Team management, twinning, and telemedicine in retinoblastoma: a 3-tier approach implemented in the first eye salvage program in Jordan

Strategies to improve diagnosis and access to treatment of retinoblastoma in low- and middle-income countries: A systematic review

Retinoblastoma, the most common intraocular tumor in childhood, still faces challenges in diagnosis and treatment, particularly in low- and middle-income countries. Identifying strategies to improve the time to diagnosis and access to treatment is crucial to enhance survival rates and preserve ocular health. We conducted a systematic review to identify interventions that have demonstrated potential in addressing these challenges. We performed a comprehensive search across databases until March 2023. Out of the studies reviewed, 21 met the inclusion criteria and were categorized into five main areas: surveillance strategies, genetic counseling, education, public assistance, and international partnership. Despite the obstacles faced, the initiatives identified in this review present acts toward improving the time to diagnosis and access to treatment for retinoblastoma. Based on the extracted data, we propose a comprehensive chain of initiatives. We firmly believe that implementing this chain of initiatives can lead to improved clinical outcomes for retinoblastoma patients.

Teleoncology: Novel Approaches for Improving Cancer Care in North America

Due to widespread healthcare workforce shortages, many patients living in remote and rural North America currently have reduced access to various medical specialists. These shortages, coupled with the aging North American population, highlight the need to transform contemporary healthcare delivery systems. The exchange of medical information via telecommunication technology, known as telemedicine, offers promising solutions to address the medical needs of an aging population and the increased demand for specialty medical services. This progressive movement has also improved access to quality health care by mitigating the current shortage of trained subspecialists. Minimizing the effects of these shortages is particularly urgent in the care of cancer patients, many of whom require regular follow-up and close monitoring. Cancer patients living in remote areas of North America have reduced access to specialized care and, thus, have unacceptably high mortality and morbidity rates. Teleoncology, or the use of telemedicine to provide oncology services remotely, has the ability to improve access to high-quality care and assist in alleviating the burden of some of the severe adverse events associated with cancer. In this review, the authors describe how recent advances in teleoncology can reduce healthcare disparities and improve future cancer care in North America.

Libyan cancer patients at King Hussein Cancer Center for more than a decade, the current situation, and a future vision

Background

Since 2011, the Libyan civil war crisis had affected all dimensions of livelihood including cancer care. This has resulted in a steady incline in the number of Libyan patients with cancer seeking oncologic care and management in Tunisia, Egypt and Jordan, among others. King Hussein Cancer Center (KHCC) has been one of the main destinations for Libyan patients with cancer for more than a decade.

Aim

We are reporting on the characteristics of Libyan patients with cancer presenting to KHCC during the past fourteen years.

Methods

We performed a retrospective chart review of all Libyan patients with cancer presenting to KHCC between 2006 and 2019.

Results

A total of 3170 records were included in the final analysis. The overall sample was predominantly adults (71%) with a male-to-female ratio of 1:1.2. Overall, the most common referred cancers to KHCC were breast (21%), hematolymphoid (HL) (17%), and gastrointestinal tract (GIT) (16.2%) cancers. Breast cancer was the most common among adult females (41.7%), GIT among adult males (23.6%), and HL among pediatrics (38.5%). Around 37.8% of patients presented with distant metastasis at their first encounter at KHCC, among which 14.7% were candidates for palliative care.

Conclusion

The sustenance of treatment for Libyan patients with cancer requires extensive collaboration between governmental and private sectors. The Libyan oncological landscape could benefit from national screening and awareness programs, twining programs and telemedicine, introduction of multidisciplinary boards, and the formulation of a national cancer registry. Adopting the successful models at KHCC can help to augment the oncology services within the Libyan healthcare sector.

Knowledge, Attitudes, and Perceptions of Jordanians Toward Adopting and Using Telemedicine: National Cross-sectional Study

Background

Due to the upsurge of COVID-19, nations are increasingly adopting telemedicine programs in anticipation of similar crises. Similar to all nations worldwide, Jordan is implementing efforts to adopt such technologies, yet it is far from complete.

