Ethical dilemmas in prioritizing patients for scarce radiotherapy resources.

BACKGROUND: Radiotherapy is an essential component of cancer treatment, yet many countries do not have adequate capacity to serve all patients who would benefit from it. Allocation systems are needed to guide patient prioritization for radiotherapy in resource-limited contexts. These systems should be informed by allocation principles deemed relevant to stakeholders. This study explores the ethical dilemmas and views of decision-makers engaged in real-world prioritization of scarce radiotherapy resources at a cancer center in Rwanda in order to identify relevant principles. METHODS: Semi-structured interviews were conducted with a purposive sample of 22 oncology clinicians, program leaders, and clinical advisors. Interviews explored the factors considered by decision-makers when prioritizing patients for radiotherapy. The framework method of thematic analysis was used to characterize these factors. Bioethical analysis was then applied to determine their underlying normative principles. RESULTS: Participants considered both clinical and non-clinical factors relevant to patient prioritization for radiotherapy. They widely agreed that disease curability should be the primary overarching driver of prioritization, with the goal of saving the most lives. However, they described tension between curability and competing factors including age, palliative benefit, and waiting time. They were divided about the role that non-clinical factors such as social value should play, and agreed that poverty should not be a barrier. CONCLUSIONS: Multiple competing principles create tension with the agreed upon overarching goal of maximizing lives saved, including another utilitarian approach of maximizing life-years saved as well as non-utilitarian principles, such as egalitarianism, prioritarianism, and deontology. Clinical guidelines for patient prioritization for radiotherapy can combine multiple principles into a single allocation system to a significant extent. However, conflicting views about the role that social factors should play, and the dynamic nature of resource availability, highlight the need for ongoing work to evaluate and refine priority setting systems based on stakeholder views.

Implementation research: including breast examinations in a cervical cancer screening programme, Rwanda.

Objective: To evaluate whether integrating breast and cervical cancer screening in Rwanda's Women's Cancer Early Detection Program led to early breast cancer diagnoses in asymptomatic women. Methods: Launched in three districts in 2018-2019, the early detection programme offered clinical breast examination screening for all women receiving cervical cancer screening, and diagnostic breast examination for women with breast cancer symptoms. Women with abnormal breast examinations were referred to district hospitals and then to referral hospitals if needed. We examined how often clinics were held, patient volumes and number of referrals. We also examined intervals between referrals and visits to the next care level and, among women diagnosed with cancer, their initial reasons for seeking care. Findings: Health centres held clinics > 68% of the weeks. Overall, 9763 women received cervical cancer screening and clinical breast examination and 7616 received breast examination alone. Of 585 women referred from health centres, 436 (74.5%) visited the district hospital after a median of 9 days (interquartile range, IQR: 3-19). Of 200 women referred to referral hospitals, 179 (89.5%) attended after a median of 11 days (IQR: 4-18). Of 29 women diagnosed with breast cancer, 19 were ≥ 50 years and 23 had stage III or stage IV disease. All women with breast cancer whose reasons for seeking care were known (23 women) had experienced breast cancer symptoms. Conclusion: In the short-term, integrating clinical breast examination with cervical cancer screening was not associated with detection of early-stage breast cancer among asymptomatic women. Priority should be given to encouraging women to seek timely care for symptoms.

Impact of facilitating continued accessibility to cancer care during COVID-19 lockdown on perceived wellbeing of cancer patients at a rural cancer center in Rwanda.

