A structured protocol for breaking diagnosis gynecological cancer in Gabon: a two-phase feasibility study

A structured protocol for breaking diagnosis gynecological cancer in Gabon: a two-phase feasibility study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A structured protocol for breaking diagnosis gynecological cancer in Gabon: a two-phase feasibility study Béa-Christelle Ndjengue Bengone, Julia Diloussou, Angela-Christie Filankembo Kava, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8365394/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Objective To develop and implement a structured protocol for breaking gynecological cancer diagnoses in Gabon, and evaluate its feasibility and acceptability among healthcare professionals and patients. Methods Two-phase prospective study (2024–2025). Phase 1: exploratory survey among 19 professionals documenting existing practices and needs. Phase 2: protocol implementation in five healthcare facilities followed by satisfaction surveys among 23 professionals and 50 patients with breast or cervical cancer. Quantitative analyses (Mann-Whitney test) and thematic qualitative analyses were performed. Results Phase 1 revealed major gaps: insufficient training (89.5%), lack of standardized tools (68.4%), and limited institutional support (63.2%). Phase 2 demonstrated favorable acceptability: 56.5% of professionals reported high comfort levels, 61% practice improvement, and 60.9% positive overall satisfaction. Oncologists-radiotherapists perceived significantly superior impact compared to gynecologists on practice evolution (p = 0.004 ), first contact improvement ( p = 0.025) , and professional well-being (p = 0.032). Among patients, 84% found communication clear and 80.0% understood information, but 70.0% deemed emotional support insufficient. Main limitations: impersonal nature (39.1%) and lack of transcultural adaptation (21.7%). Conclusions This first-in-Gabon protocol demonstrates feasibility and acceptability. However, optimal effectiveness requires complementary training in relational skills and cultural adaptation. Controlled longitudinal studies are needed to measure long-term impact on quality of life and treatment adherence. Breaking bad news communication Gabon Gynecologic neoplasms Sub-Saharan Africa INTRODUCTION Breaking bad news of cancer diagnosis represents a pivotal moment in the oncological journey, determinant for therapeutic relationship, treatment adherence, and patients' quality of life This critical step requires adapted, empathetic, and structured communication, as emphasized by international guidelines protocols such as SPIKES demonstrate continued relevance ( 1 ). with, recent validation studies across diverse settings confirming their effectiveness in standardizing disclosure practices ( 2 , 3 ) However, in sub-Saharan Africa (SSA), diagnostic disclosure remains largely unstandardized, facing multiple challenges: limited resources, overburdened health systems, cultural and linguistic diversity, and insufficient professional training ( 4 , 5 ). In Gabon, despite rising incidence of gynecological cancers ( 6 , 7 )—particularly breast cancer (25.8 per 100,000 women) and cervical cancer (22.7 per 100,000)—no formalized protocol for diagnostic disclosure exists to date. Previous work documented needs expressed by Gabonese patients concerning improvement of disclosure quality ( 8 ). Facing this reality, this study aims to develop and implement a structured protocol for diagnostic disclosure adapted to the Gabonese context, then evaluate its operational feasibility and acceptability among healthcare professionals and patients. METHODS √ Study design Prospective observational two-phase study conducted at the Institut de Cancérologie d’Akanda (ICA) and four other Gabonese healthcare facilities between December 2024 and July 2025. Phase 1 (December 2024): Cross-sectional exploratory survey among professionals documenting existing practices and identifying needs. Phase 2 (January-July 2025): Feasibility and implementation study of the structured protocol, followed by satisfaction surveys among professionals and patients. √ Study populations Healthcare professionals. Phase 1: 19 physicians and residents recruited during weekly multidisciplinary team meetings at ICA. Phase 2: 23 professionals (gynecologists, oncologists, radiotherapists, residents) practicing in five facilities. Patients : 50 patients aged ≥ 18 years, having received histological diagnosis of breast or cervical cancer between February-July 2025, recruited through consecutive sampling at ICA. Exclusion criteria: severe cognitive disorders, significant general condition deterioration, inability to communicate in French. √ Protocol development The protocol was developed based on: ( 1 ) exploratory survey results (Phase 1), ( 2 ) international recommendations (notably SPIKES, appendix 1), ( 3 ) adaptation to local healthcare and cultural realities, ( 4 ) participatory process involving multidisciplinary professionals. √ Implementation The protocol was deployed over 7 months (January-July 2025) after a professional training session. Continuous support was provided to ensure device appropriation. Data collection Phase 1 Anonymous self-administered questionnaire exploring sociodemographic characteristics, disclosure practices, difficulties encountered, training and resource needs, and current device perceptions (appendix 2). Phase 2: Professionals : Satisfaction questionnaire (May 2025) evaluating feasibility, perceived utility, practice impact, and improvement suggestions (appendix 3). Patients : Questionnaire administered during consultation documenting sociodemographic and clinical data, disclosure conditions, communication quality, emotional support received, psychosocial impact, and improvement suggestions (appendix 4). √ Statistical Analysis Data entered in Excel 2016 and analyzed with SPSS v.21. Quantitative variables expressed as mean ± standard deviation, categorical variables as frequencies and percentages. Between-group comparisons (gynecologists vs. oncologists-radiotherapists; two patient groups) performed using non-parametric Mann-Whitney U test. Significance threshold set at p < 0.05 . Inductive thematic analysis of open responses. RESULTS Phase 1: Exploratory survey among professionals √ Participant characteristics (n = 19) Mean age: 44.3 ± 8.0 years; professional experience: 9.0 ± 6.7 years; disclosure frequency: 5.9 ± 2.7/month. Balanced gender distribution (9M/10F). Profiles: predominantly oncologists, followed by residents and radiotherapists. √ Current practices and needs assessment Training and resources : Only 10.5% (n = 2) received specific training in disclosure, with only one considering it satisfactory. All (100%) untrained professionals desired training. Only 31.6% had necessary resources (psychologist: n = 4; brochures: n = 2). Hierarchical support was deemed insufficient by 63.2%. Main difficulties Apprehension about patients' emotional reactions (63.1%), lack of appropriate setting (47.3%), inappropriate communication/language (26.3%), absence of psychologist (26.3%). Reported practices : Preparation through thorough medical file analysis (79.0%), preference for calm environment (63.0%), presence of companion/psychologist (47;0%). Quality criteria identified: discourse clarity and language adaptation (68.0%), respect for confidentiality and consistency (53.0%), companion presence (37.0%). The main difficulties reported included apprehension about patients' emotional reactions (63.1%), lack of an appropriate setting (47.3%), use of inappropriate language (26.3%), and absence of a psychologist (26.3%). Phase 2: Protocol implementation and evaluation (appendix 5) √ Professional evaluation (n = 23) Characteristics : Mean age 43.7 ± 8.3 years; experience 9.9 ± 7.8 years; disclosure frequency 5.3 ± 5.1/month. Distribution: gynecologists 47.8%, oncologists 26.1%, radiotherapists 13.0%, residents 13.0%. Perception and acceptability (Table 1 ): Comfort level favorable for 56.5% (score > 5/10). Comfort sources: clear structuring (61.0%), perceived support (57.0%), communication facilitation (52.0%). Interprofessional collaboration smooth for 78.3%. Overall satisfaction moderate to strong for 60.9%. Table 1 Protocol perception by professionals (Phase 2, n = 23) Variable Modality Effective (n) Percentage (%) Comfort level Low-Moderate (≤ 5) 10 43.5 Good-Excellent (> 5) 13 56.5 Interprofessional collaboration Low (≤ 3) 05 21.7 Moderate-Strong (> 3) 18 78.3 Overall satisfaction Low (≤ 4) 09 39.1 Moderate-Strong (> 4) 14 60.9 Perceived impact Strong impact reported on practice evolution (61.0%), first contact improvement (61.0%), professional well-being (57.0%). Between-specialty comparison (Table 2 ): Significant differences between gynecologists and oncologists-radiotherapists. The latter perceived superior global impact (median 7 vs. 4, p = 0.015), more marked practice evolution (p = 0.004), better first contact improvement (p = 0.025), higher well-being impact (p = 