Skip to main content
PMC home page
PLOS ONE logoLink to PLOS ONE
. 2022 Apr 27;17(4):e0267571. doi: 10.1371/journal.pone.0267571

Prevalence and determinants of late-stage presentation among cervical cancer patients, a systematic review and meta-analysis

Tiwabwork Tekalign 1,*, Mister Teshome 1
Editor: Obinna Ikechukwu Ekwunife2
PMCID: PMC9045598  PMID: 35476851

Abstract

Background

An estimated 570,000 women were diagnosed with cervical cancer worldwide, and about 311,000 women died from the disease. Cervical cancer is possibly the most curable human cancer; if detected at the precancerous stage. Additionally, early diagnosis and management other factors are essential to decrease mortality rate among those patients. So this review was aimed to identify the prevalence and determinants of late-stage presentation among cervical cancer patients.

Methods

A systematic search had carried out on PubMed, EMBASE, MEDLINE, Cochrane, Scopus, Web of Science CINAHL, and manually on Google Scholar. This meta-analysis follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The modified Newcastle-Ottawa Scale (NOS) was used to assess the quality of each study. A meta-analysis was done using a random-effects method using the STATA™ Version 14 software.

Result

Twenty-five studies from 3 world regions with 53,233 participants were enrolled in this meta-analysis. The overall estimated global pooled prevalence of late-stage presentation among cervical cancer patients with a random-effects model was 60.66% (95% CI: 56.27, 65.06). The subgroup analysis revealed that the prevalence of late-stage presentation was 62.60% in Africa, 69.30% in Asia, 46.51% in Europe, and 50.16% in North America. Educational status (p = 0.031) and place of residence (p = 0.004) are determinants of late-stage presentation.

Conclusion

The results of this meta-analysis indicated that the prevalence of late-stage presentation of cervical cancer is substantially high. Place of residence and educational status were significantly associated with late-stage presentation. Health care organizations should work on early screening, management, and on increasing community awareness to minimize late stage at presentation among those patients.

Introduction

World Health Organization (WHO) reports that cervical cancer is the fourth most common cancer in women. An estimated 570, 000 women were diagnosed with cervical cancer worldwide from them around 311, 000 women died from the disease in 2018. Cervical cancer is possibly the foremost curable human cancer, if detected at the precancerous stage [1]. The challenge is that 80% of women in the developing countries seek treatment after they have developed signs and symptoms [2].

Presentation of cervical cancer in a sophisticated stage of disease is the outcome of multiple complex factors including availability of health services for screening, diagnosis, and other cultural and social issues [3]. Reports showed late stage at diagnosis is correlated with lower survival rates in cervical cancer patients [4–6].

Advanced cervical cancer is one among of the main causes of cancer related mortality in women because of poor access to appropriate management especially, in low- and medium income countries. One amongst the foremost important prognostic factors for cervical cancer is how early the disease is detected and how far it’s spread. Recently, delay in diagnosis and treatment continues to be the leading obstacle to overcome in the fight to cure cancer [7–9].

Several studies worldwide have investigated the factors related to delayed diagnosis and disparities in its fatality rate in different racial, geographic and socio-economic groups [10–13]; is also knowledge on pooled determinants of delays for this cancer may be useful in establishing comprehensive preventative strategies.

The concept of delayed diagnosis of cervical cancer is categorized in four components including patient delay, health care provider delay, referral delay and system delay. In most countries of the globe, especially in developing countries patients and health care providers delay have more crucial role [14–16].

In Africa, high incidence of cervical cancer has been reported at rates exceeding 50 per 100,000 populations [17]. In sub-Saharan Africa, cervical cancer is the second commonest cause of cancer morbidity and the leading reason for a mortality over 577,000 deaths annually; the same is true in Eastern Africa [18].

Quick scale-up of immunization and double lifetime uterine cervix screening in the world could prevent up to 13.4 million malignancies over the long run half century [19, 20]. Additionally, early diagnosis and managing other factors will decrease mortality and also the prevalence among those patients [21]. So, this systematic review and meta-analysis aimed is to identify pooled prevalence and determinants of late-stage presentation among cervical cancer patients.

Objective of the review

  • To determine pooled prevalence of late stage presentation among cervical cancer patient

  • To identify determinants of late stage presentation among cervical cancer patient

Methods

Inclusion and exclusion criteria

This systematic review and meta-analysis included all types of studies conducted in different regions of the world which reports the prevalence and determinants of late-stage presentation among cervical cancer patients, regardless of women’s age until July, 17, 2021; whereas, studies which were not fully accessed in which an attempt was made to contact the corresponding author and studies with methodological problems were excluded.

Information sources, search strategy, and study selection

The studies were retrieved through manual and electronic searches. The databases systematically searched were; PubMed, Scopus, Web of Science, institutional repositories, Academic Search Premier, and manually from reference lists of the previous study. Electronic database searching followed by reference lists search used to identify studies; then exported into EndNote version 7.0 to remove duplicates. Screening of titles and abstracts was done by authors independently. The Cochrane acronym POCC, which stands for population, Condition, and Context, was used to decide on all keywords. The keywords used were, “cervical cancer patient, cervical cancer cases, Late-stage presentation, late diagnosis, delayed diagnosis, advanced disease, early diagnosis, delayed presentation, late tumor stage, prolonged time to diagnosis, delayed care seeking, cancer presentation, delayed access to care, stage of diagnosis, delayed treatment initiation, patient delay, delays in diagnosis, stage at diagnosis, advanced disease at presentation, late-stage cervical cancer, and advanced stage at diagnosis. Finally, this meta-analysis was reported under the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement 2020 guidelines [22]. We registered the protocol on Prospero (ID: CRD42021284177).

