Feasibility of decentralized cervical cancer survivorship care at district hospitals in Rwanda: a multi-site pilot implementation study.

backgroundCervical cancer is the leading cause of cancer death among women in sub-Saharan Africa, yet structured survivorship care remains concentrated in tertiary centers and is often inaccessible to survivors living far from oncology services. Decentralizing follow-up to district hospitals may reduce patient burden and improve continuity of care, but prospective implementation evidence from low- and middle-income country settings remains limited. We evaluated the feasibility, acceptability, fidelity, safety, and patient burden of gynecologist-led district-hospital cervical cancer survivorship follow-up in Rwanda.

methodsThis prospective, mixed-methods, multi-site pilot study enrolled 12 cervical cancer survivors at 4 purposively selected district hospitals. Participants underwent quarterly gynecologist-led follow-up over 12 months. Prespecified implementation outcomes, guided by Proctor's taxonomy, included on-time visit completion within 14 days of the planned date as the primary feasibility metric, with a threshold of ≥80%; clinician and patient acceptability and appropriateness using acceptability of intervention measure (AIM)/ intervention appropriateness measure (IAM); clinician feasibility using feasibility of intervention measure (FIM); and visit-level protocol fidelity assessed by structured chart review. Safety was assessed through clinical record and referral documentation review. Patient travel time and transport costs were compared with self-reported pre-enrollment tertiary-center data. consolidated framework for implementation research-informed interviews explored contextual determinants.

resultsTwelve women were enrolled, with median age 69 years (interquartile range [IQR] 54-72) and FIGO stage II-IVA disease. Of 60 scheduled visits, 51 were completed within the prespecified 14-day window (85.0%; 95% confidence interval [CI] 73.4-92.9), meeting the feasibility threshold. Site-level on-time completion ranged from 66.7% to 93.8%. Acceptability, appropriateness, and feasibility were high among clinicians and patients: clinician AIM 4.5, IAM 4.3, FIM 4.3; patient AIM 4.4 and IAM 4.2, with all respondents scoring ≥4. Visit-level protocol fidelity was low, with median fidelity of 64.2% (IQR 58.9-67.4), and only 4.3% of visits met the ≥85% threshold. No serious adverse events attributable to district-level follow-up were identified under passive surveillance. Median travel time decreased by 75%, and transport costs by 71%.

conclusionDistrict-hospital cervical cancer survivorship follow-up was acceptable, feasible, and reduced patient burden, but fidelity strengthening and prospective safety monitoring are needed before scale-up.