0.032), and significantly superior overall satisfaction (median 6 vs. 4, p = 0.005). Table 2 Comparison gynecologists vs. oncologists-radiotherapists Variable Gynecologists Median (IQR) Onco-RT Median (IQR) p-value* Global device impact 4 (± 3) 7 (± 2) 0.015 Practice evolution 3 (± 13) 4 (± 14) 0.004 First contact improvement 3 (± 15) 4 (± 19) 0.025 Well-being impact 4 (± 16) 4 (± 18) 0.032 Overall satisfaction 4 (± 2.27) 6 (± 1.57) 0.005 *Mann-Whitney U test; Improvement suggestions More in-depth training (30.4%), real-time feedback system (30.4%), personalization options (26.1%), minor adjustments (26.1%), satisfactory as is (21.7%). Identified advantages Communication clarity (39.1%), patient support framework (39.1%), essential tool (34.8%), information access/anxiety reduction (30.4%). Perceived limitations Impersonal character (39.1%), lack of individual emotion adaptation (26.1%), usage complexity (21.7%), empathy alteration risk (21.7%), absence of transcultural adaptation (21.7%). √ Patient evaluation (n = 50) Characteristics : Mean age 48.9 ± 10.6 years. Gabonese nationality 94.0%. Locations: breast 68.0%, cervical 32.0%. Education level: none/primary 40.0%, secondary 44.0%, higher 16.0%. Marital status: married 42.0%, single/cohabiting 30.0%, widowed 28.0%. Professional status: income-generating activity 66.0%. Disclosure conditions : The announcement took place in a hospital setting for 92.0% of patients, with a companion present in 66% of cases (initiated by the patient in 69.7% of situations). Perceived communication quality (Table 3 ): Information understanding 80.0%, clear terms 84.0%, question opportunities 82.0%. However, emotional support deemed insufficient by 70.0% (not/little supported). Table 3 Communication quality perceived by patients (n = 50) Variable Yes n (%) No n (%) Information understanding 40 (80.0) 10 (20.0) Clear terms 42 (84.0) 8 (16.0) Question/answer opportunities 41 (82.0) 9 (18.0) Sufficient emotional listening/support 15 (30.0) 35 (70.0) Psychosocial impact (Table 4 ): Negative affect at disclosure 84.0%, but improvement at current state (positive affect 70.0%). Positive impact reported on daily life (74.0%), social/family life (64.0%), general well-being (72.0%). Current needs expressed by 56.0%. Table 4 Psychosocial impact of disclosure (n = 50) Variable Positive n (%) Negative n (%) Feeling at disclosure 8 (16.0) 42 (84.0) Current feeling 35 (70.0) 15 (30.0) Daily life impact 37 (74.0) 13 (26.0) Social/family life impact 32 (64.0) 18 (36.0) General well-being impact 36 (72.0) 14 (28.0) Suggestions : Relational priorities: compassion/listening/time (24.0%), more listening (6.0%), clarifications/compassion (16.0%), support group (2.0%). Between-group comparison (gynecologists n = 26 vs. oncologists-radiotherapists n = 24): No statistically significant differences (p > 0.05) on information understanding, term clarity, companion presence, feelings, or expressed needs. DISCUSSION This study represents the first evaluation of a structured protocol for gynecological cancer diagnostic disclosure in Gabon, providing essential insights into its feasibility and acceptability in an SSA context. √ Need for structured device The exploratory survey revealed major gaps: insufficient training (89.5%), absence of standardized tools (68.4%), limited institutional support (63.2%). These findings corroborate international literature highlighting deficits in bad news disclosure training despite its recognized impact on care quality ( 9 , 10 ). Reported difficulties—apprehension about emotions (63.1%), lack of appropriate setting (47.3%)—reflect manifest need for structuring, as demonstrated by Rimé ( 11 ) on social sharing of emotions importance, and other authors on interprofessional approaches ( 12 ). √ Protocol feasibility and acceptability Implementation demonstrated globally favorable acceptability. Over half of professionals (56.5%) felt comfortable with the device, 61.0% reported practice improvements, and 60.9% expressed positive satisfaction. These results align with recent evidence demonstrating that structured protocols and communication training significantly improve clinician confidence ( 10 , 13 , 14 )and reduce professional uncertainty ( 15 – 17 ). Interprofessional collaboration perceived as smooth (78.3%) underscores team work importance in oncological management ( 12 , 18 , 19 ). √ Between-specialty divergences A major observation concerns significant differences between gynecologists and oncologists-radiotherapists. The latter perceived superior impact and satisfaction ( p < 0.05 on all variables). This disparity could be explained by increased emotional burden among gynecologists, as first disclosers, versus oncologists-radiotherapists intervening later in therapeutic planning. The protocol appears better adapted to follow-up phases, suggesting need for personalization according to professional role and disclosure timing. √ Relational dimension: A persistent challenge Paradoxically, despite effective informational communication (84.0% of patients finding terms clear, 80% understanding information), strong relational demand persists. Emotional support was deemed insufficient by 70.0% of patients, 39.1% of professionals perceived the device as impersonal, and 30.0% of patients demanded more compassion and listening. This hiatus between technical efficacy and human dimension constitutes a fundamental challenge: how to guarantee informational clarity while preserving empathy and personalization? ( 20 ). The fact that 56% of patients still express psychological support needs indicates necessity for integrated and prolonged psychosocial care ( 21 , 22 ). Contemporary research confirms persistent gaps between informational clarity and emotional support ( 23 , 24 ), highlighting the need for integrated psychosocial interventions beyond protocol implementation ( 22 , 25 ). √ Cultural and linguistic adaptation Absence of transcultural and linguistic adaptation, identified by 21.7% of professionals, represents a major limitation in the multicultural and multilingual Gabonese context. Recent work emphasizes the necessity of culturally adapted approaches in diverse healthcare contexts ( 26 , 27 ) particularly in regions with linguistic and cultural heterogeneity similar to Gabon. Clinical implications This study demonstrates for the first time in Gabon the feasibility of a structured protocol for breaking gynecological cancer diagnoses, paving the way for its integration into routine oncology practice. Its use contributes to better organizing disclosure time, clarifying informational content, and strengthening interprofessional coordination (key elements for securing the care pathway from entry into the oncological trajectory). Regarding medical practices, the perceived improvement in first contact quality, practice evolution, and professional well-being, particularly among oncologists-radiotherapists (significant difference p < 0.05), suggests that this protocol can serve as a support mechanism against the emotional burden associated with disclosure. Protocol dissemination could thus be coupled with continuing education programs in communication, including role-play workshops and supervision sessions, to strengthen clinicians' confidence and prevent professional burnout risk. From the patients' perspective, the high proportion of women reporting satisfactory information understanding, yet insufficient emotional support (70.0% of patients), highlights the necessity of articulating this protocol with systematic psycho-oncology interventions. Concretely, this implies scheduling dedicated listening time, facilitating access to a psychologist, as well as referral systems to support groups or patient associations, particularly in the immediate aftermath of disclosure. The limitations identified by professionals, notably the perceived "impersonal" nature of the device and absence of transcultural adaptation, underscore the importance of flexible implementation, allowing protocol adjustment to patients' linguistic, cultural, and religious realities. Clinically, this requires co-developing with local teams simplified or translated versions, and training teams in the use of culturally relevant expressions and metaphors, to preserve empathy and personalization of the clinician-patient relationship. Finally, this study advocates for recognizing structured diagnosis disclosure as a quality indicator in oncological care, linked to quality of life and treatment adherence. Long-term, clinical audit mechanisms and longitudinal follow-up (QoL, adherence, supportive care utilization) could document the protocol's impact and guide institutional adjustments, particularly regarding human resources (psychologists, social workers) and public health policy in oncology. Strengths and limitations This prospective study fills an important documentary gap in SSA, adopting mixed methodology enabling holistic understanding. The dual perspective (professionals/patients) enriches analysis. However, several limitations