During the COVID-19 pandemic in Rwanda, Partners In Health Inshuti Mu Buzima collaborated with the Butaro Cancer Center of Excellence (BCCOE) to mitigate disruptions to cancer care by providing patients with free transportation to treatment sites and medication delivery at patients' local health facilities. We assessed the relationship between facilitated access to care and self-reported wellbeing outcomes. This cross-sectional telephone survey included cancer patients enrolled at BCCOE in March 2020. We used linear regression to compare six dimensions of quality of life (EORTC QLQ-C30), depression (PHQ-9), anxiety (GAD-7), and financial toxicity (COST) among patients who did and did not receive facilitated access to care. We also assessed access to cancer care and whether patient wellbeing and its association with facilitated access to care differed by socioeconomic status. Of 214 respondents, 34.6% received facilitated access to care. Facilitated patients were more likely to have breast cancer and be on chemotherapy. Facilitation was significantly associated with more frequent in-person clinical encounters, improved perceived quality of cancer care, and reduced transportation-related barriers. Facilitated patients had significantly better global health status (ß = 9.14, 95% CI: 2.3, 16.0, p <0.01) and less financial toxicity (ß = 2.62, 95% CI: 0.2,5.0, p = 0.03). However, over half of patients reported missing or delaying appointment. Patient wellbeing was low overall and differed by patient socioeconomic status, with poor patients consistently showing worse outcomes. Socioeconomic status did not modify the association between facilitated access to care and wellbeing indicators. Further, facilitation did not lead to equitable wellbeing outcomes between richer and poorer patients. Facilitated access to care during COVID-19 pandemic was associated with some improvements in access to cancer care and patient wellbeing. However, cancer patients still experienced substantial disruptions to care and reported low overall levels of wellbeing, with socioeconomic disparities persisting despite facilitated access to care. Implementing more robust, equity-minded facilitation and better patient outreach programs during health emergencies may promote better care and strengthen patient care overall and effect better patients' outcomes.

Breast cancer molecular diagnostics in Rwanda: a cost-minimization study of immunohistochemistry versus a novel GeneXpert® mRNA expression assay.

Objective: To compare the financial and time cost of breast cancer biomarker analysis by immunohistochemistry with that by the Xpert® STRAT4 assay. Methods: We estimated costs (personnel, location, consumables and indirect) and time involved in breast cancer diagnosis at the Butaro Cancer Centre of Excellence, Rwanda, using time-driven activity-based costing. We performed a cost-minimization analysis to compare the cost of biomarker analysis for estrogen receptor, progesterone receptor and human epidermal growth factor receptor-2 status with immunohistochemistry versus STRAT4. We performed sensitivity analyses by altering laboratory-specific parameters for the two methods. Findings: We estimated that breast cancer diagnosis in Rwanda costs 138.29 United States dollars (US$) per patient when conducting biomarker analysis by immunohistochemistry. At a realistic immunohistochemistry antibody utilization efficiency of 70%, biomarker analysis comprises 48.7% (US$ 67.33) of diagnostic costs and takes 33 min. We determined that biomarker analysis with STRAT4 yields a reduction in diagnosis cost of US$ 7.33 (10.9%; 7.33/67.33), and in pathologist and technician time of 20 min (60.6%; 20/33), per patient. Our sensitivity analysis revealed that no cost savings would be made in laboratories with antibody utilization efficiencies over 90%, or where only estrogen and/or progesterone receptor status are assessed; however, such operational efficiencies are unlikely, and more laboratories are pursuing human epidermal growth factor receptor-2 analysis as targeted therapies become increasingly available. Conclusion: Breast cancer biomarker analysis with STRAT4 has the potential to reduce the required human and capital resources in sub-Saharan African laboratories, leading to improved treatment selection and better clinical outcomes.

Assessing the utilization of cancer medicines in Rwanda: an analysis of treatment patterns.

Introduction: Cancer is a growing public health concern in Africa, especially in low- and middle-income countries (LMICs) like Rwanda. Increased cancer incidences translate into increased utilisation of cancer medicine. Access to affordable cancer medicines in Rwanda is a pressing issue as the National Health Insurance plan does not provide coverage for cancer medicines. In this study, we investigated the utilisation patterns of cancer medicines in Rwanda. Methods: This retrospective cross-sectional study was conducted at all referral hospitals (n = 3) capable of delivering chemotherapy in Rwanda. The data collection was over a period of 6 months, during which a team of trained research assistants reviewed a convenience sample of selected patient charts. Both paper charts and electronic medical records were used to collect patients' data, including cancer type, stage, treatment setting, type of drugs or regimen used and completed cycles. Data were analysed using descriptive statistics. Results: A total of 630 patients received chemotherapy during the study period and were included. Seventy-seven percent (n = 486) were female and mean age was 51 (SD ± 13). Among all patients receiving chemotherapy, 43% (n = 270) had breast cancer, 22% (n = 140) had cervical cancer and 19% (n = 121) had colorectal cancer. The majority of patients (71%) had a community-based insurance. Butaro Cancer Centre treated the most patients (48%, n = 303). Thirty-six percent (221/630) had stage III cancer. The most common regimens within the cohort were adriamycin, cyclophosphamide and taxane, capecitabine and oxaliplatin (CAPOX), paclitaxel + carboplatin and a single agent cisplatin given concurrently with radiotherapy. The proportion of chemotherapy that was given in the curative and palliative setting was 72% and 28% respectively. Conclusion: Access to affordable cancer medicines remains a challenge in Rwanda. The study's findings provide valuable information on the utilisation patterns of cancer medicines in Rwanda, which can be used to guide policy decisions and improve cancer care in the country.

