cc
BY NC ND
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 19
Número 2
1
REE 19(2) Riobamba may. - ago. 2025
Prevalence of cancer and time to referral care in oncology patients
Prevalencia de cáncer y tiempo de atención de referencias en pacientes oncológicos.
https://doi.org/10.37135/ee.04.23.01
Authors:
Carlos Andrés Yépez Salgado1 - https://orcid.org/0009-0009-4722-8348
Zully Mayra Romero Orellana1,2 - https://orcid.org/0009-0000-6323-7548
David Cristóbal Orozco Brito3 - https://orcid.org/0000-0002-3945-3301
Nancy Paola Buenano Zambrano1 - https://orcid.org/0009-0003-2505-9236
Yesenia Liliana Chandi Japón4 - https://orcid.org/0009-0000-5672-0451
Affiliation:
1Hospital Provincial General Docente Riobamba.
2Universidad Nacional de Chimborazo.
3Escuela Superior Politécnica de Chimborazo.
4Centro de Salud Pungala Grande.
Corresponding author: Carlos Andrés Yépez Salgado. Hospital Provincial General Docente Riobamba.
Dirección postal: 060104. Email: med.carlos.andres@gmail.com / docenciahpgdrcoordinacion@gmail.
com Phone: +593984109505.
Received: January 24, 2025 Accepted: abril 01, 2025
ABSTRACT
Cancer represents a worldwide problem. In 2022, there were 30888 new cases of cancer and 16158
deaths in Ecuador. Considering the high morbidity and mortality due to this disease, health systems are
trying to meet the demand of these patients in public and private health services. Our main objective
was to establish the prevalence of cancer and the time of care of oncological patients referred to the
second level from the first of care during January-July 2024 at the Hospital Provincial General
Docente Riobamba. An original, observational, retrospective, descriptive, and correlational study
was presented. The prevalence of neoplasms is 3.11 %, and 45.09 % are malignant. The prevalence
of cancer in total hospitalizations is 1.4 %, and the average waiting time for care is 35 days. There
was a high prevalence of cancer in the hospital, where Internal medicine and Surgery are the services
with the most hospitalizations for this pathology.
Keywords: Cancer; Neoplasms; Epidemiology; Community Health Planning; Secondary Care Centers.
RESUMEN
El cáncer representa un problema a nivel mundial, en el año 2022 en el Ecuador existieron 30888
nuevos casos de cáncer y 16158 muertes, considerando una elevada morbimortalidad a causa de este
padecimiento, los sistemas de salud realizan un esfuerzo por solventar la demanda de estos pacientes
en los servicios de salud públicos y privados. El objetivo de esta investigación fue establecer la
prevalencia de cáncer y el tiempo de atención de referencias de pacientes oncológicos referidos desde
el primer nivel de atención al segundo nivel de atención de enero a julio de 2024 en el Hospital
Provincial General Docente de Riobamba. Se presentó un estudio original, observacional, transversal
retrospectivo, descriptivo y correlacional. La prevalencia de neoplasias es de 3,11 % y el 45,09 % son
malignas. La prevalencia de cáncer en el total de hospitalizaciones es 1,4% y el promedio de tiempo
de espera para la atención es de 35 días. Existió una elevada prevalencia de cáncer en el hospital,
siendo medicina interna y cirugía los servicios con más hospitalizaciones por esta patología.
Palabras clave: cáncer; neoplasias; epidemiología; planificación sanitaria comunitaria; centros de
atención secundaria.
.
INTRODUCTION
Cancer is a term used to refer to a broad group of diseases of complex and multifactorial origin caused
by abnormal cells that multiply autonomously and irregularly, invading other tissues locally and at a
distance.(1) The degree of malignancy is variable. It depends on the aggressiveness of its cells and
biological characteristics(2). They can spread and cause metastasis from different routes of dissemination
(lymphatic, blood, or by extension and direct invasion of neighboring tissues).(2,3) In general, if their
natural evolution is sought, they tend to lead to the death of the affected person in the short term.(4)
Currently, more than 200 different types of cancer are known, depending on the tissue from which they
are derived. The most common are those of the skin, lungs, breast, colon, and rectum.(5)
According to PAHO, cancer is one of the leading causes of mortality in the Americas. The figures indicate
that its incidence is growing rapidly worldwide, becoming a significant barrier to increasing life
expectancy. It is estimated that in 2022, there were 20 million new cases of cancer and 9.7 million
deaths in the region. (6,7)
Statistics from the International Agency for Research on Cancer indicate that in 2022 in Ecuador there
were 30888 new cases of cancer, 16,158 deaths, a risk of 7.3 % of dying from cancer before the age of
75; Prostate (29.4 %), stomach (11.2 %) and colorectal (8.4 %) cancer are more prevalent in our coun-
try; In female sex, lung cancer (23 %), cervical cancer (10.5 %) and colorectal cancer (8.0 %) are the
main ones; It is also mentioned that by 2040 there will be more than 53,701 cases detected during the
year in Ecuador. (8)
When analyzing the statistics, we observe that in Ecuador, as in the rest of the world, the incidence of
cancer is increasing, which is why it is necessary to have a health system that provides the opportunity
for each user to have adequate and timely care for their diagnosis and treatment.(8,9) It has been shown
that the delay in the care of this type of patient has been directly related to survival rates.(9) A study in
London about the survival of patients with breast cancer related to delayed uptake and treatment
showed that 32 % of patients with delays of 12 weeks or more had locally advanced or metastatic
disease, compared to only 10 % of those with delays of less than 12 weeks, which shows us the importance
of early recruitment.(10)
The national health system in Ecuador has a system of universality and progressive free healthcare
based on the Comprehensive Health Care model, which is supported by the user referral system to
improve healthcare.(11,12) This regulation is applied at all levels of care, thus allowing adequate care to
be provided to all users who require it according to the degree of complexity to achieve complete,
acceptable, and timely care.(13)
The health system of Ecuador offers a model that allows recruitment at the first level of health, which
is responsible for making the referral to the next step.(14) The time that elapses from the recruitment of
an oncology patient to the moment they obtain specialized care is usually long since the influx of
patients within the public health system is large.(11,15) Now, there are no studies that report the approximate
time of care for this type of patient.
This study in general terms aimed to establish the prevalence of cancer and the waiting time for the
care of cancer patients referred from the first to the second level of care from January to July 2024 at
the Hospital Provincial General Docente Riobamba (HPGDR).
The hypothesis proposed was that there is a high prevalence of cancer patients treated in the hospital
and a delay in the care of cancer patients due to the high demand for examinations and specialist
doctors that are not paid for by the Ministry of Public Health.
MATERIAL Y MÉTODOS
An original, observational, cross-sectional, retrospective study with a quantitative, descriptive, and
correlational approach was presented.
We worked with the entire population, representing the total number of patients hospitalized in all
specialties of the HPGDR, internal medicine, pediatrics, gynecology and obstetrics, Surgery, and ICU
from January to July 2024, p= 6559. By working with the entire population, we avoid sampling and
selection bias. The patient matrix called "Hospital discharges January to July 2024" is in the Hospital's
statistics service, which was provided to the researchers of an anonymized nature with the required
data according to the variables to be studied and before the delivery of a confidentiality commitment
from the authors and a general informed consent by the hospital's medical management.
Inclusion criteria.
• Patients treated in the hospital and registered in the hospital discharge matrix.
• Patients diagnosed with neoplastic pathology of any organ.
• Patients who have complied with the referral from the first level to the second level of care for
the calculation of the average days of waiting for referral care.
Exclusion criteria.
• Patients who do not provide the service where they were hospitalized in their database record.
Variables
Age, sex, diagnosis, date of care at the first level of care, date of care at the second level of care, type
of cancer, and hospitalization service.
The data obtained for the analysis correspond to the records of referral matrices and hospital discharge
matrices. These matrices are mandatory to report to the authorities of Ecuador's Zonal Coordination 3,
who evaluate care times to determine the productivity of treating medical professionals and hospital-level
productivity. The data are subject to review and registration in the Epidemiology Department. This
ensures the validity and quality of the data.
Once the final database was obtained in Excel, it was imported into the SPSS27 statistical package for
the coding of variables and statistical analysis. A univariate analysis was carried out to calculate the
prevalence of neoplasms and cancer based on the population. Ratios, proportions, and percentages for
qualitative variables; Measures of central tendency and dispersion for quantitative variables, always
accompanied by their 95 % confidence interval. The multivariate analysis looked for factors that
influence the presence of neoplasms and the presence of cancer, for which a logistic regression analysis
was performed.
The filling method was used for data processing with the average of the data obtained. This method was
used to analyze the average waiting time for referrals of oncology patients from primary to secondary care.
The study was approved by a human research ethics committee code: IO-29-CEISH- ESPOCH-2024.
RESULTS
Univariate analysis
The prevalence of patients with benign and malignant neoplasms of any organ calculated using the
formula: [(# of patients diagnosed with neoplasia / P) *100] [(204/6559)*100] is equal to 3.11 % (95 %
CI 3 %-4 %) from January to July 2024 in the HPGDR. 75.49 % were women (n=154) and 24.51%
were men (n=50).
The average age of patients with neoplasms, regardless of sex (n=204), is 49 years (95 % CI, 46 – 51
years) (minimum n = 1 year and maximum n = 94 years).
Based on the total population, the prevalence of cancer (malignant neoplasms) [(92/6559)*100] is
1.4% (95 % CI 1 %-2 %) from January to July 2024 in HPGDR. The prevalence of cancer concerning
the total number of patients diagnosed with neoplasia [(92/204)*100] is 45.09 % (9 5% CI 38 %-52 %).
Therefore, almost half of the patients hospitalized for neoplasms are malignant. About sex, 57.61%
(n=53) were women versus 42.39 % (n=39) were men.
The mean age, regardless of sex, of patients with malignant neoplasms is 56 years (95 % CI 52 – 59
years) (minimum n = 15 years and maximum n = 94 years).
Tables 1 and 2 represent the description of the tumors according to the hospitalization service.
Table 1. Benign tumors according to the hospitalization service.
Table 2. Malignant tumors according to the hospitalization service.
Benign and malignant tumors are described below according to their prevalence and hospitalization
services.
Tabla 3. Benign tumors.
The benign tumors with a frequency of 1 (0,9 %) each in Surgery are: tumor of the tongue; tumor of
the nasopharynx; tumor of the rectosigmoid junction; tumor of the meninges, part not specified;
tumor of the anal canal and anus; tumor of the lower jaw; kidney tumor; lipomatous tumor of the
intra-abdominal organs; and tumor of uncertain or unknown behavior of the brain, unspecified part.
Tabla 4. Malignant tumors.
Malignant tumors with a frequency of 1 (1.1 %) each in Internal medicine are: lymphoid leukemia,
no other specification; carcinoma in situ of the stomach; lymphoid leukemia, no other specification;
acute myeloblastic leukemia; chronic myeloid leukemia bcr/abl-positive; hodgkin's lymphoma
unspecified; non-follicular (diffuse) lymphoma not otherwise specified; multiple myeloma; kaposi's
sarcoma of the soft tissue; tumor of the thyroid gland; tumor of the skin of the trunk; tumor of the
central portion of the breast; tumor of the bones of the skull and face; tumor of the abdomen; tumor
of the cerebellum; brain tumor, except lobes and ventricles; tumor of the upper outer quadrant of the
breast; tumor of the body of the stomach; tumor of the body of the uterus, part not specified; tumor
of the esophagus, part not specified; tumor of the exocervix; liver tumor unspecified; ileum tumor;
tumor of the frontal lobe; tumor of the upper lobe, bronchus, or lung; tumor of the ovary; and tumor
of the testicle, unspecified.
To establish the mean number of days that patients were required to wait to receive care at the
second level, the total number of cancers (n=92) was taken. However, there was significant data
loss. It was only possible to obtain information on waiting days for care for 36 patients (39.13 %)
versus 56 (60.87 %) patients who did not have information on the days they waited to receive care
in the hospital.
Taking the data from the 36 patients, the average number of days required to be seen in the HPGDR
was 35 (95 % CI 19 – 51 days). The minimum waiting time was 2 days. The maximum was 204 days
waiting for care, and a Mode=2.
Multivariate analysis
Table 5 is presented below. A logistic regression model was performed to explain the dependent
variable presence of neoplasms, p= 6559.
Table 5. Logistic regression Presence of neoplasms.
It can be seen that the variables that explain the appearance of neoplasms are sex, age, and belonging
to the Surgery or gynecology service. Men are less likely to have a neoplasm (benign or malignant)
diagnosis OR 0.477, statistically significant, compared to women.
Concerning the 204 patients who presented neoplasms, a logistic regression was performed to explain
the dependent variable presence of malignant neoplasms. The results are shown below in Table 6.
Table 6. Logistic regression Presence of malignant neoplasms.
The variables that explain the presence of malignant neoplasms are age when the cut-off point is 65
years, and sex. Being male confers a higher chance of having malignancies (OR 5.99). Being younger
than 65 is less likely to get cancer (OR 0.25).
DISCUSSIÓN
The prevalence of benign or malignant neoplasms (3.11 %) represents a high percentage concerning
all HPGDR care that required hospitalization because it is a second-level hospital. If we divide the
number of neoplasms, we obtain that approximately 34 patients are hospitalized per month on average.
The hospital must ensure quality care for all patients.(11) It should be considered that approximately
half of the neoplasms are malignant (45.09 %). In most cases, more complex and expensive diagnostic
tests are required to determine their nature.(16-18) The percentage obtained in this study on the prevalence
of cancer shows a global reality, being the leading cause of death in 2020.(19)
In the univariate analysis, there were differences concerning age and sex, which were corroborated by
the multivariate analysis, where men have a lower risk of having a neoplasm (OR 0.47) p= 0.045.
However, men have a higher risk of malignancies (OR 5.99) p=0.000. According to international
statistics, men have an age-standardized incidence rate of 212.6, with a cumulative risk of developing
cancer before the age of 75 of 21.8 %, compared to women who have a standardized incidence rate of
186.3 with a risk of 18.5 %. (19,20) Similarly, our study shows that those younger than 65 represent a
lower cancer risk (OR 0.25) p=0.035.
Although supported by evidence, the methodological nature of the study confers results that must be
corroborated with more powerful studies and stricter inclusion and selection criteria. Age and sex
should also be considered as confounding variables.
Gynecology represents 66.96 % of hospitalizations for benign tumors, which is consistent with the most
frequent types of benign tumors treated, uterine leiomyomas and ovarian and breast tumors. In the
second place, Surgery is found with 27.68 % for the resolution mainly of lipomas.
Internal medicine is the leading cancer care service, accounting for 77.17 % of hospitalizations. The
main types of cancer are leukemias, lymphomas, skin, lung, and gastric. The second service with the
highest percentage of hospitalizations is Surgery, with 16.30 %, where gastric and urological cancer are
mainly treated. The main types of cancer worldwide are lung, breast, colorectal, prostate, stomach, liver,
thyroid, and uterine cervix. (20-24)
A timely cancer diagnosis represents a greater probability of long-term survival, implementing early
surgical or clinical treatments. (25-28) We found an average wait of 35 days to be seen as referrals from the
first level, in charge of the health centers, to the second level of care, in charge of the HPGDR. These
data represent an essential information bias due to the number of losses, which made it impossible to
have a waiting time for analysis. Longitudinal studies are recommended to have a more accurate
follow-up and not have losses from that follow-up.
The National Institute for Health and Care Excellence recommends referring patients with metastatic
cancer of unknown origin for care within two weeks of referral.(29) It is necessary to create public policies
to address medical and non-medical expenses to improve the quality of life of cancer patients and mitigate
barriers to access to care since a timely diagnosis and approach reduce subsequent treatment costs.(30,31)
The strengths of this study are the rigor of the results obtained since the appropriate statistics were used,
providing 95 % CI and p values; it represents epidemiological data that can be extrapolated to the gene-
ral population since there were no sampling biases, obtaining adequate external validity; and it is the
starting point for more rigorous investigations in search of data that explain causality.
Limitations:
The main limitation of this study is the impossibility of stricter follow-up and control of the participants.
It was not possible to analyze more factors that contributed to the diagnosis of cancer.
To establish causal relationships, the design of our study is limited, as we present a cross-sectional
design. However, this type of design does allow for the analysis of relationships between variables that
present associations, such as the prevalence ratio, OR, etc. In medicine, it is impossible to establish
specific cause-and-effect relationships since pathologies, primarily cancer, are multifactorial.
The main limitation regarding the analysis of waiting times for care was the loss of data, which confers
little external validity to our results. These losses are primarily attributed to the fact that all hospital
discharges for cancer were considered, and many of them originate from emergency departments,
where there is no care policy based on primary care referrals.
Recommendations:
Mandatory, real-time health record keeping should be implemented, in addition to the referral form
(Form 053) to monitor patients. This would facilitate longitudinal studies.
Consider including oncology professionals at least once or twice a week to support outpatient care,
perform procedures, and diagnose patients with suspected cancer.
CONCLUSIONS
The prevalence of neoplasms in HPGDR from January to July 2024 is 3.11 % (95 % CI 3 %-4 %), and
45.09 % (95 % CI 38 %-52 %) corresponds to malignant neoplasms. The prevalence of cancer in the
total hospitalizations from January to July 2024 in HPGDR is 1.4 % (95 % CI 1 %-2 %).
Gynecology is the main service that treats benign neoplasms, the most frequent being leiomyomas,
ovarian or breast. The second service corresponds to Surgery for the resolution of lipomas.
The main cancer care service is internal medicine, which is used to treat leukemias, lymphomas, skin,
lung, and gastric cancers. The second service is Surgery for gastric and urological cancer care.
The waiting time required by patients to receive care by referrals from health centers to HPGDR is 35
days (95 % CI 19 – 51 days).
Funding: The authors funded this research.
Acknowledgments:
• To the authorities of the HPGDR.: Dr. María Sánchez, Manager; Dr. Evelyn Inca, medical director,
for promoting research and contributing to administrative procedures. To the Statistics service
for collaborating with the required data.
• To the National University of Chimborazo.
• To the Polytechnic School of Chimborazo.
Conflicts of interest: The authors declare no conflict of interest in this research.
Contribution Statement:
Conceptualization: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana. Data
curation, Formal analysis, Methodology, Software, Validation, Visualization, and Writing – review and
editing: Md. M.Sc. Carlos Andrés Yépez Salgado. Acquisition of funds: project self-financed by the
authors. Research: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana; Dr.
Paola Buenaño; Dr. David Orozco; Md. Yesenia Chandi. Project administration: Dr. Paola Buenaño; Dr.
David Orozco; Md. Yesenia Chandi. Supervision: Dr. Zully Mayra Romero Orellana; Dr. Paola Buenaño;
Dr. David Orozco. Writing – original draft: Md. Yesenia Chandi. All authors have read and agreed to the
published version of the manuscript.
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of Noninvasive Colorectal Cancer Screening in Community Clinics. JAMA Netw Open.
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journals/jamanetworkopen/fullarticle/2829267.
31. Behzadifar M, Beiranvand M, Rezapour A, Ehsanzadeh SJ, Azari S, et al. The economic
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com/articles/10.1186/s41043-025-00738-0#Sec1.
cc
BY NC ND
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 19
Número 2
2
REE 19(2) Riobamba may. - ago. 2025
Prevalence of cancer and time to referral care in oncology patients
Prevalencia de cáncer y tiempo de atención de referencias en pacientes oncológicos.
https://doi.org/10.37135/ee.04.23.01
Authors:
Carlos Andrés Yépez Salgado1 - https://orcid.org/0009-0009-4722-8348
Zully Mayra Romero Orellana1,2 - https://orcid.org/0009-0000-6323-7548
David Cristóbal Orozco Brito3 - https://orcid.org/0000-0002-3945-3301
Nancy Paola Buenano Zambrano1 - https://orcid.org/0009-0003-2505-9236
Yesenia Liliana Chandi Japón4 - https://orcid.org/0009-0000-5672-0451
Affiliation:
1Hospital Provincial General Docente Riobamba.
2Universidad Nacional de Chimborazo.
3Escuela Superior Politécnica de Chimborazo.
4Centro de Salud Pungala Grande.
Corresponding author: Carlos Andrés Yépez Salgado. Hospital Provincial General Docente Riobamba.
Dirección postal: 060104. Email: med.carlos.andres@gmail.com / docenciahpgdrcoordinacion@gmail.
com Phone: +593984109505.
Received: January 24, 2025 Accepted: abril 01, 2025
ABSTRACT
Cancer represents a worldwide problem. In 2022, there were 30888 new cases of cancer and 16158
deaths in Ecuador. Considering the high morbidity and mortality due to this disease, health systems are
trying to meet the demand of these patients in public and private health services. Our main objective
was to establish the prevalence of cancer and the time of care of oncological patients referred to the
second level from the first of care during January-July 2024 at the Hospital Provincial General
Docente Riobamba. An original, observational, retrospective, descriptive, and correlational study
was presented. The prevalence of neoplasms is 3.11 %, and 45.09 % are malignant. The prevalence
of cancer in total hospitalizations is 1.4 %, and the average waiting time for care is 35 days. There
was a high prevalence of cancer in the hospital, where Internal medicine and Surgery are the services
with the most hospitalizations for this pathology.
Keywords: Cancer; Neoplasms; Epidemiology; Community Health Planning; Secondary Care Centers.
RESUMEN
El cáncer representa un problema a nivel mundial, en el año 2022 en el Ecuador existieron 30888
nuevos casos de cáncer y 16158 muertes, considerando una elevada morbimortalidad a causa de este
padecimiento, los sistemas de salud realizan un esfuerzo por solventar la demanda de estos pacientes
en los servicios de salud públicos y privados. El objetivo de esta investigación fue establecer la
prevalencia de cáncer y el tiempo de atención de referencias de pacientes oncológicos referidos desde
el primer nivel de atención al segundo nivel de atención de enero a julio de 2024 en el Hospital
Provincial General Docente de Riobamba. Se presentó un estudio original, observacional, transversal
retrospectivo, descriptivo y correlacional. La prevalencia de neoplasias es de 3,11 % y el 45,09 % son
malignas. La prevalencia de cáncer en el total de hospitalizaciones es 1,4% y el promedio de tiempo
de espera para la atención es de 35 días. Existió una elevada prevalencia de cáncer en el hospital,
siendo medicina interna y cirugía los servicios con más hospitalizaciones por esta patología.
Palabras clave: cáncer; neoplasias; epidemiología; planificación sanitaria comunitaria; centros de
atención secundaria.
.
INTRODUCTION
Cancer is a term used to refer to a broad group of diseases of complex and multifactorial origin caused
by abnormal cells that multiply autonomously and irregularly, invading other tissues locally and at a
distance.(1) The degree of malignancy is variable. It depends on the aggressiveness of its cells and
biological characteristics(2). They can spread and cause metastasis from different routes of dissemination
(lymphatic, blood, or by extension and direct invasion of neighboring tissues).(2,3) In general, if their
natural evolution is sought, they tend to lead to the death of the affected person in the short term.(4)
Currently, more than 200 different types of cancer are known, depending on the tissue from which they
are derived. The most common are those of the skin, lungs, breast, colon, and rectum.(5)
According to PAHO, cancer is one of the leading causes of mortality in the Americas. The figures indicate
that its incidence is growing rapidly worldwide, becoming a significant barrier to increasing life
expectancy. It is estimated that in 2022, there were 20 million new cases of cancer and 9.7 million
deaths in the region. (6,7)
Statistics from the International Agency for Research on Cancer indicate that in 2022 in Ecuador there
were 30888 new cases of cancer, 16,158 deaths, a risk of 7.3 % of dying from cancer before the age of
75; Prostate (29.4 %), stomach (11.2 %) and colorectal (8.4 %) cancer are more prevalent in our coun-
try; In female sex, lung cancer (23 %), cervical cancer (10.5 %) and colorectal cancer (8.0 %) are the
main ones; It is also mentioned that by 2040 there will be more than 53,701 cases detected during the
year in Ecuador. (8)
When analyzing the statistics, we observe that in Ecuador, as in the rest of the world, the incidence of
cancer is increasing, which is why it is necessary to have a health system that provides the opportunity
for each user to have adequate and timely care for their diagnosis and treatment.(8,9) It has been shown
that the delay in the care of this type of patient has been directly related to survival rates.(9) A study in
London about the survival of patients with breast cancer related to delayed uptake and treatment
showed that 32 % of patients with delays of 12 weeks or more had locally advanced or metastatic
disease, compared to only 10 % of those with delays of less than 12 weeks, which shows us the importance
of early recruitment.(10)
The national health system in Ecuador has a system of universality and progressive free healthcare
based on the Comprehensive Health Care model, which is supported by the user referral system to
improve healthcare.(11,12) This regulation is applied at all levels of care, thus allowing adequate care to
be provided to all users who require it according to the degree of complexity to achieve complete,
acceptable, and timely care.(13)
The health system of Ecuador offers a model that allows recruitment at the first level of health, which
is responsible for making the referral to the next step.(14) The time that elapses from the recruitment of
an oncology patient to the moment they obtain specialized care is usually long since the influx of
patients within the public health system is large.(11,15) Now, there are no studies that report the approximate
time of care for this type of patient.
This study in general terms aimed to establish the prevalence of cancer and the waiting time for the
care of cancer patients referred from the first to the second level of care from January to July 2024 at
the Hospital Provincial General Docente Riobamba (HPGDR).
The hypothesis proposed was that there is a high prevalence of cancer patients treated in the hospital
and a delay in the care of cancer patients due to the high demand for examinations and specialist
doctors that are not paid for by the Ministry of Public Health.
MATERIAL Y MÉTODOS
An original, observational, cross-sectional, retrospective study with a quantitative, descriptive, and
correlational approach was presented.
We worked with the entire population, representing the total number of patients hospitalized in all
specialties of the HPGDR, internal medicine, pediatrics, gynecology and obstetrics, Surgery, and ICU
from January to July 2024, p= 6559. By working with the entire population, we avoid sampling and
selection bias. The patient matrix called "Hospital discharges January to July 2024" is in the Hospital's
statistics service, which was provided to the researchers of an anonymized nature with the required
data according to the variables to be studied and before the delivery of a confidentiality commitment
from the authors and a general informed consent by the hospital's medical management.
Inclusion criteria.
• Patients treated in the hospital and registered in the hospital discharge matrix.
• Patients diagnosed with neoplastic pathology of any organ.
• Patients who have complied with the referral from the first level to the second level of care for
the calculation of the average days of waiting for referral care.
Exclusion criteria.
• Patients who do not provide the service where they were hospitalized in their database record.
Variables
Age, sex, diagnosis, date of care at the first level of care, date of care at the second level of care, type
of cancer, and hospitalization service.
The data obtained for the analysis correspond to the records of referral matrices and hospital discharge
matrices. These matrices are mandatory to report to the authorities of Ecuador's Zonal Coordination 3,
who evaluate care times to determine the productivity of treating medical professionals and hospital-level
productivity. The data are subject to review and registration in the Epidemiology Department. This
ensures the validity and quality of the data.
Once the final database was obtained in Excel, it was imported into the SPSS27 statistical package for
the coding of variables and statistical analysis. A univariate analysis was carried out to calculate the
prevalence of neoplasms and cancer based on the population. Ratios, proportions, and percentages for
qualitative variables; Measures of central tendency and dispersion for quantitative variables, always
accompanied by their 95 % confidence interval. The multivariate analysis looked for factors that
influence the presence of neoplasms and the presence of cancer, for which a logistic regression analysis
was performed.
The filling method was used for data processing with the average of the data obtained. This method was
used to analyze the average waiting time for referrals of oncology patients from primary to secondary care.
The study was approved by a human research ethics committee code: IO-29-CEISH- ESPOCH-2024.
RESULTS
Univariate analysis
The prevalence of patients with benign and malignant neoplasms of any organ calculated using the
formula: [(# of patients diagnosed with neoplasia / P) *100] [(204/6559)*100] is equal to 3.11 % (95 %
CI 3 %-4 %) from January to July 2024 in the HPGDR. 75.49 % were women (n=154) and 24.51%
were men (n=50).
The average age of patients with neoplasms, regardless of sex (n=204), is 49 years (95 % CI, 46 – 51
years) (minimum n = 1 year and maximum n = 94 years).
Based on the total population, the prevalence of cancer (malignant neoplasms) [(92/6559)*100] is
1.4% (95 % CI 1 %-2 %) from January to July 2024 in HPGDR. The prevalence of cancer concerning
the total number of patients diagnosed with neoplasia [(92/204)*100] is 45.09 % (9 5% CI 38 %-52 %).
Therefore, almost half of the patients hospitalized for neoplasms are malignant. About sex, 57.61%
(n=53) were women versus 42.39 % (n=39) were men.
The mean age, regardless of sex, of patients with malignant neoplasms is 56 years (95 % CI 52 – 59
years) (minimum n = 15 years and maximum n = 94 years).
Tables 1 and 2 represent the description of the tumors according to the hospitalization service.
Table 1. Benign tumors according to the hospitalization service.
Table 2. Malignant tumors according to the hospitalization service.
Benign and malignant tumors are described below according to their prevalence and hospitalization
services.
Tabla 3. Benign tumors.
The benign tumors with a frequency of 1 (0,9 %) each in Surgery are: tumor of the tongue; tumor of
the nasopharynx; tumor of the rectosigmoid junction; tumor of the meninges, part not specified;
tumor of the anal canal and anus; tumor of the lower jaw; kidney tumor; lipomatous tumor of the
intra-abdominal organs; and tumor of uncertain or unknown behavior of the brain, unspecified part.
Tabla 4. Malignant tumors.
Malignant tumors with a frequency of 1 (1.1 %) each in Internal medicine are: lymphoid leukemia,
no other specification; carcinoma in situ of the stomach; lymphoid leukemia, no other specification;
acute myeloblastic leukemia; chronic myeloid leukemia bcr/abl-positive; hodgkin's lymphoma
unspecified; non-follicular (diffuse) lymphoma not otherwise specified; multiple myeloma; kaposi's
sarcoma of the soft tissue; tumor of the thyroid gland; tumor of the skin of the trunk; tumor of the
central portion of the breast; tumor of the bones of the skull and face; tumor of the abdomen; tumor
of the cerebellum; brain tumor, except lobes and ventricles; tumor of the upper outer quadrant of the
breast; tumor of the body of the stomach; tumor of the body of the uterus, part not specified; tumor
of the esophagus, part not specified; tumor of the exocervix; liver tumor unspecified; ileum tumor;
tumor of the frontal lobe; tumor of the upper lobe, bronchus, or lung; tumor of the ovary; and tumor
of the testicle, unspecified.
To establish the mean number of days that patients were required to wait to receive care at the
second level, the total number of cancers (n=92) was taken. However, there was significant data
loss. It was only possible to obtain information on waiting days for care for 36 patients (39.13 %)
versus 56 (60.87 %) patients who did not have information on the days they waited to receive care
in the hospital.
Taking the data from the 36 patients, the average number of days required to be seen in the HPGDR
was 35 (95 % CI 19 – 51 days). The minimum waiting time was 2 days. The maximum was 204 days
waiting for care, and a Mode=2.
Multivariate analysis
Table 5 is presented below. A logistic regression model was performed to explain the dependent
variable presence of neoplasms, p= 6559.
Table 5. Logistic regression Presence of neoplasms.
It can be seen that the variables that explain the appearance of neoplasms are sex, age, and belonging
to the Surgery or gynecology service. Men are less likely to have a neoplasm (benign or malignant)
diagnosis OR 0.477, statistically significant, compared to women.
Concerning the 204 patients who presented neoplasms, a logistic regression was performed to explain
the dependent variable presence of malignant neoplasms. The results are shown below in Table 6.
Table 6. Logistic regression Presence of malignant neoplasms.
The variables that explain the presence of malignant neoplasms are age when the cut-off point is 65
years, and sex. Being male confers a higher chance of having malignancies (OR 5.99). Being younger
than 65 is less likely to get cancer (OR 0.25).
DISCUSSIÓN
The prevalence of benign or malignant neoplasms (3.11 %) represents a high percentage concerning
all HPGDR care that required hospitalization because it is a second-level hospital. If we divide the
number of neoplasms, we obtain that approximately 34 patients are hospitalized per month on average.
The hospital must ensure quality care for all patients.(11) It should be considered that approximately
half of the neoplasms are malignant (45.09 %). In most cases, more complex and expensive diagnostic
tests are required to determine their nature.(16-18) The percentage obtained in this study on the prevalence
of cancer shows a global reality, being the leading cause of death in 2020.(19)
In the univariate analysis, there were differences concerning age and sex, which were corroborated by
the multivariate analysis, where men have a lower risk of having a neoplasm (OR 0.47) p= 0.045.
However, men have a higher risk of malignancies (OR 5.99) p=0.000. According to international
statistics, men have an age-standardized incidence rate of 212.6, with a cumulative risk of developing
cancer before the age of 75 of 21.8 %, compared to women who have a standardized incidence rate of
186.3 with a risk of 18.5 %. (19,20) Similarly, our study shows that those younger than 65 represent a
lower cancer risk (OR 0.25) p=0.035.
Although supported by evidence, the methodological nature of the study confers results that must be
corroborated with more powerful studies and stricter inclusion and selection criteria. Age and sex
should also be considered as confounding variables.
Gynecology represents 66.96 % of hospitalizations for benign tumors, which is consistent with the most
frequent types of benign tumors treated, uterine leiomyomas and ovarian and breast tumors. In the
second place, Surgery is found with 27.68 % for the resolution mainly of lipomas.
Internal medicine is the leading cancer care service, accounting for 77.17 % of hospitalizations. The
main types of cancer are leukemias, lymphomas, skin, lung, and gastric. The second service with the
highest percentage of hospitalizations is Surgery, with 16.30 %, where gastric and urological cancer are
mainly treated. The main types of cancer worldwide are lung, breast, colorectal, prostate, stomach, liver,
thyroid, and uterine cervix. (20-24)
A timely cancer diagnosis represents a greater probability of long-term survival, implementing early
surgical or clinical treatments. (25-28) We found an average wait of 35 days to be seen as referrals from the
first level, in charge of the health centers, to the second level of care, in charge of the HPGDR. These
data represent an essential information bias due to the number of losses, which made it impossible to
have a waiting time for analysis. Longitudinal studies are recommended to have a more accurate
follow-up and not have losses from that follow-up.
The National Institute for Health and Care Excellence recommends referring patients with metastatic
cancer of unknown origin for care within two weeks of referral.(29) It is necessary to create public policies
to address medical and non-medical expenses to improve the quality of life of cancer patients and mitigate
barriers to access to care since a timely diagnosis and approach reduce subsequent treatment costs.(30,31)
The strengths of this study are the rigor of the results obtained since the appropriate statistics were used,
providing 95 % CI and p values; it represents epidemiological data that can be extrapolated to the gene-
ral population since there were no sampling biases, obtaining adequate external validity; and it is the
starting point for more rigorous investigations in search of data that explain causality.
Limitations:
The main limitation of this study is the impossibility of stricter follow-up and control of the participants.
It was not possible to analyze more factors that contributed to the diagnosis of cancer.
To establish causal relationships, the design of our study is limited, as we present a cross-sectional
design. However, this type of design does allow for the analysis of relationships between variables that
present associations, such as the prevalence ratio, OR, etc. In medicine, it is impossible to establish
specific cause-and-effect relationships since pathologies, primarily cancer, are multifactorial.
The main limitation regarding the analysis of waiting times for care was the loss of data, which confers
little external validity to our results. These losses are primarily attributed to the fact that all hospital
discharges for cancer were considered, and many of them originate from emergency departments,
where there is no care policy based on primary care referrals.
Recommendations:
Mandatory, real-time health record keeping should be implemented, in addition to the referral form
(Form 053) to monitor patients. This would facilitate longitudinal studies.
Consider including oncology professionals at least once or twice a week to support outpatient care,
perform procedures, and diagnose patients with suspected cancer.
