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J Glob Oncol. 2018 Oct;(4):1-12. doi: 10.1200/JGO.18.00089.

International Radiotherapy Referrals From Rural Rwanda: Implementation Processes and Early Clinical Outcomes.

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Maud Hanappe, Free University of Brussels, Brussels, Belgium; Lowell T. Nicholson, Duke University School of Medicine, Durham, NC; Shekinah N.C. Elmore, Harvard Radiation Oncology Program; Shekinah N.C. Elmore and Paul H. Park, Harvard Medical School; Ryan C. Borg, Boston College School of Social Work; Paul H. Park, Brigham and Women's Hospital; Paul H. Park, Partners in Health, Boston, MA; Alexandra E. Fehr, Jean Bosco Bigirimana, Cyprien Shyirambere, Egide Mpanumusingo, Marie O. Benewe, and Christian Rusangwa, Inshuti mu Buzima/Partners in Health; John Butonzi, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Dan M. Kanyike, Uganda Cancer Institute, Kampala, Uganda; Scott Triedman, The Warren Alpert Medical School of Brown University, Providence, RI; and Lawrence N. Shulman, University of Pennsylvania, Philadelphia, PA.



Low- and middle-income countries disproportionately comprise 65% of cancer deaths. Cancer care delivery in resource-limited settings, especially low-income countries in sub-Saharan Africa, is exceedingly complex, requiring multiple modalities of diagnosis and treatment. Given the vast human, technical, and financial resources required, access to radiotherapy remains limited in sub-Saharan Africa. Through 2017, Rwanda has not had in-country radiotherapy services. The aim of this study was to describe the implementation and early outcomes of the radiotherapy referral program at the Butaro Cancer Centre of Excellence and to identify both successful pathways and barriers to care.


Butaro District Hospital is located in a rural area of the Northern Province and is home to the Butaro Cancer Centre of Excellence. We performed a retrospective study from routinely collected data of all patients with a diagnosis of cervical, head and neck, or rectal cancer between July 2012 and June 2015.


Between 2012 and 2015, 580 patients were identified with these diagnoses and were potential candidates for radiation. Two hundred eight (36%) were referred for radiotherapy treatment in Uganda. Of those referred, 160 (77%) had cervical cancer, 31 (15%) had head and neck cancer, and 17 (8%) had rectal cancer. At the time of data collection, 101 radiotherapy patients (49%) were alive and had completed treatment with no evidence of recurrence, 11 (5%) were alive and continuing treatment, and 12 (6%) were alive and had completed treatment with evidence of recurrence.


This study demonstrates the feasibility of a rural cancer facility to successfully conduct out-of-country radiotherapy referrals with promising early outcomes. The results of this study also highlight the many challenges and lessons learned in providing comprehensive cancer care in resource-limited settings.


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