Improving outcomes for children with cancer in low-income countries in Latin America: a report on the recent meetings of the Monza International School of Pediatric Hematology/Oncology (MISPHO)-Part I

International Society of Paediatric Oncology (SIOP) Global Mapping Programme: Latin American Society of Pediatric Oncology (SLAOP) country-level report

BACKGROUND

Latin American countries are improving childhood cancer care, showing strong commitment to implement the Global Initiative for Childhood Cancer, but there are scant publications of the situation at a continental level.

METHODS

As part of the International Society of Paediatric Oncology Global Mapping project, delegates of each country participating in the Latin American Society of Pediatric Oncology (SLAOP) and chairs of national pediatric oncology societies and cooperative groups were invited to provide information regarding availability of national pediatric cancer control programs (NPCCP), pediatric oncology laws, pediatric oncology tumor registries, and training programs and support to diagnosis and treatment.

RESULTS

Nineteen of the 20 countries participating in SLAOP responded. National delegates reported nine countries with NPCCP and four of them were launched in the past 5 years. National pediatric tumor registries are available in eight countries, and three provided published survival results. Fellowship programs for training pediatric oncologists are available in 12 countries. National delegates reported that eight countries provide support to most essential diagnosis and treatments and 11 provide partial or minimal support that is supplemented by civil society organizations. Seven countries have a pediatric oncology law. There are three international cooperative groups and four national societies for pediatric oncology.

CONCLUSION

Despite many challenges, there were dramatic advances in survivorship, access to treatment, and availability of NPCCP in Latin America. Countries with highest social development scores in general provide more complete support and are more likely to have NPCCP, training programs, and reported survival results.

Pediatric oncology services in Nepal: A special focus on pharmacy practice

The role of clinical pharmacists or oncology pharmacists in pediatric oncology has been established as important in anticancer regimen review, dose calculation, recommendation, chemocounseling, identification of drug-related problems, its resolution, and, prevention and monitoring of adverse drug reactions within high-income countries. With several hospitals providing pediatric oncology services in Nepal, clinical pharmacist involvement in these hospitals is very poor. Upon reviewing the reputed organization and association focused on pediatric oncology pharmacy practice, it looks imperative for Nepal to initiate clinical pharmacy services which will further help in improving patient health outcomes. As such in this commentary, we try to accentuate the pediatric oncology services and pediatric pharmacy practice within Nepal and try to pinpoint the potential areas for clinical pharmacists to focus if they intend to provide services in pediatric oncology pharmacy practice.

Treatment of high-risk Hodgkin lymphoma with a modified Stanford V regimen in the AHOPCA: Substituting chemotherapy agents and hampered outcomes

BACKGROUND/OBJECTIVES

High-risk Hodgkin lymphoma (HRHL) in children is curable with combined modality therapy. The Association of Pediatric Hematology-Oncology of Central America (AHOPCA) is a consortium of cancer centers from Central America. In 2004, AHOPCA implemented a guideline with a short course of chemotherapy (mStanfordV), strict diagnostics, and radiation guidelines, aimed at reducing abandonment and improving outcomes.

METHODS

Newly diagnosed children less than 18 years of age with high-risk HL (Ann Arbor stages: IIB, IIIB, IV) from AHOPCA centers were staged with chest radiography and ultrasound or computed tomography. Therapy was a modified Stanford V (mStanfordV), substituting cyclophosphamide for mechlorethamine and involved field radiation.

RESULTS

Of 219 patients with HRHL, 181 patients were eligible and evaluable; 146 (81%) were boys, 22% being less than 6 years; 43 were stage IIB, 84 IIIB, and 54 IV. Thirty-one (17%) abandoned therapy, 28 (15%) progressed, 30 (17%) relapsed, and eight (4%) died of toxicity. Radiation guidelines were not followed. Five-year abandonment-sensitive event-free survival and overall survival (AS-EFS, AS-OS ± SE) for the cohort were 46% ± 4% and 56% ± 4%; 5-year AS-OS for stages IIB, IIIB, and IV was 76% ± 7%, 59% ± 7%, and 35% ± 7% (p = .0006).

CONCLUSION

Despite instituting a short treatment guideline, it did not improve the abandonment rate (17%) and did not achieve the reported outcomes of Stanford V. The cyclophosphamide dose used to replace merchlorethamine was inadequate. Despite strict guidelines, the radiation therapy application was inaccurate. Weekly chemotherapy may have adversely affected abandonment of therapy by increasing the burden of travel time. Based on these results, AHOPCA established a new abandonment strategy and a new guideline.

Improving the Quality of the Delivery of Nutritional Care Among Children Undergoing Treatment for Cancer in a Low- and Middle-Income Country

PURPOSE

International twinning programs have been well-established between institutions in childhood cancer and have led to pediatric cancer units in low- and middle-income countries (LMICs) adopting multidisciplinary forms of care. To advance nutritional care in LMICs, the International Initiative for Pediatrics and Nutrition (IIPAN) provided the structural framework and personnel for the delivery of nutritional care. We describe the impact of a newly established nutrition program on the delivery of nutritional care and nutrition-related clinical outcomes in children and adolescents undergoing treatment for cancer in Nicaragua and Honduras.

METHODS

A prospective cohort (N = 126) collected clinical data over a 2-year period. Collection of IIPAN's nutritional services received during treatment and clinical data were abstracted from medical charts and registered in Research Electronic Data Capture (REDCap) database. Chi-square, ANOVA, and generalized linear mixed models were used; P < .05 was considered statistically significant.

RESULTS

Nutritional assessments led to a higher number of patients receiving recommended standard of care. Children classified as underweight during treatment presented higher number of infections and toxicities, length of hospital stay, and days of treatment delays during treatment. Overall, from the start to end of treatment, 32.5% of patients improved nutritional status, 35.7% maintained it, and 17.5% worsened. On the basis of metrics, the cost per consultation was less than 4.80 US dollars (USD; Honduras) and 1.60 USD (Nicaragua).

CONCLUSION

Integration and equitable access of the nutritional care process for all patients needs to be recognized as a component of the basic management in pediatric oncology care. IIPAN's nutritional program demonstrates that nutritional care is economical and feasible in a limited resource setting.

Pediatric cancer outcomes after the implementation of a residential hostel in Tanzania

BACKGROUND

A large survival disparity exists for pediatric cancer patients in low- and middle-income countries compared with high-income countries. A variety of factors contribute to this gap, including late-stage disease at presentation, high rates of abandonment of care, and lack of supportive care infrastructure. A residential hostel was established in Mwanza, Tanzania, to reduce barriers to accessing and maintaining care among patients being treated for childhood cancer at a regional referral hospital. This study examines the effect of the hostel on one-year survival and treatment abandonment for children diagnosed with cancer.

METHODS

Medical records were retrospectively reviewed for all patients presenting from May 2017 to April 2018, following the establishment of a pediatric cancer hostel at the referral hospital. Active follow-up was used to confirm survival data.

