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Pace LE, Dusengimana JMV, Hategekimana V, Rugema V, Umwizerwa A, Frost E, Kwait D, Schleimer LE, Huang C, Shyirambere C, Bigirimana JB, Shulman LN, Mpunga T, Raza S. Clinical Diagnoses and Outcomes After Diagnostic Breast Ultrasound by Nurses and General Practitioner Physicians in Rural Rwanda. J Am Coll Radiol 2022; 19:983-989. [PMID: 35738413 DOI: 10.1016/j.jacr.2022.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/24/2022] [Accepted: 04/26/2022] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Lydia E Pace
- Director of Women's Health Policy and Advocacy and Director of the Global Women's Health Fellowship, Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | | | | | | | | | - Elisabeth Frost
- Director of Women's Health Policy and Advocacy and Director of the Global Women's Health Fellowship, Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Dylan Kwait
- Director of Women's Health Policy and Advocacy and Director of the Global Women's Health Fellowship, Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | | | - ChuanChin Huang
- Director of Women's Health Policy and Advocacy and Director of the Global Women's Health Fellowship, Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | | | | | - Lawrence N Shulman
- Deputy Director for Clinical Services and Director of Global Cancer Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tharcisse Mpunga
- Minister of State for Public Health and Primary Care, Government of Rwanda, Rwanda
| | - Sughra Raza
- Director of Global Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts
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Rosa WE, Parekh de Campos A, Abedini NC, Gray TF, Huijer HAS, Bhadelia A, Boit JM, Byiringiro S, Crisp N, Dahlin C, Davidson PM, Davis S, De Lima L, Farmer PE, Ferrell BR, Hategekimana V, Karanja V, Knaul FM, Kpoeh JDN, Lusaka J, Matula ST, McMahon C, Meghani SH, Moreland PJ, Ntizimira C, Radbruch L, Rajagopal MR, Downing J. Optimizing the Global Nursing Workforce to Ensure Universal Palliative Care Access and Alleviate Serious Health-Related Suffering Worldwide. J Pain Symptom Manage 2022; 63:e224-e236. [PMID: 34332044 PMCID: PMC8799766 DOI: 10.1016/j.jpainsymman.2021.07.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 06/21/2021] [Accepted: 07/22/2021] [Indexed: 11/16/2022]
Abstract
CONTEXT Palliative care access is fundamental to the highest attainable standard of health and a core component of universal health coverage. Forging universal palliative care access is insurmountable without strategically optimizing the nursing workforce and integrating palliative nursing into health systems at all levels. The COVID-19 pandemic has underscored both the critical need for accessible palliative care to alleviate serious health-related suffering and the key role of nurses to achieve this goal. OBJECTIVES 1) Summarize palliative nursing contributions to the expansion of palliative care access; 2) identify emerging nursing roles in alignment with global palliative care recommendations and policy agendas; 3) promote nursing leadership development to enhance universal access to palliative care services. METHODS Empirical and policy literature review; best practice models; recommendations to optimize the palliative nursing workforce. RESULTS Nurses working across settings provide a considerable untapped resource that can be leveraged to advance palliative care access and palliative care program development. Best practice models demonstrate promising approaches and outcomes related to education and training, policy and advocacy, and academic-practice partnerships. CONCLUSION An estimated 28 million nurses account for 59% of the international healthcare workforce and deliver up to 90% of primary health services. It has been well-documented that nurses are often the first or only healthcare provider available in many parts of the world. Strategic investments in international and interdisciplinary collaboration, as well as policy changes and the safe expansion of high-quality nursing care, can optimize the efforts of the global nursing workforce to mitigate serious health-related suffering.
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Affiliation(s)
- William E Rosa
- Department of Psychiatry and Behavioral Sciences (W.E.R.), Memorial Sloan Kettering Cancer Center, New York, USA.
| | - Amisha Parekh de Campos
- University of Connecticut School of Nursing (A.P.D.C.), Storrs & Hospice Program, Middlesex Health, Connecticut, USA
| | - Nauzley C Abedini
- Division of Gerontology and Geriatric Medicine (N.C.A.), Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Tamryn F Gray
- Harvard Medical School (T.F.G.), Department of Psychosocial Oncology and Palliative Care, Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Afsan Bhadelia
- Harvard T.H. Chan School of Public Health (A.B.), Boston, Massachusetts, USA
| | | | - Samuel Byiringiro
- Johns Hopkins University School of Nursing (S.B.), Baltimore, Maryland, USA
| | - Nigel Crisp
- All-Party Parliamentary Group on Global Health (N.C.), House of Lords, Nursing Now Global Campaign, London, UK
| | | | - Patricia M Davidson
- The Vice-Chancellor's Unit (P.M.D.), University of Wollongong, New South Wales, Australia
| | - Sheila Davis
- Partners In Health (S.D., C.M.), Boston, Massachusetts, USA
| | - Liliana De Lima
- International Association for Hospice & Palliative Care (L.D.L.), Houston, Texas, USA
| | - Paul E Farmer
- Department of Global Health and Social Medicine (P.E.F.), Harvard Medical School, Boston, Massachusetts, USA
| | - Betty R Ferrell
- Division of Nursing Research and Education (B.R.F.), Department of Population Sciences, City of Hope Medical Center, Duarte, California, USA
| | - Vedaste Hategekimana
- Pain Free Hospital Initiative (V.H.), Rwanda Biomedical Center and Ministry of Health, Butaro, Rwanda
| | - Viola Karanja
- Partners In Health Liberia (V.K., J.D.N.K, J.L.), Harper, Maryland County, Liberia
| | - Felicia Marie Knaul
- University of Miami Institute for Advanced Study of the Americas (F.M.K.), Coral Gables, Florida, USA
| | - Julius D N Kpoeh
- Partners In Health Liberia (V.K., J.D.N.K, J.L.), Harper, Maryland County, Liberia
| | - Joseph Lusaka
- Partners In Health Liberia (V.K., J.D.N.K, J.L.), Harper, Maryland County, Liberia
| | - Samuel T Matula
- University of Botswana School of Nursing (S.T.M.), Gabarone, Botswana
| | - Cory McMahon
- Partners In Health (S.D., C.M.), Boston, Massachusetts, USA
| | - Salimah H Meghani
- University of Pennsylvania School of Nursing (S.H.M.), Philadelphia, Pennsylvania, USA
| | - Patricia J Moreland
- Emory University Nell Hodgson Woodruff School of Nursing (P.J.M.), Atlanta, Georgia, USA
| | | | - Lukas Radbruch
- Department of Palliative Medicine (L.R.), University Hospital Bonn, Bonn, Germany
| | - M R Rajagopal
- Trivandrum Institute of Palliative Sciences (M.R.R.), Trivandrum, Kerala, India
| | - Julia Downing
- International Children's Palliative Care Network (J.D.), Makerere University, Kampala, Uganda
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Raza S, Frost E, Kwait D, Bowerson M, Rugema V, Hategekimana V, Umwizerwa A, Shabani K, Shulman L, Lee YS, Huang CC, Mpunga T, Shyirambere C, Dusengimana JMV, Pace LE. Training Nonradiologist Clinicians in Diagnostic Breast Ultrasound in Rural Rwanda: Impact on Knowledge and Skills. J Am Coll Radiol 2020; 18:121-127. [PMID: 32916158 DOI: 10.1016/j.jacr.2020.08.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/19/2020] [Accepted: 08/20/2020] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Sughra Raza
- Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Elisabeth Frost
- Harvard Medical School, Boston, Massachusetts; Associate Director Breast Imaging, Brigham and Women's Hospital, Boston, Massachusetts
| | - Dylan Kwait
- Harvard Medical School, Boston, Massachusetts; Chief of Radiology, Brigham and Women's Faulkner Hospital, Boston, Massachusetts
| | | | - Vestine Rugema
- WCED Project Mentor/Supervisor Butaro Hospital, Butaro, Rwanda; Ministry of Health, Butaro, Rwanda
| | - Vedaste Hategekimana
- Pain Free Hospital Initiative Senior Officer(PFHI), Rwanda Biomedical Center, Rwanda; Ministry of Health, Butaro, Rwanda
| | | | | | - Lawrence Shulman
- Director, Center for Global Cancer Medicine, Abramson, Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Tharcisse Mpunga
- Ministry of Health, Butaro, Rwanda; Director General, Butaro Hospital/CCOE, Butaro, Rwanda
| | | | | | - Lydia E Pace
- Harvard Medical School, Boston, Massachusetts; Director, Global Women's Health Fellowship, Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital, Boston, Massachusetts
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Pace LE, Dusengimana JMV, Shulman LN, Schleimer LE, Shyirambere C, Rusangwa C, Muvugabigwi G, Park PH, Huang C, Bigirimana JB, Hategekimana V, Rugema V, Umwizerwa A, Keating NL, Mpunga T. Cluster Randomized Trial to Facilitate Breast Cancer Early Diagnosis in a Rural District of Rwanda. J Glob Oncol 2020; 5:1-13. [PMID: 31774713 PMCID: PMC6882507 DOI: 10.1200/jgo.19.00209] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Feasible and effective strategies are needed to facilitate earlier diagnosis of breast cancer in low-income countries. The goal of this study was to examine the impact of health worker breast health training on health care utilization, patient diagnoses, and cancer stage in a rural Rwandan district. METHODS We conducted a cluster randomized trial of a training intervention at 12 of the 19 health centers (HCs) in Burera District, Rwanda, in 2 phases. We evaluated the trainings’ impact on the volume of patient visits for breast concerns using difference-in-difference models. We used generalized estimating equations to evaluate incidence of HC and hospital visits for breast concerns, biopsies, benign breast diagnoses, breast cancer, and early-stage disease in catchment areas served by intervention versus control HCs. RESULTS From April 2015 to April 2017, 1,484 patients visited intervention HCs, and 308 visited control HCs for breast concerns. The intervention led to an increase of 4.7 visits/month for phase 1 HCs (P = .001) and 7.9 visits/month for phase 2 HCs (P = .007) compared with control HCs. The population served by intervention HCs had more hospital visits (115.1 v 20.5/100,000 person-years, P < .001) and biopsies (36.6 v 8.9/100,000 person-years, P < .001) and higher breast cancer incidence (6.9 v 3.3/100,000 person-years; P = .28). The incidence of early-stage breast cancer was 3.3 per 100,000 in intervention areas and 0.7 per 100,000 in control areas (P = .048). CONCLUSION In this cluster randomized trial in rural Rwanda, the training of health workers and establishment of regular breast clinics were associated with increased numbers of patients who presented with breast concerns at health facilities, more breast biopsies, and a higher incidence of benign breast diagnoses and early-stage breast cancers.
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Affiliation(s)
- Lydia E Pace
- Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | | | | | | | | | | | | | - Paul H Park
- Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - ChuanChin Huang
- Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | | | | | | | | | - Nancy L Keating
- Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
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Ratanaprasatporn L, Umwizerwa A, Hategekimana V, Rugema V, Raza S. A Young Man in a Rural Breast Clinic. JGR 2019. [DOI: 10.7191/jgr.2019.1084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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6
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Pace LE, Dusengimana JMV, Keating NL, Hategekimana V, Rugema V, Bigirimana JB, Costas-Chavarri A, Umwizera A, Park PH, Shulman LN, Mpunga T. Impact of Breast Cancer Early Detection Training on Rwandan Health Workers' Knowledge and Skills. J Glob Oncol 2019; 4:1-10. [PMID: 30241228 PMCID: PMC6223427 DOI: 10.1200/jgo.17.00098] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Purpose In April 2015, we initiated a training program to facilitate earlier diagnosis of breast cancer among women with breast symptoms in rural Rwanda. The goal of this study was to assess the impact of the training intervention in breast cancer detection on knowledge and skills among health center nurses and community health workers (CHWs). Methods We assessed nurses’ and CHWs’ knowledge about breast cancer risk factors, signs and symptoms, and treatability through a written test administered immediately before, immediately after, and 3 months after trainings. We assessed nurses’ skills in clinical breast examination immediately before and after trainings and then during ongoing mentorship by a nurse midwife. We also examined the appropriateness of referrals made to the hospital by health center nurses. Results Nurses’ and CHWs’ written test scores improved substantially after the trainings (overall percentage correct increased from 73.9% to 91.3% among nurses and from 75.0% to 93.8% among CHWs (P < .001 for both), and this improvement was sustained 3 months after the trainings. On checklists that assessed skills, nurses’ median percentage of actions performed correctly was 24% before the training. Nurses’ skills improved significantly after the training and were maintained during the mentorship period (the median score was 88% after training and during mentorship; P < .001). In total, 96.1% of patients seen for breast concerns at the project’s hospital-based clinic were deemed to have been appropriately referred. Conclusion Nurses and CHWs demonstrated substantially improved knowledge about breast cancer and skills in evaluating and managing breast concerns after brief trainings. With adequate training, mentorship, and established care delivery and referral systems, primary health care providers in sub-Saharan Africa can play a critical role in earlier detection of breast cancer.
