Table 2 Outline of Rwanda national cancer protocols, using breast cancer as an example

• Places evidence-based practices in the context of national resources. Where clinical trials specific to resource-constrained settings have been conducted, associated protocols are applied (e.g. nephroblastoma, acute lymphoblastic leukemia, and Burkitt lymphoma).

• Is organized in a consistent format, with each protocol including subsections on screening, presenting signs and symptoms, pathology-based diagnosis, staging, treatment, and long-term follow up.

• Specifies the minimal essential work-up required to yield accurate, pathology-based diagnosis and inform management decision-making within the treatment options available. At BCCOE, testing for HER2 status is not routinely performed given limited availability of HER2-targeted therapies such as trastuzumab.

• Reflects staging classification that is clinically relevant and in line with treatment options. Three broad classifications/treatment groups for breast cancer are: early, locally advanced and metastatic.

• Takes into account the currently limited availability of radiotherapy. Mastectomy (with level I/II lymph node dissection) is prioritized as surgical treatment of choice over lumpectomy.

• Allows flexibility to address socioeconomic and logistical challenges seen in these settings. Weekly dosing of paclitaxel is employed where possible, however every three weeks dosing is offered given fewer barriers associated with the fewer hospital visits.