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

Wilms tumor (WT) is a highly treatable form of childhood cancer, with five-year survival rates greater than 90% in high-income countries. In low- and middle-income countries, survival is still low. Delayed surgery is one of the leading factors for poor survival, as it leads to tumor complications, making subsequent treatment more complex. However, there is a paucity of information in Uganda on the prevalence and factors associated with delayed surgery. This study aimed to determine the prevalence and factors associated with delayed surgery, and to explore the barriers and facilitators of timely surgery among children with WT at Mulago Hospital. The study employed a convergent concurrent mixed-methods design. The quantitative component involved a retrospective cross-sectional design using 261 patient records selected through consecutive sampling and reviewed via a data abstraction tool. Modified Poisson regression was used to assess associated factors. The qualitative component included in-depth interviews with 10 healthcare workers and 10 caregivers selected purposively and was analyzed via inductive thematic analysis. The prevalence of delayed surgery was 63.6% (95% confidence interval (CI) 57.0-68.7). The year of diagnosis (2021: adjusted prevalence ratio (aPR) 2.26, 95% CI 1.40–3.65, p value 0.001; 2022: aPR 1.78, 95% CI 1.07–2.99, p value 0.026; and 2023: aPR 2.01, 95% CI 1.24–3.25, p value 0.004), tumor laterality (aPR 1.41, 95% CI 1.07–1.85, p value 0.014), hemoglobin level after preoperative chemotherapy (POPC; aPR 1.22, 95% CI 1.05–1.51, p value 0.032), and chemotherapy regimen (VAD: aPR 1.32, 95% CI 1.11–1.57, p value 0.02; and AV/CE: aPR 1.46, 95% CI 1.07–1.99) were associated with delayed surgery. Qualitative findings revealed systemic, patient-level, chemotherapy, and tumor-related barriers to and facilitators of timely surgery. The prevalence of delayed surgery was high among children with WT. Delayed surgery results from a complex interplay of clinical, systemic, and patient-related factors. Addressing barriers at both the institutional and patient levels may help reduce surgical delays and improve outcomes.