Data collection process and data items

Data extraction was done by both authors (TT and MT) independently by using a data extraction format prepared in a Microsoft Excel 2013 spreadsheet. The extracted data were: the Author’s name, publication year, country, design, sample size, the prevalence of late-stage presentation, and associated factors with their odds ratio.

The outcome of the review

The primary outcome of this review was the prevalence of late-stage presentation. The second outcome of this review was determinants of late-stage presentation with their odds ratio.

Quality assessment

The modified Newcastle-Ottawa Scale (NOS) for cross-sectional studies was used to assess the quality of studies [23]. Studies that scored five and more on the NOS were included [24]. Any disagreement while data extractions were resolved through discussion.

Publication bias and heterogeneity

Funnel plot and Egger’s test had used to assess publication bias. A p-value< 0.05 had used to declare the statistical significance of publication bias. I2-statics were computed to assess heterogeneity among reported prevalence I2 test statistics had used to check the heterogeneity of studies. In which if, < 50 declared as low, 50–75% as moderate, and > 75% as having high heterogeneity [25].

Data synthesis and analysis

A random-effects meta-analysis model was used to estimate the Der Simonian and Laird’s pooled effect to show heterogeneity. Subgroup analysis was conducted to adjust random variation between point estimates of original study and investigate how failure fluctuates across subgroup participants. Outlier within the included articles was checked using sensitivity analysis. Publication bias across studies was assessed using funnel plot and egger’s regression test, at P < 0.05 to indicate publication bias. Forest plot format was used to present the point prevalence and 95% CIs. In this plot, the weight of study indicated by the size of each box, while each crossed line referred to 95% confidence interval. For the secondary outcomes, odds ratio was used to determine the association between late stage presentation and associated factors. STATA™ V14 software was used to carry out the all Meta-analysis.

Results

Study selection

Initially, a total of 64,059 studies had retrieved from the databases and manual searching. From this, 33,547 duplicates were found and removed. The rest, 35,771 articles’ were screened by their titles and abstracts. Then 29,835 were irrelevant and removed. Finally, 81 full-text articles were assessed for eligibility, and then due to failure to report the outcome of interest 56, articles were excluded. Finally, a total of 25 studies was fulfilled the inclusion criteria and enrolled in the study. The detailed retrieval process is shown in (Fig 1).

Fig 1. PRISMA flowchart diagram of the study selection.

Fig 1

Open in a new tab

Study characteristics

The 25 studies [26–50] included 53,233 participants. Most of the included studies were cross-sectional studies and the sample size ranged from 50 [33] to 13624 [50]. Most studies were conducted in Ethiopia. Among the included studies, prevalence of late stage presentation among cervical cancer patients were ranged from 28 [42] to 89.1 [32] (Table 1).

Table 1. Characteristics of the included studies in the systematic review and meta-analysis.

Authors Name Publication Year Study area Study design Sample size Prevalence (95% CI)
Wassie M, Fentie B. 2021 Ethiopia Cross-sectional 1057 56.8(53.81–59.78)
Mlange R, et al. 2016 Tanzania Cross-sectional 202 63.9(57.27–70.52)
Dunyo P 2018 Ethiopia Cross-sectional 157 65.97(58.55–73.38)
Ndlovu N 2003 Zimbabwe Cross-sectional 108 80(72.45–87.54)
Ibrahim A, et al. 2011 Sudan Cohort 197 72(65.72–78.27)
Gyenwali D, et al. 2013 Nepal Cross-sectional 110 80.9(73.55–88.24)
Behnamfar F, Azadehrah M 2015 Iran Cross-sectional 55 89.1(80.86–97.33)
Dereje N, et al. 2020 Ethiopia Cross-sectional 50 60.4(46.84–73.95)
Zeleke S, et al. 2021 Ethiopia Cross-sectional 410 86.3(82.97–89.62)
Begoihn M, et al. 2019 Ethiopia Cohort 1575 55.2(52.74–57.65)
Tanturovski D, et al. 2013 Macedonia Cross-sectional 107 72(63.49–80.50)
Ouasmani F et al. 2016 Morocco Cross-sectional 401 39.9(35.10–44.69)
Panda J, et al. 2020 India Cross-sectional 122 39.3(30.63–47.96)
Berraho M, et al. 2012 Morocco Cross-sectional 200 54.5(47.59–61.40)
Frida KM, et al. 2017 Kenya Cross-sectional 152 53.9(45.97–61.82)
Kaku M, et al. 2008 India Cross-sectional 473 50.4(45.89–54.90)
Lim AW, et al. 2014 England Cross-sectional 128 28(20.22–35.77)
Ferrante JM, et al. 2000 USA Cross-sectional 852 45.3(41.95–48.64)
Friebel-Klingner TM, et al. 2021 Botswana Cross-sectional 984 44.7(41.59–47.80)
Mwaka AD, et al. 2016 Uganda Cross-sectional 149 65(57.34–72.65)
El Ibrahimi S, Pinheiro PS. 2017 USA Cross-sectional 31425 59(58.45–59.54)
Senapati R, 2016 India Cross-sectional 246 78.04(72.86–83.21)
Tiwari V, et al. 2015 India Cross-sectional 300 77.87(73.17–82.56)
Nassali MN, et al. 2018 Botswana Cross-sectional 149 55.1(47.11–63.08)
Saghari S, et al. 2015 USA Cross-sectional 13624 46(45.16–46.83)
Open in a new tab

Meta-analysis

Based on this study, the overall estimated pooled prevalence of late-stage presentation among cervical cancer patients with a random-effects model was 60.66% (95% CI: 56.27, 65.06) with a heterogeneity index (I2) of 98.4% (p = 0.000) (Fig 2).