RESULTS

There were 149 patients who presented to the referral hospital during the study period with 130 eligible for evaluation. A total of 34% (n = 44) used the hostel services and 66% did not use the hostel (n = 86). Patients who used the hostel did not significantly differ by age, sex, or diagnosis compared with patients who did not use the hostel. Patients who used the hostel had lower treatment abandonment (27% vs 37%) and higher one-year overall survival (47% vs 37%) compared with patients who did not use the hostel.

CONCLUSION

Our findings suggest key supportive programs such as a family hostel may be beneficial for patients with childhood cancer and can improve pediatric cancer treatment outcomes in LMICs.

It Takes a Village

OBJECTIVES

Partnerships between low- to middle-income countries (LMICs) and high-income countries (HICs) is one strategy to mitigate observed health disparities. Cambodia's Angkor Hospital for Children (AHC), an LMIC institution, faces shortages in health care resources, including pathology services. A partnership was created with Children's Wisconsin (CW), an HIC hospital, including provision of pathology services. We describe our established pathology workflow, examine cases seen in AHC patients, and evaluate the impact of CW's interpretations.

METHODS

AHC provides clinical history and impression and ships samples to CW, which processes the samples, and pathologists provide interpretations, sending reports electronically to AHC. For analysis, final diagnoses were considered "concordant," "refined," or "discordant" based on agreement with the clinical impression. Cases were also classified as "did not change management" or "changed management" based on how CW interpretation affected clinical management.

RESULTS

We included 347 specimens (177 malignant, 146 benign, 24 insufficient for diagnosis). Of these cases, 31% were discordant and 44% of cases with clinical follow-up had a change in management with CW interpretation.

CONCLUSIONS

Inclusion of pathology services in LMIC-HIC partnerships is crucial for resolving health disparities between the institutions involved. The described partnership and established pathology workflow can be adapted to the needs and resources of many institutions.

Childhood aggressive B-cell non-Hodgkin lymphoma in low-middle-income countries

In high-income countries (HICs) paediatric aggressive B-cell lymphomas are curable in about 90% of cases. Much worse results, with cure rates ranging from less than 30% to about 70%, are achieved in low- and middle-income countries (LMICs), where 90% of paediatric non-Hodgkin lymphomas occur. Low socio-economic and cultural conditions, the lack of optimal diagnostic procedures, laboratory facilities and adequate supportive care exert a strong negative impact on compliance, treatment delivery, toxicity and, consequently, on the clinical outcome. Published data are scarce, generally originating from single institutions, and are difficult to compare. National and international cooperation projects have been undertaken to reduce the unacceptable gap between HICs and LMICs in the management of children with cancer, by promoting the sharing of knowledge and by implementing adequate local healthcare facilities, with initial promising results. In the present review, we will summarize the results so far obtained in the management of paediatric aggressive B-cell NHL in LMICs.

Childhood acute lymphoblastic leukemia treatment in an academic hospital in Kenya: Treatment outcomes and health-care providers' perspectives

BACKGROUND

Early deaths and treatment nonadherence are major reasons for low childhood acute lymphoblastic leukemia (ALL) survival in low- and middle-income countries. This study assessed treatment outcomes of children presenting with ALL and evaluated perspectives of health-care providers (HCP) on ALL treatment at a Kenyan academic hospital.

METHODS

This was a combined retrospective medical records and cross-sectional questionnaire study. Treatment outcomes of 136 children diagnosed with ALL between 2010 and 2016 were collected. Questionnaires were completed by 245 HCP (response rate, 86%) between September and October 2016.

RESULTS

Childhood ALL treatment outcomes were death (30%), progressive or relapsed disease (26%), abandonment (24%), and event-free survival (20%). Of all deaths, 80% were early deaths (prior or during induction), whereas 20% occurred in remission. Probability of event-free survival at three years was 18%. Only 57% of HCP believed childhood ALL can be cured, with more doctors (96%) than other HCP (45%) believing in curability of ALL (P < 0.001). The majority of HCP (96%) thought that experienced doctors should put more time and effort into making parents understand the diagnosis and necessity to complete treatment. According to HCP, reasons for protocol nonadherence included parental financial difficulties (94%) and use of alternative treatment (79%).

CONCLUSIONS

Event-free survival for ALL in Kenya is low. The primary reason for treatment failure is early death from treatment-related complications. More efforts should be directed toward improving supportive care strategies. In the opinion of HCPs, improved communication with parents and supervision of junior staff will improve ALL treatment outcomes.

Scaling Up the Surveillance of Childhood Cancer: A Global Roadmap

The World Health Organization recently launched the Global Initiative for Childhood Cancer aiming to substantially increase survival among children with cancer by 2030. The ultimate goal concerns particularly less developed countries where survival estimates are considerably lower than in high-income countries where children with cancer attain approximately 80% survival. Given the vast gap in high-quality data availability between more and less developed countries, measuring the success of the Global Initiative for Childhood Cancer will also require substantial support to childhood cancer registries to enable them to provide survival data at the population level. Based on our experience acquired at the International Agency for Research on Cancer in global cancer surveillance, we hereby review crucial aspects to consider in the development of childhood cancer registration and present our vision on how the Global Initiative for Cancer Registry Development can accelerate the measurement of the outcome of children with cancer.

The Practice of Paediatric Radiation Oncology in Low- and Middle-income Countries: Outcomes of an International Atomic Energy Agency Study

AIMS

Childhood cancer survival is suboptimal in most low- and middle-income countries (LMICs). Radiotherapy plays a significant role in the standard care of many patients. To assess the current status of paediatric radiotherapy, the International Atomic Energy Agency (IAEA) undertook a global survey and a review of practice in eight leading treatment centres in middle-income countries (MICs) under Coordinated Research Project E3.30.31; 'Paediatric radiation oncology practice in low and middle income countries: a patterns-of-care study by the International Atomic Energy Agency.'

MATERIALS AND METHODS

A survey of paediatric radiotherapy practices was distributed to 189 centres worldwide. Eight leading radiotherapy centres in MICs treating a significant number of children were selected and developed a database of individual patients treated in their centres comprising 46 variables related to radiotherapy technique.

RESULTS

Data were received from 134 radiotherapy centres in 42 countries. The percentage of children treated with curative intent fell sequentially from high-income countries (HICs; 82%) to low-income countries (53%). Increasing deficiencies were identified in diagnostic imaging, radiation staff numbers, radiotherapy technology and supportive care. More than 92.3% of centres in HICs practice multidisciplinary tumour board decision making, whereas only 65.5% of centres in LMICs use this process. Clinical guidelines were used in most centres. Practice in the eight specialist centres in MICs approximated more closely to that in HICs, but only 52% of patients were treated according to national/international protocols whereas institution-based protocols were used in 41%.

