Financial Toxicity: Unveiling the Burden of Cancer Care on Patients in Rwanda.

INTRODUCTION: Cancer is a major public health problem in Rwanda and other low- and middle-income countries (LMICs). While there have been some improvements in access to cancer treatment, the cost of care has increased, leading to financial toxicity and treatment barriers for many patients. This study explores the financial toxicity of cancer care in Rwanda. METHODS: This prospective cross-sectional study was conducted at 3 referral hospitals in Rwanda, which deliver most of the country's cancer care. Data were collected over 6 months from June 1 to December 1, 2022 by trained research assistants (RAs) using a modified validated data collection tool. RAs interviewed consecutive eligible patients with breast cancer, cervical cancer, colorectal cancer, Hodgkin's and non-Hodgkin's lymphoma who were on active systemic therapy. The study aimed to identify sources of financial burden. Data were analyzed using descriptive statistics. RESULTS: 239 patients were included; 75% (n = 180/239) were female and mean age was 51 years. Breast, cervix, and colorectal cancers were the most common diagnoses (42%, 100/239; 24%, 58/239; and 24%, 57/239, respectively) and 54% (n = 129/239) were diagnosed with advanced stage (stages III-IV). Financial burden was high; 44% (n = 106/239) of respondents sold property, 29% (n = 70/239) asked for charity from public, family, or friends, and 16% (n = 37/239) took loans with interest to fund cancer treatment. CONCLUSION: Despite health insurance which covers many elements of cancer care, a substantial proportion of patients on anti-cancer treatment in Rwanda experience major financial toxicity. Novel health financing solutions are needed to ensure accessible and affordable cancer care.

State of Cancer Control in Rwanda: Past, Present, and Future Opportunities.

Rwanda is a densely populated low-income country in East Africa. Previously considered a failed state after the genocide against the Tutsi in 1994, Rwanda has seen remarkable growth over the past 2 decades. Health care in Rwanda is predominantly delivered through public hospitals and is emerging in the private sector. More than 80% of patients are covered by community-based health insurance (Mutuelle de Santé). The cancer unit at the Rwanda Biomedical Center (a branch of the Ministry of Health) is responsible for setting and implementing cancer care policy. Rwanda has made progress with human papillomavirus (HPV) and hepatitis B vaccination. Recently, the cancer unit at the Rwanda Biomedical Center launched the country's 5-year National Cancer Control Plan. Over the past decade, patients with cancer have been able to receive chemotherapy at Butaro Cancer Center, and recently, the Rwanda Cancer Center was launched with 2 linear accelerator radiotherapy machines, which greatly reduced the number of referrals for treatment abroad. Palliative care services are increasing in Rwanda. A cancer registry has now been strengthened, and more clinicians are becoming active in cancer research. Despite these advances, there is still substantial work to be done and there are many outstanding challenges, including the need to build capacity in cancer awareness among the general population (and shift toward earlier diagnosis), cancer care workforce (more in-country training programs are needed), and research.

Osteoblastic Osteosarcoma Arising beneath an Osteochondroma in an 11-Year-Old Male with Multiple Hereditary Exostoses.

INTRODUCTION: Multiple hereditary exostoses (MHE) is a rare autosomal dominant disorder characterized by the presence of multiple skeletal deformities. They are painless slow-growing lesions. Malignant transformation tends to occur later in adulthood and has only been seen in 1-5% of patients. OBJECTIVE: We describe the clinical, radiological, and pathological characteristics of a child with MHE who developed osteoblastic osteosarcoma beneath an osteochondroma. CASE PRESENTATION: An 11-year-old male Rwandan presented to our hospital with a two-week history of a dull persistent pain in his left distal femur and loss of weight and appetite. There was no relief with pain killers. He was a known case of multiple hereditary exostoses diagnosed at age 3. He began experiencing mild symptoms 6 months prior to admission which worsened in the last two weeks prior to his admission. On examination, he had multiple palpable bony swellings bilaterally on the proximal humeri and distal femurs. X-rays showed multiple exostoses and MRI showed a lesion with heterogeneous signal intensities that suggested malignant transformation. At surgery, a necrotic lesion beneath the exostosis was excised and sent for histopathological analysis which confirmed osteochondroma with an osteoblastic osteosarcoma in the marrow cavity. Chemotherapy and limb-salvaging surgery were done and he has recovered well. CONCLUSION: Osteosarcomas arising at sites of MHE have not been previously reported in Africa. These tumors rarely undergo malignant transformation.

Stroke Burden in Rwanda: A Multicenter Study of Stroke Management and Outcome.

BACKGROUND: Cerebrovascular accidents or stroke constitute the second leading cause of mortality worldwide. Low- and middle-income countries bear most of the stroke burden worldwide. The main objective of this study is to determine the burden of stroke in Rwanda. METHODS: This was a prospective observational study in 2 parts: 6 months baseline data collection and outcome assessment sessions at 1 year. RESULTS: A total of 96 patients were enrolled in our series. Stroke constituted 2100 per 100,000 population. Of all patients, 55.2% were male and most (60%) were 55 years and older. Of all patients and/or caretakers, 22% were not aware of their previous health status and 53.5% of hypertensive patients were not on treatment by the time of the event. Median presentation delay was 72 hours for patients with ischemic stroke and 24 hours for patients with hemorrhagic stroke. Most patients had hemorrhagic stroke (65% vs. 35%), and more patients with hemorrhagic stroke presented with loss of consciousness (80% vs. 51%). Many patients (62% ischemic group and 44% hemorrhagic group) presented with severe stroke scores, and this was associated with worst outcome (P = 0.004). At 1 year follow-up, 24.7% had no or mild disability, 14.3% were significantly disabled, and 61% had died. CONCLUSIONS: Our results show that stroke is a significant public health concern in Rwanda. Risk factor awareness and control are still low and case fatality of stroke is significantly high. The significant delay in presentation to care and presentation with severe stroke are major contributors for the high mortality and severe disability rates.

