Abstract
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.
Keywords: cancer, financial toxicity, Africa, LMICs, Rwanda
Cancer is a major public health challenge in low- and middle-income countries. 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 explored the financial toxicity of cancer care in Rwanda.
Implications for Practice.
The study findings underscore the need for policymakers to develop strategies to reduce the financial burden of cancer treatment and ensure equitable access to health insurance.
Introduction
Cancer has become a major public health threat worldwide, and its burden is increasing in many low- and middle-income countries (LMICs) including those in Africa.1 The number of cancer cases and deaths in many African countries including Rwanda is expected to grow rapidly as populations grow, age, and adopt lifestyle behaviors that increase cancer risks.2 Globally, over the last 3 decades, a number of advances in treatment of cancer have been registered.3,4 However, these advances have led to cancer becoming one of the most expensive disease to treat.5 The indirect and direct costs of cancer care have led to several forms of financial burden and to what is now widely known as financial toxicity (FT).6 Previous research, especially that done in high-income countries, shows that patients with cancer are at a greater risk for financial burden than those without cancer.7
One of the most pressing problems across emerging cancer systems is ensuring access and affordability of cancer care.8 Hence, FT and costs of cancer care are particularly challenging in LMICs.9 While high-income countries are starting to acknowledge FT as a significant policy concern, it has been, and continues to be, a major obstacle in providing high-quality cancer care in many African countries.8
Rwanda is a landlocked low-income country located in East Africa. The national population is approximately 13.2 million, with Kigali the capital city having 1.7 million (13%).10The current life expectancy is 69 years,10 and the 2022 average monthly household living income for the general Rwanda population is $183 USD.11 Currently, there are 8 referral/tertiary hospitals, 4 of them being University Teaching Hospitals.
Over the past 2 decades, Rwanda has witnessed substantial advancements in the field of oncology.12 Notably, the introduction of systemic therapy services at Butaro Cancer Centre and King Faisal Hospital, as well as the provision of both systemic therapy and radiotherapy services at Rwanda Military Hospital. Expansion of these centers have significantly reduced the number of patients referred outside the country.12 Surgical and diagnostic including pathology and imaging services are available in most tertiary hospitals.12,13
Currently, most cancer care services including physician fees, diagnostic investigation, treatment, and follow-up visits are covered by the community-based health insurance (CBHI); more than 90% of Rwandans are included in this plan, and the remaining are insured through other plans.14 Both the CBHI and other private insurance use a copay system, with the patient expected to pay an out pocket fee of the total care bill equaling 10% and 15% for CBHI and private insurances, respectively. However, cancer medicines are not covered by CBHI and are neither available nor affordable to every patient with cancer in Rwanda. This exposes many patients to financial hardships, and/or inferior survival outcomes for those who cannot afford effective treatments. In addition, due to scarcity of cancer centers in the country, many patients travel long distances to access cancer services hence enduring financial burden due to indirect cost. In a recent study by Fadelu et al showed that 13%, 41%, and 85% of Rwandans can access cancer centers within 1, 2, and 4 hours of travel, respectively.15 The same study also shows that some provinces in Rwanda have no access to cancer centers, hence patients have to travel long distances to other get diagnosed and treated for cancer in other provinces.
In this paper, we explored the financial toxicity of cancer care in Rwanda. This study aimed to inform policy within Rwanda’s health system and other LMICs.
Methods
Study Design and Sites
This prospective cross-sectional study was conducted at the 3 referral hospitals that treat patients with either radiotherapy or systemic therapy in Rwanda. These include Butaro Cancer Centre of Excellence (BCCOE), King Faisal Hospital (KFH), and Rwanda Military Hospital (RMH). While the others are entirely public institutions, KFH functions as a public-private entity. Rwanda Military, King Faisal, and Kigali University Teaching Hospitals are found in the capital city of Kigali; BCCOE is situated outside of the city in the Northern Province. Travel time from Kigali to BCCOE can take up to 3-4 hours by bus. Only Butaro Cancer Center of Excellence (BCCOE) provide some systemic therapy free of charge. At KFH and RMH patients without insurances including CBHI have to pay out-of-pocket for systemic therapy. However, at RMH, other systemic therapy infusion consumables such as presystemic therapy drugs, infusion fluids are covered CBHI, only cancer drugs are not. The data were gathered over the course of 6 months, from June to December 2022, by a group of trained research assistants. The Rwanda National Ethics Committee approved this study.