CONCLUSIONS

Quality levels in paediatric radiotherapy differ among countries but also between centres within countries. In many LMICs, resources are scarce, coordination with paediatric oncology is poor or non-existent and access to supportive care is limited. Multidisciplinary treatment planning enhances care and development may represent an area where external partners can help. Commitment to the use of protocols is evident, but current international guidelines may lack relevance; the development of resources that reflect the capacity and needs of LMICs is required. In some LMICs, there are already leading centres experienced in paediatric radiotherapy where patient care approximates to that in HICs. These centres have the potential to drive improvements in service, training, mentorship and research in their regions and ultimately to improve the care and outcomes for paediatric cancer patients.

Childhood cancer in Latin America: from detection to palliative care and survivorship

BACKGROUND

Treatment options for childhood cancer have improved substantially, although in many low- and middle-income countries survival is lagging behind. Integral childhood cancer care involves the whole spectrum from detection and diagnosis to palliative and survivorship care.

METHODS

Based on a literature review and expert opinions, we summarized current practice and recommendations on the following aspects of childhood cancer in Latin America: diagnostic processes and time to diagnosis, stage at diagnosis, treatments and complications, survivorship programs and palliative care and end-of-life services.

RESULTS

Latin America is a huge and heterogeneous continent. Identified barriers show similar problems between countries, both logistically (time and distance to centers, treatment interruptions) and financially (cost of care, cost of absence from work). Governmental actions in several countries improved the survival of children with cancer, but difficulties persist in timely diagnosis and providing adequate treatment to all childhood cancer patients in institutions with complete infrastructure. Treatment abandonment is still common, although the situation is improving. Cancer care in the region has mostly focused on acute treatment of the disease and has not adequately considered palliative and end-of-life care and monitoring of survivors.

CONCLUSIONS

Decentralizing diagnostic activities and centralizing specialized treatment will remain necessary; measures to facilitate logistics and costs of transportation of the child and caretakers should be implemented. Twinning actions with specialized centers in high income countries for help in diagnosis, treatment and education of professionals and family members have been shown to work. Palliative and end-of-life care as well as childhood cancer survivorship plans are needed.

Treatment of Wilms Tumor in Sub-Saharan Africa: Results of the Second French African Pediatric Oncology Group Study

PURPOSE

Multidisciplinary management of Wilms tumor has been defined through multicenter prospective studies and an average expected patient cure rate of 90%. In sub-Saharan Africa, such studies are uncommon. After the encouraging results of the first Groupe Franco-Africain d'Oncologie Pédiatrique (GFAOP) study, we report the results of the GFAOP-NEPHRO-02 study using an adaptation of the International Society of Paediatric Oncology 2001 protocol.

PATIENTS AND METHODS

From April 1, 2005, to March 31, 2011, seven African units participated in a nonrandomized prospective study. All patients who were referred with a clinical and radiologic diagnosis of renal tumor were screened. Those older than age 6 months and younger than 18 years with a unilateral tumor previously untreated were pre-included and received preoperative chemotherapy. Patients with unfavorable histology or with a tumor other than Wilms, or with a nonresponding stage IV tumor were excluded secondarily.

RESULTS

Three hundred thirteen patients were initially screened. Two hundred fifty-seven patients were pre-included and 169 with histologic confirmation of intermediate-risk nephroblastoma were registered in the study and administered postoperative treatment. Thirty-one percent of patients were classified as stage I, 38% stage II, 24% stage III, and 7% stage IV. Radiotherapy was not available for any stage III patients. Three-year overall survival rate was 72% for all study patients and 73% for those with localized disease.

CONCLUSION

It was possible to conduct sub-Saharan African multicenter therapeutic studies within the framework of GFAOP. Survival results were satisfactory. Improvements in procedure, data collection, and outcome are expected in a new study. Radiotherapy is needed to reduce the relapse rate in patients with stage III disease.

Evidence From Ghana Indicates That Childhood Cancer Treatment in Sub-Saharan Africa Is Very Cost Effective: A Report From the Childhood Cancer 2030 Network

Purpose

No published study to date has examined total cost and cost-effectiveness of maintaining a pediatric oncology treatment center in an African setting, thus limiting childhood cancer advocacy and policy efforts.

Methods

Within the Korle Bu Teaching Hospital in Accra, Ghana, costing data were gathered for all inputs related to operating a pediatric cancer unit. Cost and volume data for relevant clinical services (eg, laboratory, pathology, medications) were obtained retrospectively or prospectively. Salaries were determined and multiplied by proportion of time dedicated toward pediatric patients with cancer. Costs associated with inpatient bed use, outpatient clinic use, administrative fees, and overhead were estimated. Costs were summed for a total annual operating cost. Cost-effectiveness was calculated based on annual patients with newly diagnosed disease, survival rates, and life expectancy.

Results

The Korle Bu Teaching Hospital pediatric cancer unit treats on average 170 new diagnoses annually. Total operating cost was $1.7 million/y. Personnel salaries and operating room costs were the most expensive inputs, contributing 45% and 21% of total costs. Together, medications, imaging, radiation, and pathology services accounted for 7%. The cost per disability-adjusted life-year averted was $1,034, less than the Ghanaian per capita income, and thus considered very cost effective as per WHO-CHOICE methodology.

Conclusion

To our knowledge, this study is the first to examine institution-level costs and cost-effectiveness of a childhood cancer program in an African setting, demonstrating that operating such a program in this setting is very cost effective. These results will inform national childhood cancer strategies in Africa and other low- and middle-income country settings.

Adherence to childhood cancer treatment: a prospective cohort study from Northern Vietnam

OBJECTIVES

Global incidence and attention to childhood cancer is increasing and treatment abandonment is a major cause of treatment failure in low- and middle-income countries. The purpose of this study was to gain an understanding of factors contributing to non-adherence to treatment.

DESIGN

A prospective cohort study with 2 year follow-up of incidence, family-reported motives and risk factors.

SETTING

The largest tertiary paediatric oncology centre in Northern Vietnam.

PARTICIPANTS

All children offered curative cancer treatment, from January 2008 to December 2009.

PRIMARY AND SECONDARY OUTCOME MEASURES

Family decision to start treatment was analysed with multivariable logistic regression, and family decision to continue treatment was analysed with a multivariable Cox model. This assessment of non-adherence is thereby methodologically consistent with the accepted definitions and recommended practices for evaluation of treatment abandonment.

RESULTS

Among 731 consecutively admitted patients, 677 were eligible for treatment and were followed for a maximum 2 years. Almost half the parents chose to decline curative care (45.5%), either before (35.2%) or during (10.3%) the course of treatment. Most parents reported perceived poor prognosis as the main reason for non-adherence, followed by financial constraints and traditional medicine preference. The odds of starting treatment increased throughout the study-period (OR 1.04 per month (1.01 to 1.07), p=0.002), and were independently associated with prognosis (OR 0.51 (0.41 to 0.64), p=<0.0001) and travel distance to hospital (OR 0.998 per km (0.996 to 0.999), p=0.004). The results also suggest that adherence to initiated treatment was significantly higher among boys than girls (HR 1.69 (1.05 to 2.73), p=0.03).