Fig 2. Forest plot showing pooled global prevalence of late stage presentation among cervical cancer patient.

Fig 2

Open in a new tab

To adjust, the reported heterogeneity of the study (I2 = 98.4%), the subgroup analysis based on the world region had done; accordingly, the prevalence of late-stage presentation among cervical cancer patients was found 62.60% in Africa, 69.30% in Asia, 46.51% in Europe, and 50.16% in North America (Fig 3).

Fig 3. Subgroup analysis of global late stage presentation among cervical cancer patients.

Fig 3

Open in a new tab

Meta-regression was conducted to identify the source of heterogeneity by using sample size and year of publication as a covariate; the result showed there is no effect of sample size and year of publication on heterogeneity between studies (Table 2). A publication bias was assessed using funnel plot and objectively by Egger test at a 5% significant level. A funnel plot showed asymmetrical distribution evidencing publication bias, and the Egger tests were not statistically significant with a p-value = 0.623 (Fig 4).

Table 2. Meta-regression analysis of factors affecting between-study heterogeneity on prevalence of late-stage presentation.

Heterogeneity source Coefficients Std. Err. P-value
Sample size 0.0000892 .0.0017334 0.959
Year of publication 0.0231892 2.083469 0.991
Open in a new tab

Fig 4. Funnel plot to test the publication bias in 25 studies with 95% confidence limits.

Fig 4

Open in a new tab

Sensitivity analysis had carried out by removing studies step by step to evaluate the effect of a single study on the overall effect estimate but, removing of a single study wouldn’t have a significant influence on pooled prevalence. Additionally, there is no study away from the lower and upper limit of confidence interval (Fig 5).

Fig 5. Sensitivity analysis of pooled prevalence of late stage presentation for each study being removed one at a time.

Fig 5

Open in a new tab

Determinants of late stage presentation

Five variables were extracted to identify determinants of late-stage presentation among cervical cancer patients. Of those, two variables (educational status and place of residence) had identified as significant factors (Table 3).

Table 3. Determinants of late-stage presentation among cervical cancer patients.

Determinants Comparison No of studies Sample size OR(95%CI) P -value I2 (%) Heterogeneity test (p value) Egger’s test (P -value)
Educational status No formal education Vs primary and above 7 1014 0.39(0.17–0.91) 0.031 85.4 < 0.001 0.413
Age of the patient < 50 years old Vs > = 50 years old 3 14833 1.91(0.94–3.90) 0.073 96.0 < 0.001 0.681
Marital status Married Vs others 6 15735 1.433(0.86–2.37) 0.162 92.3 < 0.001 0.760
Place of residence Urban Vs Rural 5 4814 2.87(1.38–5.93) 0.004 94.9 < 0.001 0.200
Screening history Yes vs No 4 1194 2.31(0.91–5.85) 0.077 72.2 0.013 0.374
Open in a new tab

Accordingly, those patients educated primary and above were 61% less likely to have the late presentation of cervical cancer than those with no formal education (OR: 0.39(95%CI 0.17–0.19), p = 0.031, I2: 85.4%, the heterogeneity test (p< 0.001).

Those patient who came from the rural area were 2.87 times more likely to have a late presentation of cervical cancer than who come from urban areas (OR: 2.87(95%CI 1.38–5.93), p = 0.004, I2: 94.9%, the heterogeneity test (p< 0.001).

Discussion

A study showed the fate of patients after proved diagnosis of cervical cancer was 98% of the patients’ consent to further medical care, and around 27% finally had a hysterectomy [51]. The figure is one indication of the worse effect of cervical cancer.

According to this Meta-analysis, the overall estimated pooled prevalence of late-stage presentation among cervical cancer patients with a random-effects model was 60.66% (95% CI: 56.27, 65.06) with a heterogeneity index (I2) of 98.4% (p = 0.000). The increased prevalence of late stage presentation of this preventable and curable cancer puts a patient at higher risk of death [52]. The subgroup analysis showed that the prevalence of late-stage presentation among cervical cancer patients was 62.60% in Africa, 69.30 in Asia, 46.51% in Europe, and 50.16% in North America. The highest prevalence in low-medium income countries might be due to poor urbanization level, demographic, and low socio-economic characteristics of the study participants. This systematic review and meta-analysis also identified pooled determinants of late presentation among cervical cancer patients. Among the extracted factors’ educational status and place of residence are significantly associated.

There is an association between educational level and late-stage presentation. This study t also indicated, patients educated primary and above were 61% less likely to have the late stage presentation of cervical cancer than those with no formal education (OR: 0.39(95%CI 0.17–0.19). Different studies showed that low educational level is a risk factor and determinant of health-seeking behavior among patients [53, 54]. Those patient who came from the rural area were 2.87 times more likely to have a late -stage presentation of cervical cancer than who come from urban areas (OR: 2.87(95%CI 1.38–5.93). Place of residence determines health care service utilization, and in advance, it’s related to premature mortality [55, 56] secondary to delayed presentation and poor health care seeking behavior.