Intensive point-of-care ultrasound training with long-term follow-up in a cohort of Rwandan physicians.

OBJECTIVE: We delivered a point-of-care ultrasound training programme in a resource-limited setting in Rwanda, and sought to determine participants' knowledge and skill retention. We also measured trainees' assessment of the usefulness of ultrasound in clinical practice. METHODS: This was a prospective cohort study of 17 Rwandan physicians participating in a point-of-care ultrasound training programme. The follow-up period was 1 year. Participants completed a 10-day ultrasound course, with follow-up training delivered over the subsequent 12 months. Trainee knowledge acquisition and skill retention were assessed via observed structured clinical examinations (OSCEs) administered at six points during the study, and an image-based assessment completed at three points. RESULTS: Trainees reported minimal structured ultrasound education and little confidence using point-of-care ultrasound before the training. Mean scores on the image-based assessment increased from 36.9% (95% CI 32-41.8%) before the initial 10-day training to 74.3% afterwards (95% CI 69.4-79.2; P < 0.001). The mean score on the initial OSCE after the introductory course was 81.7% (95% CI 78-85.4%). The mean OSCE performance at each subsequent evaluation was at least 75%, and the mean OSCE score at the 58-week follow up was 84.9% (95% CI 80.9-88.9%). CONCLUSIONS: Physicians providing acute care in a resource-limited setting demonstrated sustained improvement in their ultrasound knowledge and skill 1 year after completing a clinical ultrasound training programme. They also reported improvements in their ability to provide patient care and in job satisfaction.

Association of Abnormal Liver Function Parameters with HIV Serostatus and CD4 Count in Antiretroviral-Naive Rwandan Women.

We determined the associations of HIV infection/CD4 count with markers of hepatocellular damage [elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT)] and liver synthetic function (decreased albumin) in HIV-infected (HIV(+)) antiretroviral therapy (ART)-naive and uninfected (HIV(-)) Rwandan women. In 2005, 710 HIV(+) ART-naive and 226 HIV(-) women enrolled in the Rwanda Women's Interassociation Study and Assessment. Liver enzymes were measured with abnormality defined as either AST or ALT ≥1.25 times the upper limit of normal. Low serum albumin level was defined as <3.5 g/dl. Multivariable logistic regression analysis identified independent predictors of elevated AST/ALT and low serum albumin. HIV(-) women had the lowest prevalence (6.6%) of abnormal AST/ALT, with the highest prevalence (16.4%) in HIV(+) women with CD4 <200 cells/µl (p=0.01). The odds of having serum albumin <3.5 g/dl was 5.7-fold higher in HIV(+) than HIV(-) women (OR=5.68, 95% CI: 3.32-9.71). The risk of low albumin decreased from low to high CD4 count, with OR=2.62, 95% CI: 1.66, 4.14 and OR=1.57, 95% CI: 1.01, 2.43 in HIV(+) women with a CD4 count <200 and 200-350 cells/µl, respectively vs. HIV(+) with CD4 >350 (p<0.001 and p<0.05 for all comparisons). Our findings suggest that HIV-associated liver damage may occur in ART-naive patients. Although liver abnormality prevalences in this cohort of HIV-infected Rwandan women are less than reported in developed countries, caution is needed for risk assessment measures to monitor and screen HIV-infected patients pre- and post-ART initiation in African clinical settings to curtail potential risks associated with HIV infection.

Over-reported peripheral neuropathy symptoms in a cohort of HIV infected and uninfected Rwandan women: the need for validated locally appropriate questionnaires.

BACKGROUND: Peripheral neuropathy symptoms (PNS) are commonly manifested in HIV-infected (HIV+) individuals, although data are limited on the prevalence and predictors of PNS in HIV+ patients from sub-Saharan Africa. OBJECTIVE: To determine the prevalence and predictors of PNS in HIV+ and HIV-uninfected (HIV-) Rwandan women. METHODS: Data were analysed from 936 (710 HIV+ and 226 HIV-) women from the Rwanda Women Interassociation Study and Assessment (RWISA), an observational prospective cohort study investigating the effectiveness and toxicity of ART in HIV+ women. RESULTS: Of 936 enrolled, 920 (98.3%) were included in this analysis with 44% of HIV- and 52% of the HIV+ women reporting PNS (p=0.06). CD4+ count was not associated with PNS, although there was a non-significant trend towards higher prevalence in those with lower CD4+ counts. For the HIV- women, only alcohol and co-trimoxazole use were independently associated with PNS. WHO HIV stage IV illness and albumin ≤ 3.5 were associated with PNS in HIV+ women. CONCLUSIONS: The rate of peripheral neuropathy symptoms reported in this cohort of HIV-infected African women seems implausible, and rather suggests that the screening tool for peripheral neuropathy in culturally diverse African settings be locally validated.