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Affiliation(s)
- Lydia E Pace
- Lydia E. Pace, Nancy L. Keating, and Paul H. Park, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Jean Bosco Bigirimana, and Paul H. Park, Partners in Health/Inshuti Mu Buzima; Ainhoa Costas-Chavarri, Rwanda Military Hospital, Kigali; Vedaste Hategekimana, Vestine Rugema, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Butaro, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Jean-Marie Vianney Dusengimana
- Lydia E. Pace, Nancy L. Keating, and Paul H. Park, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Jean Bosco Bigirimana, and Paul H. Park, Partners in Health/Inshuti Mu Buzima; Ainhoa Costas-Chavarri, Rwanda Military Hospital, Kigali; Vedaste Hategekimana, Vestine Rugema, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Butaro, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Nancy L Keating
- Lydia E. Pace, Nancy L. Keating, and Paul H. Park, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Jean Bosco Bigirimana, and Paul H. Park, Partners in Health/Inshuti Mu Buzima; Ainhoa Costas-Chavarri, Rwanda Military Hospital, Kigali; Vedaste Hategekimana, Vestine Rugema, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Butaro, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Vedaste Hategekimana
- Lydia E. Pace, Nancy L. Keating, and Paul H. Park, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Jean Bosco Bigirimana, and Paul H. Park, Partners in Health/Inshuti Mu Buzima; Ainhoa Costas-Chavarri, Rwanda Military Hospital, Kigali; Vedaste Hategekimana, Vestine Rugema, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Butaro, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Vestine Rugema
- Lydia E. Pace, Nancy L. Keating, and Paul H. Park, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Jean Bosco Bigirimana, and Paul H. Park, Partners in Health/Inshuti Mu Buzima; Ainhoa Costas-Chavarri, Rwanda Military Hospital, Kigali; Vedaste Hategekimana, Vestine Rugema, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Butaro, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Jean Bosco Bigirimana
- Lydia E. Pace, Nancy L. Keating, and Paul H. Park, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Jean Bosco Bigirimana, and Paul H. Park, Partners in Health/Inshuti Mu Buzima; Ainhoa Costas-Chavarri, Rwanda Military Hospital, Kigali; Vedaste Hategekimana, Vestine Rugema, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Butaro, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Ainhoa Costas-Chavarri
- Lydia E. Pace, Nancy L. Keating, and Paul H. Park, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Jean Bosco Bigirimana, and Paul H. Park, Partners in Health/Inshuti Mu Buzima; Ainhoa Costas-Chavarri, Rwanda Military Hospital, Kigali; Vedaste Hategekimana, Vestine Rugema, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Butaro, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Aline Umwizera
- Lydia E. Pace, Nancy L. Keating, and Paul H. Park, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Jean Bosco Bigirimana, and Paul H. Park, Partners in Health/Inshuti Mu Buzima; Ainhoa Costas-Chavarri, Rwanda Military Hospital, Kigali; Vedaste Hategekimana, Vestine Rugema, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Butaro, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Paul H Park
- Lydia E. Pace, Nancy L. Keating, and Paul H. Park, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Jean Bosco Bigirimana, and Paul H. Park, Partners in Health/Inshuti Mu Buzima; Ainhoa Costas-Chavarri, Rwanda Military Hospital, Kigali; Vedaste Hategekimana, Vestine Rugema, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Butaro, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Lawrence N Shulman
- Lydia E. Pace, Nancy L. Keating, and Paul H. Park, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Jean Bosco Bigirimana, and Paul H. Park, Partners in Health/Inshuti Mu Buzima; Ainhoa Costas-Chavarri, Rwanda Military Hospital, Kigali; Vedaste Hategekimana, Vestine Rugema, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Butaro, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Tharcisse Mpunga
- Lydia E. Pace, Nancy L. Keating, and Paul H. Park, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Jean Bosco Bigirimana, and Paul H. Park, Partners in Health/Inshuti Mu Buzima; Ainhoa Costas-Chavarri, Rwanda Military Hospital, Kigali; Vedaste Hategekimana, Vestine Rugema, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Butaro, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
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Habimana O, Mukeshimana V, Ahishakiye A, Makuza P, Hategekimana V, Muhayimana C, Dushimana E, Shyirambere C, Haley J, Urusaro S, Kennell-Heiling S, Buswell L. Standardization of Education of Patients With Cancer in a Low- and Middle-Income Country: A Quality Improvement Project Using the Cancer and You Booklet. J Glob Oncol 2019; 5:1-6. [PMID: 31283411 PMCID: PMC6690653 DOI: 10.1200/jgo.19.00118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE The Butaro Cancer Centre of Excellence is the first comprehensive referral cancer center in Rwanda and at its inception did not have a standardized patient education program. Partners in Health/Inshuti Mu Buzima and the Rwandan Ministry of Health conducted a quality improvement project to increase patient knowledge by implementing a standardized oncology education program using picture-based and culturally appropriate materials designed for patients with cancer in low- and middle-income countries. METHODS Four Rwandan nurses were trained to provide patient education using the Cancer and You education booklet created by Global Oncology. A pre- and post-test design was used to evaluate patients’ knowledge of cancer, treatment, and management of adverse effects. Nurses administered a posteducation questionnaire in Kinyarwanda to determine patients’ level of satisfaction with the education session and booklet. The four nurses were interviewed at the completion of the project for their feedback. A total of 40 oncology patients were included in the pilot project, of which 85% reported completing primary school or less. RESULTS On average, participants improved 19% (95% CI, 13.9% to 24.1%; standard deviation, 16%) from pre- to postevaluation, demonstrating a significant increase in knowledge (P ≤ .001). Nearly all patients (97.5%) reported that they were either satisfied or very satisfied with the education program. Oncology nurses gave positive feedback, highlighting that it was helpful to have a standard tool for education with descriptive illustrations for those patients with low literacy. CONCLUSION Implementation of a standardized patient education program demonstrated a statistically significant increase in patient knowledge and a high level of satisfaction among patients and nurses. The project serves as an example for other low- and middle-income countries looking to standardize oncology patient education.
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Affiliation(s)
| | | | | | - Protais Makuza
- Butaro District Hospital, Ministry of Health, Butaro, Rwanda
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8
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Park PH, Davey S, Fehr AE, Butonzi J, Shyirambere C, Hategekimana V, Bigirimana JB, Borg R, Uwizeye R, Tapela N, Shulman LN, Randall T, Mpanumusingo E, Mpunga T. Patient Characteristics, Early Outcomes, and Implementation Lessons of Cervical Cancer Treatment Services in Rural Rwanda. J Glob Oncol 2019; 4:1-11. [PMID: 30582433 PMCID: PMC7010450 DOI: 10.1200/jgo.18.00120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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.
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Affiliation(s)
- Paul H Park
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Sonya Davey
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Alexandra E Fehr
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - John Butonzi
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Cyprien Shyirambere
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Vedaste Hategekimana
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Jean Bosco Bigirimana
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Ryan Borg
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Regis Uwizeye
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Neo Tapela
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Lawrence N Shulman
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Thomas Randall
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Egide Mpanumusingo
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Tharcisse Mpunga
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
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Pace LE, Keating NL, Dusengimana JMV, Hategekimana V, Rugema V, Muvugabigwi G, Schleimer LE, Umwizerwa A, Shyirambere C, Shulman LN, Mpunga T. Impact of an Early Detection Program on Breast Cancer Services, Incidence, and Stage in Rural Rwanda. J Glob Oncol 2018. [DOI: 10.1200/jgo.18.10380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose In low-income countries, most women with breast cancer present with advanced-stage disease. To facilitate earlier diagnoses of symptomatic disease, feasible and effective early detection strategies are needed. We assessed health care use and patient outcomes from a randomized pilot study of an early detection program in Burera, a rural Rwandan district, where the Butaro Cancer Center of Excellence (BCCOE) is located. Methods The intervention included training for community health workers in breast health, training for health center (HC) nurses in the evaluation of breast concerns, and weekly breast clinics at HCs and BCCOE. Twelve of 18 eligible HCs were randomly assigned to receive the intervention—seven beginning in April and May 2015, and five in November and December 2015—and six served as controls for the entire study period. We abstracted HC and hospital records of patients seen between April 2015 and April 2017 and used generalized linear models to compare the incidence of biopsies, breast cancer diagnoses, and early-stage diagnoses in the geographic sectors served by intervention versus control HCs. Results Overall, 276,282 person-years were in intervention sectors and 302,856 in control sectors. Of patients, 1,500 patients sought care at intervention HCs for breast concerns versus 600 at control HCs. Three hundred eighteen patients that were referred from intervention HCs were evaluated at BCCOE compared with 62 from control HCs. The biopsy rate was 36.6 per 100,000 person-years from intervention sectors versus 8.9 per 100,000 from control sectors ( P < .001). Breast cancer was diagnosed in 19 of 101 patients from intervention HCs who underwent biopsy (18.8%) compared with 10 (37.0%) of 27 patients from control HCs. Breast cancer incidence was 6.9 per 100,000 in intervention sectors versus 3.3 per 100,000 in control sectors ( P = .35). Nine patients from intervention HCs had early-stage disease (47.4%) versus two from control HCs (20.0%). The incidence rate of early-stage breast cancer was 3.7 per 100,000 in intervention sectors versus 0.7 per 100,000 in control sectors ( P = .08). Conclusion Over 2 years, our early detection program was associated with more patients referred for hospital-level evaluation and requiring biopsies. Most patients referred by intervention HCs had benign conditions; however, there was a trend toward a higher incidence of early-stage breast cancer among patients from intervention regions. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . Lydia E. Pace Stock or Other Ownership: Firefly Health
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Affiliation(s)
- Lydia E. Pace
- Lydia E. Pace, Nancy L. Keating, Brigham and Women’s Hospital; Lydia E. Pace, Nancy L. Keating, Lauren E. Schleimer, Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Vestine Rugema, Gaspard Muvugabigwi, Aline Umwizerwa, and Tharcisse Mpunga, Rwanda Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Nancy L. Keating
- Lydia E. Pace, Nancy L. Keating, Brigham and Women’s Hospital; Lydia E. Pace, Nancy L. Keating, Lauren E. Schleimer, Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Vestine Rugema, Gaspard Muvugabigwi, Aline Umwizerwa, and Tharcisse Mpunga, Rwanda Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Jean-Marie Vianney Dusengimana
- Lydia E. Pace, Nancy L. Keating, Brigham and Women’s Hospital; Lydia E. Pace, Nancy L. Keating, Lauren E. Schleimer, Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Vestine Rugema, Gaspard Muvugabigwi, Aline Umwizerwa, and Tharcisse Mpunga, Rwanda Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Vedaste Hategekimana
- Lydia E. Pace, Nancy L. Keating, Brigham and Women’s Hospital; Lydia E. Pace, Nancy L. Keating, Lauren E. Schleimer, Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Vestine Rugema, Gaspard Muvugabigwi, Aline Umwizerwa, and Tharcisse Mpunga, Rwanda Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Vestine Rugema