CONCLUSIONS
The prevalence of neoplasms in HPGDR from January to July 2024 is 3.11 % (95 % CI 3 %-4 %), and
45.09 % (95 % CI 38 %-52 %) corresponds to malignant neoplasms. The prevalence of cancer in the
total hospitalizations from January to July 2024 in HPGDR is 1.4 % (95 % CI 1 %-2 %).
Gynecology is the main service that treats benign neoplasms, the most frequent being leiomyomas,
ovarian or breast. The second service corresponds to Surgery for the resolution of lipomas.
The main cancer care service is internal medicine, which is used to treat leukemias, lymphomas, skin,
lung, and gastric cancers. The second service is Surgery for gastric and urological cancer care.
The waiting time required by patients to receive care by referrals from health centers to HPGDR is 35
days (95 % CI 19 – 51 days).
Funding: The authors funded this research.
Acknowledgments:
• To the authorities of the HPGDR.: Dr. María Sánchez, Manager; Dr. Evelyn Inca, medical director,
for promoting research and contributing to administrative procedures. To the Statistics service
for collaborating with the required data.
• To the National University of Chimborazo.
• To the Polytechnic School of Chimborazo.
Conflicts of interest: The authors declare no conflict of interest in this research.
Contribution Statement:
Conceptualization: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana. Data
curation, Formal analysis, Methodology, Software, Validation, Visualization, and Writing – review and
editing: Md. M.Sc. Carlos Andrés Yépez Salgado. Acquisition of funds: project self-financed by the
authors. Research: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana; Dr.
Paola Buenaño; Dr. David Orozco; Md. Yesenia Chandi. Project administration: Dr. Paola Buenaño; Dr.
David Orozco; Md. Yesenia Chandi. Supervision: Dr. Zully Mayra Romero Orellana; Dr. Paola Buenaño;
Dr. David Orozco. Writing – original draft: Md. Yesenia Chandi. All authors have read and agreed to the
published version of the manuscript.
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28. Elie Rassy A, Parent P, Lefort F, Boussios S, Baciarello G, Pavlidis N, et al. New rising entities
in cancer of unknown primary: Is there a real therapeutic benefit? [Internet] 2020[cited 16
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pii/S1040842820300202.
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com/articles/10.1186/s41043-025-00738-0#Sec1.
cc
BY NC ND
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 19
Número 2
3
REE 19(2) Riobamba may. - ago. 2025
Prevalence of cancer and time to referral care in oncology patients
Prevalencia de cáncer y tiempo de atención de referencias en pacientes oncológicos.
https://doi.org/10.37135/ee.04.23.01
Authors:
Carlos Andrés Yépez Salgado1 - https://orcid.org/0009-0009-4722-8348
Zully Mayra Romero Orellana1,2 - https://orcid.org/0009-0000-6323-7548
David Cristóbal Orozco Brito3 - https://orcid.org/0000-0002-3945-3301
Nancy Paola Buenano Zambrano1 - https://orcid.org/0009-0003-2505-9236
Yesenia Liliana Chandi Japón4 - https://orcid.org/0009-0000-5672-0451
Affiliation:
1Hospital Provincial General Docente Riobamba.
2Universidad Nacional de Chimborazo.
3Escuela Superior Politécnica de Chimborazo.
4Centro de Salud Pungala Grande.
Corresponding author: Carlos Andrés Yépez Salgado. Hospital Provincial General Docente Riobamba.
Dirección postal: 060104. Email: med.carlos.andres@gmail.com / docenciahpgdrcoordinacion@gmail.
com Phone: +593984109505.
Received: January 24, 2025 Accepted: abril 01, 2025
ABSTRACT
Cancer represents a worldwide problem. In 2022, there were 30888 new cases of cancer and 16158
deaths in Ecuador. Considering the high morbidity and mortality due to this disease, health systems are
trying to meet the demand of these patients in public and private health services. Our main objective
was to establish the prevalence of cancer and the time of care of oncological patients referred to the
second level from the first of care during January-July 2024 at the Hospital Provincial General
Docente Riobamba. An original, observational, retrospective, descriptive, and correlational study
was presented. The prevalence of neoplasms is 3.11 %, and 45.09 % are malignant. The prevalence
of cancer in total hospitalizations is 1.4 %, and the average waiting time for care is 35 days. There
was a high prevalence of cancer in the hospital, where Internal medicine and Surgery are the services
with the most hospitalizations for this pathology.
Keywords: Cancer; Neoplasms; Epidemiology; Community Health Planning; Secondary Care Centers.
RESUMEN
El cáncer representa un problema a nivel mundial, en el año 2022 en el Ecuador existieron 30888
nuevos casos de cáncer y 16158 muertes, considerando una elevada morbimortalidad a causa de este
padecimiento, los sistemas de salud realizan un esfuerzo por solventar la demanda de estos pacientes
en los servicios de salud públicos y privados. El objetivo de esta investigación fue establecer la
prevalencia de cáncer y el tiempo de atención de referencias de pacientes oncológicos referidos desde
el primer nivel de atención al segundo nivel de atención de enero a julio de 2024 en el Hospital
Provincial General Docente de Riobamba. Se presentó un estudio original, observacional, transversal
retrospectivo, descriptivo y correlacional. La prevalencia de neoplasias es de 3,11 % y el 45,09 % son
malignas. La prevalencia de cáncer en el total de hospitalizaciones es 1,4% y el promedio de tiempo
de espera para la atención es de 35 días. Existió una elevada prevalencia de cáncer en el hospital,
siendo medicina interna y cirugía los servicios con más hospitalizaciones por esta patología.
Palabras clave: cáncer; neoplasias; epidemiología; planificación sanitaria comunitaria; centros de
atención secundaria.
.
INTRODUCTION
Cancer is a term used to refer to a broad group of diseases of complex and multifactorial origin caused
by abnormal cells that multiply autonomously and irregularly, invading other tissues locally and at a
distance.(1) The degree of malignancy is variable. It depends on the aggressiveness of its cells and
biological characteristics(2). They can spread and cause metastasis from different routes of dissemination
(lymphatic, blood, or by extension and direct invasion of neighboring tissues).(2,3) In general, if their
natural evolution is sought, they tend to lead to the death of the affected person in the short term.(4)
Currently, more than 200 different types of cancer are known, depending on the tissue from which they
are derived. The most common are those of the skin, lungs, breast, colon, and rectum.(5)
According to PAHO, cancer is one of the leading causes of mortality in the Americas. The figures indicate
that its incidence is growing rapidly worldwide, becoming a significant barrier to increasing life
expectancy. It is estimated that in 2022, there were 20 million new cases of cancer and 9.7 million
deaths in the region. (6,7)
Statistics from the International Agency for Research on Cancer indicate that in 2022 in Ecuador there
were 30888 new cases of cancer, 16,158 deaths, a risk of 7.3 % of dying from cancer before the age of
75; Prostate (29.4 %), stomach (11.2 %) and colorectal (8.4 %) cancer are more prevalent in our coun-
try; In female sex, lung cancer (23 %), cervical cancer (10.5 %) and colorectal cancer (8.0 %) are the
main ones; It is also mentioned that by 2040 there will be more than 53,701 cases detected during the
year in Ecuador. (8)
When analyzing the statistics, we observe that in Ecuador, as in the rest of the world, the incidence of
cancer is increasing, which is why it is necessary to have a health system that provides the opportunity
for each user to have adequate and timely care for their diagnosis and treatment.(8,9) It has been shown
that the delay in the care of this type of patient has been directly related to survival rates.(9) A study in
London about the survival of patients with breast cancer related to delayed uptake and treatment
showed that 32 % of patients with delays of 12 weeks or more had locally advanced or metastatic
disease, compared to only 10 % of those with delays of less than 12 weeks, which shows us the importance
of early recruitment.(10)
The national health system in Ecuador has a system of universality and progressive free healthcare
based on the Comprehensive Health Care model, which is supported by the user referral system to
improve healthcare.(11,12) This regulation is applied at all levels of care, thus allowing adequate care to
be provided to all users who require it according to the degree of complexity to achieve complete,
acceptable, and timely care.(13)
The health system of Ecuador offers a model that allows recruitment at the first level of health, which
is responsible for making the referral to the next step.(14) The time that elapses from the recruitment of
an oncology patient to the moment they obtain specialized care is usually long since the influx of
patients within the public health system is large.(11,15) Now, there are no studies that report the approximate
time of care for this type of patient.
This study in general terms aimed to establish the prevalence of cancer and the waiting time for the
care of cancer patients referred from the first to the second level of care from January to July 2024 at
the Hospital Provincial General Docente Riobamba (HPGDR).
The hypothesis proposed was that there is a high prevalence of cancer patients treated in the hospital
and a delay in the care of cancer patients due to the high demand for examinations and specialist
doctors that are not paid for by the Ministry of Public Health.
MATERIAL Y MÉTODOS
An original, observational, cross-sectional, retrospective study with a quantitative, descriptive, and
correlational approach was presented.
We worked with the entire population, representing the total number of patients hospitalized in all
specialties of the HPGDR, internal medicine, pediatrics, gynecology and obstetrics, Surgery, and ICU
from January to July 2024, p= 6559. By working with the entire population, we avoid sampling and
selection bias. The patient matrix called "Hospital discharges January to July 2024" is in the Hospital's
statistics service, which was provided to the researchers of an anonymized nature with the required
data according to the variables to be studied and before the delivery of a confidentiality commitment
from the authors and a general informed consent by the hospital's medical management.
Inclusion criteria.
• Patients treated in the hospital and registered in the hospital discharge matrix.
• Patients diagnosed with neoplastic pathology of any organ.
• Patients who have complied with the referral from the first level to the second level of care for
the calculation of the average days of waiting for referral care.
Exclusion criteria.
• Patients who do not provide the service where they were hospitalized in their database record.
Variables
Age, sex, diagnosis, date of care at the first level of care, date of care at the second level of care, type
of cancer, and hospitalization service.
The data obtained for the analysis correspond to the records of referral matrices and hospital discharge
matrices. These matrices are mandatory to report to the authorities of Ecuador's Zonal Coordination 3,
who evaluate care times to determine the productivity of treating medical professionals and hospital-level
productivity. The data are subject to review and registration in the Epidemiology Department. This
ensures the validity and quality of the data.
Once the final database was obtained in Excel, it was imported into the SPSS27 statistical package for
the coding of variables and statistical analysis. A univariate analysis was carried out to calculate the
prevalence of neoplasms and cancer based on the population. Ratios, proportions, and percentages for
qualitative variables; Measures of central tendency and dispersion for quantitative variables, always
accompanied by their 95 % confidence interval. The multivariate analysis looked for factors that
influence the presence of neoplasms and the presence of cancer, for which a logistic regression analysis
was performed.
The filling method was used for data processing with the average of the data obtained. This method was
used to analyze the average waiting time for referrals of oncology patients from primary to secondary care.
The study was approved by a human research ethics committee code: IO-29-CEISH- ESPOCH-2024.
RESULTS
Univariate analysis
The prevalence of patients with benign and malignant neoplasms of any organ calculated using the
formula: [(# of patients diagnosed with neoplasia / P) *100] [(204/6559)*100] is equal to 3.11 % (95 %
CI 3 %-4 %) from January to July 2024 in the HPGDR. 75.49 % were women (n=154) and 24.51%
were men (n=50).
The average age of patients with neoplasms, regardless of sex (n=204), is 49 years (95 % CI, 46 – 51
years) (minimum n = 1 year and maximum n = 94 years).
Based on the total population, the prevalence of cancer (malignant neoplasms) [(92/6559)*100] is
1.4% (95 % CI 1 %-2 %) from January to July 2024 in HPGDR. The prevalence of cancer concerning
the total number of patients diagnosed with neoplasia [(92/204)*100] is 45.09 % (9 5% CI 38 %-52 %).
Therefore, almost half of the patients hospitalized for neoplasms are malignant. About sex, 57.61%
(n=53) were women versus 42.39 % (n=39) were men.
The mean age, regardless of sex, of patients with malignant neoplasms is 56 years (95 % CI 52 – 59
years) (minimum n = 15 years and maximum n = 94 years).
Tables 1 and 2 represent the description of the tumors according to the hospitalization service.
Table 1. Benign tumors according to the hospitalization service.
Table 2. Malignant tumors according to the hospitalization service.
Benign and malignant tumors are described below according to their prevalence and hospitalization
services.
Tabla 3. Benign tumors.
The benign tumors with a frequency of 1 (0,9 %) each in Surgery are: tumor of the tongue; tumor of
the nasopharynx; tumor of the rectosigmoid junction; tumor of the meninges, part not specified;
tumor of the anal canal and anus; tumor of the lower jaw; kidney tumor; lipomatous tumor of the
intra-abdominal organs; and tumor of uncertain or unknown behavior of the brain, unspecified part.
Tabla 4. Malignant tumors.
Malignant tumors with a frequency of 1 (1.1 %) each in Internal medicine are: lymphoid leukemia,
no other specification; carcinoma in situ of the stomach; lymphoid leukemia, no other specification;
acute myeloblastic leukemia; chronic myeloid leukemia bcr/abl-positive; hodgkin's lymphoma
unspecified; non-follicular (diffuse) lymphoma not otherwise specified; multiple myeloma; kaposi's
sarcoma of the soft tissue; tumor of the thyroid gland; tumor of the skin of the trunk; tumor of the
central portion of the breast; tumor of the bones of the skull and face; tumor of the abdomen; tumor
of the cerebellum; brain tumor, except lobes and ventricles; tumor of the upper outer quadrant of the
breast; tumor of the body of the stomach; tumor of the body of the uterus, part not specified; tumor
of the esophagus, part not specified; tumor of the exocervix; liver tumor unspecified; ileum tumor;
tumor of the frontal lobe; tumor of the upper lobe, bronchus, or lung; tumor of the ovary; and tumor
of the testicle, unspecified.
To establish the mean number of days that patients were required to wait to receive care at the
second level, the total number of cancers (n=92) was taken. However, there was significant data
loss. It was only possible to obtain information on waiting days for care for 36 patients (39.13 %)
versus 56 (60.87 %) patients who did not have information on the days they waited to receive care
in the hospital.
Taking the data from the 36 patients, the average number of days required to be seen in the HPGDR
was 35 (95 % CI 19 – 51 days). The minimum waiting time was 2 days. The maximum was 204 days
waiting for care, and a Mode=2.
Multivariate analysis
Table 5 is presented below. A logistic regression model was performed to explain the dependent
variable presence of neoplasms, p= 6559.
Table 5. Logistic regression Presence of neoplasms.
It can be seen that the variables that explain the appearance of neoplasms are sex, age, and belonging
to the Surgery or gynecology service. Men are less likely to have a neoplasm (benign or malignant)
diagnosis OR 0.477, statistically significant, compared to women.
Concerning the 204 patients who presented neoplasms, a logistic regression was performed to explain
the dependent variable presence of malignant neoplasms. The results are shown below in Table 6.
Table 6. Logistic regression Presence of malignant neoplasms.
The variables that explain the presence of malignant neoplasms are age when the cut-off point is 65
years, and sex. Being male confers a higher chance of having malignancies (OR 5.99). Being younger
than 65 is less likely to get cancer (OR 0.25).
DISCUSSIÓN
The prevalence of benign or malignant neoplasms (3.11 %) represents a high percentage concerning
all HPGDR care that required hospitalization because it is a second-level hospital. If we divide the
number of neoplasms, we obtain that approximately 34 patients are hospitalized per month on average.
The hospital must ensure quality care for all patients.(11) It should be considered that approximately
half of the neoplasms are malignant (45.09 %). In most cases, more complex and expensive diagnostic
tests are required to determine their nature.(16-18) The percentage obtained in this study on the prevalence
of cancer shows a global reality, being the leading cause of death in 2020.(19)
In the univariate analysis, there were differences concerning age and sex, which were corroborated by
the multivariate analysis, where men have a lower risk of having a neoplasm (OR 0.47) p= 0.045.
However, men have a higher risk of malignancies (OR 5.99) p=0.000. According to international
statistics, men have an age-standardized incidence rate of 212.6, with a cumulative risk of developing
cancer before the age of 75 of 21.8 %, compared to women who have a standardized incidence rate of
186.3 with a risk of 18.5 %. (19,20) Similarly, our study shows that those younger than 65 represent a
lower cancer risk (OR 0.25) p=0.035.
Although supported by evidence, the methodological nature of the study confers results that must be
corroborated with more powerful studies and stricter inclusion and selection criteria. Age and sex
should also be considered as confounding variables.
Gynecology represents 66.96 % of hospitalizations for benign tumors, which is consistent with the most
frequent types of benign tumors treated, uterine leiomyomas and ovarian and breast tumors. In the
second place, Surgery is found with 27.68 % for the resolution mainly of lipomas.
Internal medicine is the leading cancer care service, accounting for 77.17 % of hospitalizations. The
main types of cancer are leukemias, lymphomas, skin, lung, and gastric. The second service with the
highest percentage of hospitalizations is Surgery, with 16.30 %, where gastric and urological cancer are
mainly treated. The main types of cancer worldwide are lung, breast, colorectal, prostate, stomach, liver,
thyroid, and uterine cervix. (20-24)
A timely cancer diagnosis represents a greater probability of long-term survival, implementing early
surgical or clinical treatments. (25-28) We found an average wait of 35 days to be seen as referrals from the
first level, in charge of the health centers, to the second level of care, in charge of the HPGDR. These
data represent an essential information bias due to the number of losses, which made it impossible to
have a waiting time for analysis. Longitudinal studies are recommended to have a more accurate
follow-up and not have losses from that follow-up.
The National Institute for Health and Care Excellence recommends referring patients with metastatic
cancer of unknown origin for care within two weeks of referral.(29) It is necessary to create public policies
to address medical and non-medical expenses to improve the quality of life of cancer patients and mitigate
barriers to access to care since a timely diagnosis and approach reduce subsequent treatment costs.(30,31)
The strengths of this study are the rigor of the results obtained since the appropriate statistics were used,
providing 95 % CI and p values; it represents epidemiological data that can be extrapolated to the gene-
ral population since there were no sampling biases, obtaining adequate external validity; and it is the
starting point for more rigorous investigations in search of data that explain causality.
Limitations:
The main limitation of this study is the impossibility of stricter follow-up and control of the participants.
It was not possible to analyze more factors that contributed to the diagnosis of cancer.
To establish causal relationships, the design of our study is limited, as we present a cross-sectional
design. However, this type of design does allow for the analysis of relationships between variables that
present associations, such as the prevalence ratio, OR, etc. In medicine, it is impossible to establish
specific cause-and-effect relationships since pathologies, primarily cancer, are multifactorial.
The main limitation regarding the analysis of waiting times for care was the loss of data, which confers
little external validity to our results. These losses are primarily attributed to the fact that all hospital
discharges for cancer were considered, and many of them originate from emergency departments,
where there is no care policy based on primary care referrals.
Recommendations:
Mandatory, real-time health record keeping should be implemented, in addition to the referral form
(Form 053) to monitor patients. This would facilitate longitudinal studies.
Consider including oncology professionals at least once or twice a week to support outpatient care,
perform procedures, and diagnose patients with suspected cancer.
CONCLUSIONS
The prevalence of neoplasms in HPGDR from January to July 2024 is 3.11 % (95 % CI 3 %-4 %), and
45.09 % (95 % CI 38 %-52 %) corresponds to malignant neoplasms. The prevalence of cancer in the
total hospitalizations from January to July 2024 in HPGDR is 1.4 % (95 % CI 1 %-2 %).
Gynecology is the main service that treats benign neoplasms, the most frequent being leiomyomas,
ovarian or breast. The second service corresponds to Surgery for the resolution of lipomas.
The main cancer care service is internal medicine, which is used to treat leukemias, lymphomas, skin,
lung, and gastric cancers. The second service is Surgery for gastric and urological cancer care.
The waiting time required by patients to receive care by referrals from health centers to HPGDR is 35
days (95 % CI 19 – 51 days).
Funding: The authors funded this research.
Acknowledgments:
• To the authorities of the HPGDR.: Dr. María Sánchez, Manager; Dr. Evelyn Inca, medical director,
for promoting research and contributing to administrative procedures. To the Statistics service
for collaborating with the required data.
• To the National University of Chimborazo.
• To the Polytechnic School of Chimborazo.
Conflicts of interest: The authors declare no conflict of interest in this research.
Contribution Statement:
Conceptualization: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana. Data
curation, Formal analysis, Methodology, Software, Validation, Visualization, and Writing – review and
editing: Md. M.Sc. Carlos Andrés Yépez Salgado. Acquisition of funds: project self-financed by the
authors. Research: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana; Dr.
Paola Buenaño; Dr. David Orozco; Md. Yesenia Chandi. Project administration: Dr. Paola Buenaño; Dr.
David Orozco; Md. Yesenia Chandi. Supervision: Dr. Zully Mayra Romero Orellana; Dr. Paola Buenaño;
Dr. David Orozco. Writing – original draft: Md. Yesenia Chandi. All authors have read and agreed to the
published version of the manuscript.
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cc
BY NC ND
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 19
Número 2
4
REE 19(2) Riobamba may. - ago. 2025
Prevalence of cancer and time to referral care in oncology patients
Prevalencia de cáncer y tiempo de atención de referencias en pacientes oncológicos.
https://doi.org/10.37135/ee.04.23.01
Authors:
Carlos Andrés Yépez Salgado1 - https://orcid.org/0009-0009-4722-8348
Zully Mayra Romero Orellana1,2 - https://orcid.org/0009-0000-6323-7548
David Cristóbal Orozco Brito3 - https://orcid.org/0000-0002-3945-3301
Nancy Paola Buenano Zambrano1 - https://orcid.org/0009-0003-2505-9236
Yesenia Liliana Chandi Japón4 - https://orcid.org/0009-0000-5672-0451
Affiliation:
1Hospital Provincial General Docente Riobamba.
2Universidad Nacional de Chimborazo.
3Escuela Superior Politécnica de Chimborazo.
4Centro de Salud Pungala Grande.
Corresponding author: Carlos Andrés Yépez Salgado. Hospital Provincial General Docente Riobamba.
Dirección postal: 060104. Email: med.carlos.andres@gmail.com / docenciahpgdrcoordinacion@gmail.
com Phone: +593984109505.
Received: January 24, 2025 Accepted: abril 01, 2025
ABSTRACT
Cancer represents a worldwide problem. In 2022, there were 30888 new cases of cancer and 16158
deaths in Ecuador. Considering the high morbidity and mortality due to this disease, health systems are
trying to meet the demand of these patients in public and private health services. Our main objective
was to establish the prevalence of cancer and the time of care of oncological patients referred to the
second level from the first of care during January-July 2024 at the Hospital Provincial General
Docente Riobamba. An original, observational, retrospective, descriptive, and correlational study
was presented. The prevalence of neoplasms is 3.11 %, and 45.09 % are malignant. The prevalence
of cancer in total hospitalizations is 1.4 %, and the average waiting time for care is 35 days. There
was a high prevalence of cancer in the hospital, where Internal medicine and Surgery are the services
with the most hospitalizations for this pathology.
Keywords: Cancer; Neoplasms; Epidemiology; Community Health Planning; Secondary Care Centers.
RESUMEN
El cáncer representa un problema a nivel mundial, en el año 2022 en el Ecuador existieron 30888
nuevos casos de cáncer y 16158 muertes, considerando una elevada morbimortalidad a causa de este
padecimiento, los sistemas de salud realizan un esfuerzo por solventar la demanda de estos pacientes
en los servicios de salud públicos y privados. El objetivo de esta investigación fue establecer la
prevalencia de cáncer y el tiempo de atención de referencias de pacientes oncológicos referidos desde
el primer nivel de atención al segundo nivel de atención de enero a julio de 2024 en el Hospital
Provincial General Docente de Riobamba. Se presentó un estudio original, observacional, transversal
retrospectivo, descriptivo y correlacional. La prevalencia de neoplasias es de 3,11 % y el 45,09 % son
malignas. La prevalencia de cáncer en el total de hospitalizaciones es 1,4% y el promedio de tiempo
de espera para la atención es de 35 días. Existió una elevada prevalencia de cáncer en el hospital,
siendo medicina interna y cirugía los servicios con más hospitalizaciones por esta patología.
Palabras clave: cáncer; neoplasias; epidemiología; planificación sanitaria comunitaria; centros de
atención secundaria.
.
INTRODUCTION
Cancer is a term used to refer to a broad group of diseases of complex and multifactorial origin caused
by abnormal cells that multiply autonomously and irregularly, invading other tissues locally and at a
distance.(1) The degree of malignancy is variable. It depends on the aggressiveness of its cells and
biological characteristics(2). They can spread and cause metastasis from different routes of dissemination
(lymphatic, blood, or by extension and direct invasion of neighboring tissues).(2,3) In general, if their
natural evolution is sought, they tend to lead to the death of the affected person in the short term.(4)
Currently, more than 200 different types of cancer are known, depending on the tissue from which they
are derived. The most common are those of the skin, lungs, breast, colon, and rectum.(5)
According to PAHO, cancer is one of the leading causes of mortality in the Americas. The figures indicate
that its incidence is growing rapidly worldwide, becoming a significant barrier to increasing life
expectancy. It is estimated that in 2022, there were 20 million new cases of cancer and 9.7 million
deaths in the region. (6,7)
Statistics from the International Agency for Research on Cancer indicate that in 2022 in Ecuador there
were 30888 new cases of cancer, 16,158 deaths, a risk of 7.3 % of dying from cancer before the age of
75; Prostate (29.4 %), stomach (11.2 %) and colorectal (8.4 %) cancer are more prevalent in our coun-
try; In female sex, lung cancer (23 %), cervical cancer (10.5 %) and colorectal cancer (8.0 %) are the
main ones; It is also mentioned that by 2040 there will be more than 53,701 cases detected during the
year in Ecuador. (8)
When analyzing the statistics, we observe that in Ecuador, as in the rest of the world, the incidence of
cancer is increasing, which is why it is necessary to have a health system that provides the opportunity
for each user to have adequate and timely care for their diagnosis and treatment.(8,9) It has been shown
that the delay in the care of this type of patient has been directly related to survival rates.(9) A study in
London about the survival of patients with breast cancer related to delayed uptake and treatment
showed that 32 % of patients with delays of 12 weeks or more had locally advanced or metastatic
disease, compared to only 10 % of those with delays of less than 12 weeks, which shows us the importance
of early recruitment.(10)
The national health system in Ecuador has a system of universality and progressive free healthcare
based on the Comprehensive Health Care model, which is supported by the user referral system to
improve healthcare.(11,12) This regulation is applied at all levels of care, thus allowing adequate care to
be provided to all users who require it according to the degree of complexity to achieve complete,
acceptable, and timely care.(13)
The health system of Ecuador offers a model that allows recruitment at the first level of health, which
is responsible for making the referral to the next step.(14) The time that elapses from the recruitment of
an oncology patient to the moment they obtain specialized care is usually long since the influx of
patients within the public health system is large.(11,15) Now, there are no studies that report the approximate
time of care for this type of patient.
This study in general terms aimed to establish the prevalence of cancer and the waiting time for the
care of cancer patients referred from the first to the second level of care from January to July 2024 at
the Hospital Provincial General Docente Riobamba (HPGDR).
The hypothesis proposed was that there is a high prevalence of cancer patients treated in the hospital
and a delay in the care of cancer patients due to the high demand for examinations and specialist
doctors that are not paid for by the Ministry of Public Health.
MATERIAL Y MÉTODOS
An original, observational, cross-sectional, retrospective study with a quantitative, descriptive, and
correlational approach was presented.
We worked with the entire population, representing the total number of patients hospitalized in all
specialties of the HPGDR, internal medicine, pediatrics, gynecology and obstetrics, Surgery, and ICU
from January to July 2024, p= 6559. By working with the entire population, we avoid sampling and
selection bias. The patient matrix called "Hospital discharges January to July 2024" is in the Hospital's
statistics service, which was provided to the researchers of an anonymized nature with the required
data according to the variables to be studied and before the delivery of a confidentiality commitment
from the authors and a general informed consent by the hospital's medical management.
Inclusion criteria.
• Patients treated in the hospital and registered in the hospital discharge matrix.
• Patients diagnosed with neoplastic pathology of any organ.
• Patients who have complied with the referral from the first level to the second level of care for
the calculation of the average days of waiting for referral care.
Exclusion criteria.
• Patients who do not provide the service where they were hospitalized in their database record.
Variables
Age, sex, diagnosis, date of care at the first level of care, date of care at the second level of care, type
of cancer, and hospitalization service.
The data obtained for the analysis correspond to the records of referral matrices and hospital discharge
matrices. These matrices are mandatory to report to the authorities of Ecuador's Zonal Coordination 3,
who evaluate care times to determine the productivity of treating medical professionals and hospital-level
productivity. The data are subject to review and registration in the Epidemiology Department. This
ensures the validity and quality of the data.
Once the final database was obtained in Excel, it was imported into the SPSS27 statistical package for
the coding of variables and statistical analysis. A univariate analysis was carried out to calculate the
prevalence of neoplasms and cancer based on the population. Ratios, proportions, and percentages for
qualitative variables; Measures of central tendency and dispersion for quantitative variables, always
accompanied by their 95 % confidence interval. The multivariate analysis looked for factors that
influence the presence of neoplasms and the presence of cancer, for which a logistic regression analysis
was performed.
The filling method was used for data processing with the average of the data obtained. This method was
used to analyze the average waiting time for referrals of oncology patients from primary to secondary care.
The study was approved by a human research ethics committee code: IO-29-CEISH- ESPOCH-2024.
RESULTS
Univariate analysis
The prevalence of patients with benign and malignant neoplasms of any organ calculated using the
formula: [(# of patients diagnosed with neoplasia / P) *100] [(204/6559)*100] is equal to 3.11 % (95 %
CI 3 %-4 %) from January to July 2024 in the HPGDR. 75.49 % were women (n=154) and 24.51%
were men (n=50).
The average age of patients with neoplasms, regardless of sex (n=204), is 49 years (95 % CI, 46 – 51
years) (minimum n = 1 year and maximum n = 94 years).
Based on the total population, the prevalence of cancer (malignant neoplasms) [(92/6559)*100] is
1.4% (95 % CI 1 %-2 %) from January to July 2024 in HPGDR. The prevalence of cancer concerning
the total number of patients diagnosed with neoplasia [(92/204)*100] is 45.09 % (9 5% CI 38 %-52 %).
Therefore, almost half of the patients hospitalized for neoplasms are malignant. About sex, 57.61%
(n=53) were women versus 42.39 % (n=39) were men.
The mean age, regardless of sex, of patients with malignant neoplasms is 56 years (95 % CI 52 – 59
years) (minimum n = 15 years and maximum n = 94 years).
Tables 1 and 2 represent the description of the tumors according to the hospitalization service.
Table 1. Benign tumors according to the hospitalization service.
Table 2. Malignant tumors according to the hospitalization service.
Benign and malignant tumors are described below according to their prevalence and hospitalization
services.
Tabla 3. Benign tumors.
The benign tumors with a frequency of 1 (0,9 %) each in Surgery are: tumor of the tongue; tumor of
the nasopharynx; tumor of the rectosigmoid junction; tumor of the meninges, part not specified;
tumor of the anal canal and anus; tumor of the lower jaw; kidney tumor; lipomatous tumor of the
intra-abdominal organs; and tumor of uncertain or unknown behavior of the brain, unspecified part.
Tabla 4. Malignant tumors.
Malignant tumors with a frequency of 1 (1.1 %) each in Internal medicine are: lymphoid leukemia,
no other specification; carcinoma in situ of the stomach; lymphoid leukemia, no other specification;
acute myeloblastic leukemia; chronic myeloid leukemia bcr/abl-positive; hodgkin's lymphoma
unspecified; non-follicular (diffuse) lymphoma not otherwise specified; multiple myeloma; kaposi's
sarcoma of the soft tissue; tumor of the thyroid gland; tumor of the skin of the trunk; tumor of the
central portion of the breast; tumor of the bones of the skull and face; tumor of the abdomen; tumor
of the cerebellum; brain tumor, except lobes and ventricles; tumor of the upper outer quadrant of the
breast; tumor of the body of the stomach; tumor of the body of the uterus, part not specified; tumor
of the esophagus, part not specified; tumor of the exocervix; liver tumor unspecified; ileum tumor;
tumor of the frontal lobe; tumor of the upper lobe, bronchus, or lung; tumor of the ovary; and tumor
of the testicle, unspecified.
To establish the mean number of days that patients were required to wait to receive care at the
second level, the total number of cancers (n=92) was taken. However, there was significant data
loss. It was only possible to obtain information on waiting days for care for 36 patients (39.13 %)
versus 56 (60.87 %) patients who did not have information on the days they waited to receive care
in the hospital.
Taking the data from the 36 patients, the average number of days required to be seen in the HPGDR
was 35 (95 % CI 19 – 51 days). The minimum waiting time was 2 days. The maximum was 204 days
waiting for care, and a Mode=2.
Multivariate analysis
Table 5 is presented below. A logistic regression model was performed to explain the dependent
variable presence of neoplasms, p= 6559.
Table 5. Logistic regression Presence of neoplasms.
It can be seen that the variables that explain the appearance of neoplasms are sex, age, and belonging
to the Surgery or gynecology service. Men are less likely to have a neoplasm (benign or malignant)
diagnosis OR 0.477, statistically significant, compared to women.
Concerning the 204 patients who presented neoplasms, a logistic regression was performed to explain
the dependent variable presence of malignant neoplasms. The results are shown below in Table 6.
Table 6. Logistic regression Presence of malignant neoplasms.
The variables that explain the presence of malignant neoplasms are age when the cut-off point is 65
years, and sex. Being male confers a higher chance of having malignancies (OR 5.99). Being younger
than 65 is less likely to get cancer (OR 0.25).
DISCUSSIÓN
The prevalence of benign or malignant neoplasms (3.11 %) represents a high percentage concerning
all HPGDR care that required hospitalization because it is a second-level hospital. If we divide the
number of neoplasms, we obtain that approximately 34 patients are hospitalized per month on average.
The hospital must ensure quality care for all patients.(11) It should be considered that approximately
half of the neoplasms are malignant (45.09 %). In most cases, more complex and expensive diagnostic
tests are required to determine their nature.(16-18) The percentage obtained in this study on the prevalence
of cancer shows a global reality, being the leading cause of death in 2020.(19)
In the univariate analysis, there were differences concerning age and sex, which were corroborated by
the multivariate analysis, where men have a lower risk of having a neoplasm (OR 0.47) p= 0.045.
However, men have a higher risk of malignancies (OR 5.99) p=0.000. According to international
statistics, men have an age-standardized incidence rate of 212.6, with a cumulative risk of developing
cancer before the age of 75 of 21.8 %, compared to women who have a standardized incidence rate of
186.3 with a risk of 18.5 %. (19,20) Similarly, our study shows that those younger than 65 represent a
lower cancer risk (OR 0.25) p=0.035.
Although supported by evidence, the methodological nature of the study confers results that must be
corroborated with more powerful studies and stricter inclusion and selection criteria. Age and sex
should also be considered as confounding variables.
Gynecology represents 66.96 % of hospitalizations for benign tumors, which is consistent with the most
frequent types of benign tumors treated, uterine leiomyomas and ovarian and breast tumors. In the
second place, Surgery is found with 27.68 % for the resolution mainly of lipomas.
Internal medicine is the leading cancer care service, accounting for 77.17 % of hospitalizations. The
main types of cancer are leukemias, lymphomas, skin, lung, and gastric. The second service with the
highest percentage of hospitalizations is Surgery, with 16.30 %, where gastric and urological cancer are
mainly treated. The main types of cancer worldwide are lung, breast, colorectal, prostate, stomach, liver,
thyroid, and uterine cervix. (20-24)
A timely cancer diagnosis represents a greater probability of long-term survival, implementing early
surgical or clinical treatments. (25-28) We found an average wait of 35 days to be seen as referrals from the
first level, in charge of the health centers, to the second level of care, in charge of the HPGDR. These
data represent an essential information bias due to the number of losses, which made it impossible to
have a waiting time for analysis. Longitudinal studies are recommended to have a more accurate
follow-up and not have losses from that follow-up.
