Neo Tapela

Rwanda 20 years on: investing in life

Two decades ago, the genocide against the Tutsis in Rwanda led to the deaths of 1 million people, and the displacement of millions more. Injury and trauma were followed by the effects of a devastated health system and economy. In the years that followed, a new course set by a new government set into motion equity-oriented national policies focusing on social cohesion and people-centred development. Premature mortality rates have fallen precipitously in recent years, and life expectancy has doubled since the mid-1990s. Here we reflect on the lessons learned in rebuilding Rwandas health sector during the past two decades, as the country now prepares itself to take on new challenges in health-care delivery.

Delays in Breast Cancer Presentation and Diagnosis at Two Rural Cancer Referral Centers in Rwanda

BACKGROUND Breast cancer incidence is increasing in low- and middle-income countries (LMICs). Mortality/incidence ratios in LMICs are higher than in high-income countries, likely at least in part because of delayed diagnoses leading to advanced-stage presentations. In the present study, we investigated the magnitude, impact of, and risk factors for, patient and system delays in breast cancer diagnosis in Rwanda. MATERIALS AND METHODS We interviewed patients with breast complaints at two rural Rwandan hospitals providing cancer care and reviewed their medical records to determine the diagnosis, diagnosis date, and breast cancer stage. RESULTS A total of 144 patients were included in our analysis. Median total delay was 15 months, and median patient and system delays were both 5 months. In multivariate analyses, patient and system delays of ≥6 months were significantly associated with more advanced-stage disease. Adjusting for other social, demographic, and clinical characteristics, a low level of education and seeing a traditional healer first were significantly associated with a longer patient delay. Having made ≥5 health facility visits before the diagnosis was significantly associated with a longer system delay. However, being from the same district as one of the two hospitals was associated with a decreased likelihood of system delay. CONCLUSION Patients with breast cancer in Rwanda experience long patient and system delays before diagnosis; these delays increase the likelihood of more advanced-stage presentations. Educating communities and healthcare providers about breast cancer and facilitating expedited referrals could potentially reduce delays and hence mortality from breast cancer in Rwanda and similar settings. IMPLICATIONS FOR PRACTICE Breast cancer rates are increasing in low- and middle-income countries, and case fatality rates are high, in part because of delayed diagnosis and treatment. This study examined the delays experienced by patients with breast cancer at two rural Rwandan cancer facilities. Both patient delays (the interval between symptom development and the patients first presentation to a healthcare provider) and system delays (the interval between the first presentation and diagnosis) were long. The total delays were the longest reported in published studies. Longer delays were associated with more advanced-stage disease. These findings suggest that an opportunity exists to reduce breast cancer mortality in Rwanda by addressing barriers in the community and healthcare system to promote earlier detection.

Bringing cancer care to the poor: experiences from Rwanda.

The knowledge and tools to cure many cancer patients exist in developed countries but are unavailable to many who live in the developing world, resulting in unnecessary loss of life. Bringing cancer care to the poor, particularly to low-income countries, is a great challenge, but it is one that we believe can be met through partnerships, careful planning and a set of guiding principles. Alongside vaccinations, screening and other cancer-prevention efforts, treatment must be a central component of any cancer programme from the start. It is also critical that these programmes include implementation research to determine programmatic efficacy, where gaps in care still exist and where improvements can be made. This article discusses these issues using the example of Rwandas expanding national cancer programme.

Diagnosis of cancer in rural Rwanda: early outcomes of a phased approach to implement anatomic pathology services in resource-limited settings.