Objective

This study aims to assess the knowledge, attitudes, and perceptions of Jordanians toward telemedicine, to identify key factors predisposing individuals to its use or acting as barriers to its implementation.

Methods

We implemented a cross-sectional design using an online, self-administered questionnaire executed in Google Forms and distributed through social media. Differences in knowledge and attitude scores were examined using independent sample t tests and ANOVA. A multivariate linear regression model was computed to assess predictors of awareness toward telemedicine.

Results

A total of 1201 participants fully completed the questionnaire. Participants were characterized by a mean age of 36.3 (SD 14.4) years and a male-to-female ratio of nearly 1:1. About 50% (619/1201, 51.5%) of our studied population were aware of telemedicine, while nearly 25% (299/1201, 24.9%) declared they had observed it in action. Approximatively 68% (814/1201, 67.8%) of respondents were willing to use telemedicine. The majority of the sample portrayed favorable and positive views toward telemedicine. Higher educational degrees, living in urban districts, and having a higher perception of electronic usage ability were associated with higher knowledge and better attitudes toward telemedicine (all P<.05). The multivariate linear regression analysis demonstrated that perceived ability to use electronics was associated with positive attitudes (β=0.394; 95% CI 0.224 to 0.563), while living in Southern Jordan predicted poor attitudes toward telemedicine (β=–2.896; 95% CI –4.873 to –0.919).

Conclusions

Jordanians portray favorable perceptions of telemedicine. Nonetheless, concerns with regards to privacy, medical errors, and capacity for accurate diagnoses are prevalent. Furthermore, Jordanians believe that integrating telemedicine within the health care system is not applicable due to limited resources.

Building the ecosystem for pediatric neuro-oncology care in Pakistan: Results of a 7-year long twinning program between Canada and Pakistan

BACKGROUND

Low- and middle-income countries sustain the majority of pediatric cancer burden, with significantly poorer survival rates compared to high-income countries. Collaboration between institutions in low- and middle-income countries and high-income countries is one of the ways to improve cancer outcomes.

METHODS

Patient characteristics and effects of a pediatric neuro-oncology twinning program between the Hospital for Sick Children in Toronto, Canada and several hospitals in Karachi, Pakistan over 7 years are described in this article.

RESULTS

A total of 460 patients were included in the study. The most common primary central nervous system tumors were low-grade gliomas (26.7%), followed by medulloblastomas (18%), high-grade gliomas (15%), ependymomas (11%), and craniopharyngiomas (11.7%). Changes to the proposed management plans were made in consultation with expert physicians from the Hospital for Sick Children in Toronto, Canada. On average, 24% of the discussed cases required a change in the original management plan over the course of the twinning program. However, a decreasing trend in change in management plans was observed, from 36% during the first 3.5 years to 16% in the last 3 years. This program also led to the launch of a national pediatric neuro-oncology telemedicine program in Pakistan.

CONCLUSIONS

Multidisciplinary and collaborative efforts by experts from across the world have aided in the correct diagnosis and treatment of children with brain tumors and helped establish local treatment protocols. This experience may be a model for other low- and middle-income countries that are planning on creating similar programs.

Comprehensive global collaboration in the care of 1182 pediatric oncology patients over 12 years: The Iraqi-Italian experience

BACKGROUND

Iraq's health care system has gradually declined after several decades of wars, terrorism, and UN economic sanctions. The Oncology Unit at Children's Welfare Teaching Hospital (CWTH) in Baghdad was lacking basic facilities and support. To address this shortcoming, a humanitarian and educational partnership was established between CWTH and Sapienza University of Rome (SUR).

METHODS

We investigated the outcomes of 80 online and 16 onsite educational sessions and 142 teleconsultation sessions from 2006 to 2014. We also determined the outcomes of pathology reviews by SUR of 1216 tissue specimens submitted by CWTH from 2007 until 2019 for second opinions. The primary outcomes were discordance, concordance, and changes among clinical diagnoses and pathology review findings. The measures included the frequency of teleconsultation and tele-education sessions, the topics discussed in these sessions, and the number of pathology samples requiring second opinions.