merit consideration: limited sample size (n = 19 then n = 23 professionals; n = 50 patients) restricting statistical power and generalization; cross-sectional design without control group preventing causality establishment; absence of longitudinal analysis of quality of life, treatment adherence, and survival impact; monocentric recruitment for patients (ICA only); absence of vernacular language-adapted version; potential social desirability bias in self-questionnaires. Perspectives This study lays foundations for future research. Multicentric randomized controlled trials are necessary to measure long-term impact on clinical and psychosocial trajectories. The protocol requires adaptations: ( 1 ) targeted training integration on relational skills (active listening, empathy, emotional management); ( 2 ) culturally and linguistically adapted version development; ( 3 ) personalization according to professional role and disclosure timing; ( 4 ) real-time feedback system; ( 5 ) integrated psychological support reinforcement. CONCLUSION This work demonstrates feasibility and acceptability of a structured protocol for gynecological cancer diagnostic disclosure in Gabon, the first initiative of this type in SSA. The device significantly improves practice structuring and professional confidence while ensuring clear informational communication to patients. Nevertheless, optimal effectiveness requires integration with relational skills training and cultural adaptation. This pioneering study opens the way to substantial improvement in oncological diagnostic disclosure quality in resource-limited contexts, thus contributing to humanizing the care pathway and optimizing patient experience from oncological process entry. Abbreviations SSA Sub-Saharan Africa ICA Institut de Cancérologie d’Akanda SPIKES Setting, Perception, Invitation, Knowledge, Emotions, Strategy and Summary QoL Quality of Life IQR Interquartile Range Declarations Ethics approval and consent to participate This study received approval from the Institutional Review Board of the Institut de Cancérologie d'Akanda, Ministry of National Defense, Directorate General of Military Health Services, Institut de Cancérologie d'Akanda, Medical Oncology Department, Akanda, Gabon (Approval No. 001-AP-26/2023.MDN/DGSSM/ICA/ONCO-MED, January 26, 2023). All procedures performed in studies involving human participants were conducted in accordance with the ethical standards of the institutional research committee and with the 2024 Helsinki Declaration. Informed consent was obtained from all individual participants included in the study. Consent for publication Not applicable. This manuscript does not contain any individual person's data in any form (including individual details, images, or videos). Competing Interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author Contribution BCNB: Conceptualization, methodology, investigation, data collection, formal analysis, writing - original draft, project administration.JD: Data collection, investigation, validation.ACFK: Methodology, data collection, writing - review and editing.CIM: Supervision, validation.writing-review.EBN: Supervision, validation, writing - review and editing.EB: Supervision, validation, writing-review and editingPMP: Supervision, writing - review and editing, validation.All authors read and approved the final manuscript. Acknowledgements The authors would like to thank all healthcare professionals and patients who participated in this study. We are grateful to the Institute of Cancer of Akanda for providing institutional support and facilities for this research. Data Availability The data that support the findings of this study are available from the corresponding author, Béa-Christelle Ndjengue Bengone ( [ [email protected] ](mailto: [email protected] ) ), upon reasonable request. References Mills LM, Cate OT, Boscardin C, O’Sullivan PS. Breaking Bad News to Learners: How Well Does the SPIKES Clinical Model Translate? Perspect Med Educ 27 déc. 2024;13(1):684–92. Henok Fisseha W, Mulugeta RA, Kassu T, Geleta, Hailemichael Desalegn. Perspectives of Protocol Based Breaking Bad News among Medical Patients and Physicians in a Teaching Hospital, Ethiopia. Ethiop J Health Sci [Internet] 1 nov 2020 [cité 27 nov 2025];30(6). Disponible sur: https://www.ajol.info/index.php/ejhs/article/view/201980 Ipinnimo TM, Asake OT, Olowoselu OO, Sanni TA, Adekeye AP, Adepoju RA, et al. Breaking bad news: a cross-sectional study assessing SPIKES protocol adherence and other methods employed among medical doctors in Nigeria. BMC Prim Care 28 avr. 2025;26(1):133. 2e Congrès international francophone de soins palliatifs 2013. Ateliers Rev Int Soins Palliatifs. 2013;28(1):9–106. Ngoungou EB, Preux PM, Etude CAP, Connaissances. attitudes et pratiques à l’égard du cancer du sein et du cancer du col de l’utérus au Gabon. Enquête Nationale. Libreville: Fondation Sylvia Bongo Ondimba pour la famille; 2020. Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin mai. 2024;74(3):229–63. Organisation Mondiale de la Santé (OMS). Global cancer Observatory (Globocan). International Agency for Research on cancer [Internet]. 2022. Disponible sur: https://gco.iarc.who.int/media/globocan/factsheets/populations/900-world-fact-sheet.pdf Ndjengue Bengone BC, Filankembo Kava AC, Belembaogo E, Ngoungou EB, Preux PM. Conditions d’annonce du diagnostic d’un cancer gynécologique en Afrique subsaharienne. Revue systématique. Médecine Palliat nov. 2024;23(6):303–15. Ruiz Sancho E, Pérez Nieto MÁ, Román FJ, León Mateos L, Sánchez Escamilla F, Enrech Francés S et al. Differences in the Communication of Cancer Diagnoses by Different Health Professionals and the Impact of Oncologist Communication on Patients’ Emotions. Cancers. 2024;16(13). Gil FL, Hernández-Ribas R, Sánchez N, Gil J, Casellas-Grau A. Communication skills training for medical residents: Enhancing a psychosocial approach of patient care. Palliat Support Care. 2022/03/08 éd. 2023;21(3):392–8. Rimé B. Interpersonal emotion regulation. The Guilford Press. J J Gross. 2007;466–85. Sulosaari V, Dodlek N, Brandl A, De Munter J, Eriksen JG, McInally W et al. Interprofessional education in cancer care – a scoping review. BMC Med Educ. 16 juill. 2024;24(1):767. Christensen M, Kumar KA Jr, Wang W, Dharmarajan KV, Siropaides C. Patient-Centered Communication Training among Radiation Oncology Residents. Int J Radiat Oncol Biol Phys 1 nov. 2022;114(3):e425. Christensen M, Kumar KA, Wang WS, Dharmarajan KV, Chang Z, McStay CK, et al. Serious Illness Communication Training Among Radiation Oncology Residents. Pract Radiat Oncol mai. 2023;13(3):e220–9. Haute Autorité de Santé (HAS). Guide parcours de soins. Annonce et accompagnement du diagnostic d’un patient ayant une maladie chronique. 2024. Stiefel F, Bourquin C, Salmon P, Achtari Jeanneret L, Dauchy S, Ernstmann N et al. Communication and support of patients and caregivers in chronic cancer care: ESMO Clinical Practice Guideline☆. ESMO Open [Internet]. 1 juill 2024 [cité 16 août 2025];9(7). Disponible sur: https://doi.org/10.1016/j.esmoop.2024.103496 Druel V, Gimenez L, Paricaud K, Delord JP, Grosclaude P, Boussier N, et al. Improving communication between the general practitioner and the oncologist: a key role in coordinating care for patients suffering from cancer. BMC Cancer 1 juin. 2020;20(1):495. Salette N, Massoubre B, Bouillat C, Massoubre C. L’annonce des mauvaises nouvelles. Formation à la pratique par le jeu de rôle. J Psychol. 2023;N° Hors-série(HS2):27–34. Fallowfield L, Jenkins V, Farewell V, Saul J, Duffy A, Eves R. Efficacy of a Cancer Research UK communication skills training model for oncologists: a randomised controlled trial. Lancet 23 févr. 2002;359(9307):650–6. von Blanckenburg P, Hofmann M, Rief W, Seifart U, Seifart C. Assessing patients´ preferences for breaking Bad News according to the SPIKES-Protocol: the MABBAN scale. Patient Educ Couns 1 août. 2020;103(8):1623–9. Schuit AS, Holtmaat K, Van Zwieten V, Aukema EJ, Gransier L, Cuijpers P, et al. Organizing Psycho-Oncological Care for Cancer Patients: The Patient’s Perspective. Front Psychol 22 avr. 2021;12:625117. Anghel T, Melania BL, Costea I, Albai O, Marinca A, Levai CM et al. Review of Psychological Interventions in Oncology: Current Trends and Future Directions. Medicina (Mex). 6 févr. 2025;61(2):279. Guan Q, Ran H, Yang J, Yang X, Guo G, Shen N. Attitudes toward Cancer Diagnosis Disclosure and Resilience among Suspicious Lung Cancer Patients, Lung Cancer Patients, and Their Families. Sahgal P, éditeur. Eur J Cancer Care (Engl) 26 déc. 2023;2023:1–10. Sutar R, Chaudhary P. Prognostic disclosure in cancer care: a systematic literature review. Palliat Care Soc Pract 1 janv. 2022;16:26323524221101077. Zingler H, Steinmann D, Ernst J, Goerling U, Hermann M, Hornemann B et al. Psychosocial distress, perceived need and utilization of psycho- social support services in patients in the early phase after the first cancer diagnosis. J Cancer Res Clin Oncol. 