Conclusion

The results of this meta-analysis indicated that the prevalence of late-stage presentation of cervical cancer is substantially high. Place of residence and educational status were significantly associated with late-stage presentation. Health care organizations should work on early screening, management, and on increasing community awareness to minimize late stage at presentation among those patients.

Limitation of the study

This systematic review and meta-analysis presented up-to-date evidence on the prevalence of late-stage presentation and determinants of cervical cancer; it might have faced the following limitations. First, the lack of studies from three regions of the world may affect the generalizability of the finding. Secondly, we have faced difficulties comparing our findings due to the lack of regional and worldwide systematic reviews and meta-analyses.

Supporting information

S1 Checklist. PRISMA checklist.

(DOCX)

Click here for additional data file. (36.2KB, docx)
S1 File. Search strategy.

(DOCX)

Click here for additional data file. (21.4KB, docx)
S1 Data. Data of meta-analysis.

(XLSX)

Click here for additional data file. (43.4KB, xlsx)

Acknowledgments

We would like to thank all authors of studies included in this systematic review and meta-analysis.

List of abbreviations

CI

Confidence Interval

NOS

Newcastle Ottawa Scale

OR

Odds Ratio

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

WHO

World Health Organization

Data Availability

The data underlying the results presented in the study are available from journal and All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

The authors received no specific funding for this work.

