A lifeline for cancer patients in Africa

In Rwanda, many people with cancer are diagnosed too late because of low awareness of the disease coupled with a lack of specialist facilities and staff. The opening of a specialist centre in the northern part of the country is extending and saving lives.

It seems an unlikely, but impossibly romantic site for a hospital: high in the hills among scented eucalyptus trees, on a remote winding red dirt track above a lake miles from the nearest town.

But it is here that the first centre of excellence for cancer care outside a capital city anywhere in East Africa has opened – with nurses playing a key role in the delivery of care.

Standing outside the centre, which is built from volcanic rock from the local Virunga mountains, cancer nurse Murangora Naasson says demand for its services is growing: ‘The cancer centre is still new but it’s already known about by many people – and more will come.’

First of its kind: The Butaro Cancer Center of Excellence in northern Rwanda, East Africa

Services offered at the Butaro Cancer Center of Excellence in northern Rwanda include pathology-based diagnosis, surgery and chemotherapy – both palliative and curative – all of which is a huge step forward.

There are very few specialist nurses in Rwanda; those that exist are mainly in mental health. But the opening of the cancer centre in 2012, and outpatient ambulatory care at the 156-bed Butaro District Hospital a year later, has led to around 30 general nurses effectively specialising in oncology.

There is no radiotherapy machine here – nor in the whole of Rwanda. There are only two oncologists in the country, and so there are no permanent oncologists at Butaro, just onco-clinicians. There is one general surgeon for the entire hospital, which has a pathology lab but no permanent pathologist. But it is all a marked improvement on what went before.

‘Previously, we just gave patients painkillers and told them to go home and wait,’ district clinical director Christian Rusangwa says bluntly.

His colleague, US internist Becky DeBoer, says: ‘Now, we treat mostly with curative intent, although there are a handful of cancers that we try to palliate with chemotherapy.’

She adds: ‘The nursing programme is impressive here. We now have several nurses who are trained to mix and administer chemotherapy, and they do a fantastic job. That takes a lot of investment in training and support for ongoing quality control, so that’s been a great success.’

The situation is improving. Lives have been saved and life expectancy increased

Collaboration and support

Treatment is free for patients, made possible by the international NGO Partners In Health, which has helped build the centre with other collaborators and pays for all of the chemotherapy and supportive care.

The hospital has a catchment of 340,000 people in the Burera district for its general services, but referrals for cancer are made from other district hospitals further afield, including from neighbouring Uganda.

There is a 24-bed ward for adult and paediatric cancer patients, with three isolation rooms where two-day and five-day chemo takes place along with other treatment. At the chemotherapy centre, patients have one-day infusions Monday to Friday. Clinics are frequently oversubscribed.

Three nurse trainers have been mentored by visiting nurses from Dana-Farber Cancer Institute in Boston in the US.

The need for specialist nursing cancer care in Rwanda is growing, while deaths from infectious diseases such HIV and malaria are in decline. Life expectancy has risen from 42 in 1994 – the year of the civil war genocide – to 64 now.

A total of 3,430 cancer cases were registered from 2007 to 2011 – but a large number go undiagnosed and unreported. Breast cancer is the most common, followed by gastrointestinal, lymphoma and cervical cancers. The biggest problem is late diagnoses, with patients often arriving with fungating external growths.

The nurses combine their cancer care with other general duties. There are no healthcare assistants; cleaners help by cutting up material for dressings and transporting the dead to the mortuary, for example.

Nursing staff are keen to take on the new challenges that cancer brings. They are led by director of nursing Emmanuel Dushimimana. He says: ‘I am happy dealing with patients, but what has pushed me in my career is directing and encouraging other nurses.’

Getting the cancer message across

Awareness of cancer is not high in this rural community of bean and banana farmers.

A study of breast cancer patients in 2012-14 carried out by the NGO Partners In Health and the Ministry of Health found that the median time from breast cancer onset to diagnosis was 15 months – six times as long as it would be in a country with widespread routine mammograms. To tackle late diagnosis, they are collaborating to raise awareness among health centre nurses and volunteer community health workers.

Nurses are being taught the importance of referring women for biopsies if they present with a lump, rather than giving them painkillers at home. Trainers are using a mannequin to practise evaluating symptoms and performing a clinical breast exam.

His team includes Therese Uwamahoro, a mother of six, whose training in cancer consisted of one week of theory and two weeks practical work. ‘The new system is helpful; we have increased our knowledge to help patients,’ she says.

Ms Uwamahoro says the worst thing about her job is when the cancer has reached the advanced stage and is untreatable. Mr Naasson says that for him the biggest challenges are attempting to deal with pain and the side effects of the treatment. But he adds: ‘The situation is improving. Lives have been saved, and life expectancy increased – some people get better completely.’

Staff often work late, with no overtime payment added to their basic Rwandan Francs 172,000 (£161) a month. Ms Uwamahoro explains why she does so with a laugh: ‘Because we are short of nurses and have lots of patients.’

Mr Dushimimana says the hospital’s remote location makes it difficult to retain nurses. However, there are plans to tarmac the long approach road to make the hospital more accessible, and to build a new university with a nursing and medical school. ‘In the future, nurses will have a school nearby and there will be night courses for them,’ says Mr Dushimimana. ‘That makes me happy’.

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