6 févr. 2025;151(2):65. Graetz DE, Caceres-Serrano A, Radhakrishnan V, Salaverria CE, Kambugu JB, Sisk BA. A proposed global framework for pediatric cancer communication research. Cancer 15 mai. 2022;128(10):1888–93. Rost M, De Clercq E, Arnold L, Rakic M. Interventions to enhance cross-cultural competence in oncology: A meta-analysis of effectiveness studies and a qualitative review. Eur J Oncol Nurs [Internet]. 1 juin 2023 [cité 27 nov 2025];64. Disponible sur: https://doi.org/10.1016/j.ejon.2023.102277 Additional Declarations No competing interests reported. Supplementary Files Appendix.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 18 May, 2026 Reviewers agreed at journal 09 May, 2026 Reviewers agreed at journal 08 Feb, 2026 Reviewers agreed at journal 05 Feb, 2026 Reviews received at journal 27 Jan, 2026 Reviewers agreed at journal 25 Jan, 2026 Reviewers invited by journal 22 Jan, 2026 Editor invited by journal 21 Jan, 2026 Editor assigned by journal 21 Jan, 2026 Submission checks completed at journal 20 Jan, 2026 First submitted to journal 20 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8365394","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":579976156,"identity":"128cad55-ecb8-47bc-8c29-282524bd947d","order_by":0,"name":"Béa-Christelle Ndjengue Bengone","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYHACAwMwxd4AYluQooXnAIgtQZwWCCWRACYJq+ef3byh4OOO2sR+yedXN/wokGDgb+9OwKtF4s6xAsOZZ44nzpydU3azB+gwiTNnN+B3lUSOgTFv27HEDbdz0m7wALUYSOQSoeUvUMv+m2fSbv4hWgtjW03iBgn2Y7eJskXiRlqBYW/bAeMZZ3LYbssYSPAQ9Av/jORtBj/b6mT7248/u/nmj40cf3svfi1AwAaMmMNAmgccQTyElIMA8wMGhjogzf6AGNWjYBSMglEwAgEAYAVKrDCqW5oAAAAASUVORK5CYII=","orcid":"","institution":"University of Limoges","correspondingAuthor":true,"prefix":"","firstName":"Béa-Christelle","middleName":"Ndjengue","lastName":"Bengone","suffix":""},{"id":579976158,"identity":"04456dcc-be01-42ba-b471-03be677e85ae","order_by":1,"name":"Julia Diloussou","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Libreville","correspondingAuthor":false,"prefix":"","firstName":"Julia","middleName":"","lastName":"Diloussou","suffix":""},{"id":579976163,"identity":"47b33039-3b40-44d2-a39a-66bd9bfbb428","order_by":2,"name":"Angela-Christie Filankembo Kava","email":"","orcid":"","institution":"Institut de Cancérologie d'Akanda","correspondingAuthor":false,"prefix":"","firstName":"Angela-Christie","middleName":"Filankembo","lastName":"Kava","suffix":""},{"id":579976164,"identity":"042912a5-7cd5-46b2-acd1-066fa0cbcaf6","order_by":3,"name":"Chimène Igabouyi-Moussadji","email":"","orcid":"","institution":"Institut de Cancérologie d'Akanda","correspondingAuthor":false,"prefix":"","firstName":"Chimène","middleName":"","lastName":"Igabouyi-Moussadji","suffix":""},{"id":579976167,"identity":"7580a95c-2e67-4ae2-97fa-9e7e41200cdf","order_by":4,"name":"Edgard Brice Ngoungou","email":"","orcid":"","institution":"University of Limoges","correspondingAuthor":false,"prefix":"","firstName":"Edgard","middleName":"Brice","lastName":"Ngoungou","suffix":""},{"id":579976168,"identity":"063d0d1f-4d5c-4c0f-ae42-7e250341b720","order_by":5,"name":"Ernest Belembaogo","email":"","orcid":"","institution":"Institut de Cancérologie d'Akanda","correspondingAuthor":false,"prefix":"","firstName":"Ernest","middleName":"","lastName":"Belembaogo","suffix":""},{"id":579976169,"identity":"a5c69885-7821-4fa4-9976-f53bfceb56b1","order_by":6,"name":"Pierre-Marie Preux","email":"","orcid":"","institution":"University of Limoges","correspondingAuthor":false,"prefix":"","firstName":"Pierre-Marie","middleName":"","lastName":"Preux","suffix":""}],"badges":[],"createdAt":"2025-12-15 11:08:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8365394/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8365394/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101297314,"identity":"94b45b79-5502-4cba-b835-3c6ed7e7174b","added_by":"auto","created_at":"2026-01-28 09:26:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1075119,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8365394/v1/bde54306-81d1-4fba-80b5-3e66224c6cf6.pdf"},{"id":101258281,"identity":"d3953c96-6032-478a-9f37-53ad2c68a96a","added_by":"auto","created_at":"2026-01-27 19:35:59","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":645633,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-8365394/v1/53162aa69cc4e4ff0a472fc1.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"A structured protocol for breaking diagnosis gynecological cancer in Gabon: a two-phase feasibility study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eBreaking bad news of cancer diagnosis represents a pivotal moment in the oncological journey, determinant for therapeutic relationship, treatment adherence, and patients' quality of life This critical step requires adapted, empathetic, and structured communication, as emphasized by international guidelines protocols such as SPIKES demonstrate continued relevance (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). with, recent validation studies across diverse settings confirming their effectiveness in standardizing disclosure practices (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eHowever, in sub-Saharan Africa (SSA), diagnostic disclosure remains largely unstandardized, facing multiple challenges: limited resources, overburdened health systems, cultural and linguistic diversity, and insufficient professional training (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In Gabon, despite rising incidence of gynecological cancers (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u0026mdash;particularly breast cancer (25.8 per 100,000 women) and cervical cancer (22.7 per 100,000)\u0026mdash;no formalized protocol for diagnostic disclosure exists to date.\u003c/p\u003e \u003cp\u003ePrevious work documented needs expressed by Gabonese patients concerning improvement of disclosure quality (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Facing this reality, this study aims to develop and implement a structured protocol for diagnostic disclosure adapted to the Gabonese context, then evaluate its operational feasibility and acceptability among healthcare professionals and patients.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e√ Study design\u003c/h2\u003e \u003cp\u003eProspective observational two-phase study conducted at the Institut de Canc\u0026eacute;rologie d\u0026rsquo;Akanda (ICA) and four other Gabonese healthcare facilities between December 2024 and July 2025.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhase 1\u003c/b\u003e (December 2024): Cross-sectional exploratory survey among professionals documenting existing practices and identifying needs.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhase 2\u003c/b\u003e (January-July 2025): Feasibility and implementation study of the structured protocol, followed by satisfaction surveys among professionals and patients.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e√ Study populations\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eHealthcare professionals.\u003c/b\u003e Phase 1: 19 physicians and residents recruited during weekly multidisciplinary team meetings at ICA. Phase 2: 23 professionals (gynecologists, oncologists, radiotherapists, residents) practicing in five facilities.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePatients\u003c/b\u003e: 50 patients aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years, having received histological diagnosis of breast or cervical cancer between February-July 2025, recruited through consecutive sampling at ICA. Exclusion criteria: severe cognitive disorders, significant general condition deterioration, inability to communicate in French.\u003c/p\u003e\n\u003ch3\u003e√ Protocol development\u003c/h3\u003e\n\u003cp\u003eThe protocol was developed based on: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) exploratory survey results (Phase 1), (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) international recommendations (notably SPIKES, appendix 1), (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) adaptation to local healthcare and cultural realities, (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) participatory process involving multidisciplinary professionals.\u003c/p\u003e\n\u003ch3\u003e√ Implementation\u003c/h3\u003e\n\u003cp\u003eThe protocol was deployed over 7 months (January-July 2025) after a professional training session. Continuous support was provided to ensure device appropriation.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003ePhase 1\u003c/strong\u003e \u003cp\u003eAnonymous self-administered questionnaire exploring sociodemographic characteristics, disclosure practices, difficulties encountered, training and resource needs, and current device perceptions (appendix 2).\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePhase 2:\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eProfessionals\u003c/b\u003e: Satisfaction questionnaire (May 2025) evaluating feasibility, perceived utility, practice impact, and improvement suggestions (appendix 3).