The number of people seeking care at the Butaro Cancer Center of Excellence in Rwanda has been rising consistently over the last decade. Prior to that, very few people in Rwanda received cancer care, not because no one had cancer but because Rwanda had virtually no cancer care services.
Over the last 12 years, the Butaro Cancer Center of Excellence has become the major referral center for cancer care in Rwanda. When cancer is diagnosed in Rwanda, patients are most often sent to Butaro, the only place in the country where care is provided for free.
“They don’t turn anyone away,” says Dana-Farber medical oncologist Sarah Slater, MD, a Clark Family Investigator in Gastrointestinal Oncology.
Many patients arrive at Butaro with late-stage disease which may be treatable but is no longer curable. There is a recognition that along with treatment of their cancer, patients also need access to palliative care services, which focus on providing pain and symptoms management, as well as providing psychosocial, spiritual, and practical support. In late 2024, Slater and a team from Dana-Farber’s Center for Global Cancer Medicine helped them establish a dedicated palliative care team.
“The oncology team there has always tried to address palliative care needs, but they didn’t have anyone who was dedicated to palliative care,” says Slater. “They really wanted additional focused support to improve the quality-of-life of patients and their families.”
Dana-Farber’s relationship with the Butaro hospital stretches back to 2012. At that time, Dana-Farber’s Center for Global Cancer Medicine, in partnership with Partners in Health, started working with the hospital in Rwanda to provide cancer care services. Today, the Center for Global Cancer Medicine is part of the Center for Global Health Equity, which was established in 2023 to centralize and enhance Dana-Farber’s global health activities and to address inequities in cancer prevention, care, and outcomes.
In Butaro, oncologists, nurses, and other health providers from Rwanda staff the oncology service. The Dana-Farber team meets with them regularly to provide support, such as to help develop clinical protocols or to review cases via tumor boards. They also listen to the challenges the team is facing and recommend possible solutions.
Over the past few years, the oncologists at Butaro have recognized the increasing needs for palliative care in their clinic. In meetings with Slater and others at Dana-Farber, they’ve mentioned the challenges their team is facing in meeting those needs. There are too many cases and not enough time or expertise.
With philanthropic support, Slater was able to respond to that emerging need and start a dedicated palliative care service in Rwanda.
The first hurdle was hiring what would be a team of two — one doctor and one nurse. Slater and her colleagues reviewed applicants and made recommendations, but the team on the ground in Rwanda chose who to hire.
The new team members, Olive Mukeshimana, MD, and Francois Sebishyimbo, both from Rwanda, started in late 2024.
Slater and her colleagues support the new team with weekly meetings to understand what the challenges are for the new team, to review palliative care intake and assessment tools, and to provide virtual support. There are many patients who would benefit from palliative care. The team is working to create a workflow that prioritizes those with the highest need.
“What’s the trigger for palliative care when so many patients would benefit from it?” asks Slater.
For example, some patients are receiving palliative chemotherapy to control late-stage disease and need symptom management. Others might be transitioning off chemotherapy and need palliative care as they approach the end of their lives. Another concern is how to support patients when they return home, often to a rural environment where palliative medicines might not be easily accessible.
While developing a process is important, says Slater, real patients don’t always fit into neat categories. In addition, there are many cultural differences and resource limitations to consider.
The development of a multi-disciplinary team which includes social workers, psychologists, and others on staff at Butaro is currently underway. Additionally, the DFCI team will support further development of the palliative care team’s expertise with additional training in palliative care at Hospice Africa Uganda in nearby Kampala, Uganda.
“There’s a learning curve when it comes to incorporating a dedicated palliative care service into the workflow there, and it’s really exciting to be a part of it,” says Slater. “But it is also challenging from afar.”
Slater plans to visit Rwanda for several weeks in February to meet the new team in person, to better understand how the service is operating, and how to best meet the needs of the patients.