CONCLUSIONS

Non-adherence influenced the prognosis of childhood cancer, and was associated with cultural and local perceptions of cancer and the economic power of the affected families. Prevention of abandonment is a prerequisite for successful cancer care, and a crucial early step in quality improvements to care for all children with cancer.

Unmet Needs in Nutritional Care in African Paediatric Oncology Units

BACKGROUND

Up to 50% of children diagnosed with cancer in low- and middle-income countries are malnourished, which likely affects survival.

SUBJECTS AND METHODS

An online survey to paediatric oncology units (POUs) in Africa was done regarding nutritional assessment and care.

RESULTS

Sixty-six surveys were received from POUs in 31 countries. Only 44.4% had a dedicated dietician for nutritional assessment and support; 29.6% undertook routine nutritional assessment during treatment. None reported defined criteria for nutritional intervention. Total parenteral nutrition was not available for 42.6% of POUs, while 51.8% did not have access to commercial enteral nutrition for inpatients, and 25.9% of the hospitals could not supply any home-based nutritional supplements.

CONCLUSION

Nutritional assessment in POUs in Africa is neither routinely undertaken nor are there defined criteria to initiate nutritional interventions. Standardized guidelines for nutritional assessment and interventions are needed for African POUs to enable improved outcome.

Preventing treatment abandonment for children with solid tumors: A single-center experience in Brazil

BACKGROUND

High rates of treatment abandonment have been considered one of the major limitations to achieving high cure rates of childhood cancer in developing countries. The aims of this study were to report the prevalence and factors associated with treatment abandonment for children diagnosed with solid tumors in one reference center in Brazil and to describe effective strategies to prevent it.

PROCEDURES

A retrospective review was conducted using data from 1139 children (0-18 years) treated for solid tumors at the Brazilian National Cancer Institute, during the period between January 2012 and December 2017. Treatment abandonment was defined as recommended by the International Society of Pediatric Oncology. The impact of implementing a patient-tracking system was evaluated. Descriptive statistics were used to analyze patient characteristics. Chi-square test was used for statistical analysis, with the significance level <0.05.

RESULTS

Of 1139 patients, 1.66% refused or abandoned treatment. Although from 2012 to 2013 there was an increase in the abandonment rate, it then decreased by 63.8% from 2013 to 2017 (2.5% to 0.9%). In the multivariate model, only retinoblastoma diagnosis was associated with abandonment (odds ratio = 5.0; 95% confidence interval, 1.2-20.4; P = 0.025). In our cohort, abandonment rates were not associated with increased death.

CONCLUSION

Monitoring missed appointments, and early interventions to address issues associated with providing resources to help families during treatment were effective in achieving very low abandonment rates.

Nutritional status at diagnosis of cancer in children and adolescents in Guatemala and its relationship to socioeconomic disadvantage: A retrospective cohort study

BACKGROUND

At least 80% of children with cancer live in low- and middle-income countries where the prevalence of malnutrition and socioeconomic disadvantage is high. We examined the relationship between nutritional status (NS), assessed by arm anthropometry, and socioeconomic status (SES) in children diagnosed with cancer at Unidad Nacional de Oncologia Pediatrica (UNOP) in Guatemala over a three-year period.

METHOD

Patients aged 0 to 18 years of age diagnosed between January 2015 and December 2017 were included. NS was evaluated by mid-upper arm circumference, triceps skin fold thickness, and serum albumin level, and subjects were classified as adequately nourished, moderately depleted, and severely depleted nutritionally. SES was measured by a 15-item instrument developed at UNOP.

RESULTS

Of 1365 patients diagnosed in the study period, 1060 (78%) fulfilled the eligibility criteria. Only 6% of patients were classified as medium to high, the remainder as medium-low to extremely low SES. Almost 47% were severely depleted at diagnosis, 19% moderately depleted, and 34% adequately nourished. SES was shown to be a determinant of NS; with progressively lower SES, the probability of a decline in NS increased by a factor of 1.04 points (P < 0.0001). Leukemia and lymphoma were also important predictors of nutritional depletion with odds ratios of 6.08 (95% CI, 1.74-28.28; P = 0.008) for leukemias and 4.83 (95% CI, 1.33-23.03; P = 0.03) for lymphomas.

CONCLUSION

Both low SES and a diagnosis of leukemia or lymphoma are strong predictors of poor NS at diagnosis in children with cancer in Guatemala.

Science and health for all children with cancer

Each year ~429,000 children and adolescents aged 0 to 19 years are expected to develop cancer. Five-year survival rates exceed 80% for the 45,000 children with cancer in high-income countries (HICs) but are less than 30% for the 384,000 children in lower-middle-income countries (LMICs). Improved survival rates in HICs have been achieved through multidisciplinary care and research, with treatment regimens using mostly generic medicines and optimized risk stratification. Children’s outcomes in LMICs can be improved through global collaborative partnerships that help local leaders adapt effective treatments to local resources and clinical needs, as well as address common problems such as delayed diagnosis and treatment abandonment. Together, these approaches may bring within reach the global survival target recently set by the World Health Organization: 60% survival for all children with cancer by 2030.

Burkitt lymphoma: Trends in children below 15 years reveal priority areas for early diagnosis activities in north-west Cameroon

Background: Burkitt lymphoma is one of the most common childhood cancers in Cameroon. Incidence rates of 5.9/100 000 and 2.58 per 100 000 have been reported in two studies in 2005 and 2012 amongst children below 15 years in the North-West Region.Aim: This study seeks to examine how Burkitt lymphoma incidence has varied between the various health districts of north-west Cameroon from 2003 to 2015.Setting: North-West region of Cameroon.Method: Ethics approval was obtained from the relevant university and Health Services Institutional Review Board. Population data was obtained from the regional delegation of public health. The Paediatric Oncology Networked Database registry from two hospitals and two pathology-based registries were reviewed for cases per year from the various districts. Age-standardised incidence rates were computed for all districts by year using the World Health Organizaion world standard populations.Results: A total of 317 cases were registered. Overall age-standardised incidence rate was 3.07 per 100 000. Annual incidence ranged from 0.09 in 2003 to 6.12 in 2010. The districts with the highest incidence rates for the entire study period include Nwa with 10.54; Ndop with 5.63; Benakuma with 5.48; Ako with 4.97; and Nkambe with 4.73.Conclusion: Clustering of Burkitt lymphoma is seen in the region, with the highest incidence in Nwa, Ndop, Benakuma, Ako and Nkambe. These districts should be prioritised for awareness creation campaigns. There is need for a population-based childhood cancer registry in the region, which will use both active and passive surveillance methods to record all childhood cancer cases.

