the study provides valuable insights into the challenges faced in managing gynecological malignancies in a tertiary care setting. Graphs and charts were generated using Microsoft Excel 2019 and SPSS Graphics to illustrate the findings effectively.

A total of 159 patients with gynecological malignancies were analyzed at ESIC Medical College & PGIMSR, Chennai, during 2019-2023. The mean age of presentation was 54.3 years (range: 32-78 years). The majority of patients (37.7%) were aged ≥60 years, followed by 40-49 years (25.8%). Most patients were married (96.2%), and 41.5% belonged to low socioeconomic status. The study population showed nearly equal distribution between urban (51.6%) and rural (48.4%) residencies (Table 1).

Table 1: Socio-demographic Profile of Study Population (N=159)

Cervical cancer was the most prevalent malignancy (40.9%), followed by ovarian (33.3%) and endometrial cancer (25.2%). Advanced stage (III/IV) presentation was observed in 52.2% of cases (Table 2).

Table 2: Pattern and Stage-wise Distribution of Gynecological Malignancies (N=159)

The clinical presentation and diagnostic methods varied among patients, with different presenting symptoms for different cancer types (Table 3).

Table 3: Clinical Presentation and Diagnostic Methods (N=159)

Several challenges were identified in cancer management, with late presentation and diagnostic delays being significant issues (Table 4).

Table 4: Challenges in Management - Diagnostic Delays (N=159)

                                    *Chi-square test

The treatment modalities and histopathological characteristics varied among patients (Table 6).

Table 6: Treatment Modalities and Histopathological Characteristics (N=159)

                                  *Others include chemoradiation, discharged against medical advice, and referred cases

Table 7: Reproductive Characteristics of Study Population (N=159)

Table 8: Treatment Outcomes and Follow-up Patterns (N=159)

   *Chi-square test **others include expired, not known, and missed follow-up cases

The analysis of treatment outcomes revealed significant associations between socioeconomic factors and treatment success. Among patients who completed treatment, quality of life assessments showed better outcomes in those with regular follow-up (p=0.008). Table 9 presents these associations in detail.

Table 9: Associations between Socioeconomic Factors and Treatment Outcomes (N=159)

                       *Chi-square test

The impact of various treatment modalities on survival and quality of life varied significantly across cancer types and stages (Table 10).

Table 10: Treatment Outcomes by Cancer Type and Treatment Modality (N=159)

                   *Chi-square test

The follow-up analysis demonstrated significant correlation between regular follow-up and improved outcomes (Table 11).

Table 11: Impact of Follow-up Patterns on Treatment Outcomes (N=159)

                           *Chi-square test

The analysis of treatment delays and their impact on outcomes revealed significant associations (Table 12).

Table 12: Analysis of Treatment Delays and Impact on Outcomes (N=159)

                 *Chi-square test for association with poor outcomes, mean delay presented as mean ± SD

These findings demonstrate the complex interplay between socioeconomic factors, treatment accessibility, and outcomes in gynecological cancer management. The data particularly highlights the importance of regular follow-up and early intervention in improving treatment outcomes.

The present study offers comprehensive insights into the multifaceted challenges encountered in managing gynecological malignancies at a tertiary care center in South India. Our findings reveal complex interactions between sociodemographic factors, healthcare accessibility, and treatment outcomes, while highlighting several critical areas requiring intervention.

The demographic analysis of our cohort revealed a mean age of 54.3 years, with a notable predominance of patients aged ≥60 years (37.7%). This age distribution pattern, while consistent with findings from North Indian studies by Sharma et al. [8], shows a higher proportion of elderly patients compared to previous South Indian cohorts [9]. This variance might reflect changing demographics or differences in healthcare-seeking behavior across regions. Interestingly, our study population demonstrated nearly equal urban-rural distribution (51.6% vs 48.4%), providing a balanced perspective on healthcare challenges across different settings.