The National Institute for Health and Care Excellence recommends referring patients with metastatic
cancer of unknown origin for care within two weeks of referral.(29) It is necessary to create public policies
to address medical and non-medical expenses to improve the quality of life of cancer patients and mitigate
barriers to access to care since a timely diagnosis and approach reduce subsequent treatment costs.(30,31)
The strengths of this study are the rigor of the results obtained since the appropriate statistics were used,
providing 95 % CI and p values; it represents epidemiological data that can be extrapolated to the gene-
ral population since there were no sampling biases, obtaining adequate external validity; and it is the
starting point for more rigorous investigations in search of data that explain causality.
Limitations:
The main limitation of this study is the impossibility of stricter follow-up and control of the participants.
It was not possible to analyze more factors that contributed to the diagnosis of cancer.
To establish causal relationships, the design of our study is limited, as we present a cross-sectional
design. However, this type of design does allow for the analysis of relationships between variables that
present associations, such as the prevalence ratio, OR, etc. In medicine, it is impossible to establish
specific cause-and-effect relationships since pathologies, primarily cancer, are multifactorial.
The main limitation regarding the analysis of waiting times for care was the loss of data, which confers
little external validity to our results. These losses are primarily attributed to the fact that all hospital
discharges for cancer were considered, and many of them originate from emergency departments,
where there is no care policy based on primary care referrals.
Recommendations:
Mandatory, real-time health record keeping should be implemented, in addition to the referral form
(Form 053) to monitor patients. This would facilitate longitudinal studies.
Consider including oncology professionals at least once or twice a week to support outpatient care,
perform procedures, and diagnose patients with suspected cancer.
CONCLUSIONS
The prevalence of neoplasms in HPGDR from January to July 2024 is 3.11 % (95 % CI 3 %-4 %), and
45.09 % (95 % CI 38 %-52 %) corresponds to malignant neoplasms. The prevalence of cancer in the
total hospitalizations from January to July 2024 in HPGDR is 1.4 % (95 % CI 1 %-2 %).
Gynecology is the main service that treats benign neoplasms, the most frequent being leiomyomas,
ovarian or breast. The second service corresponds to Surgery for the resolution of lipomas.
The main cancer care service is internal medicine, which is used to treat leukemias, lymphomas, skin,
lung, and gastric cancers. The second service is Surgery for gastric and urological cancer care.
The waiting time required by patients to receive care by referrals from health centers to HPGDR is 35
days (95 % CI 19 – 51 days).
Funding: The authors funded this research.
Acknowledgments:
• To the authorities of the HPGDR.: Dr. María Sánchez, Manager; Dr. Evelyn Inca, medical director,
for promoting research and contributing to administrative procedures. To the Statistics service
for collaborating with the required data.
• To the National University of Chimborazo.
• To the Polytechnic School of Chimborazo.
Conflicts of interest: The authors declare no conflict of interest in this research.
Contribution Statement:
Conceptualization: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana. Data
curation, Formal analysis, Methodology, Software, Validation, Visualization, and Writing – review and
editing: Md. M.Sc. Carlos Andrés Yépez Salgado. Acquisition of funds: project self-financed by the
authors. Research: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana; Dr.
Paola Buenaño; Dr. David Orozco; Md. Yesenia Chandi. Project administration: Dr. Paola Buenaño; Dr.
David Orozco; Md. Yesenia Chandi. Supervision: Dr. Zully Mayra Romero Orellana; Dr. Paola Buenaño;
Dr. David Orozco. Writing – original draft: Md. Yesenia Chandi. All authors have read and agreed to the
published version of the manuscript.
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cc
BY NC ND
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 19
Número 2
5
REE 19(2) Riobamba may. - ago. 2025
Prevalence of cancer and time to referral care in oncology patients
Prevalencia de cáncer y tiempo de atención de referencias en pacientes oncológicos.
https://doi.org/10.37135/ee.04.23.01
Authors:
Carlos Andrés Yépez Salgado1 - https://orcid.org/0009-0009-4722-8348
Zully Mayra Romero Orellana1,2 - https://orcid.org/0009-0000-6323-7548
David Cristóbal Orozco Brito3 - https://orcid.org/0000-0002-3945-3301
Nancy Paola Buenano Zambrano1 - https://orcid.org/0009-0003-2505-9236
Yesenia Liliana Chandi Japón4 - https://orcid.org/0009-0000-5672-0451
Affiliation:
1Hospital Provincial General Docente Riobamba.
2Universidad Nacional de Chimborazo.
3Escuela Superior Politécnica de Chimborazo.
4Centro de Salud Pungala Grande.
Corresponding author: Carlos Andrés Yépez Salgado. Hospital Provincial General Docente Riobamba.
Dirección postal: 060104. Email: med.carlos.andres@gmail.com / docenciahpgdrcoordinacion@gmail.
com Phone: +593984109505.
Received: January 24, 2025 Accepted: abril 01, 2025
ABSTRACT
Cancer represents a worldwide problem. In 2022, there were 30888 new cases of cancer and 16158
deaths in Ecuador. Considering the high morbidity and mortality due to this disease, health systems are
trying to meet the demand of these patients in public and private health services. Our main objective
was to establish the prevalence of cancer and the time of care of oncological patients referred to the
second level from the first of care during January-July 2024 at the Hospital Provincial General
Docente Riobamba. An original, observational, retrospective, descriptive, and correlational study
was presented. The prevalence of neoplasms is 3.11 %, and 45.09 % are malignant. The prevalence
of cancer in total hospitalizations is 1.4 %, and the average waiting time for care is 35 days. There
was a high prevalence of cancer in the hospital, where Internal medicine and Surgery are the services
with the most hospitalizations for this pathology.
Keywords: Cancer; Neoplasms; Epidemiology; Community Health Planning; Secondary Care Centers.
RESUMEN
El cáncer representa un problema a nivel mundial, en el año 2022 en el Ecuador existieron 30888
nuevos casos de cáncer y 16158 muertes, considerando una elevada morbimortalidad a causa de este
padecimiento, los sistemas de salud realizan un esfuerzo por solventar la demanda de estos pacientes
en los servicios de salud públicos y privados. El objetivo de esta investigación fue establecer la
prevalencia de cáncer y el tiempo de atención de referencias de pacientes oncológicos referidos desde
el primer nivel de atención al segundo nivel de atención de enero a julio de 2024 en el Hospital
Provincial General Docente de Riobamba. Se presentó un estudio original, observacional, transversal
retrospectivo, descriptivo y correlacional. La prevalencia de neoplasias es de 3,11 % y el 45,09 % son
malignas. La prevalencia de cáncer en el total de hospitalizaciones es 1,4% y el promedio de tiempo
de espera para la atención es de 35 días. Existió una elevada prevalencia de cáncer en el hospital,
siendo medicina interna y cirugía los servicios con más hospitalizaciones por esta patología.
Palabras clave: cáncer; neoplasias; epidemiología; planificación sanitaria comunitaria; centros de
atención secundaria.
.
INTRODUCTION
Cancer is a term used to refer to a broad group of diseases of complex and multifactorial origin caused
by abnormal cells that multiply autonomously and irregularly, invading other tissues locally and at a
distance.(1) The degree of malignancy is variable. It depends on the aggressiveness of its cells and
biological characteristics(2). They can spread and cause metastasis from different routes of dissemination
(lymphatic, blood, or by extension and direct invasion of neighboring tissues).(2,3) In general, if their
natural evolution is sought, they tend to lead to the death of the affected person in the short term.(4)
Currently, more than 200 different types of cancer are known, depending on the tissue from which they
are derived. The most common are those of the skin, lungs, breast, colon, and rectum.(5)
According to PAHO, cancer is one of the leading causes of mortality in the Americas. The figures indicate
that its incidence is growing rapidly worldwide, becoming a significant barrier to increasing life
expectancy. It is estimated that in 2022, there were 20 million new cases of cancer and 9.7 million
deaths in the region. (6,7)
Statistics from the International Agency for Research on Cancer indicate that in 2022 in Ecuador there
were 30888 new cases of cancer, 16,158 deaths, a risk of 7.3 % of dying from cancer before the age of
75; Prostate (29.4 %), stomach (11.2 %) and colorectal (8.4 %) cancer are more prevalent in our coun-
try; In female sex, lung cancer (23 %), cervical cancer (10.5 %) and colorectal cancer (8.0 %) are the
main ones; It is also mentioned that by 2040 there will be more than 53,701 cases detected during the
year in Ecuador. (8)
When analyzing the statistics, we observe that in Ecuador, as in the rest of the world, the incidence of
cancer is increasing, which is why it is necessary to have a health system that provides the opportunity
for each user to have adequate and timely care for their diagnosis and treatment.(8,9) It has been shown
that the delay in the care of this type of patient has been directly related to survival rates.(9) A study in
London about the survival of patients with breast cancer related to delayed uptake and treatment
showed that 32 % of patients with delays of 12 weeks or more had locally advanced or metastatic
disease, compared to only 10 % of those with delays of less than 12 weeks, which shows us the importance
of early recruitment.(10)
The national health system in Ecuador has a system of universality and progressive free healthcare
based on the Comprehensive Health Care model, which is supported by the user referral system to
improve healthcare.(11,12) This regulation is applied at all levels of care, thus allowing adequate care to
be provided to all users who require it according to the degree of complexity to achieve complete,
acceptable, and timely care.(13)
The health system of Ecuador offers a model that allows recruitment at the first level of health, which
is responsible for making the referral to the next step.(14) The time that elapses from the recruitment of
an oncology patient to the moment they obtain specialized care is usually long since the influx of
patients within the public health system is large.(11,15) Now, there are no studies that report the approximate
time of care for this type of patient.
This study in general terms aimed to establish the prevalence of cancer and the waiting time for the
care of cancer patients referred from the first to the second level of care from January to July 2024 at
the Hospital Provincial General Docente Riobamba (HPGDR).
The hypothesis proposed was that there is a high prevalence of cancer patients treated in the hospital
and a delay in the care of cancer patients due to the high demand for examinations and specialist
doctors that are not paid for by the Ministry of Public Health.
MATERIAL Y MÉTODOS
An original, observational, cross-sectional, retrospective study with a quantitative, descriptive, and
correlational approach was presented.
We worked with the entire population, representing the total number of patients hospitalized in all
specialties of the HPGDR, internal medicine, pediatrics, gynecology and obstetrics, Surgery, and ICU
from January to July 2024, p= 6559. By working with the entire population, we avoid sampling and
selection bias. The patient matrix called "Hospital discharges January to July 2024" is in the Hospital's
statistics service, which was provided to the researchers of an anonymized nature with the required
data according to the variables to be studied and before the delivery of a confidentiality commitment
from the authors and a general informed consent by the hospital's medical management.
Inclusion criteria.
• Patients treated in the hospital and registered in the hospital discharge matrix.
• Patients diagnosed with neoplastic pathology of any organ.
• Patients who have complied with the referral from the first level to the second level of care for
the calculation of the average days of waiting for referral care.
Exclusion criteria.
• Patients who do not provide the service where they were hospitalized in their database record.
Variables
Age, sex, diagnosis, date of care at the first level of care, date of care at the second level of care, type
of cancer, and hospitalization service.
The data obtained for the analysis correspond to the records of referral matrices and hospital discharge
matrices. These matrices are mandatory to report to the authorities of Ecuador's Zonal Coordination 3,
who evaluate care times to determine the productivity of treating medical professionals and hospital-level
productivity. The data are subject to review and registration in the Epidemiology Department. This
ensures the validity and quality of the data.
Once the final database was obtained in Excel, it was imported into the SPSS27 statistical package for
the coding of variables and statistical analysis. A univariate analysis was carried out to calculate the
prevalence of neoplasms and cancer based on the population. Ratios, proportions, and percentages for
qualitative variables; Measures of central tendency and dispersion for quantitative variables, always
accompanied by their 95 % confidence interval. The multivariate analysis looked for factors that
influence the presence of neoplasms and the presence of cancer, for which a logistic regression analysis
was performed.
The filling method was used for data processing with the average of the data obtained. This method was
used to analyze the average waiting time for referrals of oncology patients from primary to secondary care.
The study was approved by a human research ethics committee code: IO-29-CEISH- ESPOCH-2024.
RESULTS
Univariate analysis
The prevalence of patients with benign and malignant neoplasms of any organ calculated using the
formula: [(# of patients diagnosed with neoplasia / P) *100] [(204/6559)*100] is equal to 3.11 % (95 %
CI 3 %-4 %) from January to July 2024 in the HPGDR. 75.49 % were women (n=154) and 24.51%
were men (n=50).
The average age of patients with neoplasms, regardless of sex (n=204), is 49 years (95 % CI, 46 – 51
years) (minimum n = 1 year and maximum n = 94 years).
Based on the total population, the prevalence of cancer (malignant neoplasms) [(92/6559)*100] is
1.4% (95 % CI 1 %-2 %) from January to July 2024 in HPGDR. The prevalence of cancer concerning
the total number of patients diagnosed with neoplasia [(92/204)*100] is 45.09 % (9 5% CI 38 %-52 %).
Therefore, almost half of the patients hospitalized for neoplasms are malignant. About sex, 57.61%
(n=53) were women versus 42.39 % (n=39) were men.
The mean age, regardless of sex, of patients with malignant neoplasms is 56 years (95 % CI 52 – 59
years) (minimum n = 15 years and maximum n = 94 years).
Tables 1 and 2 represent the description of the tumors according to the hospitalization service.
Table 1. Benign tumors according to the hospitalization service.
Table 2. Malignant tumors according to the hospitalization service.
Benign and malignant tumors are described below according to their prevalence and hospitalization
services.
Tabla 3. Benign tumors.
The benign tumors with a frequency of 1 (0,9 %) each in Surgery are: tumor of the tongue; tumor of
the nasopharynx; tumor of the rectosigmoid junction; tumor of the meninges, part not specified;
tumor of the anal canal and anus; tumor of the lower jaw; kidney tumor; lipomatous tumor of the
intra-abdominal organs; and tumor of uncertain or unknown behavior of the brain, unspecified part.
Tabla 4. Malignant tumors.
Malignant tumors with a frequency of 1 (1.1 %) each in Internal medicine are: lymphoid leukemia,
no other specification; carcinoma in situ of the stomach; lymphoid leukemia, no other specification;
acute myeloblastic leukemia; chronic myeloid leukemia bcr/abl-positive; hodgkin's lymphoma
unspecified; non-follicular (diffuse) lymphoma not otherwise specified; multiple myeloma; kaposi's
sarcoma of the soft tissue; tumor of the thyroid gland; tumor of the skin of the trunk; tumor of the
central portion of the breast; tumor of the bones of the skull and face; tumor of the abdomen; tumor
of the cerebellum; brain tumor, except lobes and ventricles; tumor of the upper outer quadrant of the
breast; tumor of the body of the stomach; tumor of the body of the uterus, part not specified; tumor
of the esophagus, part not specified; tumor of the exocervix; liver tumor unspecified; ileum tumor;
tumor of the frontal lobe; tumor of the upper lobe, bronchus, or lung; tumor of the ovary; and tumor
of the testicle, unspecified.
To establish the mean number of days that patients were required to wait to receive care at the
second level, the total number of cancers (n=92) was taken. However, there was significant data
loss. It was only possible to obtain information on waiting days for care for 36 patients (39.13 %)
versus 56 (60.87 %) patients who did not have information on the days they waited to receive care
in the hospital.
Taking the data from the 36 patients, the average number of days required to be seen in the HPGDR
was 35 (95 % CI 19 – 51 days). The minimum waiting time was 2 days. The maximum was 204 days
waiting for care, and a Mode=2.
Multivariate analysis
Table 5 is presented below. A logistic regression model was performed to explain the dependent
variable presence of neoplasms, p= 6559.
Table 5. Logistic regression Presence of neoplasms.
It can be seen that the variables that explain the appearance of neoplasms are sex, age, and belonging
to the Surgery or gynecology service. Men are less likely to have a neoplasm (benign or malignant)
diagnosis OR 0.477, statistically significant, compared to women.
Concerning the 204 patients who presented neoplasms, a logistic regression was performed to explain
the dependent variable presence of malignant neoplasms. The results are shown below in Table 6.
Table 6. Logistic regression Presence of malignant neoplasms.
The variables that explain the presence of malignant neoplasms are age when the cut-off point is 65
years, and sex. Being male confers a higher chance of having malignancies (OR 5.99). Being younger
than 65 is less likely to get cancer (OR 0.25).
DISCUSSIÓN
The prevalence of benign or malignant neoplasms (3.11 %) represents a high percentage concerning
all HPGDR care that required hospitalization because it is a second-level hospital. If we divide the
number of neoplasms, we obtain that approximately 34 patients are hospitalized per month on average.
The hospital must ensure quality care for all patients.(11) It should be considered that approximately
half of the neoplasms are malignant (45.09 %). In most cases, more complex and expensive diagnostic
tests are required to determine their nature.(16-18) The percentage obtained in this study on the prevalence
of cancer shows a global reality, being the leading cause of death in 2020.(19)
In the univariate analysis, there were differences concerning age and sex, which were corroborated by
the multivariate analysis, where men have a lower risk of having a neoplasm (OR 0.47) p= 0.045.
However, men have a higher risk of malignancies (OR 5.99) p=0.000. According to international
statistics, men have an age-standardized incidence rate of 212.6, with a cumulative risk of developing
cancer before the age of 75 of 21.8 %, compared to women who have a standardized incidence rate of
186.3 with a risk of 18.5 %. (19,20) Similarly, our study shows that those younger than 65 represent a
lower cancer risk (OR 0.25) p=0.035.
Although supported by evidence, the methodological nature of the study confers results that must be
corroborated with more powerful studies and stricter inclusion and selection criteria. Age and sex
should also be considered as confounding variables.
Gynecology represents 66.96 % of hospitalizations for benign tumors, which is consistent with the most
frequent types of benign tumors treated, uterine leiomyomas and ovarian and breast tumors. In the
second place, Surgery is found with 27.68 % for the resolution mainly of lipomas.
Internal medicine is the leading cancer care service, accounting for 77.17 % of hospitalizations. The
main types of cancer are leukemias, lymphomas, skin, lung, and gastric. The second service with the
highest percentage of hospitalizations is Surgery, with 16.30 %, where gastric and urological cancer are
mainly treated. The main types of cancer worldwide are lung, breast, colorectal, prostate, stomach, liver,
thyroid, and uterine cervix. (20-24)
A timely cancer diagnosis represents a greater probability of long-term survival, implementing early
surgical or clinical treatments. (25-28) We found an average wait of 35 days to be seen as referrals from the
first level, in charge of the health centers, to the second level of care, in charge of the HPGDR. These
data represent an essential information bias due to the number of losses, which made it impossible to
have a waiting time for analysis. Longitudinal studies are recommended to have a more accurate
follow-up and not have losses from that follow-up.
The National Institute for Health and Care Excellence recommends referring patients with metastatic
cancer of unknown origin for care within two weeks of referral.(29) It is necessary to create public policies
to address medical and non-medical expenses to improve the quality of life of cancer patients and mitigate
barriers to access to care since a timely diagnosis and approach reduce subsequent treatment costs.(30,31)
The strengths of this study are the rigor of the results obtained since the appropriate statistics were used,
providing 95 % CI and p values; it represents epidemiological data that can be extrapolated to the gene-
ral population since there were no sampling biases, obtaining adequate external validity; and it is the
starting point for more rigorous investigations in search of data that explain causality.
Limitations:
The main limitation of this study is the impossibility of stricter follow-up and control of the participants.
It was not possible to analyze more factors that contributed to the diagnosis of cancer.
To establish causal relationships, the design of our study is limited, as we present a cross-sectional
design. However, this type of design does allow for the analysis of relationships between variables that
present associations, such as the prevalence ratio, OR, etc. In medicine, it is impossible to establish
specific cause-and-effect relationships since pathologies, primarily cancer, are multifactorial.
The main limitation regarding the analysis of waiting times for care was the loss of data, which confers
little external validity to our results. These losses are primarily attributed to the fact that all hospital
discharges for cancer were considered, and many of them originate from emergency departments,
where there is no care policy based on primary care referrals.
Recommendations:
Mandatory, real-time health record keeping should be implemented, in addition to the referral form
(Form 053) to monitor patients. This would facilitate longitudinal studies.
Consider including oncology professionals at least once or twice a week to support outpatient care,
perform procedures, and diagnose patients with suspected cancer.
CONCLUSIONS
The prevalence of neoplasms in HPGDR from January to July 2024 is 3.11 % (95 % CI 3 %-4 %), and
45.09 % (95 % CI 38 %-52 %) corresponds to malignant neoplasms. The prevalence of cancer in the
total hospitalizations from January to July 2024 in HPGDR is 1.4 % (95 % CI 1 %-2 %).
Gynecology is the main service that treats benign neoplasms, the most frequent being leiomyomas,
ovarian or breast. The second service corresponds to Surgery for the resolution of lipomas.
The main cancer care service is internal medicine, which is used to treat leukemias, lymphomas, skin,
lung, and gastric cancers. The second service is Surgery for gastric and urological cancer care.
The waiting time required by patients to receive care by referrals from health centers to HPGDR is 35
days (95 % CI 19 – 51 days).
Funding: The authors funded this research.
Acknowledgments:
• To the authorities of the HPGDR.: Dr. María Sánchez, Manager; Dr. Evelyn Inca, medical director,
for promoting research and contributing to administrative procedures. To the Statistics service
for collaborating with the required data.
• To the National University of Chimborazo.
• To the Polytechnic School of Chimborazo.
Conflicts of interest: The authors declare no conflict of interest in this research.
Contribution Statement:
Conceptualization: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana. Data
curation, Formal analysis, Methodology, Software, Validation, Visualization, and Writing – review and
editing: Md. M.Sc. Carlos Andrés Yépez Salgado. Acquisition of funds: project self-financed by the
authors. Research: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana; Dr.
Paola Buenaño; Dr. David Orozco; Md. Yesenia Chandi. Project administration: Dr. Paola Buenaño; Dr.
David Orozco; Md. Yesenia Chandi. Supervision: Dr. Zully Mayra Romero Orellana; Dr. Paola Buenaño;
Dr. David Orozco. Writing – original draft: Md. Yesenia Chandi. All authors have read and agreed to the
published version of the manuscript.
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pii/S1040842820300202.
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Nutr [Internet]. 2025 [cited 22 Jan 2025];44(1):16. Available from: https://jhpn.biomedcentral.
com/articles/10.1186/s41043-025-00738-0#Sec1.
BENING NEOPLASM
SERVICE
n
%
SURGERY
31
27.68
INTERNAL MEDICINE
2
1.79
GYNECOLOGY AND OBSTETRICS
75
66.96
PEDIATRICS
4
3.57
TOTAL
112
100
MALIGNANT NEOPLASMS
SERVICE
n
%
SURGERY
15
16.30
INTERNAL MEDICINE
71
77.17
GYNECOLOGY AND OBSTETRICS
6
6.52
PEDIATRICS
0
0.00
TOTAL
92
100
cc
BY NC ND
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 19
Número 2
6
REE 19(2) Riobamba may. - ago. 2025
Prevalence of cancer and time to referral care in oncology patients
Prevalencia de cáncer y tiempo de atención de referencias en pacientes oncológicos.
https://doi.org/10.37135/ee.04.23.01
Authors:
Carlos Andrés Yépez Salgado1 - https://orcid.org/0009-0009-4722-8348
Zully Mayra Romero Orellana1,2 - https://orcid.org/0009-0000-6323-7548
David Cristóbal Orozco Brito3 - https://orcid.org/0000-0002-3945-3301
Nancy Paola Buenano Zambrano1 - https://orcid.org/0009-0003-2505-9236
Yesenia Liliana Chandi Japón4 - https://orcid.org/0009-0000-5672-0451
Affiliation:
1Hospital Provincial General Docente Riobamba.
2Universidad Nacional de Chimborazo.
3Escuela Superior Politécnica de Chimborazo.
4Centro de Salud Pungala Grande.
Corresponding author: Carlos Andrés Yépez Salgado. Hospital Provincial General Docente Riobamba.
Dirección postal: 060104. Email: med.carlos.andres@gmail.com / docenciahpgdrcoordinacion@gmail.
com Phone: +593984109505.
Received: January 24, 2025 Accepted: abril 01, 2025
ABSTRACT
Cancer represents a worldwide problem. In 2022, there were 30888 new cases of cancer and 16158
deaths in Ecuador. Considering the high morbidity and mortality due to this disease, health systems are
trying to meet the demand of these patients in public and private health services. Our main objective
was to establish the prevalence of cancer and the time of care of oncological patients referred to the
second level from the first of care during January-July 2024 at the Hospital Provincial General
Docente Riobamba. An original, observational, retrospective, descriptive, and correlational study
was presented. The prevalence of neoplasms is 3.11 %, and 45.09 % are malignant. The prevalence
of cancer in total hospitalizations is 1.4 %, and the average waiting time for care is 35 days. There
was a high prevalence of cancer in the hospital, where Internal medicine and Surgery are the services
with the most hospitalizations for this pathology.
Keywords: Cancer; Neoplasms; Epidemiology; Community Health Planning; Secondary Care Centers.
RESUMEN
El cáncer representa un problema a nivel mundial, en el año 2022 en el Ecuador existieron 30888
nuevos casos de cáncer y 16158 muertes, considerando una elevada morbimortalidad a causa de este
padecimiento, los sistemas de salud realizan un esfuerzo por solventar la demanda de estos pacientes
en los servicios de salud públicos y privados. El objetivo de esta investigación fue establecer la
prevalencia de cáncer y el tiempo de atención de referencias de pacientes oncológicos referidos desde
el primer nivel de atención al segundo nivel de atención de enero a julio de 2024 en el Hospital
Provincial General Docente de Riobamba. Se presentó un estudio original, observacional, transversal
retrospectivo, descriptivo y correlacional. La prevalencia de neoplasias es de 3,11 % y el 45,09 % son
malignas. La prevalencia de cáncer en el total de hospitalizaciones es 1,4% y el promedio de tiempo
de espera para la atención es de 35 días. Existió una elevada prevalencia de cáncer en el hospital,
siendo medicina interna y cirugía los servicios con más hospitalizaciones por esta patología.
Palabras clave: cáncer; neoplasias; epidemiología; planificación sanitaria comunitaria; centros de
atención secundaria.
.
INTRODUCTION
Cancer is a term used to refer to a broad group of diseases of complex and multifactorial origin caused
by abnormal cells that multiply autonomously and irregularly, invading other tissues locally and at a
distance.(1) The degree of malignancy is variable. It depends on the aggressiveness of its cells and
biological characteristics(2). They can spread and cause metastasis from different routes of dissemination
(lymphatic, blood, or by extension and direct invasion of neighboring tissues).(2,3) In general, if their
natural evolution is sought, they tend to lead to the death of the affected person in the short term.(4)
Currently, more than 200 different types of cancer are known, depending on the tissue from which they
are derived. The most common are those of the skin, lungs, breast, colon, and rectum.(5)
According to PAHO, cancer is one of the leading causes of mortality in the Americas. The figures indicate
that its incidence is growing rapidly worldwide, becoming a significant barrier to increasing life
expectancy. It is estimated that in 2022, there were 20 million new cases of cancer and 9.7 million
deaths in the region. (6,7)
Statistics from the International Agency for Research on Cancer indicate that in 2022 in Ecuador there
were 30888 new cases of cancer, 16,158 deaths, a risk of 7.3 % of dying from cancer before the age of
75; Prostate (29.4 %), stomach (11.2 %) and colorectal (8.4 %) cancer are more prevalent in our coun-
try; In female sex, lung cancer (23 %), cervical cancer (10.5 %) and colorectal cancer (8.0 %) are the
main ones; It is also mentioned that by 2040 there will be more than 53,701 cases detected during the
year in Ecuador. (8)
When analyzing the statistics, we observe that in Ecuador, as in the rest of the world, the incidence of
cancer is increasing, which is why it is necessary to have a health system that provides the opportunity
for each user to have adequate and timely care for their diagnosis and treatment.(8,9) It has been shown
that the delay in the care of this type of patient has been directly related to survival rates.(9) A study in
London about the survival of patients with breast cancer related to delayed uptake and treatment
showed that 32 % of patients with delays of 12 weeks or more had locally advanced or metastatic
disease, compared to only 10 % of those with delays of less than 12 weeks, which shows us the importance
of early recruitment.(10)
The national health system in Ecuador has a system of universality and progressive free healthcare
based on the Comprehensive Health Care model, which is supported by the user referral system to
improve healthcare.(11,12) This regulation is applied at all levels of care, thus allowing adequate care to
be provided to all users who require it according to the degree of complexity to achieve complete,
acceptable, and timely care.(13)
The health system of Ecuador offers a model that allows recruitment at the first level of health, which
is responsible for making the referral to the next step.(14) The time that elapses from the recruitment of
an oncology patient to the moment they obtain specialized care is usually long since the influx of
patients within the public health system is large.(11,15) Now, there are no studies that report the approximate
time of care for this type of patient.
This study in general terms aimed to establish the prevalence of cancer and the waiting time for the
care of cancer patients referred from the first to the second level of care from January to July 2024 at
the Hospital Provincial General Docente Riobamba (HPGDR).
The hypothesis proposed was that there is a high prevalence of cancer patients treated in the hospital
and a delay in the care of cancer patients due to the high demand for examinations and specialist
doctors that are not paid for by the Ministry of Public Health.
MATERIAL Y MÉTODOS
An original, observational, cross-sectional, retrospective study with a quantitative, descriptive, and
correlational approach was presented.
We worked with the entire population, representing the total number of patients hospitalized in all
specialties of the HPGDR, internal medicine, pediatrics, gynecology and obstetrics, Surgery, and ICU
from January to July 2024, p= 6559. By working with the entire population, we avoid sampling and
selection bias. The patient matrix called "Hospital discharges January to July 2024" is in the Hospital's
statistics service, which was provided to the researchers of an anonymized nature with the required
data according to the variables to be studied and before the delivery of a confidentiality commitment
from the authors and a general informed consent by the hospital's medical management.
Inclusion criteria.
• Patients treated in the hospital and registered in the hospital discharge matrix.
• Patients diagnosed with neoplastic pathology of any organ.
• Patients who have complied with the referral from the first level to the second level of care for
the calculation of the average days of waiting for referral care.
Exclusion criteria.
• Patients who do not provide the service where they were hospitalized in their database record.
Variables
Age, sex, diagnosis, date of care at the first level of care, date of care at the second level of care, type
of cancer, and hospitalization service.
The data obtained for the analysis correspond to the records of referral matrices and hospital discharge
matrices. These matrices are mandatory to report to the authorities of Ecuador's Zonal Coordination 3,
who evaluate care times to determine the productivity of treating medical professionals and hospital-level
productivity. The data are subject to review and registration in the Epidemiology Department. This
ensures the validity and quality of the data.
Once the final database was obtained in Excel, it was imported into the SPSS27 statistical package for
the coding of variables and statistical analysis. A univariate analysis was carried out to calculate the
prevalence of neoplasms and cancer based on the population. Ratios, proportions, and percentages for
qualitative variables; Measures of central tendency and dispersion for quantitative variables, always
accompanied by their 95 % confidence interval. The multivariate analysis looked for factors that
influence the presence of neoplasms and the presence of cancer, for which a logistic regression analysis
was performed.
The filling method was used for data processing with the average of the data obtained. This method was
used to analyze the average waiting time for referrals of oncology patients from primary to secondary care.
The study was approved by a human research ethics committee code: IO-29-CEISH- ESPOCH-2024.
RESULTS
Univariate analysis
The prevalence of patients with benign and malignant neoplasms of any organ calculated using the
formula: [(# of patients diagnosed with neoplasia / P) *100] [(204/6559)*100] is equal to 3.11 % (95 %
CI 3 %-4 %) from January to July 2024 in the HPGDR. 75.49 % were women (n=154) and 24.51%
were men (n=50).
The average age of patients with neoplasms, regardless of sex (n=204), is 49 years (95 % CI, 46 – 51
years) (minimum n = 1 year and maximum n = 94 years).
Based on the total population, the prevalence of cancer (malignant neoplasms) [(92/6559)*100] is
1.4% (95 % CI 1 %-2 %) from January to July 2024 in HPGDR. The prevalence of cancer concerning
the total number of patients diagnosed with neoplasia [(92/204)*100] is 45.09 % (9 5% CI 38 %-52 %).
Therefore, almost half of the patients hospitalized for neoplasms are malignant. About sex, 57.61%
(n=53) were women versus 42.39 % (n=39) were men.
The mean age, regardless of sex, of patients with malignant neoplasms is 56 years (95 % CI 52 – 59
years) (minimum n = 15 years and maximum n = 94 years).
Tables 1 and 2 represent the description of the tumors according to the hospitalization service.
Table 1. Benign tumors according to the hospitalization service.
Table 2. Malignant tumors according to the hospitalization service.
Benign and malignant tumors are described below according to their prevalence and hospitalization
services.
Tabla 3. Benign tumors.
The benign tumors with a frequency of 1 (0,9 %) each in Surgery are: tumor of the tongue; tumor of
the nasopharynx; tumor of the rectosigmoid junction; tumor of the meninges, part not specified;
tumor of the anal canal and anus; tumor of the lower jaw; kidney tumor; lipomatous tumor of the
intra-abdominal organs; and tumor of uncertain or unknown behavior of the brain, unspecified part.
Tabla 4. Malignant tumors.
Malignant tumors with a frequency of 1 (1.1 %) each in Internal medicine are: lymphoid leukemia,
no other specification; carcinoma in situ of the stomach; lymphoid leukemia, no other specification;
acute myeloblastic leukemia; chronic myeloid leukemia bcr/abl-positive; hodgkin's lymphoma
unspecified; non-follicular (diffuse) lymphoma not otherwise specified; multiple myeloma; kaposi's
sarcoma of the soft tissue; tumor of the thyroid gland; tumor of the skin of the trunk; tumor of the
central portion of the breast; tumor of the bones of the skull and face; tumor of the abdomen; tumor
of the cerebellum; brain tumor, except lobes and ventricles; tumor of the upper outer quadrant of the
breast; tumor of the body of the stomach; tumor of the body of the uterus, part not specified; tumor
of the esophagus, part not specified; tumor of the exocervix; liver tumor unspecified; ileum tumor;
tumor of the frontal lobe; tumor of the upper lobe, bronchus, or lung; tumor of the ovary; and tumor
of the testicle, unspecified.
To establish the mean number of days that patients were required to wait to receive care at the
second level, the total number of cancers (n=92) was taken. However, there was significant data
loss. It was only possible to obtain information on waiting days for care for 36 patients (39.13 %)
versus 56 (60.87 %) patients who did not have information on the days they waited to receive care
in the hospital.
Taking the data from the 36 patients, the average number of days required to be seen in the HPGDR
was 35 (95 % CI 19 – 51 days). The minimum waiting time was 2 days. The maximum was 204 days
waiting for care, and a Mode=2.
Multivariate analysis
Table 5 is presented below. A logistic regression model was performed to explain the dependent
variable presence of neoplasms, p= 6559.
Table 5. Logistic regression Presence of neoplasms.
It can be seen that the variables that explain the appearance of neoplasms are sex, age, and belonging
to the Surgery or gynecology service. Men are less likely to have a neoplasm (benign or malignant)
diagnosis OR 0.477, statistically significant, compared to women.
Concerning the 204 patients who presented neoplasms, a logistic regression was performed to explain
the dependent variable presence of malignant neoplasms. The results are shown below in Table 6.