OBJECTIVES Adequate pathology services are a prerequisite to accurate cancer diagnoses and tailoring appropriate treatment. Limitations in skilled personnel and infrastructure are among the challenges faced by developing countries. We describe a stepwise implementation of anatomic pathology laboratory services at Butaro District Hospital, designated as a Cancer Center of Excellence in rural Rwanda. METHODS The phased approach to developing pathology services up to December 2012 is described. A retrospective review of specimens submitted to Butaro District Hospital between July 1, 2012, and December 31, 2012, was conducted. Patient clinical characteristics and sociodemographics are also described. RESULTS During the study period, a total of 437 tissue specimens were submitted. Among these, 143 (32.7%) were from male patients, 244 (55.8%) were confirmed as malignant, 163 (37.3%) were benign, 28 (6.4%) were inconclusive, and two (0.5%) results were not available at the time of analysis. The median time from specimen receipt at Butaro to final reporting was 32 days (range, 7-193 days; interquartile range, 23-44 days). CONCLUSIONS Our experience demonstrates that anatomic pathology services can be established in resource-limited settings and local capacity can be built to support accurate diagnoses. Our approach included leveraging partnerships, volunteer experts, and task shifting and will be expanded to include telepathology.

HIV Infection and Survival Among Women With Cervical Cancer

Purpose Cervical cancer is the leading cause of cancer death among the 20 million women with HIV worldwide. We sought to determine whether HIV infection affected survival in women with invasive cervical cancer. Patients and Methods We enrolled sequential patients with cervical cancer in Botswana from 2010 to 2015. Standard treatment included external beam radiation and brachytherapy with concurrent cisplatin chemotherapy. The effect of HIV on survival was estimated by using an inverse probability weighted marginal Cox model. Results A total of 348 women with cervical cancer were enrolled, including 231 (66.4%) with HIV and 96 (27.6%) without HIV. The majority (189 [81.8%]) of women with HIV received antiretroviral therapy before cancer diagnosis. The median CD4 cell count for women with HIV was 397 (interquartile range, 264 to 555). After a median follow-up of 19.7 months, 117 (50.7%) women with HIV and 40 (41.7%) without HIV died. One death was attributed to HIV and the remaining to cancer. Three-year survival for the women with HIV was 35% (95% CI, 27% to 44%) and 48% (95% CI, 35% to 60%) for those without HIV. In an adjusted analysis, HIV infection significantly increased the risk for death among all women (hazard ratio, 1.95; 95% CI, 1.20 to 3.17) and in the subset that received guideline-concordant curative treatment (hazard ratio, 2.63; 95% CI, 1.05 to 6.55). The adverse effect of HIV on survival was greater for women with a more-limited stage cancer ( P = .035), those treated with curative intent ( P = .003), and those with a lower CD4 cell count ( P = .036). Advanced stage and poor treatment completion contributed to high mortality overall. Conclusion In the context of good access to and use of antiretroviral treatment in Botswana, HIV infection significantly decreases cervical cancer survival.

Cervical Cancer in Botswana: Current State and Future Steps for Screening and Treatment Programs.

Botswana has a high burden of cervical cancer due to a limited screening program and high HIV prevalence. About 60% of the cervical cancer patients are HIV positive; most present with advanced cervical disease. Through initiatives by the Botswana Ministry of Health and various strategic partnerships, strides have been made in treatment of pre-invasive and invasive cancer. The See and Treat program for cervical cancer is expanding throughout the country. Starting in 2015, school-going girls will be vaccinated against HPV. In regards to treatment of invasive cancer, a multidisciplinary clinic has been initiated at the main oncology hospital to streamline care. However, challenges remain such as delays in treatment, lack of trained human personnel, limited follow-up care, and little patient education. Despite improvements in the care of pre-invasive and invasive cervical cancer patients, for declines in cervical cancer-related morbidity and mortality to be achieved, Botswana needs to continue to invest in decreasing the burden of disease and improving patient outcomes of patients with cervical cancer.

Implementation and Validation of Telepathology Triage at Cancer Referral Center in Rural Rwanda

Purpose Connecting a cancer patient to the appropriate treatment requires the correct diagnosis provided in a timely manner. In resource-limited settings, the anatomic pathology bridge to efficient, accurate, and timely cancer care is often challenging. In this study, we present the first phase of an anatomic telepathology triage system, which was implemented and validated at the Butaro District Hospital in northern rural Rwanda. Methods Select cases over a 9-month period in three segments were evaluated by static image telepathology and were independently evaluated by standard glass slide histology. Each case via telepathology was classified as malignant, benign, infectious/inflammatory, or nondiagnostic and was given an exact histologic diagnosis. Results For cases triaged as appropriate for telepathology, correlation with classification and exact diagnosis demonstrated greater than 95% agreement over the study. Cases in which there was disagreement were analyzed for cause, and the triage process was adjusted to avoid future problems. Conclusion Challenges to obtaining a correct and complete diagnosis with telepathology alone included the need for immunohistochemistry, assessment of the quality of images, and the lack of images representing an entire sample. The next phase of the system will assess the effect of telepathology triage on turnaround time and the value of on-site immunohistochemistry in reducing that metric and the need for evaluation outside of telepathology.