Outcomes of Low-Intensity Treatment of Acute Lymphoblastic Leukemia at Butaro Cancer Center of Excellence in Rwanda

Purpose

Children with acute lymphoblastic leukemia (ALL) in low-income countries have disproportionately lower cure rates than those in high-income countries. At Butaro Cancer Center of Excellence (BCCOE), physicians treated patients with ALL with the first arm of the Hunger Protocol, a graduated-intensity method tailored for resource-limited settings. This article provides the first published outcomes, to our knowledge, of patients with ALL treated with this protocol.

Methods

This is a retrospective descriptive study of patients with ALL enrolled at BCCOE from July 1, 2012 to June 30, 2014; data were collected through December 31, 2015. Descriptive statistics were used to calculate patient demographics, disease characteristics, and outcomes; event-free survival was assessed at 2 years using the Kaplan-Meier method.

Results

Forty-two consecutive patients with ALL were included. At the end of the study period, 19% (eight) were alive without evidence of relapse: three completed treatment and five were continuing treatment. Among the remaining patients, 71% (30) had died and 10% (four) were lost to follow-up. A total of 83% (25) of the deaths were disease related, 3% (one) treatment-related, and 13% (four) unclear. Event-free survival was 22% (95% CI, 11% to 36%), considering lost to follow-up as an event, and 26% (95% CI, 13% to 41%) if lost to follow-up is censored.

Conclusion

As expected, relapse was the major cause of failure with this low-intensity regimen. However, toxicity was acceptably low, and BCCOE has decided to advance to intensity level 2. These results reflect the necessity of a data-driven approach and a continual improvement process to care for complex patients in resource-constrained settings.

Improving Immunohistochemistry Capability for Pediatric Cancer Care in the Central American and Caribbean Region: A Report From the AHOPCA Pathology Working Group

Accessibility to immunohistochemistry (IHC) is invaluable to proper diagnosis and treatment of pediatric patients with malignant neoplasms. Whereas IHC is widely available in anatomic pathology laboratories in high-income countries, access to it in anatomic pathology laboratories of low- and middle-income countries remains a struggle, with many limitations. To advance the quality of the pathology service offered to children with cancer in areas with limited resources, a 5-day pathology training workshop was offered to pathologists and histotechnologists from various countries of the Central American and Caribbean region. An initial assessment of the workshop participants’ current laboratory capacities was performed, and a regional training center was selected. Didactic and hands-on activities were offered, and review and evaluation of the IHC slides produced during the training course were compared with original slides from the participants’ sites. This model of intensive 5-day training appears to be effective and can potentially be used in other budget-constrained regions. Moreover, it can serve as a continuing education activity for pathologists and histotechnologists, and as part of validations and quality improvement projects to build capacity and develop IHC assay proficiency in low- and middle-income countries.

Oral Nutritional Supplementation in Children Treated for Cancer in Low- and Middle-Income Countries Is Feasible and Effective: the Experience of the Children's Hospital Manuel De Jesus Rivera "La Mascota" in Nicaragua

Children with cancer are particularly vulnerable to malnutrition, which can affect their tolerance of chemotherapy and outcome. In Nicaragua approximately two-thirds of children diagnosed with cancer present with under-nutrition. A nutritional program for children with cancer has been developed at “La Mascota” Hospital. Results of this oral nutritional intervention including difficulties, benefits, and relevance for children treated for cancer in low− and middle-income countries are here reported and discussed.

Factors associated with abandonment of therapy by children diagnosed with solid tumors in Peru

BACKGROUND

Abandonment of treatment is a major cause of treatment failure and poor survival in children with cancer in low- and middle-income countries. The incidence of treatment abandonment in Peru has not been reported. The aim of this study was to examine the prevalence of and factors associated with treatment abandonment by pediatric patients with solid tumors in Peru.

METHODS

We retrospectively reviewed the sociodemographic and clinical data of children referred between January 2012 and December 2014 to the two main tertiary centers for childhood cancer in Peru. The definition of treatment abandonment followed the International Society of Paediatric Oncology, Paediatric Oncology in Developing Countries, Abandonment of Treatment recommendation.

RESULTS

Data from 1135 children diagnosed with malignant solid tumors were analyzed, of which 209 (18.4%) abandoned treatment. Bivariate logistic regression analysis showed significantly higher abandonment rates in children living outside the capital city, Lima (forest; odds ratio [OR] 3.25; P < 0.001), those living in a rural setting (OR 3.44; P < 0.001), and those whose parent(s) lacked formal employment (OR 4.39; P = 0.001). According to cancer diagnosis, children with retinoblastoma were more likely to abandon treatment compared to children with other solid tumors (OR 1.79; P = 0.02). In multivariate regression analyses, rural origin (OR 2.02; P = 0.001) and lack of formal parental employment (OR 2.88; P = 0.001) were independently predictive of abandonment.

CONCLUSION

Treatment abandonment prevalence of solid tumors in Peru is high and closely related to sociodemographical factors. Treatment outcomes could be substantially improved by strategies that help prevent abandonment of therapy based on these results.

Medical Schools in Fragile States: Implications for Delivery of Care

OBJECTIVE

To report on medical schools in fragile states, countries with severe development challenges, and the impact on the workforce for health care delivery.

DATA SOURCES

2007 and 2012 World Bank Harmonized List of Fragile Situations; 1998-2012 WHO Global Health Observatory; 2014 World Directory of Medical Schools.

DATA EXTRACTION

Fragile classification established from 2007 and 2012 World Bank status. Population, gross national income, health expenditure, and life expectancy were 2007 figures. Physician density was most recently available from WHO Global Health Observatory (1998-2012), with number of medical schools from 2014 World Directory of Medical Schools.

STUDY DESIGN

Regression analyses assessed impact of fragile state status in 2012 on the number of medical schools in 2014.

PRINCIPAL FINDINGS

Fragile states were 1.76 (95 percent CI 1.07-2.45) to 2.37 (95 percent CI 1.44-3.30) times more likely to have fewer than two medical schools than nonfragile states.

CONCLUSIONS

Fragile states lack the infrastructure to train sufficient numbers of medical professionals to meet their population health needs.

A Profile of Pediatric Solid Tumors: A Single Institution Experience in Kashmir

Aims:

The purpose of this retroprospective study was to study the epidemiological characteristics and outcomes of children with solid tumors at our institution.

Subjects and Methods:

Three hundred and three pediatrics patients registered at Regional Cancer Centre (RCC), Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Srinagar, Kashmir, between January 2008 and June 2014, were analyzed with regard to demographic status, presenting complaints, investigations, treatment, morbidity, and outcomes. Standard statistical methods were used for analysis.