Table 6. Logistic regression Presence of malignant neoplasms.
The variables that explain the presence of malignant neoplasms are age when the cut-off point is 65
years, and sex. Being male confers a higher chance of having malignancies (OR 5.99). Being younger
than 65 is less likely to get cancer (OR 0.25).
DISCUSSIÓN
The prevalence of benign or malignant neoplasms (3.11 %) represents a high percentage concerning
all HPGDR care that required hospitalization because it is a second-level hospital. If we divide the
number of neoplasms, we obtain that approximately 34 patients are hospitalized per month on average.
The hospital must ensure quality care for all patients.(11) It should be considered that approximately
half of the neoplasms are malignant (45.09 %). In most cases, more complex and expensive diagnostic
tests are required to determine their nature.(16-18) The percentage obtained in this study on the prevalence
of cancer shows a global reality, being the leading cause of death in 2020.(19)
In the univariate analysis, there were differences concerning age and sex, which were corroborated by
the multivariate analysis, where men have a lower risk of having a neoplasm (OR 0.47) p= 0.045.
However, men have a higher risk of malignancies (OR 5.99) p=0.000. According to international
statistics, men have an age-standardized incidence rate of 212.6, with a cumulative risk of developing
cancer before the age of 75 of 21.8 %, compared to women who have a standardized incidence rate of
186.3 with a risk of 18.5 %. (19,20) Similarly, our study shows that those younger than 65 represent a
lower cancer risk (OR 0.25) p=0.035.
Although supported by evidence, the methodological nature of the study confers results that must be
corroborated with more powerful studies and stricter inclusion and selection criteria. Age and sex
should also be considered as confounding variables.
Gynecology represents 66.96 % of hospitalizations for benign tumors, which is consistent with the most
frequent types of benign tumors treated, uterine leiomyomas and ovarian and breast tumors. In the
second place, Surgery is found with 27.68 % for the resolution mainly of lipomas.
Internal medicine is the leading cancer care service, accounting for 77.17 % of hospitalizations. The
main types of cancer are leukemias, lymphomas, skin, lung, and gastric. The second service with the
highest percentage of hospitalizations is Surgery, with 16.30 %, where gastric and urological cancer are
mainly treated. The main types of cancer worldwide are lung, breast, colorectal, prostate, stomach, liver,
thyroid, and uterine cervix. (20-24)
A timely cancer diagnosis represents a greater probability of long-term survival, implementing early
surgical or clinical treatments. (25-28) We found an average wait of 35 days to be seen as referrals from the
first level, in charge of the health centers, to the second level of care, in charge of the HPGDR. These
data represent an essential information bias due to the number of losses, which made it impossible to
have a waiting time for analysis. Longitudinal studies are recommended to have a more accurate
follow-up and not have losses from that follow-up.
The National Institute for Health and Care Excellence recommends referring patients with metastatic
cancer of unknown origin for care within two weeks of referral.(29) It is necessary to create public policies
to address medical and non-medical expenses to improve the quality of life of cancer patients and mitigate
barriers to access to care since a timely diagnosis and approach reduce subsequent treatment costs.(30,31)
The strengths of this study are the rigor of the results obtained since the appropriate statistics were used,
providing 95 % CI and p values; it represents epidemiological data that can be extrapolated to the gene-
ral population since there were no sampling biases, obtaining adequate external validity; and it is the
starting point for more rigorous investigations in search of data that explain causality.
Limitations:
The main limitation of this study is the impossibility of stricter follow-up and control of the participants.
It was not possible to analyze more factors that contributed to the diagnosis of cancer.
To establish causal relationships, the design of our study is limited, as we present a cross-sectional
design. However, this type of design does allow for the analysis of relationships between variables that
present associations, such as the prevalence ratio, OR, etc. In medicine, it is impossible to establish
specific cause-and-effect relationships since pathologies, primarily cancer, are multifactorial.
The main limitation regarding the analysis of waiting times for care was the loss of data, which confers
little external validity to our results. These losses are primarily attributed to the fact that all hospital
discharges for cancer were considered, and many of them originate from emergency departments,
where there is no care policy based on primary care referrals.
Recommendations:
Mandatory, real-time health record keeping should be implemented, in addition to the referral form
(Form 053) to monitor patients. This would facilitate longitudinal studies.
Consider including oncology professionals at least once or twice a week to support outpatient care,
perform procedures, and diagnose patients with suspected cancer.
CONCLUSIONS
The prevalence of neoplasms in HPGDR from January to July 2024 is 3.11 % (95 % CI 3 %-4 %), and
45.09 % (95 % CI 38 %-52 %) corresponds to malignant neoplasms. The prevalence of cancer in the
total hospitalizations from January to July 2024 in HPGDR is 1.4 % (95 % CI 1 %-2 %).
Gynecology is the main service that treats benign neoplasms, the most frequent being leiomyomas,
ovarian or breast. The second service corresponds to Surgery for the resolution of lipomas.
The main cancer care service is internal medicine, which is used to treat leukemias, lymphomas, skin,
lung, and gastric cancers. The second service is Surgery for gastric and urological cancer care.
The waiting time required by patients to receive care by referrals from health centers to HPGDR is 35
days (95 % CI 19 – 51 days).
Funding: The authors funded this research.
Acknowledgments:
• To the authorities of the HPGDR.: Dr. María Sánchez, Manager; Dr. Evelyn Inca, medical director,
for promoting research and contributing to administrative procedures. To the Statistics service
for collaborating with the required data.
• To the National University of Chimborazo.
• To the Polytechnic School of Chimborazo.
Conflicts of interest: The authors declare no conflict of interest in this research.
Contribution Statement:
Conceptualization: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana. Data
curation, Formal analysis, Methodology, Software, Validation, Visualization, and Writing – review and
editing: Md. M.Sc. Carlos Andrés Yépez Salgado. Acquisition of funds: project self-financed by the
authors. Research: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana; Dr.
Paola Buenaño; Dr. David Orozco; Md. Yesenia Chandi. Project administration: Dr. Paola Buenaño; Dr.
David Orozco; Md. Yesenia Chandi. Supervision: Dr. Zully Mayra Romero Orellana; Dr. Paola Buenaño;
Dr. David Orozco. Writing – original draft: Md. Yesenia Chandi. All authors have read and agreed to the
published version of the manuscript.
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com/articles/10.1186/s41043-025-00738-0#Sec1.
SURGERY
INTERNAL
MEDICINE
GYNECOLOGY
PEDIATRICS
-benign lipomatous
tumor of the skin
and subcutaneous
tissue of the trunk
(5.4 %)
-benign lipomatous
tumor from other
specified sites (4.5
%)
-benign lipomatous
tumor of the skin
and subcutaneous
tissue of the head,
face, and neck (3.6
%)
-benign lipomatous
tumor of
unspecified site
(3.6 %)
-non-toxic
multinodular goiter
(2.7 %)
-benign lipomatous
tumor of the skin
and subcutaneous
tissue of the limbs
(2.7 %)
-tumor of
uncertain or
unknown behavior
of the lip, oral
cavity, and
pharynx (0.9 %)
-leiomyoma of the
uterus, not otherwise
specified (56.3%)
-benign ovarian
tumor (7.1 %)
-benign breast tumor
(2.7 %)
-hydatidiform mole,
unspecified (0.9 %)
-Benign tumor of
the skin of the
upper limb,
including the
shoulder (0.9 %)
-Benign tumor of
connective tissue
and other soft
tissues of the head,
face, and neck (0.9
%)
cc
BY NC ND
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 19
Número 2
7
REE 19(2) Riobamba may. - ago. 2025
Prevalence of cancer and time to referral care in oncology patients
Prevalencia de cáncer y tiempo de atención de referencias en pacientes oncológicos.
https://doi.org/10.37135/ee.04.23.01
Authors:
Carlos Andrés Yépez Salgado1 - https://orcid.org/0009-0009-4722-8348
Zully Mayra Romero Orellana1,2 - https://orcid.org/0009-0000-6323-7548
David Cristóbal Orozco Brito3 - https://orcid.org/0000-0002-3945-3301
Nancy Paola Buenano Zambrano1 - https://orcid.org/0009-0003-2505-9236
Yesenia Liliana Chandi Japón4 - https://orcid.org/0009-0000-5672-0451
Affiliation:
1Hospital Provincial General Docente Riobamba.
2Universidad Nacional de Chimborazo.
3Escuela Superior Politécnica de Chimborazo.
4Centro de Salud Pungala Grande.
Corresponding author: Carlos Andrés Yépez Salgado. Hospital Provincial General Docente Riobamba.
Dirección postal: 060104. Email: med.carlos.andres@gmail.com / docenciahpgdrcoordinacion@gmail.
com Phone: +593984109505.
Received: January 24, 2025 Accepted: abril 01, 2025
ABSTRACT
Cancer represents a worldwide problem. In 2022, there were 30888 new cases of cancer and 16158
deaths in Ecuador. Considering the high morbidity and mortality due to this disease, health systems are
trying to meet the demand of these patients in public and private health services. Our main objective
was to establish the prevalence of cancer and the time of care of oncological patients referred to the
second level from the first of care during January-July 2024 at the Hospital Provincial General
Docente Riobamba. An original, observational, retrospective, descriptive, and correlational study
was presented. The prevalence of neoplasms is 3.11 %, and 45.09 % are malignant. The prevalence
of cancer in total hospitalizations is 1.4 %, and the average waiting time for care is 35 days. There
was a high prevalence of cancer in the hospital, where Internal medicine and Surgery are the services
with the most hospitalizations for this pathology.
Keywords: Cancer; Neoplasms; Epidemiology; Community Health Planning; Secondary Care Centers.
RESUMEN
El cáncer representa un problema a nivel mundial, en el año 2022 en el Ecuador existieron 30888
nuevos casos de cáncer y 16158 muertes, considerando una elevada morbimortalidad a causa de este
padecimiento, los sistemas de salud realizan un esfuerzo por solventar la demanda de estos pacientes
en los servicios de salud públicos y privados. El objetivo de esta investigación fue establecer la
prevalencia de cáncer y el tiempo de atención de referencias de pacientes oncológicos referidos desde
el primer nivel de atención al segundo nivel de atención de enero a julio de 2024 en el Hospital
Provincial General Docente de Riobamba. Se presentó un estudio original, observacional, transversal
retrospectivo, descriptivo y correlacional. La prevalencia de neoplasias es de 3,11 % y el 45,09 % son
malignas. La prevalencia de cáncer en el total de hospitalizaciones es 1,4% y el promedio de tiempo
de espera para la atención es de 35 días. Existió una elevada prevalencia de cáncer en el hospital,
siendo medicina interna y cirugía los servicios con más hospitalizaciones por esta patología.
Palabras clave: cáncer; neoplasias; epidemiología; planificación sanitaria comunitaria; centros de
atención secundaria.
.
INTRODUCTION
Cancer is a term used to refer to a broad group of diseases of complex and multifactorial origin caused
by abnormal cells that multiply autonomously and irregularly, invading other tissues locally and at a
distance.(1) The degree of malignancy is variable. It depends on the aggressiveness of its cells and
biological characteristics(2). They can spread and cause metastasis from different routes of dissemination
(lymphatic, blood, or by extension and direct invasion of neighboring tissues).(2,3) In general, if their
natural evolution is sought, they tend to lead to the death of the affected person in the short term.(4)
Currently, more than 200 different types of cancer are known, depending on the tissue from which they
are derived. The most common are those of the skin, lungs, breast, colon, and rectum.(5)
According to PAHO, cancer is one of the leading causes of mortality in the Americas. The figures indicate
that its incidence is growing rapidly worldwide, becoming a significant barrier to increasing life
expectancy. It is estimated that in 2022, there were 20 million new cases of cancer and 9.7 million
deaths in the region. (6,7)
Statistics from the International Agency for Research on Cancer indicate that in 2022 in Ecuador there
were 30888 new cases of cancer, 16,158 deaths, a risk of 7.3 % of dying from cancer before the age of
75; Prostate (29.4 %), stomach (11.2 %) and colorectal (8.4 %) cancer are more prevalent in our coun-
try; In female sex, lung cancer (23 %), cervical cancer (10.5 %) and colorectal cancer (8.0 %) are the
main ones; It is also mentioned that by 2040 there will be more than 53,701 cases detected during the
year in Ecuador. (8)
When analyzing the statistics, we observe that in Ecuador, as in the rest of the world, the incidence of
cancer is increasing, which is why it is necessary to have a health system that provides the opportunity
for each user to have adequate and timely care for their diagnosis and treatment.(8,9) It has been shown
that the delay in the care of this type of patient has been directly related to survival rates.(9) A study in
London about the survival of patients with breast cancer related to delayed uptake and treatment
showed that 32 % of patients with delays of 12 weeks or more had locally advanced or metastatic
disease, compared to only 10 % of those with delays of less than 12 weeks, which shows us the importance
of early recruitment.(10)
The national health system in Ecuador has a system of universality and progressive free healthcare
based on the Comprehensive Health Care model, which is supported by the user referral system to
improve healthcare.(11,12) This regulation is applied at all levels of care, thus allowing adequate care to
be provided to all users who require it according to the degree of complexity to achieve complete,
acceptable, and timely care.(13)
The health system of Ecuador offers a model that allows recruitment at the first level of health, which
is responsible for making the referral to the next step.(14) The time that elapses from the recruitment of
an oncology patient to the moment they obtain specialized care is usually long since the influx of
patients within the public health system is large.(11,15) Now, there are no studies that report the approximate
time of care for this type of patient.
This study in general terms aimed to establish the prevalence of cancer and the waiting time for the
care of cancer patients referred from the first to the second level of care from January to July 2024 at
the Hospital Provincial General Docente Riobamba (HPGDR).
The hypothesis proposed was that there is a high prevalence of cancer patients treated in the hospital
and a delay in the care of cancer patients due to the high demand for examinations and specialist
doctors that are not paid for by the Ministry of Public Health.
MATERIAL Y MÉTODOS
An original, observational, cross-sectional, retrospective study with a quantitative, descriptive, and
correlational approach was presented.
We worked with the entire population, representing the total number of patients hospitalized in all
specialties of the HPGDR, internal medicine, pediatrics, gynecology and obstetrics, Surgery, and ICU
from January to July 2024, p= 6559. By working with the entire population, we avoid sampling and
selection bias. The patient matrix called "Hospital discharges January to July 2024" is in the Hospital's
statistics service, which was provided to the researchers of an anonymized nature with the required
data according to the variables to be studied and before the delivery of a confidentiality commitment
from the authors and a general informed consent by the hospital's medical management.
Inclusion criteria.
• Patients treated in the hospital and registered in the hospital discharge matrix.
• Patients diagnosed with neoplastic pathology of any organ.
• Patients who have complied with the referral from the first level to the second level of care for
the calculation of the average days of waiting for referral care.
Exclusion criteria.
• Patients who do not provide the service where they were hospitalized in their database record.
Variables
Age, sex, diagnosis, date of care at the first level of care, date of care at the second level of care, type
of cancer, and hospitalization service.
The data obtained for the analysis correspond to the records of referral matrices and hospital discharge
matrices. These matrices are mandatory to report to the authorities of Ecuador's Zonal Coordination 3,
who evaluate care times to determine the productivity of treating medical professionals and hospital-level
productivity. The data are subject to review and registration in the Epidemiology Department. This
ensures the validity and quality of the data.
Once the final database was obtained in Excel, it was imported into the SPSS27 statistical package for
the coding of variables and statistical analysis. A univariate analysis was carried out to calculate the
prevalence of neoplasms and cancer based on the population. Ratios, proportions, and percentages for
qualitative variables; Measures of central tendency and dispersion for quantitative variables, always
accompanied by their 95 % confidence interval. The multivariate analysis looked for factors that
influence the presence of neoplasms and the presence of cancer, for which a logistic regression analysis
was performed.
The filling method was used for data processing with the average of the data obtained. This method was
used to analyze the average waiting time for referrals of oncology patients from primary to secondary care.
The study was approved by a human research ethics committee code: IO-29-CEISH- ESPOCH-2024.
RESULTS
Univariate analysis
The prevalence of patients with benign and malignant neoplasms of any organ calculated using the
formula: [(# of patients diagnosed with neoplasia / P) *100] [(204/6559)*100] is equal to 3.11 % (95 %
CI 3 %-4 %) from January to July 2024 in the HPGDR. 75.49 % were women (n=154) and 24.51%
were men (n=50).
The average age of patients with neoplasms, regardless of sex (n=204), is 49 years (95 % CI, 46 – 51
years) (minimum n = 1 year and maximum n = 94 years).
Based on the total population, the prevalence of cancer (malignant neoplasms) [(92/6559)*100] is
1.4% (95 % CI 1 %-2 %) from January to July 2024 in HPGDR. The prevalence of cancer concerning
the total number of patients diagnosed with neoplasia [(92/204)*100] is 45.09 % (9 5% CI 38 %-52 %).
Therefore, almost half of the patients hospitalized for neoplasms are malignant. About sex, 57.61%
(n=53) were women versus 42.39 % (n=39) were men.
The mean age, regardless of sex, of patients with malignant neoplasms is 56 years (95 % CI 52 – 59
years) (minimum n = 15 years and maximum n = 94 years).
Tables 1 and 2 represent the description of the tumors according to the hospitalization service.
Table 1. Benign tumors according to the hospitalization service.
Table 2. Malignant tumors according to the hospitalization service.
Benign and malignant tumors are described below according to their prevalence and hospitalization
services.
Tabla 3. Benign tumors.
The benign tumors with a frequency of 1 (0,9 %) each in Surgery are: tumor of the tongue; tumor of
the nasopharynx; tumor of the rectosigmoid junction; tumor of the meninges, part not specified;
tumor of the anal canal and anus; tumor of the lower jaw; kidney tumor; lipomatous tumor of the
intra-abdominal organs; and tumor of uncertain or unknown behavior of the brain, unspecified part.
Tabla 4. Malignant tumors.
Malignant tumors with a frequency of 1 (1.1 %) each in Internal medicine are: lymphoid leukemia,
no other specification; carcinoma in situ of the stomach; lymphoid leukemia, no other specification;
acute myeloblastic leukemia; chronic myeloid leukemia bcr/abl-positive; hodgkin's lymphoma
unspecified; non-follicular (diffuse) lymphoma not otherwise specified; multiple myeloma; kaposi's
sarcoma of the soft tissue; tumor of the thyroid gland; tumor of the skin of the trunk; tumor of the
central portion of the breast; tumor of the bones of the skull and face; tumor of the abdomen; tumor
of the cerebellum; brain tumor, except lobes and ventricles; tumor of the upper outer quadrant of the
breast; tumor of the body of the stomach; tumor of the body of the uterus, part not specified; tumor
of the esophagus, part not specified; tumor of the exocervix; liver tumor unspecified; ileum tumor;
tumor of the frontal lobe; tumor of the upper lobe, bronchus, or lung; tumor of the ovary; and tumor
of the testicle, unspecified.
To establish the mean number of days that patients were required to wait to receive care at the
second level, the total number of cancers (n=92) was taken. However, there was significant data
loss. It was only possible to obtain information on waiting days for care for 36 patients (39.13 %)
versus 56 (60.87 %) patients who did not have information on the days they waited to receive care
in the hospital.
Taking the data from the 36 patients, the average number of days required to be seen in the HPGDR
was 35 (95 % CI 19 – 51 days). The minimum waiting time was 2 days. The maximum was 204 days
waiting for care, and a Mode=2.
Multivariate analysis
Table 5 is presented below. A logistic regression model was performed to explain the dependent
variable presence of neoplasms, p= 6559.
Table 5. Logistic regression Presence of neoplasms.
It can be seen that the variables that explain the appearance of neoplasms are sex, age, and belonging
to the Surgery or gynecology service. Men are less likely to have a neoplasm (benign or malignant)
diagnosis OR 0.477, statistically significant, compared to women.
Concerning the 204 patients who presented neoplasms, a logistic regression was performed to explain
the dependent variable presence of malignant neoplasms. The results are shown below in Table 6.
Table 6. Logistic regression Presence of malignant neoplasms.
The variables that explain the presence of malignant neoplasms are age when the cut-off point is 65
years, and sex. Being male confers a higher chance of having malignancies (OR 5.99). Being younger
than 65 is less likely to get cancer (OR 0.25).
DISCUSSIÓN
The prevalence of benign or malignant neoplasms (3.11 %) represents a high percentage concerning
all HPGDR care that required hospitalization because it is a second-level hospital. If we divide the
number of neoplasms, we obtain that approximately 34 patients are hospitalized per month on average.
The hospital must ensure quality care for all patients.(11) It should be considered that approximately
half of the neoplasms are malignant (45.09 %). In most cases, more complex and expensive diagnostic
tests are required to determine their nature.(16-18) The percentage obtained in this study on the prevalence
of cancer shows a global reality, being the leading cause of death in 2020.(19)
In the univariate analysis, there were differences concerning age and sex, which were corroborated by
the multivariate analysis, where men have a lower risk of having a neoplasm (OR 0.47) p= 0.045.
However, men have a higher risk of malignancies (OR 5.99) p=0.000. According to international
statistics, men have an age-standardized incidence rate of 212.6, with a cumulative risk of developing
cancer before the age of 75 of 21.8 %, compared to women who have a standardized incidence rate of
186.3 with a risk of 18.5 %. (19,20) Similarly, our study shows that those younger than 65 represent a
lower cancer risk (OR 0.25) p=0.035.
Although supported by evidence, the methodological nature of the study confers results that must be
corroborated with more powerful studies and stricter inclusion and selection criteria. Age and sex
should also be considered as confounding variables.
Gynecology represents 66.96 % of hospitalizations for benign tumors, which is consistent with the most
frequent types of benign tumors treated, uterine leiomyomas and ovarian and breast tumors. In the
second place, Surgery is found with 27.68 % for the resolution mainly of lipomas.
Internal medicine is the leading cancer care service, accounting for 77.17 % of hospitalizations. The
main types of cancer are leukemias, lymphomas, skin, lung, and gastric. The second service with the
highest percentage of hospitalizations is Surgery, with 16.30 %, where gastric and urological cancer are
mainly treated. The main types of cancer worldwide are lung, breast, colorectal, prostate, stomach, liver,
thyroid, and uterine cervix. (20-24)
A timely cancer diagnosis represents a greater probability of long-term survival, implementing early
surgical or clinical treatments. (25-28) We found an average wait of 35 days to be seen as referrals from the
first level, in charge of the health centers, to the second level of care, in charge of the HPGDR. These
data represent an essential information bias due to the number of losses, which made it impossible to
have a waiting time for analysis. Longitudinal studies are recommended to have a more accurate
follow-up and not have losses from that follow-up.
The National Institute for Health and Care Excellence recommends referring patients with metastatic
cancer of unknown origin for care within two weeks of referral.(29) It is necessary to create public policies
to address medical and non-medical expenses to improve the quality of life of cancer patients and mitigate
barriers to access to care since a timely diagnosis and approach reduce subsequent treatment costs.(30,31)
The strengths of this study are the rigor of the results obtained since the appropriate statistics were used,
providing 95 % CI and p values; it represents epidemiological data that can be extrapolated to the gene-
ral population since there were no sampling biases, obtaining adequate external validity; and it is the
starting point for more rigorous investigations in search of data that explain causality.
Limitations:
The main limitation of this study is the impossibility of stricter follow-up and control of the participants.
It was not possible to analyze more factors that contributed to the diagnosis of cancer.
To establish causal relationships, the design of our study is limited, as we present a cross-sectional
design. However, this type of design does allow for the analysis of relationships between variables that
present associations, such as the prevalence ratio, OR, etc. In medicine, it is impossible to establish
specific cause-and-effect relationships since pathologies, primarily cancer, are multifactorial.
The main limitation regarding the analysis of waiting times for care was the loss of data, which confers
little external validity to our results. These losses are primarily attributed to the fact that all hospital
discharges for cancer were considered, and many of them originate from emergency departments,
where there is no care policy based on primary care referrals.
Recommendations:
Mandatory, real-time health record keeping should be implemented, in addition to the referral form
(Form 053) to monitor patients. This would facilitate longitudinal studies.
Consider including oncology professionals at least once or twice a week to support outpatient care,
perform procedures, and diagnose patients with suspected cancer.
CONCLUSIONS
The prevalence of neoplasms in HPGDR from January to July 2024 is 3.11 % (95 % CI 3 %-4 %), and
45.09 % (95 % CI 38 %-52 %) corresponds to malignant neoplasms. The prevalence of cancer in the
total hospitalizations from January to July 2024 in HPGDR is 1.4 % (95 % CI 1 %-2 %).
Gynecology is the main service that treats benign neoplasms, the most frequent being leiomyomas,
ovarian or breast. The second service corresponds to Surgery for the resolution of lipomas.
The main cancer care service is internal medicine, which is used to treat leukemias, lymphomas, skin,
lung, and gastric cancers. The second service is Surgery for gastric and urological cancer care.
The waiting time required by patients to receive care by referrals from health centers to HPGDR is 35
days (95 % CI 19 – 51 days).
Funding: The authors funded this research.
Acknowledgments:
• To the authorities of the HPGDR.: Dr. María Sánchez, Manager; Dr. Evelyn Inca, medical director,
for promoting research and contributing to administrative procedures. To the Statistics service
for collaborating with the required data.
• To the National University of Chimborazo.
• To the Polytechnic School of Chimborazo.
Conflicts of interest: The authors declare no conflict of interest in this research.
Contribution Statement:
Conceptualization: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana. Data
curation, Formal analysis, Methodology, Software, Validation, Visualization, and Writing – review and
editing: Md. M.Sc. Carlos Andrés Yépez Salgado. Acquisition of funds: project self-financed by the
authors. Research: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana; Dr.
Paola Buenaño; Dr. David Orozco; Md. Yesenia Chandi. Project administration: Dr. Paola Buenaño; Dr.
David Orozco; Md. Yesenia Chandi. Supervision: Dr. Zully Mayra Romero Orellana; Dr. Paola Buenaño;
Dr. David Orozco. Writing – original draft: Md. Yesenia Chandi. All authors have read and agreed to the
published version of the manuscript.
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com/articles/10.1186/s41043-025-00738-0#Sec1.
SURGERY
INTERNAL MEDICINE
GYNECOLOGY
- malignant skin tumor,
unspecified site (3.3 %)
- malignant tumor of the
colon, part not specified (2.2)
- malignant tumor of the
prostate (1.1 %)
- malignant tumor of the
urinary bladder, part not
specified (1.1 %)
- malignant tumor of the
kidney, except the renal
pelvis (1.1 %)
- malignant tumor of the
maxillary sinus (1.1 %)
- malignant tumor of the
connective tissue and soft
tissue of the head, face, and
neck (1.1 %)
- malignant tumor of the
testicle, unspecified (1.1 %)
- non-Hodgkin's lymphoma,
unspecified (6.5 %)
- malignant tumor of the
stomach, unspecified part (6.5
%)
- acute lymphoblastic
leukemia (4.3 %)
- malignant tumor of the
bronchi or lung, part not
specified (4.3 %)
- malignant tumor of the
prostate (3.3 %)
- malignant tumor of the
kidney, except of the renal
pelvis (3.3 %)
- secondary malignant tumor
of the peritoneum and
retroperitoneum (3.3 %)
- malignant tumor of the
pancreas, part not specified
(3.3 %)
- intrahepatic bile duct
carcinoma (2.2 %)
- malignant tumor of the
breast, part not specified (2.2
%)
- malignant tumor of the skin
of the upper limb, including
the shoulder (2.2 %)
- malignant skin tumor,
unspecified site (2.2 %)
- malignant extrahepatic bile
duct tumor (2.2 %)
- malignant tumor of the
specified part of the
peritoneum (2.2 %)
- malignant tumor of the liver
angle (2.2 %)
- malignant cardia tumor (2.2
%)
- malignant tumor of the
gastric fundus (2.2 %)
- malignant tumor of the
breast, part not specified (1.1
%)
- malignant tumor of the
pelvis (1.1 %)
- malignant tumor of the
cervix, not otherwise
specified (1.1 %)
- malignant tumor of the
fundus of the uterus (1.1 %)
- secondary malignant tumor
of the peritoneum and
retroperitoneum (1.1 %)
cc
BY NC ND
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 19
Número 2
8
REE 19(2) Riobamba may. - ago. 2025
Prevalence of cancer and time to referral care in oncology patients
Prevalencia de cáncer y tiempo de atención de referencias en pacientes oncológicos.
https://doi.org/10.37135/ee.04.23.01
Authors:
Carlos Andrés Yépez Salgado1 - https://orcid.org/0009-0009-4722-8348
Zully Mayra Romero Orellana1,2 - https://orcid.org/0009-0000-6323-7548
David Cristóbal Orozco Brito3 - https://orcid.org/0000-0002-3945-3301
Nancy Paola Buenano Zambrano1 - https://orcid.org/0009-0003-2505-9236
Yesenia Liliana Chandi Japón4 - https://orcid.org/0009-0000-5672-0451
Affiliation:
1Hospital Provincial General Docente Riobamba.
2Universidad Nacional de Chimborazo.
3Escuela Superior Politécnica de Chimborazo.
4Centro de Salud Pungala Grande.
Corresponding author: Carlos Andrés Yépez Salgado. Hospital Provincial General Docente Riobamba.
Dirección postal: 060104. Email: med.carlos.andres@gmail.com / docenciahpgdrcoordinacion@gmail.
com Phone: +593984109505.
Received: January 24, 2025 Accepted: abril 01, 2025
ABSTRACT
Cancer represents a worldwide problem. In 2022, there were 30888 new cases of cancer and 16158
deaths in Ecuador. Considering the high morbidity and mortality due to this disease, health systems are
trying to meet the demand of these patients in public and private health services. Our main objective
was to establish the prevalence of cancer and the time of care of oncological patients referred to the
second level from the first of care during January-July 2024 at the Hospital Provincial General
Docente Riobamba. An original, observational, retrospective, descriptive, and correlational study
was presented. The prevalence of neoplasms is 3.11 %, and 45.09 % are malignant. The prevalence
of cancer in total hospitalizations is 1.4 %, and the average waiting time for care is 35 days. There
was a high prevalence of cancer in the hospital, where Internal medicine and Surgery are the services
with the most hospitalizations for this pathology.
Keywords: Cancer; Neoplasms; Epidemiology; Community Health Planning; Secondary Care Centers.
RESUMEN
El cáncer representa un problema a nivel mundial, en el año 2022 en el Ecuador existieron 30888
nuevos casos de cáncer y 16158 muertes, considerando una elevada morbimortalidad a causa de este
padecimiento, los sistemas de salud realizan un esfuerzo por solventar la demanda de estos pacientes
en los servicios de salud públicos y privados. El objetivo de esta investigación fue establecer la
prevalencia de cáncer y el tiempo de atención de referencias de pacientes oncológicos referidos desde
el primer nivel de atención al segundo nivel de atención de enero a julio de 2024 en el Hospital
Provincial General Docente de Riobamba. Se presentó un estudio original, observacional, transversal
retrospectivo, descriptivo y correlacional. La prevalencia de neoplasias es de 3,11 % y el 45,09 % son
malignas. La prevalencia de cáncer en el total de hospitalizaciones es 1,4% y el promedio de tiempo
de espera para la atención es de 35 días. Existió una elevada prevalencia de cáncer en el hospital,
siendo medicina interna y cirugía los servicios con más hospitalizaciones por esta patología.
Palabras clave: cáncer; neoplasias; epidemiología; planificación sanitaria comunitaria; centros de
atención secundaria.
.
INTRODUCTION
Cancer is a term used to refer to a broad group of diseases of complex and multifactorial origin caused
by abnormal cells that multiply autonomously and irregularly, invading other tissues locally and at a
distance.(1) The degree of malignancy is variable. It depends on the aggressiveness of its cells and
biological characteristics(2). They can spread and cause metastasis from different routes of dissemination
(lymphatic, blood, or by extension and direct invasion of neighboring tissues).(2,3) In general, if their
natural evolution is sought, they tend to lead to the death of the affected person in the short term.(4)
Currently, more than 200 different types of cancer are known, depending on the tissue from which they
are derived. The most common are those of the skin, lungs, breast, colon, and rectum.(5)
According to PAHO, cancer is one of the leading causes of mortality in the Americas. The figures indicate
that its incidence is growing rapidly worldwide, becoming a significant barrier to increasing life
expectancy. It is estimated that in 2022, there were 20 million new cases of cancer and 9.7 million
deaths in the region. (6,7)
Statistics from the International Agency for Research on Cancer indicate that in 2022 in Ecuador there
were 30888 new cases of cancer, 16,158 deaths, a risk of 7.3 % of dying from cancer before the age of
75; Prostate (29.4 %), stomach (11.2 %) and colorectal (8.4 %) cancer are more prevalent in our coun-
try; In female sex, lung cancer (23 %), cervical cancer (10.5 %) and colorectal cancer (8.0 %) are the
main ones; It is also mentioned that by 2040 there will be more than 53,701 cases detected during the
year in Ecuador. (8)
When analyzing the statistics, we observe that in Ecuador, as in the rest of the world, the incidence of
cancer is increasing, which is why it is necessary to have a health system that provides the opportunity
for each user to have adequate and timely care for their diagnosis and treatment.(8,9) It has been shown
that the delay in the care of this type of patient has been directly related to survival rates.(9) A study in
London about the survival of patients with breast cancer related to delayed uptake and treatment
showed that 32 % of patients with delays of 12 weeks or more had locally advanced or metastatic
disease, compared to only 10 % of those with delays of less than 12 weeks, which shows us the importance
of early recruitment.(10)
The national health system in Ecuador has a system of universality and progressive free healthcare
based on the Comprehensive Health Care model, which is supported by the user referral system to
improve healthcare.(11,12) This regulation is applied at all levels of care, thus allowing adequate care to
be provided to all users who require it according to the degree of complexity to achieve complete,
acceptable, and timely care.(13)
The health system of Ecuador offers a model that allows recruitment at the first level of health, which
is responsible for making the referral to the next step.(14) The time that elapses from the recruitment of
an oncology patient to the moment they obtain specialized care is usually long since the influx of
patients within the public health system is large.(11,15) Now, there are no studies that report the approximate
time of care for this type of patient.
This study in general terms aimed to establish the prevalence of cancer and the waiting time for the
care of cancer patients referred from the first to the second level of care from January to July 2024 at
the Hospital Provincial General Docente Riobamba (HPGDR).
The hypothesis proposed was that there is a high prevalence of cancer patients treated in the hospital
and a delay in the care of cancer patients due to the high demand for examinations and specialist
doctors that are not paid for by the Ministry of Public Health.
MATERIAL Y MÉTODOS
An original, observational, cross-sectional, retrospective study with a quantitative, descriptive, and
correlational approach was presented.
We worked with the entire population, representing the total number of patients hospitalized in all
specialties of the HPGDR, internal medicine, pediatrics, gynecology and obstetrics, Surgery, and ICU
from January to July 2024, p= 6559. By working with the entire population, we avoid sampling and
selection bias. The patient matrix called "Hospital discharges January to July 2024" is in the Hospital's
statistics service, which was provided to the researchers of an anonymized nature with the required
data according to the variables to be studied and before the delivery of a confidentiality commitment
from the authors and a general informed consent by the hospital's medical management.
Inclusion criteria.
• Patients treated in the hospital and registered in the hospital discharge matrix.
• Patients diagnosed with neoplastic pathology of any organ.
• Patients who have complied with the referral from the first level to the second level of care for
the calculation of the average days of waiting for referral care.
Exclusion criteria.
• Patients who do not provide the service where they were hospitalized in their database record.
Variables
Age, sex, diagnosis, date of care at the first level of care, date of care at the second level of care, type
of cancer, and hospitalization service.