FINDINGS

A total of 500 cases were discussed via teleconsultations during the study period. The median patient age was 7 years (range, 24 days to 16·4 years), and the cases comprised 79 benign tumors, 299 leukemias, 120 lymphomas, and 97 solid tumors. The teleconsultation sessions yielded 27 diagnostic changes, 123 confirmed diagnoses, and 13 equivocal impacts. The pathology reviews by SUR were concordant for 996 (81·9%) cases, discordant for 186 (15·3%), and inconclusive for 34 (2·8%). The major cause of discordance was inadequate immunohistochemical staining. The percentage of discordance markedly decreased over time (from 40% to 10%). The cause of the improvement is multifactorial: training of two CWTH pathologists at SUR, better immunohistochemical staining, and the ongoing clinical and pathologic telemedicine activities. The partnership yielded 12 publications, six posters, and three oral presentations by CWTH investigators.

INTERPRETATION

The exchange of knowledge and expertise across continental boundaries meaningfully improved the diagnoses and management of pediatric cancer at CWTH.

Mapping Pediatric Oncology Clinical Trial Collaborative Groups on the Global Stage

The global pediatric oncology clinical research landscape, particularly in Central and South America, Africa, and Asia, which bear the highest burden of global childhood cancer cases, is less characterized in the literature. Review of how existing pediatric cancer clinical trial groups internationally have been formed and how their research goals have been pursued is critical for building global collaborative research and data-sharing efforts, in line with the WHO Global Initiative for Childhood Cancer.

Local stakeholder engagement is necessary to collaborate with global pediatric cancer trial groups.

Impact of Implementing Teleophthalmology Referral Guidelines Using the eyeSmart EMR App in 63,703 Patients from India

Objective. To describe the clinical indications and the impact of implementation of specific teleophthalmology referral guidelines in a large rural village vision centre network in India. Methods. This cross-sectional vision centre-based study included 1,016,284 patients presenting between January 2017 and March 2020. Patients who were referred for a teleophthalmology opinion were included as cases. The data were collected using the eyeSmart EMR app on a smart tablet. A training intervention was done to reinforce the implementation of targeted teleophthalmology referral guidelines. Results. Overall, 63,703 (6.3%) patients were referred for a teleophthalmology opinion and were included for analysis. The median age was 41 (IQR: 26-59) years, and adults (88.4%) were commonly referred for a consult. The two most common age groups were between 31-40 years (17.4%) and 21-30 years (16.3%), and the majority of patients were male (59.1%). The most common clinical indication was cornea and anterior segment disorders (71.05%). The most common queries for teleophthalmology referral before versus after the reinforcement of implementation of guidelines were red eye (33.4% vs. 45.6%) followed by cataract (21.2% vs. 8.1%). There was an increase in the red eye (<0.001) and a decrease in cataract (<0.001) which was statistically significant. The proportion of patients for whom a teleophthalmology consult could have been requested but not sent was minimal (2.3%). Conclusion. Implementation of targeted teleophthalmology referral guidelines enables an effective triage to seek opinion for more pertinent ocular diseases that require care. Adult male patients with cornea and anterior segment disorders are most commonly referred for a teleophthalmology opinion.

Follow-up evaluation of a web-based pediatric brain tumor board in Latin America

BACKGROUND

Since 2013, pediatric oncologists from Central and South America discuss neuro-oncology cases with experts from North America and Europe in a web-based "Latin American Tumor Board" (LATB). Here, we evaluate the feasibility of recommendations rendered by the Board.

METHODS

An electronic questionnaire was distributed to physicians who had received recommendations between October 2017 and October 2018. Physicians were asked regarding the feasibility of each recommendation given during the LATB discussion. Baseline case characteristics of all presented cases were obtained from anonymized minutes.

RESULTS

Of the 142 patients discussed, data on 103 patients from 15 countries were available, corresponding to 283 recommendations. Physicians followed 60% of diagnostic procedural recommendations and 69% of therapeutic recommendations. The most difficult recommendations to follow were genetic and molecular testing, pathology review, chemotherapy, surgery, and molecular targeted therapies. Histological diagnoses changed in eight of 18 cases in which a pathology review was undertaken. Fifty-four percent of the recommendations that could not be implemented were considered not feasible in the specific context of the patient, while 31% were not implemented due to a decision of the medical staff or the parents (15% not specified). However, 96% of respondents considered the recommendations useful.