References

  • 1.Devi BC, Tang TS, Corbex M. Reducing by half the percentage of late-stage presentation for breast and cervix cancer over 4 years: a pilot study of clinical downstaging in Sarawak, Malaysia. Annals of oncology. 2007. Jul 1;18(7):1172–6. doi: 10.1093/annonc/mdm105 [DOI] [PubMed] [Google Scholar]
  • 2.Chadza E, Chirwa E, Maluwa A, Kazembe A, Chimwaza A. Factors that contribute to delay in seeking cervical cancer diagnosis and treatment among women in Malawi 2012. September 21:4(11):1015–22. [Google Scholar]
  • 3.Hicks ML, Yap OS, Mathews R, Parham G. Disparities in cervical cancer screening, treatment and outcomes. Ethnicity and Disease. 2006. Jan 1;16(2):S3. [PubMed] [Google Scholar]
  • 4.Waggoner SE. Cervical cancer. The Lancet. 2003. Jun 28;361(9376):2217–25. doi: 10.1016/S0140-6736(03)13778-6 [DOI] [PubMed] [Google Scholar]
  • 5.Gizaw M, Addissie A, Getachew S, Ayele W, Mitiku I, Moelle U, et al. Cervical cancer patients presentation and survival in the only oncology referral hospital, Ethiopia: a retrospective cohort study. Infectious Agents and Cancer. 2017. Dec;12(1):1–7. doi: 10.1186/s13027-017-0171-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Thomson CS, Forman D. Cancer survival in England and the influence of early diagnosis: what can we learn from recent EUROCARE results?. British journal of cancer. 2009. Dec;101(2):S102–9. doi: 10.1038/sj.bjc.6605399 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Vinh-Hung V, Bourgain C, Vlastos G, Cserni G, De Ridder M, Storme G, et al. Prognostic value of histopathology and trends in cervical cancer: a SEER population study. BMC cancer. 2007. Dec;7(1):1–3. doi: 10.1186/1471-2407-7-164 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Kantelhardt EJ, Moelle U, Begoihn M, Addissie A, Trocchi P, Yonas B, et al. Cervical cancer in Ethiopia: survival of 1,059 patients who received oncologic therapy. The oncologist. 2014. Jul;19(7):727. doi: 10.1634/theoncologist.2013-0326 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Chen CP, Kung PT, Wang YH, Tsai WC. Effect of time interval from diagnosis to treatment for cervical cancer on survival: a nationwide cohort study. PLoS One. 2019. Sep 4;14(9):e0221946. doi: 10.1371/journal.pone.0221946 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Ma J, Zhu Q, Han S, Zhang Y, Ou W, Wang H, et al. Effect of socio-economic factors on delayed access to health care among Chinese cervical cancer patients with late rectal complications after radiotherapy. Gynecologic oncology. 2012. Mar 1;124(3):395–8. doi: 10.1016/j.ygyno.2011.11.040 [DOI] [PubMed] [Google Scholar]
  • 11.Brewer N, Pearce N, Jeffreys M, White P, Ellison-Loschmann L. Demographic differences in stage at diagnosis and cervical cancer survival in New Zealand, 1994–2005. Journal of Women’s Health. 2009. Jul 1;18(7):955–63. doi: 10.1089/jwh.2008.1163 [DOI] [PubMed] [Google Scholar]
  • 12.Yu CK, Chiu C, McCormack M, Olaitan A. Delayed diagnosis of cervical cancer in young women. Journal of obstetrics and gynaecology. 2005. May 1;25(4):367–70. doi: 10.1080/01443610500118814 [DOI] [PubMed] [Google Scholar]
  • 13.Ibfelt E, Kjær SK, Johansen C, Høgdall C, Steding-Jessen M, Frederiksen K, et al. Socioeconomic position and stage of cervical cancer in Danish women diagnosed 2005 to 2009. Cancer Epidemiology and Prevention Biomarkers. 2012. May 1;21(5):835–42. doi: 10.1158/1055-9965.EPI-11-1159 [DOI] [PubMed] [Google Scholar]
  • 14.Hansen RP, Olesen F, Sørensen HT, Sokolowski I, Søndergaard J. Socioeconomic patient characteristics predict delay in cancer diagnosis: a Danish cohort study. BMC health services research. 2008. Dec;8(1):1–0. doi: 10.1186/1472-6963-8-49 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Arndt V, Stürmer T, Stegmaier C, Ziegler H, Dhom G, Brenner H. Patient delay and stage of diagnosis among breast cancer patients in Germany–a population based study. British journal of cancer. 2002. Apr;86(7):1034–40. doi: 10.1038/sj.bjc.6600209 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Shen SC, Hung YC, Kung PT, Yang WH, Wang YH, Tsai WC. Factors involved in the delay of treatment initiation for cervical cancer patients: a nationwide population-based study. Medicine. 2016. Aug;95(33). doi: 10.1097/MD.0000000000004568 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Jacques Ferlay IS, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2014;136:29. doi: 10.1002/ijc.29210 [DOI] [PubMed] [Google Scholar]
  • 18.World Health Organization. Human Papillomavirus and related cancers in Ethiopia: summary report 2010. View Article.
  • 19.Canfell K. Towards the global elimination of cervical cancer. Papillomavirus Res. 2019; 8: 100170. doi: 10.1016/j.pvr.2019.100170 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Cohen PA, Jhingran A, Oaknin A, Denny L. Cervical cancer. The Lancet. 2019. Jan 12;393(10167):169–82. [DOI] [PubMed] [Google Scholar]
  • 21.Wassie M, Argaw Z, Tsige Y, Abebe M, Kisa S. Survival status and associated factors of death among cervical cancer patients attending at Tikur Anbesa Specialized Hospital, Addis Ababa, Ethiopia: a retrospective cohort study. BMC cancer. 2019. Dec;19(1):1–1. doi: 10.1186/s12885-018-5219-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Bmj. 2021. Mar 29;372. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Modesti P. A., Reboldi G., & Cappuccio F. P. (2016). Newcastle-Ottawa Quality Assessment Scale (adapted for cross sectional studies). PLoS One. [Google Scholar]
  • 24.Herzog R, Álvarez-Pasquin MJ, Díaz C, Del Barrio JL, Estrada JM, Gil Á. Are healthcare workers’ intentions to vaccinate related to their knowledge, beliefs and attitudes? A systematic review. BMC public health. 2013. Dec;13(1):1–7. doi: 10.1186/1471-2458-13-154 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analysis. BMJ. 2003;327(7414):557. doi: 10.1136/bmj.327.7414.557 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Wassie M, Fentie B. Prevalence of late-stage presentation and associated factors of cervical cancer patients in Tikur Anbesa Specialized Hospital, Ethiopia: institutional based cross-sectional study. Infectious Agents and Cancer. 2021. Dec;16(1):1–6. doi: 10.1186/s13027-020-00340-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Mlange R, Matovelo D, Rambau P, Kidenya B. Patient and disease characteristics associated with late tumour stage at presentation of cervical cancer in northwestern Tanzania. BMC women’s health. 2015. Dec;16(1):1–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Dunyo P, Effah K, Udofia EA. Factors associated with late presentation of cervical cancer cases at a district hospital: a retrospective study. BMC Public Health. 2018. Dec;18(1):1–0. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Ndlovu N, Kambarami R. Factors associated with tumour stage at presentation in invasive cervical cancer. [PubMed] [Google Scholar]
  • 30.Ibrahim A, Rasch V, Pukkala E, Aro AR. Predictors of cervical cancer being at an advanced stage at diagnosis in Sudan. International journal of women’s health. 2011;3:385. doi: 10.2147/IJWH.S21063 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Gyenwali D, Pariyar J, Onta SR. Factors associated with late diagnosis of cervical cancer in Nepal. Asian Pacific Journal of Cancer Prevention. 2013;14(7):4373–7. doi: 10.7314/apjcp.2013.14.7.4373 [DOI] [PubMed] [Google Scholar]
