International Radiotherapy Referrals From Rural Rwanda: Implementation Processes and Early Clinical Outcomes

Abstract

Purpose Low- and middle-income countries disproportionately comprise 65% of cancer deaths. Cancer care delivery in resource-limited settings, especially low-income countries in sub-Saharan Africa, is exceedingly complex, requiring multiple modalities of diagnosis and treatment. Given the vast human, technical, and financial resources required, access to radiotherapy remains limited in sub-Saharan Africa. Through 2017, Rwanda has not had in-country radiotherapy services. The aim of this study was to describe the implementation and early outcomes of the radiotherapy referral program at the Butaro Cancer Centre of Excellence and to identify both successful pathways and barriers to care. Methods Butaro District Hospital is located in a rural area of the Northern Province and is home to the Butaro Cancer Centre of Excellence. We performed a retrospective study from routinely collected data of all patients with a diagnosis of cervical, head and neck, or rectal cancer between July 2012 and June 2015. Results Between 2012 and 2015, 580 patients were identified with these diagnoses and were potential candidates for radiation. Two hundred eight (36%) were referred for radiotherapy treatment in Uganda. Of those referred, 160 (77%) had cervical cancer, 31 (15%) had head and neck cancer, and 17 (8%) had rectal cancer. At the time of data collection, 101 radiotherapy patients (49%) were alive and had completed treatment with no evidence of recurrence, 11 (5%) were alive and continuing treatment, and 12 (6%) were alive and had completed treatment with evidence of recurrence. Conclusion This study demonstrates the feasibility of a rural cancer facility to successfully conduct out-of-country radiotherapy referrals with promising early outcomes. The results of this study also highlight the many challenges and lessons learned in providing comprehensive cancer care in resource-limited settings.

State of Cancer Control in Rwanda: Past, Present, and Future Opportunities

“…A small number of patients who need radiotherapy enrolled under the PIH program and had to be referred to surgical centers abroad for treatment. 33 , 34 The first radiation therapy center in Rwanda started treating patients at Rwanda Military Hospital in early 2019. Since then, more than 500 new patients have been treated.…”

Cervical cancer treatment in Rwanda: Resource-driven adaptations, quality indicators, and patient outcomes

“…Among patients who did receive definitive treatment, performance on SGO-proposed quality indicators was generally very high (Table 2). Other quality goals for our program were achieved, representing overall improvement from earlier BCCOE cohorts [8]. Intervals from diagnosis to surgery (median 7.7 weeks) and from last neoadjuvant chemotherapy to surgery (median 5.9 weeks) were acceptable, and rates of chemotherapy and CRT adherence and timely completion were high, once started.…”

“…Initially, BCCOE patients with locally advanced cervical cancer were treated at the Uganda Cancer Institute (UCI) with cobalt-60 radiotherapy [8,9]. In a previously reported cohort of 412 patients with cervical cancer enrolled to BCCOE between 2012 and 2015, 160 (39%) received radiotherapy at UCI.…”

“…In a previously reported cohort of 412 patients with cervical cancer enrolled to BCCOE between 2012 and 2015, 160 (39%) received radiotherapy at UCI. After a median follow up of 12 months, 59% of radiotherapy recipients had completed treatment with no evidence of recurrence, 3% had recurred, 15% had died or been referred for palliation only, 16% were lost to follow up, and 8% fell into "other" categories [8]. In 2016, the radiotherapy machine at UCI broke down beyond repair [10], and BCCOE established a referral program with Nairobi Hospital, which provides 3D conformal radiotherapy with a linear accelerator.…”

Integration of Chronic Oncology Services in Noncommunicable Disease Clinic in Rural Rwanda

“…Central University Hospital in Kigali (CHUK), Rwanda Military Hospital, also in the capital city, Kigali, and Central University Hospital in Butare (CHUB) of the Southern Province provided key support as referral hospitals, especially with respect to treatment plan, follow-up, surgeries, CT scans, and biopsies [13]. Radiotherapy required transfer to cancer centers in Uganda and Kenya [14].…”