Impact of COVID-19 on access to cancer care in Rwanda: a retrospective time-series study using electronic medical records data.

INTRODUCTION: The COVID-19 pandemic has caused disruptions in access to routine healthcare services worldwide, with a particularly high impact on chronic care patients and low and middle-income countries. In this study, we used routinely collected electronic medical records data to assess the impact of the COVID-19 pandemic on access to cancer care at the Butaro Cancer Center of Excellence (BCCOE) in rural Rwanda. METHODS: We conducted a retrospective time-series study among all Rwandan patients who received cancer care at the BCCOE between 1 January 2016 and 31 July 2021. The primary outcomes of interest included a comparison of the number of patients who were predicted based on time-series models of pre-COVID-19 trends versus the actual number of patients who presented during the COVID-19 period (between March 2020 and July 2021) across four key indicators: the number of new patients, number of scheduled appointments, number of clinical visits attended and the proportion of scheduled appointments completed on time. RESULTS: In total, 8970 patients (7140 patients enrolled before COVID-19 and 1830 patients enrolled during COVID-19) were included in this study. During the COVID-19 period, enrolment of new patients dropped by 21.7% (95% prediction interval (PI): -31.3%, -11.7%) compared with the pre-COVID-19 period. Similarly, the number of clinical visits was 25.0% (95% PI: -31.1%, -19.1%) lower than expected and the proportion of scheduled visits completed on time was 27.9% (95% PI: -39.8%, -14.1%) lower than expected. However, the number of scheduled visits did not deviate significantly from expected. CONCLUSION: Although scheduling procedures for visits continued as expected, our findings reveal that the COVID-19 pandemic interrupted patients' ability to access cancer care and attend scheduled appointments at the BCCOE. This interruption in care suggests delayed diagnosis and loss to follow-up, potentially resulting in a higher rate of negative health outcomes among cancer patients in Rwanda.

Nephroblastoma Treatment and Outcomes in a Low-Income Setting.

PURPOSE: Nephroblastoma is a highly curable pediatric cancer that requires multidisciplinary care. Few reports have assessed long-term treatment outcomes in low-resource settings using a task-shifting model of care. We report outcomes of a large cohort and factors associated with survival. METHODS: We performed a retrospective chart review of all patients with nephroblastoma presenting to the Butaro Cancer Center of Excellence in Rwanda between July 2012 and June 2018. RESULTS: In total, 136 patients were identified and treated according to International Society of Pediatric Oncology guidelines for low-income settings. Median age at diagnosis was 39.7 months (interquartile range, 25.3-61.8 months); 56.6% were female. Sixty-one (44.9%) patients presented with stage I-III disease, 35 (25.7%) with stage IV disease, and 6 (4.4%) with stage V disease; the remainder were unstaged (n = 34; 25.0%). Most patients completed surgery (n = 97; 71.3%) and postoperative chemotherapy (n = 82; 60.2%); 17 patients received radiotherapy. With a median follow-up time of 18.1 months, 44.9% of patients were alive, 41.9% had died, 8.8% were lost to follow-up, and 4.4% were referred for palliative care or declined further care at the end of the study. Three-year overall survival was 57.5% (95% CI, 48.1 to 65.8) for the entire cohort, and 80.1% (95% CI, 66.8 to 88.5) and 44.0% (95% CI, 26.8 to 60.0) for stages I-III and IV-V, respectively. CONCLUSION: We demonstrate that patients with nephroblastoma can be successfully treated in a low-resource setting. Survival remains lower than in high-income countries, in part due to early deaths, contributing to approximately 30% of patients not being medically able to receive surgical intervention. Next steps include the development of strategies that focus on earlier diagnosis, supportive care during the early phases of therapy, and efficient and timely transitions between specialties for multimodal care.

A Ten-Year Experience of Treating Chronic Myeloid Leukemia in Rural Rwanda: Outcomes and Insights for a Changing Landscape.