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003ePatients\u003c/b\u003e: Questionnaire administered during consultation documenting sociodemographic and clinical data, disclosure conditions, communication quality, emotional support received, psychosocial impact, and improvement suggestions (appendix 4).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e√ Statistical Analysis\u003c/h2\u003e \u003cp\u003eData entered in Excel 2016 and analyzed with SPSS v.21. Quantitative variables expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, categorical variables as frequencies and percentages. Between-group comparisons (gynecologists vs. oncologists-radiotherapists; two patient groups) performed using non-parametric Mann-Whitney U test. Significance threshold set at \u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/em\u003e. Inductive thematic analysis of open responses.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePhase 1: Exploratory survey among professionals\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e√ Participant characteristics (n\u0026thinsp;=\u0026thinsp;19)\u003c/h2\u003e \u003cp\u003eMean age: 44.3\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0 years; professional experience: 9.0\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7 years; disclosure frequency: 5.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7/month. Balanced gender distribution (9M/10F). Profiles: predominantly oncologists, followed by residents and radiotherapists.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e√ Current practices and needs assessment\u003c/h2\u003e \u003cp\u003e \u003cb\u003eTraining and resources\u003c/b\u003e: Only 10.5% (n\u0026thinsp;=\u0026thinsp;2) received specific training in disclosure, with only one considering it satisfactory. All (100%) untrained professionals desired training. Only 31.6% had necessary resources (psychologist: n\u0026thinsp;=\u0026thinsp;4; brochures: n\u0026thinsp;=\u0026thinsp;2). Hierarchical support was deemed insufficient by 63.2%.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eMain difficulties\u003c/strong\u003e \u003cp\u003eApprehension about patients' emotional reactions (63.1%), lack of appropriate setting (47.3%), inappropriate communication/language (26.3%), absence of psychologist (26.3%).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eReported practices\u003c/b\u003e: Preparation through thorough medical file analysis (79.0%), preference for calm environment (63.0%), presence of companion/psychologist (47;0%). Quality criteria identified: discourse clarity and language adaptation (68.0%), respect for confidentiality and consistency (53.0%), companion presence (37.0%). The main difficulties reported included apprehension about patients' emotional reactions (63.1%), lack of an appropriate setting (47.3%), use of inappropriate language (26.3%), and absence of a psychologist (26.3%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePhase 2: Protocol implementation and evaluation (appendix 5)\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e√ Professional evaluation (n\u0026thinsp;=\u0026thinsp;23)\u003c/h2\u003e \u003cp\u003e \u003cb\u003eCharacteristics\u003c/b\u003e: Mean age 43.7\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3 years; experience 9.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8 years; disclosure frequency 5.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1/month. Distribution: gynecologists 47.8%, oncologists 26.1%, radiotherapists 13.0%, residents 13.0%.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePerception and acceptability\u003c/b\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e): Comfort level favorable for 56.5% (score\u0026thinsp;\u0026gt;\u0026thinsp;5/10). Comfort sources: clear structuring (61.0%), perceived support (57.0%), communication facilitation (52.0%). Interprofessional collaboration smooth for 78.3%. Overall satisfaction moderate to strong for 60.9%.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eProtocol perception by professionals (Phase 2, n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModality\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEffective (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComfort level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow-Moderate (\u0026le;\u0026thinsp;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood-Excellent (\u0026gt;\u0026thinsp;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e56.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterprofessional collaboration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow (\u0026le;\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate-Strong (\u0026gt;\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e78.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall satisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow (\u0026le;\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate-Strong (\u0026gt;\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e60.9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePerceived impact\u003c/strong\u003e \u003cp\u003eStrong impact reported on practice evolution (61.0%), first contact improvement (61.0%), professional well-being (57.0%).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eBetween-specialty comparison\u003c/b\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e): Significant differences between gynecologists and oncologists-radiotherapists. The latter perceived superior global impact (median 7 vs. 4, p\u0026thinsp;=\u0026thinsp;0.015), more marked practice evolution (p\u0026thinsp;=\u0026thinsp;0.004), better first contact improvement (p\u0026thinsp;=\u0026thinsp;0.025), higher well-being impact (p\u0026thinsp;=\u0026thinsp;0.032), and significantly superior overall satisfaction (median 6 vs. 4, p\u0026thinsp;=\u0026thinsp;0.005).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison gynecologists vs. oncologists-radiotherapists\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGynecologists Median (IQR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOnco-RT Median (IQR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlobal device impact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (\u0026plusmn;\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (\u0026plusmn;\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePractice evolution\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (\u0026plusmn;\u0026thinsp;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (\u0026plusmn;\u0026thinsp;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst contact improvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (\u0026plusmn;\u0026thinsp;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (\u0026plusmn;\u0026thinsp;19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWell-being impact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (\u0026plusmn;\u0026thinsp;16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (\u0026plusmn;\u0026thinsp;18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall satisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (\u0026plusmn;\u0026thinsp;2.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (\u0026plusmn;\u0026thinsp;1.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Mann-Whitney U test;\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eImprovement suggestions\u003c/strong\u003e \u003cp\u003eMore in-depth training (30.4%), real-time feedback system (30.4%), personalization options (26.1%), minor adjustments (26.1%), satisfactory as is (21.7%).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eIdentified advantages\u003c/strong\u003e \u003cp\u003eCommunication clarity (39.1%), patient support framework (39.1%), essential tool (34.8%), information access/anxiety reduction (30.4%).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePerceived limitations\u003c/strong\u003e \u003cp\u003eImpersonal character (39.1%), lack of individual emotion adaptation (26.1%), usage complexity (21.7%), empathy alteration risk (21.7%), absence of transcultural adaptation (21.7%).\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e√ Patient evaluation (n\u0026thinsp;=\u0026thinsp;50)\u003c/h2\u003e \u003cp\u003e \u003cb\u003eCharacteristics\u003c/b\u003e: Mean age 48.9\u0026thinsp;\u0026plusmn;\u0026thinsp;10.6 years. Gabonese nationality 94.0%. Locations: breast 68.0%, cervical 32.0%. Education level: none/primary 40.0%, secondary 44.0%, higher 16.0%. Marital status: married 42.0%, single/cohabiting 30.0%, widowed 28.0%. Professional status: income-generating activity 66.0%.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDisclosure\u003c/strong\u003e \u003cp\u003e \u003cb\u003econditions\u003c/b\u003e: The announcement took place in a hospital setting for 92.0% of patients, with a companion present in 66% of cases (initiated by the patient in 69.7% of situations).