Study Population
The eligibility criteria were as follows: female and male patients aged over 18 years with available medical records, diagnosis of any of the following cancers; breast, cervix, colorectal, Hodgkin’s, and non-Hodgkin’s lymphoma. Eligible patients were those treated at one of the 3 sites between June and December 2022 and who had received at least 3 cycles of systemic therapy.
Data Collection
Consecutive eligible patients were interviewed using a modified validated questionnaire specifically targeting potential sources of financial burden among patients with a cancer diagnosis.16 The tool was adapted from survey in Nepalese patients with acute leukemia. Three core questions identified significant financial toxicity: (1) whether patients asked for charity from public or relatives for their cancer care; (2) whether they borrowed money with interests from friends and relatives; or (3) whether they sold their properties to fund their cancer treatment. Questions about possible indirect cost of care, such as amount of money used for transportation, food, accommodation, or out-of-pocket expenditure for treatment other than systemic therapy were also included. Detailed review of charts of these patients was also done. The extracted information included: basic demographic data (age, gender, and residence), type of insurance used, cancer type/disease site, stage, treatment setting, and intent (whether neoadjuvant, adjuvant, palliative, or definitive). We piloted the data capture tool on 15 patients; no modifications were needed, hence, these patients are included in the final study sample. Regular quality checks were conducted by the study principal investigator to ensure data quality and to identify any errors or inconsistencies.
Data Analysis
Data were collected in Qualtrics and exported into IBM SPSS (version 27.0 for Windows, Armonk, New York, 2022) for statistical analysis. Data were analyzed using descriptive statistics, including frequencies and percentages for categorical data; means (standard deviations) or medians (quartiles) for continuous data; Pearson chi-square tests, the Fisher’s Exact test or the Fisher-Freeman-Halton Exact test (depending on cell size and number of categories) were utilized for assessing associations between pairs of variables. A P-value of < .05 was considered to be statistically significant; no adjustment was made for multiple comparisons in this primarily descriptive study.
Results
Patient Demographics
Two hundred and thirty-nine patients were included in this study; characteristics of the study cohort are shown in Table 1. The mean age was 51 (SD ± 12) years, and the majority (75%) were female. About one-quarter (24%, n = 57) resided in the southern province. Seventy-four percent of patients (n = 176) used the community-based health insurance (CBHI) and the remaining used private insurances. Among the study cohort, Butaro Cancer Centre treated the most patients (45%, n = 107) followed by Rwanda Military Hospital (42%, n = 101).
Table 1.
Demographics and patients’ characteristics patients with cancer treated with systemic therapy in Rwanda (n = 239) during 2022.
| Gender | N (%) |
| Female | 180(75) |
| Male | 58(24) |
| Missing | 1(0) |
| Hospitals | N (%) |
| Rwanda Military Hospital | 101(42) |
| King Faisal Hospital | 31(13) |
| Butaro | 107(45 |
| Insurance | N (%) |
| CBHI | 176(74) |
| RSSB | 31(13) |
| MMI | 9(4) |
| Others | 23(0) |
| Province of residence | N (%) |
| East | 47(20) |
| West | 44(18) |
| South | 57(24) |
| North | 39(16.3) |
| Kigali | 51(21) |
| Missing | 1(0) |
Abbreviations: RSSB: Rwanda Social Security Board; MMI: Military Medical Insurance; CBHI: Community Based Health Insurance.
Disease and Treatment Characteristics
As shown in Table 2, the most common cancers in the cohort were breast (42%, n = 100) breast, cervix (24%, n = 58), and colorectal (24%, n = 57). Among those with available staging data, half of patients (54%, n = 129) were diagnosed with advanced stage disease; 39% (n = 92) with stage III and 16% (n = 37) with stage IV. Stage was unavailable for 26% (n = 63) of patients. Most patients (41%, 98/239) were treated in adjuvant settings, neoadjuvant was 24% (n = 57/239), 5% (n = 12/239) got definitive systemic therapy, 2% (n = 4/239) got induction/temporalizing systemic therapy, while 25% (n = 59/239) were treated as palliative.