PURPOSE: In describing our ten-year experience with treating chronic myeloid leukemia (CML) as part of the Glivec Patient Assistance Program (GIPAP) in rural Rwanda, we evaluate (1) patient characteristics and treatment outcomes, (2) resource-adapted management strategies, and (3) the impact of diagnostic capacity development. METHODS: We retrospectively reviewed all patients with BCR-ABL-positive CML enrolled in this GIPAP program between 2009 and 2018. Clinical data were analyzed using descriptive statistics, Kaplan-Meier methods, proportional hazards regression, and the Kruskal-Wallis test. RESULTS: One hundred twenty-four patients were included. The median age at diagnosis was 34 (range 8-81) years. On imatinib, 91% achieved complete hematologic response (CHR) after a median of 49 days. Seven (6%) and 12 (11%) patients had primary and secondary imatinib resistance, respectively. The 3-year overall survival was 80% (95% CI, 72 to 87) for the cohort, with superior survival in imatinib responders compared with those with primary and secondary resistance. The median time from imatinib initiation to CHR was 59 versus 38 days (P = .040) before and after in-country diagnostic testing, whereas the median time to diagnosis (P = .056) and imatinib initiation (P = .170) was not significantly different. CONCLUSION: Coupling molecular diagnostics with affordable access to imatinib within a comprehensive cancer care delivery program is a successful long-term strategy to treat CML in resource-constrained settings. Our patients are younger and have higher rates of imatinib resistance compared with historic cohorts in high-income countries. High imatinib resistance rates highlight the need for access to molecular monitoring, resistance testing, and second-generation tyrosine kinase inhibitors, as well as systems to support drug adherence. Hematologic response is an accurate resource-adapted predictor of survival in this setting. Local diagnostic capacity development has allowed for continuous, timely CML care delivery in Rwanda.

Clinical Diagnoses and Outcomes After Diagnostic Breast Ultrasound by Nurses and General Practitioner Physicians in Rural Rwanda.

PURPOSE: To scale up early detection of breast cancer in low- and middle-income countries, research is needed to inform the role of diagnostic breast ultrasound performed by nonradiologists in resource-constrained settings. The authors examined 2-year clinical follow-up and outcomes among women who underwent diagnostic breast ultrasound performed by nonradiologist clinicians participating in a breast ultrasound training and mentorship program at a rural Rwandan hospital. METHODS: Imaging findings, management plans, and pathologic results were prospectively collected during the training using a standardized form. Data on follow-up and outcomes for patients receiving breast ultrasound between January 2016 and March 2017 were retrospectively collected through medical record review. RESULTS: Two hundred twenty-nine breast palpable findings (199 patients) met the study's eligibility criteria. Of 104 lesions initially biopsied, 38 were malignant on initial biopsy; 3 lesions were identified as malignant on repeat biopsy. All 34 patients ultimately diagnosed with cancer received initial recommendations for either biopsy or aspiration by trainees. The positive predictive value of trainee biopsy recommendation was 34.8% (95% confidence interval, 24.8%-45.0%). The sensitivity of trainees' biopsy recommendation for identifying malignant lesions was 92.7% (95% confidence interval, 84.2%-100%). Of 46 patients who did not receive biopsy and were told to return for clinical or imaging follow-up, 37.0% did not return. CONCLUSIONS: Trained nonradiologist clinicians in Rwanda successfully identified suspicious breast lesions on diagnostic breast ultrasound. Loss to follow-up was common among patients instructed to return for surveillance, so lower biopsy thresholds, decentralized surveillance, or patient navigation should be considered for patients with low- or intermediate-suspicion lesions.

Health system costs of a breast cancer early diagnosis programme in a rural district of Rwanda: a retrospective, cross-sectional economic analysis.