- Lydia E. Pace, Nancy L. Keating, Brigham and Women’s Hospital; Lydia E. Pace, Nancy L. Keating, Lauren E. Schleimer, Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Vestine Rugema, Gaspard Muvugabigwi, Aline Umwizerwa, and Tharcisse Mpunga, Rwanda Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Gaspard Muvugabigwi
- Lydia E. Pace, Nancy L. Keating, Brigham and Women’s Hospital; Lydia E. Pace, Nancy L. Keating, Lauren E. Schleimer, Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Vestine Rugema, Gaspard Muvugabigwi, Aline Umwizerwa, and Tharcisse Mpunga, Rwanda Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Lauren E. Schleimer
- Lydia E. Pace, Nancy L. Keating, Brigham and Women’s Hospital; Lydia E. Pace, Nancy L. Keating, Lauren E. Schleimer, Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Vestine Rugema, Gaspard Muvugabigwi, Aline Umwizerwa, and Tharcisse Mpunga, Rwanda Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Aline Umwizerwa
- Lydia E. Pace, Nancy L. Keating, Brigham and Women’s Hospital; Lydia E. Pace, Nancy L. Keating, Lauren E. Schleimer, Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Vestine Rugema, Gaspard Muvugabigwi, Aline Umwizerwa, and Tharcisse Mpunga, Rwanda Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Cyprien Shyirambere
- Lydia E. Pace, Nancy L. Keating, Brigham and Women’s Hospital; Lydia E. Pace, Nancy L. Keating, Lauren E. Schleimer, Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Vestine Rugema, Gaspard Muvugabigwi, Aline Umwizerwa, and Tharcisse Mpunga, Rwanda Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Lawrence N. Shulman
- Lydia E. Pace, Nancy L. Keating, Brigham and Women’s Hospital; Lydia E. Pace, Nancy L. Keating, Lauren E. Schleimer, Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Vestine Rugema, Gaspard Muvugabigwi, Aline Umwizerwa, and Tharcisse Mpunga, Rwanda Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Tharcisse Mpunga
- Lydia E. Pace, Nancy L. Keating, Brigham and Women’s Hospital; Lydia E. Pace, Nancy L. Keating, Lauren E. Schleimer, Harvard Medical School, Boston, MA; Jean-Marie Vianney Dusengimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Vestine Rugema, Gaspard Muvugabigwi, Aline Umwizerwa, and Tharcisse Mpunga, Rwanda Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
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10
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Pace LE, Dusengimana J, Rugema V, Hategekimana V, Bigirimana JB, Shyirambere C, Shabani K, Butonzi J, Raja SC, Umwizerwa A, Shulman LN, Sebahungu F, Muvugabigwi G, Mpunga T, Raza S. Clinical Impact of Diagnostic Breast Ultrasound Performed by Generalist Doctors and Nurses in Rwanda. J Glob Oncol 2018. [DOI: 10.1200/jgo.18.10390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Diagnostic breast ultrasound (US) can be an important tool for the early detection of breast cancer in low-resource settings where efficient strategies to refine the likelihood of malignancy among palpable breast masses are needed. However, the feasibility and clinical role of breast US in such settings has not been described. We trained four general practitioners and five nurses in diagnostic breast US at a rural Rwandan district hospital that serves as a cancer referral facility. We examined management plans, biopsy rates, and patient diagnoses after trainee breast US to determine the impact on clinical care. Methods We abstracted US assessment forms and medical records to determine outcomes from trainee US during 21 months of in-person and electronic training by Boston-based radiologists. We examined management plans, biopsy rate, cancer detection rate, rate of benign diagnoses, and cancers diagnosed among patients discharged after initial evaluation. Results Between January 2016 and September 2017, 307 patients had trainee-performed diagnostic breast US. After US, 158 (51%) were recommended to undergo biopsy, 30 (10%) were recommended to have aspiration/drainage, 49 (16%) were recommended for clinical/US surveillance, one (0.3%) was referred elsewhere, 65 (21%) were discharged, and four—all with no abnormalities on US—had missing recommendations. Of those recommended for initial biopsy, 151 patients (96%) underwent biopsy at that time. Fifty-six patients (37%) were diagnosed with breast cancer, 44 (30%) with fibroadenoma, and 50 (33%) with other benign diagnoses. Among those with breast masses on US (n = 255), 149 patients (58%) underwent biopsy and 55 (22%) were diagnosed with cancer. As of November 2017, all patients ultimately diagnosed with cancer had had a biopsy at their initial visit. No patients who had been discharged or were receiving surveillance had been subsequently diagnosed with cancer. Conclusion Diagnostic breast US by general practitioners and nurses has been a useful tool for the evaluation of breast lesions at a rural Rwandan facility and has helped avoid biopsy for 42% of patients with breast masses on US. Clinical follow-up is ongoing to assess longer-term outcomes and examine cancer detection rates and loss-to-follow-up rates among patients not initially biopsied. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . Lydia E. Pace Stock or Other Ownership: Firefly Health Sughra Raza Honoraria: Fujifilm Medical Services Travel, Accommodations, Expenses: Fujifilm Medical Services
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Affiliation(s)
- Lydia E. Pace
- Lydia E. Pace, Sahitya C. Raja, and Sughra Raza, Brigham and Women's Hospital; Lydia E. Pace and Sughra Raza, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, and Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu, Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - J.M.V. Dusengimana
- Lydia E. Pace, Sahitya C. Raja, and Sughra Raza, Brigham and Women's Hospital; Lydia E. Pace and Sughra Raza, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, and Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu, Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Vestine Rugema
- Lydia E. Pace, Sahitya C. Raja, and Sughra Raza, Brigham and Women's Hospital; Lydia E. Pace and Sughra Raza, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, and Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu, Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Vedaste Hategekimana
- Lydia E. Pace, Sahitya C. Raja, and Sughra Raza, Brigham and Women's Hospital; Lydia E. Pace and Sughra Raza, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, and Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu, Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Jean Bosco Bigirimana
- Lydia E. Pace, Sahitya C. Raja, and Sughra Raza, Brigham and Women's Hospital; Lydia E. Pace and Sughra Raza, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, and Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu, Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Cyprien Shyirambere
- Lydia E. Pace, Sahitya C. Raja, and Sughra Raza, Brigham and Women's Hospital; Lydia E. Pace and Sughra Raza, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, and Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu, Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Kassim Shabani
- Lydia E. Pace, Sahitya C. Raja, and Sughra Raza, Brigham and Women's Hospital; Lydia E. Pace and Sughra Raza, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, and Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu, Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - John Butonzi
- Lydia E. Pace, Sahitya C. Raja, and Sughra Raza, Brigham and Women's Hospital; Lydia E. Pace and Sughra Raza, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, and Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu, Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Sahitya C. Raja
- Lydia E. Pace, Sahitya C. Raja, and Sughra Raza, Brigham and Women's Hospital; Lydia E. Pace and Sughra Raza, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, and Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu, Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Aline Umwizerwa
- Lydia E. Pace, Sahitya C. Raja, and Sughra Raza, Brigham and Women's Hospital; Lydia E. Pace and Sughra Raza, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, and Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu, Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Lawrence N. Shulman
- Lydia E. Pace, Sahitya C. Raja, and Sughra Raza, Brigham and Women's Hospital; Lydia E. Pace and Sughra Raza, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, and Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu, Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Fidele Sebahungu
- Lydia E. Pace, Sahitya C. Raja, and Sughra Raza, Brigham and Women's Hospital; Lydia E. Pace and Sughra Raza, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, and Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu, Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Gaspard Muvugabigwi
- Lydia E. Pace, Sahitya C. Raja, and Sughra Raza, Brigham and Women's Hospital; Lydia E. Pace and Sughra Raza, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, and Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu, Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Tharcisse Mpunga
- Lydia E. Pace, Sahitya C. Raja, and Sughra Raza, Brigham and Women's Hospital; Lydia E. Pace and Sughra Raza, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, and Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu, Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Sughra Raza
- Lydia E. Pace, Sahitya C. Raja, and Sughra Raza, Brigham and Women's Hospital; Lydia E. Pace and Sughra Raza, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, and Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu, Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
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11
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Pace L, Dusengimana J, Rugema V, Hategekimana V, Bigirimana J, Shyirambere C, Shabani K, Butonzi J, Raja S, Umwizerwa A, Shulman L, Sebahungu F, Muvugabigwi G, Mpunga T, Raza S. Early Clinical Impact of Diagnostic Breast Ultrasound Performed by General Practitioners and Nurses in Rwanda. J Glob Oncol 2018. [DOI: 10.1200/jgo.18.49400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Diagnostic breast ultrasound (US) could be an important tool for early detection of breast cancer in low-resource settings, where efficient strategies to refine the likelihood of malignancy among palpable breast masses are needed. However, the feasibility and clinical role of diagnostic ultrasound in such settings has not been described. We trained 4 general practitioner doctors (GPs) and 5 nurses in diagnostic breast US at a rural district hospital in Rwanda that serves as a cancer referral facility. Aim: Assess management plans, biopsy rates and patient diagnoses after nurse- and GP-performed breast ultrasounds to determine the impact of diagnostic US on clinical care. Methods: We reviewed outcomes from trainees' ultrasounds during 21 months of in-person and electronic training and mentorship by Boston-based radiologists. Trainees' US assessments and management plans were recorded on structured clinical forms. Patient diagnoses and follow-up were extracted from medical records using a standardized data collection form. Among patients who received breast US, we examined a) clinicians' management plans; b) biopsy rate; c) cancer detection rate; c) rate of benign diagnoses; d) cancers diagnosed among patients who were sent home after initial evaluation. Results: Between January 1, 2016 and September 30, 2017, 307 patients with breast concerns had a diagnostic breast US and a documented trainee US assessment. Of these, following their initial US, 158 (51%) were recommended to receive a biopsy, 30 (10%) were recommended to have aspiration/drainage, 49 (16%) were recommended for clinical or US surveillance, 1 (0.3%) was referred to another facility, 65 (21%) were discharged, and 4 (all with no abnormalities on US) had missing recommendations. Of those recommended for biopsy at initial presentation, 151 (96%) had a biopsy at that time. 56 (37%) were diagnosed with breast cancer, 37 (25%) with fibroadenoma, 7 (5%) with lactating adenoma, and 50 (33%) with other benign diagnoses. Among those with breast masses on US (n=255), 149 (58%) received a biopsy and 55 (22%) were diagnosed with cancer. As of November 23, 2017, all patients ultimately diagnosed with cancer had had a biopsy at their initial visit, and no patients who had been discharged or recommended for clinical or radiographic surveillance had been subsequently diagnosed with cancer. Conclusion: Diagnostic breast US by GPs and nurses has been a useful tool in the evaluation of breast lesions, including palpable masses, at a rural cancer facility in Rwanda. Early findings suggest that it has allowed avoidance of biopsy for 42% of patients with breast masses noted on US. Clinical follow-up and evaluation are ongoing to assess longer-term patient outcomes, cancer detection rates among patients who are not initially biopsied, and rates of follow-up among patients recommended to have clinical or radiographic surveillance.
