Quality of Breast Cancer Treatment at a Rural Cancer Center in Rwanda

Abstract

PurposeAs 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 MethodsWe 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.ResultsAmong 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.ConclusionAppropriate 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.

Real-world use of chemotherapy for Kaposi’s sarcoma in a large community-based HIV primary care system in Kenya

“…We know that there is often a significant delay between symptom recognition and successful initiation of cancer care in Africa [28]. Our results for KS echo data from other cancers in Africa, such as lymphoma and breast cancer, with similar delays [29] and non-initiation of chemotherapy [30]. A particular strength of our study comes from linking severity of disease at time of diagnosis with subsequent treatment course in a real-world setting.…”

Neoadjuvant Chemotherapy Use for Nonmetastatic Breast Cancer at Five Public South African Hospitals and Impact on Time to Initial Cancer Therapy

“…For instance, given the log‐kill hypothesis of chemotherapy dosing, all planned cycles of preoperative chemotherapy should be delivered without interruption for surgery . At a large hospital in Rwanda, 22% of patients with breast cancer had chemotherapy split into neoadjuvant and adjuvant portions, typically because surgical timing was often delayed and unpredictable . The patients in our cohort did not receive such split chemotherapy, but the practice may be common in poorer areas of SSA.…”

Breast Cancer in Low- and Middle-Income Countries

“…41–43 Data from Rwanda and Kenya also suggest that East Africa may have higher rates of ER-positive disease and closer to that of Europe and North America at 60% to 70%, especially in places like Rwanda, where the cold ischemic time for most samples is known. 44–47 The heterogeneity of these data is more likely to be a phenomenon of tissue handling procedures and quality of histopathology and immunohistochemistry review than a significant ethnic difference, but in the absence of knowledge about tissue handling and access to quality pathology, it is not possible to know this for certain. Increasing access to high-quality immunohistochemistry will better delineate the molecular heterogeneity of breast cancer subtypes in sub-Saharan Africa and other LMICs.…”