Table 2.
Disease and treatment characteristics of patients with cancer treated with systemic therapy in Rwanda (n = 239) during 2022.
| Disease site | N (%) |
| Breast | 100 (42) |
| Colorectal | 57(24) |
| Cervical | 58(24) |
| Hodgkin’s lymphoma | 13(5) |
| Non-Hodgkin’s lymphoma | 11(5) |
| Stage of the disease | N (%) |
| Stage I | 5(2) |
| Stage II | 36(15) |
| Stage III | 92(39) |
| Stage IV | 37(16) |
| Not mentioned | 63(26) |
| Missing | 6(3) |
| Treatment setting/intent | N (%) |
| Neo adjuvant | 57(24) |
| Adjuvant | 98(41) |
| Palliative | 59(25) |
| Definitive (eg, lymphoma) | 12(5) |
| Temporalizing chemo (eg, Cervix, NPC) | 4(2) |
| Missing | 9(4) |
Financial Burden of Cancer Treatment
A substantial proportion of patients suffered significant financial toxicity to fund their treatment costs (Table 3). Close to a third (29%, n = 70) of respondents asked for charity from the public, friends or families, 16% (n = 37) took loans with interest from friends or relatives, and 44% (n = 106) sold property to fund their cancer treatment. Forty-seven percent (n = 113) of respondents used other means to pay for care including: using their savings, selling crops, donations from friends, and family contributions. Table 4 shows the different expenses categories incurred by patients for food, transportation, and accommodation during treatment cycles. There was a significant proportion of patients that used above 10 USD every cycle 50% (n = 120/239) for transport, 19% (n = 46/239) for accommodation, 18% (n = 43/239) for food, and 26% (n = 63/239) for the out-of-pocket expenses for treatment (Table 5).
Table 3.
Financial toxicity of patients with cancer treated with systemic therapy in Rwanda (n = 239) during 2022.
| Financial Toxicity Categories | N (%) |
| Have you asked for charity from public to fund your cancer treatment? | 70 (29) |
| Have you borrowed loans subject to interest from friends or relatives to fund your cancer treatment? | 37 (16) |
| Have you sold a property as a last resort (land, house, livestock, etc) to fund your cancer treatment? | 106 (44) |
| Other means of funding cancer treatment | 113 (47) |
Table 4.
Indirect costs incurred by patients treated with systemic therapy in Rwanda (n = 239) during 2022.
| Amount Spent | Accommodation | Transport | Food | Out of pocket on treatment each cycle |
|---|---|---|---|---|
| USD | N (%) | N (%) | N (%) | N (%) |
| <$5 | 3 (1) | 26 (11) | 93 (39) | 53 (22) |
| ~$5-10 | 35 (15) | 92 (39) | 99 (41) | 68 (29) |
| ~$10-20 | 38 (16) | 83 (35) | 35 (15) | 41 (17) |
| ~$20-30 | 6 (3) | 28 (12) | 5 (2) | 10 (4) |
| ~$30-40 | 1 (0) | 8 (3) | 2 (1) | 6 (3) |
| ~$50-60 | 1 (0) | 0 (0) | 1 (0) | 6 (3) |
| ~$60-80 | 0 (0) | 0 (0) | 0 (0) | 27 (11) |
| Others | 21 (9) | 1 (0) | 2 (1) | 24 (10) |
| Not needed | 131 (55) | 0 (0) | 2 (1) | 1 (0) |
| Missing | 3 (1) | 1 (0) | 0 (0) | 3 (1) |
Table 5.