Results:

Among 19,880 patients registered at RCC, SKIMS from January 2008 till June 2014, 986 (4.9%) were of pediatric age group. Of these, 303 (30.7%) patients had pediatric solid tumors. The male-to-female ratio was 1.04, there were no infants (up to 27 days), 6% were infants and toddlers (28 days–23 months), 39% were children (2–11 years), and 55% were adolescents (12–19 years). There were 86% rural patients and 14% urban patients. Most common were central nervous system tumors (25.74%), followed by germ cell tumors (14.52%), primitive neuroectodermal tumor/Ewing sarcoma (13.86%), Wilms' tumor (8.9%), osteosarcoma (6.6%), rhabdomyosarcoma (5.6%), colorectal cancer (5.28%), neuroblastoma (4.9%), and retinoblastoma (2.6%). Outcomes: 33.9% patients went into remission, 35.64% were defaulters, 2.97% had stable disease, 2.31% had partial response, 20.79% expired, and 3.96% were still on treatment. Of all these patients, 5.28% had a relapse.

Conclusions:

Across the series, advanced stage of presentation, a high incidence of default and poor follow-up was seen. Multiple interrelated factors are responsible for the poorer outlook of childhood cancer in Kashmir.

Pattern of Pediatric Oncology Cases in the Western Region of Nepal

Childhood cancers form a rare and heterogeneous group which fortunately have a higher cure rate than adult cancers. A few non-profit organizations in Nepal have extended support to help patients suffering from cancer, but their main focus has been on adults. The objective of this study was to establish the pattern of childhood cancers in the Western region of Nepal. We reviewed cases receiving external radiotherapy with both palliative and curative intent between 28th September 2010 and 30th September 2015 at the Department of Radiotherapy and Oncology, Manipal Teaching Hospital affiliated with Manipal College of Medical Sciences, Pokhara, Nepal. Of the total of 1217 cases, 2.71% involved children. The gender distribution showed a male preponderance (M:F= 1.35:1). The patients’ mean age was 11.4 years (range 2 - 14 years). Considering the caste, Brahmins and Gurungs constituted 33.0% and 21.2%, respectively, of children with cancer.

Effects of malnutrition on treatment-related morbidity and survival of children with cancer in Nicaragua

BACKGROUND

Most children with cancer live in resource-limited countries where malnutrition is often prevalent. We identified the relationship between malnutrition and treatment-related morbidity (TRM), abandonment of therapy, and survival of children with cancer in Nicaragua to better inform targeted nutritional interventions.

PROCEDURE

We conducted a retrospective review of patients aged 6 months to 18 years with newly diagnosed acute lymphoblastic leukemia, acute myeloid leukemia (AML), Wilms tumor, Hodgkin lymphoma, or Burkitt lymphoma (BL) who were treated between January 1, 2004, and December 31, 2007 at Children's Hospital Manuel de Jesus Rivera in Managua, Nicaragua. Statistical analysis examined the relations among nutritional status and cancer type, risk category, TRM, and event-free survival (EFS).

RESULTS

Sixty-seven percent of patients (189/282) were malnourished at diagnosis. Malnutrition was highest among patients with Wilms tumor (85.7%), BL (75%), and AML (74.3%). A total of 92.2% of patients (225/244) experienced morbidity during the first 90 days. Malnutrition was associated with severe infection (P = 0.033). Severely malnourished patients had ≥grade 3 TRM on more days (P = 0.023) and were more likely to experience severe TRM on >50% of days (P = 0.032; OR, 3.27 [95% CI, 1.05-10.16]). Malnourished patients had inferior median EFS (2.25 vs. 5.58 years; P = 0.049), and abandoned therapy more frequently (P = 0.015).

CONCLUSIONS

In Nicaragua, pediatric oncology patients with malnutrition at diagnosis experienced increased TRM, abandoned therapy more frequently, and had inferior EFS. Standardized nutritional evaluation of patients with newly diagnosed cancer and targeted provision of nutritional support are essential to decrease TRM and improve outcomes.

Improvement in treatment abandonment in pediatric patients with cancer in Guatemala

BACKGROUND

Treatment refusal and abandonment are major causes of treatment failure for children with cancer in low- and middle-income countries (LMICs), like Guatemala. This study identified risk factors for and described the intervention that decreased abandonment.

METHODS

This was a retrospective study of Guatemalan children (0-18 years) with cancer treated at the Unidad Nacional de Oncología Pediátrica (UNOP), 2001-2008, using the Pediatric Oncology Network Database. Treatment refusal was a failure to begin treatment and treatment abandonment was a lapse of 4 weeks or longer in treatment. The impact of medicina integral, a multidisciplinary psychosocial intervention team at UNOP was evaluated. Cox proportional hazards analysis identified the effect of demographic and clinical factors on abandonment. Kaplan-Meier analysis estimated the survival.

RESULTS

Of 1,789 patients, 21% refused or abandoned treatment. Abandonment decreased from 27% in 2001 to 7% in 2008 following the implementation of medicina integral. Factors associated with increased risk of refusal and abandonment: greater distance to the centre (P < 0.001), younger age (P = 0.017) and earlier year of diagnosis (P < 0.001). Indigenous race/ethnicity (P = 0.002) was associated with increased risk of abandonment alone. Abandonment correlated with decreased overall survival: 0.57 ± 0.02 (survival ± standard error) for those who completed therapy versus 0.06 ± 0.02 for those who abandoned treatment (P < 0.001) at 8.3 years.

CONCLUSION

This study identified distance, age, year of diagnosis and indigenous race/ethnicity as risk factors for abandonment. A multidisciplinary intervention reduced abandonment and can be replicated in other LMICs.

An ethnographic exploration of the delivery of psychosocial care to children with cancer in Argentina

PURPOSE

The integration of psychosocial care in the routine care of cancer patients has been set as an international standard, but there are healthcare contexts where these services are lacking as psychosocial care providers are not incorporated in multidisciplinary teams and screening for psychological distress is not carried out routinely or systematically.

METHOD

In this article, we discuss the findings from an ethnographic study that focused on exploring the working experiences of psychosocial care providers from one children's hospital in Buenos Aires, Argentina. The study is based on 10 in-depth interviews with hospital staff members and participant observation in selected hospital areas. The transcripts from the interviews and fieldnotes from the observations were analyzed using thematic analysis.

RESULTS

We found that psychosocial care providers encounter difficulties while attempting to deliver services to children and their families, produced mainly by their lack of collaboration with other professional groups, insufficient human resources, and a growing patient population. As a result of this situation, psychosocial care providers often prioritize some patients over others, leaving a considerable number of patients and family members without psychosocial support.

CONCLUSIONS

The study highlighted the barriers psychosocial care providers encounter while attempting to deliver services to children and their families. Further work needs to be carried out to fully integrate psychosocial care in national health policies and ensure this type of support is available for all patients and their families.

Addressing regional disparities in pediatric oncology: Results of a collaborative initiative across the Mexican-North American border

BACKGROUND

Cancer is emerging as a major cause of childhood mortality in low- and middle-income countries. In Mexico, cancer is the number one cause of death in children aged 5-14. Until recently, many children with cancer from Baja California, Mexico, went untreated. We reasoned that an initiative inspired by the St. Jude Children's Research Hospital (SJCRH) "twinning" model could successfully be applied to the San Diego-Tijuana border region. In 2008, a twinning project was initiated by Rady Children's Hospital, SJCRH, and the General Hospital Tijuana (GHT). Our aim was to establish a pediatric oncology unit in a culturally sensitive manner, adapted to the local healthcare system.