The data obtained for the analysis correspond to the records of referral matrices and hospital discharge
matrices. These matrices are mandatory to report to the authorities of Ecuador's Zonal Coordination 3,
who evaluate care times to determine the productivity of treating medical professionals and hospital-level
productivity. The data are subject to review and registration in the Epidemiology Department. This
ensures the validity and quality of the data.
Once the final database was obtained in Excel, it was imported into the SPSS27 statistical package for
the coding of variables and statistical analysis. A univariate analysis was carried out to calculate the
prevalence of neoplasms and cancer based on the population. Ratios, proportions, and percentages for
qualitative variables; Measures of central tendency and dispersion for quantitative variables, always
accompanied by their 95 % confidence interval. The multivariate analysis looked for factors that
influence the presence of neoplasms and the presence of cancer, for which a logistic regression analysis
was performed.
The filling method was used for data processing with the average of the data obtained. This method was
used to analyze the average waiting time for referrals of oncology patients from primary to secondary care.
The study was approved by a human research ethics committee code: IO-29-CEISH- ESPOCH-2024.
RESULTS
Univariate analysis
The prevalence of patients with benign and malignant neoplasms of any organ calculated using the
formula: [(# of patients diagnosed with neoplasia / P) *100] [(204/6559)*100] is equal to 3.11 % (95 %
CI 3 %-4 %) from January to July 2024 in the HPGDR. 75.49 % were women (n=154) and 24.51%
were men (n=50).
The average age of patients with neoplasms, regardless of sex (n=204), is 49 years (95 % CI, 46 – 51
years) (minimum n = 1 year and maximum n = 94 years).
Based on the total population, the prevalence of cancer (malignant neoplasms) [(92/6559)*100] is
1.4% (95 % CI 1 %-2 %) from January to July 2024 in HPGDR. The prevalence of cancer concerning
the total number of patients diagnosed with neoplasia [(92/204)*100] is 45.09 % (9 5% CI 38 %-52 %).
Therefore, almost half of the patients hospitalized for neoplasms are malignant. About sex, 57.61%
(n=53) were women versus 42.39 % (n=39) were men.
The mean age, regardless of sex, of patients with malignant neoplasms is 56 years (95 % CI 52 – 59
years) (minimum n = 15 years and maximum n = 94 years).
Tables 1 and 2 represent the description of the tumors according to the hospitalization service.
Table 1. Benign tumors according to the hospitalization service.
Table 2. Malignant tumors according to the hospitalization service.
Benign and malignant tumors are described below according to their prevalence and hospitalization
services.
Tabla 3. Benign tumors.
The benign tumors with a frequency of 1 (0,9 %) each in Surgery are: tumor of the tongue; tumor of
the nasopharynx; tumor of the rectosigmoid junction; tumor of the meninges, part not specified;
tumor of the anal canal and anus; tumor of the lower jaw; kidney tumor; lipomatous tumor of the
intra-abdominal organs; and tumor of uncertain or unknown behavior of the brain, unspecified part.
Tabla 4. Malignant tumors.
Malignant tumors with a frequency of 1 (1.1 %) each in Internal medicine are: lymphoid leukemia,
no other specification; carcinoma in situ of the stomach; lymphoid leukemia, no other specification;
acute myeloblastic leukemia; chronic myeloid leukemia bcr/abl-positive; hodgkin's lymphoma
unspecified; non-follicular (diffuse) lymphoma not otherwise specified; multiple myeloma; kaposi's
sarcoma of the soft tissue; tumor of the thyroid gland; tumor of the skin of the trunk; tumor of the
central portion of the breast; tumor of the bones of the skull and face; tumor of the abdomen; tumor
of the cerebellum; brain tumor, except lobes and ventricles; tumor of the upper outer quadrant of the
breast; tumor of the body of the stomach; tumor of the body of the uterus, part not specified; tumor
of the esophagus, part not specified; tumor of the exocervix; liver tumor unspecified; ileum tumor;
tumor of the frontal lobe; tumor of the upper lobe, bronchus, or lung; tumor of the ovary; and tumor
of the testicle, unspecified.
To establish the mean number of days that patients were required to wait to receive care at the
second level, the total number of cancers (n=92) was taken. However, there was significant data
loss. It was only possible to obtain information on waiting days for care for 36 patients (39.13 %)
versus 56 (60.87 %) patients who did not have information on the days they waited to receive care
in the hospital.
Taking the data from the 36 patients, the average number of days required to be seen in the HPGDR
was 35 (95 % CI 19 – 51 days). The minimum waiting time was 2 days. The maximum was 204 days
waiting for care, and a Mode=2.
Multivariate analysis
Table 5 is presented below. A logistic regression model was performed to explain the dependent
variable presence of neoplasms, p= 6559.
Table 5. Logistic regression Presence of neoplasms.
It can be seen that the variables that explain the appearance of neoplasms are sex, age, and belonging
to the Surgery or gynecology service. Men are less likely to have a neoplasm (benign or malignant)
diagnosis OR 0.477, statistically significant, compared to women.
Concerning the 204 patients who presented neoplasms, a logistic regression was performed to explain
the dependent variable presence of malignant neoplasms. The results are shown below in Table 6.
Table 6. Logistic regression Presence of malignant neoplasms.
The variables that explain the presence of malignant neoplasms are age when the cut-off point is 65
years, and sex. Being male confers a higher chance of having malignancies (OR 5.99). Being younger
than 65 is less likely to get cancer (OR 0.25).
DISCUSSIÓN
The prevalence of benign or malignant neoplasms (3.11 %) represents a high percentage concerning
all HPGDR care that required hospitalization because it is a second-level hospital. If we divide the
number of neoplasms, we obtain that approximately 34 patients are hospitalized per month on average.
The hospital must ensure quality care for all patients.(11) It should be considered that approximately
half of the neoplasms are malignant (45.09 %). In most cases, more complex and expensive diagnostic
tests are required to determine their nature.(16-18) The percentage obtained in this study on the prevalence
of cancer shows a global reality, being the leading cause of death in 2020.(19)
In the univariate analysis, there were differences concerning age and sex, which were corroborated by
the multivariate analysis, where men have a lower risk of having a neoplasm (OR 0.47) p= 0.045.
However, men have a higher risk of malignancies (OR 5.99) p=0.000. According to international
statistics, men have an age-standardized incidence rate of 212.6, with a cumulative risk of developing
cancer before the age of 75 of 21.8 %, compared to women who have a standardized incidence rate of
186.3 with a risk of 18.5 %. (19,20) Similarly, our study shows that those younger than 65 represent a
lower cancer risk (OR 0.25) p=0.035.
Although supported by evidence, the methodological nature of the study confers results that must be
corroborated with more powerful studies and stricter inclusion and selection criteria. Age and sex
should also be considered as confounding variables.
Gynecology represents 66.96 % of hospitalizations for benign tumors, which is consistent with the most
frequent types of benign tumors treated, uterine leiomyomas and ovarian and breast tumors. In the
second place, Surgery is found with 27.68 % for the resolution mainly of lipomas.
Internal medicine is the leading cancer care service, accounting for 77.17 % of hospitalizations. The
main types of cancer are leukemias, lymphomas, skin, lung, and gastric. The second service with the
highest percentage of hospitalizations is Surgery, with 16.30 %, where gastric and urological cancer are
mainly treated. The main types of cancer worldwide are lung, breast, colorectal, prostate, stomach, liver,
thyroid, and uterine cervix. (20-24)
A timely cancer diagnosis represents a greater probability of long-term survival, implementing early
surgical or clinical treatments. (25-28) We found an average wait of 35 days to be seen as referrals from the
first level, in charge of the health centers, to the second level of care, in charge of the HPGDR. These
data represent an essential information bias due to the number of losses, which made it impossible to
have a waiting time for analysis. Longitudinal studies are recommended to have a more accurate
follow-up and not have losses from that follow-up.
The National Institute for Health and Care Excellence recommends referring patients with metastatic
cancer of unknown origin for care within two weeks of referral.(29) It is necessary to create public policies
to address medical and non-medical expenses to improve the quality of life of cancer patients and mitigate
barriers to access to care since a timely diagnosis and approach reduce subsequent treatment costs.(30,31)
The strengths of this study are the rigor of the results obtained since the appropriate statistics were used,
providing 95 % CI and p values; it represents epidemiological data that can be extrapolated to the gene-
ral population since there were no sampling biases, obtaining adequate external validity; and it is the
starting point for more rigorous investigations in search of data that explain causality.
Limitations:
The main limitation of this study is the impossibility of stricter follow-up and control of the participants.
It was not possible to analyze more factors that contributed to the diagnosis of cancer.
To establish causal relationships, the design of our study is limited, as we present a cross-sectional
design. However, this type of design does allow for the analysis of relationships between variables that
present associations, such as the prevalence ratio, OR, etc. In medicine, it is impossible to establish
specific cause-and-effect relationships since pathologies, primarily cancer, are multifactorial.
The main limitation regarding the analysis of waiting times for care was the loss of data, which confers
little external validity to our results. These losses are primarily attributed to the fact that all hospital
discharges for cancer were considered, and many of them originate from emergency departments,
where there is no care policy based on primary care referrals.
Recommendations:
Mandatory, real-time health record keeping should be implemented, in addition to the referral form
(Form 053) to monitor patients. This would facilitate longitudinal studies.
Consider including oncology professionals at least once or twice a week to support outpatient care,
perform procedures, and diagnose patients with suspected cancer.
CONCLUSIONS
The prevalence of neoplasms in HPGDR from January to July 2024 is 3.11 % (95 % CI 3 %-4 %), and
45.09 % (95 % CI 38 %-52 %) corresponds to malignant neoplasms. The prevalence of cancer in the
total hospitalizations from January to July 2024 in HPGDR is 1.4 % (95 % CI 1 %-2 %).
Gynecology is the main service that treats benign neoplasms, the most frequent being leiomyomas,
ovarian or breast. The second service corresponds to Surgery for the resolution of lipomas.
The main cancer care service is internal medicine, which is used to treat leukemias, lymphomas, skin,
lung, and gastric cancers. The second service is Surgery for gastric and urological cancer care.
The waiting time required by patients to receive care by referrals from health centers to HPGDR is 35
days (95 % CI 19 – 51 days).
Funding: The authors funded this research.
Acknowledgments:
• To the authorities of the HPGDR.: Dr. María Sánchez, Manager; Dr. Evelyn Inca, medical director,
for promoting research and contributing to administrative procedures. To the Statistics service
for collaborating with the required data.
• To the National University of Chimborazo.
• To the Polytechnic School of Chimborazo.
Conflicts of interest: The authors declare no conflict of interest in this research.
Contribution Statement:
Conceptualization: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana. Data
curation, Formal analysis, Methodology, Software, Validation, Visualization, and Writing – review and
editing: Md. M.Sc. Carlos Andrés Yépez Salgado. Acquisition of funds: project self-financed by the
authors. Research: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana; Dr.
Paola Buenaño; Dr. David Orozco; Md. Yesenia Chandi. Project administration: Dr. Paola Buenaño; Dr.
David Orozco; Md. Yesenia Chandi. Supervision: Dr. Zully Mayra Romero Orellana; Dr. Paola Buenaño;
Dr. David Orozco. Writing – original draft: Md. Yesenia Chandi. All authors have read and agreed to the
published version of the manuscript.
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Variables in the Equation
B
Sig.
Exp(B)
(OR)
95% CI for EXP(B)
Lower
Upper
GENDER (REF
WOMAN)
-0.741
0.045
0.477
0.231
0.983
AGE
0.062
0.000
1.064
1.049
1.079
REF.
PEDIATRICS
0.000
SURGERY
-1.752
0.011
0.173
0.045
0.673
INTERNAL
MEDICINE
-4.787
0.000
0.008
0.001
0.060
GYNECOLOGY
0.089
0.874
1.093
0.361
3.311
Constant
22.983
0.995
9577236694.826
a. Variable(s) entered on step 1: GENDER, AGE, SERVICE.
cc
BY NC ND
ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 19
Número 2
9
REE 19(2) Riobamba may. - ago. 2025
Prevalence of cancer and time to referral care in oncology patients
Prevalencia de cáncer y tiempo de atención de referencias en pacientes oncológicos.
https://doi.org/10.37135/ee.04.23.01
Authors:
Carlos Andrés Yépez Salgado1 - https://orcid.org/0009-0009-4722-8348
Zully Mayra Romero Orellana1,2 - https://orcid.org/0009-0000-6323-7548
David Cristóbal Orozco Brito3 - https://orcid.org/0000-0002-3945-3301
Nancy Paola Buenano Zambrano1 - https://orcid.org/0009-0003-2505-9236
Yesenia Liliana Chandi Japón4 - https://orcid.org/0009-0000-5672-0451
Affiliation:
1Hospital Provincial General Docente Riobamba.
2Universidad Nacional de Chimborazo.
3Escuela Superior Politécnica de Chimborazo.
4Centro de Salud Pungala Grande.
Corresponding author: Carlos Andrés Yépez Salgado. Hospital Provincial General Docente Riobamba.
Dirección postal: 060104. Email: med.carlos.andres@gmail.com / docenciahpgdrcoordinacion@gmail.
com Phone: +593984109505.
Received: January 24, 2025 Accepted: abril 01, 2025
ABSTRACT
Cancer represents a worldwide problem. In 2022, there were 30888 new cases of cancer and 16158
deaths in Ecuador. Considering the high morbidity and mortality due to this disease, health systems are
trying to meet the demand of these patients in public and private health services. Our main objective
was to establish the prevalence of cancer and the time of care of oncological patients referred to the
second level from the first of care during January-July 2024 at the Hospital Provincial General
Docente Riobamba. An original, observational, retrospective, descriptive, and correlational study
was presented. The prevalence of neoplasms is 3.11 %, and 45.09 % are malignant. The prevalence
of cancer in total hospitalizations is 1.4 %, and the average waiting time for care is 35 days. There
was a high prevalence of cancer in the hospital, where Internal medicine and Surgery are the services
with the most hospitalizations for this pathology.
Keywords: Cancer; Neoplasms; Epidemiology; Community Health Planning; Secondary Care Centers.
RESUMEN
El cáncer representa un problema a nivel mundial, en el año 2022 en el Ecuador existieron 30888
nuevos casos de cáncer y 16158 muertes, considerando una elevada morbimortalidad a causa de este
padecimiento, los sistemas de salud realizan un esfuerzo por solventar la demanda de estos pacientes
en los servicios de salud públicos y privados. El objetivo de esta investigación fue establecer la
prevalencia de cáncer y el tiempo de atención de referencias de pacientes oncológicos referidos desde
el primer nivel de atención al segundo nivel de atención de enero a julio de 2024 en el Hospital
Provincial General Docente de Riobamba. Se presentó un estudio original, observacional, transversal
retrospectivo, descriptivo y correlacional. La prevalencia de neoplasias es de 3,11 % y el 45,09 % son
malignas. La prevalencia de cáncer en el total de hospitalizaciones es 1,4% y el promedio de tiempo
de espera para la atención es de 35 días. Existió una elevada prevalencia de cáncer en el hospital,
siendo medicina interna y cirugía los servicios con más hospitalizaciones por esta patología.
Palabras clave: cáncer; neoplasias; epidemiología; planificación sanitaria comunitaria; centros de
atención secundaria.
.
INTRODUCTION
Cancer is a term used to refer to a broad group of diseases of complex and multifactorial origin caused
by abnormal cells that multiply autonomously and irregularly, invading other tissues locally and at a
distance.(1) The degree of malignancy is variable. It depends on the aggressiveness of its cells and
biological characteristics(2). They can spread and cause metastasis from different routes of dissemination
(lymphatic, blood, or by extension and direct invasion of neighboring tissues).(2,3) In general, if their
natural evolution is sought, they tend to lead to the death of the affected person in the short term.(4)
Currently, more than 200 different types of cancer are known, depending on the tissue from which they
are derived. The most common are those of the skin, lungs, breast, colon, and rectum.(5)
According to PAHO, cancer is one of the leading causes of mortality in the Americas. The figures indicate
that its incidence is growing rapidly worldwide, becoming a significant barrier to increasing life
expectancy. It is estimated that in 2022, there were 20 million new cases of cancer and 9.7 million
deaths in the region. (6,7)
Statistics from the International Agency for Research on Cancer indicate that in 2022 in Ecuador there
were 30888 new cases of cancer, 16,158 deaths, a risk of 7.3 % of dying from cancer before the age of
75; Prostate (29.4 %), stomach (11.2 %) and colorectal (8.4 %) cancer are more prevalent in our coun-
try; In female sex, lung cancer (23 %), cervical cancer (10.5 %) and colorectal cancer (8.0 %) are the
main ones; It is also mentioned that by 2040 there will be more than 53,701 cases detected during the
year in Ecuador. (8)
When analyzing the statistics, we observe that in Ecuador, as in the rest of the world, the incidence of
cancer is increasing, which is why it is necessary to have a health system that provides the opportunity
for each user to have adequate and timely care for their diagnosis and treatment.(8,9) It has been shown
that the delay in the care of this type of patient has been directly related to survival rates.(9) A study in
London about the survival of patients with breast cancer related to delayed uptake and treatment
showed that 32 % of patients with delays of 12 weeks or more had locally advanced or metastatic
disease, compared to only 10 % of those with delays of less than 12 weeks, which shows us the importance
of early recruitment.(10)
The national health system in Ecuador has a system of universality and progressive free healthcare
based on the Comprehensive Health Care model, which is supported by the user referral system to
improve healthcare.(11,12) This regulation is applied at all levels of care, thus allowing adequate care to
be provided to all users who require it according to the degree of complexity to achieve complete,
acceptable, and timely care.(13)
The health system of Ecuador offers a model that allows recruitment at the first level of health, which
is responsible for making the referral to the next step.(14) The time that elapses from the recruitment of
an oncology patient to the moment they obtain specialized care is usually long since the influx of
patients within the public health system is large.(11,15) Now, there are no studies that report the approximate
time of care for this type of patient.
This study in general terms aimed to establish the prevalence of cancer and the waiting time for the
care of cancer patients referred from the first to the second level of care from January to July 2024 at
the Hospital Provincial General Docente Riobamba (HPGDR).
The hypothesis proposed was that there is a high prevalence of cancer patients treated in the hospital
and a delay in the care of cancer patients due to the high demand for examinations and specialist
doctors that are not paid for by the Ministry of Public Health.
MATERIAL Y MÉTODOS
An original, observational, cross-sectional, retrospective study with a quantitative, descriptive, and
correlational approach was presented.
We worked with the entire population, representing the total number of patients hospitalized in all
specialties of the HPGDR, internal medicine, pediatrics, gynecology and obstetrics, Surgery, and ICU
from January to July 2024, p= 6559. By working with the entire population, we avoid sampling and
selection bias. The patient matrix called "Hospital discharges January to July 2024" is in the Hospital's
statistics service, which was provided to the researchers of an anonymized nature with the required
data according to the variables to be studied and before the delivery of a confidentiality commitment
from the authors and a general informed consent by the hospital's medical management.
Inclusion criteria.
• Patients treated in the hospital and registered in the hospital discharge matrix.
• Patients diagnosed with neoplastic pathology of any organ.
• Patients who have complied with the referral from the first level to the second level of care for
the calculation of the average days of waiting for referral care.
Exclusion criteria.
• Patients who do not provide the service where they were hospitalized in their database record.
Variables
Age, sex, diagnosis, date of care at the first level of care, date of care at the second level of care, type
of cancer, and hospitalization service.
The data obtained for the analysis correspond to the records of referral matrices and hospital discharge
matrices. These matrices are mandatory to report to the authorities of Ecuador's Zonal Coordination 3,
who evaluate care times to determine the productivity of treating medical professionals and hospital-level
productivity. The data are subject to review and registration in the Epidemiology Department. This
ensures the validity and quality of the data.
Once the final database was obtained in Excel, it was imported into the SPSS27 statistical package for
the coding of variables and statistical analysis. A univariate analysis was carried out to calculate the
prevalence of neoplasms and cancer based on the population. Ratios, proportions, and percentages for
qualitative variables; Measures of central tendency and dispersion for quantitative variables, always
accompanied by their 95 % confidence interval. The multivariate analysis looked for factors that
influence the presence of neoplasms and the presence of cancer, for which a logistic regression analysis
was performed.
The filling method was used for data processing with the average of the data obtained. This method was
used to analyze the average waiting time for referrals of oncology patients from primary to secondary care.
The study was approved by a human research ethics committee code: IO-29-CEISH- ESPOCH-2024.
RESULTS
Univariate analysis
The prevalence of patients with benign and malignant neoplasms of any organ calculated using the
formula: [(# of patients diagnosed with neoplasia / P) *100] [(204/6559)*100] is equal to 3.11 % (95 %
CI 3 %-4 %) from January to July 2024 in the HPGDR. 75.49 % were women (n=154) and 24.51%
were men (n=50).
The average age of patients with neoplasms, regardless of sex (n=204), is 49 years (95 % CI, 46 – 51
years) (minimum n = 1 year and maximum n = 94 years).
Based on the total population, the prevalence of cancer (malignant neoplasms) [(92/6559)*100] is
1.4% (95 % CI 1 %-2 %) from January to July 2024 in HPGDR. The prevalence of cancer concerning
the total number of patients diagnosed with neoplasia [(92/204)*100] is 45.09 % (9 5% CI 38 %-52 %).
Therefore, almost half of the patients hospitalized for neoplasms are malignant. About sex, 57.61%
(n=53) were women versus 42.39 % (n=39) were men.
The mean age, regardless of sex, of patients with malignant neoplasms is 56 years (95 % CI 52 – 59
years) (minimum n = 15 years and maximum n = 94 years).
Tables 1 and 2 represent the description of the tumors according to the hospitalization service.
Table 1. Benign tumors according to the hospitalization service.
Table 2. Malignant tumors according to the hospitalization service.
Benign and malignant tumors are described below according to their prevalence and hospitalization
services.
Tabla 3. Benign tumors.
The benign tumors with a frequency of 1 (0,9 %) each in Surgery are: tumor of the tongue; tumor of
the nasopharynx; tumor of the rectosigmoid junction; tumor of the meninges, part not specified;
tumor of the anal canal and anus; tumor of the lower jaw; kidney tumor; lipomatous tumor of the
intra-abdominal organs; and tumor of uncertain or unknown behavior of the brain, unspecified part.
Tabla 4. Malignant tumors.
Malignant tumors with a frequency of 1 (1.1 %) each in Internal medicine are: lymphoid leukemia,
no other specification; carcinoma in situ of the stomach; lymphoid leukemia, no other specification;
acute myeloblastic leukemia; chronic myeloid leukemia bcr/abl-positive; hodgkin's lymphoma
unspecified; non-follicular (diffuse) lymphoma not otherwise specified; multiple myeloma; kaposi's
sarcoma of the soft tissue; tumor of the thyroid gland; tumor of the skin of the trunk; tumor of the
central portion of the breast; tumor of the bones of the skull and face; tumor of the abdomen; tumor
of the cerebellum; brain tumor, except lobes and ventricles; tumor of the upper outer quadrant of the
breast; tumor of the body of the stomach; tumor of the body of the uterus, part not specified; tumor
of the esophagus, part not specified; tumor of the exocervix; liver tumor unspecified; ileum tumor;
tumor of the frontal lobe; tumor of the upper lobe, bronchus, or lung; tumor of the ovary; and tumor
of the testicle, unspecified.
To establish the mean number of days that patients were required to wait to receive care at the
second level, the total number of cancers (n=92) was taken. However, there was significant data
loss. It was only possible to obtain information on waiting days for care for 36 patients (39.13 %)
versus 56 (60.87 %) patients who did not have information on the days they waited to receive care
in the hospital.
Taking the data from the 36 patients, the average number of days required to be seen in the HPGDR
was 35 (95 % CI 19 – 51 days). The minimum waiting time was 2 days. The maximum was 204 days
waiting for care, and a Mode=2.
Multivariate analysis
Table 5 is presented below. A logistic regression model was performed to explain the dependent
variable presence of neoplasms, p= 6559.
Table 5. Logistic regression Presence of neoplasms.
It can be seen that the variables that explain the appearance of neoplasms are sex, age, and belonging
to the Surgery or gynecology service. Men are less likely to have a neoplasm (benign or malignant)
diagnosis OR 0.477, statistically significant, compared to women.
Concerning the 204 patients who presented neoplasms, a logistic regression was performed to explain
the dependent variable presence of malignant neoplasms. The results are shown below in Table 6.
Table 6. Logistic regression Presence of malignant neoplasms.
The variables that explain the presence of malignant neoplasms are age when the cut-off point is 65
years, and sex. Being male confers a higher chance of having malignancies (OR 5.99). Being younger
than 65 is less likely to get cancer (OR 0.25).
DISCUSSIÓN
The prevalence of benign or malignant neoplasms (3.11 %) represents a high percentage concerning
all HPGDR care that required hospitalization because it is a second-level hospital. If we divide the
number of neoplasms, we obtain that approximately 34 patients are hospitalized per month on average.
The hospital must ensure quality care for all patients.(11) It should be considered that approximately
half of the neoplasms are malignant (45.09 %). In most cases, more complex and expensive diagnostic
tests are required to determine their nature.(16-18) The percentage obtained in this study on the prevalence
of cancer shows a global reality, being the leading cause of death in 2020.(19)
In the univariate analysis, there were differences concerning age and sex, which were corroborated by
the multivariate analysis, where men have a lower risk of having a neoplasm (OR 0.47) p= 0.045.
However, men have a higher risk of malignancies (OR 5.99) p=0.000. According to international
statistics, men have an age-standardized incidence rate of 212.6, with a cumulative risk of developing
cancer before the age of 75 of 21.8 %, compared to women who have a standardized incidence rate of
186.3 with a risk of 18.5 %. (19,20) Similarly, our study shows that those younger than 65 represent a
lower cancer risk (OR 0.25) p=0.035.
Although supported by evidence, the methodological nature of the study confers results that must be
corroborated with more powerful studies and stricter inclusion and selection criteria. Age and sex
should also be considered as confounding variables.
Gynecology represents 66.96 % of hospitalizations for benign tumors, which is consistent with the most
frequent types of benign tumors treated, uterine leiomyomas and ovarian and breast tumors. In the
second place, Surgery is found with 27.68 % for the resolution mainly of lipomas.
Internal medicine is the leading cancer care service, accounting for 77.17 % of hospitalizations. The
main types of cancer are leukemias, lymphomas, skin, lung, and gastric. The second service with the
highest percentage of hospitalizations is Surgery, with 16.30 %, where gastric and urological cancer are
mainly treated. The main types of cancer worldwide are lung, breast, colorectal, prostate, stomach, liver,
thyroid, and uterine cervix. (20-24)
A timely cancer diagnosis represents a greater probability of long-term survival, implementing early
surgical or clinical treatments. (25-28) We found an average wait of 35 days to be seen as referrals from the
first level, in charge of the health centers, to the second level of care, in charge of the HPGDR. These
data represent an essential information bias due to the number of losses, which made it impossible to
have a waiting time for analysis. Longitudinal studies are recommended to have a more accurate
follow-up and not have losses from that follow-up.
The National Institute for Health and Care Excellence recommends referring patients with metastatic
cancer of unknown origin for care within two weeks of referral.(29) It is necessary to create public policies
to address medical and non-medical expenses to improve the quality of life of cancer patients and mitigate
barriers to access to care since a timely diagnosis and approach reduce subsequent treatment costs.(30,31)
The strengths of this study are the rigor of the results obtained since the appropriate statistics were used,
providing 95 % CI and p values; it represents epidemiological data that can be extrapolated to the gene-
ral population since there were no sampling biases, obtaining adequate external validity; and it is the
starting point for more rigorous investigations in search of data that explain causality.
Limitations:
The main limitation of this study is the impossibility of stricter follow-up and control of the participants.
It was not possible to analyze more factors that contributed to the diagnosis of cancer.
To establish causal relationships, the design of our study is limited, as we present a cross-sectional
design. However, this type of design does allow for the analysis of relationships between variables that
present associations, such as the prevalence ratio, OR, etc. In medicine, it is impossible to establish
specific cause-and-effect relationships since pathologies, primarily cancer, are multifactorial.
The main limitation regarding the analysis of waiting times for care was the loss of data, which confers
little external validity to our results. These losses are primarily attributed to the fact that all hospital
discharges for cancer were considered, and many of them originate from emergency departments,
where there is no care policy based on primary care referrals.
Recommendations:
Mandatory, real-time health record keeping should be implemented, in addition to the referral form
(Form 053) to monitor patients. This would facilitate longitudinal studies.
Consider including oncology professionals at least once or twice a week to support outpatient care,
perform procedures, and diagnose patients with suspected cancer.
CONCLUSIONS
The prevalence of neoplasms in HPGDR from January to July 2024 is 3.11 % (95 % CI 3 %-4 %), and
45.09 % (95 % CI 38 %-52 %) corresponds to malignant neoplasms. The prevalence of cancer in the
total hospitalizations from January to July 2024 in HPGDR is 1.4 % (95 % CI 1 %-2 %).
Gynecology is the main service that treats benign neoplasms, the most frequent being leiomyomas,
ovarian or breast. The second service corresponds to Surgery for the resolution of lipomas.
The main cancer care service is internal medicine, which is used to treat leukemias, lymphomas, skin,
lung, and gastric cancers. The second service is Surgery for gastric and urological cancer care.
The waiting time required by patients to receive care by referrals from health centers to HPGDR is 35
days (95 % CI 19 – 51 days).
Funding: The authors funded this research.
Acknowledgments:
• To the authorities of the HPGDR.: Dr. María Sánchez, Manager; Dr. Evelyn Inca, medical director,
for promoting research and contributing to administrative procedures. To the Statistics service
for collaborating with the required data.
• To the National University of Chimborazo.
• To the Polytechnic School of Chimborazo.
Conflicts of interest: The authors declare no conflict of interest in this research.
Contribution Statement:
Conceptualization: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana. Data
curation, Formal analysis, Methodology, Software, Validation, Visualization, and Writing – review and
editing: Md. M.Sc. Carlos Andrés Yépez Salgado. Acquisition of funds: project self-financed by the
authors. Research: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana; Dr.
Paola Buenaño; Dr. David Orozco; Md. Yesenia Chandi. Project administration: Dr. Paola Buenaño; Dr.
David Orozco; Md. Yesenia Chandi. Supervision: Dr. Zully Mayra Romero Orellana; Dr. Paola Buenaño;
Dr. David Orozco. Writing – original draft: Md. Yesenia Chandi. All authors have read and agreed to the
published version of the manuscript.
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Variables in the Equation
B
Sig.
Exp(B)
(OR)
95% CI for EXP(B)
Lower
Upper
GENDER (REF
WOMAN)
-0.741
0.045
0.477
0.231
0.983
AGE
0.062
0.000
1.064
1.049
1.079
REF.
PEDIATRICS
0.000
SURGERY
-1.752
0.011
0.173
0.045
0.673
INTERNAL
MEDICINE
-4.787
0.000
0.008
0.001
0.060
GYNECOLOGY
0.089
0.874
1.093
0.361
3.311
Constant
22.983
0.995
9577236694.826
a. Variable(s) entered on step 1: GENDER, AGE, SERVICE.
Prevalence of cancer and time to referral care in oncology patients
Prevalencia de cáncer y tiempo de atención de referencias en pacientes oncológicos.
https://doi.org/10.37135/ee.04.23.01
Authors:
Carlos Andrés Yépez Salgado1 - https://orcid.org/0009-0009-4722-8348
Zully Mayra Romero Orellana1,2 - https://orcid.org/0009-0000-6323-7548
David Cristóbal Orozco Brito3 - https://orcid.org/0000-0002-3945-3301
Nancy Paola Buenano Zambrano1 - https://orcid.org/0009-0003-2505-9236
Yesenia Liliana Chandi Japón4 - https://orcid.org/0009-0000-5672-0451
Affiliation:
1Hospital Provincial General Docente Riobamba.
2Universidad Nacional de Chimborazo.
3Escuela Superior Politécnica de Chimborazo.
4Centro de Salud Pungala Grande.
Corresponding author: Carlos Andrés Yépez Salgado. Hospital Provincial General Docente Riobamba.
Dirección postal: 060104. Email: med.carlos.andres@gmail.com / docenciahpgdrcoordinacion@gmail.
com Phone: +593984109505.
Received: January 24, 2025 Accepted: abril 01, 2025
ABSTRACT
Cancer represents a worldwide problem. In 2022, there were 30888 new cases of cancer and 16158
deaths in Ecuador. Considering the high morbidity and mortality due to this disease, health systems are
trying to meet the demand of these patients in public and private health services. Our main objective
was to establish the prevalence of cancer and the time of care of oncological patients referred to the
second level from the first of care during January-July 2024 at the Hospital Provincial General
Docente Riobamba. An original, observational, retrospective, descriptive, and correlational study
was presented. The prevalence of neoplasms is 3.11 %, and 45.09 % are malignant. The prevalence
of cancer in total hospitalizations is 1.4 %, and the average waiting time for care is 35 days. There
was a high prevalence of cancer in the hospital, where Internal medicine and Surgery are the services
with the most hospitalizations for this pathology.
Keywords: Cancer; Neoplasms; Epidemiology; Community Health Planning; Secondary Care Centers.
RESUMEN
El cáncer representa un problema a nivel mundial, en el año 2022 en el Ecuador existieron 30888
nuevos casos de cáncer y 16158 muertes, considerando una elevada morbimortalidad a causa de este
padecimiento, los sistemas de salud realizan un esfuerzo por solventar la demanda de estos pacientes
en los servicios de salud públicos y privados. El objetivo de esta investigación fue establecer la
prevalencia de cáncer y el tiempo de atención de referencias de pacientes oncológicos referidos desde
el primer nivel de atención al segundo nivel de atención de enero a julio de 2024 en el Hospital
Provincial General Docente de Riobamba. Se presentó un estudio original, observacional, transversal
retrospectivo, descriptivo y correlacional. La prevalencia de neoplasias es de 3,11 % y el 45,09 % son
malignas. La prevalencia de cáncer en el total de hospitalizaciones es 1,4% y el promedio de tiempo
de espera para la atención es de 35 días. Existió una elevada prevalencia de cáncer en el hospital,
siendo medicina interna y cirugía los servicios con más hospitalizaciones por esta patología.
Palabras clave: cáncer; neoplasias; epidemiología; planificación sanitaria comunitaria; centros de
atención secundaria.
.
INTRODUCTION
Cancer is a term used to refer to a broad group of diseases of complex and multifactorial origin caused
by abnormal cells that multiply autonomously and irregularly, invading other tissues locally and at a
distance.(1) The degree of malignancy is variable. It depends on the aggressiveness of its cells and
biological characteristics(2). They can spread and cause metastasis from different routes of dissemination
(lymphatic, blood, or by extension and direct invasion of neighboring tissues).(2,3) In general, if their
natural evolution is sought, they tend to lead to the death of the affected person in the short term.(4)
Currently, more than 200 different types of cancer are known, depending on the tissue from which they
are derived. The most common are those of the skin, lungs, breast, colon, and rectum.(5)
According to PAHO, cancer is one of the leading causes of mortality in the Americas. The figures indicate
that its incidence is growing rapidly worldwide, becoming a significant barrier to increasing life
expectancy. It is estimated that in 2022, there were 20 million new cases of cancer and 9.7 million
deaths in the region. (6,7)
Statistics from the International Agency for Research on Cancer indicate that in 2022 in Ecuador there
were 30888 new cases of cancer, 16,158 deaths, a risk of 7.3 % of dying from cancer before the age of
75; Prostate (29.4 %), stomach (11.2 %) and colorectal (8.4 %) cancer are more prevalent in our coun-
try; In female sex, lung cancer (23 %), cervical cancer (10.5 %) and colorectal cancer (8.0 %) are the
main ones; It is also mentioned that by 2040 there will be more than 53,701 cases detected during the
year in Ecuador. (8)
When analyzing the statistics, we observe that in Ecuador, as in the rest of the world, the incidence of
cancer is increasing, which is why it is necessary to have a health system that provides the opportunity
for each user to have adequate and timely care for their diagnosis and treatment.(8,9) It has been shown
that the delay in the care of this type of patient has been directly related to survival rates.(9) A study in
London about the survival of patients with breast cancer related to delayed uptake and treatment
showed that 32 % of patients with delays of 12 weeks or more had locally advanced or metastatic
disease, compared to only 10 % of those with delays of less than 12 weeks, which shows us the importance
of early recruitment.(10)
The national health system in Ecuador has a system of universality and progressive free healthcare
based on the Comprehensive Health Care model, which is supported by the user referral system to
improve healthcare.(11,12) This regulation is applied at all levels of care, thus allowing adequate care to
be provided to all users who require it according to the degree of complexity to achieve complete,
acceptable, and timely care.(13)
The health system of Ecuador offers a model that allows recruitment at the first level of health, which
is responsible for making the referral to the next step.(14) The time that elapses from the recruitment of
an oncology patient to the moment they obtain specialized care is usually long since the influx of
patients within the public health system is large.(11,15) Now, there are no studies that report the approximate
time of care for this type of patient.