Expenditure on transportation by hospitals by patients with cancer treated with systemic therapy in Rwanda (n = 239) during 2022.
| Expenditure on transportation each cycle in USD | Hospital | |||
|---|---|---|---|---|
| RMH N (%) |
KFH N (%) |
Butaro N (%) |
Total N (%) |
|
| ~<$5 | 16 (16.0) | 2 (6.7) | 8 (7.5) | 26 (11.0) |
| ~$5-10 | 45 (45.0) | 12 (40.0) | 35 (32.7) | 92 (38.8) |
| ~$10-20 | 31 (31.0) | 11 (36.7) | 41 (38.3) | 83 (35.0) |
| ~$20-30 | 7 (7.0) | 4 (13.3) | 17 (15.9) | 28 (11.8) |
| ~$30-40 | 1 (1.0) | 1 (3.3) | 6 (5.6) | 8 (3.4) |
| Total | 100 | 30 | 107 | 237 |
P = .082, Fisher-Freeman-Halton Exact test.
Factors Associated With Financial Toxicity
As shown in Table 6, there is significant variations in financial toxicity across different factors such as hospitals, insurance status, and cancer types. Butaro Hospital had the highest financial toxicity, as indicated by the highest proportions of patients seeking charity, borrowing loans, and selling property for cancer treatment. Patients insured by CBHI also experienced higher financial toxicity compared to those with other types of insurance. Patients with breast cancer had the highest rates of financial toxicity. No statistically significant relationship was found between gender and any of the financial burden factors.
Table 6.
Financial toxicities by hospital, insurance type, and disease site of patients with cancer treated with systemic therapy in Rwanda (n = 239) during 2022.
| Financial Toxicity categories | Asking for charity | Borrowing loans with interest | Selling property |
|---|---|---|---|
| Hospitals | |||
| Butaro | 93% (65/70) | 92% (34/37) | 58% (62/106) |
| RMH | 4% (3/70) | 0% (0/37) | 0% (0/37) |
| KFH | 3% (2/70) | 8% (3/37) | 2% (2/106) |
| Insurance | |||
| CBHI | 90% (63/70) | 87% (32/37) | 92% (97/106) |
| Others | 10% (7/70) | 13% (5/37) | 8% (9/106) |
| Cancer type | |||
| Breast | 70% (49/70) | 84% (31/37) | 44% (47/106) |
| Colorectal | 21% (15/70) | 8% (3/37) | 18% (19/106) |
| Cervical | 4% (3/70) | 3% (1/37) | 26% (28/106) |
| HL | 0% (0/70) | 3% (1/37) | 4% (4/106) |
| NHL | 4% (3/70) | 3% (1/37) | 3% (1/37) |
Abbreviations: HL: Hodgkin’s lymphoma; NHL: Non-Hodgkin’s lymphoma.
Discussion
The present study aimed to explore the financial burden experienced by patients treated with systemic therapy in Rwanda. Five major findings were identified: (1) a substantial proportion of patients experience significant financial toxicity associated with systemic therapy treatment for cancer; (2) patients resort to a variety of means to fund their treatment costs; (3) out-of-pocket indirect costs for transportation, accommodation, and food are significant; and (4) insurance type, cancer type, length of treatment, and hospital, where patients are treated were associated with different levels of financial toxicity.
These findings of FT experienced by patients with cancer undergoing systemic therapy in Rwanda are particularly significant when considering the context of the average monthly income of an average Rwandan. As of 2022, the estimated monthly income for an average Rwandan was $183 USD.11 It becomes apparent that the financial burden associated with cancer treatment is substantial when compared to the average income. The findings of the present study are consistent with previous studies that highlight the financial burden experienced by patients with cancer in LMICs.17 A scoping review of cancer treatment-related financial toxicity experienced by patients in LMICs shows that many patients encounter various hardships such as negative psychological responses, and it also showed that financial toxicity is linked to lack of good insurance coverage and lower socioeconomic status which are common in many African countries.18 A recent systematic review and meta-analysis found a pooled prevalence of objective financial toxicity of 57% among patients with cancer diagnosis in LMICs.19 The present study found that patients with cancer in Rwanda resort to different means to finance their treatment, such as selling their properties or borrowing loans with interest. This is consistent with studies conducted in other LMICs, where patients with cancer are more likely to experience FT of varying levels due to the high cost of cancer treatment.
