Patient Characteristics, Early Outcomes, and Implementation Lessons of Cervical Cancer Treatment Services in Rural Rwanda

Abstract

Purpose Low- and middle-income countries account for 86% of all cervical cancer cases and 88% of cervical cancer mortality globally. Successful management of cervical cancer requires resources that are scarce in sub-Saharan Africa, especially in rural settings. Here, we describe the early clinical outcomes and implementation lessons learned from the Rwanda Ministry of Health’s first national cancer referral center, the Butaro Cancer Center of Excellence (BCCOE). We hypothesize that those patients presenting at earlier stage and receiving treatment will have higher rates of being alive. Methods The implementation of cervical cancer services included developing partnerships, clinical protocols, pathology services, and tools for monitoring and evaluation. We conducted a retrospective study of patients with cervical cancer who presented at BCCOE between July 1, 2012, and June 30, 2015. Data were collected from the electronic medical record system and by manually reviewing medical records. Descriptive, bivariable and multivariable statistical analyses were conducted to describe patient demographics, disease profiles, treatment, and clinical outcomes. Results In all, 373 patients met the study inclusion criteria. The median age was 53 years (interquartile rage, 45 to 60 years), and 98% were residents of Rwanda. Eighty-nine percent of patients had a documented disease stage: 3% were stage I, 48% were stage II, 29% were stage III, and 8% were stage IV at presentation. Fifty percent of patients were planned to be treated with a curative intent, and 54% were referred to chemoradiotherapy in Uganda. Forty percent of patients who received chemoradiotherapy were in remission. Overall, 25% were lost to follow-up. Conclusion BCCOE illustrates the feasibility and challenges of implementing effective cervical cancer treatment services in a rural setting in a low-income country.

Surgical candidacy and treatment initiation among women with cervical cancer at public referral hospitals in Kampala, Uganda: a descriptive cohort study

“…A survey from rural Rwanda reported that 80% of the patients with cervical cancer at the Butaro Cancer Center of Excellence (BCCOE) who were referred to UCI for chemoradiation (there is no available radiation in Rwanda) were able to access treatment. 30 This high proportion of treatment initiation contrasts our findings that women were generally unable to access out-of-country radiation. As expected, in our study, women with locally advanced disease (stage IIB–IIIB) were less likely to be recommended for standard-of-care chemoradiation when there was no available incountry radiation.…”

“…The proportion of participants presenting at late stage (IIB–IVB), 76%, is similar to 20-year-old estimates from the Kampala Cancer Registry, 6 as well as to more recent regional estimates from Northern Uganda, 5 Ghana 29 and Rwanda. 30 Given the lack of national screening and nascent human papillomavirus vaccination efforts, it is unsurprising that the proportion of late-stage disease is unchanged over the last two decades in Uganda.…”

Factors Associated with Loss to Follow-up among Cervical Cancer Patients in Rwanda

“…Patients who were in palliative care at BCCOE as their type of treatment were more likely to be LTFU compared to patients who were receiving curative chemoradiation. In our setting, palliative care services are provided at BCCOE, but most of these patients receive these services at their local district hospitals, closer to their home to reduce the burden of travelling [ 16 ]. Information sharing between facilities may be imperfect, and thus transfers of patients for palliative care may appear as LTFU in BCCOE records.…”

“…Patients are asked to return every three months for the first year, every six months for the second year and once per year thereafter. Further details about cervical cancer treatment at BCCOE can be found in Park et al, 2018 [ 16 ].…”

Surgical candidacy and treatment uptake among women with cervical cancer at public referral hospitals in Kampala, Uganda

“…The proportion of participants presenting at late stage (IIB-IVB), 76%, is similar to 20 year-old estimates from the Kamala Cancer Registry, 6 as well as to more recent regional estimates from Northern Uganda, 5 Ghana, 27 and Rwanda. 28 Given the lack of national screening and nascent HPV vaccination efforts, it is unsurprising that the proportion of late stage disease is unchanged over the last two decades in Uganda.…”