OBJECTIVES: This study aimed to quantify the health system cost of the first 2 years of a Breast Cancer Early Detection (BCED) programme in a rural district in Rwanda. We also aimed to estimate the cost of implementing the programme in other districts with different referral pathways and identify opportunities for enhanced cost efficiency. DESIGN: Retrospective, cross-sectional analysis using time-driven activity-based costing, based on timed patient clinical encounters, retrospective patient data and unit costs of resources abstracted from administrative and finance records. SETTING: The BCED programme focused on timely evaluation of individuals with breast symptoms. The study evaluated the health system cost of the BCED programme at seven health centres (HCs) in Burera district and Butaro Cancer Centre of Excellence (BCCOE) at Butaro District Hospital. OUTCOME MEASURES: Health system costs per patient visit and cost per cancer diagnosed were quantified. Total start-up and recurring operational costs were also estimated, as well as health system costs of different scale-up adaptations in other districts. RESULTS: One-time start-up costswere US$36 917, recurring operational costswere US$67 711 and clinical costswere US$14 824 over 2 years. Clinical breast examinations (CBE) at HCs cost US$3.27/visit. At BCCOE, CBE-only visits cost US$13.47/visit, CBE/ultrasound US$14.79/visit and CBE/ultrasound/biopsy/pathology US$147.81/visit. Overall, clinical cost per breast cancer diagnosed was US$1482. Clinicalcost drivers were personnel at HCs (55%) and biopsy/pathology supplies at BCCOE (46%). In other districts, patients experience a longer breast evaluation pathway, adding about US$14.00/patient; this could be decreased if ultrasound services were decentralised. CONCLUSION: Clinical costs associated with BCED services at HCs were modest, similar to other general outpatient services. The BCED programme's start-up and operational costs were high but could be reduced by using local trainers and virtual mentorship. In other districts, decentralising ultrasound and/or biopsies to district hospitals could reduce costs.

Toward Equitable Access to Tertiary Cancer Care in Rwanda: A Geospatial Analysis.

PURPOSE: Geographic access to care is an important measure of health equity. In this study, we describe geographic access to cancer care centers (CCCs) in Rwanda with the current facilities providing care and examine how access could change with expanded care infrastructure. METHODS: Health facilities included are public hospitals administered by the Rwanda Ministry of Health. The WorldPop Project was used to estimate population distribution, and OpenStreetMap was used to determine travel routes. On the basis of geolocations of the facilities, AccessMod 5 was used to estimate the percentage of the population that live within 1 hour, 2 hours, and 4 hours of CCCs under the current (two facilities) and expanded care (seven facilities) scenarios. Variations in access by region, poverty, and level of urbanization were described. RESULTS: Currently, 13%, 41%, and 85% of Rwandans can access CCCs within one, two, and 4 hours of travel, respectively. With expansion of CCCs to seven facilities, access increases to 37%, 84%, and 99%, respectively. There is a substantial variation in current geographic access by province, with 1-hour access in Kigali at 98%, whereas access in the Western Province is 0%; care expansion could increase 2-hour access in the Western Province from 1% to 71%. Variation in access is also seen across the level of urbanization, with current 1-hour access in urban versus rural areas of 45% and 8%, respectively. Expanded care results in improvement of 1-hour access to 67% and 33%, respectively. Similar trends were also noted across poverty levels. CONCLUSION: Geographical access to CCCs varies substantially by province, level of urbanization, and poverty. These disparities can be alleviated by strategic care expansion to other tertiary care facilities across Rwanda.

Procedural fairness for radiotherapy priority setting in a low resource context.

Radiotherapy is an essential component of cancer treatment, yet many countries do not have adequate capacity to serve their populations. This mismatch between demand and supply creates the need for priority setting. There is no widely accepted system to guide patient prioritization for radiotherapy in a low resource context. In the absence of consensus on allocation principles, fair procedures for priority setting should be established. Research is needed to understand what elements of procedural fairness are important to decision makers in diverse settings, assess the feasibility of implementing fair procedures for priority setting in low resource contexts, and improve these processes. This study presents the views of decision makers engaged in everyday radiotherapy priority setting at a cancer center in Rwanda. Semi-structured interviews with 22 oncology physicians, nurses, program leaders, and advisors were conducted. Participants evaluated actual radiotherapy priority setting procedures at the program (meso) and patient (micro) levels, reporting facilitators, barriers, and recommendations. We discuss our findings in relation to the leading Accountability for Reasonableness (AFR) framework. Participants emphasized procedural elements that facilitate adherence to normative principles, such as objective criteria that maximize lives saved. They ascribed fairness to AFR's substantive requirement of relevance more than transparency, appeals, and enforcement. They identified several challenges unresolved by AFR, such as conflicting relevant rationales and unintended consequences of publicity and appeals. Implementing fair procedure itself is resource intensive, a paradox that calls for innovative, context-appropriate solutions. Finally, socioeconomic and structural barriers to care that undermine procedural fairness must be addressed.