Rates of financial toxicities do not compare to those found by Poudyal et al, who found that 94% of Nepalese patients ask for charity compared to 29% in our study, 88% borrowed loans from friends or relatives compared to 16% while 87% of their cohort sold their properties to fund their cancer treatment compared to 44% in our cohort.16 This can be explained by the fact that over 90% of Rwanda population is covered by CBHI and also systemic therapy drugs are given free of charge at Butaro Cancer Center of Excellence which treats a large proportion of patients.12 Also, 25% of patients in the Nepalese study were children, and this can influence parents willingness to pay and the extent of debt that they are willing to take on.
The present study adds to the existing literature by identifying the specific factors associated with financial toxicity in Rwanda, such as insurance type, cancer type, and hospital. The full costs and enduring impact of cancer diagnosis and treatment on patients, families, and the community at large are far-reaching and immense in scale.20 Financial toxicities from direct and indirect cost of cancer care affects both the insured and non-insured patients with cancer. It is well established that FT is associated with immediate and long-term consequences including treatment non adherence, decreased health-related quality of life, bankruptcy, selling possessions, withdrawing savings, reduced leisure activities, and an increased risk of mortality.20 Assessment of the FT of cancer care in LMICs showed that FT is prevalent and higher among patients with cancer with household size of more than 4 people.19 Recent work from India and Nepal has found that FT is associated with poor quality of life and noncompliance with treatment.16
Two major findings deserve further discussion. First, Butaro Cancer Centre treated the most patients, and a significant proportion of patients who sought charity and borrowed loans with interest were treated at Butaro. This may be due to the fact that Butaro Cancer Center offers systemic therapy free of charge and attracts many patients who would otherwise not afford cancer medicine privately. However, given that this center is in a rural and remote area, patients spend significantly on transportation. A study by Fadelu et al showed that 13%, 41%, and 85% of Rwandans access cancer centers within 1, 2, and 4 hours of travel respectively. Second, insurance type was found to be associated with financial toxicity, with patients insured by CBHI being more likely to experience financial difficulties. In addition, as of 2023, not all cancers, and not all the lines of treatment are offered in Butaro, leaving a group of CBHI-insured patients with cancers needing systemic therapy having to pay the full amount of systemic therapy. These findings suggests that the current insurance policies in Rwanda may not be sufficient to cover the high cost of cancer treatment.
This study has important policy implications. The flat charge of 10% for CBHI members is prohibitive when it comes to cancer care. For example, as per local experience, the 10% of conventional fractionation of radiotherapy for locally advanced prostate cancer is ~$200 USD which is not affordable by many Rwandese. The findings highlight the need for policymakers to develop strategies to reduce the financial burden experienced by patients with cancer in Rwanda. Possible strategies include the development of more comprehensive insurance policies that cover the cost of cancer treatment, the establishment of a national cancer fund, and the provision of financial support for patients with cancer who cannot afford treatment. In addition, there is a need to decentralize cancer care especially in provincial hospitals closer to patients so that they spend more on transport, accommodation, and food.
This study has limitations. First, the study was conducted in a single country, and the findings may not be generalizable to other countries. Second, the study relied on self-reported data, which may be subject to bias. Third, the study did not collect data on the socioeconomic status of patients, which may have influenced their ability to finance their treatment. Fourth, our study likely underestimates the true impact of FT on cancer care in Rwanda, as we only included patients who received systemic therapy, yet some patients may have not received systemic therapy due to the major costs associated with pursuing care. Moreover, this study only included those patients who had the means to seek diagnosis and treatment for their cancer. Accordingly, the extent of financial challenges identified in this study are likely to significantly underestimate the problem. Finally, our study did not explore other potential sources of financial toxicities such as difficulties in maintaining employment due to the physical and emotional toll of the disease and its treatment, reduced productivity, and expenses related to other elements of care including surgery and diagnostic imaging. Despite these limitations, the present study provides valuable insights into the financial burden experienced by patients with cancer in Rwanda and identifies areas for future research.