This study in general terms aimed to establish the prevalence of cancer and the waiting time for the
care of cancer patients referred from the first to the second level of care from January to July 2024 at
the Hospital Provincial General Docente Riobamba (HPGDR).
The hypothesis proposed was that there is a high prevalence of cancer patients treated in the hospital
and a delay in the care of cancer patients due to the high demand for examinations and specialist
doctors that are not paid for by the Ministry of Public Health.
MATERIAL Y MÉTODOS
An original, observational, cross-sectional, retrospective study with a quantitative, descriptive, and
correlational approach was presented.
We worked with the entire population, representing the total number of patients hospitalized in all
specialties of the HPGDR, internal medicine, pediatrics, gynecology and obstetrics, Surgery, and ICU
from January to July 2024, p= 6559. By working with the entire population, we avoid sampling and
selection bias. The patient matrix called "Hospital discharges January to July 2024" is in the Hospital's
statistics service, which was provided to the researchers of an anonymized nature with the required
data according to the variables to be studied and before the delivery of a confidentiality commitment
from the authors and a general informed consent by the hospital's medical management.
Inclusion criteria.
• Patients treated in the hospital and registered in the hospital discharge matrix.
• Patients diagnosed with neoplastic pathology of any organ.
• Patients who have complied with the referral from the first level to the second level of care for
the calculation of the average days of waiting for referral care.
Exclusion criteria.
• Patients who do not provide the service where they were hospitalized in their database record.
Variables
Age, sex, diagnosis, date of care at the first level of care, date of care at the second level of care, type
of cancer, and hospitalization service.
The data obtained for the analysis correspond to the records of referral matrices and hospital discharge
matrices. These matrices are mandatory to report to the authorities of Ecuador's Zonal Coordination 3,
who evaluate care times to determine the productivity of treating medical professionals and hospital-level
productivity. The data are subject to review and registration in the Epidemiology Department. This
ensures the validity and quality of the data.
Once the final database was obtained in Excel, it was imported into the SPSS27 statistical package for
the coding of variables and statistical analysis. A univariate analysis was carried out to calculate the
prevalence of neoplasms and cancer based on the population. Ratios, proportions, and percentages for
qualitative variables; Measures of central tendency and dispersion for quantitative variables, always
accompanied by their 95 % confidence interval. The multivariate analysis looked for factors that
influence the presence of neoplasms and the presence of cancer, for which a logistic regression analysis
was performed.
The filling method was used for data processing with the average of the data obtained. This method was
used to analyze the average waiting time for referrals of oncology patients from primary to secondary care.
The study was approved by a human research ethics committee code: IO-29-CEISH- ESPOCH-2024.
RESULTS
Univariate analysis
The prevalence of patients with benign and malignant neoplasms of any organ calculated using the
formula: [(# of patients diagnosed with neoplasia / P) *100] [(204/6559)*100] is equal to 3.11 % (95 %
CI 3 %-4 %) from January to July 2024 in the HPGDR. 75.49 % were women (n=154) and 24.51%
were men (n=50).
The average age of patients with neoplasms, regardless of sex (n=204), is 49 years (95 % CI, 46 – 51
years) (minimum n = 1 year and maximum n = 94 years).
Based on the total population, the prevalence of cancer (malignant neoplasms) [(92/6559)*100] is
1.4% (95 % CI 1 %-2 %) from January to July 2024 in HPGDR. The prevalence of cancer concerning
the total number of patients diagnosed with neoplasia [(92/204)*100] is 45.09 % (9 5% CI 38 %-52 %).
Therefore, almost half of the patients hospitalized for neoplasms are malignant. About sex, 57.61%
(n=53) were women versus 42.39 % (n=39) were men.
The mean age, regardless of sex, of patients with malignant neoplasms is 56 years (95 % CI 52 – 59
years) (minimum n = 15 years and maximum n = 94 years).
Tables 1 and 2 represent the description of the tumors according to the hospitalization service.
Table 1. Benign tumors according to the hospitalization service.
Table 2. Malignant tumors according to the hospitalization service.
Benign and malignant tumors are described below according to their prevalence and hospitalization
services.
Tabla 3. Benign tumors.
The benign tumors with a frequency of 1 (0,9 %) each in Surgery are: tumor of the tongue; tumor of
the nasopharynx; tumor of the rectosigmoid junction; tumor of the meninges, part not specified;
tumor of the anal canal and anus; tumor of the lower jaw; kidney tumor; lipomatous tumor of the
intra-abdominal organs; and tumor of uncertain or unknown behavior of the brain, unspecified part.
Tabla 4. Malignant tumors.
Malignant tumors with a frequency of 1 (1.1 %) each in Internal medicine are: lymphoid leukemia,
no other specification; carcinoma in situ of the stomach; lymphoid leukemia, no other specification;
acute myeloblastic leukemia; chronic myeloid leukemia bcr/abl-positive; hodgkin's lymphoma
unspecified; non-follicular (diffuse) lymphoma not otherwise specified; multiple myeloma; kaposi's
sarcoma of the soft tissue; tumor of the thyroid gland; tumor of the skin of the trunk; tumor of the
central portion of the breast; tumor of the bones of the skull and face; tumor of the abdomen; tumor
of the cerebellum; brain tumor, except lobes and ventricles; tumor of the upper outer quadrant of the
breast; tumor of the body of the stomach; tumor of the body of the uterus, part not specified; tumor
of the esophagus, part not specified; tumor of the exocervix; liver tumor unspecified; ileum tumor;
tumor of the frontal lobe; tumor of the upper lobe, bronchus, or lung; tumor of the ovary; and tumor
of the testicle, unspecified.
To establish the mean number of days that patients were required to wait to receive care at the
second level, the total number of cancers (n=92) was taken. However, there was significant data
loss. It was only possible to obtain information on waiting days for care for 36 patients (39.13 %)
versus 56 (60.87 %) patients who did not have information on the days they waited to receive care
in the hospital.
Taking the data from the 36 patients, the average number of days required to be seen in the HPGDR
was 35 (95 % CI 19 – 51 days). The minimum waiting time was 2 days. The maximum was 204 days
waiting for care, and a Mode=2.
Multivariate analysis
Table 5 is presented below. A logistic regression model was performed to explain the dependent
variable presence of neoplasms, p= 6559.
Table 5. Logistic regression Presence of neoplasms.
It can be seen that the variables that explain the appearance of neoplasms are sex, age, and belonging
to the Surgery or gynecology service. Men are less likely to have a neoplasm (benign or malignant)
diagnosis OR 0.477, statistically significant, compared to women.
Concerning the 204 patients who presented neoplasms, a logistic regression was performed to explain
the dependent variable presence of malignant neoplasms. The results are shown below in Table 6.
Table 6. Logistic regression Presence of malignant neoplasms.
The variables that explain the presence of malignant neoplasms are age when the cut-off point is 65
years, and sex. Being male confers a higher chance of having malignancies (OR 5.99). Being younger
than 65 is less likely to get cancer (OR 0.25).
DISCUSSIÓN
The prevalence of benign or malignant neoplasms (3.11 %) represents a high percentage concerning
all HPGDR care that required hospitalization because it is a second-level hospital. If we divide the
number of neoplasms, we obtain that approximately 34 patients are hospitalized per month on average.
The hospital must ensure quality care for all patients.(11) It should be considered that approximately
half of the neoplasms are malignant (45.09 %). In most cases, more complex and expensive diagnostic
tests are required to determine their nature.(16-18) The percentage obtained in this study on the prevalence
of cancer shows a global reality, being the leading cause of death in 2020.(19)
In the univariate analysis, there were differences concerning age and sex, which were corroborated by
the multivariate analysis, where men have a lower risk of having a neoplasm (OR 0.47) p= 0.045.
However, men have a higher risk of malignancies (OR 5.99) p=0.000. According to international
cc
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ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 19
Número 2
10
REE 19(2) Riobamba may. - ago. 2025
statistics, men have an age-standardized incidence rate of 212.6, with a cumulative risk of developing
cancer before the age of 75 of 21.8 %, compared to women who have a standardized incidence rate of
186.3 with a risk of 18.5 %. (19,20) Similarly, our study shows that those younger than 65 represent a
lower cancer risk (OR 0.25) p=0.035.
Although supported by evidence, the methodological nature of the study confers results that must be
corroborated with more powerful studies and stricter inclusion and selection criteria. Age and sex
should also be considered as confounding variables.
Gynecology represents 66.96 % of hospitalizations for benign tumors, which is consistent with the most
frequent types of benign tumors treated, uterine leiomyomas and ovarian and breast tumors. In the
second place, Surgery is found with 27.68 % for the resolution mainly of lipomas.
Internal medicine is the leading cancer care service, accounting for 77.17 % of hospitalizations. The
main types of cancer are leukemias, lymphomas, skin, lung, and gastric. The second service with the
highest percentage of hospitalizations is Surgery, with 16.30 %, where gastric and urological cancer are
mainly treated. The main types of cancer worldwide are lung, breast, colorectal, prostate, stomach, liver,
thyroid, and uterine cervix. (20-24)
A timely cancer diagnosis represents a greater probability of long-term survival, implementing early
surgical or clinical treatments. (25-28) We found an average wait of 35 days to be seen as referrals from the
first level, in charge of the health centers, to the second level of care, in charge of the HPGDR. These
data represent an essential information bias due to the number of losses, which made it impossible to
have a waiting time for analysis. Longitudinal studies are recommended to have a more accurate
follow-up and not have losses from that follow-up.
The National Institute for Health and Care Excellence recommends referring patients with metastatic
cancer of unknown origin for care within two weeks of referral.(29) It is necessary to create public policies
to address medical and non-medical expenses to improve the quality of life of cancer patients and mitigate
barriers to access to care since a timely diagnosis and approach reduce subsequent treatment costs.(30,31)
The strengths of this study are the rigor of the results obtained since the appropriate statistics were used,
providing 95 % CI and p values; it represents epidemiological data that can be extrapolated to the gene-
ral population since there were no sampling biases, obtaining adequate external validity; and it is the
starting point for more rigorous investigations in search of data that explain causality.
Limitations:
The main limitation of this study is the impossibility of stricter follow-up and control of the participants.
It was not possible to analyze more factors that contributed to the diagnosis of cancer.
To establish causal relationships, the design of our study is limited, as we present a cross-sectional
design. However, this type of design does allow for the analysis of relationships between variables that
present associations, such as the prevalence ratio, OR, etc. In medicine, it is impossible to establish
specific cause-and-effect relationships since pathologies, primarily cancer, are multifactorial.
The main limitation regarding the analysis of waiting times for care was the loss of data, which confers
little external validity to our results. These losses are primarily attributed to the fact that all hospital
discharges for cancer were considered, and many of them originate from emergency departments,
where there is no care policy based on primary care referrals.
Recommendations:
Mandatory, real-time health record keeping should be implemented, in addition to the referral form
(Form 053) to monitor patients. This would facilitate longitudinal studies.
Consider including oncology professionals at least once or twice a week to support outpatient care,
perform procedures, and diagnose patients with suspected cancer.
CONCLUSIONS
The prevalence of neoplasms in HPGDR from January to July 2024 is 3.11 % (95 % CI 3 %-4 %), and
45.09 % (95 % CI 38 %-52 %) corresponds to malignant neoplasms. The prevalence of cancer in the
total hospitalizations from January to July 2024 in HPGDR is 1.4 % (95 % CI 1 %-2 %).
Gynecology is the main service that treats benign neoplasms, the most frequent being leiomyomas,
ovarian or breast. The second service corresponds to Surgery for the resolution of lipomas.
The main cancer care service is internal medicine, which is used to treat leukemias, lymphomas, skin,
lung, and gastric cancers. The second service is Surgery for gastric and urological cancer care.
The waiting time required by patients to receive care by referrals from health centers to HPGDR is 35
days (95 % CI 19 – 51 days).
Funding: The authors funded this research.
Acknowledgments:
• To the authorities of the HPGDR.: Dr. María Sánchez, Manager; Dr. Evelyn Inca, medical director,
for promoting research and contributing to administrative procedures. To the Statistics service
for collaborating with the required data.
• To the National University of Chimborazo.
• To the Polytechnic School of Chimborazo.
Conflicts of interest: The authors declare no conflict of interest in this research.
Contribution Statement:
Conceptualization: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana. Data
curation, Formal analysis, Methodology, Software, Validation, Visualization, and Writing – review and
editing: Md. M.Sc. Carlos Andrés Yépez Salgado. Acquisition of funds: project self-financed by the
authors. Research: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana; Dr.
Paola Buenaño; Dr. David Orozco; Md. Yesenia Chandi. Project administration: Dr. Paola Buenaño; Dr.
David Orozco; Md. Yesenia Chandi. Supervision: Dr. Zully Mayra Romero Orellana; Dr. Paola Buenaño;
Dr. David Orozco. Writing – original draft: Md. Yesenia Chandi. All authors have read and agreed to the
published version of the manuscript.
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Prevalence of cancer and time to referral care in oncology patients
Prevalencia de cáncer y tiempo de atención de referencias en pacientes oncológicos.
https://doi.org/10.37135/ee.04.23.01
Authors:
Carlos Andrés Yépez Salgado1 - https://orcid.org/0009-0009-4722-8348
Zully Mayra Romero Orellana1,2 - https://orcid.org/0009-0000-6323-7548
David Cristóbal Orozco Brito3 - https://orcid.org/0000-0002-3945-3301
Nancy Paola Buenano Zambrano1 - https://orcid.org/0009-0003-2505-9236
Yesenia Liliana Chandi Japón4 - https://orcid.org/0009-0000-5672-0451
Affiliation:
1Hospital Provincial General Docente Riobamba.
2Universidad Nacional de Chimborazo.
3Escuela Superior Politécnica de Chimborazo.
4Centro de Salud Pungala Grande.
Corresponding author: Carlos Andrés Yépez Salgado. Hospital Provincial General Docente Riobamba.
Dirección postal: 060104. Email: med.carlos.andres@gmail.com / docenciahpgdrcoordinacion@gmail.
com Phone: +593984109505.
Received: January 24, 2025 Accepted: abril 01, 2025
ABSTRACT
Cancer represents a worldwide problem. In 2022, there were 30888 new cases of cancer and 16158
deaths in Ecuador. Considering the high morbidity and mortality due to this disease, health systems are
trying to meet the demand of these patients in public and private health services. Our main objective
was to establish the prevalence of cancer and the time of care of oncological patients referred to the
second level from the first of care during January-July 2024 at the Hospital Provincial General
Docente Riobamba. An original, observational, retrospective, descriptive, and correlational study
was presented. The prevalence of neoplasms is 3.11 %, and 45.09 % are malignant. The prevalence
of cancer in total hospitalizations is 1.4 %, and the average waiting time for care is 35 days. There
was a high prevalence of cancer in the hospital, where Internal medicine and Surgery are the services
with the most hospitalizations for this pathology.
Keywords: Cancer; Neoplasms; Epidemiology; Community Health Planning; Secondary Care Centers.
RESUMEN
El cáncer representa un problema a nivel mundial, en el año 2022 en el Ecuador existieron 30888
nuevos casos de cáncer y 16158 muertes, considerando una elevada morbimortalidad a causa de este
padecimiento, los sistemas de salud realizan un esfuerzo por solventar la demanda de estos pacientes
en los servicios de salud públicos y privados. El objetivo de esta investigación fue establecer la
prevalencia de cáncer y el tiempo de atención de referencias de pacientes oncológicos referidos desde
el primer nivel de atención al segundo nivel de atención de enero a julio de 2024 en el Hospital
Provincial General Docente de Riobamba. Se presentó un estudio original, observacional, transversal
retrospectivo, descriptivo y correlacional. La prevalencia de neoplasias es de 3,11 % y el 45,09 % son
malignas. La prevalencia de cáncer en el total de hospitalizaciones es 1,4% y el promedio de tiempo
de espera para la atención es de 35 días. Existió una elevada prevalencia de cáncer en el hospital,
siendo medicina interna y cirugía los servicios con más hospitalizaciones por esta patología.
Palabras clave: cáncer; neoplasias; epidemiología; planificación sanitaria comunitaria; centros de
atención secundaria.
.
INTRODUCTION
Cancer is a term used to refer to a broad group of diseases of complex and multifactorial origin caused
by abnormal cells that multiply autonomously and irregularly, invading other tissues locally and at a
distance.(1) The degree of malignancy is variable. It depends on the aggressiveness of its cells and
biological characteristics(2). They can spread and cause metastasis from different routes of dissemination
(lymphatic, blood, or by extension and direct invasion of neighboring tissues).(2,3) In general, if their
natural evolution is sought, they tend to lead to the death of the affected person in the short term.(4)
Currently, more than 200 different types of cancer are known, depending on the tissue from which they
are derived. The most common are those of the skin, lungs, breast, colon, and rectum.(5)
According to PAHO, cancer is one of the leading causes of mortality in the Americas. The figures indicate
that its incidence is growing rapidly worldwide, becoming a significant barrier to increasing life
expectancy. It is estimated that in 2022, there were 20 million new cases of cancer and 9.7 million
deaths in the region. (6,7)
Statistics from the International Agency for Research on Cancer indicate that in 2022 in Ecuador there
were 30888 new cases of cancer, 16,158 deaths, a risk of 7.3 % of dying from cancer before the age of
75; Prostate (29.4 %), stomach (11.2 %) and colorectal (8.4 %) cancer are more prevalent in our coun-
try; In female sex, lung cancer (23 %), cervical cancer (10.5 %) and colorectal cancer (8.0 %) are the
main ones; It is also mentioned that by 2040 there will be more than 53,701 cases detected during the
year in Ecuador. (8)
When analyzing the statistics, we observe that in Ecuador, as in the rest of the world, the incidence of
cancer is increasing, which is why it is necessary to have a health system that provides the opportunity
for each user to have adequate and timely care for their diagnosis and treatment.(8,9) It has been shown
that the delay in the care of this type of patient has been directly related to survival rates.(9) A study in
London about the survival of patients with breast cancer related to delayed uptake and treatment
showed that 32 % of patients with delays of 12 weeks or more had locally advanced or metastatic
disease, compared to only 10 % of those with delays of less than 12 weeks, which shows us the importance
of early recruitment.(10)
The national health system in Ecuador has a system of universality and progressive free healthcare
based on the Comprehensive Health Care model, which is supported by the user referral system to
improve healthcare.(11,12) This regulation is applied at all levels of care, thus allowing adequate care to
be provided to all users who require it according to the degree of complexity to achieve complete,
acceptable, and timely care.(13)
The health system of Ecuador offers a model that allows recruitment at the first level of health, which
is responsible for making the referral to the next step.(14) The time that elapses from the recruitment of
an oncology patient to the moment they obtain specialized care is usually long since the influx of
patients within the public health system is large.(11,15) Now, there are no studies that report the approximate
time of care for this type of patient.
This study in general terms aimed to establish the prevalence of cancer and the waiting time for the
care of cancer patients referred from the first to the second level of care from January to July 2024 at
the Hospital Provincial General Docente Riobamba (HPGDR).
The hypothesis proposed was that there is a high prevalence of cancer patients treated in the hospital
and a delay in the care of cancer patients due to the high demand for examinations and specialist
doctors that are not paid for by the Ministry of Public Health.
MATERIAL Y MÉTODOS
An original, observational, cross-sectional, retrospective study with a quantitative, descriptive, and
correlational approach was presented.
We worked with the entire population, representing the total number of patients hospitalized in all
specialties of the HPGDR, internal medicine, pediatrics, gynecology and obstetrics, Surgery, and ICU
from January to July 2024, p= 6559. By working with the entire population, we avoid sampling and
selection bias. The patient matrix called "Hospital discharges January to July 2024" is in the Hospital's
statistics service, which was provided to the researchers of an anonymized nature with the required
data according to the variables to be studied and before the delivery of a confidentiality commitment
from the authors and a general informed consent by the hospital's medical management.
Inclusion criteria.
• Patients treated in the hospital and registered in the hospital discharge matrix.
• Patients diagnosed with neoplastic pathology of any organ.
• Patients who have complied with the referral from the first level to the second level of care for
the calculation of the average days of waiting for referral care.
Exclusion criteria.
• Patients who do not provide the service where they were hospitalized in their database record.
Variables
Age, sex, diagnosis, date of care at the first level of care, date of care at the second level of care, type
of cancer, and hospitalization service.
The data obtained for the analysis correspond to the records of referral matrices and hospital discharge
matrices. These matrices are mandatory to report to the authorities of Ecuador's Zonal Coordination 3,
who evaluate care times to determine the productivity of treating medical professionals and hospital-level
productivity. The data are subject to review and registration in the Epidemiology Department. This
ensures the validity and quality of the data.
Once the final database was obtained in Excel, it was imported into the SPSS27 statistical package for
the coding of variables and statistical analysis. A univariate analysis was carried out to calculate the
prevalence of neoplasms and cancer based on the population. Ratios, proportions, and percentages for
qualitative variables; Measures of central tendency and dispersion for quantitative variables, always
accompanied by their 95 % confidence interval. The multivariate analysis looked for factors that
influence the presence of neoplasms and the presence of cancer, for which a logistic regression analysis
was performed.
The filling method was used for data processing with the average of the data obtained. This method was
used to analyze the average waiting time for referrals of oncology patients from primary to secondary care.
The study was approved by a human research ethics committee code: IO-29-CEISH- ESPOCH-2024.
RESULTS
Univariate analysis
The prevalence of patients with benign and malignant neoplasms of any organ calculated using the
formula: [(# of patients diagnosed with neoplasia / P) *100] [(204/6559)*100] is equal to 3.11 % (95 %
CI 3 %-4 %) from January to July 2024 in the HPGDR. 75.49 % were women (n=154) and 24.51%
were men (n=50).
The average age of patients with neoplasms, regardless of sex (n=204), is 49 years (95 % CI, 46 – 51
years) (minimum n = 1 year and maximum n = 94 years).
Based on the total population, the prevalence of cancer (malignant neoplasms) [(92/6559)*100] is
1.4% (95 % CI 1 %-2 %) from January to July 2024 in HPGDR. The prevalence of cancer concerning
the total number of patients diagnosed with neoplasia [(92/204)*100] is 45.09 % (9 5% CI 38 %-52 %).
Therefore, almost half of the patients hospitalized for neoplasms are malignant. About sex, 57.61%
(n=53) were women versus 42.39 % (n=39) were men.
The mean age, regardless of sex, of patients with malignant neoplasms is 56 years (95 % CI 52 – 59
years) (minimum n = 15 years and maximum n = 94 years).
Tables 1 and 2 represent the description of the tumors according to the hospitalization service.
Table 1. Benign tumors according to the hospitalization service.
Table 2. Malignant tumors according to the hospitalization service.
Benign and malignant tumors are described below according to their prevalence and hospitalization
services.
Tabla 3. Benign tumors.
The benign tumors with a frequency of 1 (0,9 %) each in Surgery are: tumor of the tongue; tumor of
the nasopharynx; tumor of the rectosigmoid junction; tumor of the meninges, part not specified;
tumor of the anal canal and anus; tumor of the lower jaw; kidney tumor; lipomatous tumor of the
intra-abdominal organs; and tumor of uncertain or unknown behavior of the brain, unspecified part.
Tabla 4. Malignant tumors.
Malignant tumors with a frequency of 1 (1.1 %) each in Internal medicine are: lymphoid leukemia,
no other specification; carcinoma in situ of the stomach; lymphoid leukemia, no other specification;
acute myeloblastic leukemia; chronic myeloid leukemia bcr/abl-positive; hodgkin's lymphoma
unspecified; non-follicular (diffuse) lymphoma not otherwise specified; multiple myeloma; kaposi's
sarcoma of the soft tissue; tumor of the thyroid gland; tumor of the skin of the trunk; tumor of the
central portion of the breast; tumor of the bones of the skull and face; tumor of the abdomen; tumor
of the cerebellum; brain tumor, except lobes and ventricles; tumor of the upper outer quadrant of the
breast; tumor of the body of the stomach; tumor of the body of the uterus, part not specified; tumor
of the esophagus, part not specified; tumor of the exocervix; liver tumor unspecified; ileum tumor;
tumor of the frontal lobe; tumor of the upper lobe, bronchus, or lung; tumor of the ovary; and tumor
of the testicle, unspecified.
To establish the mean number of days that patients were required to wait to receive care at the
second level, the total number of cancers (n=92) was taken. However, there was significant data
loss. It was only possible to obtain information on waiting days for care for 36 patients (39.13 %)
versus 56 (60.87 %) patients who did not have information on the days they waited to receive care
in the hospital.
Taking the data from the 36 patients, the average number of days required to be seen in the HPGDR
was 35 (95 % CI 19 – 51 days). The minimum waiting time was 2 days. The maximum was 204 days
waiting for care, and a Mode=2.
Multivariate analysis
Table 5 is presented below. A logistic regression model was performed to explain the dependent
variable presence of neoplasms, p= 6559.
Table 5. Logistic regression Presence of neoplasms.
It can be seen that the variables that explain the appearance of neoplasms are sex, age, and belonging
to the Surgery or gynecology service. Men are less likely to have a neoplasm (benign or malignant)
diagnosis OR 0.477, statistically significant, compared to women.
Concerning the 204 patients who presented neoplasms, a logistic regression was performed to explain
the dependent variable presence of malignant neoplasms. The results are shown below in Table 6.
Table 6. Logistic regression Presence of malignant neoplasms.
The variables that explain the presence of malignant neoplasms are age when the cut-off point is 65
years, and sex. Being male confers a higher chance of having malignancies (OR 5.99). Being younger
than 65 is less likely to get cancer (OR 0.25).
DISCUSSIÓN
The prevalence of benign or malignant neoplasms (3.11 %) represents a high percentage concerning
all HPGDR care that required hospitalization because it is a second-level hospital. If we divide the
number of neoplasms, we obtain that approximately 34 patients are hospitalized per month on average.
The hospital must ensure quality care for all patients.(11) It should be considered that approximately
half of the neoplasms are malignant (45.09 %). In most cases, more complex and expensive diagnostic
tests are required to determine their nature.(16-18) The percentage obtained in this study on the prevalence
of cancer shows a global reality, being the leading cause of death in 2020.(19)
In the univariate analysis, there were differences concerning age and sex, which were corroborated by
the multivariate analysis, where men have a lower risk of having a neoplasm (OR 0.47) p= 0.045.
However, men have a higher risk of malignancies (OR 5.99) p=0.000. According to international
cc
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ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 19
Número 2
11
REE 19(2) Riobamba may. - ago. 2025
statistics, men have an age-standardized incidence rate of 212.6, with a cumulative risk of developing
cancer before the age of 75 of 21.8 %, compared to women who have a standardized incidence rate of
186.3 with a risk of 18.5 %. (19,20) Similarly, our study shows that those younger than 65 represent a
lower cancer risk (OR 0.25) p=0.035.
Although supported by evidence, the methodological nature of the study confers results that must be
corroborated with more powerful studies and stricter inclusion and selection criteria. Age and sex
should also be considered as confounding variables.
Gynecology represents 66.96 % of hospitalizations for benign tumors, which is consistent with the most
frequent types of benign tumors treated, uterine leiomyomas and ovarian and breast tumors. In the
second place, Surgery is found with 27.68 % for the resolution mainly of lipomas.
Internal medicine is the leading cancer care service, accounting for 77.17 % of hospitalizations. The
main types of cancer are leukemias, lymphomas, skin, lung, and gastric. The second service with the
highest percentage of hospitalizations is Surgery, with 16.30 %, where gastric and urological cancer are
mainly treated. The main types of cancer worldwide are lung, breast, colorectal, prostate, stomach, liver,
thyroid, and uterine cervix. (20-24)
A timely cancer diagnosis represents a greater probability of long-term survival, implementing early
surgical or clinical treatments. (25-28) We found an average wait of 35 days to be seen as referrals from the
first level, in charge of the health centers, to the second level of care, in charge of the HPGDR. These
data represent an essential information bias due to the number of losses, which made it impossible to
have a waiting time for analysis. Longitudinal studies are recommended to have a more accurate
follow-up and not have losses from that follow-up.
The National Institute for Health and Care Excellence recommends referring patients with metastatic
cancer of unknown origin for care within two weeks of referral.(29) It is necessary to create public policies
to address medical and non-medical expenses to improve the quality of life of cancer patients and mitigate
barriers to access to care since a timely diagnosis and approach reduce subsequent treatment costs.(30,31)
The strengths of this study are the rigor of the results obtained since the appropriate statistics were used,
providing 95 % CI and p values; it represents epidemiological data that can be extrapolated to the gene-
ral population since there were no sampling biases, obtaining adequate external validity; and it is the
starting point for more rigorous investigations in search of data that explain causality.
Limitations:
The main limitation of this study is the impossibility of stricter follow-up and control of the participants.
It was not possible to analyze more factors that contributed to the diagnosis of cancer.
To establish causal relationships, the design of our study is limited, as we present a cross-sectional
design. However, this type of design does allow for the analysis of relationships between variables that
present associations, such as the prevalence ratio, OR, etc. In medicine, it is impossible to establish
specific cause-and-effect relationships since pathologies, primarily cancer, are multifactorial.
The main limitation regarding the analysis of waiting times for care was the loss of data, which confers
little external validity to our results. These losses are primarily attributed to the fact that all hospital
discharges for cancer were considered, and many of them originate from emergency departments,
where there is no care policy based on primary care referrals.
Recommendations:
Mandatory, real-time health record keeping should be implemented, in addition to the referral form
(Form 053) to monitor patients. This would facilitate longitudinal studies.
Consider including oncology professionals at least once or twice a week to support outpatient care,
perform procedures, and diagnose patients with suspected cancer.
CONCLUSIONS
The prevalence of neoplasms in HPGDR from January to July 2024 is 3.11 % (95 % CI 3 %-4 %), and
45.09 % (95 % CI 38 %-52 %) corresponds to malignant neoplasms. The prevalence of cancer in the
total hospitalizations from January to July 2024 in HPGDR is 1.4 % (95 % CI 1 %-2 %).
Gynecology is the main service that treats benign neoplasms, the most frequent being leiomyomas,
ovarian or breast. The second service corresponds to Surgery for the resolution of lipomas.
The main cancer care service is internal medicine, which is used to treat leukemias, lymphomas, skin,
lung, and gastric cancers. The second service is Surgery for gastric and urological cancer care.
The waiting time required by patients to receive care by referrals from health centers to HPGDR is 35
days (95 % CI 19 – 51 days).
Funding: The authors funded this research.
Acknowledgments:
• To the authorities of the HPGDR.: Dr. María Sánchez, Manager; Dr. Evelyn Inca, medical director,
for promoting research and contributing to administrative procedures. To the Statistics service
for collaborating with the required data.
• To the National University of Chimborazo.
• To the Polytechnic School of Chimborazo.
Conflicts of interest: The authors declare no conflict of interest in this research.
Contribution Statement:
Conceptualization: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana. Data
curation, Formal analysis, Methodology, Software, Validation, Visualization, and Writing – review and
editing: Md. M.Sc. Carlos Andrés Yépez Salgado. Acquisition of funds: project self-financed by the
authors. Research: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana; Dr.
Paola Buenaño; Dr. David Orozco; Md. Yesenia Chandi. Project administration: Dr. Paola Buenaño; Dr.
David Orozco; Md. Yesenia Chandi. Supervision: Dr. Zully Mayra Romero Orellana; Dr. Paola Buenaño;
Dr. David Orozco. Writing – original draft: Md. Yesenia Chandi. All authors have read and agreed to the
published version of the manuscript.
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Prevalence of cancer and time to referral care in oncology patients
Prevalencia de cáncer y tiempo de atención de referencias en pacientes oncológicos.
https://doi.org/10.37135/ee.04.23.01
Authors:
Carlos Andrés Yépez Salgado1 - https://orcid.org/0009-0009-4722-8348
Zully Mayra Romero Orellana1,2 - https://orcid.org/0009-0000-6323-7548
David Cristóbal Orozco Brito3 - https://orcid.org/0000-0002-3945-3301
Nancy Paola Buenano Zambrano1 - https://orcid.org/0009-0003-2505-9236
Yesenia Liliana Chandi Japón4 - https://orcid.org/0009-0000-5672-0451
Affiliation:
1Hospital Provincial General Docente Riobamba.
2Universidad Nacional de Chimborazo.
3Escuela Superior Politécnica de Chimborazo.
4Centro de Salud Pungala Grande.
Corresponding author: Carlos Andrés Yépez Salgado. Hospital Provincial General Docente Riobamba.
Dirección postal: 060104. Email: med.carlos.andres@gmail.com / docenciahpgdrcoordinacion@gmail.
com Phone: +593984109505.
Received: January 24, 2025 Accepted: abril 01, 2025
ABSTRACT
Cancer represents a worldwide problem. In 2022, there were 30888 new cases of cancer and 16158
deaths in Ecuador. Considering the high morbidity and mortality due to this disease, health systems are
trying to meet the demand of these patients in public and private health services. Our main objective
was to establish the prevalence of cancer and the time of care of oncological patients referred to the
second level from the first of care during January-July 2024 at the Hospital Provincial General
Docente Riobamba. An original, observational, retrospective, descriptive, and correlational study
was presented. The prevalence of neoplasms is 3.11 %, and 45.09 % are malignant. The prevalence
of cancer in total hospitalizations is 1.4 %, and the average waiting time for care is 35 days. There
was a high prevalence of cancer in the hospital, where Internal medicine and Surgery are the services
with the most hospitalizations for this pathology.
Keywords: Cancer; Neoplasms; Epidemiology; Community Health Planning; Secondary Care Centers.
RESUMEN
El cáncer representa un problema a nivel mundial, en el año 2022 en el Ecuador existieron 30888
nuevos casos de cáncer y 16158 muertes, considerando una elevada morbimortalidad a causa de este
padecimiento, los sistemas de salud realizan un esfuerzo por solventar la demanda de estos pacientes
en los servicios de salud públicos y privados. El objetivo de esta investigación fue establecer la
prevalencia de cáncer y el tiempo de atención de referencias de pacientes oncológicos referidos desde
el primer nivel de atención al segundo nivel de atención de enero a julio de 2024 en el Hospital
Provincial General Docente de Riobamba. Se presentó un estudio original, observacional, transversal
retrospectivo, descriptivo y correlacional. La prevalencia de neoplasias es de 3,11 % y el 45,09 % son
malignas. La prevalencia de cáncer en el total de hospitalizaciones es 1,4% y el promedio de tiempo
de espera para la atención es de 35 días. Existió una elevada prevalencia de cáncer en el hospital,
siendo medicina interna y cirugía los servicios con más hospitalizaciones por esta patología.
Palabras clave: cáncer; neoplasias; epidemiología; planificación sanitaria comunitaria; centros de
atención secundaria.
.