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Affiliation(s)
- L.E. Pace
- Brigham and Women's Hospital, Boston, MA
| | | | - V. Rugema
- Brigham and Women's Hospital, Boston, MA
| | | | | | | | - K. Shabani
- Brigham and Women's Hospital, Boston, MA
| | - J. Butonzi
- Brigham and Women's Hospital, Boston, MA
| | - S.C. Raja
- Brigham and Women's Hospital, Boston, MA
| | | | | | | | | | - T. Mpunga
- Brigham and Women's Hospital, Boston, MA
| | - S. Raza
- Brigham and Women's Hospital, Boston, MA
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12
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Raza S, Dusengimana J, Rugema V, Hategekimana V, Bigirimana JB, Shyirambere C, Shabani K, Butonzi J, Raja SC, Umwizerwa A, Shulman LN, Sebahungu F, Muvugabigwi G, Mpunga T, Pace LE. Impact of Training on Rwandan Health Care Staffs’ Skills in Diagnostic Breast Ultrasound. J Glob Oncol 2018. [DOI: 10.1200/jgo.18.10440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Ultrasound (US) is a key tool in the evaluation of palpable breast masses and helps to refine the likelihood of malignancy and need for additional diagnostic studies. US is available in many low-resource settings, but there is little expertise. We launched a breast US training program for general practitioners (GPs) and nurses at a rural Rwandan district hospital that is a cancer referral facility. We assessed the skills of the GPs and nurses in diagnostic breast US after intensive training. Methods Four breast radiologists from Boston trained five nurses and four GPs in Rwanda over 9 weeks of in-person training and 21 months of weekly remote mentoring using electronic image review and feedback. During the in-person training, trainees and radiologists evaluated patients separately. Remote assessments were based on emailed image sharing. We compared lesions with radiologist and trainee assessments to calculate trainee sensitivity using the radiologist assessments as the gold standard. Results Of 323 breast and axillary lesions assessed by trainees and radiologists, 279 were breast lesions. Of these, 114 (41%) were evaluated by radiologists in person and 165 (59%) through e-mail. Two hundred thirty-seven lesions (85%) were determined to be breast masses by radiologists, 164 of these as solid masses, 25 complex solid/cystic, 15 definite or probable cysts, 31 normal lymph nodes, and two other masses. The sensitivity of trainees’ assessments in identifying solid masses was 90.2% (95% CI, 85.9% to 94.9%) overall. Among trainees who scanned ≥ 10 lesions, mean sensitivity was 90.6% in the first 14 months and 94.0% in the second 9 months, after in-person training ( P = .3, paired t tests). In cases in which radiologists and trainees perceived solid masses (n = 148), trainees’ sensitivity was 81.4% (95% CI, 72.3% to 90.5%) for detecting suspicious masses or probably benign but in need of additional evaluation ( v benign with no additional evaluation needed). Among trainees who scanned ≥ 10 lesions, sensitivity was 79.1% in the first 14 months and 96.2% in the second 9 months ( P = .03, paired t tests). Conclusion Nurses and GPs in a rural sub-Saharan African facility built strong skills in diagnostic US with in-person training and remote electronic mentoring. The sensitivity of assessments for identifying suspicious masses demonstrated significant improvement after sustained mentorship. Assessment of the impact of the training on patient care and outcomes is ongoing. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . Sughra Raza Honoraria: Fujifilm Medical Services Travel, Accommodations, Expenses: Fujifilm Medical Services
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Affiliation(s)
- Sughra Raza
- Sughra Raza, Sahitya C. Raja, and Lydia E. Pace, Brigham and Women's Hospital; Sughra Raza and Lydia E. Pace, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu¸ Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - J.M.V. Dusengimana
- Sughra Raza, Sahitya C. Raja, and Lydia E. Pace, Brigham and Women's Hospital; Sughra Raza and Lydia E. Pace, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu¸ Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Vestine Rugema
- Sughra Raza, Sahitya C. Raja, and Lydia E. Pace, Brigham and Women's Hospital; Sughra Raza and Lydia E. Pace, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu¸ Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Vedaste Hategekimana
- Sughra Raza, Sahitya C. Raja, and Lydia E. Pace, Brigham and Women's Hospital; Sughra Raza and Lydia E. Pace, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu¸ Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Jean Bosco Bigirimana
- Sughra Raza, Sahitya C. Raja, and Lydia E. Pace, Brigham and Women's Hospital; Sughra Raza and Lydia E. Pace, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu¸ Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Cyprien Shyirambere
- Sughra Raza, Sahitya C. Raja, and Lydia E. Pace, Brigham and Women's Hospital; Sughra Raza and Lydia E. Pace, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu¸ Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Kassim Shabani
- Sughra Raza, Sahitya C. Raja, and Lydia E. Pace, Brigham and Women's Hospital; Sughra Raza and Lydia E. Pace, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu¸ Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - John Butonzi
- Sughra Raza, Sahitya C. Raja, and Lydia E. Pace, Brigham and Women's Hospital; Sughra Raza and Lydia E. Pace, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu¸ Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Sahitya C. Raja
- Sughra Raza, Sahitya C. Raja, and Lydia E. Pace, Brigham and Women's Hospital; Sughra Raza and Lydia E. Pace, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu¸ Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Aline Umwizerwa
- Sughra Raza, Sahitya C. Raja, and Lydia E. Pace, Brigham and Women's Hospital; Sughra Raza and Lydia E. Pace, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu¸ Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Lawrence N. Shulman
- Sughra Raza, Sahitya C. Raja, and Lydia E. Pace, Brigham and Women's Hospital; Sughra Raza and Lydia E. Pace, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu¸ Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Fidele Sebahungu
- Sughra Raza, Sahitya C. Raja, and Lydia E. Pace, Brigham and Women's Hospital; Sughra Raza and Lydia E. Pace, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu¸ Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Gaspard Muvugabigwi
- Sughra Raza, Sahitya C. Raja, and Lydia E. Pace, Brigham and Women's Hospital; Sughra Raza and Lydia E. Pace, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu¸ Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Tharcisse Mpunga
- Sughra Raza, Sahitya C. Raja, and Lydia E. Pace, Brigham and Women's Hospital; Sughra Raza and Lydia E. Pace, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu¸ Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Lydia E. Pace
- Sughra Raza, Sahitya C. Raja, and Lydia E. Pace, Brigham and Women's Hospital; Sughra Raza and Lydia E. Pace, Harvard Medical School, Boston, MA; J.M.V. Dusengimana, Vestine Rugema, Jean Bosco Bigirimana, Cyprien Shyirambere, Partners in Health; Vedaste Hategekimana, Kassim Shabani, John Butonzi, Aline Umwizerwa, Fidele Sebahungu¸ Gaspard Muvugabigwi, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
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Rugema V, Pace L, Mpunga T, Dusengimana J, Frost E, Umwizerwa A, Huang C, Hategekimana V, Shabani K, Bigirimana J, Butonzi J, Sebahungu F, Kwait D, Shulman L, Shyirambere C, Raza S. Impact of In-Person and Electronic Training by Breast Radiologists on Rwandan General Practitioners' and Nurses' Skills in Diagnostic Breast Ultrasound. J Glob Oncol 2018. [DOI: 10.1200/jgo.18.16400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Ultrasound (US) is a key tool in evaluation of palpable breast masses and can help refine the likelihood of malignancy and the need for further diagnostic studies. US technology is available in many low-resource settings, but there are few specialized radiologists. We launched a diagnostic breast ultrasound training program for general practitioner doctors (GPs) and nurses at a rural Rwandan district hospital that serves as a cancer referral facility. Aim: Assess GPs' and nurses' skill in diagnostic breast ultrasound over 23 months of intensive in-person and online supervision and mentorship. Methods: 4 rotating breast radiologists from Brigham and Women's Hospital trained 5 nurses and 4 doctors in Rwanda over 9 weeks of in-person training and 21 months of weekly remote case consultations and mentorship using electronic review of images with emailed feedback. During in-person trainings, trainees and radiologists evaluated patients separately, while radiologists' electronic assessments were based on emailed images and assessments from trainees. Among breast lesions with documented radiologist and trainee assessments, we compared written trainee and radiologist assessments to calculate the sensitivity of trainee assessments, with radiologist assessments as the gold standard. We used paired t-tests to examine whether the sensitivity varied between the first 14 months (stage I) and the last 9 months (stage 2), after the final in-person training. Results: Of 323 breast and axillary lesions assessed by trainees and radiologists, 279 were breast lesions. Of these, 114 (41%) were evaluated by radiologists in-person, and 165 (59%) through electronic evaluation. 237 (85%) were determined to be breast masses by the radiologists, with 164 of these solid masses, 25 complex solid/cystic lesions, 15 definite or probable simple cysts, 31 normal intramammary lymph nodes, and 2 other masses. Sensitivity of trainees' assessments for identifying a solid mass was 90.2% (95% CI 85.9-94.9) overall. Among trainees who scanned ≥ 10 lesions each, mean sensitivity was 90.6% in stage I, and 94.0% in stage 2 ( P = 0.3). In cases where both radiologists and trainees perceived solid masses (n=148), trainees' assessments had a sensitivity of 81.4% (95% CI 72.3-90.5) overall for detecting masses suspicious for malignancy, or probably benign but needing further evaluation (versus benign with no further evaluation needed). Among trainees who scanned ≥ 10 lesions each, sensitivity was 79.1% during stage I and 96.2% during the stage 2 ( P = 0.03). Conclusion: Nurses and GPs in a rural sub-Saharan African facility built strong skills in diagnostic ultrasound over 23 months of combined in-person training and distance learning via electronic case reviews. The sensitivity of their assessments for identifying masses concerning for malignancy showed significant improvement after sustained mentorship. Assessment of impact on patient care and outcomes is ongoing.
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Affiliation(s)
- V. Rugema
- Ministry of Health, Rwanda, Butaro, Rwanda
| | - L.E. Pace
- Ministry of Health, Rwanda, Butaro, Rwanda
| | - T. Mpunga
- Ministry of Health, Rwanda, Butaro, Rwanda
| | | | - E. Frost
- Ministry of Health, Rwanda, Butaro, Rwanda
| | | | - C.C. Huang
- Ministry of Health, Rwanda, Butaro, Rwanda
| | | | - K. Shabani
- Ministry of Health, Rwanda, Butaro, Rwanda
| | | | - J. Butonzi
- Ministry of Health, Rwanda, Butaro, Rwanda
| | | | - D. Kwait
- Ministry of Health, Rwanda, Butaro, Rwanda
| | | | | | - S. Raza
- Ministry of Health, Rwanda, Butaro, Rwanda
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Rubagumya F, Xu MJ, May L, Driscoll C, Uwizeye FR, Shyirambere C, Larrabee K, Fehr AE, Gilbert UD, Muhayimana C, Hategekimana V, Elmore S, Mpunga T, Moore M, Shulman LN, Lehmann L. Outcomes of Low-Intensity Treatment of Acute Lymphoblastic Leukemia at Butaro Cancer Center of Excellence in Rwanda. J Glob Oncol 2018; 4:1-11. [PMID: 30241148 PMCID: PMC6180843 DOI: 10.1200/jgo.2017.009290] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Purpose Children with acute lymphoblastic leukemia (ALL) in low-income countries have
disproportionately lower cure rates than those in high-income countries. At
Butaro Cancer Center of Excellence (BCCOE), physicians treated patients with
ALL with the first arm of the Hunger Protocol, a graduated-intensity method
tailored for resource-limited settings. This article provides the first
published outcomes, to our knowledge, of patients with ALL treated with this
protocol. Methods This is a retrospective descriptive study of patients with ALL enrolled at
BCCOE from July 1, 2012 to June 30, 2014; data were collected through
December 31, 2015. Descriptive statistics were used to calculate patient
demographics, disease characteristics, and outcomes; event-free survival was
assessed at 2 years using the Kaplan-Meier method. Results Forty-two consecutive patients with ALL were included. At the end of the
study period, 19% (eight) were alive without evidence of relapse: three
completed treatment and five were continuing treatment. Among the remaining
patients, 71% (30) had died and 10% (four) were lost to follow-up. A total
of 83% (25) of the deaths were disease related, 3% (one) treatment-related,
and 13% (four) unclear. Event-free survival was 22% (95% CI, 11% to 36%),
considering lost to follow-up as an event, and 26% (95% CI, 13% to 41%) if
lost to follow-up is censored. Conclusion As expected, relapse was the major cause of failure with this low-intensity
regimen. However, toxicity was acceptably low, and BCCOE has decided to
advance to intensity level 2. These results reflect the necessity of a
data-driven approach and a continual improvement process to care for complex
patients in resource-constrained settings.