Predictors of Timely Access of Oncology Services and Advanced-Stage Cancer in an HIV-Endemic Setting

This study explored predictors of timely oncology care and whether being engaged in the medical system for HIV care improved time to access. According to records and interviews of cancer patients in Botswana, the median time from first symptom to specialized oncology care was 13 months. HIV status did not affect time to oncology care; however, advanced cancer stage and use of traditional medicine/healers was associated with earlier oncology access.

Caring for patients with surgically resectable cancers: experience from a specialised centre in rural Rwanda

SETTING Butaro Cancer Centre of Excellence (BCCOE), Burera District, Rwanda. OBJECTIVES To describe characteristics, management and 6-month outcome of adult patients presenting with potentially surgically resectable cancers. DESIGN Retrospective cohort study of patients presenting between 1 July and 31 December 2012. RESULTS Of 278 patients, 76.6% were female, 51.4% were aged 50-74 years and 75% were referred from other district or tertiary hospitals in Rwanda. For the 250 patients with treatment details, 115 (46%) underwent surgery, with or without chemotherapy/radiotherapy. Median time from admission to surgery was 21 days (IQR 2-91). Breast cancer was the most common type of cancer treated at BCCOE, while other forms of cancer (cervical, colorectal and head and neck) were mainly operated on in tertiary facilities. Ninety-nine patients had no treatment; 52% of these were referred out within 6 months, primarily for palliative care. At 6 months, 6.8% had died or were lost to follow-up. CONCLUSION Surgical care was provided for many cancer patients referred to BCCOE. However, challenges such as inadequate surgical infrastructure and skills, and patients presenting late with advanced and unresectable disease can limit the ability to manage all cases. This study highlights opportunities and challenges in cancer care relevant to other hospitals in rural settings.

Benign and Malignant Breast Disease at Rwanda’s First Public Cancer Referral Center

BACKGROUND Breast cancer incidence is rising in low- and middle-income countries. Understanding the distribution of breast disease seen in clinical practice in such settings can guide early detection efforts and clinical algorithms, as well as support future monitoring of cancer detection rates and stage. PATIENTS AND METHODS We conducted a retrospective medical record review of 353 patients who presented to Butaro Cancer Center of Excellence in Rwanda with an undiagnosed breast concern during the first 18 months of the cancer program. RESULTS Eighty-two percent of patients presented with a breast mass. Of these, 55% were diagnosed with breast cancer and 36% were diagnosed with benign disease. Cancer rates were highest among women 50 years and older. Among all patients diagnosed with breast cancer, 20% had stage I or II disease at diagnosis, 46% had locally advanced (stage III) disease, and 31% had metastatic disease. CONCLUSION After the launch of Rwandas first public cancer referral center and breast clinic, cancer detection rates were high among patients presenting with an undiagnosed breast concern. These findings will provide initial data to allow monitoring of changes in the distribution of benign and malignant disease and of cancer stage as cancer awareness and services expand nationally. IMPLICATIONS FOR PRACTICE The numbers of cases and deaths from breast cancer are rising in low-income countries. In many of these settings, health care systems to address breast problems and efficiently refer patients with symptoms concerning for cancer are rudimentary. Understanding the distribution of breast disease seen in such settings can guide early detection efforts and clinical algorithms. This study describes the characteristics of patients who came with a breast concern to Rwandas first public cancer referral center during its first 18 months. More than half of patients with a breast mass were diagnosed with cancer; most had late-stage disease. Monitoring changes in the types of breast disease and cancer stages seen in Rwanda will be critical as breast cancer awareness and services grow.