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

OBJECTIVE: Most cervical cancer cases and deaths occur in low- and middle-income countries, yet clinical research from these contexts is significantly underrepresented. We aimed to describe the treatment quality, resource-driven adaptations, and outcomes of cervical cancer patients in Rwanda. METHODS: A retrospective cohort study was conducted of all patients with newly diagnosed cervical cancer enrolled between April 2016 and June 2018. Data were abstracted from medical records and analyzed using descriptive statistics, Kaplan Meier methods, and Cox proportional hazards regression. RESULTS: A total of 379 patients were included; median age 54 years, 21% HIV-infected. A majority (55%) had stage III or IV disease. Thirty-four early-stage patients underwent radical hysterectomy. Of 254 patients added to a waiting list for chemoradiation, 114 ultimately received chemoradiation. Of these, 30 (26%) received upfront chemoradiation after median 126 days from diagnosis, and 83 (73%) received carboplatin/paclitaxel while waiting, with a median 56 days from diagnosis to chemotherapy and 207 days to chemoradiation. There was no survival difference between the upfront chemoradiation and prior chemotherapy subgroups. Most chemotherapy recipients (77%) reported improvement in symptoms. Three-year event-free survival was 90% with radical hysterectomy (95% CI 72-97%), 66% with chemoradiation (95% CI 55-75%), and 12% with chemotherapy only (95% CI 6-20%). CONCLUSIONS: Multi-modality treatment of cervical cancer is effective in low resource settings through coordinated care and pragmatic approaches. Our data support a role for temporizing chemotherapy if delays to chemoradiation are anticipated. Sustainable access to gynecologic oncology surgery and expanded access to radiotherapy are urgently needed.

Moral Distress and Resilience Associated with Cancer Care Priority Setting in a Resource-Limited Context.

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 low- and middle-income countries are well positioned to provide insight into the moral experience of cancer care priority setting and expertise to guide solutions. METHODS: Semistructured 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 in-depth 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 the authors' 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.

Barriers and coping mechanisms to accessing healthcare during the COVID-19 lockdown: a cross-sectional survey among patients with chronic diseases in rural Rwanda.

BACKGROUND: Large scale physical distancing measures and movement restrictions imposed to contain COVID-19, often referred to as 'lockdowns', abruptly and ubiquitously restricted access to routine healthcare services. This study describes reported barriers and coping mechanisms to accessing healthcare among chronic care patients during the nationwide COVID-19 lockdown in Rwanda. METHODS: This cross-sectional study was conducted among chronic care patients enrolled in pediatric development, HIV/AIDS, non-communicable diseases, mental health, and oncology programs at 3 rural Rwandan districts. Active patients with an appointment scheduled between March-June 2020 and a phone number recorded in the electronic medical record system were eligible. Data were collected by telephone interviews between 23rd April and 11th May 2020, with proxy reporting by caregivers for children and critically ill-patients. Fisher's exact tests were used to measure associations. Logistic regression analysis was also used to assess factors associated with reporting at least one barrier to accessing healthcare during the lockdown. RESULTS: Of 220 patient respondents, 44% reported at least one barrier to accessing healthcare. Barriers included lack of access to emergency care (n = 50; 22.7%), lack of access to medication (n = 44; 20.0%) and skipping clinical appointments (n = 37; 16.8%). Experiencing barriers was associated with the clinical program (p < 0.001), with oncology patients being highly affected (64.5%), and with increasing distance from home to the health facility (p = 0.031). In the adjusted logistic regression model, reporting at least one barrier to accessing healthcare was associated with the patient's clinical program and district of residence. Forty (18.2%) patients identified positive coping mechanisms to ensure continuation of care, such as walking long distances during suspension of public transport (n = 21; 9.6%), contacting clinicians via telephone for guidance or rescheduling appointments (n = 15; 6.8%), and delegating someone else for medication pick-up (n = 6; 2.7%). Of 124 patients who reported no barriers to accessing healthcare, 9% used positive coping mechanisms. CONCLUSION: A large proportion of chronic care patients experienced barriers to accessing healthcare during the COVID-19 lockdown. However, many patients also independently identified positive coping mechanisms to ensure continuation of care - strategies that could be formally adopted by healthcare systems in Rwanda and similar settings to mitigate effects of future lockdowns on patients.

Multisector Collaborations and Global Oncology: The Only Way Forward.