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Affiliation(s)
- Fidel Rubagumya
- Fidel Rubagumya, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Mary Jue Xu, University of California, San Francisco, San Francisco, CA; Leana May, Children's Hospital Colorado, Aurora, CO; Caitlin Driscoll, Mount Sinai Medical School, New York, NY; Frank Regis Uwizeye, Cyprien Shyirambere, and Alexandra E. Fehr, Inshuti Mu Buzima/Partners In Health; Umuhizi Denis Gilbert, Clemence Muhayimana, Vedaste Hategekimana, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Katherine Larrabee, Geisinger Commonwealth School of Medicine, Scranton; Lawrence N. Shulman, University of Pennsylvania, Philadelphia, PA; Shekinah Elmore, Harvard Radiation Oncology Program; Leslie Lehmann, Dana Farber Cancer Institute; Boston Children's Hospital, Boston, MA; and Molly Moore, University of Vermont, Burlington, VT
| | - Mary Jue Xu
- Fidel Rubagumya, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Mary Jue Xu, University of California, San Francisco, San Francisco, CA; Leana May, Children's Hospital Colorado, Aurora, CO; Caitlin Driscoll, Mount Sinai Medical School, New York, NY; Frank Regis Uwizeye, Cyprien Shyirambere, and Alexandra E. Fehr, Inshuti Mu Buzima/Partners In Health; Umuhizi Denis Gilbert, Clemence Muhayimana, Vedaste Hategekimana, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Katherine Larrabee, Geisinger Commonwealth School of Medicine, Scranton; Lawrence N. Shulman, University of Pennsylvania, Philadelphia, PA; Shekinah Elmore, Harvard Radiation Oncology Program; Leslie Lehmann, Dana Farber Cancer Institute; Boston Children's Hospital, Boston, MA; and Molly Moore, University of Vermont, Burlington, VT
| | - Leana May
- Fidel Rubagumya, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Mary Jue Xu, University of California, San Francisco, San Francisco, CA; Leana May, Children's Hospital Colorado, Aurora, CO; Caitlin Driscoll, Mount Sinai Medical School, New York, NY; Frank Regis Uwizeye, Cyprien Shyirambere, and Alexandra E. Fehr, Inshuti Mu Buzima/Partners In Health; Umuhizi Denis Gilbert, Clemence Muhayimana, Vedaste Hategekimana, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Katherine Larrabee, Geisinger Commonwealth School of Medicine, Scranton; Lawrence N. Shulman, University of Pennsylvania, Philadelphia, PA; Shekinah Elmore, Harvard Radiation Oncology Program; Leslie Lehmann, Dana Farber Cancer Institute; Boston Children's Hospital, Boston, MA; and Molly Moore, University of Vermont, Burlington, VT
| | - Caitlin Driscoll
- Fidel Rubagumya, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Mary Jue Xu, University of California, San Francisco, San Francisco, CA; Leana May, Children's Hospital Colorado, Aurora, CO; Caitlin Driscoll, Mount Sinai Medical School, New York, NY; Frank Regis Uwizeye, Cyprien Shyirambere, and Alexandra E. Fehr, Inshuti Mu Buzima/Partners In Health; Umuhizi Denis Gilbert, Clemence Muhayimana, Vedaste Hategekimana, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Katherine Larrabee, Geisinger Commonwealth School of Medicine, Scranton; Lawrence N. Shulman, University of Pennsylvania, Philadelphia, PA; Shekinah Elmore, Harvard Radiation Oncology Program; Leslie Lehmann, Dana Farber Cancer Institute; Boston Children's Hospital, Boston, MA; and Molly Moore, University of Vermont, Burlington, VT
| | - Frank Regis Uwizeye
- Fidel Rubagumya, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Mary Jue Xu, University of California, San Francisco, San Francisco, CA; Leana May, Children's Hospital Colorado, Aurora, CO; Caitlin Driscoll, Mount Sinai Medical School, New York, NY; Frank Regis Uwizeye, Cyprien Shyirambere, and Alexandra E. Fehr, Inshuti Mu Buzima/Partners In Health; Umuhizi Denis Gilbert, Clemence Muhayimana, Vedaste Hategekimana, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Katherine Larrabee, Geisinger Commonwealth School of Medicine, Scranton; Lawrence N. Shulman, University of Pennsylvania, Philadelphia, PA; Shekinah Elmore, Harvard Radiation Oncology Program; Leslie Lehmann, Dana Farber Cancer Institute; Boston Children's Hospital, Boston, MA; and Molly Moore, University of Vermont, Burlington, VT
| | - Cyprien Shyirambere
- Fidel Rubagumya, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Mary Jue Xu, University of California, San Francisco, San Francisco, CA; Leana May, Children's Hospital Colorado, Aurora, CO; Caitlin Driscoll, Mount Sinai Medical School, New York, NY; Frank Regis Uwizeye, Cyprien Shyirambere, and Alexandra E. Fehr, Inshuti Mu Buzima/Partners In Health; Umuhizi Denis Gilbert, Clemence Muhayimana, Vedaste Hategekimana, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Katherine Larrabee, Geisinger Commonwealth School of Medicine, Scranton; Lawrence N. Shulman, University of Pennsylvania, Philadelphia, PA; Shekinah Elmore, Harvard Radiation Oncology Program; Leslie Lehmann, Dana Farber Cancer Institute; Boston Children's Hospital, Boston, MA; and Molly Moore, University of Vermont, Burlington, VT
| | - Katherine Larrabee
- Fidel Rubagumya, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Mary Jue Xu, University of California, San Francisco, San Francisco, CA; Leana May, Children's Hospital Colorado, Aurora, CO; Caitlin Driscoll, Mount Sinai Medical School, New York, NY; Frank Regis Uwizeye, Cyprien Shyirambere, and Alexandra E. Fehr, Inshuti Mu Buzima/Partners In Health; Umuhizi Denis Gilbert, Clemence Muhayimana, Vedaste Hategekimana, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Katherine Larrabee, Geisinger Commonwealth School of Medicine, Scranton; Lawrence N. Shulman, University of Pennsylvania, Philadelphia, PA; Shekinah Elmore, Harvard Radiation Oncology Program; Leslie Lehmann, Dana Farber Cancer Institute; Boston Children's Hospital, Boston, MA; and Molly Moore, University of Vermont, Burlington, VT
| | - Alexandra E Fehr
- Fidel Rubagumya, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Mary Jue Xu, University of California, San Francisco, San Francisco, CA; Leana May, Children's Hospital Colorado, Aurora, CO; Caitlin Driscoll, Mount Sinai Medical School, New York, NY; Frank Regis Uwizeye, Cyprien Shyirambere, and Alexandra E. Fehr, Inshuti Mu Buzima/Partners In Health; Umuhizi Denis Gilbert, Clemence Muhayimana, Vedaste Hategekimana, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Katherine Larrabee, Geisinger Commonwealth School of Medicine, Scranton; Lawrence N. Shulman, University of Pennsylvania, Philadelphia, PA; Shekinah Elmore, Harvard Radiation Oncology Program; Leslie Lehmann, Dana Farber Cancer Institute; Boston Children's Hospital, Boston, MA; and Molly Moore, University of Vermont, Burlington, VT
| | - Umuhizi Denis Gilbert
- Fidel Rubagumya, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Mary Jue Xu, University of California, San Francisco, San Francisco, CA; Leana May, Children's Hospital Colorado, Aurora, CO; Caitlin Driscoll, Mount Sinai Medical School, New York, NY; Frank Regis Uwizeye, Cyprien Shyirambere, and Alexandra E. Fehr, Inshuti Mu Buzima/Partners In Health; Umuhizi Denis Gilbert, Clemence Muhayimana, Vedaste Hategekimana, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Katherine Larrabee, Geisinger Commonwealth School of Medicine, Scranton; Lawrence N. Shulman, University of Pennsylvania, Philadelphia, PA; Shekinah Elmore, Harvard Radiation Oncology Program; Leslie Lehmann, Dana Farber Cancer Institute; Boston Children's Hospital, Boston, MA; and Molly Moore, University of Vermont, Burlington, VT
| | - Clemence Muhayimana
- Fidel Rubagumya, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Mary Jue Xu, University of California, San Francisco, San Francisco, CA; Leana May, Children's Hospital Colorado, Aurora, CO; Caitlin Driscoll, Mount Sinai Medical School, New York, NY; Frank Regis Uwizeye, Cyprien Shyirambere, and Alexandra E. Fehr, Inshuti Mu Buzima/Partners In Health; Umuhizi Denis Gilbert, Clemence Muhayimana, Vedaste Hategekimana, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Katherine Larrabee, Geisinger Commonwealth School of Medicine, Scranton; Lawrence N. Shulman, University of Pennsylvania, Philadelphia, PA; Shekinah Elmore, Harvard Radiation Oncology Program; Leslie Lehmann, Dana Farber Cancer Institute; Boston Children's Hospital, Boston, MA; and Molly Moore, University of Vermont, Burlington, VT
| | - Vedaste Hategekimana
- Fidel Rubagumya, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Mary Jue Xu, University of California, San Francisco, San Francisco, CA; Leana May, Children's Hospital Colorado, Aurora, CO; Caitlin Driscoll, Mount Sinai Medical School, New York, NY; Frank Regis Uwizeye, Cyprien Shyirambere, and Alexandra E. Fehr, Inshuti Mu Buzima/Partners In Health; Umuhizi Denis Gilbert, Clemence Muhayimana, Vedaste Hategekimana, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Katherine Larrabee, Geisinger Commonwealth School of Medicine, Scranton; Lawrence N. Shulman, University of Pennsylvania, Philadelphia, PA; Shekinah Elmore, Harvard Radiation Oncology Program; Leslie Lehmann, Dana Farber Cancer Institute; Boston Children's Hospital, Boston, MA; and Molly Moore, University of Vermont, Burlington, VT
| | - Shekinah Elmore
- Fidel Rubagumya, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Mary Jue Xu, University of California, San Francisco, San Francisco, CA; Leana May, Children's Hospital Colorado, Aurora, CO; Caitlin Driscoll, Mount Sinai Medical School, New York, NY; Frank Regis Uwizeye, Cyprien Shyirambere, and Alexandra E. Fehr, Inshuti Mu Buzima/Partners In Health; Umuhizi Denis Gilbert, Clemence Muhayimana, Vedaste Hategekimana, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Katherine Larrabee, Geisinger Commonwealth School of Medicine, Scranton; Lawrence N. Shulman, University of Pennsylvania, Philadelphia, PA; Shekinah Elmore, Harvard Radiation Oncology Program; Leslie Lehmann, Dana Farber Cancer Institute; Boston Children's Hospital, Boston, MA; and Molly Moore, University of Vermont, Burlington, VT
| | - Tharcisse Mpunga
- Fidel Rubagumya, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Mary Jue Xu, University of California, San Francisco, San Francisco, CA; Leana May, Children's Hospital Colorado, Aurora, CO; Caitlin Driscoll, Mount Sinai Medical School, New York, NY; Frank Regis Uwizeye, Cyprien Shyirambere, and Alexandra E. Fehr, Inshuti Mu Buzima/Partners In Health; Umuhizi Denis Gilbert, Clemence Muhayimana, Vedaste Hategekimana, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Katherine Larrabee, Geisinger Commonwealth School of Medicine, Scranton; Lawrence N. Shulman, University of Pennsylvania, Philadelphia, PA; Shekinah Elmore, Harvard Radiation Oncology Program; Leslie Lehmann, Dana Farber Cancer Institute; Boston Children's Hospital, Boston, MA; and Molly Moore, University of Vermont, Burlington, VT
| | - Molly Moore
- Fidel Rubagumya, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Mary Jue Xu, University of California, San Francisco, San Francisco, CA; Leana May, Children's Hospital Colorado, Aurora, CO; Caitlin Driscoll, Mount Sinai Medical School, New York, NY; Frank Regis Uwizeye, Cyprien Shyirambere, and Alexandra E. Fehr, Inshuti Mu Buzima/Partners In Health; Umuhizi Denis Gilbert, Clemence Muhayimana, Vedaste Hategekimana, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Katherine Larrabee, Geisinger Commonwealth School of Medicine, Scranton; Lawrence N. Shulman, University of Pennsylvania, Philadelphia, PA; Shekinah Elmore, Harvard Radiation Oncology Program; Leslie Lehmann, Dana Farber Cancer Institute; Boston Children's Hospital, Boston, MA; and Molly Moore, University of Vermont, Burlington, VT
| | - Lawrence N Shulman
- Fidel Rubagumya, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Mary Jue Xu, University of California, San Francisco, San Francisco, CA; Leana May, Children's Hospital Colorado, Aurora, CO; Caitlin Driscoll, Mount Sinai Medical School, New York, NY; Frank Regis Uwizeye, Cyprien Shyirambere, and Alexandra E. Fehr, Inshuti Mu Buzima/Partners In Health; Umuhizi Denis Gilbert, Clemence Muhayimana, Vedaste Hategekimana, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Katherine Larrabee, Geisinger Commonwealth School of Medicine, Scranton; Lawrence N. Shulman, University of Pennsylvania, Philadelphia, PA; Shekinah Elmore, Harvard Radiation Oncology Program; Leslie Lehmann, Dana Farber Cancer Institute; Boston Children's Hospital, Boston, MA; and Molly Moore, University of Vermont, Burlington, VT
| | - Leslie Lehmann
- Fidel Rubagumya, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Mary Jue Xu, University of California, San Francisco, San Francisco, CA; Leana May, Children's Hospital Colorado, Aurora, CO; Caitlin Driscoll, Mount Sinai Medical School, New York, NY; Frank Regis Uwizeye, Cyprien Shyirambere, and Alexandra E. Fehr, Inshuti Mu Buzima/Partners In Health; Umuhizi Denis Gilbert, Clemence Muhayimana, Vedaste Hategekimana, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Katherine Larrabee, Geisinger Commonwealth School of Medicine, Scranton; Lawrence N. Shulman, University of Pennsylvania, Philadelphia, PA; Shekinah Elmore, Harvard Radiation Oncology Program; Leslie Lehmann, Dana Farber Cancer Institute; Boston Children's Hospital, Boston, MA; and Molly Moore, University of Vermont, Burlington, VT
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15
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Dusengimana JMV, Hategekimana V, Borg R, Hedt-Gauthier B, Gupta N, Troyan S, Shulman LN, Nzayisenga I, Fadelu T, Mpunga T, Pace LE. Pregnancy-associated breast cancer in rural Rwanda: the experience of the Butaro Cancer Center of Excellence. BMC Cancer 2018; 18:634. [PMID: 29866062 PMCID: PMC5987575 DOI: 10.1186/s12885-018-4535-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 05/21/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Breast cancer is the most common malignancy encountered during pregnancy. However, the burden of pregnancy-associated breast cancer (PABC) and subsequent care is understudied in sub-Saharan Africa (SSA). Here, we describe the characteristics, diagnostic delays and treatment of women with PABC seeking care at a rural cancer referral facility in Rwanda. METHODS Data from female patients aged 18-50 years with pathologically confirmed breast cancer who presented for treatment between July 1, 2012 and February 28, 2014 were retrospectively reviewed. PABC was defined as breast cancer diagnosed in a woman who was pregnant or breastfeeding. Numbers and frequencies are reported for demographic and diagnostic delay variables and Wilcoxon rank sum and Fisher's exact tests are used to compare characteristics of women with PABC to women with non-PABC at the alpha = 0.05 significance level. Treatment and outcomes are described for women with PABC only. RESULTS Of the 117 women with breast cancer, 12 (10.3%) had PABC based on medical record review. The only significant demographic differences were that women with PABC were younger (p = 0.006) and more likely to be married (p = 0.035) compared to women with non-PABC. There were no significant differences in diagnostic delays or stage at diagnosis between women with PABC and women with non-PABC women. Eleven of the women with PABC received treatment, three had documented treatment delays or modifications due to their pregnancy or breastfeeding, and four stopped breastfeeding to initiate treatment. At the end of the study period, six patients were alive, three were deceased and three patients were lost to follow-up. CONCLUSIONS PABC was relatively common in our cohort but may have been underreported. Although patients with PABC did not experience greater diagnostic delays, most had treatment modifications, emphasizing the potential value of PABC-specific treatment protocols in SSA. Larger prospective studies of PABC are needed to better understand particular challenges faced by these patients and inform policies and practices to optimize care for women with PABC in Rwanda and similar settings.