  • 32.Behnamfar F, Azadehrah M. Factors associated with delayed diagnosis of cervical cancer in iran-a survey in isfahan city. Asian Pacific Journal of Cancer Prevention. 2015;16(2):635–9. doi: 10.7314/apjcp.2015.16.2.635 [DOI] [PubMed] [Google Scholar]
  • 33.Dereje N, Gebremariam A, Addissie A, Worku A, Assefa M, Abraha A, et al. Factors associated with advanced stage at diagnosis of cervical cancer in Addis Ababa, Ethiopia: a population-based study. BMJ open. 2020. Oct 1;10(10):e040645. doi: 10.1136/bmjopen-2020-040645 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Zeleke S, Anley M, Kefale D, Wassihun B. Factors Associated with Delayed Diagnosis of Cervical Cancer in Tikur Anbesa Specialized Hospital, Ethiopia, 2019: Cross-Sectional Study. Cancer Management and Research. 2021;13:579. doi: 10.2147/CMAR.S285621 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Begoihn M, Mathewos A, Aynalem A, Wondemagegnehu T, Moelle U, Gizaw M, et al. Cervical cancer in Ethiopia–predictors of advanced stage and prolonged time to diagnosis. Infectious agents and cancer. 2019. Dec;14(1):1–7. doi: 10.1186/s13027-019-0255-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Tanturovski D, Zafirova E, Stojovski M, Basheska N, Jovanovska V. Impact of socio-demographic factors on the delayed diagnosis and advanced stage presentation of patients with invasive cervical cancer in Macedonia. Pril Makedon Akad Na Nauk Umet Oddelenie Za Biološki Med Nauki Contrib Maced Acad Sci Arts Sect Biol Med Sci. 2013. Jan 1;34(3):71–8. [PubMed] [Google Scholar]
  • 37.Ouasmani F, Hanchi Z, Haddou Rahou B, Bekkali R, Ahid S, Mesfioui A. Determinants of patient delay in seeking diagnosis and treatment among Moroccan women with cervical cancer. Obstetrics and gynecology international. 2016. Nov 2;2016. doi: 10.1155/2016/4840762 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38.Panda J, Das A, Panigrahi A. Delays in diagnosis of cervical cancer among women attending tertiary care cancer diagnostic hospitals in Bhubaneswar, India. Indian Journal of Gynecologic Oncology. 2020. Mar;18(1):1–0. [Google Scholar]
  • 39.Berraho M, Obtel M, Bendahhou K, Zidouh A, Errihani H, Benider A, et al. Sociodemographic factors and delay in the diagnosis of cervical cancer in Morocco. Pan African Medical Journal. 2012;12(1). [PMC free article] [PubMed] [Google Scholar]
  • 40.Frida KM, Atieno WM, Habtu M. Socio-Demographic Factors Associated with Advanced Stage of Cervical Cancer at Diagnosis in Kenyatta National Hospital, Kenya: A Cross Sectional StudyJ Cancer Sci Ther 2017. July: 9: 554–61. [Google Scholar]
  • 41.Kaku M, Mathew A, Rajan B. Impact of socio-economic factors in delayed reporting and late-stage presentation among patients with cervix cancer in a major cancer hospital in South India. Asian Pac J Cancer Prev. 2008. Oct 1;9(4):589–94. [PubMed] [Google Scholar]
  • 42.Lim AW, Ramirez AJ, Hamilton W, Sasieni P, Patnick J, Forbes LJ. Delays in diagnosis of young females with symptomatic cervical cancer in England: an interview-based study. British Journal of General Practice. 2014. Oct 1;64(627):e602–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Ferrante JM, Gonzalez EC, Roetzheim RG, Pal N, Woodard L. Clinical and demographic predictors of late-stage cervical cancer. Archives of family medicine. 2000. May 1;9(5):439. doi: 10.1001/archfami.9.5.439 [DOI] [PubMed] [Google Scholar]
  • 44.Friebel-Klingner TM, Luckett R, Bazzett-Matabele L, Ralefala TB, Monare B, Nassali MN, et al. Clinical and sociodemographic factors associated with late stage cervical cancer diagnosis in Botswana. BMC Women’s Health. 2021. Dec;21(1):1–9. doi: 10.1186/s12905-020-01152-w [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Mwaka AD, Garimoi CO, Were EM, Roland M, Wabinga H, Lyratzopoulos G. Social, demographic and healthcare factors associated with stage at diagnosis of cervical cancer: cross-sectional study in a tertiary hospital in Northern Uganda. BMJ open. 2016. Jan 1;6(1):e007690. doi: 10.1136/bmjopen-2015-007690 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.El Ibrahimi S, Pinheiro PS. The effect of marriage on stage at diagnosis and survival in women with cervical cancer. Psycho‐oncology. 2017. May;26(5):704–10. doi: 10.1002/pon.4070 [DOI] [PubMed] [Google Scholar]
  • 47.Senapati R, Nayak B, Kar SK, Dwibedi B. Why cervical cancer cases are being lately diagnosed in Eastern India? An analysis of the associated factors. Indian Journal of Obstetrics and Gynecology Research. 2016;3(4):418–21. [Google Scholar]
  • 48.Tiwari V, Yogi V, Ghori HU, Singh OP, Peepre K, Yadav S, et al. Identifying the factors causing delayed presentation of cancer patients to a government medical college of Central India. Journal of clinical and diagnostic research: JCDR. 2015. Sep;9(9):XC09. doi: 10.7860/JCDR/2015/15104.6512 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Nassali MN, Tadele M, Nkuba RM, Modimowame J, Enyeribe I, Katse E. Predictors of locally advanced disease at presentation and clinical outcomes among cervical cancer patients admitted at a tertiary hospital in Botswana. International Journal of Gynecologic Cancer. 2018. Jun 1;28(6). [DOI] [PubMed] [Google Scholar]
  • 50.Saghari S, Ghamsary M, Marie-Mitchell A, Oda K, Morgan JW. Sociodemographic predictors of delayed-versus early-stage cervical cancer in California. Annals of epidemiology. 2015. Apr 1;25(4):250–5. doi: 10.1016/j.annepidem.2015.01.008 [DOI] [PubMed] [Google Scholar]
  • 51.Eze JN, Emeka-Irem EN, Edegbe FO. A six-year study of the clinical presentation of cervical cancer and the management challenges encountered at a state teaching hospital in southeast Nigeria. Clinical Medicine Insights: Oncology. 2013. Jan;7:CMO-S12017. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 52.Musa J, Nankat J, Achenbach CJ, Shambe IH, Taiwo BO, Mandong B, et al. Cervical cancer survival in a resource-limited setting-North Central Nigeria. Infectious Agents and Cancer. 2016. Dec;11(1):1–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 53.Bosch FX, Munoz N, De Sanjose S, Izarzugaza I, Gili M, Viladiu P, et al. Risk factors for cervical cancer in Colombia and Spain. International journal of cancer. 1992. Nov 11;52(5):750–8. doi: 10.1002/ijc.2910520514 [DOI] [PubMed] [Google Scholar]
  • 54.Latunji OO, Akinyemi OO. Factors influencing health-seeking behaviour among civil servants in Ibadan, Nigeria. Annals of Ibadan postgraduate medicine. 2018. Jul 17;16(1):52–60. [PMC free article] [PubMed] [Google Scholar]
  • 55.Lahana E, Pappa E, Niakas D. Do place of residence and ethnicity affect health services utilization? Evidence from Greece. International journal for equity in health. 2011. Dec;10(1):1–9. doi: 10.1186/1475-9276-10-16 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 56.Eberhardt MS, Pamuk ER. The importance of place of residence: examining health in rural and nonrural areas. American journal of public health. 2004. Oct;94(10):1682–6. doi: 10.2105/ajph.94.10.1682 [DOI] [PMC free article] [PubMed] [Google Scholar]