CONCLUSION

Recommendations were frequently perceived as useful, and were applicable in the participating institutions. Nevertheless, limitations in availability of diagnostic procedures and treatment modalities affected the feasibility of some recommendations. Tele-oncology tumor boards offer physicians from low- and middle-income countries access to real-time, high-level subspecialist expertise and provide a valuable platform for worldwide information exchange.

A national telemedicine program in the Kingdom of Jordan - Editorial

The coronavirus disease 2019 (COVID19) is on the rise in the Kingdom of Jordan. The healthcare system is under pressure to handle the increasing numbers of COVID19 cases while providing routine and emergent care to the population. Telemedicine represents an opportunity to utilize during the pandemic. The feasibility of telemedicine in Jordan has been established in a few small projects over the past two decades. Here, we present a timely proposal for a national telemedicine program to be designed and deployed during the pandemic and sustain after the pandemic. Further, we identify the stakeholders and the steps to design and implement the program.

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Telemedicine is feasible in the Kingdom of Jordan.

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A National telemedicine program is lacking but is needed in the setting of the coronavirus pandemic and beyond.

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Identified key stakeholders for a national telemedicine program.

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Proposed the key steps for the design and implementation of a national telemedicine program.

Characterization of international partnerships in global retinoblastoma care and research: A network analysis

Global cooperation is an integral component of global health research and practice. One Retinoblastoma World (1RBW) is a cooperative network of global treatment centers that care for children affected by retinoblastoma. The study aimed to determine the number, scope and nature of collaborations within 1RBW, and uncover how they are perceived to contribute towards improving retinoblastoma outcomes. A cross-sectional, mixed-methods egocentric network analysis was conducted. Treatment centers (n = 170) were invited to complete an electronic survey to identify collaborative activities between their institution (ego), and respective partners (alters). Network maps were generated to visualize connectivity. Key informants (n = 18) participated in semi-structured interviews to add details about the reported collaborations. Interviews were analysed through inductive thematic analysis. Surveys were completed by 56/170 (33%) of 1RBW treatment centers. Collectively, they identified 112 unique alters (80 treatment centers; 32 other organizations) for a total network size of 168 nodes. Most collaborations involved patient referrals, consultations and twinning/capacity building. Interviews identified four main themes: conceptualization of partnership; primary motivation for collaborations; common challenges to collaboration; and benefits to partnership. There is extensive global collaboration to reduce global retinoblastoma mortality, but there is room to expand connectivity through active efforts to include actors located at network peripheries.

Circular RNAs in childhood-related diseases and cancers: A review

Research into the diagnosis, treatment and prevention of childhood-related diseases is the key to reducing their morbidity and mortality. Circular RNAs (circRNAs) play critical roles, both in physiology and pathology, and there is ample evidence to show that they play varying roles in tissue development and gene regulation. Studies on circRNAs in different childhood-related diseases have confirmed their great potential for disease prevention and treatment. These breakthroughs highlight the pathological role of circRNAs in cancers, as well as cardiovascular and hereditary childhood illnesses. In this review, we summarize the role of circRNAs in childhood-related diseases and cancer, and provide an update of the possible diagnostic and therapeutic application of circRNAs.

Assessment of Retinoblastoma Capacity in the Middle East, North Africa, and West Asia Region

PURPOSE

We aimed to evaluate the capacity to treat retinoblastoma in the Middle East, North Africa, and West Asia region.

METHODS

A Web-based assessment that investigated retinoblastoma-related pediatric oncology and ophthalmology infrastructure and associated capacity at member institutions of the Pediatric Oncology East and Mediterranean group was distributed. Data were analyzed in terms of availability, location, and confidence of use for each resource needed for the management of retinoblastoma. Resources were categorized by diagnostics, focal therapy, chemotherapy, advanced treatment, and supportive care. Responding institutions were further divided into an asset-based tiered system.