INTRODUCTION
Cancer is a term used to refer to a broad group of diseases of complex and multifactorial origin caused
by abnormal cells that multiply autonomously and irregularly, invading other tissues locally and at a
distance.(1) The degree of malignancy is variable. It depends on the aggressiveness of its cells and
biological characteristics(2). They can spread and cause metastasis from different routes of dissemination
(lymphatic, blood, or by extension and direct invasion of neighboring tissues).(2,3) In general, if their
natural evolution is sought, they tend to lead to the death of the affected person in the short term.(4)
Currently, more than 200 different types of cancer are known, depending on the tissue from which they
are derived. The most common are those of the skin, lungs, breast, colon, and rectum.(5)
According to PAHO, cancer is one of the leading causes of mortality in the Americas. The figures indicate
that its incidence is growing rapidly worldwide, becoming a significant barrier to increasing life
expectancy. It is estimated that in 2022, there were 20 million new cases of cancer and 9.7 million
deaths in the region. (6,7)
Statistics from the International Agency for Research on Cancer indicate that in 2022 in Ecuador there
were 30888 new cases of cancer, 16,158 deaths, a risk of 7.3 % of dying from cancer before the age of
75; Prostate (29.4 %), stomach (11.2 %) and colorectal (8.4 %) cancer are more prevalent in our coun-
try; In female sex, lung cancer (23 %), cervical cancer (10.5 %) and colorectal cancer (8.0 %) are the
main ones; It is also mentioned that by 2040 there will be more than 53,701 cases detected during the
year in Ecuador. (8)
When analyzing the statistics, we observe that in Ecuador, as in the rest of the world, the incidence of
cancer is increasing, which is why it is necessary to have a health system that provides the opportunity
for each user to have adequate and timely care for their diagnosis and treatment.(8,9) It has been shown
that the delay in the care of this type of patient has been directly related to survival rates.(9) A study in
London about the survival of patients with breast cancer related to delayed uptake and treatment
showed that 32 % of patients with delays of 12 weeks or more had locally advanced or metastatic
disease, compared to only 10 % of those with delays of less than 12 weeks, which shows us the importance
of early recruitment.(10)
The national health system in Ecuador has a system of universality and progressive free healthcare
based on the Comprehensive Health Care model, which is supported by the user referral system to
improve healthcare.(11,12) This regulation is applied at all levels of care, thus allowing adequate care to
be provided to all users who require it according to the degree of complexity to achieve complete,
acceptable, and timely care.(13)
The health system of Ecuador offers a model that allows recruitment at the first level of health, which
is responsible for making the referral to the next step.(14) The time that elapses from the recruitment of
an oncology patient to the moment they obtain specialized care is usually long since the influx of
patients within the public health system is large.(11,15) Now, there are no studies that report the approximate
time of care for this type of patient.
This study in general terms aimed to establish the prevalence of cancer and the waiting time for the
care of cancer patients referred from the first to the second level of care from January to July 2024 at
the Hospital Provincial General Docente Riobamba (HPGDR).
The hypothesis proposed was that there is a high prevalence of cancer patients treated in the hospital
and a delay in the care of cancer patients due to the high demand for examinations and specialist
doctors that are not paid for by the Ministry of Public Health.
MATERIAL Y MÉTODOS
An original, observational, cross-sectional, retrospective study with a quantitative, descriptive, and
correlational approach was presented.
We worked with the entire population, representing the total number of patients hospitalized in all
specialties of the HPGDR, internal medicine, pediatrics, gynecology and obstetrics, Surgery, and ICU
from January to July 2024, p= 6559. By working with the entire population, we avoid sampling and
selection bias. The patient matrix called "Hospital discharges January to July 2024" is in the Hospital's
statistics service, which was provided to the researchers of an anonymized nature with the required
data according to the variables to be studied and before the delivery of a confidentiality commitment
from the authors and a general informed consent by the hospital's medical management.
Inclusion criteria.
• Patients treated in the hospital and registered in the hospital discharge matrix.
• Patients diagnosed with neoplastic pathology of any organ.
• Patients who have complied with the referral from the first level to the second level of care for
the calculation of the average days of waiting for referral care.
Exclusion criteria.
• Patients who do not provide the service where they were hospitalized in their database record.
Variables
Age, sex, diagnosis, date of care at the first level of care, date of care at the second level of care, type
of cancer, and hospitalization service.
The data obtained for the analysis correspond to the records of referral matrices and hospital discharge
matrices. These matrices are mandatory to report to the authorities of Ecuador's Zonal Coordination 3,
who evaluate care times to determine the productivity of treating medical professionals and hospital-level
productivity. The data are subject to review and registration in the Epidemiology Department. This
ensures the validity and quality of the data.
Once the final database was obtained in Excel, it was imported into the SPSS27 statistical package for
the coding of variables and statistical analysis. A univariate analysis was carried out to calculate the
prevalence of neoplasms and cancer based on the population. Ratios, proportions, and percentages for
qualitative variables; Measures of central tendency and dispersion for quantitative variables, always
accompanied by their 95 % confidence interval. The multivariate analysis looked for factors that
influence the presence of neoplasms and the presence of cancer, for which a logistic regression analysis
was performed.
The filling method was used for data processing with the average of the data obtained. This method was
used to analyze the average waiting time for referrals of oncology patients from primary to secondary care.
The study was approved by a human research ethics committee code: IO-29-CEISH- ESPOCH-2024.
RESULTS
Univariate analysis
The prevalence of patients with benign and malignant neoplasms of any organ calculated using the
formula: [(# of patients diagnosed with neoplasia / P) *100] [(204/6559)*100] is equal to 3.11 % (95 %
CI 3 %-4 %) from January to July 2024 in the HPGDR. 75.49 % were women (n=154) and 24.51%
were men (n=50).
The average age of patients with neoplasms, regardless of sex (n=204), is 49 years (95 % CI, 46 – 51
years) (minimum n = 1 year and maximum n = 94 years).
Based on the total population, the prevalence of cancer (malignant neoplasms) [(92/6559)*100] is
1.4% (95 % CI 1 %-2 %) from January to July 2024 in HPGDR. The prevalence of cancer concerning
the total number of patients diagnosed with neoplasia [(92/204)*100] is 45.09 % (9 5% CI 38 %-52 %).
Therefore, almost half of the patients hospitalized for neoplasms are malignant. About sex, 57.61%
(n=53) were women versus 42.39 % (n=39) were men.
The mean age, regardless of sex, of patients with malignant neoplasms is 56 years (95 % CI 52 – 59
years) (minimum n = 15 years and maximum n = 94 years).
Tables 1 and 2 represent the description of the tumors according to the hospitalization service.
Table 1. Benign tumors according to the hospitalization service.
Table 2. Malignant tumors according to the hospitalization service.
Benign and malignant tumors are described below according to their prevalence and hospitalization
services.
Tabla 3. Benign tumors.
The benign tumors with a frequency of 1 (0,9 %) each in Surgery are: tumor of the tongue; tumor of
the nasopharynx; tumor of the rectosigmoid junction; tumor of the meninges, part not specified;
tumor of the anal canal and anus; tumor of the lower jaw; kidney tumor; lipomatous tumor of the
intra-abdominal organs; and tumor of uncertain or unknown behavior of the brain, unspecified part.
Tabla 4. Malignant tumors.
Malignant tumors with a frequency of 1 (1.1 %) each in Internal medicine are: lymphoid leukemia,
no other specification; carcinoma in situ of the stomach; lymphoid leukemia, no other specification;
acute myeloblastic leukemia; chronic myeloid leukemia bcr/abl-positive; hodgkin's lymphoma
unspecified; non-follicular (diffuse) lymphoma not otherwise specified; multiple myeloma; kaposi's
sarcoma of the soft tissue; tumor of the thyroid gland; tumor of the skin of the trunk; tumor of the
central portion of the breast; tumor of the bones of the skull and face; tumor of the abdomen; tumor
of the cerebellum; brain tumor, except lobes and ventricles; tumor of the upper outer quadrant of the
breast; tumor of the body of the stomach; tumor of the body of the uterus, part not specified; tumor
of the esophagus, part not specified; tumor of the exocervix; liver tumor unspecified; ileum tumor;
tumor of the frontal lobe; tumor of the upper lobe, bronchus, or lung; tumor of the ovary; and tumor
of the testicle, unspecified.
To establish the mean number of days that patients were required to wait to receive care at the
second level, the total number of cancers (n=92) was taken. However, there was significant data
loss. It was only possible to obtain information on waiting days for care for 36 patients (39.13 %)
versus 56 (60.87 %) patients who did not have information on the days they waited to receive care
in the hospital.
Taking the data from the 36 patients, the average number of days required to be seen in the HPGDR
was 35 (95 % CI 19 – 51 days). The minimum waiting time was 2 days. The maximum was 204 days
waiting for care, and a Mode=2.
Multivariate analysis
Table 5 is presented below. A logistic regression model was performed to explain the dependent
variable presence of neoplasms, p= 6559.
Table 5. Logistic regression Presence of neoplasms.
It can be seen that the variables that explain the appearance of neoplasms are sex, age, and belonging
to the Surgery or gynecology service. Men are less likely to have a neoplasm (benign or malignant)
diagnosis OR 0.477, statistically significant, compared to women.
Concerning the 204 patients who presented neoplasms, a logistic regression was performed to explain
the dependent variable presence of malignant neoplasms. The results are shown below in Table 6.
Table 6. Logistic regression Presence of malignant neoplasms.
The variables that explain the presence of malignant neoplasms are age when the cut-off point is 65
years, and sex. Being male confers a higher chance of having malignancies (OR 5.99). Being younger
than 65 is less likely to get cancer (OR 0.25).
DISCUSSIÓN
The prevalence of benign or malignant neoplasms (3.11 %) represents a high percentage concerning
all HPGDR care that required hospitalization because it is a second-level hospital. If we divide the
number of neoplasms, we obtain that approximately 34 patients are hospitalized per month on average.
The hospital must ensure quality care for all patients.(11) It should be considered that approximately
half of the neoplasms are malignant (45.09 %). In most cases, more complex and expensive diagnostic
tests are required to determine their nature.(16-18) The percentage obtained in this study on the prevalence
of cancer shows a global reality, being the leading cause of death in 2020.(19)
In the univariate analysis, there were differences concerning age and sex, which were corroborated by
the multivariate analysis, where men have a lower risk of having a neoplasm (OR 0.47) p= 0.045.
However, men have a higher risk of malignancies (OR 5.99) p=0.000. According to international
cc
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ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 19
Número 2
12
REE 19(2) Riobamba may. - ago. 2025
statistics, men have an age-standardized incidence rate of 212.6, with a cumulative risk of developing
cancer before the age of 75 of 21.8 %, compared to women who have a standardized incidence rate of
186.3 with a risk of 18.5 %. (19,20) Similarly, our study shows that those younger than 65 represent a
lower cancer risk (OR 0.25) p=0.035.
Although supported by evidence, the methodological nature of the study confers results that must be
corroborated with more powerful studies and stricter inclusion and selection criteria. Age and sex
should also be considered as confounding variables.
Gynecology represents 66.96 % of hospitalizations for benign tumors, which is consistent with the most
frequent types of benign tumors treated, uterine leiomyomas and ovarian and breast tumors. In the
second place, Surgery is found with 27.68 % for the resolution mainly of lipomas.
Internal medicine is the leading cancer care service, accounting for 77.17 % of hospitalizations. The
main types of cancer are leukemias, lymphomas, skin, lung, and gastric. The second service with the
highest percentage of hospitalizations is Surgery, with 16.30 %, where gastric and urological cancer are
mainly treated. The main types of cancer worldwide are lung, breast, colorectal, prostate, stomach, liver,
thyroid, and uterine cervix. (20-24)
A timely cancer diagnosis represents a greater probability of long-term survival, implementing early
surgical or clinical treatments. (25-28) We found an average wait of 35 days to be seen as referrals from the
first level, in charge of the health centers, to the second level of care, in charge of the HPGDR. These
data represent an essential information bias due to the number of losses, which made it impossible to
have a waiting time for analysis. Longitudinal studies are recommended to have a more accurate
follow-up and not have losses from that follow-up.
The National Institute for Health and Care Excellence recommends referring patients with metastatic
cancer of unknown origin for care within two weeks of referral.(29) It is necessary to create public policies
to address medical and non-medical expenses to improve the quality of life of cancer patients and mitigate
barriers to access to care since a timely diagnosis and approach reduce subsequent treatment costs.(30,31)
The strengths of this study are the rigor of the results obtained since the appropriate statistics were used,
providing 95 % CI and p values; it represents epidemiological data that can be extrapolated to the gene-
ral population since there were no sampling biases, obtaining adequate external validity; and it is the
starting point for more rigorous investigations in search of data that explain causality.
Limitations:
The main limitation of this study is the impossibility of stricter follow-up and control of the participants.
It was not possible to analyze more factors that contributed to the diagnosis of cancer.
To establish causal relationships, the design of our study is limited, as we present a cross-sectional
design. However, this type of design does allow for the analysis of relationships between variables that
present associations, such as the prevalence ratio, OR, etc. In medicine, it is impossible to establish
specific cause-and-effect relationships since pathologies, primarily cancer, are multifactorial.
The main limitation regarding the analysis of waiting times for care was the loss of data, which confers
little external validity to our results. These losses are primarily attributed to the fact that all hospital
discharges for cancer were considered, and many of them originate from emergency departments,
where there is no care policy based on primary care referrals.
Recommendations:
Mandatory, real-time health record keeping should be implemented, in addition to the referral form
(Form 053) to monitor patients. This would facilitate longitudinal studies.
Consider including oncology professionals at least once or twice a week to support outpatient care,
perform procedures, and diagnose patients with suspected cancer.
CONCLUSIONS
The prevalence of neoplasms in HPGDR from January to July 2024 is 3.11 % (95 % CI 3 %-4 %), and
45.09 % (95 % CI 38 %-52 %) corresponds to malignant neoplasms. The prevalence of cancer in the
total hospitalizations from January to July 2024 in HPGDR is 1.4 % (95 % CI 1 %-2 %).
Gynecology is the main service that treats benign neoplasms, the most frequent being leiomyomas,
ovarian or breast. The second service corresponds to Surgery for the resolution of lipomas.
The main cancer care service is internal medicine, which is used to treat leukemias, lymphomas, skin,
lung, and gastric cancers. The second service is Surgery for gastric and urological cancer care.
The waiting time required by patients to receive care by referrals from health centers to HPGDR is 35
days (95 % CI 19 – 51 days).
Funding: The authors funded this research.
Acknowledgments:
• To the authorities of the HPGDR.: Dr. María Sánchez, Manager; Dr. Evelyn Inca, medical director,
for promoting research and contributing to administrative procedures. To the Statistics service
for collaborating with the required data.
• To the National University of Chimborazo.
• To the Polytechnic School of Chimborazo.
Conflicts of interest: The authors declare no conflict of interest in this research.
Contribution Statement:
Conceptualization: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana. Data
curation, Formal analysis, Methodology, Software, Validation, Visualization, and Writing – review and
editing: Md. M.Sc. Carlos Andrés Yépez Salgado. Acquisition of funds: project self-financed by the
authors. Research: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana; Dr.
Paola Buenaño; Dr. David Orozco; Md. Yesenia Chandi. Project administration: Dr. Paola Buenaño; Dr.
David Orozco; Md. Yesenia Chandi. Supervision: Dr. Zully Mayra Romero Orellana; Dr. Paola Buenaño;
Dr. David Orozco. Writing – original draft: Md. Yesenia Chandi. All authors have read and agreed to the
published version of the manuscript.
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Prevalence of cancer and time to referral care in oncology patients
Prevalencia de cáncer y tiempo de atención de referencias en pacientes oncológicos.
https://doi.org/10.37135/ee.04.23.01
Authors:
Carlos Andrés Yépez Salgado1 - https://orcid.org/0009-0009-4722-8348
Zully Mayra Romero Orellana1,2 - https://orcid.org/0009-0000-6323-7548
David Cristóbal Orozco Brito3 - https://orcid.org/0000-0002-3945-3301
Nancy Paola Buenano Zambrano1 - https://orcid.org/0009-0003-2505-9236
Yesenia Liliana Chandi Japón4 - https://orcid.org/0009-0000-5672-0451
Affiliation:
1Hospital Provincial General Docente Riobamba.
2Universidad Nacional de Chimborazo.
3Escuela Superior Politécnica de Chimborazo.
4Centro de Salud Pungala Grande.
Corresponding author: Carlos Andrés Yépez Salgado. Hospital Provincial General Docente Riobamba.
Dirección postal: 060104. Email: med.carlos.andres@gmail.com / docenciahpgdrcoordinacion@gmail.
com Phone: +593984109505.
Received: January 24, 2025 Accepted: abril 01, 2025
ABSTRACT
Cancer represents a worldwide problem. In 2022, there were 30888 new cases of cancer and 16158
deaths in Ecuador. Considering the high morbidity and mortality due to this disease, health systems are
trying to meet the demand of these patients in public and private health services. Our main objective
was to establish the prevalence of cancer and the time of care of oncological patients referred to the
second level from the first of care during January-July 2024 at the Hospital Provincial General
Docente Riobamba. An original, observational, retrospective, descriptive, and correlational study
was presented. The prevalence of neoplasms is 3.11 %, and 45.09 % are malignant. The prevalence
of cancer in total hospitalizations is 1.4 %, and the average waiting time for care is 35 days. There
was a high prevalence of cancer in the hospital, where Internal medicine and Surgery are the services
with the most hospitalizations for this pathology.
Keywords: Cancer; Neoplasms; Epidemiology; Community Health Planning; Secondary Care Centers.
RESUMEN
El cáncer representa un problema a nivel mundial, en el año 2022 en el Ecuador existieron 30888
nuevos casos de cáncer y 16158 muertes, considerando una elevada morbimortalidad a causa de este
padecimiento, los sistemas de salud realizan un esfuerzo por solventar la demanda de estos pacientes
en los servicios de salud públicos y privados. El objetivo de esta investigación fue establecer la
prevalencia de cáncer y el tiempo de atención de referencias de pacientes oncológicos referidos desde
el primer nivel de atención al segundo nivel de atención de enero a julio de 2024 en el Hospital
Provincial General Docente de Riobamba. Se presentó un estudio original, observacional, transversal
retrospectivo, descriptivo y correlacional. La prevalencia de neoplasias es de 3,11 % y el 45,09 % son
malignas. La prevalencia de cáncer en el total de hospitalizaciones es 1,4% y el promedio de tiempo
de espera para la atención es de 35 días. Existió una elevada prevalencia de cáncer en el hospital,
siendo medicina interna y cirugía los servicios con más hospitalizaciones por esta patología.
Palabras clave: cáncer; neoplasias; epidemiología; planificación sanitaria comunitaria; centros de
atención secundaria.
.
INTRODUCTION
Cancer is a term used to refer to a broad group of diseases of complex and multifactorial origin caused
by abnormal cells that multiply autonomously and irregularly, invading other tissues locally and at a
distance.(1) The degree of malignancy is variable. It depends on the aggressiveness of its cells and
biological characteristics(2). They can spread and cause metastasis from different routes of dissemination
(lymphatic, blood, or by extension and direct invasion of neighboring tissues).(2,3) In general, if their
natural evolution is sought, they tend to lead to the death of the affected person in the short term.(4)
Currently, more than 200 different types of cancer are known, depending on the tissue from which they
are derived. The most common are those of the skin, lungs, breast, colon, and rectum.(5)
According to PAHO, cancer is one of the leading causes of mortality in the Americas. The figures indicate
that its incidence is growing rapidly worldwide, becoming a significant barrier to increasing life
expectancy. It is estimated that in 2022, there were 20 million new cases of cancer and 9.7 million
deaths in the region. (6,7)
Statistics from the International Agency for Research on Cancer indicate that in 2022 in Ecuador there
were 30888 new cases of cancer, 16,158 deaths, a risk of 7.3 % of dying from cancer before the age of
75; Prostate (29.4 %), stomach (11.2 %) and colorectal (8.4 %) cancer are more prevalent in our coun-
try; In female sex, lung cancer (23 %), cervical cancer (10.5 %) and colorectal cancer (8.0 %) are the
main ones; It is also mentioned that by 2040 there will be more than 53,701 cases detected during the
year in Ecuador. (8)
When analyzing the statistics, we observe that in Ecuador, as in the rest of the world, the incidence of
cancer is increasing, which is why it is necessary to have a health system that provides the opportunity
for each user to have adequate and timely care for their diagnosis and treatment.(8,9) It has been shown
that the delay in the care of this type of patient has been directly related to survival rates.(9) A study in
London about the survival of patients with breast cancer related to delayed uptake and treatment
showed that 32 % of patients with delays of 12 weeks or more had locally advanced or metastatic
disease, compared to only 10 % of those with delays of less than 12 weeks, which shows us the importance
of early recruitment.(10)
The national health system in Ecuador has a system of universality and progressive free healthcare
based on the Comprehensive Health Care model, which is supported by the user referral system to
improve healthcare.(11,12) This regulation is applied at all levels of care, thus allowing adequate care to
be provided to all users who require it according to the degree of complexity to achieve complete,
acceptable, and timely care.(13)
The health system of Ecuador offers a model that allows recruitment at the first level of health, which
is responsible for making the referral to the next step.(14) The time that elapses from the recruitment of
an oncology patient to the moment they obtain specialized care is usually long since the influx of
patients within the public health system is large.(11,15) Now, there are no studies that report the approximate
time of care for this type of patient.
This study in general terms aimed to establish the prevalence of cancer and the waiting time for the
care of cancer patients referred from the first to the second level of care from January to July 2024 at
the Hospital Provincial General Docente Riobamba (HPGDR).
The hypothesis proposed was that there is a high prevalence of cancer patients treated in the hospital
and a delay in the care of cancer patients due to the high demand for examinations and specialist
doctors that are not paid for by the Ministry of Public Health.
MATERIAL Y MÉTODOS
An original, observational, cross-sectional, retrospective study with a quantitative, descriptive, and
correlational approach was presented.
We worked with the entire population, representing the total number of patients hospitalized in all
specialties of the HPGDR, internal medicine, pediatrics, gynecology and obstetrics, Surgery, and ICU
from January to July 2024, p= 6559. By working with the entire population, we avoid sampling and
selection bias. The patient matrix called "Hospital discharges January to July 2024" is in the Hospital's
statistics service, which was provided to the researchers of an anonymized nature with the required
data according to the variables to be studied and before the delivery of a confidentiality commitment
from the authors and a general informed consent by the hospital's medical management.
Inclusion criteria.
• Patients treated in the hospital and registered in the hospital discharge matrix.
• Patients diagnosed with neoplastic pathology of any organ.
• Patients who have complied with the referral from the first level to the second level of care for
the calculation of the average days of waiting for referral care.
Exclusion criteria.
• Patients who do not provide the service where they were hospitalized in their database record.
Variables
Age, sex, diagnosis, date of care at the first level of care, date of care at the second level of care, type
of cancer, and hospitalization service.
The data obtained for the analysis correspond to the records of referral matrices and hospital discharge
matrices. These matrices are mandatory to report to the authorities of Ecuador's Zonal Coordination 3,
who evaluate care times to determine the productivity of treating medical professionals and hospital-level
productivity. The data are subject to review and registration in the Epidemiology Department. This
ensures the validity and quality of the data.
Once the final database was obtained in Excel, it was imported into the SPSS27 statistical package for
the coding of variables and statistical analysis. A univariate analysis was carried out to calculate the
prevalence of neoplasms and cancer based on the population. Ratios, proportions, and percentages for
qualitative variables; Measures of central tendency and dispersion for quantitative variables, always
accompanied by their 95 % confidence interval. The multivariate analysis looked for factors that
influence the presence of neoplasms and the presence of cancer, for which a logistic regression analysis
was performed.
The filling method was used for data processing with the average of the data obtained. This method was
used to analyze the average waiting time for referrals of oncology patients from primary to secondary care.
The study was approved by a human research ethics committee code: IO-29-CEISH- ESPOCH-2024.
RESULTS
Univariate analysis
The prevalence of patients with benign and malignant neoplasms of any organ calculated using the
formula: [(# of patients diagnosed with neoplasia / P) *100] [(204/6559)*100] is equal to 3.11 % (95 %
CI 3 %-4 %) from January to July 2024 in the HPGDR. 75.49 % were women (n=154) and 24.51%
were men (n=50).
The average age of patients with neoplasms, regardless of sex (n=204), is 49 years (95 % CI, 46 – 51
years) (minimum n = 1 year and maximum n = 94 years).
Based on the total population, the prevalence of cancer (malignant neoplasms) [(92/6559)*100] is
1.4% (95 % CI 1 %-2 %) from January to July 2024 in HPGDR. The prevalence of cancer concerning
the total number of patients diagnosed with neoplasia [(92/204)*100] is 45.09 % (9 5% CI 38 %-52 %).
Therefore, almost half of the patients hospitalized for neoplasms are malignant. About sex, 57.61%
(n=53) were women versus 42.39 % (n=39) were men.
The mean age, regardless of sex, of patients with malignant neoplasms is 56 years (95 % CI 52 – 59
years) (minimum n = 15 years and maximum n = 94 years).
Tables 1 and 2 represent the description of the tumors according to the hospitalization service.
Table 1. Benign tumors according to the hospitalization service.
Table 2. Malignant tumors according to the hospitalization service.
Benign and malignant tumors are described below according to their prevalence and hospitalization
services.
Tabla 3. Benign tumors.
The benign tumors with a frequency of 1 (0,9 %) each in Surgery are: tumor of the tongue; tumor of
the nasopharynx; tumor of the rectosigmoid junction; tumor of the meninges, part not specified;
tumor of the anal canal and anus; tumor of the lower jaw; kidney tumor; lipomatous tumor of the
intra-abdominal organs; and tumor of uncertain or unknown behavior of the brain, unspecified part.
Tabla 4. Malignant tumors.
Malignant tumors with a frequency of 1 (1.1 %) each in Internal medicine are: lymphoid leukemia,
no other specification; carcinoma in situ of the stomach; lymphoid leukemia, no other specification;
acute myeloblastic leukemia; chronic myeloid leukemia bcr/abl-positive; hodgkin's lymphoma
unspecified; non-follicular (diffuse) lymphoma not otherwise specified; multiple myeloma; kaposi's
sarcoma of the soft tissue; tumor of the thyroid gland; tumor of the skin of the trunk; tumor of the
central portion of the breast; tumor of the bones of the skull and face; tumor of the abdomen; tumor
of the cerebellum; brain tumor, except lobes and ventricles; tumor of the upper outer quadrant of the
breast; tumor of the body of the stomach; tumor of the body of the uterus, part not specified; tumor
of the esophagus, part not specified; tumor of the exocervix; liver tumor unspecified; ileum tumor;
tumor of the frontal lobe; tumor of the upper lobe, bronchus, or lung; tumor of the ovary; and tumor
of the testicle, unspecified.
To establish the mean number of days that patients were required to wait to receive care at the
second level, the total number of cancers (n=92) was taken. However, there was significant data
loss. It was only possible to obtain information on waiting days for care for 36 patients (39.13 %)
versus 56 (60.87 %) patients who did not have information on the days they waited to receive care
in the hospital.
Taking the data from the 36 patients, the average number of days required to be seen in the HPGDR
was 35 (95 % CI 19 – 51 days). The minimum waiting time was 2 days. The maximum was 204 days
waiting for care, and a Mode=2.
Multivariate analysis
Table 5 is presented below. A logistic regression model was performed to explain the dependent
variable presence of neoplasms, p= 6559.
Table 5. Logistic regression Presence of neoplasms.
It can be seen that the variables that explain the appearance of neoplasms are sex, age, and belonging
to the Surgery or gynecology service. Men are less likely to have a neoplasm (benign or malignant)
diagnosis OR 0.477, statistically significant, compared to women.
Concerning the 204 patients who presented neoplasms, a logistic regression was performed to explain
the dependent variable presence of malignant neoplasms. The results are shown below in Table 6.
Table 6. Logistic regression Presence of malignant neoplasms.
The variables that explain the presence of malignant neoplasms are age when the cut-off point is 65
years, and sex. Being male confers a higher chance of having malignancies (OR 5.99). Being younger
than 65 is less likely to get cancer (OR 0.25).
DISCUSSIÓN
The prevalence of benign or malignant neoplasms (3.11 %) represents a high percentage concerning
all HPGDR care that required hospitalization because it is a second-level hospital. If we divide the
number of neoplasms, we obtain that approximately 34 patients are hospitalized per month on average.
The hospital must ensure quality care for all patients.(11) It should be considered that approximately
half of the neoplasms are malignant (45.09 %). In most cases, more complex and expensive diagnostic
tests are required to determine their nature.(16-18) The percentage obtained in this study on the prevalence
of cancer shows a global reality, being the leading cause of death in 2020.(19)
In the univariate analysis, there were differences concerning age and sex, which were corroborated by
the multivariate analysis, where men have a lower risk of having a neoplasm (OR 0.47) p= 0.045.
However, men have a higher risk of malignancies (OR 5.99) p=0.000. According to international
cc
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ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 19
Número 2
13
REE 19(2) Riobamba may. - ago. 2025
statistics, men have an age-standardized incidence rate of 212.6, with a cumulative risk of developing
cancer before the age of 75 of 21.8 %, compared to women who have a standardized incidence rate of
186.3 with a risk of 18.5 %. (19,20) Similarly, our study shows that those younger than 65 represent a
lower cancer risk (OR 0.25) p=0.035.
Although supported by evidence, the methodological nature of the study confers results that must be
corroborated with more powerful studies and stricter inclusion and selection criteria. Age and sex
should also be considered as confounding variables.
Gynecology represents 66.96 % of hospitalizations for benign tumors, which is consistent with the most
frequent types of benign tumors treated, uterine leiomyomas and ovarian and breast tumors. In the
second place, Surgery is found with 27.68 % for the resolution mainly of lipomas.
Internal medicine is the leading cancer care service, accounting for 77.17 % of hospitalizations. The
main types of cancer are leukemias, lymphomas, skin, lung, and gastric. The second service with the
highest percentage of hospitalizations is Surgery, with 16.30 %, where gastric and urological cancer are
mainly treated. The main types of cancer worldwide are lung, breast, colorectal, prostate, stomach, liver,
thyroid, and uterine cervix. (20-24)
A timely cancer diagnosis represents a greater probability of long-term survival, implementing early
surgical or clinical treatments. (25-28) We found an average wait of 35 days to be seen as referrals from the
first level, in charge of the health centers, to the second level of care, in charge of the HPGDR. These
data represent an essential information bias due to the number of losses, which made it impossible to
have a waiting time for analysis. Longitudinal studies are recommended to have a more accurate
follow-up and not have losses from that follow-up.
The National Institute for Health and Care Excellence recommends referring patients with metastatic
cancer of unknown origin for care within two weeks of referral.(29) It is necessary to create public policies
to address medical and non-medical expenses to improve the quality of life of cancer patients and mitigate
barriers to access to care since a timely diagnosis and approach reduce subsequent treatment costs.(30,31)
The strengths of this study are the rigor of the results obtained since the appropriate statistics were used,
providing 95 % CI and p values; it represents epidemiological data that can be extrapolated to the gene-
ral population since there were no sampling biases, obtaining adequate external validity; and it is the
starting point for more rigorous investigations in search of data that explain causality.
Limitations:
The main limitation of this study is the impossibility of stricter follow-up and control of the participants.
It was not possible to analyze more factors that contributed to the diagnosis of cancer.
To establish causal relationships, the design of our study is limited, as we present a cross-sectional
design. However, this type of design does allow for the analysis of relationships between variables that
present associations, such as the prevalence ratio, OR, etc. In medicine, it is impossible to establish
specific cause-and-effect relationships since pathologies, primarily cancer, are multifactorial.
The main limitation regarding the analysis of waiting times for care was the loss of data, which confers
little external validity to our results. These losses are primarily attributed to the fact that all hospital
discharges for cancer were considered, and many of them originate from emergency departments,
where there is no care policy based on primary care referrals.
Recommendations:
Mandatory, real-time health record keeping should be implemented, in addition to the referral form
(Form 053) to monitor patients. This would facilitate longitudinal studies.
Consider including oncology professionals at least once or twice a week to support outpatient care,
perform procedures, and diagnose patients with suspected cancer.
CONCLUSIONS
The prevalence of neoplasms in HPGDR from January to July 2024 is 3.11 % (95 % CI 3 %-4 %), and
45.09 % (95 % CI 38 %-52 %) corresponds to malignant neoplasms. The prevalence of cancer in the
total hospitalizations from January to July 2024 in HPGDR is 1.4 % (95 % CI 1 %-2 %).
Gynecology is the main service that treats benign neoplasms, the most frequent being leiomyomas,
ovarian or breast. The second service corresponds to Surgery for the resolution of lipomas.
The main cancer care service is internal medicine, which is used to treat leukemias, lymphomas, skin,
lung, and gastric cancers. The second service is Surgery for gastric and urological cancer care.
The waiting time required by patients to receive care by referrals from health centers to HPGDR is 35
days (95 % CI 19 – 51 days).
Funding: The authors funded this research.
Acknowledgments:
• To the authorities of the HPGDR.: Dr. María Sánchez, Manager; Dr. Evelyn Inca, medical director,
for promoting research and contributing to administrative procedures. To the Statistics service
for collaborating with the required data.
• To the National University of Chimborazo.
• To the Polytechnic School of Chimborazo.
Conflicts of interest: The authors declare no conflict of interest in this research.
Contribution Statement:
Conceptualization: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana. Data
curation, Formal analysis, Methodology, Software, Validation, Visualization, and Writing – review and
editing: Md. M.Sc. Carlos Andrés Yépez Salgado. Acquisition of funds: project self-financed by the
authors. Research: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana; Dr.
Paola Buenaño; Dr. David Orozco; Md. Yesenia Chandi. Project administration: Dr. Paola Buenaño; Dr.
David Orozco; Md. Yesenia Chandi. Supervision: Dr. Zully Mayra Romero Orellana; Dr. Paola Buenaño;
Dr. David Orozco. Writing – original draft: Md. Yesenia Chandi. All authors have read and agreed to the
published version of the manuscript.
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Prevalence of cancer and time to referral care in oncology patients
Prevalencia de cáncer y tiempo de atención de referencias en pacientes oncológicos.
https://doi.org/10.37135/ee.04.23.01
Authors:
Carlos Andrés Yépez Salgado1 - https://orcid.org/0009-0009-4722-8348
Zully Mayra Romero Orellana1,2 - https://orcid.org/0009-0000-6323-7548
David Cristóbal Orozco Brito3 - https://orcid.org/0000-0002-3945-3301
Nancy Paola Buenano Zambrano1 - https://orcid.org/0009-0003-2505-9236
Yesenia Liliana Chandi Japón4 - https://orcid.org/0009-0000-5672-0451
Affiliation:
1Hospital Provincial General Docente Riobamba.
2Universidad Nacional de Chimborazo.
3Escuela Superior Politécnica de Chimborazo.
4Centro de Salud Pungala Grande.
Corresponding author: Carlos Andrés Yépez Salgado. Hospital Provincial General Docente Riobamba.
Dirección postal: 060104. Email: med.carlos.andres@gmail.com / docenciahpgdrcoordinacion@gmail.
com Phone: +593984109505.
Received: January 24, 2025 Accepted: abril 01, 2025
ABSTRACT
Cancer represents a worldwide problem. In 2022, there were 30888 new cases of cancer and 16158
deaths in Ecuador. Considering the high morbidity and mortality due to this disease, health systems are
trying to meet the demand of these patients in public and private health services. Our main objective
was to establish the prevalence of cancer and the time of care of oncological patients referred to the
second level from the first of care during January-July 2024 at the Hospital Provincial General
Docente Riobamba. An original, observational, retrospective, descriptive, and correlational study
was presented. The prevalence of neoplasms is 3.11 %, and 45.09 % are malignant. The prevalence
of cancer in total hospitalizations is 1.4 %, and the average waiting time for care is 35 days. There
was a high prevalence of cancer in the hospital, where Internal medicine and Surgery are the services
with the most hospitalizations for this pathology.