Decision Letter 0

Obinna Ikechukwu Ekwunife

9 Feb 2022

PONE-D-21-23859Determinants of late-stage presentation among cervical cancer patients, a systematic review and Meta-analysisPLOS ONE

Dear Dr. Tiwabwork Tekalign, 

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Mar 24 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Obinna Ikechukwu Ekwunife, PhD

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at 

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and 

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please provide the full electronic search strategy for at least one database, including any limits used, such that it could be repeated.

3. Thank you for stating the following financial disclosure: 

N/A

At this time, please address the following queries:

a) Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution. 

b) State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

c) If any authors received a salary from any of your funders, please state which authors and which funders.

d) If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.”

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. 

5. We noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed:

- https://www.hindawi.com/journals/ogi/2016/4840762/

- http://koreascience.or.kr/journal/view.jsp?kj=POCPA9&py=2015&vnc=v16n2&sp=635

- https://www.dovepress.com/front_end/factors-associated-with-delayed-diagnosis-of-cervical-cancer-in-tikur--peer-reviewed-fulltext-article-CMAR

In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: No

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: 1.The topic is not novel enough, there is no important clinical value.

2.The meta-analysis unreported preliminary design analysis.

3.Literature Searches and Search terms are incomplete. To ensure a high recall rate, otherwise it will affect the reliability and authenticity of the conclusions of Meta analysis. Please attach search terms that were used in each database as supplement for Data source and search strategies in the manuscript. Please provide details search terms in supplementary documents. Please attach syntax used in each database as supplementary.

4.There is still a considerable heterogeneity as in your limitation. Researchers can perform a subgroup analysis or Meta-regression analysis.

Reviewer #2: Thank you for the opportunity to review this paper. This is an interesting topic but there so many issues that need to be addressed. First, the language is very poor. The authors need a support from a native English language writer or seek the journal’s language editing service. Second, the study objectives and methodology were poorly written. They stated under “outcome measure” that the primary measure was “prevalence” while the secondary measure was “determinants” but the title of this paper was “determinants”. So many missing information and not adhering to PRISMA guideline. Also not registered in PROSPERO. Results and tables were poorly presented. The authors should seek support from a librarian or an expert in systematic review to review this interesting paper. Below are a few comments. I could not present all errors I found in the paper due to its fundamental flaws.

Abstract:

1. The authors need to specify that they also want to estimate the prevalence and not only the determinants.

2. Several descriptive and grammatical errors. Please have a review of the choice of word. Example first sentence in the results

“From 64,059 obtained studies, 25 studies from 3 world regions involving 53,233 participants enrolled in this meta-analysis.”

Also in the conclusion:

“…..Therefore health care organizations should work on early screening and treatment, as well as increasing community awareness to minimize premature death among those patients is essential” needs to be rephrased. The use of the term “therefore” doesn’t fit in.

Also see the Introduction section:

“Several studies worldwide have investigated the factors associated with delayed diagnosis of the cancer and disparities in its mortality rate in different racial, geographic and socio-economic groups [10-13]. However knowledge of delays for this cancer could be useful in establishing comprehensive preventative strategies.” The use of However is a problem here.

Please check other through out this paper. I found so many disconnect and wrong use of coordinating and subordinating conjunctions.

Introduction

1. I would move this statement forward to the first or second paragraph:

“In Africa, high incidences of cervical cancer are reported at rates exceeding 50 per 100,000 populations [17]. In sub-Saharan Africa, cervical cancer is the second commonest cancer morbidity and the leading cause of mortality with over 577,000 deaths annually; furthermore, in Eastern Africa it is the number one commonest cancer in women [18].”

2. “Other factors were scattered studied so, this systematic

review and meta-analysis aimed is to identify pooled determinants of late-stage presentation among cervical cancer patients”???.

This sentence is not clear.

3. Authors need to align their study objectives to the study title.

Methods

1. The methodology of this review was poorly written. The authors claim to follow the PRISMA guideline, but I could not verify this in the methodology.

2. Looks like this systematic review was not registered in PROSPERO

3. “…The databases used were EMBASE, MEDLINE, Cochrane, Scopus, Web of Science,

CINAHL, and manually on Google Scholar.” This should be under information sources.