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003ePerceived communication quality\u003c/b\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e): Information understanding 80.0%, clear terms 84.0%, question opportunities 82.0%. However, emotional support deemed insufficient by 70.0% (not/little supported).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCommunication quality perceived by patients (n\u0026thinsp;=\u0026thinsp;50)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInformation understanding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40 (80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClear terms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42 (84.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (16.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuestion/answer opportunities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41 (82.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (18.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSufficient emotional listening/support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35 (70.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003ePsychosocial impact\u003c/b\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e): Negative affect at disclosure 84.0%, but improvement at current state (positive affect 70.0%). Positive impact reported on daily life (74.0%), social/family life (64.0%), general well-being (72.0%). Current needs expressed by 56.0%.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePsychosocial impact of disclosure (n\u0026thinsp;=\u0026thinsp;50)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNegative n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeeling at disclosure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8 (16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42 (84.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent feeling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35 (70.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (30.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaily life impact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37 (74.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (26.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial/family life impact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32 (64.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 (36.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral well-being impact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36 (72.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (28.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSuggestions\u003c/b\u003e: Relational priorities: compassion/listening/time (24.0%), more listening (6.0%), clarifications/compassion (16.0%), support group (2.0%).\u003c/p\u003e \u003cp\u003e \u003cb\u003eBetween-group comparison\u003c/b\u003e (gynecologists n\u0026thinsp;=\u0026thinsp;26 vs. oncologists-radiotherapists n\u0026thinsp;=\u0026thinsp;24): No statistically significant differences (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) on information understanding, term clarity, companion presence, feelings, or expressed needs.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study represents the first evaluation of a structured protocol for gynecological cancer diagnostic disclosure in Gabon, providing essential insights into its feasibility and acceptability in an SSA context.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e√ Need for structured device\u003c/h2\u003e \u003cp\u003eThe exploratory survey revealed major gaps: insufficient training (89.5%), absence of standardized tools (68.4%), limited institutional support (63.2%). These findings corroborate international literature highlighting deficits in bad news disclosure training despite its recognized impact on care quality (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Reported difficulties\u0026mdash;apprehension about emotions (63.1%), lack of appropriate setting (47.3%)\u0026mdash;reflect manifest need for structuring, as demonstrated by Rim\u0026eacute; (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) on social sharing of emotions importance, and other authors on interprofessional approaches (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e√ Protocol feasibility and acceptability\u003c/h2\u003e \u003cp\u003eImplementation demonstrated globally favorable acceptability. Over half of professionals (56.5%) felt comfortable with the device, 61.0% reported practice improvements, and 60.9% expressed positive satisfaction. These results align with recent evidence demonstrating that structured protocols and communication training significantly improve clinician confidence (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)and reduce professional uncertainty (\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Interprofessional collaboration perceived as smooth (78.3%) underscores team work importance in oncological management (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e√ Between-specialty divergences\u003c/h2\u003e \u003cp\u003eA major observation concerns significant differences between gynecologists and oncologists-radiotherapists. The latter perceived superior impact and satisfaction (\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/em\u003e on all variables). This disparity could be explained by increased emotional burden among gynecologists, as first disclosers, versus oncologists-radiotherapists intervening later in therapeutic planning. The protocol appears better adapted to follow-up phases, suggesting need for personalization according to professional role and disclosure timing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e√ Relational dimension: A persistent challenge\u003c/h2\u003e \u003cp\u003eParadoxically, despite effective informational communication (84.0% of patients finding terms clear, 80% understanding information), strong relational demand persists. Emotional support was deemed insufficient by 70.0% of patients, 39.1% of professionals perceived the device as impersonal, and 30.0% of patients demanded more compassion and listening. This hiatus between technical efficacy and human dimension constitutes a fundamental challenge: how to guarantee informational clarity while preserving empathy and personalization? (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The fact that 56% of patients still express psychological support needs indicates necessity for integrated and prolonged psychosocial care (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Contemporary research confirms persistent gaps between informational clarity and emotional support (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), highlighting the need for integrated psychosocial interventions beyond protocol implementation (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e√ Cultural and linguistic adaptation\u003c/h2\u003e \u003cp\u003eAbsence of transcultural and linguistic adaptation, identified by 21.7% of professionals, represents a major limitation in the multicultural and multilingual Gabonese context. Recent work emphasizes the necessity of culturally adapted approaches in diverse healthcare contexts (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) particularly in regions with linguistic and cultural heterogeneity similar to Gabon.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eClinical implications\u003c/h2\u003e \u003cp\u003eThis study demonstrates for the first time in Gabon the feasibility of a structured protocol for breaking gynecological cancer diagnoses, paving the way for its integration into routine oncology practice. Its use contributes to better organizing disclosure time, clarifying informational content, and strengthening interprofessional coordination (key elements for securing the care pathway from entry into the oncological trajectory).\u003c/p\u003e \u003cp\u003eRegarding medical practices, the perceived improvement in first contact quality, practice evolution, and professional well-being, particularly among oncologists-radiotherapists (significant difference p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), suggests that this protocol can serve as a support mechanism against the emotional burden associated with disclosure. Protocol dissemination could thus be coupled with continuing education programs in communication, including role-play workshops and supervision sessions, to strengthen clinicians' confidence and prevent professional burnout risk.\u003c/p\u003e \u003cp\u003eFrom the patients' perspective, the high proportion of women reporting satisfactory information understanding, yet insufficient emotional support (70.0% of patients), highlights the necessity of articulating this protocol with systematic psycho-oncology interventions. Concretely, this implies scheduling dedicated listening time, facilitating access to a psychologist, as well as referral systems to support groups or patient associations, particularly in the immediate aftermath of disclosure.