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Affiliation(s)
| | | | - Ryan Borg
- Partners In Health/Inshuti Mu Buzima, P.O.Box 3432, Kigali, Rwanda
| | - Bethany Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima, P.O.Box 3432, Kigali, Rwanda
- Harvard Medical School, Boston, MA USA
| | - Neil Gupta
- Partners In Health/Inshuti Mu Buzima, P.O.Box 3432, Kigali, Rwanda
- Harvard Medical School, Boston, MA USA
- Brigham and Women’s Hospital, Boston, MA USA
| | - Susan Troyan
- Harvard Medical School, Boston, MA USA
- Brigham and Women’s Hospital, Boston, MA USA
| | | | | | | | | | - Lydia E. Pace
- Harvard Medical School, Boston, MA USA
- Brigham and Women’s Hospital, Boston, MA USA
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16
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Buswell L, Umuhizi D, Hategekimana V, Muhayimana C, Kennell-Heiling S. Voices of Hope From Rural Rwanda: Three Oncology Nurse Leaders Emerge. Oncol Nurs Forum 2017; 43:661-4. [PMID: 27541559 DOI: 10.1188/16.onf.661-664] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The cancer burden in low- and middle-income countries (LMICs) has been well described in the literature (International Agency for Research on Cancer, 2012; Ott, Ullrich, Mascarenhas, & Stevens, 2011; Thun, DeLancey, Center, Jemal, & Ward, 2010). According to the World Health Organization ([WHO], 2015), about 14 million new cancer cases occurred in 2012, and more than 60% of those cases were in Africa, Asia, and Central and South America; of the 8.2 million cancer-related deaths in 2012, more than 70% occurred in these regions (Bray & Møller, 2006).
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17
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O'Neil DS, Keating NL, Dusengimana JMV, Hategekimana V, Umwizera A, Mpunga T, Shulman LN, Pace LE. Quality of Breast Cancer Treatment at a Rural Cancer Center in Rwanda. J Glob Oncol 2017; 4:1-11. [PMID: 30241207 PMCID: PMC6180813 DOI: 10.1200/jgo.2016.008672] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE As breast cancer incidence and mortality rise in sub-Saharan Africa, it is critical to identify strategies for delivery of high-quality breast cancer care in settings with limited resources and few oncology specialists. We investigated the quality of treatments received by a cohort of patients with breast cancer at Butaro Cancer Center of Excellence (BCCOE), Rwanda's first public cancer center. PATIENTS AND METHODS We reviewed medical records of all female patients diagnosed with invasive breast cancer at BCCOE between July 2012 and December 2013. We evaluated the provision of chemotherapy, endocrine therapy, surgery, and chemotherapy dose densities. We also applied modified international quality metrics and estimated overall survival using interval-censored analysis. RESULTS Among 150 patients, 28 presented with early-stage, 64 with locally advanced, and 53 with metastatic disease. Among potentially curable patients (ie, those with early-stage or locally advanced disease), 74% received at least four cycles of chemotherapy and 63% received surgery. Among hormone receptor-positive patients, 83% received endocrine therapy within 1 year of diagnosis. Fifty-seven percent of potentially curable patients completed surgery and chemotherapy and initiated endocrine therapy if indicated within 1 year of biopsy. Radiotherapy was not available. At the end of follow-up, 62% of potentially curable patients were alive, 24% were dead, and 14% were lost to follow-up. CONCLUSION Appropriate delivery of chemotherapy and endocrine therapy for breast cancer is possible in rural sub-Saharan African even without oncologists based on site. Performing timely surgery and ensuring treatment completion were key challenges after the opening of BCCOE. Further investigation should examine persistent quality gaps and the relationship between treatment quality and survival.
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Affiliation(s)
- Daniel S O'Neil
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Nancy L Keating
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Jean Marie V Dusengimana
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Vedaste Hategekimana
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Aline Umwizera
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Tharcisse Mpunga
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Lawrence N Shulman
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Lydia E Pace
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
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18
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Uwizeye F, Driscoll C, Park P, Hategekimana V, Umwizerwa A, Umuhizi D, Smith C, Shulman L. Risk factors for loss to follow-up and treatment abandonment in adult
cancer patients at the Butaro Cancer Center of Excellence in Rural
Rwanda. Ann Glob Health 2016. [DOI: 10.1016/j.aogh.2016.04.154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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19
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Nzayisenga I, Segal R, Pritchett N, Xu MJ, Park PH, Mpanumusingo EV, Umuhizi DG, Goldstein DP, Berkowitz RS, Hategekimana V, Muhayimana C, Rubagumya F, Fadelu T, Tapela N, Mpunga T, Ghebre RG. Gestational Trophoblastic Neoplasia Treatment at the Butaro Cancer Center of Excellence in Rwanda. J Glob Oncol 2016; 2:365-374. [PMID: 28717722 PMCID: PMC5493245 DOI: 10.1200/jgo.2015.002568] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
PURPOSE Gestational trophoblastic neoplasia (GTN) is a highly treatable disease, most often affecting young women of childbearing age. This study reviewed patients managed for GTN at the Butaro Cancer Center of Excellence (BCCOE) in Rwanda to determine initial program outcomes. PATIENTS AND METHODS A retrospective medical record review was performed for 35 patients with GTN assessed or treated between May 1, 2012, and November 30, 2014. Stage, risk score, and low or high GTN risk category were based on International Federation of Gynecology and Obstetrics staging and the WHO scoring system and determined by beta human chorionic gonadotropin level, chest x-ray, and ultrasound per protocol guidelines for resource-limited settings. Pathology reports and computed tomography scans were assessed when possible. Treatment was based on a predetermined protocol stratified by risk status. RESULTS Of the 35 patients (mean age, 32 years), 26 (74%) had high-risk and nine (26%) had low-risk disease. Nineteen patients (54%) had undergone dilation and curettage and 11 (31%) had undergone hysterectomy before evaluation at BCCOE. Pathology reports were available in 48% of the molar pregnancy surgical cases. Systemic chemotherapy was initiated in 30 of the initial 35 patients: 13 (43%) received single-agent oral methotrexate, 15 (50%) received EMACO (etoposide, methotrexate, dactinomycin, cyclophosphamide, and vincristine), and two (7%) received alternate regimens. Of the 13 patients initiating methotrexate, three had their treatment intensified to EMACO. Four patients experienced treatment delays because of medication stockouts. At a median follow-up of 7.8 months, the survival probability for low-risk patients was 1.00; for high-risk patients, it was 0.63. CONCLUSION This experience demonstrates the feasibility of GTN treatment in rural, resource-limited settings. GTN is a curable disease and can be treated following the BCCOE model of cancer care.
