Background. Moral distress and burnout are highly prevalent among oncology clinicians. Research is needed to better understand how resource constraints and systemic inequalities contribute to moral distress in order to develop effective mitigation strategies. Oncology providers in lowand middle-income countries (LMICs) are well positioned to provide insight into the moral experience of cancer care priority setting and expertise to guide solutions. Methods. Semi-structured interviews were conducted with a purposive sample of 22 oncology physicians, nurses, program leaders, and clinical advisors at a cancer center in Rwanda. Interviews were recorded, transcribed verbatim, and analyzed using the framework method. Results. Participants identified sources of moral distress at three levels of engagement with resource prioritization: witnessing program-level resource constraints drive cancer disparities, implementing priority setting decisions into care of individual patients, and communicating with patients directly about resource prioritization implications. They recommended individual and organizational level interventions to foster resilience, such as communication skills training and mental health support for clinicians, interdisciplinary team-building, fair procedures for priority setting, and collective advocacy for resource expansion and equity. Conclusion. This study adds to the current literature an indepth examination of the impact of resource constraints and inequities on clinicians in a low resource setting. Effective interventions are urgently needed to address moral distress, reduce clinician burnout, and promote well-being among a critical but strained oncology workforce. Collective advocacy is concomitantly needed to address the structural forces that constrain resources unevenly and perpetuate disparities in cancer care and outcomes.Implications for Practice:: For many oncology clinicians worldwide, resource limitations constrain routine clinical practice and necessitate decisions about prioritizing cancer care. To our knowledge, this study is the first in-depth analysis of how resource constraints and priority setting lead to moral distress among oncology clinicians in a low resource setting. Effective individual and organizational interventions and collective advocacy for equity in cancer care are urgently needed to address moral distress and reduce clinician burnout among a strained global oncology workforce. Lessons from low resource settings can be gleaned as high-income countries face growing needs to prioritize oncology resources. The Oncologist 2021;9999:• •

e16081 Background: There are few studies on CRC in sub-Saharan Africa. BCCOE in Rwanda provides patients with CRC access to chemotherapy, surgery and radiotherapy referrals. Here, we describe patient characteristics, treatments delivered and outcomes. Methods: This retrospective observational study included 136 patients with CRC who presented between July 2012 and June 2018. We abstracted patient characteristics, diagnostic and treatment data, and outcomes from electronic and paper records. We compared baseline and treatment characteristics for colon cancer (CC) versus (vs.) rectal cancer (RC) patients. For patients treated with curative intent, we plotted Kaplan Meier estimation of disease free survival (DFS), defined as time from presentation to cancer recurrence, progression or death. Log-rank test was used to examine subgroup differences. Results: The mean age was 52.5, and 71 (52.2%) were female. 101 (74.2%) patients had RC. Compared to CC, patients with RC were older 54.5 vs. 46.9 (p = 0.0084), and more likely female 59.4 vs. 31.4 (p = 0.0043). All provinces in Rwanda were represented including 14 (10.3%) from outside Rwanda; 79 (58.1%) patients lived in rural areas. Median duration of symptoms prior to presentation was 12 months, and 57 (41.9%) had used traditional medicine prior to presentation. 72 (52.9%) patients were non-metastatic, 46 (33.8%) de novo metastatic, 4 (2.9%) recurrent, and 14 (10.2%) had indeterminate stage. Of the patients treated with curative intent, 54 (65.1%) had neoadjuvant and/or adjuvant chemotherapy, while only 34 (41.0%) had curative surgery. 40 (48.2%) patients received a permanent colostomy. 18 (27.7%) patients with RC received concurrent chemoradiation. Over the follow up period, 49 (36%) patients died or were referred for end of life care, 13 (9.3%) remain in surveillance, while 65 (47.8%) were lost to follow up. Median DFS for patients with non-metastatic disease was 22.2 months. On exploratory analyses, there were no statistically significant differences in DFS by cancer type, gender, or performance status, though these analyses were underpowered and follow-up short. Conclusions: CRC treatment requires multidisciplinary care, which is a challenge in low-resource settings. Our results highlight gaps in CRC care delivery and suboptimal patient outcomes; most striking gaps were the low rates of surgery and radiation, and high loss to follow up rates. Rigorous research is needed to understand the underlying causes, and to develop interventions to address these gaps.

PURPOSE The burden of cancer is growing in low- and middle-income countries (LMICs), including sub-Saharan Africa. Ensuring the delivery of high-quality cancer care in such regions is a pressing concern. There is a need for strategies to identify meaningful and relevant quality measures that are applicable to and usable for quality measurement and improvement in resource-constrained settings. METHODS To identify quality measures for breast cancer care at Butaro Cancer Center of Excellence (BCCOE) in Rwanda, we used a modified Delphi process engaging two panels of experts, one with expertise in breast cancer evidence and measures used in high-income countries and one with expertise in cancer care delivery in Rwanda. RESULTS Our systematic review of the literature yielded no publications describing breast cancer quality measures developed in a low-income country, but it did provide 40 quality measures, which we adapted for relevance to our setting. After two surveys, one conference call, and one in-person meeting, 17 measures were identified as relevant to pathology, staging and treatment planning, surgery, chemotherapy, endocrine therapy, palliative care, and retention in care. Successes of the process included participation by a diverse set of global experts and engagement of the BCCOE community in quality measurement and improvement. Anticipated challenges include the need to continually refine these measures as resources, protocols, and measurement capacity rapidly evolve in Rwanda. CONCLUSION A modified Delphi process engaging both global and local expertise was a promising strategy to identify quality measures for breast cancer in Rwanda. The process and resulting measures may also be relevant for other LMIC cancer facilities. Next steps include validation of these measures in a retrospective cohort of patients with breast cancer.

ObjectivesTo determine the prevalence of proximal deep vein thrombosis (DVT) by ultrasound scanning, as well as associated clinical features and known risk factors, among medical and obstetrics–gynaecology inpatients in two Rwandan tertiary hospitals.DesignCross-sectional study.SettingsRwanda teaching hospitals: Kigali and Butare University Teaching Hospitals.Participants901 adult patients admitted to the Departments of Internal Medicine and Obstetrics–Gynecology (O&G) who were at least 21 years of age and willing to provide a consent.OutcomesPrevalence of proximal DVT, clinical features and known risk factors associated with DVT.MethodsBetween August 2015 and August 2016, participants were screened for DVT by compressive ultrasound of femoral and popliteal veins, conducted as a monthly cross-sectional survey of all consenting eligible inpatients. Patients completed a self-report survey on DVT risk factors. Prevalence of proximal DVT by compression ultrasonography was the primary endpoint, with univariate and multivariate regression analyses performed to assess associated clinical features and risk factors.ResultsProximal DVT was found in 5.5% of the study population, with similar rates in medical and O&G inpatients. The mean age was 41±16 SD (range, 21–91), 70% were female and 7% were pregnant. Univariate analysis showed active malignancy, immobilisation, prolonged recent travel and history of DVT to be significant risk factors for proximal DVT (all p values <0.05); while only active malignancy was an independent risk factor on multivariate regression (OR 5.2; 95% CI 2.0 to 13). Leg pain or tenderness, increased calf circumference, unilateral limb swelling or pitting oedema were predictive clinical features of DVT on both univariate analysis and multivariate regression (all p values <0.05).ConclusionProximal DVT prevalence is high among hospitalised medical and O&G patients in two tertiary hospitals in Rwanda. For reducing morbidity and mortality, research to develop Africa-specific clinical prediction tools for DVT and interventions to increase thromboprophylaxis use in the region are urgently needed.