\u003c/p\u003e \u003cp\u003eThe limitations identified by professionals, notably the perceived \"impersonal\" nature of the device and absence of transcultural adaptation, underscore the importance of flexible implementation, allowing protocol adjustment to patients' linguistic, cultural, and religious realities. Clinically, this requires co-developing with local teams simplified or translated versions, and training teams in the use of culturally relevant expressions and metaphors, to preserve empathy and personalization of the clinician-patient relationship.\u003c/p\u003e \u003cp\u003eFinally, this study advocates for recognizing structured diagnosis disclosure as a quality indicator in oncological care, linked to quality of life and treatment adherence. Long-term, clinical audit mechanisms and longitudinal follow-up (QoL, adherence, supportive care utilization) could document the protocol's impact and guide institutional adjustments, particularly regarding human resources (psychologists, social workers) and public health policy in oncology.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThis prospective study fills an important documentary gap in SSA, adopting mixed methodology enabling holistic understanding. The dual perspective (professionals/patients) enriches analysis. However, several limitations merit consideration: limited sample size (n\u0026thinsp;=\u0026thinsp;19 then n\u0026thinsp;=\u0026thinsp;23 professionals; n\u0026thinsp;=\u0026thinsp;50 patients) restricting statistical power and generalization; cross-sectional design without control group preventing causality establishment; absence of longitudinal analysis of quality of life, treatment adherence, and survival impact; monocentric recruitment for patients (ICA only); absence of vernacular language-adapted version; potential social desirability bias in self-questionnaires.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003ePerspectives\u003c/h2\u003e \u003cp\u003eThis study lays foundations for future research. Multicentric randomized controlled trials are necessary to measure long-term impact on clinical and psychosocial trajectories. The protocol requires adaptations: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) targeted training integration on relational skills (active listening, empathy, emotional management); (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) culturally and linguistically adapted version development; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) personalization according to professional role and disclosure timing; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) real-time feedback system; (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) integrated psychological support reinforcement.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis work demonstrates feasibility and acceptability of a structured protocol for gynecological cancer diagnostic disclosure in Gabon, the first initiative of this type in SSA. The device significantly improves practice structuring and professional confidence while ensuring clear informational communication to patients. Nevertheless, optimal effectiveness requires integration with relational skills training and cultural adaptation. This pioneering study opens the way to substantial improvement in oncological diagnostic disclosure quality in resource-limited contexts, thus contributing to humanizing the care pathway and optimizing patient experience from oncological process entry.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSSA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSub-Saharan Africa\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInstitut de Canc\u0026eacute;rologie d\u0026rsquo;Akanda\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPIKES\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSetting, Perception, Invitation, Knowledge, Emotions, Strategy and Summary\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eQoL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eQuality of Life\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIQR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInterquartile Range\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003e This study received approval from the Institutional Review Board of the Institut de Canc\u0026eacute;rologie d'Akanda, Ministry of National Defense, Directorate General of Military Health Services, Institut de Canc\u0026eacute;rologie d'Akanda, Medical Oncology Department, Akanda, Gabon (Approval No. 001-AP-26/2023.MDN/DGSSM/ICA/ONCO-MED, January 26, 2023). All procedures performed in studies involving human participants were conducted in accordance with the ethical standards of the institutional research committee and with the 2024 Helsinki Declaration. Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable. This manuscript does not contain any individual person's data in any form (including individual details, images, or videos).\u003c/p\u003e \u003ch2\u003eCompeting Interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eBCNB: Conceptualization, methodology, investigation, data collection, formal analysis, writing - original draft, project administration.JD: Data collection, investigation, validation.ACFK: Methodology, data collection, writing - review and editing.CIM: Supervision, validation.writing-review.EBN: Supervision, validation, writing - review and editing.EB: Supervision, validation, writing-review and editingPMP: Supervision, writing - review and editing, validation.All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eThe authors would like to thank all healthcare professionals and patients who participated in this study. We are grateful to the Institute of Cancer of Akanda for providing institutional support and facilities for this research.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data that support the findings of this study are available from the corresponding author, B\u0026eacute;a-Christelle Ndjengue Bengone ( [[email protected]](mailto:[email protected]) ), upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMills LM, Cate OT, Boscardin C, O\u0026rsquo;Sullivan PS. Breaking Bad News to Learners: How Well Does the SPIKES Clinical Model Translate? Perspect Med Educ 27 d\u0026eacute;c. 2024;13(1):684\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHenok Fisseha W, Mulugeta RA, Kassu T, Geleta, Hailemichael Desalegn. Perspectives of Protocol Based Breaking Bad News among Medical Patients and Physicians in a Teaching Hospital, Ethiopia. Ethiop J Health Sci [Internet] 1 nov 2020 [cit\u0026eacute; 27 nov 2025];30(6). Disponible sur: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ajol.info/index.php/ejhs/article/view/201980\u003c/span\u003e\u003cspan address=\"https://www.ajol.info/index.php/ejhs/article/view/201980\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIpinnimo TM, Asake OT, Olowoselu OO, Sanni TA, Adekeye AP, Adepoju RA, et al. Breaking bad news: a cross-sectional study assessing SPIKES protocol adherence and other methods employed among medical doctors in Nigeria. BMC Prim Care 28 avr. 2025;26(1):133.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e2e Congr\u0026egrave;s international francophone de soins palliatifs 2013. Ateliers Rev Int Soins Palliatifs. 2013;28(1):9\u0026ndash;106.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNgoungou EB, Preux PM, Etude CAP, Connaissances. attitudes et pratiques \u0026agrave; l\u0026rsquo;\u0026eacute;gard du cancer du sein et du cancer du col de l\u0026rsquo;ut\u0026eacute;rus au Gabon. Enqu\u0026ecirc;te Nationale. Libreville: Fondation Sylvia Bongo Ondimba pour la famille; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin mai. 2024;74(3):229\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrganisation Mondiale de la Sant\u0026eacute; (OMS). Global cancer Observatory (Globocan). International Agency for Research on cancer [Internet]. 2022. Disponible sur: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://gco.iarc.who.int/media/globocan/factsheets/populations/900-world-fact-sheet.pdf\u003c/span\u003e\u003cspan address=\"https://gco.iarc.who.int/media/globocan/factsheets/populations/900-world-fact-sheet.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNdjengue Bengone BC, Filankembo Kava AC, Belembaogo E, Ngoungou EB, Preux PM. Conditions d\u0026rsquo;annonce du diagnostic d\u0026rsquo;un cancer gyn\u0026eacute;cologique en Afrique subsaharienne. Revue syst\u0026eacute;matique. M\u0026eacute;decine Palliat nov. 2024;23(6):303\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRuiz Sancho E, P\u0026eacute;rez Nieto M\u0026Aacute;, Rom\u0026aacute;n FJ, Le\u0026oacute;n Mateos L, S\u0026aacute;nchez Escamilla F, Enrech Franc\u0026eacute;s S et al. Differences in the Communication of Cancer Diagnoses by Different Health Professionals and the Impact of Oncologist Communication on Patients\u0026rsquo; Emotions. Cancers. 2024;16(13).