PROCEDURE

An initial assessment revealed that despite existence of basic hospital infrastructure at the GHT, the essential elements of a pediatric cancer unit were lacking, including dedicated space, trained staff, and uniform treatment. A 5-year action plan was designed to offer training, support the staff financially, and improve the infrastructure.

RESULTS

After 7 years, accomplishments include the opening of a new inpatient unit with updated technology, fully trained staff, and a dedicated, interdisciplinary team. Over 700 children have benefited from accurate diagnosis and treatment.

CONCLUSIONS

Initiatives that implement long-term partnerships between institutions along the Mexican-North American border can be highly effective in establishing successful pediatric cancer control programs. The geographic proximity facilitated accelerated training and close monitoring of project development. Similar initiatives across other disciplines may benefit additional patients and synergize with pediatric oncology programs to reduce health disparities in underserved areas.

Prediagnostic Intervals in Retinoblastoma: Experience at an Oncology Center in Brazil

Purpose

Retinoblastoma is the most common intraocular malignancy of childhood. In most cases, parents are the first to notice leukocoria and other symptoms before undergoing a prolonged period of stress before diagnosis. The purpose of this study was to determine prediagnostic intervals of patients with retinoblastoma at an oncology tertiary center (Instituto Nacional de Cancer) in Rio de Janeiro, Brazil, and relate them to stage at diagnosis, eye salvage, and survival.

Methods

Parents or caregivers of children with retinoblastoma registered between January 2006 and September 2013 were interviewed using a semistructured individually applied questionnaire, concerning their trajectory before registration.

Results

Out of 76 patients, 39 (51%) were girls, 52 (68%) had unilateral retinoblastoma, and 24 (32%) had bilateral retinoblastoma, totaling 100 affected eyes. The most common stage of diagnosis was the intraocular group, with 63 (83%) patients; nine (12%) were extraocular, and four (5%) had metastatic disease. During the follow-up time of 37 ± 24.5 months, 10 (13%) patients died and 70 (70%) eyes were enucleated. Mean family interval was 1.6 ± 2.6 months, mean medical interval was 5.0 ± 6.2 months, mean referral interval was 0.2 ± 1.4 months, and mean overall interval was 7.1 ± 6.9 months. In univariate analysis, age at diagnosis, maternal education, medical interval, and overall interval were significantly related to advanced stage at diagnosis and survival. In multivariate analysis, maternal education and medical interval were significantly related to advanced stage at diagnosis and survival. No variables affected eye salvage.

Conclusion

Medical interval was responsible for 70% of the overall interval; therefore, programs or campaigns targeting retinoblastoma early diagnosis should focus emphasize in medical awareness.

Tracking children with acute lymphoblastic leukemia who abandoned therapy: Experience, challenges, parental perspectives, and impact of treatment subsidies and intensified counseling

Refusal for treatment and therapy abandonment are important reasons for unfavorable outcome of childhood acute lymphoblastic leukemia (ALL) in resource-poor countries. The present study, conducted on children with ALL whose treatment was abandoned, attempted to track all these children to ascertain the causes and outcome of therapy abandonment/refusal. In order to improve outcome of ALL, measures to prevent abandonment were introduced in the form of treatment subsidies and intensified multistage counseling. Of the 77 (of 418) children abandoning therapy, 17 (22%) refused upfront, whereas the rest abandoned during various phases of chemotherapy. Only 39 (50.6%) of these 77 families could be subsequently contacted. Financial problems, too many dependents at home, and wrong perceptions about cancer led to abandonment in majority. Children abandoning treatment before completion of induction had a significantly shorter survival than who abandoned post induction (P < .0001). Intensified preabandonment counseling and subsidized treatment led to significant reduction in abandonment rates (P < .0001).

A 10-Year Follow-up Survey of Treatment Abandonment of Children With Acute Myeloid Leukemia in Suzhou, China

A survey of the clinical data on acute myeloid leukemia (AML) over the past 10 years in the treatment center of Children's Hospital was presented. The aim of the study was to identify the factors influencing the treatment abandonment rate (AR) of AML. Of the 474 AML cases examined, 264 were abandoned (55.7%). The most important factor affecting AR appeared to be the AML subtype-that is, the M3 versus non-M3 (42% vs. 60%). Patient age was observed to be closely related to AR-the older the patients, the lower the AR-and infants had the highest prevalence of abandonment (84.2%). The patient's residential location was markedly correlated to AR, which was almost inversely proportional to the size of the township where the patient came from. From large cities, intermediate and small towns to countryside villages, the AR increased linearly. So was the correlation with health insurance coverage, which decreased in the same way. Sex and karyotypes did not affect AR. In conclusion, the patients' financial burden and the perceived incurability of AML were the 2 leading factors dominating the decision for abandonment in parents and caregivers.

Clinical Trials Infrastructure as a Quality Improvement Intervention in Low- and Middle-Income Countries

Mounting evidence suggests that participation in clinical trials confers neither advantage nor disadvantage on those enrolled. Narrow focus on the question of a "trial effect," however, distracts from a broader mechanism by which patients may benefit from ongoing clinical research. We hypothesize that the existence of clinical trials infrastructure-the organizational culture, systems, and expertise that develop as a product of sustained participation in cooperative clinical trials research-may function as a quality improvement lever, improving the quality of care and outcomes of all patients within an institution or region independent of their individual participation in trials. We further contend that this "infrastructure effect" can yield particular benefits for patients in low- and middle-income countries (LMICs). The hypothesis of an infrastructure effect as a quality improvement intervention, if correct, justifies enhanced research capacity in LMIC as a pillar of health system development.

Caregivers' Self-Reported Absence of Social Support Networks is Related to Treatment Abandonment in Children With Cancer

BACKGROUND

Treatment abandonment (TxA) is a primary cause of therapy failure in children with cancer in low-/middle-income countries. We explored the absence of social support network (SSN), among other predictive factors, and TxA in children with cancer in Cali, Colombia.

PROCEDURE

In this prospective cohort study, we included children diagnosed with cancer at a public university hospital. A social worker and a psychologist administered semistructured questionnaires to patients' caregivers. We extracted information from the questionnaires about social, economic, and psychological conditions of the patients' families. Outcomes were death, relapse, and TxA. Failure either to start or to continue the planned course of curative treatment for 4 weeks or more was defined as TxA. We identified events with Cali's childhood cancer outcomes surveillance system (VIGICANCER). We adjusted the hazard ratios (HRs) for potential confounders using multivariate Cox regression analyses.

RESULTS

Among 188 patients diagnosed from January 2011 to June 2013, 99 interviews were conducted. Median age was 5 years old (range: 0.3, 14.9), 53% were male, 17% were of Colombian-Indian ethnicity, and 68% lived in rural areas. The 2-year cumulative incidence of TxA was 21% (95% confidence interval [CI]: 13, 35) and the annual proportion was 14%. The adjusted HR for the absence of SSN was 4.9 (95% CI: 1.6, 15.3).

