Partners In Health Generalist/Specialist Twinning: A Health Delivery Model Used in Treating Childhood Lymphoma in Rural Rwanda,

Abstract 4222

In the developed world approximately 80% of children with lymphoma can be cured. As global health initiatives have broadened to address noncommunicable diseases the approach to cancer care for children in resource poor settings becomes of increasing concern. Traditional models of tertiary care provision will not be applicable as there is not an adequate number of existing pediatricians subspecializing in oncology to provide for the world's children. At Rwinkwavu, a Partners In Health (PIH) supported government district hospital in rural Rwanda, a small cohort of children with lymphoma have received therapy over the past 4 years using a unique approach to care delivery. Each case is managed by a team consisting of a Rwandan physician with no specialty training, a Rwandan nurse coordinator focused on oncology patients, a Rwanda-based US trained pediatrician and a US- based pediatric oncologist. Biopsies and radiologic staging studies were obtained in Rwanda but all pathologic diagnoses were made at Brigham and Women's Hospital, a Harvard teaching hospital, through a formal arrangement. A treatment plan for each patient was formulated with the consulting pediatric oncologist and a road map was generated. Chemotherapy was administered by nurses in the Rwinkwavu pediatric ward under the daily supervision of the local generalist and with the support of the pediatrician. Blood counts and broad spectrum antibiotics were available but blood cultures could not be performed. If radiation therapy was required patients were transported to Uganda for the treatments. Ten patients aged 3–15 (median age 9.5 years) have been treated using this approach. 5 (50%) have completed therapy - Hodgkin's Disease (HD) n =2, HIV-associated large cell lymphoma (HIV LCL) n =2, Burkitt's Lymphoma (BL) n=1. They received either CHOP (cyclophosphamide, adriamycin, vincristine, prednisone), n=3 or ABVD (adriamycin, bleomycin, vincristine, dacarbazine), n=1; 1 patient with Stage 1 Lymphocyte Predominant HD is being observed without adjuvant therapy after complete surgical excision. All 5 have no evidence of disease recurrence 4 months - 4 years following completion of therapy (median = 14 months). 2 patients are currently on therapy (recurrent HD, HIV LCL) and are in remission. 2 patients succumbed to treatment complications (HD- died from cardiomyopathy, BL- died from transverse myelopathy) and 1 patient (BL) died of progressive disease while receiving chemotherapy. We can not determine the number of pediatric patients with lymphoma who died before a diagnosis was made or before receiving appropriate therapy. In the developing world lymphoma is one of the most common oncologic diseases in children. These data suggest that chemotherapy can be administered with curative intent to a subset of these patients in the setting of a confirmed pathological diagnosis. This approach provides a platform for models of care that rely on local physicians acting in concert with trained consultants from the developed countries to deliver subspeciality care in resource poor settings.