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGil FL, Hern\u0026aacute;ndez-Ribas R, S\u0026aacute;nchez N, Gil J, Casellas-Grau A. Communication skills training for medical residents: Enhancing a psychosocial approach of patient care. Palliat Support Care. 2022/03/08 \u0026eacute;d. 2023;21(3):392\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRim\u0026eacute; B. Interpersonal emotion regulation. The Guilford Press. J J Gross. 2007;466\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSulosaari V, Dodlek N, Brandl A, De Munter J, Eriksen JG, McInally W et al. Interprofessional education in cancer care \u0026ndash; a scoping review. BMC Med Educ. 16 juill. 2024;24(1):767.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChristensen M, Kumar KA Jr, Wang W, Dharmarajan KV, Siropaides C. Patient-Centered Communication Training among Radiation Oncology Residents. Int J Radiat Oncol Biol Phys 1 nov. 2022;114(3):e425.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChristensen M, Kumar KA, Wang WS, Dharmarajan KV, Chang Z, McStay CK, et al. Serious Illness Communication Training Among Radiation Oncology Residents. Pract Radiat Oncol mai. 2023;13(3):e220\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaute Autorit\u0026eacute; de Sant\u0026eacute; (HAS). Guide parcours de soins. Annonce et accompagnement du diagnostic d\u0026rsquo;un patient ayant une maladie chronique. 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStiefel F, Bourquin C, Salmon P, Achtari Jeanneret L, Dauchy S, Ernstmann N et al. Communication and support of patients and caregivers in chronic cancer care: ESMO Clinical Practice Guideline☆. ESMO Open [Internet]. 1 juill 2024 [cit\u0026eacute; 16 ao\u0026ucirc;t 2025];9(7). Disponible sur: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.esmoop.2024.103496\u003c/span\u003e\u003cspan address=\"10.1016/j.esmoop.2024.103496\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDruel V, Gimenez L, Paricaud K, Delord JP, Grosclaude P, Boussier N, et al. Improving communication between the general practitioner and the oncologist: a key role in coordinating care for patients suffering from cancer. BMC Cancer 1 juin. 2020;20(1):495.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalette N, Massoubre B, Bouillat C, Massoubre C. L\u0026rsquo;annonce des mauvaises nouvelles. Formation \u0026agrave; la pratique par le jeu de r\u0026ocirc;le. J Psychol. 2023;N\u0026deg; Hors-s\u0026eacute;rie(HS2):27\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFallowfield L, Jenkins V, Farewell V, Saul J, Duffy A, Eves R. Efficacy of a Cancer Research UK communication skills training model for oncologists: a randomised controlled trial. Lancet 23 f\u0026eacute;vr. 2002;359(9307):650\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evon Blanckenburg P, Hofmann M, Rief W, Seifart U, Seifart C. Assessing patients\u0026acute; preferences for breaking Bad News according to the SPIKES-Protocol: the MABBAN scale. Patient Educ Couns 1 ao\u0026ucirc;t. 2020;103(8):1623\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchuit AS, Holtmaat K, Van Zwieten V, Aukema EJ, Gransier L, Cuijpers P, et al. Organizing Psycho-Oncological Care for Cancer Patients: The Patient\u0026rsquo;s Perspective. Front Psychol 22 avr. 2021;12:625117.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnghel T, Melania BL, Costea I, Albai O, Marinca A, Levai CM et al. Review of Psychological Interventions in Oncology: Current Trends and Future Directions. Medicina (Mex). 6 f\u0026eacute;vr. 2025;61(2):279.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuan Q, Ran H, Yang J, Yang X, Guo G, Shen N. Attitudes toward Cancer Diagnosis Disclosure and Resilience among Suspicious Lung Cancer Patients, Lung Cancer Patients, and Their Families. Sahgal P, \u0026eacute;diteur. Eur J Cancer Care (Engl) 26 d\u0026eacute;c. 2023;2023:1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSutar R, Chaudhary P. Prognostic disclosure in cancer care: a systematic literature review. Palliat Care Soc Pract 1 janv. 2022;16:26323524221101077.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZingler H, Steinmann D, Ernst J, Goerling U, Hermann M, Hornemann B et al. Psychosocial distress, perceived need and utilization of psycho- social support services in patients in the early phase after the first cancer diagnosis. J Cancer Res Clin Oncol. 6 f\u0026eacute;vr. 2025;151(2):65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGraetz DE, Caceres-Serrano A, Radhakrishnan V, Salaverria CE, Kambugu JB, Sisk BA. A proposed global framework for pediatric cancer communication research. Cancer 15 mai. 2022;128(10):1888\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRost M, De Clercq E, Arnold L, Rakic M. Interventions to enhance cross-cultural competence in oncology: A meta-analysis of effectiveness studies and a qualitative review. Eur J Oncol Nurs [Internet]. 1 juin 2023 [cit\u0026eacute; 27 nov 2025];64. Disponible sur: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ejon.2023.102277\u003c/span\u003e\u003cspan address=\"10.1016/j.ejon.2023.102277\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Breaking bad news, communication, Gabon, Gynecologic neoplasms, Sub-Saharan Africa","lastPublishedDoi":"10.21203/rs.3.rs-8365394/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8365394/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo develop and implement a structured protocol for breaking gynecological cancer diagnoses in Gabon, and evaluate its feasibility and acceptability among healthcare professionals and patients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eTwo-phase prospective study (2024\u0026ndash;2025). Phase 1: exploratory survey among 19 professionals documenting existing practices and needs. Phase 2: protocol implementation in five healthcare facilities followed by satisfaction surveys among 23 professionals and 50 patients with breast or cervical cancer. Quantitative analyses (Mann-Whitney test) and thematic qualitative analyses were performed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePhase 1 revealed major gaps: insufficient training (89.5%), lack of standardized tools (68.4%), and limited institutional support (63.2%). Phase 2 demonstrated favorable acceptability: 56.5% of professionals reported high comfort levels, 61% practice improvement, and 60.9% positive overall satisfaction. Oncologists-radiotherapists perceived significantly superior impact compared to gynecologists on practice evolution \u003cem\u003e(p\u0026thinsp;=\u0026thinsp;0.004\u003c/em\u003e), first contact improvement (\u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.025)\u003c/em\u003e, and professional well-being \u003cem\u003e(p\u0026thinsp;=\u0026thinsp;0.032).\u003c/em\u003e Among patients, 84% found communication clear and 80.0% understood information, but 70.0% deemed emotional support insufficient. Main limitations: impersonal nature (39.1%) and lack of transcultural adaptation (21.7%).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis first-in-Gabon protocol demonstrates feasibility and acceptability. However, optimal effectiveness requires complementary training in relational skills and cultural adaptation. Controlled longitudinal studies are needed to measure long-term impact on quality of life and treatment adherence.\u003c/p\u003e","manuscriptTitle":"A structured protocol for breaking diagnosis gynecological cancer in Gabon: a two-phase feasibility study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-27 19:35:55","doi":"10.21203/rs.3.rs-8365394/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-18T12:37:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"24924996504037972661167844070083576355","date":"2026-05-09T14:31:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"233848098145610206352612564740372505909","date":"2026-02-08T05:51:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"65708601707823060033306558894352288160","date":"2026-02-05T08:29:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-27T19:52:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"302077363623884387583671206286877637786","date":"2026-01-25T06:17:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-22T13:53:11+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-21T11:49:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-21T11:45:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-20T10:58:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-01-20T10:47:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f3905a04-74d0-4d19-ae15-4a86eeb5bb1a","owner":[],"postedDate":"January 27th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-18T12:37:48+00:00","index":88,"fulltext":""},{"type":"reviewerAgreed","content":"24924996504037972661167844070083576355","date":"2026-05-09T14:31:34+00:00","index":86,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-27T19:35:55+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-27 19:35:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8365394","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8365394","identity":"rs-8365394","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}