PURPOSE: At the 12th meeting of AORTIC (African Organization for Research and Training in Cancer) in Maputo, Mozambique, held between November 5 and November 8, 2019, a special workshop was organized to focus on the need for collaboration and coordination between governments and health systems in Africa with academic, industry, association, and other nongovernmental organizations to effect sustainable positive change for the care of patients with cancer. METHODS: Representatives from seven different projects in Africa presented implementation science and demonstration projects of their to date efforts in cancer system improvement including patient access, South-South partnerships, in-country specialized training, palliative care consortium, treatment outcomes, and focused pathology and diagnostic capacity building. Key partners of the various projects served as moderators and commentators during the session. RESULTS: From across all the presentations, lessons learned and exemplary evidence of the value of partnerships were gathered and summarized. CONCLUSION: The concluding synthesis of the presentations determined that with the broad needs across cancer requiring in-depth expertise at each point on a patient's journey, no single organization can effect change alone. Multipartner collaborations not only should be the norm but should also be coordinated so that efforts are not duplicated and maximum patient access to cancer diagnosis and care is achieved.

Training Nonradiologist Clinicians in Diagnostic Breast Ultrasound in Rural Rwanda: Impact on Knowledge and Skills.

OBJECTIVE: To assess the effectiveness of diagnostic breast ultrasound training provided for general practitioners and nurses in Rwanda via intensive in-person and subsequent online supervision and mentorship. METHODS: Four breast radiologists from Brigham and Women's Hospital trained two general practitioner physicians and five nurses in Rwanda over 9 total weeks of in-person training and 20 months of remote mentorship using electronic image review with emailed feedback. Independently recorded assessments were compared to calculate the sensitivity and specificity of trainee assessments, with radiologist assessments as the gold standard. We compared performance in the first versus second half of the training. RESULTS: Trainees' performance on written knowledge assessments improved after training (57.7% versus 98.1% correct, P = .03). Mean sensitivity of trainee-performed ultrasound for identifying a solid breast mass was 90.6% (SD 4.2%) in the first half of the training (period 1) and 94.0% (SD 6.7%) in period 2 (P = .32). Mean specificity was 94.7% (SD 5.4%) in period 1 and 100.0% (SD 0) in period 2 (P = .10). Mean sensitivity for identifying a medium- or high-suspicion solid mass increased from 79.2% (SD 11.0%) in period 1 to 96.3% (SD 6.4%) in period 2 (P = .03). Specificity was 84.4% (SD 15.0%) in period 1 and 96.7% (SD 5.8%) in period 2 (P = .31). DISCUSSION: Nonradiologist clinicians (doctors and nurses) in a rural sub-Saharan African hospital built strong skills in diagnostic breast ultrasound over 23 months of combined in-person training and remote mentorship. The sensitivity of trainees' assessments in identifying masses concerning for malignancy improved after sustained mentorship. Assessment of impact on patient care and outcomes is ongoing.

Identifying Breast Cancer Care Quality Measures for a Cancer Facility in Rural Sub-Saharan Africa: Results of a Systematic Literature Review and Modified Delphi Process.

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.

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

Rwanda is a densely populated low-income country in East Africa. Previously considered a failed state after the genocide against the Tutsi in 1994, Rwanda has seen remarkable growth over the past 2 decades. Health care in Rwanda is predominantly delivered through public hospitals and is emerging in the private sector. More than 80% of patients are covered by community-based health insurance (Mutuelle de Santé). The cancer unit at the Rwanda Biomedical Center (a branch of the Ministry of Health) is responsible for setting and implementing cancer care policy. Rwanda has made progress with human papillomavirus (HPV) and hepatitis B vaccination. Recently, the cancer unit at the Rwanda Biomedical Center launched the country's 5-year National Cancer Control Plan. Over the past decade, patients with cancer have been able to receive chemotherapy at Butaro Cancer Center, and recently, the Rwanda Cancer Center was launched with 2 linear accelerator radiotherapy machines, which greatly reduced the number of referrals for treatment abroad. Palliative care services are increasing in Rwanda. A cancer registry has now been strengthened, and more clinicians are becoming active in cancer research. Despite these advances, there is still substantial work to be done and there are many outstanding challenges, including the need to build capacity in cancer awareness among the general population (and shift toward earlier diagnosis), cancer care workforce (more in-country training programs are needed), and research.