CONCLUSIONS

We found a strong association between the absence of SSN and TxA that was independent of other covariates, including surrogate measures of wealth. Our findings highlight the imperative understanding of social ties and support surrounding children's families for planning strategies to prevent TxA.

Improving Care for Children With Cancer in Low- and Middle-Income Countries--a SIOP PODC Initiative

The Paediatric Oncology in Developing Countries (PODC) committee of International Society of Paediatric Oncology (SIOP) has 10 working groups that provide a forum for individuals to engage, network, and implement improvements in the care of children with cancer in low- and middle-income countries. The development of adapted guidelines (medulloblastoma, retinoblastoma, Wilms tumor, neuroblastoma, retinoblastoma, Burkitt lymphoma, supportive care), advocacy and awareness (on hospital detention and essential drugs), education and training, and global mapping (nutritional practice, abandonment rates, and twinning collaborations) have been the initial areas of focus, and the impact of some of these activities is evident, for example, in the SIOP Africa PODC Collaborative Wilms tumor project.

Anaplastic Large Cell Lymphoma in Central America: A Report From the Central American Association of Pediatric Hematology Oncology (AHOPCA)

BACKGROUND

Although anaplastic large cell lymphoma (ALCL) is curable in high-income countries (HIC), data from low- and middle-income countries (LMIC) are lacking. We therefore conducted a retrospective study of the Central American Association of Pediatric Hematology Oncology (AHOPCA) experience in treating ALCL.

PROCEDURE

We included all patients age <18 years newly diagnosed with ALCL treated between 2000 and 2013 in seven AHOPCA institutions. Retrospective data were extracted from the Pediatric Oncology Network Database.

RESULTS

Thirty-one patients met inclusion criteria. Twenty-five (81%) had advanced disease (stages III and IV), six (19%) were treated on the APO (doxorubicin, prednisone, vincristine) regimen, 15 (49%) on multi-agent chemotherapy designed for T-cell lineage malignancies (GuatALCL protocol), and 10 (32%) on BFM-based treatment regimens. Five-year overall event-free survival and overall survival were, respectively, 67.1 ± 8.6% and 66.7 ± 8.7%. All 10 events occurred in patients treated on BFM-based treatment regimens or the GuatALCL protocol, none on APO treatment: two patients experienced relapse, six treatment related mortality (TRM), and two abandonment.

CONCLUSIONS

Treatment of ALCL in countries with limited resources is feasible with similar outcomes as in HIC, though the causes of treatment failure differ. Less intensive regimens may be preferable in order to decrease TRM and improve outcomes. Prospective clinical trials determining the ideal treatment for LMIC children with ALCL are necessary.

A strategy to improve treatment-related mortality and abandonment of therapy for childhood ALL in a developing country reveals the impact of treatment delays

BACKGROUND

Treatment-related mortality and abandonment of therapy are major barriers to successful treatment of childhood acute lymphoblastic leukemia (ALL) in the developing world.

PROCEDURE

A collaboration was undertaken between Instituto Nacional de Cancerologia (Bogota, Colombia), which serves a poor patient population in an upper-middle income country, and Dana-Farber/Boston Children's Cancer and Blood Disorders Center (Boston, USA). Several interventions aimed at reducing toxic deaths and abandonment were implemented, including a reduced-intensity treatment regimen and a psychosocial effort targeting abandonment. We performed a cohort study to assess impact.

RESULTS

The Study Population comprised 99 children with ALL diagnosed between 2007 and 2010, and the Historic Cohort comprised 181 children treated prior to the study interventions (1995-2004). Significant improvements were achieved in the rate of deaths in complete remission (13% to 3%; P = 0.005), abandonment (32% to 9%; P < 0.001), and event-free survival with abandonment considered an event (47% to 65% at 2 years; P = 0.016). However, relapse rate did not improve. Medically unnecessary treatment delays were common, and landmark analysis revealed that initiating the PIII phase of therapy ≥4 weeks delayed predicted markedly inferior disease-free survival (P = 0.016). Conversely, patients who received therapy without excessive delays had outcomes approaching those achieved in high-income countries.

CONCLUSIONS

Implementation of a twinning program was followed by reductions in abandonment and toxic deaths, but relapse rate did not improve. Inappropriate treatment delays were common and strongly predicted treatment failure. These findings highlight the importance of adherence to treatment schedule for effective therapy of ALL.

Building a National Pediatric Cancer Center and Network in Paraguay: Lessons for Addressing Challenges in a Low-income Country

In Paraguay, cancer is among the leading causes of death among children. We report challenges and solutions for building the country's first pediatric cancer center at the National University School of Medicine (PCC-SM) and describe the outcomes of the National Network for Pediatric Cancer. We found that children with acute lymphoblastic leukemia treated between 2008 and 2012 had higher 3-year survival rates and lower treatment abandonment rates than did children treated between 2000 and 2007 before the network was established. This improvement directly coincided with the increased treatment capacity of the PCC-SM. Herein, we describe the role of local, national, and international contributors in improving the health care at Paraguay's PCC-SM and discuss how expediting access to specialized cancer diagnosis and care and implementing a system for referral and follow-up visits can improve cancer outcomes in other low-resource countries.

Improving Pediatric Cancer Care Disparities Across the United States-Mexico Border: Lessons Learned from a Transcultural Partnership between San Diego and Tijuana

In 2007, the 5-year survival rate for children with acute leukemia in Baja California, Mexico was estimated at 10% (vs. 88% in the United States). In response, stakeholders at St. Jude Children’s Research Hospital, Rady Children’s Hospital San Diego, and the Hospital General de Tijuana (HGT) implemented a transcultural partnership to establish a pediatric oncology program. The aim was to improve clinical outcomes and overall survival for children in Baja California. An initial needs assessment evaluation was performed and a culturally sensitive, comprehensive, 5-year plan was designed and implemented. After six years, healthcare system accomplishments include the establishment of a fully functional pediatric oncology unit with 60 new healthcare providers (vs. five in 2007). Patient outcome improvements include a rise in 5-year survival for leukemia from 10 to 43%, a rise in new cases diagnosed per year from 21 to 70, a reduction in the treatment abandonment rate from 10% to 2%, and a 45% decrease in the infection rate. More than 600 patients have benefited from this program. Knowledge sharing has taken place between teams at the HGT and Rady Children’s Hospital San Diego. Further, one of the most significant outcomes is that the HGT has transitioned into a regional referral center and now mentors other hospitals in Mexico. Our results show that collaborative initiatives that implement long-term partnerships along the United States–Mexico border can effectively build local capacity and reduce the survival gap between children with cancer in the two nations. Long-term collaborative partnerships should be encouraged across other disciplines in medicine to further reduce health disparities across the United States–Mexico border.