Conclusions
In conclusion, this study highlights the significant financial burden faced by patients with cancer in Rwanda and its associated factors. The findings underscore the need for policymakers to develop strategies to reduce the financial burden of cancer treatment and ensure equitable access to health insurance. Future research should explore the psychological and emotional impact of financial toxicity experienced by patients with cancer and examine the effectiveness of different financing mechanisms in reducing the financial burden of cancer treatment in LMICs.
Acknowledgments
We acknowledge the patients who contributed to this research.
Contributor Information
Fidel Rubagumya, Department of Oncology, Rwanda Military Hospital, Kicukiro, Kigali, Rwanda; Department of Oncology, Research for Development (RD), Gasabo, Kigali, Rwanda; Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, Ontario, Canada; Departments of Oncology, Queen’s University, Kingston, Ontario, Canada; Department of Oncology, Dartmouth Cancer Center, Lebanon, NH, USA.
Brooke Wilson, Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, Ontario, Canada; Departments of Oncology, Queen’s University, Kingston, Ontario, Canada; University of Sydney, School of Public Health, Sydney, NSW, Australia.
Achille Manirakiza, Oncology Unit, Department of Medicine, King Faisal Hospital, Gasabo, Kigali, Rwanda.
Emmanuel Mutabazi, Department of Oncology, Rwanda Military Hospital, Kicukiro, Kigali, Rwanda.
Diane A. Ndoli, Department of Oncology, Rwanda Military Hospital, Kicukiro, Kigali, Rwanda.
Emmanuel Rudakemwa, Department of Oncology, Rwanda Military Hospital, Kicukiro, Kigali, Rwanda.
Mary D Chamberlin, Department of Oncology, Dartmouth Cancer Center, Lebanon, NH, USA.
Wilma M Hopman, Department of Oncology, Kingston Health Sciences, Kingston, Ontario, Canada.
Christopher M Booth, Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, Ontario, Canada; Departments of Oncology, Queen’s University, Kingston, Ontario, Canada.
Funding
None declared.
Conflict of Interest
The authors indicated no financial relationships.
Author Contributions
F.R.: Conception/design, provision of study material or patients, collection and/or assembly of data, data analysis and interpretation, manuscript writing, final approval of manuscript. B.W.: Data analysis and interpretation, manuscript writing, final approval of manuscript. A.M.: Data analysis and interpretation, manuscript writing, final approval of manuscript. E.M.: Manuscript writing, final approval of manuscript. D.A.N.: Manuscript writing, final approval of manuscript. E.R.: Manuscript writing, final approval of manuscript. M.D.C.: Manuscript writing, final approval of manuscript. W.M.H.: Data analysis and interpretation, manuscript writing, final approval of manuscript. C.M.B.: Conception/design, provision of study material or patients, collection and/or assembly of data, data analysis and interpretation, manuscript writing, final approval of manuscript.
Data Availability
The data will be shared on reasonable request to the corresponding author.
References
- 1. Rubagumya F, Costas-Chavarri A, Manirakiza A, et al. State of cancer control in rwanda: past, present, and future opportunities. JCO Glob Oncol. 2020;6(6):1171-1177. 10.1200/GO.20.00281 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Torre LA, Siegel RL, Ward EM, Jemal A.. Global cancer incidence and mortality rates and trends - an update. Cancer Epidemiol Biomarkers Prev. 2016;25(1):16-27. 10.1158/1055-9965.EPI-15-0578 [DOI] [PubMed] [Google Scholar]