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Affiliation(s)
- Ignace Nzayisenga
- , , , , and , Partners In Health-Inshuti Mu Buzima; , , , , , and , Rwandan Ministry of Health; , Human Resources for Health Program Rwanda, Kigali, Rwanda; , Ottawa University, Ottawa, Ontario, Canada; , , , , , and , Harvard Medical School; , , , , and , Brigham and Women's Hospital, Boston, MA; and , University of Minnesota Medical School, Minneapolis, MN, and Yale School of Medicine, New Haven, CT
| | - Roanne Segal
- , , , , and , Partners In Health-Inshuti Mu Buzima; , , , , , and , Rwandan Ministry of Health; , Human Resources for Health Program Rwanda, Kigali, Rwanda; , Ottawa University, Ottawa, Ontario, Canada; , , , , , and , Harvard Medical School; , , , , and , Brigham and Women's Hospital, Boston, MA; and , University of Minnesota Medical School, Minneapolis, MN, and Yale School of Medicine, New Haven, CT
| | - Natalie Pritchett
- , , , , and , Partners In Health-Inshuti Mu Buzima; , , , , , and , Rwandan Ministry of Health; , Human Resources for Health Program Rwanda, Kigali, Rwanda; , Ottawa University, Ottawa, Ontario, Canada; , , , , , and , Harvard Medical School; , , , , and , Brigham and Women's Hospital, Boston, MA; and , University of Minnesota Medical School, Minneapolis, MN, and Yale School of Medicine, New Haven, CT
| | - Mary J Xu
- , , , , and , Partners In Health-Inshuti Mu Buzima; , , , , , and , Rwandan Ministry of Health; , Human Resources for Health Program Rwanda, Kigali, Rwanda; , Ottawa University, Ottawa, Ontario, Canada; , , , , , and , Harvard Medical School; , , , , and , Brigham and Women's Hospital, Boston, MA; and , University of Minnesota Medical School, Minneapolis, MN, and Yale School of Medicine, New Haven, CT
| | - Paul H Park
- , , , , and , Partners In Health-Inshuti Mu Buzima; , , , , , and , Rwandan Ministry of Health; , Human Resources for Health Program Rwanda, Kigali, Rwanda; , Ottawa University, Ottawa, Ontario, Canada; , , , , , and , Harvard Medical School; , , , , and , Brigham and Women's Hospital, Boston, MA; and , University of Minnesota Medical School, Minneapolis, MN, and Yale School of Medicine, New Haven, CT
| | - Edgie V Mpanumusingo
- , , , , and , Partners In Health-Inshuti Mu Buzima; , , , , , and , Rwandan Ministry of Health; , Human Resources for Health Program Rwanda, Kigali, Rwanda; , Ottawa University, Ottawa, Ontario, Canada; , , , , , and , Harvard Medical School; , , , , and , Brigham and Women's Hospital, Boston, MA; and , University of Minnesota Medical School, Minneapolis, MN, and Yale School of Medicine, New Haven, CT
| | - Denis G Umuhizi
- , , , , and , Partners In Health-Inshuti Mu Buzima; , , , , , and , Rwandan Ministry of Health; , Human Resources for Health Program Rwanda, Kigali, Rwanda; , Ottawa University, Ottawa, Ontario, Canada; , , , , , and , Harvard Medical School; , , , , and , Brigham and Women's Hospital, Boston, MA; and , University of Minnesota Medical School, Minneapolis, MN, and Yale School of Medicine, New Haven, CT
| | - Donald P Goldstein
- , , , , and , Partners In Health-Inshuti Mu Buzima; , , , , , and , Rwandan Ministry of Health; , Human Resources for Health Program Rwanda, Kigali, Rwanda; , Ottawa University, Ottawa, Ontario, Canada; , , , , , and , Harvard Medical School; , , , , and , Brigham and Women's Hospital, Boston, MA; and , University of Minnesota Medical School, Minneapolis, MN, and Yale School of Medicine, New Haven, CT
| | - Ross S Berkowitz
- , , , , and , Partners In Health-Inshuti Mu Buzima; , , , , , and , Rwandan Ministry of Health; , Human Resources for Health Program Rwanda, Kigali, Rwanda; , Ottawa University, Ottawa, Ontario, Canada; , , , , , and , Harvard Medical School; , , , , and , Brigham and Women's Hospital, Boston, MA; and , University of Minnesota Medical School, Minneapolis, MN, and Yale School of Medicine, New Haven, CT
| | - Vedaste Hategekimana
- , , , , and , Partners In Health-Inshuti Mu Buzima; , , , , , and , Rwandan Ministry of Health; , Human Resources for Health Program Rwanda, Kigali, Rwanda; , Ottawa University, Ottawa, Ontario, Canada; , , , , , and , Harvard Medical School; , , , , and , Brigham and Women's Hospital, Boston, MA; and , University of Minnesota Medical School, Minneapolis, MN, and Yale School of Medicine, New Haven, CT
| | - Clemence Muhayimana
- , , , , and , Partners In Health-Inshuti Mu Buzima; , , , , , and , Rwandan Ministry of Health; , Human Resources for Health Program Rwanda, Kigali, Rwanda; , Ottawa University, Ottawa, Ontario, Canada; , , , , , and , Harvard Medical School; , , , , and , Brigham and Women's Hospital, Boston, MA; and , University of Minnesota Medical School, Minneapolis, MN, and Yale School of Medicine, New Haven, CT
| | - Fidel Rubagumya
- , , , , and , Partners In Health-Inshuti Mu Buzima; , , , , , and , Rwandan Ministry of Health; , Human Resources for Health Program Rwanda, Kigali, Rwanda; , Ottawa University, Ottawa, Ontario, Canada; , , , , , and , Harvard Medical School; , , , , and , Brigham and Women's Hospital, Boston, MA; and , University of Minnesota Medical School, Minneapolis, MN, and Yale School of Medicine, New Haven, CT
| | - Temidayo Fadelu
- , , , , and , Partners In Health-Inshuti Mu Buzima; , , , , , and , Rwandan Ministry of Health; , Human Resources for Health Program Rwanda, Kigali, Rwanda; , Ottawa University, Ottawa, Ontario, Canada; , , , , , and , Harvard Medical School; , , , , and , Brigham and Women's Hospital, Boston, MA; and , University of Minnesota Medical School, Minneapolis, MN, and Yale School of Medicine, New Haven, CT
| | - Neo Tapela
- , , , , and , Partners In Health-Inshuti Mu Buzima; , , , , , and , Rwandan Ministry of Health; , Human Resources for Health Program Rwanda, Kigali, Rwanda; , Ottawa University, Ottawa, Ontario, Canada; , , , , , and , Harvard Medical School; , , , , and , Brigham and Women's Hospital, Boston, MA; and , University of Minnesota Medical School, Minneapolis, MN, and Yale School of Medicine, New Haven, CT
| | - Tharcisse Mpunga
- , , , , and , Partners In Health-Inshuti Mu Buzima; , , , , , and , Rwandan Ministry of Health; , Human Resources for Health Program Rwanda, Kigali, Rwanda; , Ottawa University, Ottawa, Ontario, Canada; , , , , , and , Harvard Medical School; , , , , and , Brigham and Women's Hospital, Boston, MA; and , University of Minnesota Medical School, Minneapolis, MN, and Yale School of Medicine, New Haven, CT
| | - Rahel G Ghebre
- , , , , and , Partners In Health-Inshuti Mu Buzima; , , , , , and , Rwandan Ministry of Health; , Human Resources for Health Program Rwanda, Kigali, Rwanda; , Ottawa University, Ottawa, Ontario, Canada; , , , , , and , Harvard Medical School; , , , , and , Brigham and Women's Hospital, Boston, MA; and , University of Minnesota Medical School, Minneapolis, MN, and Yale School of Medicine, New Haven, CT
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Pace LE, Dusengimana JMV, Hategekimana V, Habineza H, Bigirimana JB, Tapela N, Mutumbira C, Mpanumusingo E, Brock JE, Meserve E, Uwumugambi A, Dillon D, Keating NL, Shulman LN, Mpunga T. Benign and Malignant Breast Disease at Rwanda's First Public Cancer Referral Center. Oncologist 2016; 21:571-5. [PMID: 27009935 DOI: 10.1634/theoncologist.2015-0388] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [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: 09/28/2015] [Accepted: 01/12/2016] [Indexed: 01/02/2023] Open
Abstract
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 Rwanda's 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 Rwanda's 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.
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Affiliation(s)
- Lydia E Pace
- Brigham and Women's Hospital, Boston, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | | | - Neo Tapela
- Brigham and Women's Hospital, Boston, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA Partners in Health/Inshuti Mu Buzima, Kigali, Rwanda
| | | | | | - Jane E Brock
- Brigham and Women's Hospital, Boston, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA
| | - Emily Meserve
- Brigham and Women's Hospital, Boston, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA
| | | | - Deborah Dillon
- Brigham and Women's Hospital, Boston, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA
| | - Nancy L Keating
- Brigham and Women's Hospital, Boston, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA
| | - Lawrence N Shulman
- Harvard Medical School, Boston, Massachusetts, USA Partners in Health/Inshuti Mu Buzima, Kigali, Rwanda Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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21
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Tapela NM, Mpunga T, Hedt-Gauthier B, Moore M, Mpanumusingo E, Xu MJ, Nzayisenga I, Hategekimana V, Umuhizi DG, Pace LE, Bigirimana JB, Wang J, Driscoll C, Uwizeye FR, Drobac PC, Ngoga G, Shyirambere C, Muhayimana C, Lehmann L, Shulman LN. Pursuing equity in cancer care: implementation, challenges and preliminary findings of a public cancer referral center in rural Rwanda. BMC Cancer 2016; 16:237. [PMID: 26992690 PMCID: PMC4797361 DOI: 10.1186/s12885-016-2256-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 03/08/2016] [Indexed: 11/29/2022] Open
Abstract
Background Cancer services are inaccessible in many low-income countries, and few published examples describe oncology programs within the public sector. In 2011, the Rwanda Ministry of Health (RMOH) established Butaro Cancer Center of Excellence (BCCOE) to expand cancer services nationally. In hopes of informing cancer care delivery in similar settings, we describe program-level experience implementing BCCOE, patient characteristics, and challenges encountered. Methods Butaro Cancer Center of Excellence was founded on diverse partnerships that emphasize capacity building. Services available include pathology-based diagnosis, basic imaging, chemotherapy, surgery, referral for radiotherapy, palliative care and socioeconomic access supports. Retrospective review of electronic medical records (EMR) of patients enrolled between July 1, 2012 and June 30, 2014 was conducted, supplemented by manual review of paper charts and programmatic records. Results In the program’s first 2 years, 2326 patients presented for cancer-related care. Of these, 70.5 % were female, 4.3 % children, and 74.3 % on public health insurance. In the first year, 66.3 % (n = 1144) were diagnosed with cancer. Leading adult diagnoses were breast, cervical, and skin cancer. Among children, nephroblastoma, acute lymphoblastic leukemia, and Hodgkin lymphoma were predominant. As of June 30, 2013, 95 cancer patients had died. Challenges encountered include documentation gaps and staff shortages. Conclusion Butaro Cancer Center of Excellence demonstrates that complex cancer care can be delivered in the most resource-constrained settings, accessible to vulnerable patients. Key attributes that have made BCCOE possible are: meaningful North–south partnerships, innovative task- and infrastructure-shifting, RMOH leadership, and an equity-driven agenda. Going forward, we will apply our experiences and lessons learned to further strengthen BCCOE, and employ the developed EMR system as a valuable platform to assess long-term clinical outcomes and improve care.
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Affiliation(s)
- Neo M Tapela
- Botswana Ministry of Health, Gaborone, Botswana. .,Dana-Farber/Brigham & Women's Cancer Center, Boston, USA. .,Harvard Medical School, Boston, USA. .,Division of Global Health Equity, Brigham and Women's Hospital, Boston, USA.
| | | | - Bethany Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Dana-Farber/Brigham & Women's Cancer Center, Boston, USA.,Harvard Medical School, Boston, USA
| | - Molly Moore
- University of Vermont College of Medicine, Burlington, USA
| | | | | | | | | | | | | | | | - JingJing Wang
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | | | | | - Peter C Drobac
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Dana-Farber/Brigham & Women's Cancer Center, Boston, USA.,Harvard Medical School, Boston, USA
| | - Gedeon Ngoga
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | | | | | - Leslie Lehmann
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Dana-Farber/Brigham & Women's Cancer Center, Boston, USA.,Harvard Medical School, Boston, USA.,Boston Children's Hospital, Boston, USA
| | - Lawrence N Shulman
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Dana-Farber/Brigham & Women's Cancer Center, Boston, USA.,Abramson Cancer Center, University of Pennsylvania, Philadelphia, USA
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22
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Tapela N, Nzayisenga I, Sethi R, Bigirimana JB, Habineza H, Hategekimana V, Mantini N, Mpunga T, Shulman LN, Lehmann L. Treatment of Chronic Myeloid Leukemia in Rural Rwanda: Promising Early Outcomes. J Glob Oncol 2016; 2:129-137. [PMID: 28717692 PMCID: PMC5495451 DOI: 10.1200/jgo.2015.001727] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Purpose The burden of cancer is rising in low- and middle-income countries, yet cancer treatment requires resources that are often not available in these settings. Although management of chronic myeloid leukemia (CML) has been described in low- and middle-income countries, few programs involve patients treated in rural settings. We describe characteristics and early outcomes of patients treated for CML at rural district hospitals in Rwanda. Methods We conducted a retrospective review of patients with confirmed BCR-ABL–positive CML who were enrolled between July 1, 2009 and June 30, 2014. Types of data included patient demographics, diagnostic work up, treatment, clinical examination, laboratory testing, and death. Results Forty-three patients were included, with a maximum follow-up of 58 months. Of 31 patients who were imatinib-naïve at enrollment, 54.8% were men and the median age at diagnosis was 36.9 years (interquartile range: 29-42 years). Approximately two-thirds of patients (67.7%) were on the national public insurance scheme. The imatinib dose was reduced for 16 patients and discontinued for five. Thirty-two of the 43 patients continued to have normal blood counts at last follow-up. Four patients have died and four are lost to follow-up. Conclusion Our experience indicates that CML can be effectively managed in a resource-constrained rural setting, despite limited availability of on-site diagnostic resources or specialty oncology personnel. The importance of model public-private partnerships as a strategy to bring high-cost, life-saving treatment to people who do not have the ability to pay is also highlighted.