RESULTS

In total, responses from 23 institutions were obtained. Fifteen institutions reported the availability of an ophthalmologist, 12 of which held primary off-site appointments. All institutions reported the availability of a pediatric oncologist and systemic chemotherapy A significant portion of available resources was located off site. Green laser was available on site at seven institutions, diode laser at six institutions, cryotherapy at 12 institutions, and brachytherapy at nine institutions. There existed marked disparity between the availability of some specific ophthalmic resources and oncologic resources.

CONCLUSION

The assessment revealed common themes related to the treatment of retinoblastoma in low- and- middle-income countries, including decentralization of care, limited resources, and lack of multidisciplinary care. Resource disparities warrant targeted intervention in the Middle East, North Africa, and West Asia region to advance the management of retinoblastoma in the region.

Global Retinoblastoma Treatment Outcomes: Association with National Income Level

PURPOSE

To compare metastasis-related mortality, local treatment failure, and globe salvage after retinoblastoma in countries with different national income levels.

DESIGN

International, multicenter, registry-based retrospective case series.

PARTICIPANTS

Two thousand one hundred ninety patients, 18 ophthalmic oncology centers, and 13 countries on 6 continents.

METHODS

Multicenter registry-based data were pooled from retinoblastoma patients enrolled between January 2001 and December 2013. Adequate data to allow American Joint Committee on Cancer staging, eighth edition, and analysis for the main outcome measures were available for 2085 patients. Each country was classified by national income level, as defined by the 2017 United Nations World Population Prospects, and included high-income countries (HICs), upper middle-income countries (UMICs), and lower middle-income countries (LMICs). Patient survival was estimated with the Kaplan-Meier method. Logistic and Cox proportional hazards regression models were used to determine associations between national income and treatment outcomes.

MAIN OUTCOME MEASURES

Metastasis-related mortality and local treatment failure (defined as use of secondary enucleation or external beam radiation therapy).

RESULTS

Most (60%) study patients resided in UMICs and LMICs. The global median age at diagnosis was 17.0 months and higher in UMICs (20.0 months) and LMICs (20.0 months) than HICs (14.0 months; P < 0.001). Patients in UMICs and LMICs reported higher rates of disease-specific metastasis-related mortality and local treatment failure. As compared with HICs, metastasis-related mortality was 10.3-fold higher for UMICs and 9.3-fold higher for LMICs, and the risk for local treatment failure was 2.2-fold and 1.6-fold higher, respectively (all P < 0.001).

CONCLUSIONS

This international, multicenter, registry-based analysis of retinoblastoma management revealed that lower national income levels were associated with significantly higher rates of metastasis-related mortality, local treatment failure, and lower globe salvage.

Travel burden and clinical presentation of retinoblastoma: analysis of 1024 patients from 43 African countries and 518 patients from 40 European countries

BACKGROUND

The travel distance from home to a treatment centre, which may impact the stage at diagnosis, has not been investigated for retinoblastoma, the most common childhood eye cancer. We aimed to investigate the travel burden and its impact on clinical presentation in a large sample of patients with retinoblastoma from Africa and Europe.

METHODS

A cross-sectional analysis including 518 treatment-naïve patients with retinoblastoma residing in 40 European countries and 1024 treatment-naïve patients with retinoblastoma residing in 43 African countries.

RESULTS

Capture rate was 42.2% of expected patients from Africa and 108.8% from Europe. African patients were older (95% CI -12.4 to -5.4, p<0.001), had fewer cases of familial retinoblastoma (95% CI 2.0 to 5.3, p<0.001) and presented with more advanced disease (95% CI 6.0 to 9.8, p<0.001); 43.4% and 15.4% of Africans had extraocular retinoblastoma and distant metastasis at the time of diagnosis, respectively, compared to 2.9% and 1.0% of the Europeans. To reach a retinoblastoma centre, European patients travelled 421.8 km compared to Africans who travelled 185.7 km (p<0.001). On regression analysis, lower-national income level, African residence and older age (p<0.001), but not travel distance (p=0.19), were risk factors for advanced disease.