- 3. Roy R, Singh SK, Misra S.. Advancements in cancer immunotherapies. Vaccines. 2023;11(1):Art. no. 1. 10.3390/vaccines11010059 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Manjali JJ, Krishnatry R, Palta JR, Agarwal J.. Quality and safety with technological advancements in radiotherapy: an overview and journey narrative from a low- and middle-income country institution. JCO Glob Oncol. 2022;8(8):e2100367. 10.1200/GO.21.00367 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Zeng C, Wen W, Morgans AK, et al. Disparities by race, age, and sex in the improvement of survival for major cancers: results from the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program in the United States, 1990 to 2010. JAMA Oncol. 2015;1(1):88-96. 10.1001/jamaoncol.2014.161 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Witte J, Mehlis K, Surmann B, et al. Methods for measuring financial toxicity after cancer diagnosis and treatment: a systematic review and its implications. Ann Oncol. 2019;30(7):1061-1070. 10.1093/annonc/mdz140 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Nipp RD, Shui A, Kirchhoff AC, et al. Financial burden in adult cancer survivors: care affordability and accessibility. J Clin Oncol. 2016;34(15_suppl):6535-6535. 10.1200/jco.2016.34.15_suppl.6535 [DOI] [Google Scholar]
- 8. Barrios C, de Lima Lopes G., Yusof MM, et al. Barriers in access to oncology drugs — a global crisis. Nat Rev Clin Oncol. 2023;20(1):Art. no. 1. 10.1038/s41571-022-00700-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. De Souza JA, Yap BJ, Hlubocky FJ, et al. The development of a financial toxicity patient‐reported outcome in cancer: the COST measure. Cancer. 2014;120(20):3245-3253. 10.1002/cncr.28814 [DOI] [PubMed] [Google Scholar]
- 10. Fifth Population and Housing Census – 2022. National Institute of Statistics Rwanda. https://www.statistics.gov.rw/datasource/171 (accessed March 7, 2023).
- 11. The Anker Living Wage and Income Research Institute. Living Income Reference Value - Rural Rwanda Global Living Wage Coalition. https://www.globallivingwage.org/living-income-reference-value-rural-rwanda/ (accessed June 8, 2023). [Google Scholar]
- 12. Rubagumya F, Costas-Chavarri A, Manirakiza A, et al. State of cancer control in rwanda: past, present, and future opportunities. JCO Glob Oncol. 2020;6(6):1171-1177. 10.1200/GO.20.00281 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Mpunga T, Tapela N, Hedt-Gauthier BL, et al. Diagnosis of cancer in rural rwanda: early outcomes of a phased approach to implement anatomic pathology services in resource-limited settings. Am J Clin Pathol. 2014;142(4):541-545. 10.1309/AJCPYPDES6Z8ELEY [DOI] [PubMed] [Google Scholar]
- 14. World Health Organization - Rwanda. Rwanda: the beacon of Universal Health Coverage in Africa. WHO; Regional Office for Africa. https://www.afro.who.int/news/rwanda-beacon-universal-health-coverage-africa (accessed April 18, 2023). [Google Scholar]
- 15. Fadelu T, Nadella P, Iyer HS, et al. Toward equitable access to tertiary cancer care in rwanda: a geospatial analysis. JCO Global Oncol. 2022;8:e2100395. 10.1200/GO.21.00395 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16. Poudyal BS, Giri S, Tuladhar S, Neupane S, Gyawali B.. A survey in Nepalese patients with acute leukaemia: a starting point for defining financial toxicity of cancer care in low-income and middle-income countries. Lancet Haematol. 2020:7(9):e638-e639. [DOI] [PubMed] [Google Scholar]
- 17. Ngan TT, Van Minh H, Donnelly M, O’Neill C.. Financial toxicity due to breast cancer treatment in low- and middle-income countries: evidence from Vietnam. Support Care Cancer. 2021;29(11):6325-6333. 10.1007/s00520-021-06210-z [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18. Udayakumar S, Solomon E, Isaranuwatchai W, et al. Cancer treatment-related financial toxicity experienced by patients in low- and middle-income countries: a scoping review. Support Care Cancer. 2022;30(8):6463-6471. 10.1007/s00520-022-06952-4 [DOI] [PubMed] [Google Scholar]
- 19. Donkor A, Atuwo-Ampoh VD, Yakanu F, et al. Financial toxicity of cancer care in low- and middle-income countries: a systematic review and meta-analysis. Support Care Cancer. 2022;30(9):7159-7190. 10.1007/s00520-022-07044-z [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20. Arastu A, Patel A, Mohile SG, et al. Assessment of financial toxicity among older adults with advanced cancer. JAMA Netw Open 2020;3(12):e2025810. 10.1001/jamanetworkopen.2020.25810 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data will be shared on reasonable request to the corresponding author.