Investigating Barriers to Timely Surgery for Breast Cancer in Rwanda

Abstract

Background: Timely and high-quality breast surgery must be a key element of emerging breast cancer control efforts in sub-Saharan Africa. We investigated delays in pre-operative care and the impact of on-site versus off-site surgery on time to surgery for breast cancer patients at Butaro Cancer Center of Excellence (BCCOE) in Rwanda. Methods: We used a standardized data abstraction form to collect demographic data, clinical characteristics, treatments received and disease status as of November 2017 for all patients diagnosed with breast cancer at BCCOE in 2014-2015. Results: During 2014-2015, 89 patients were diagnosed with stage I-III breast cancer and treated with curative intent. Of those, 68 (76.4%) underwent curative breast surgery, 12 (13.5%) were lost to follow-up, 7 (7.8%) progressed, and 2 (2.2%) declined recommended surgery. Only 32% of patients who underwent surgery had surgery within 60 days from diagnosis or last neoadjuvant chemotherapy (NAC). Median time to surgery was 122 days from biopsy if no neoadjuvant treatments were given, and 51 days from last cycle of NAC. Patients who received no neoadjuvant treatment experienced longer median time to surgery at BCCOE (180 days) than at a referral hospital in Kigali (93 days, p=0.04). Most patients (60%) experienced a disruption in pre-operative care, frequently at the point of surgical referral. Documented reasons for disruptions and delays included patient factors, clinically indicated treatment modifications, and system factors. Conclusions: We observed frequent delays to surgery, disruptions in preoperative care and loss to follow-up, particularly at the point of surgical referral. There may be opportunities to improve breast cancer survival in Rwanda and other LMICs through interventions that facilitate more timely surgical care.