Feasibility of Decentralized Cervical Cancer Survivorship Care at District Hospitals in Rwanda: A Multi-Site Pilot Implementation Study

BACKGROUND: Cervical 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. METHODS: This prospective, mixed-methods, multi-site pilot study enrolled 12 cervical cancer survivors at four 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 AIM/IAM; clinician feasibility using 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. CFIR-informed interviews explored contextual determinants. RESULTS: Twelve women were enrolled, with median age 69 years (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% 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%. CONCLUSION: District-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.