The pattern of malignancies in our study reveals cervical cancer as the predominant type (40.9%), followed by ovarian (33.3%) and endometrial cancers (25.2%). While this distribution broadly aligns with the National Cancer Registry Program of India data [10], we observed a notably higher proportion of endometrial cancers (25.2% vs 18.7% nationally). This increased prevalence of endometrial cancer might be attributed to the growing urbanization and lifestyle changes in our catchment area, a phenomenon increasingly recognized in recent epidemiological studies [11]. Such shifts in cancer patterns emphasize the need for adaptive screening and management strategies.

Perhaps the most concerning finding of our study is the high proportion of advanced-stage presentations (52.2%). This figure, while comparable to data from other developing nations, stands in stark contrast to reports from developed countries where advanced-stage presentations typically constitute around 30% of cases [12]. Our analysis revealed a complex web of factors contributing to late presentation, with lack of screening (28.9%) and asymptomatic progression (32.1%) emerging as primary contributors. These findings echo observations from Patel et al.'s systematic review of barriers to gynecological cancer care in resource-limited settings [13], underlining the persistent challenges in early detection.

Treatment adherence emerged as a significant challenge, with only 51.6% of patients demonstrating full adherence to prescribed treatments. This finding, though concerning, aligns with observations from similar settings [14]. The strong association between socioeconomic status and treatment adherence (p=0.031) in our study provides crucial insights into the social determinants of cancer care. The higher dropout rates observed in the low socioeconomic group (34.9%) mirror findings from Maheshwari et al. [15], highlighting the pervasive impact of financial constraints on treatment continuity.

A particularly noteworthy finding is the significant impact of treatment availability on adherence patterns (p=0.012). Areas with readily available facilities demonstrated markedly better adherence rates (59.2%) compared to regions with limited accessibility (39.3%). This observation resonates with recent WHO reports on cancer care in developing countries [16] and underscores the critical need for improved healthcare infrastructure. The demonstrated correlation between regular follow-up and improved outcomes (p=0.008) further emphasizes the importance of continuous care accessibility.

Quality of life outcomes in our study showed significant stage-dependent variation (p=0.015), with early-stage disease associated with better outcomes. However, our rates of good outcomes in early-stage disease (37.3%) fell short of those reported in developed nations (45-50%) [17]. This disparity likely reflects the complex interplay of limited supportive care facilities and socioeconomic constraints characteristic of developing healthcare systems.

Treatment delays emerged as a significant concern, with financial constraints being the predominant factor (28.3%, mean delay 8.2 weeks). While these delays were shorter than those reported in some South Asian studies [18], their impact on outcomes was significant (p=0.012). The influence of educational status on treatment outcomes (p=0.028) and the observed urban-rural disparity (p=0.034) further highlight the role of social determinants in cancer care outcomes [19, 20].

Our findings carry important implications for healthcare policy and clinical practice. They emphasize the need for multifaceted interventions including enhanced screening programs, improved healthcare accessibility in rural areas, robust financial support systems for low-income patients, and strengthened follow-up mechanisms. The observed patterns of late presentation and treatment non-adherence particularly underscore the importance of community-based awareness programs and patient navigation services.

The limitations of our single-center, retrospective study design warrant consideration when interpreting these findings. However, the comprehensive nature of our data collection and analysis provides valuable insights into the challenges of managing gynecological malignancies in resource-limited settings. Future prospective, multi-center studies would be valuable in further validating these findings and developing targeted interventions.

Overall, our study revealed a significant burden of advanced-stage disease presentations, with cervical cancer emerging as the predominant malignancy, followed by ovarian and endometrial cancers. Treatment adherence emerged as a major challenge, strongly influenced by socioeconomic factors and healthcare accessibility. The findings demonstrate clear associations between treatment availability, regular follow-up, and improved outcomes, emphasizing the critical role of continuous care in cancer management. Socioeconomic disparities significantly influenced treatment outcomes, with lower socioeconomic groups experiencing higher dropout rates and poorer outcomes. These findings underline the urgent need for strengthened screening programs, improved healthcare accessibility particularly in rural areas, establishment of financial support systems, and implementation of community-based awareness programs. The study suggests that enhanced patient navigation services and supportive care, coupled with targeted interventions to address identified barriers, could significantly improve outcomes in gynecological cancer management in resource-limited settings.

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