Characteristics and early outcomes of cervical cancer patients at Butaro District Hospital, Rwanda: a retrospective review

Background: Cancer treatment facilities are scarce in rural areas of low-income and middle-income countries, where the highest burden of cervical cancer exists. The Butaro Cancer Center of Excellence (BCCOE), in rural Rwanda, is a Rwandan Ministry of Health facility supported by Partners In Health and Dana-Farber/Brigham and Women's Cancer Center. The cervical cancer programme includes diagnosis, staging, and treatment. However, because of resource limitations, only 15 patients per month could be referred for radiotherapy to the Uganda Cancer Institute. In this study, we describe cervical cancer treatment at BCCOE and early patient outcomes. Methods: In July, 2016, we retrospectively reviewed records for patients with cervical cancer enrolled between July 1, 2012, and June 30, 2015, at BCCOE. We extracted data on patients' characteristics, disease stage, treatment, and outcomes. Findings: We included 438 patients: median age was 52 years (IQR 42–60 years), 35 patients (8%) had laboratory-confirmed HIV, 142 (36%) smoked tobacco, median number of pregnancies was 7 (IQR 5–9), and 41 (10%) had had a hysterectomy before enrolment. 258 patients (60%) had a diagnosis confirmed by pathology, and 391 patients (91%) had a documented disease stage. Of these, 13 (3%) were Stage I, 183 (47%) were Stage II, 154 (39%) were Stage-III, and 41 (11%) were Stage IV. There was a curative, instead of palliative or undecided, intent for 85% of Stage I patients, 91% of Stage II, and, 12% of Stage III. 165 women (38%) were referred for concurrent radiation therapy, chemotherapy, and brachytherapy in Uganda, and 19 (4%) were referred for radical hysterectomy. At their last recorded visit, 77 patients (18%) had no evidence of recurrence, including: 6 (46%) Stage I patients, 66 (37%) Stage II, 5 (3%) Stage III, but no Stage IV patients (p =<0·0001). Overall, 114 patients (27%) were lost to follow-up during or after treatment. Interpretation: Our experience shows that a cervical cancer treatment programme is viable in a low-resource, rural setting. However, many challenges exist, especially the severity of disease at intake (about half of patients presented with Stage III or IV disease) and that there are no radiation facilities in Rwanda. Further, a quarter of patients were eventually lost to follow-up during the study. Future implementation interventions will focus on strategies to overcome these challenges. Funding: Partners in Health, Dana-Farber Cancer Institute, Rwandan Ministry of Health

Confidence and performance of health workers in cardiovascular risk factor management in rural Botswana: a cross-sectional study

Background: Social and demographic changes in Botswana are resulting in an increased prevalence of cardiovascular disease (CVD). Providers, mostly nurses, in this setting have limited training in managing CVD risk and few opportunities for continued medical education. We aimed to evaluate providers' perceived confidence in managing CVD risk factors and describe management of patients with hypertension at public-sector clinics in a rural district of Botswana. Methods: In this cross-sectional study, we invited public-sector health-care providers in 11 ambulatory clinics in the Kweneng East district of Botswana to complete an anonymous questionnaire survey. We used descriptive statistics to evaluate providers' confidence in managing CVD risk (a Likert scale from 1 [low confidence] to 5 [high confidence]). We used t tests to compare confidence levels between groups of providers and specific risk factors. Additionally, we interviewed patients and did chart reviews to assess how CVD risk factors were managed in 275 hypertensive patients at seven of the 11 sites surveyed. Uncontrolled hypertension was defined as ≥140/90 mm Hg (or ≥130/80 mm Hg in patients with diabetes) for an average of two blood pressure readings and CVD risk was defined using WHO guidelines. Findings: Of 88 health care providers invited to participate, 44 registered nurses (80%), four family nurse practitioners (7%), and seven doctors (13%) completed the survey. Providers reported feeling significantly more comfortable managing hypertension than they did diabetes (3·73 vs 3·15; p<0·0001) and had lowest confidence with a mean Likert rating of 1·95 (95% CI 1·58–2·31), 2·27 (95% CI 1·93–2·62), and 2·13 (95% CI 1·75–2·51) for prescribing aspirin, statins, and adjusting insulin, respectively. Of the 275 patients with hypertension, 55% (152) had uncontrolled hypertension, and 45% (69) of those with uncontrolled hypertension had no changes to their medications over the course of a year. Of 53 patients who also had diabetes, 51% (27) had uncontrolled disease and an additional 15% (8) had no recent blood glucose check. Of 52 patients with 10-year CVD risk of more than 10%, 55·7% (29) were prescribed aspirin and 15% (8) a statin. Interpretation: Public sector health-care providers in rural Botswana have low confidence in managing CVD risk factors. Although reported confidence was higher for management of hypertension than for diabetes, there were significant lapses in management of both diseases. CVD and diabetes account for 22% of all adult deaths in Botswana and it is imperative that training in management of these diseases is improved. To address low provider confidence and gaps in guideline-driven CVD prevention, we plan to implement an integrative training programme for health workers in the Kweneng East district of Botswana. Funding: Hospital Medicine, Beth Israel Deaconess Medical Center