CONCLUSIONS

Fewer than half the expected number of patients with retinoblastoma presented to African referral centres in 2017, suggesting poor awareness or other barriers to access. Despite the relatively shorter distance travelled by African patients, they presented with later-stage disease. Health education about retinoblastoma is needed for carers and health workers in Africa in order to increase capture rate and promote early referral.

How Telemedicine and Centralized Care Changed the Natural History of Retinoblastoma in a Developing Country: Analysis of 478 Patients

PURPOSE

To evaluate the efficacy of integrating a telemedicine-based twinning partnership and centralized care for retinoblastoma on survival and eye salvage.

DESIGN

Four hundred seventy-eight retinoblastoma patients treated at a tertiary referral cancer center (King Hussein Cancer Centre [KHCC]) from 2003 through 2019.

PARTICIPANTS

Four hundred seventy-eight retinoblastoma patients treated at KHCC after implementing a telemedicine-based program with St. Jude Children's Research Hospital.

METHODS

We reviewed the outcomes of retinoblastoma patients who were treated at KHCC after implementing a telemedicine-based eye salvage program with St. Jude Children's Research Hospital, and we compared that with outcomes for retinoblastoma patients who were treated before implementing a telemedicine-based retinoblastoma service at KHCC.

MAIN OUTCOME MEASURES

We analyzed patient demographics, clinical characteristics, treatments received, consultation type and duration, and long-term patient outcomes before and after implementing the twinning program.

RESULTS

Over 17 years, 813 eyes from 478 children with retinoblastoma were treated at KHCC. Three hundred thirty-five patients (70%) had bilateral disease. Six patients (4%) with unilateral disease and 66 patients (20%) with bilateral disease had a family history of retinoblastoma. After the twinning program was established in 2003, the mortality rate decreased from 38% to 5% (P < 0.0001), and the overall eye salvage rate increased from 4% to 61% (98% for group A, 93% for group B, 81% for group C, and 48% for group D; P < 0.0001). Initially, all cases were discussed via telemedicine, but as knowledge transfer increased, the proportion of cases that required discussion decreased to less than 3% 10 years later. Similarly, treatment changes based on consultations decreased from 70% to 7% after 10 years. Both survival and eye-salvage rates were comparable at the early and later stages of implementing the twinning program. At a median follow-up of 120 months, 5% of patients had died of metastases or secondary neoplasms, 81% were alive, and 14% were lost to follow-up.

CONCLUSIONS

Centralization of care at a single center in developing countries can achieve patient outcomes comparable with those of developed countries via twinning and telemedicine. This benefit can extend to a large region because two thirds of patients treated at KHCC were non-Jordanians.

Teleoncology for children with cancer: A scoping review on applications and outcomes

BACKGROUND AND OBJECTIVES

Teleoncology can be used to reduce the limitations due to the lack of access to specialists, inadequate resources and training, and reducing unnecessary travels and arising of the costs. The purpose of this study was to review the literatures to identify and classify the areas of application and outcomes of using teleoncology in diagnosis, management, and treatment of children with cancer.

METHODS

This scoping review of the published literatures was conducted by searching the Web of Science, PubMed/Medline, Scopus, and Cochrane Library databases in October 2019. Studies investigated telemedicine in diagnosis, management, and treatment of cancer in children were also included. We identified and classified different applications and the reported outcomes of this technology.

RESULTS

In this study, 1834 articles were retrieved, and after removing the unrelated and duplicated articles, 20 articles were reviewed ultimately. We found that, teleoncology services were provided to the patients with cancer, their parents, and nurses in various clinical fields such as telepathology, telemental care (telepsychology), teleneurology, teledermatology, telehematology, and teleophthalmology. The findings also showed that, the outcomes of using telemedicine in children with cancer can be classified into six general categories (five primary and 14 secondary outcomes). Primary outcomes including diagnosis accuracy, reduced costs as well as mortality and secondary outcomes consist of improved relationship and training, better care management, satisfaction, and workload.

