Alan Waxman, MD
Alan Waxman, MD
Obstetrics & Gynecology · Albuquerque, NM

Cervical Cancer Prevention in Rwanda

May 4th
Kigali, Rwanda

Project Description

This is part of an ongoing multi-pronged project in collaboration with the University of Rwanda to ramp up cervical cancer screening in Kigali, the capital city. Completed components have included a virtual training course for Rwandan ob/gyn residents in conjunction with MD Anderson Cancer Center in 2020 and an in person hands-on training session in conjunction with Worldwide Healing Hands in 2021. The next step will be on-site training and capacity building in cervical cancer screening at CHUK, the main teaching hospital in Kigali and the smaller Kibagabaga district hospital that will feed patients to CHUK for higher levels of care. The mission will take place May 5 – 19, 2022. The coordinating NGO is the International Organization for Women and Development (IOWD). This project will help establish a culture of screening to prevent cervical cancer, train nurses and healthcare providers to implement HPV testing and visual inspection with acetic acid, and further train resident physicians and nurse providers in treatment of preinvasive lesions.

Population Served

More Rwandan women die from cervical cancer than any other malignancy. The incidence, at 28.2 per 100,000 population is higher than the African continent in general. Rwanda has had a global vaccination program against HPV for 12 year old girls since 2013, but logistic logjams and Covid-19 have prevented implementation of widespread screening. By training local healthcare providers and helping to develop an ongoing screening program and establish a culture of screening, this project will benefit Rwandan women over 21, age cohorts not vaccinated against HPV. This phase of the program will take place in one district of Kigali, but will seed future programs in other district hospitals and ultimately outside of the capital city to benefit women nationwide.

Expected Impact

The impact of this mission will be to leave in place an ongoing cervical cancer screening program in Kibagabaga with an appropriate follow-up referral system at CHUK, where in addition to gynecology residents, a gyn oncology fellowship is starting. IOWD has a several year history of missions to Rwanda training local physicians in fistula repair and other gynecologic procedures. Follow-up missions are currently planned to continue this cervical cancer prevention project with development at districts beyond Kibagabaga. In addition, monthly virtual Project ECHO teleconferences were started in July 2021 as part of this project between women’s health experts in the U.S. and residents and faculty from the University of Rwanda. They are ongoing under the sponsorship of the Gynecologic Oncology Division of Brown University School of Medicine.

Trip Photos & Recap

I have been privileged to be a part of an ongoing effort to increase cervical cancer screening in Rwanda. This project, under the auspices of the Ob/gyn Department of the University of Rwanda began in 2020 with a virtual colposcopy course sponsored by the MD Anderson Cancer Center. With the help of the Doximity Foundation, I was able to visit Kigali for the initial in-person training the following year. On May 7, 2022, we continued our work with additional teaching and screening with volunteers from ASCCP and the International Organization for Development and Women (IOWD). The cervical cancer prevention team is now under the leadership of gynecologic oncologists from Brown University and the Cleveland Clinic. Dr. Laura Fry, and Ms. Helene Gross CNM and I represented ASCCP. Our objective was to lay the groundwork for a cervical cancer screening program at the Kibagabaga District Hospital in Kigali. We taught and worked alongside medical students and Ob/gyn residents from the University of Rwanda.
My role was threefold: 1) to develop and coordinate a didactic program of lectures, case presentations and hands-on simulation to train residents and students in the epidemiology of cervical cancer in Rwanda, the role of human papillomavirus, and screening and treatment modalities for cervical pre-cancer. 2) to join the IOWD team in screening patients for cervical cancer and pre-cancer using VIA (visual inspection with acetic acid) in a screen and treat regimen, and 3) to help train attending gynecologists in colposcopy and LEEP.
The didactic session was attended by 16 Ob/gyn residents from the University of Rwanda. It was carried out in two half day sessions. I developed the curriculum; lectures, simulations, and video clips were given by two faculty members from U. of Rwanda plus two of the IOWD volunteers and myself.
At the start of our week of screening at the Kibagabaga Hospital, we were greeted by a crowd of local women treating us to a welcoming dance. This was very moving. In the course of the week, over 100 women were screened and 10 cancers were diagnosed and referred for treatment. While most of the screenings were negative a few had features of pre-cancer requiring treatment with either thermal ablation or LEEP. These were performed either on site or referred to CHUK for care.
Helping to establish a culture of screening and the infrastructure to implement it will not happen overnight, but small steps were taken with this and our previous trip to Kigali. Plans are being made by IOWD, Brown University Gyn Oncology Division, and the U. of Rwanda Ob/gyn Dept. for a follow-up trip in October to further consolidate the foundation we have laid for a screening program and to expand screening to additional clinics. I am grateful to Doximity Foundation for their assistance in helping me to participate in this important project.