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Affiliation(s)
- Neo Tapela
- and Brigham and Women's Hospital; and Harvard Medical School; Children's Hospital of Boston, Boston, MA; and Partners In Health/Inshuti Mu Buzima; and Ministry of Health, Kigali, Rwanda; and University of Pennsylvania, Philadelphia, PA
| | - Ignace Nzayisenga
- and Brigham and Women's Hospital; and Harvard Medical School; Children's Hospital of Boston, Boston, MA; and Partners In Health/Inshuti Mu Buzima; and Ministry of Health, Kigali, Rwanda; and University of Pennsylvania, Philadelphia, PA
| | - Roshan Sethi
- and Brigham and Women's Hospital; and Harvard Medical School; Children's Hospital of Boston, Boston, MA; and Partners In Health/Inshuti Mu Buzima; and Ministry of Health, Kigali, Rwanda; and University of Pennsylvania, Philadelphia, PA
| | - Jean Bosco Bigirimana
- and Brigham and Women's Hospital; and Harvard Medical School; Children's Hospital of Boston, Boston, MA; and Partners In Health/Inshuti Mu Buzima; and Ministry of Health, Kigali, Rwanda; and University of Pennsylvania, Philadelphia, PA
| | - Hamissy Habineza
- and Brigham and Women's Hospital; and Harvard Medical School; Children's Hospital of Boston, Boston, MA; and Partners In Health/Inshuti Mu Buzima; and Ministry of Health, Kigali, Rwanda; and University of Pennsylvania, Philadelphia, PA
| | - Vedaste Hategekimana
- and Brigham and Women's Hospital; and Harvard Medical School; Children's Hospital of Boston, Boston, MA; and Partners In Health/Inshuti Mu Buzima; and Ministry of Health, Kigali, Rwanda; and University of Pennsylvania, Philadelphia, PA
| | - Nicholas Mantini
- and Brigham and Women's Hospital; and Harvard Medical School; Children's Hospital of Boston, Boston, MA; and Partners In Health/Inshuti Mu Buzima; and Ministry of Health, Kigali, Rwanda; and University of Pennsylvania, Philadelphia, PA
| | - Tharcisse Mpunga
- and Brigham and Women's Hospital; and Harvard Medical School; Children's Hospital of Boston, Boston, MA; and Partners In Health/Inshuti Mu Buzima; and Ministry of Health, Kigali, Rwanda; and University of Pennsylvania, Philadelphia, PA
| | - Lawrence N Shulman
- and Brigham and Women's Hospital; and Harvard Medical School; Children's Hospital of Boston, Boston, MA; and Partners In Health/Inshuti Mu Buzima; and Ministry of Health, Kigali, Rwanda; and University of Pennsylvania, Philadelphia, PA
| | - Leslie Lehmann
- and Brigham and Women's Hospital; and Harvard Medical School; Children's Hospital of Boston, Boston, MA; and Partners In Health/Inshuti Mu Buzima; and Ministry of Health, Kigali, Rwanda; and University of Pennsylvania, Philadelphia, PA
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Shyirambere C, Xu MJ, Elmore SN, Fadelu T, May L, Tapela N, Umuhizi DG, Uwizeye FR, Driscoll C, Muhayimana C, Hategekimana V, Rubagumya F, Nzayisenga I, Shulman LN, Mpunga T, Lehmann LE. Treating Nephroblastoma in Rwanda: Using International Society of Pediatric Oncology Guidelines in a Novel Oncologic Care Model. J Glob Oncol 2016; 2:105-113. [PMID: 28717689 PMCID: PMC5495448 DOI: 10.1200/jgo.2015.000067] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Success in treating nephroblastoma in high-income countries has been transferred to some resource-constrained settings; multicenter studies report disease-free survival of greater than 70%. However, few reports present care models with rural-based components, care tasks shifted to internists and pediatricians, and data collection structured for monitoring and evaluation. Here, we report clinical outcomes and protocol compliance for patients with nephroblastoma evaluated at Butaro Cancer Center of Excellence in Rwanda. Patients and Methods This retrospective study reports the care of 53 patients evaluated between July 1, 2012, and June 30, 2014. Patients receiving less than half of their chemotherapy at Butaro Cancer Center of Excellence were excluded. Results Of the 53 patients included, 9.4% had stage I, 13.2% had stage II, 24.5% had stage III, 26.4% had stage IV, and 5.7% had stage V disease; the remaining 20.8% had unknown stage disease from inadequate work-up or unavailable surgical report. The incidence of neutropenia increased with treatment progression, and the greatest proportion of delays occurred during the surgical referral phase. At the end of the study period, 32.1% of patients (n = 17) remained alive after treatment; 24.5% (n = 13) remained alive while continuing treatment, including one patient with recurrent disease; 30.2% (n = 16) died; and 13.2% (n = 7) were lost to follow-up. Conclusion Our findings confirm that nephroblastoma can be effectively treated in resource-constrained settings. Using an approach in which chemotherapy is delivered at a rural-based center by nononcologists and data are used for routine evaluation, care can be delivered in safe, novel ways. Protocol modifications to mitigate chemotherapy toxicities and strong communication between the multidisciplinary team members will likely minimize delays and further improve outcomes in similar settings.
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Affiliation(s)
- Cyprien Shyirambere
- , , , and , Inshuti Mu Buzima/Partners in Health Rwanda; , , , , and , Ministry of Health Rwanda, Kigali, Rwanda; , , , , and , Harvard Medical School; , , and , Brigham and Women's Hospital; and , Boston Children's Hospital; and , Dana-Farber Cancer Institute, Boston, MA; and , Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mary Jue Xu
- , , , and , Inshuti Mu Buzima/Partners in Health Rwanda; , , , , and , Ministry of Health Rwanda, Kigali, Rwanda; , , , , and , Harvard Medical School; , , and , Brigham and Women's Hospital; and , Boston Children's Hospital; and , Dana-Farber Cancer Institute, Boston, MA; and , Icahn School of Medicine at Mount Sinai, New York, NY
| | - Shekinah Nefreteri Elmore
- , , , and , Inshuti Mu Buzima/Partners in Health Rwanda; , , , , and , Ministry of Health Rwanda, Kigali, Rwanda; , , , , and , Harvard Medical School; , , and , Brigham and Women's Hospital; and , Boston Children's Hospital; and , Dana-Farber Cancer Institute, Boston, MA; and , Icahn School of Medicine at Mount Sinai, New York, NY
| | - Temidayo Fadelu
- , , , and , Inshuti Mu Buzima/Partners in Health Rwanda; , , , , and , Ministry of Health Rwanda, Kigali, Rwanda; , , , , and , Harvard Medical School; , , and , Brigham and Women's Hospital; and , Boston Children's Hospital; and , Dana-Farber Cancer Institute, Boston, MA; and , Icahn School of Medicine at Mount Sinai, New York, NY
| | - Leana May
- , , , and , Inshuti Mu Buzima/Partners in Health Rwanda; , , , , and , Ministry of Health Rwanda, Kigali, Rwanda; , , , , and , Harvard Medical School; , , and , Brigham and Women's Hospital; and , Boston Children's Hospital; and , Dana-Farber Cancer Institute, Boston, MA; and , Icahn School of Medicine at Mount Sinai, New York, NY
| | - Neo Tapela
- , , , and , Inshuti Mu Buzima/Partners in Health Rwanda; , , , , and , Ministry of Health Rwanda, Kigali, Rwanda; , , , , and , Harvard Medical School; , , and , Brigham and Women's Hospital; and , Boston Children's Hospital; and , Dana-Farber Cancer Institute, Boston, MA; and , Icahn School of Medicine at Mount Sinai, New York, NY
| | - Denis Gilbert Umuhizi
- , , , and , Inshuti Mu Buzima/Partners in Health Rwanda; , , , , and , Ministry of Health Rwanda, Kigali, Rwanda; , , , , and , Harvard Medical School; , , and , Brigham and Women's Hospital; and , Boston Children's Hospital; and , Dana-Farber Cancer Institute, Boston, MA; and , Icahn School of Medicine at Mount Sinai, New York, NY
| | - Frank Regis Uwizeye
- , , , and , Inshuti Mu Buzima/Partners in Health Rwanda; , , , , and , Ministry of Health Rwanda, Kigali, Rwanda; , , , , and , Harvard Medical School; , , and , Brigham and Women's Hospital; and , Boston Children's Hospital; and , Dana-Farber Cancer Institute, Boston, MA; and , Icahn School of Medicine at Mount Sinai, New York, NY
| | - Caitlin Driscoll
- , , , and , Inshuti Mu Buzima/Partners in Health Rwanda; , , , , and , Ministry of Health Rwanda, Kigali, Rwanda; , , , , and , Harvard Medical School; , , and , Brigham and Women's Hospital; and , Boston Children's Hospital; and , Dana-Farber Cancer Institute, Boston, MA; and , Icahn School of Medicine at Mount Sinai, New York, NY
| | - Clemence Muhayimana
- , , , and , Inshuti Mu Buzima/Partners in Health Rwanda; , , , , and , Ministry of Health Rwanda, Kigali, Rwanda; , , , , and , Harvard Medical School; , , and , Brigham and Women's Hospital; and , Boston Children's Hospital; and , Dana-Farber Cancer Institute, Boston, MA; and , Icahn School of Medicine at Mount Sinai, New York, NY
| | - Vedaste Hategekimana
- , , , and , Inshuti Mu Buzima/Partners in Health Rwanda; , , , , and , Ministry of Health Rwanda, Kigali, Rwanda; , , , , and , Harvard Medical School; , , and , Brigham and Women's Hospital; and , Boston Children's Hospital; and , Dana-Farber Cancer Institute, Boston, MA; and , Icahn School of Medicine at Mount Sinai, New York, NY
| | - Fidel Rubagumya
- , , , and , Inshuti Mu Buzima/Partners in Health Rwanda; , , , , and , Ministry of Health Rwanda, Kigali, Rwanda; , , , , and , Harvard Medical School; , , and , Brigham and Women's Hospital; and , Boston Children's Hospital; and , Dana-Farber Cancer Institute, Boston, MA; and , Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ignace Nzayisenga
- , , , and , Inshuti Mu Buzima/Partners in Health Rwanda; , , , , and , Ministry of Health Rwanda, Kigali, Rwanda; , , , , and , Harvard Medical School; , , and , Brigham and Women's Hospital; and , Boston Children's Hospital; and , Dana-Farber Cancer Institute, Boston, MA; and , Icahn School of Medicine at Mount Sinai, New York, NY
| | - Lawrence N Shulman
- , , , and , Inshuti Mu Buzima/Partners in Health Rwanda; , , , , and , Ministry of Health Rwanda, Kigali, Rwanda; , , , , and , Harvard Medical School; , , and , Brigham and Women's Hospital; and , Boston Children's Hospital; and , Dana-Farber Cancer Institute, Boston, MA; and , Icahn School of Medicine at Mount Sinai, New York, NY
| | - Tharcisse Mpunga
- , , , and , Inshuti Mu Buzima/Partners in Health Rwanda; , , , , and , Ministry of Health Rwanda, Kigali, Rwanda; , , , , and , Harvard Medical School; , , and , Brigham and Women's Hospital; and , Boston Children's Hospital; and , Dana-Farber Cancer Institute, Boston, MA; and , Icahn School of Medicine at Mount Sinai, New York, NY
| | - Leslie E Lehmann
- , , , and , Inshuti Mu Buzima/Partners in Health Rwanda; , , , , and , Ministry of Health Rwanda, Kigali, Rwanda; , , , , and , Harvard Medical School; , , and , Brigham and Women's Hospital; and , Boston Children's Hospital; and , Dana-Farber Cancer Institute, Boston, MA; and , Icahn School of Medicine at Mount Sinai, New York, NY
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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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