Keywords: Cancer; Neoplasms; Epidemiology; Community Health Planning; Secondary Care Centers.
RESUMEN
El cáncer representa un problema a nivel mundial, en el año 2022 en el Ecuador existieron 30888
nuevos casos de cáncer y 16158 muertes, considerando una elevada morbimortalidad a causa de este
padecimiento, los sistemas de salud realizan un esfuerzo por solventar la demanda de estos pacientes
en los servicios de salud públicos y privados. El objetivo de esta investigación fue establecer la
prevalencia de cáncer y el tiempo de atención de referencias de pacientes oncológicos referidos desde
el primer nivel de atención al segundo nivel de atención de enero a julio de 2024 en el Hospital
Provincial General Docente de Riobamba. Se presentó un estudio original, observacional, transversal
retrospectivo, descriptivo y correlacional. La prevalencia de neoplasias es de 3,11 % y el 45,09 % son
malignas. La prevalencia de cáncer en el total de hospitalizaciones es 1,4% y el promedio de tiempo
de espera para la atención es de 35 días. Existió una elevada prevalencia de cáncer en el hospital,
siendo medicina interna y cirugía los servicios con más hospitalizaciones por esta patología.
Palabras clave: cáncer; neoplasias; epidemiología; planificación sanitaria comunitaria; centros de
atención secundaria.
.
INTRODUCTION
Cancer is a term used to refer to a broad group of diseases of complex and multifactorial origin caused
by abnormal cells that multiply autonomously and irregularly, invading other tissues locally and at a
distance.(1) The degree of malignancy is variable. It depends on the aggressiveness of its cells and
biological characteristics(2). They can spread and cause metastasis from different routes of dissemination
(lymphatic, blood, or by extension and direct invasion of neighboring tissues).(2,3) In general, if their
natural evolution is sought, they tend to lead to the death of the affected person in the short term.(4)
Currently, more than 200 different types of cancer are known, depending on the tissue from which they
are derived. The most common are those of the skin, lungs, breast, colon, and rectum.(5)
According to PAHO, cancer is one of the leading causes of mortality in the Americas. The figures indicate
that its incidence is growing rapidly worldwide, becoming a significant barrier to increasing life
expectancy. It is estimated that in 2022, there were 20 million new cases of cancer and 9.7 million
deaths in the region. (6,7)
Statistics from the International Agency for Research on Cancer indicate that in 2022 in Ecuador there
were 30888 new cases of cancer, 16,158 deaths, a risk of 7.3 % of dying from cancer before the age of
75; Prostate (29.4 %), stomach (11.2 %) and colorectal (8.4 %) cancer are more prevalent in our coun-
try; In female sex, lung cancer (23 %), cervical cancer (10.5 %) and colorectal cancer (8.0 %) are the
main ones; It is also mentioned that by 2040 there will be more than 53,701 cases detected during the
year in Ecuador. (8)
When analyzing the statistics, we observe that in Ecuador, as in the rest of the world, the incidence of
cancer is increasing, which is why it is necessary to have a health system that provides the opportunity
for each user to have adequate and timely care for their diagnosis and treatment.(8,9) It has been shown
that the delay in the care of this type of patient has been directly related to survival rates.(9) A study in
London about the survival of patients with breast cancer related to delayed uptake and treatment
showed that 32 % of patients with delays of 12 weeks or more had locally advanced or metastatic
disease, compared to only 10 % of those with delays of less than 12 weeks, which shows us the importance
of early recruitment.(10)
The national health system in Ecuador has a system of universality and progressive free healthcare
based on the Comprehensive Health Care model, which is supported by the user referral system to
improve healthcare.(11,12) This regulation is applied at all levels of care, thus allowing adequate care to
be provided to all users who require it according to the degree of complexity to achieve complete,
acceptable, and timely care.(13)
The health system of Ecuador offers a model that allows recruitment at the first level of health, which
is responsible for making the referral to the next step.(14) The time that elapses from the recruitment of
an oncology patient to the moment they obtain specialized care is usually long since the influx of
patients within the public health system is large.(11,15) Now, there are no studies that report the approximate
time of care for this type of patient.
This study in general terms aimed to establish the prevalence of cancer and the waiting time for the
care of cancer patients referred from the first to the second level of care from January to July 2024 at
the Hospital Provincial General Docente Riobamba (HPGDR).
The hypothesis proposed was that there is a high prevalence of cancer patients treated in the hospital
and a delay in the care of cancer patients due to the high demand for examinations and specialist
doctors that are not paid for by the Ministry of Public Health.
MATERIAL Y MÉTODOS
An original, observational, cross-sectional, retrospective study with a quantitative, descriptive, and
correlational approach was presented.
We worked with the entire population, representing the total number of patients hospitalized in all
specialties of the HPGDR, internal medicine, pediatrics, gynecology and obstetrics, Surgery, and ICU
from January to July 2024, p= 6559. By working with the entire population, we avoid sampling and
selection bias. The patient matrix called "Hospital discharges January to July 2024" is in the Hospital's
statistics service, which was provided to the researchers of an anonymized nature with the required
data according to the variables to be studied and before the delivery of a confidentiality commitment
from the authors and a general informed consent by the hospital's medical management.
Inclusion criteria.
• Patients treated in the hospital and registered in the hospital discharge matrix.
• Patients diagnosed with neoplastic pathology of any organ.
• Patients who have complied with the referral from the first level to the second level of care for
the calculation of the average days of waiting for referral care.
Exclusion criteria.
• Patients who do not provide the service where they were hospitalized in their database record.
Variables
Age, sex, diagnosis, date of care at the first level of care, date of care at the second level of care, type
of cancer, and hospitalization service.
The data obtained for the analysis correspond to the records of referral matrices and hospital discharge
matrices. These matrices are mandatory to report to the authorities of Ecuador's Zonal Coordination 3,
who evaluate care times to determine the productivity of treating medical professionals and hospital-level
productivity. The data are subject to review and registration in the Epidemiology Department. This
ensures the validity and quality of the data.
Once the final database was obtained in Excel, it was imported into the SPSS27 statistical package for
the coding of variables and statistical analysis. A univariate analysis was carried out to calculate the
prevalence of neoplasms and cancer based on the population. Ratios, proportions, and percentages for
qualitative variables; Measures of central tendency and dispersion for quantitative variables, always
accompanied by their 95 % confidence interval. The multivariate analysis looked for factors that
influence the presence of neoplasms and the presence of cancer, for which a logistic regression analysis
was performed.
The filling method was used for data processing with the average of the data obtained. This method was
used to analyze the average waiting time for referrals of oncology patients from primary to secondary care.
The study was approved by a human research ethics committee code: IO-29-CEISH- ESPOCH-2024.
RESULTS
Univariate analysis
The prevalence of patients with benign and malignant neoplasms of any organ calculated using the
formula: [(# of patients diagnosed with neoplasia / P) *100] [(204/6559)*100] is equal to 3.11 % (95 %
CI 3 %-4 %) from January to July 2024 in the HPGDR. 75.49 % were women (n=154) and 24.51%
were men (n=50).
The average age of patients with neoplasms, regardless of sex (n=204), is 49 years (95 % CI, 46 – 51
years) (minimum n = 1 year and maximum n = 94 years).
Based on the total population, the prevalence of cancer (malignant neoplasms) [(92/6559)*100] is
1.4% (95 % CI 1 %-2 %) from January to July 2024 in HPGDR. The prevalence of cancer concerning
the total number of patients diagnosed with neoplasia [(92/204)*100] is 45.09 % (9 5% CI 38 %-52 %).
Therefore, almost half of the patients hospitalized for neoplasms are malignant. About sex, 57.61%
(n=53) were women versus 42.39 % (n=39) were men.
The mean age, regardless of sex, of patients with malignant neoplasms is 56 years (95 % CI 52 – 59
years) (minimum n = 15 years and maximum n = 94 years).
Tables 1 and 2 represent the description of the tumors according to the hospitalization service.
Table 1. Benign tumors according to the hospitalization service.
Table 2. Malignant tumors according to the hospitalization service.
Benign and malignant tumors are described below according to their prevalence and hospitalization
services.
Tabla 3. Benign tumors.
The benign tumors with a frequency of 1 (0,9 %) each in Surgery are: tumor of the tongue; tumor of
the nasopharynx; tumor of the rectosigmoid junction; tumor of the meninges, part not specified;
tumor of the anal canal and anus; tumor of the lower jaw; kidney tumor; lipomatous tumor of the
intra-abdominal organs; and tumor of uncertain or unknown behavior of the brain, unspecified part.
Tabla 4. Malignant tumors.
Malignant tumors with a frequency of 1 (1.1 %) each in Internal medicine are: lymphoid leukemia,
no other specification; carcinoma in situ of the stomach; lymphoid leukemia, no other specification;
acute myeloblastic leukemia; chronic myeloid leukemia bcr/abl-positive; hodgkin's lymphoma
unspecified; non-follicular (diffuse) lymphoma not otherwise specified; multiple myeloma; kaposi's
sarcoma of the soft tissue; tumor of the thyroid gland; tumor of the skin of the trunk; tumor of the
central portion of the breast; tumor of the bones of the skull and face; tumor of the abdomen; tumor
of the cerebellum; brain tumor, except lobes and ventricles; tumor of the upper outer quadrant of the
breast; tumor of the body of the stomach; tumor of the body of the uterus, part not specified; tumor
of the esophagus, part not specified; tumor of the exocervix; liver tumor unspecified; ileum tumor;
tumor of the frontal lobe; tumor of the upper lobe, bronchus, or lung; tumor of the ovary; and tumor
of the testicle, unspecified.
To establish the mean number of days that patients were required to wait to receive care at the
second level, the total number of cancers (n=92) was taken. However, there was significant data
loss. It was only possible to obtain information on waiting days for care for 36 patients (39.13 %)
versus 56 (60.87 %) patients who did not have information on the days they waited to receive care
in the hospital.
Taking the data from the 36 patients, the average number of days required to be seen in the HPGDR
was 35 (95 % CI 19 – 51 days). The minimum waiting time was 2 days. The maximum was 204 days
waiting for care, and a Mode=2.
Multivariate analysis
Table 5 is presented below. A logistic regression model was performed to explain the dependent
variable presence of neoplasms, p= 6559.
Table 5. Logistic regression Presence of neoplasms.
It can be seen that the variables that explain the appearance of neoplasms are sex, age, and belonging
to the Surgery or gynecology service. Men are less likely to have a neoplasm (benign or malignant)
diagnosis OR 0.477, statistically significant, compared to women.
Concerning the 204 patients who presented neoplasms, a logistic regression was performed to explain
the dependent variable presence of malignant neoplasms. The results are shown below in Table 6.
Table 6. Logistic regression Presence of malignant neoplasms.
The variables that explain the presence of malignant neoplasms are age when the cut-off point is 65
years, and sex. Being male confers a higher chance of having malignancies (OR 5.99). Being younger
than 65 is less likely to get cancer (OR 0.25).
DISCUSSIÓN
The prevalence of benign or malignant neoplasms (3.11 %) represents a high percentage concerning
all HPGDR care that required hospitalization because it is a second-level hospital. If we divide the
number of neoplasms, we obtain that approximately 34 patients are hospitalized per month on average.
The hospital must ensure quality care for all patients.(11) It should be considered that approximately
half of the neoplasms are malignant (45.09 %). In most cases, more complex and expensive diagnostic
tests are required to determine their nature.(16-18) The percentage obtained in this study on the prevalence
of cancer shows a global reality, being the leading cause of death in 2020.(19)
In the univariate analysis, there were differences concerning age and sex, which were corroborated by
the multivariate analysis, where men have a lower risk of having a neoplasm (OR 0.47) p= 0.045.
However, men have a higher risk of malignancies (OR 5.99) p=0.000. According to international
cc
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ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 19
Número 2
14
REE 19(2) Riobamba may. - ago. 2025
statistics, men have an age-standardized incidence rate of 212.6, with a cumulative risk of developing
cancer before the age of 75 of 21.8 %, compared to women who have a standardized incidence rate of
186.3 with a risk of 18.5 %. (19,20) Similarly, our study shows that those younger than 65 represent a
lower cancer risk (OR 0.25) p=0.035.
Although supported by evidence, the methodological nature of the study confers results that must be
corroborated with more powerful studies and stricter inclusion and selection criteria. Age and sex
should also be considered as confounding variables.
Gynecology represents 66.96 % of hospitalizations for benign tumors, which is consistent with the most
frequent types of benign tumors treated, uterine leiomyomas and ovarian and breast tumors. In the
second place, Surgery is found with 27.68 % for the resolution mainly of lipomas.
Internal medicine is the leading cancer care service, accounting for 77.17 % of hospitalizations. The
main types of cancer are leukemias, lymphomas, skin, lung, and gastric. The second service with the
highest percentage of hospitalizations is Surgery, with 16.30 %, where gastric and urological cancer are
mainly treated. The main types of cancer worldwide are lung, breast, colorectal, prostate, stomach, liver,
thyroid, and uterine cervix. (20-24)
A timely cancer diagnosis represents a greater probability of long-term survival, implementing early
surgical or clinical treatments. (25-28) We found an average wait of 35 days to be seen as referrals from the
first level, in charge of the health centers, to the second level of care, in charge of the HPGDR. These
data represent an essential information bias due to the number of losses, which made it impossible to
have a waiting time for analysis. Longitudinal studies are recommended to have a more accurate
follow-up and not have losses from that follow-up.
The National Institute for Health and Care Excellence recommends referring patients with metastatic
cancer of unknown origin for care within two weeks of referral.(29) It is necessary to create public policies
to address medical and non-medical expenses to improve the quality of life of cancer patients and mitigate
barriers to access to care since a timely diagnosis and approach reduce subsequent treatment costs.(30,31)
The strengths of this study are the rigor of the results obtained since the appropriate statistics were used,
providing 95 % CI and p values; it represents epidemiological data that can be extrapolated to the gene-
ral population since there were no sampling biases, obtaining adequate external validity; and it is the
starting point for more rigorous investigations in search of data that explain causality.
Limitations:
The main limitation of this study is the impossibility of stricter follow-up and control of the participants.
It was not possible to analyze more factors that contributed to the diagnosis of cancer.
To establish causal relationships, the design of our study is limited, as we present a cross-sectional
design. However, this type of design does allow for the analysis of relationships between variables that
present associations, such as the prevalence ratio, OR, etc. In medicine, it is impossible to establish
specific cause-and-effect relationships since pathologies, primarily cancer, are multifactorial.
The main limitation regarding the analysis of waiting times for care was the loss of data, which confers
little external validity to our results. These losses are primarily attributed to the fact that all hospital
discharges for cancer were considered, and many of them originate from emergency departments,
where there is no care policy based on primary care referrals.
Recommendations:
Mandatory, real-time health record keeping should be implemented, in addition to the referral form
(Form 053) to monitor patients. This would facilitate longitudinal studies.
Consider including oncology professionals at least once or twice a week to support outpatient care,
perform procedures, and diagnose patients with suspected cancer.
CONCLUSIONS
The prevalence of neoplasms in HPGDR from January to July 2024 is 3.11 % (95 % CI 3 %-4 %), and
45.09 % (95 % CI 38 %-52 %) corresponds to malignant neoplasms. The prevalence of cancer in the
total hospitalizations from January to July 2024 in HPGDR is 1.4 % (95 % CI 1 %-2 %).
Gynecology is the main service that treats benign neoplasms, the most frequent being leiomyomas,
ovarian or breast. The second service corresponds to Surgery for the resolution of lipomas.
The main cancer care service is internal medicine, which is used to treat leukemias, lymphomas, skin,
lung, and gastric cancers. The second service is Surgery for gastric and urological cancer care.
The waiting time required by patients to receive care by referrals from health centers to HPGDR is 35
days (95 % CI 19 – 51 days).
Funding: The authors funded this research.
Acknowledgments:
• To the authorities of the HPGDR.: Dr. María Sánchez, Manager; Dr. Evelyn Inca, medical director,
for promoting research and contributing to administrative procedures. To the Statistics service
for collaborating with the required data.
• To the National University of Chimborazo.
• To the Polytechnic School of Chimborazo.
Conflicts of interest: The authors declare no conflict of interest in this research.
Contribution Statement:
Conceptualization: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana. Data
curation, Formal analysis, Methodology, Software, Validation, Visualization, and Writing – review and
editing: Md. M.Sc. Carlos Andrés Yépez Salgado. Acquisition of funds: project self-financed by the
authors. Research: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana; Dr.
Paola Buenaño; Dr. David Orozco; Md. Yesenia Chandi. Project administration: Dr. Paola Buenaño; Dr.
David Orozco; Md. Yesenia Chandi. Supervision: Dr. Zully Mayra Romero Orellana; Dr. Paola Buenaño;
Dr. David Orozco. Writing – original draft: Md. Yesenia Chandi. All authors have read and agreed to the
published version of the manuscript.
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Prevalence of cancer and time to referral care in oncology patients
Prevalencia de cáncer y tiempo de atención de referencias en pacientes oncológicos.
https://doi.org/10.37135/ee.04.23.01
Authors:
Carlos Andrés Yépez Salgado1 - https://orcid.org/0009-0009-4722-8348
Zully Mayra Romero Orellana1,2 - https://orcid.org/0009-0000-6323-7548
David Cristóbal Orozco Brito3 - https://orcid.org/0000-0002-3945-3301
Nancy Paola Buenano Zambrano1 - https://orcid.org/0009-0003-2505-9236
Yesenia Liliana Chandi Japón4 - https://orcid.org/0009-0000-5672-0451
Affiliation:
1Hospital Provincial General Docente Riobamba.
2Universidad Nacional de Chimborazo.
3Escuela Superior Politécnica de Chimborazo.
4Centro de Salud Pungala Grande.
Corresponding author: Carlos Andrés Yépez Salgado. Hospital Provincial General Docente Riobamba.
Dirección postal: 060104. Email: med.carlos.andres@gmail.com / docenciahpgdrcoordinacion@gmail.
com Phone: +593984109505.
Received: January 24, 2025 Accepted: abril 01, 2025
ABSTRACT
Cancer represents a worldwide problem. In 2022, there were 30888 new cases of cancer and 16158
deaths in Ecuador. Considering the high morbidity and mortality due to this disease, health systems are
trying to meet the demand of these patients in public and private health services. Our main objective
was to establish the prevalence of cancer and the time of care of oncological patients referred to the
second level from the first of care during January-July 2024 at the Hospital Provincial General
Docente Riobamba. An original, observational, retrospective, descriptive, and correlational study
was presented. The prevalence of neoplasms is 3.11 %, and 45.09 % are malignant. The prevalence
of cancer in total hospitalizations is 1.4 %, and the average waiting time for care is 35 days. There
was a high prevalence of cancer in the hospital, where Internal medicine and Surgery are the services
with the most hospitalizations for this pathology.
Keywords: Cancer; Neoplasms; Epidemiology; Community Health Planning; Secondary Care Centers.
RESUMEN
El cáncer representa un problema a nivel mundial, en el año 2022 en el Ecuador existieron 30888
nuevos casos de cáncer y 16158 muertes, considerando una elevada morbimortalidad a causa de este
padecimiento, los sistemas de salud realizan un esfuerzo por solventar la demanda de estos pacientes
en los servicios de salud públicos y privados. El objetivo de esta investigación fue establecer la
prevalencia de cáncer y el tiempo de atención de referencias de pacientes oncológicos referidos desde
el primer nivel de atención al segundo nivel de atención de enero a julio de 2024 en el Hospital
Provincial General Docente de Riobamba. Se presentó un estudio original, observacional, transversal
retrospectivo, descriptivo y correlacional. La prevalencia de neoplasias es de 3,11 % y el 45,09 % son
malignas. La prevalencia de cáncer en el total de hospitalizaciones es 1,4% y el promedio de tiempo
de espera para la atención es de 35 días. Existió una elevada prevalencia de cáncer en el hospital,
siendo medicina interna y cirugía los servicios con más hospitalizaciones por esta patología.
Palabras clave: cáncer; neoplasias; epidemiología; planificación sanitaria comunitaria; centros de
atención secundaria.
.
INTRODUCTION
Cancer is a term used to refer to a broad group of diseases of complex and multifactorial origin caused
by abnormal cells that multiply autonomously and irregularly, invading other tissues locally and at a
distance.(1) The degree of malignancy is variable. It depends on the aggressiveness of its cells and
biological characteristics(2). They can spread and cause metastasis from different routes of dissemination
(lymphatic, blood, or by extension and direct invasion of neighboring tissues).(2,3) In general, if their
natural evolution is sought, they tend to lead to the death of the affected person in the short term.(4)
Currently, more than 200 different types of cancer are known, depending on the tissue from which they
are derived. The most common are those of the skin, lungs, breast, colon, and rectum.(5)
According to PAHO, cancer is one of the leading causes of mortality in the Americas. The figures indicate
that its incidence is growing rapidly worldwide, becoming a significant barrier to increasing life
expectancy. It is estimated that in 2022, there were 20 million new cases of cancer and 9.7 million
deaths in the region. (6,7)
Statistics from the International Agency for Research on Cancer indicate that in 2022 in Ecuador there
were 30888 new cases of cancer, 16,158 deaths, a risk of 7.3 % of dying from cancer before the age of
75; Prostate (29.4 %), stomach (11.2 %) and colorectal (8.4 %) cancer are more prevalent in our coun-
try; In female sex, lung cancer (23 %), cervical cancer (10.5 %) and colorectal cancer (8.0 %) are the
main ones; It is also mentioned that by 2040 there will be more than 53,701 cases detected during the
year in Ecuador. (8)
When analyzing the statistics, we observe that in Ecuador, as in the rest of the world, the incidence of
cancer is increasing, which is why it is necessary to have a health system that provides the opportunity
for each user to have adequate and timely care for their diagnosis and treatment.(8,9) It has been shown
that the delay in the care of this type of patient has been directly related to survival rates.(9) A study in
London about the survival of patients with breast cancer related to delayed uptake and treatment
showed that 32 % of patients with delays of 12 weeks or more had locally advanced or metastatic
disease, compared to only 10 % of those with delays of less than 12 weeks, which shows us the importance
of early recruitment.(10)
The national health system in Ecuador has a system of universality and progressive free healthcare
based on the Comprehensive Health Care model, which is supported by the user referral system to
improve healthcare.(11,12) This regulation is applied at all levels of care, thus allowing adequate care to
be provided to all users who require it according to the degree of complexity to achieve complete,
acceptable, and timely care.(13)
The health system of Ecuador offers a model that allows recruitment at the first level of health, which
is responsible for making the referral to the next step.(14) The time that elapses from the recruitment of
an oncology patient to the moment they obtain specialized care is usually long since the influx of
patients within the public health system is large.(11,15) Now, there are no studies that report the approximate
time of care for this type of patient.
This study in general terms aimed to establish the prevalence of cancer and the waiting time for the
care of cancer patients referred from the first to the second level of care from January to July 2024 at
the Hospital Provincial General Docente Riobamba (HPGDR).
The hypothesis proposed was that there is a high prevalence of cancer patients treated in the hospital
and a delay in the care of cancer patients due to the high demand for examinations and specialist
doctors that are not paid for by the Ministry of Public Health.
MATERIAL Y MÉTODOS
An original, observational, cross-sectional, retrospective study with a quantitative, descriptive, and
correlational approach was presented.
We worked with the entire population, representing the total number of patients hospitalized in all
specialties of the HPGDR, internal medicine, pediatrics, gynecology and obstetrics, Surgery, and ICU
from January to July 2024, p= 6559. By working with the entire population, we avoid sampling and
selection bias. The patient matrix called "Hospital discharges January to July 2024" is in the Hospital's
statistics service, which was provided to the researchers of an anonymized nature with the required
data according to the variables to be studied and before the delivery of a confidentiality commitment
from the authors and a general informed consent by the hospital's medical management.
Inclusion criteria.
• Patients treated in the hospital and registered in the hospital discharge matrix.
• Patients diagnosed with neoplastic pathology of any organ.
• Patients who have complied with the referral from the first level to the second level of care for
the calculation of the average days of waiting for referral care.
Exclusion criteria.
• Patients who do not provide the service where they were hospitalized in their database record.
Variables
Age, sex, diagnosis, date of care at the first level of care, date of care at the second level of care, type
of cancer, and hospitalization service.
The data obtained for the analysis correspond to the records of referral matrices and hospital discharge
matrices. These matrices are mandatory to report to the authorities of Ecuador's Zonal Coordination 3,
who evaluate care times to determine the productivity of treating medical professionals and hospital-level
productivity. The data are subject to review and registration in the Epidemiology Department. This
ensures the validity and quality of the data.
Once the final database was obtained in Excel, it was imported into the SPSS27 statistical package for
the coding of variables and statistical analysis. A univariate analysis was carried out to calculate the
prevalence of neoplasms and cancer based on the population. Ratios, proportions, and percentages for
qualitative variables; Measures of central tendency and dispersion for quantitative variables, always
accompanied by their 95 % confidence interval. The multivariate analysis looked for factors that
influence the presence of neoplasms and the presence of cancer, for which a logistic regression analysis
was performed.
The filling method was used for data processing with the average of the data obtained. This method was
used to analyze the average waiting time for referrals of oncology patients from primary to secondary care.
The study was approved by a human research ethics committee code: IO-29-CEISH- ESPOCH-2024.
RESULTS
Univariate analysis
The prevalence of patients with benign and malignant neoplasms of any organ calculated using the
formula: [(# of patients diagnosed with neoplasia / P) *100] [(204/6559)*100] is equal to 3.11 % (95 %
CI 3 %-4 %) from January to July 2024 in the HPGDR. 75.49 % were women (n=154) and 24.51%
were men (n=50).
The average age of patients with neoplasms, regardless of sex (n=204), is 49 years (95 % CI, 46 – 51
years) (minimum n = 1 year and maximum n = 94 years).
Based on the total population, the prevalence of cancer (malignant neoplasms) [(92/6559)*100] is
1.4% (95 % CI 1 %-2 %) from January to July 2024 in HPGDR. The prevalence of cancer concerning
the total number of patients diagnosed with neoplasia [(92/204)*100] is 45.09 % (9 5% CI 38 %-52 %).
Therefore, almost half of the patients hospitalized for neoplasms are malignant. About sex, 57.61%
(n=53) were women versus 42.39 % (n=39) were men.
The mean age, regardless of sex, of patients with malignant neoplasms is 56 years (95 % CI 52 – 59
years) (minimum n = 15 years and maximum n = 94 years).
Tables 1 and 2 represent the description of the tumors according to the hospitalization service.
Table 1. Benign tumors according to the hospitalization service.
Table 2. Malignant tumors according to the hospitalization service.
Benign and malignant tumors are described below according to their prevalence and hospitalization
services.
Tabla 3. Benign tumors.
The benign tumors with a frequency of 1 (0,9 %) each in Surgery are: tumor of the tongue; tumor of
the nasopharynx; tumor of the rectosigmoid junction; tumor of the meninges, part not specified;
tumor of the anal canal and anus; tumor of the lower jaw; kidney tumor; lipomatous tumor of the
intra-abdominal organs; and tumor of uncertain or unknown behavior of the brain, unspecified part.
Tabla 4. Malignant tumors.
Malignant tumors with a frequency of 1 (1.1 %) each in Internal medicine are: lymphoid leukemia,
no other specification; carcinoma in situ of the stomach; lymphoid leukemia, no other specification;
acute myeloblastic leukemia; chronic myeloid leukemia bcr/abl-positive; hodgkin's lymphoma
unspecified; non-follicular (diffuse) lymphoma not otherwise specified; multiple myeloma; kaposi's
sarcoma of the soft tissue; tumor of the thyroid gland; tumor of the skin of the trunk; tumor of the
central portion of the breast; tumor of the bones of the skull and face; tumor of the abdomen; tumor
of the cerebellum; brain tumor, except lobes and ventricles; tumor of the upper outer quadrant of the
breast; tumor of the body of the stomach; tumor of the body of the uterus, part not specified; tumor
of the esophagus, part not specified; tumor of the exocervix; liver tumor unspecified; ileum tumor;
tumor of the frontal lobe; tumor of the upper lobe, bronchus, or lung; tumor of the ovary; and tumor
of the testicle, unspecified.
To establish the mean number of days that patients were required to wait to receive care at the
second level, the total number of cancers (n=92) was taken. However, there was significant data
loss. It was only possible to obtain information on waiting days for care for 36 patients (39.13 %)
versus 56 (60.87 %) patients who did not have information on the days they waited to receive care
in the hospital.
Taking the data from the 36 patients, the average number of days required to be seen in the HPGDR
was 35 (95 % CI 19 – 51 days). The minimum waiting time was 2 days. The maximum was 204 days
waiting for care, and a Mode=2.
Multivariate analysis
Table 5 is presented below. A logistic regression model was performed to explain the dependent
variable presence of neoplasms, p= 6559.
Table 5. Logistic regression Presence of neoplasms.
It can be seen that the variables that explain the appearance of neoplasms are sex, age, and belonging
to the Surgery or gynecology service. Men are less likely to have a neoplasm (benign or malignant)
diagnosis OR 0.477, statistically significant, compared to women.
Concerning the 204 patients who presented neoplasms, a logistic regression was performed to explain
the dependent variable presence of malignant neoplasms. The results are shown below in Table 6.
Table 6. Logistic regression Presence of malignant neoplasms.
The variables that explain the presence of malignant neoplasms are age when the cut-off point is 65
years, and sex. Being male confers a higher chance of having malignancies (OR 5.99). Being younger
than 65 is less likely to get cancer (OR 0.25).
DISCUSSIÓN
The prevalence of benign or malignant neoplasms (3.11 %) represents a high percentage concerning
all HPGDR care that required hospitalization because it is a second-level hospital. If we divide the
number of neoplasms, we obtain that approximately 34 patients are hospitalized per month on average.
The hospital must ensure quality care for all patients.(11) It should be considered that approximately
half of the neoplasms are malignant (45.09 %). In most cases, more complex and expensive diagnostic
tests are required to determine their nature.(16-18) The percentage obtained in this study on the prevalence
of cancer shows a global reality, being the leading cause of death in 2020.(19)
In the univariate analysis, there were differences concerning age and sex, which were corroborated by
the multivariate analysis, where men have a lower risk of having a neoplasm (OR 0.47) p= 0.045.
However, men have a higher risk of malignancies (OR 5.99) p=0.000. According to international
cc
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ISSN-impreso 1390-7581
ISSN-digital 2661-6742
Volumen 19
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REE 19(2) Riobamba may. - ago. 2025
statistics, men have an age-standardized incidence rate of 212.6, with a cumulative risk of developing
cancer before the age of 75 of 21.8 %, compared to women who have a standardized incidence rate of
186.3 with a risk of 18.5 %. (19,20) Similarly, our study shows that those younger than 65 represent a
lower cancer risk (OR 0.25) p=0.035.
Although supported by evidence, the methodological nature of the study confers results that must be
corroborated with more powerful studies and stricter inclusion and selection criteria. Age and sex
should also be considered as confounding variables.
Gynecology represents 66.96 % of hospitalizations for benign tumors, which is consistent with the most
frequent types of benign tumors treated, uterine leiomyomas and ovarian and breast tumors. In the
second place, Surgery is found with 27.68 % for the resolution mainly of lipomas.
Internal medicine is the leading cancer care service, accounting for 77.17 % of hospitalizations. The
main types of cancer are leukemias, lymphomas, skin, lung, and gastric. The second service with the
highest percentage of hospitalizations is Surgery, with 16.30 %, where gastric and urological cancer are
mainly treated. The main types of cancer worldwide are lung, breast, colorectal, prostate, stomach, liver,
thyroid, and uterine cervix. (20-24)
A timely cancer diagnosis represents a greater probability of long-term survival, implementing early
surgical or clinical treatments. (25-28) We found an average wait of 35 days to be seen as referrals from the
first level, in charge of the health centers, to the second level of care, in charge of the HPGDR. These
data represent an essential information bias due to the number of losses, which made it impossible to
have a waiting time for analysis. Longitudinal studies are recommended to have a more accurate
follow-up and not have losses from that follow-up.
The National Institute for Health and Care Excellence recommends referring patients with metastatic
cancer of unknown origin for care within two weeks of referral.(29) It is necessary to create public policies
to address medical and non-medical expenses to improve the quality of life of cancer patients and mitigate
barriers to access to care since a timely diagnosis and approach reduce subsequent treatment costs.(30,31)
The strengths of this study are the rigor of the results obtained since the appropriate statistics were used,
providing 95 % CI and p values; it represents epidemiological data that can be extrapolated to the gene-
ral population since there were no sampling biases, obtaining adequate external validity; and it is the
starting point for more rigorous investigations in search of data that explain causality.
Limitations:
The main limitation of this study is the impossibility of stricter follow-up and control of the participants.
It was not possible to analyze more factors that contributed to the diagnosis of cancer.
To establish causal relationships, the design of our study is limited, as we present a cross-sectional
design. However, this type of design does allow for the analysis of relationships between variables that
present associations, such as the prevalence ratio, OR, etc. In medicine, it is impossible to establish
specific cause-and-effect relationships since pathologies, primarily cancer, are multifactorial.
The main limitation regarding the analysis of waiting times for care was the loss of data, which confers
little external validity to our results. These losses are primarily attributed to the fact that all hospital
discharges for cancer were considered, and many of them originate from emergency departments,
where there is no care policy based on primary care referrals.
Recommendations:
Mandatory, real-time health record keeping should be implemented, in addition to the referral form
(Form 053) to monitor patients. This would facilitate longitudinal studies.
Consider including oncology professionals at least once or twice a week to support outpatient care,
perform procedures, and diagnose patients with suspected cancer.
CONCLUSIONS
The prevalence of neoplasms in HPGDR from January to July 2024 is 3.11 % (95 % CI 3 %-4 %), and
45.09 % (95 % CI 38 %-52 %) corresponds to malignant neoplasms. The prevalence of cancer in the
total hospitalizations from January to July 2024 in HPGDR is 1.4 % (95 % CI 1 %-2 %).
Gynecology is the main service that treats benign neoplasms, the most frequent being leiomyomas,
ovarian or breast. The second service corresponds to Surgery for the resolution of lipomas.
The main cancer care service is internal medicine, which is used to treat leukemias, lymphomas, skin,
lung, and gastric cancers. The second service is Surgery for gastric and urological cancer care.
The waiting time required by patients to receive care by referrals from health centers to HPGDR is 35
days (95 % CI 19 – 51 days).
Funding: The authors funded this research.
Acknowledgments:
• To the authorities of the HPGDR.: Dr. María Sánchez, Manager; Dr. Evelyn Inca, medical director,
for promoting research and contributing to administrative procedures. To the Statistics service
for collaborating with the required data.
• To the National University of Chimborazo.
• To the Polytechnic School of Chimborazo.
Conflicts of interest: The authors declare no conflict of interest in this research.
Contribution Statement:
Conceptualization: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana. Data
curation, Formal analysis, Methodology, Software, Validation, Visualization, and Writing – review and
editing: Md. M.Sc. Carlos Andrés Yépez Salgado. Acquisition of funds: project self-financed by the
authors. Research: Md. M.Sc. Carlos Andrés Yépez Salgado; Dr. Zully Mayra Romero Orellana; Dr.
Paola Buenaño; Dr. David Orozco; Md. Yesenia Chandi. Project administration: Dr. Paola Buenaño; Dr.
David Orozco; Md. Yesenia Chandi. Supervision: Dr. Zully Mayra Romero Orellana; Dr. Paola Buenaño;
Dr. David Orozco. Writing – original draft: Md. Yesenia Chandi. All authors have read and agreed to the
published version of the manuscript.
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