CONCLUSION

The use of telemedicine for children with cancer is growing, and there is a tendency for using this technology for families and clinical staff. Providing teleoncology services to children with cancer may improve diagnosis accuracy and reduce the cost and mortality rate. Also, better care management, appropriate relationships and training, increased satisfaction, and decreased workload may be achieved.

Global Retinoblastoma Presentation and Analysis by National Income Level

Importance

Early diagnosis of retinoblastoma, the most common intraocular cancer, can save both a child's life and vision. However, anecdotal evidence suggests that many children across the world are diagnosed late. To our knowledge, the clinical presentation of retinoblastoma has never been assessed on a global scale.

Objectives

To report the retinoblastoma stage at diagnosis in patients across the world during a single year, to investigate associations between clinical variables and national income level, and to investigate risk factors for advanced disease at diagnosis.

Design, Setting, and Participants

A total of 278 retinoblastoma treatment centers were recruited from June 2017 through December 2018 to participate in a cross-sectional analysis of treatment-naive patients with retinoblastoma who were diagnosed in 2017.

Main Outcomes and Measures

Age at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis.

Results

The cohort included 4351 new patients from 153 countries; the median age at diagnosis was 30.5 (interquartile range, 18.3-45.9) months, and 1976 patients (45.4%) were female. Most patients (n = 3685 [84.7%]) were from low- and middle-income countries (LMICs). Globally, the most common indication for referral was leukocoria (n = 2638 [62.8%]), followed by strabismus (n = 429 [10.2%]) and proptosis (n = 309 [7.4%]). Patients from high-income countries (HICs) were diagnosed at a median age of 14.1 months, with 656 of 666 (98.5%) patients having intraocular retinoblastoma and 2 (0.3%) having metastasis. Patients from low-income countries were diagnosed at a median age of 30.5 months, with 256 of 521 (49.1%) having extraocular retinoblastoma and 94 of 498 (18.9%) having metastasis. Lower national income level was associated with older presentation age, higher proportion of locally advanced disease and distant metastasis, and smaller proportion of familial history of retinoblastoma. Advanced disease at diagnosis was more common in LMICs even after adjusting for age (odds ratio for low-income countries vs upper-middle-income countries and HICs, 17.92 [95% CI, 12.94-24.80], and for lower-middle-income countries vs upper-middle-income countries and HICs, 5.74 [95% CI, 4.30-7.68]).

Conclusions and Relevance

This study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs.

Challenge of Retinoblastoma in Mexico in 2020: Perspectives and Solutions

Early diagnosis and positive outcomes of retinoblastoma in childhood have been positively correlated with the economic wealth of high-income countries (HICs) worldwide. Adequate curability and survival rates, adherence to treatment, presence of poor prognostic initial clinical signs, and metastatic disease at diagnosis appear to have a less favorable picture in low-income countries (LICs). However, this is not always the case. An example is Argentina, where disease-free survival rates of retinoblastoma are notably higher than expected when taking into consideration its economic situation. Unfortunately, as in other Latin American LICs, retinoblastoma outcomes in Mexico are worrisome. Interestingly, the Human Development Index (HDI) in Mexico varies widely between its different geographical regions. While in some states, the HDI resembles those of high-income countries, and in others, the opposite is observed. A unifying picture of Mexico's developmental status, health resources, indicators, and other factors possibly influencing outcomes in retinoblastoma is currently unavailable. The present review explores the previously mentioned factors in Mexico and compares them to other countries. Additionally, it recommends solutions or enhancements where possible.

Identifying barriers to treatment of childhood rhabdomyosarcoma in resource-limited settings: A literature review

We performed a literature review to examine barriers for rhabdomyosarcoma treatment in low-resource settings, and identified 29 articles from 14 middle-income countries, with none from low-income countries. Notable findings included inconsistent use of local control modalities, lack of diagnostics in some settings, and high rate of abandonment specifically in low middle-income countries. Reported limitations included lack of surgical expertise and/or radiation therapy, advanced stage of disease, and absence of health insurance. Although very poor outcomes were prevalent in several settings, good outcomes were achievable in others when multidisciplinary therapy and financial coverage of medical care were made available.