4. “Both funnel plot and Egger’s test had used to assess publication bias. A p-value< 0.05 had used to declare the statistical significance of publication bias. Also, I2 test statistics had used to check the heterogeneity of studies. I2 test statistics of < 50, 50–75% and > 75% was declared as low, moderate and high heterogeneity respectively [25]”.

So many errors here and there and poorly written. The authors could not clearly describe their analytical approach and the reasons for what they did.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Charles Okafor

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Attachment

Submitted filename: REVIEWER COMMENTS.docx

Click here for additional data file. (16.4KB, docx)
PLoS One. 2022 Apr 27;17(4):e0267571. doi: 10.1371/journal.pone.0267571.r002

Author response to Decision Letter 0

3 Mar 2022

REVIEWER COMMENTS

Determinants of late-stage presentation among cervical cancer patients, a systematic review and Meta-analysis Thank you for the opportunity to review this paper. This is an interesting topic but there so many issues that need to be addressed. First, the language is very poor. The authors need a support from a native English language writer or seek the journal’s language editing service. Second, the study objectives and methodology were poorly written. They stated under “outcome measure” that the primary measure was “prevalence” while the secondary measure was “determinants” but the title of this paper was “determinants”. So many missing information and not adhering to PRISMA guideline. Also not registered in PROSPERO. Results and tables were poorly presented. The authors should seek support from a librarian or an expert in systematic review to review this interesting paper. Below are a few comments. I could not present all errors I found in the paper due to its fundamental flaws. Abstract: The authors need to specify that they also want to estimate the prevalence and not only the determinants. Response – corrected Several descriptive and grammatical errors. Please have a review of the choice of word. Example first sentence in the results “From 64,059 obtained studies, 25 studies from 3 world regions involving 53,233 participants enrolled in this meta-analysis.”Also in the conclusion: “…..Therefore health care organizations should work on early screening and treatment, as well as increasing community awareness to minimize premature death among those patients is essential” needs to be rephrased. The use of the term “therefore” doesn’t fit in.Also see the Introduction section: “Several studies worldwide have investigated the factors associated with delayed diagnosis of the cancer and disparities in its mortality rate in different racial, geographic and socio-economic groups [10-13]. However knowledge of delays for this cancer could be useful in establishing comprehensive preventative strategies.” The use of However is a problem here. Please check other through out this paper. I found so many disconnect and wrong use of coordinating and subordinating conjunctions. Response – corrected IntroductionI would move this statement forward to the first or second paragraph: “In Africa, high incidences of cervical cancer are reported at rates exceeding 50 per 100,000 populations [17]. In sub-Saharan Africa, cervical cancer is the second commonest cancer morbidity and the leading cause of mortality with over 577,000 deaths annually; furthermore, in Eastern Africa it is the number one commonest cancer in women [18].” Response – corrected “Other factors were scattered studied so, this systematicreview and meta-analysis aimed is to identify pooled determinants of late-stage presentation among cervical cancer patients”???.This sentence is not clear. Response – corrected Authors need to align their study objectives to the study title. Response – corrected MethodsThe methodology of this review was poorly written. The authors claim to follow the PRISMA guideline, but I could not verify this in the methodology.Response – corrected and followed updated PRISMA guideline Looks like this systematic review was not registered in PROSPEROResponse – corrected and registration ID was mentioned“…The databases used were EMBASE, MEDLINE, Cochrane, Scopus, Web of Science,CINAHL, and manually on Google Scholar.” This should be under information sources.Response – corrected “Both funnel plot and Egger’s test had used to assess publication bias. A p-value< 0.05 had used to declare the statistical significance of publication bias. Also, I2 test statistics had used to check the heterogeneity of studies. I2 test statistics of < 50, 50–75% and > 75% was declared as low, moderate and high heterogeneity respectively [25]”. So many errors here and there and poorly written. The authors could not clearly describe their analytical approach and the reasons for what they did. Response – corrected

Attachment

Submitted filename: response to reviewers.docx

Click here for additional data file. (19.2KB, docx)

Decision Letter 1

Obinna Ikechukwu Ekwunife

12 Apr 2022

Prevalence and determinants of late-stage presentation among cervical cancer patients, a systematic review and Meta-analysis

PONE-D-21-23859R1

Dear Dr. Tiwabwork Tekalign,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Obinna Ikechukwu Ekwunife, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #2: My concerns have been addressed. I have no further comments. The figures may need editing for qauality.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Acceptance letter

Obinna Ikechukwu Ekwunife

18 Apr 2022

PONE-D-21-23859R1

Prevalence and determinants of late-stage presentation among cervical cancer patients, a systematic review and Meta-analysis

Dear Dr. Tekalign:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Obinna Ikechukwu Ekwunife

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Checklist. PRISMA checklist.

    (DOCX)

    Click here for additional data file. (36.2KB, docx)
    S1 File. Search strategy.

    (DOCX)

    Click here for additional data file. (21.4KB, docx)
    S1 Data. Data of meta-analysis.

    (XLSX)

    Click here for additional data file. (43.4KB, xlsx)
    Attachment

    Submitted filename: REVIEWER COMMENTS.docx

    Click here for additional data file. (16.4KB, docx)
    Attachment

    Submitted filename: response to reviewers.docx

    Click here for additional data file. (19.2KB, docx)

    Data Availability Statement

    The data underlying the results presented in the study are available from journal and All relevant data are within the manuscript and its Supporting Information files.

    Articles from PLoS ONE are provided here courtesy of PLOS

    RESOURCES