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Pace LE, Mpunga T, Hategekimana V, Dusengimana JMV, Habineza H, Bigirimana JB, Mutumbira C, Mpanumusingo E, Ngiruwera JP, Tapela N, Amoroso C, Shulman LN, Keating NL. Delays in Breast Cancer Presentation and Diagnosis at Two Rural Cancer Referral Centers in Rwanda. Oncologist 2015; 20:780-8. [PMID: 26032138 DOI: 10.1634/theoncologist.2014-0493] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Accepted: 03/27/2015] [Indexed: 01/08/2023] Open
Abstract
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 patient's 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.
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Affiliation(s)
- Lydia E Pace
- Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Ministry of Health, Butaro, Rwanda; Partners in Health, Kigali, Rwanda; Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Tharcisse Mpunga
- Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Ministry of Health, Butaro, Rwanda; Partners in Health, Kigali, Rwanda; Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Vedaste Hategekimana
- Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Ministry of Health, Butaro, Rwanda; Partners in Health, Kigali, Rwanda; Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jean-Marie Vianney Dusengimana
- Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Ministry of Health, Butaro, Rwanda; Partners in Health, Kigali, Rwanda; Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Hamissy Habineza
- Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Ministry of Health, Butaro, Rwanda; Partners in Health, Kigali, Rwanda; Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jean Bosco Bigirimana
- Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Ministry of Health, Butaro, Rwanda; Partners in Health, Kigali, Rwanda; Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Cadet Mutumbira
- Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Ministry of Health, Butaro, Rwanda; Partners in Health, Kigali, Rwanda; Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Egide Mpanumusingo
- Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Ministry of Health, Butaro, Rwanda; Partners in Health, Kigali, Rwanda; Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jean Paul Ngiruwera
- Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Ministry of Health, Butaro, Rwanda; Partners in Health, Kigali, Rwanda; Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Neo Tapela
- Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Ministry of Health, Butaro, Rwanda; Partners in Health, Kigali, Rwanda; Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Cheryl Amoroso
- Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Ministry of Health, Butaro, Rwanda; Partners in Health, Kigali, Rwanda; Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Lawrence N Shulman
- Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Ministry of Health, Butaro, Rwanda; Partners in Health, Kigali, Rwanda; Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Nancy L Keating
- Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Ministry of Health, Butaro, Rwanda; Partners in Health, Kigali, Rwanda; Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Kwan GF, Bukhman AK, Miller AC, Ngoga G, Mucumbitsi J, Bavuma C, Dusabeyezu S, Rich ML, Mutabazi F, Mutumbira C, Ngiruwera JP, Amoroso C, Ball E, Fraser HS, Hirschhorn LR, Farmer P, Rusingiza E, Bukhman G. A simplified echocardiographic strategy for heart failure diagnosis and management within an integrated noncommunicable disease clinic at district hospital level for sub-Saharan Africa. JACC Heart Fail 2013; 1:230-6. [PMID: 24621875 DOI: 10.1016/j.jchf.2013.03.006] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 03/28/2013] [Accepted: 03/28/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study sought to describe a decentralized strategy for heart failure diagnosis and management and report the clinical epidemiology at district hospitals in rural Rwanda. BACKGROUND Heart failure contributes significantly to noncommunicable disease burden in sub-Saharan Africa. Specialized care is provided primarily at referral hospitals by physicians, limiting patients' access. Simplifying clinical strategies can facilitate decentralization of quality care to the district hospital level and improve care delivery. METHODS Heart failure services were established within integrated advanced noncommunicable disease clinics in 2 rural district hospitals in Rwanda. Nurses, supervised by physicians, were trained to use simplified diagnostic and treatment algorithms including echocardiography with diagnoses confirmed by a cardiologist. Data on 192 heart failure patients treated between November 2006 and March 2011 were reviewed from an electronic medical record. RESULTS In our study population, the median age was 35 years, 70% were women, 63% were subsistence farmers, and 6% smoked tobacco. At entry, 47% had New York Heart Association class III or IV functional status. Of children age <18 years (n = 54), rheumatic heart disease (48%), congenital heart disease (39%), and dilated cardiomyopathy (9%) were the leading diagnoses. Among adults (n = 138), dilated cardiomyopathy (54%), rheumatic heart disease (25%), and hypertensive heart disease (8%) were most common. During follow-up, 62% were retained in care, whereas 9% died and 29% were lost to follow-up. CONCLUSIONS In rural Rwanda, the causes of heart failure are almost exclusively nonischemic even though patients often present with advanced symptoms. Training nurses, supervised by physicians, in simplified protocols and basic echocardiography is 1 approach to integrated, decentralized care for this vulnerable population.
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Affiliation(s)
- Gene F Kwan
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Section of Cardiology, Department of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Alice K Bukhman
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ann C Miller
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | | | | | - Charlotte Bavuma
- Inshuti Mu Buzima, Rwinkwavu, Rwanda; Department of Internal Medicine, Endocrinology Unit, Centre Hospitalier Universitaire de Kigali, Kigali, Rwanda; Ministry of Health, Kigali, Rwanda
| | | | - Michael L Rich
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Partners In Health, Boston, Massachusetts
| | | | | | | | - Cheryl Amoroso
- Inshuti Mu Buzima, Rwinkwavu, Rwanda; Partners In Health, Boston, Massachusetts
| | - Ellen Ball
- Partners In Health, Boston, Massachusetts
| | - Hamish S Fraser
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Partners In Health, Boston, Massachusetts
| | - Lisa R Hirschhorn
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Partners In Health, Boston, Massachusetts
| | - Paul Farmer
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Partners In Health, Boston, Massachusetts
| | - Emmanuel Rusingiza
- Inshuti Mu Buzima, Rwinkwavu, Rwanda; Ministry of Health, Kigali, Rwanda; Department of Pediatrics, Pediatric Cardiology Unit, Centre Hospitalier Universitaire de Kigali, Kigali, Rwanda
| | - Gene Bukhman
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Ministry of Health, Kigali, Rwanda; Partners In Health, Boston, Massachusetts; VA Boston Healthcare System, Boston, Massachusetts.
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