A few weeks ago, a friend in the United States reached out to me about her sister in Rwanda, a woman in her 40s with no history of smoking. Her chest pain had progressively worsened to the point of becoming unbearable. CT imaging revealed a concerning lung mass highly suggestive of malignancy. One sentence in her medical report stood out: “PET-CT is not available locally”.
The uncertainty surrounding her case was striking. Persistent chest pain required escalating pain management, and imaging raised significant concern for malignancy. Yet a definitive diagnosis remained elusive. The location of the mass made biopsy particularly challenging, complicating efforts to obtain tissue confirmation and clarify the extent of disease. Questions about staging remained unanswered, and a critical diagnostic tool, PET-CT, was simply unavailable.
Regine Nshimiyimana Maniraho, DNP, BPharm, AOCNP
Her experience reflects a broader reality faced by many patients across low-resource settings, where the fear of cancer is compounded by the uncertainty of incomplete diagnosis. What happens when modern oncology depends on tools that entire health systems do not yet have? How many patients are treated too late, treated empirically, or never staged accurately because advanced imaging remains inaccessible?
Access to Screening Tools Remains Deeply Unequal
We are living in an era of molecular oncology, immunotherapy, precision medicine, and biomarker-driven care. Yet as oncology advances at remarkable speed, many clinicians and patients around the world still struggle to access the foundational diagnostic infrastructure required before treatment can even begin. Access to staging tools remains deeply unequal, despite the reality that precision medicine depends first on answering a more fundamental question: What exactly are we treating, and how far has it spread?
PET imaging is not necessary for every pulmonary nodule or incidental lung finding. In many cases, CT imaging, clinical judgment, and surveillance remain appropriate. However, when suspicion for malignancy is high, particularly if imaging suggests regional or metastatic spread and biopsy or staging remains uncertain, PET can meaningfully influence care decisions.1,2
In suspected lung cancer, PET may help identify occult metastatic disease, distinguish localized from advanced disease, guide biopsy to the most accessible or diagnostically informative site, and improve treatment planning while potentially avoiding unnecessary invasive procedures or futile surgery. Without accurate staging, clinicians may be forced to make decisions with incomplete information, risking delays in care, empiric management, or missed opportunities for potentially curative intervention.
Cancer Control Cannot End With Prevention Alone
Rwanda has demonstrated what is possible through investment in cancer prevention, particularly in cervical cancer through HPV vaccination and community-based public health efforts.3 These achievements underscore what sustained, community-centered cancer strategies can accomplish. Yet cancer control cannot end with prevention alone.
A strong cancer system depends not only on preventing disease, but also on ensuring timely diagnosis and accurate staging for patients with suspected malignancy. The cancer care continuum includes prevention, early detection, diagnosis, staging, treatment, and survivorship.
Importantly, limited access to PET-CT is not unique to Rwanda.4 Across many low- and middle-income countries, advanced imaging remains concentrated in a small number of urban centers or is unavailable altogether. Even in high-income countries, disparities in access and variation in care persist. The issue is not universal use of advanced imaging, but equitable and appropriate access when diagnostic uncertainty could meaningfully alter management.
Technology alone will not solve this problem. Sustainable access requires coordinated systems, partnerships, and implementation strategies tailored to local realities. Regional diagnostic hubs shared across neighboring countries may offer one pathway forward, while public-private partnerships involving governments, academic institutions, and industry could help strengthen imaging infrastructure and workforce capacity. Structured referral pathways for time-sensitive oncology imaging, supported by twinning models, radiology partnerships, and tele-oncology collaboration, may help bridge diagnostic gaps as local capacity grows. Context-specific diagnostic guidelines for low-resource settings could further support equitable and efficient care.
Navigating Cancer in Settings of Diagnostic Uncertainty
Important questions remain: When is PET imaging essential? When can CT imaging suffice? How should clinicians triage limited resources in settings where diagnostic capacity is constrained? Evidence-informed algorithms adapted to resource-limited environments may help guide decision-making while advancing both equity and stewardship.
For one woman in her 40s in Rwanda, answers remain uncertain. But her experience reflects that of many patients navigating cancer in settings where diagnostic uncertainty becomes part of the disease itself.
In oncology, timing matters. But timing depends on diagnosis, and diagnosis depends on access. For too many patients in low-resource settings, cancer is not only a disease of biology, but also a disease of delayed certainty.
A former pharmacist in Rwanda, Dr. Nshimiyimana Maniraho is currently an oncology nurse practitioner and PhD student in Population Health Science at Thomas Jefferson University, Philadelphia.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.
DISCLOSURE: Dr. Nshimiyimana Maniraho reported no conflicts of interest.
REFERENCES
1. Chakrabarty N, Mahajan A, Shetty N, et al: Imaging patterns and recommendations for diagnosis, staging, and management of lung cancer. BJR Open 7:tzaf013, 2025.
2. Jadvar H, Atkins MB, Bartel T, et al: Summary: Appropriate use criteria for 18F-FDG PET/CT for initial staging of malignant disease. J Nucl Med 66:1034-1038, 2025.
3. Nshimiyimana Maniraho R: Rwanda’s vision for increasing cervical cancer prevention one village at a time. Available at www.ascopost.com/issues/june-25-2023.
4. Gallach M, Mikhail Lette M, Abdel-Wahab M, et al: Addressing Global pnequities in positron emission tomography-computed tomography (PET-CT) for cancer management: A statistical model to guide strategic planning. Med Sci Monit 26:e926544, 2020.