The Latin American Brain Tumor Board teleconference: results of a web-based survey to evaluate participant experience utilizing this resource

PURPOSE

The Latin American Brain Tumor Board (LATB) is a weekly teleconference connecting pediatric neuro-oncologists from referral centers in high-income countries with pediatric subspecialists from 20 Latin American countries since 2013. This survey explored the participants' experience utilizing this resource.

METHODS

A cross-sectional electronic questionnaire was distributed to 159 participants through email and Cure4Kids.

RESULTS

Ninety-five respondents (60%) from all the participating countries completed the survey. Sixty-one reported frequent-attendance (≥ 1 per month), 23 reported infrequent-attendance (< 1 per month), and 11 never participated. The most frequently reported attendance-barriers were the subspecialist's workload (64%), the timing of the teleconference (38%), and Internet connectivity problems (29%). Subspecialist's workload was more frequently reported as a barrier compared with other barriers, in both the frequent- and infrequent-attendance groups (p < 0.05), with the exception of the timing of the meeting in the infrequent-attendance group. More than 80% of attendees found the frequency and duration of the teleconference were sufficient. Utilizing Spanish as the primary language was reported to enhance the recommendations by 93% of the attendees. Moreover, 84% reported that the recommendations (almost) always fit the local circumstances. Furthermore, 99% of attendees found the teleconference provided a continuing medical education opportunity. Finally, 96% of attendees (almost) always found that the provided recommendations helped to improve the outcomes/quality of life of the patients.

CONCLUSIONS

The LATB teleconference provided a valuable tool for the management of pediatric brain tumors in Latin America as it provided a feasible and easy to access continued medical education opportunity for the participants.

The Impact of Prospective Telemedicine Implementation in the Management of Childhood Acute Lymphoblastic Leukemia in Recife, Brazil

BACKGROUND

A gap in childhood cancer outcomes remains between developed and developing countries. Persistence of this gap may be caused by financial, social, or educational disparities. Twinning and distance learning initiatives may improve such disparities. Integrating telemedicine into pediatric oncology twinning programs enhances education and facilitates patient-centered capacity building.

MATERIALS AND METHODS

We performed an analysis of Web-based meetings held from August 2005 through July 2009 between the International Outreach Program at St. Jude Children's Research Hospital and the Instituto Materno Infantil de Pernambuco (IMIP) in Recife, Brazil. We determined the effect of these online conferences on the development and implementation of an innovative protocol for children with acute lymphoblastic leukemia (ALL) at IMIP.

RESULTS

Meetings occurred in 45 months of the 48-month study period with an average of two meetings per month. A total of 163 new patients were discussed during the study period; we retrieved documentation of patient-related discussions for 147 of them, constituting 286 discussions. On average, each patient was discussed 1.9 times (range, 1-15 discussions/patient). Compared with that of the era predating the online meetings (1993-2005), overall mortality, early death, and relapse of patients with ALL decreased after the telemedicine program was instituted at IMIP.

DISCUSSION

Personal dedication and institutional support are essential for successful telemedicine initiatives. Documentation and archival of meetings are important for accurately measuring outcomes and developing methods for improved care.

CONCLUSIONS

Integration of telemedicine into twinning programs facilitates communication about interventions, leading to improved outcomes of pediatric patients with cancer.

Video-Teleconferencing in Pediatric Neuro-Oncology: Ten Years of Experience

Purpose

The management of central nervous system tumors is challenging in low- and middle-income countries. Little is known about applicability of twinning initiatives with high-income countries in neuro-oncology. In 2004, a monthly neuro-oncology video-teleconference program was started between King Hussein Cancer Center (Amman, Jordan) and the Hospital for Sick Children (Toronto, Ontario, Canada). More than 100 conferences were held and > 400 cases were discussed. The aim of this work was to assess the sustainability of such an initiative and the evolution of the impact over time.

Methods

We divided the duration in to three eras according to the initial 2 to 3 years of work of three consecutive oncologists in charge of the neuro-oncology program at King Hussein Cancer Center. We retrospectively reviewed the written minutes and compared the preconference suggested plans with the postconference recommendations. Impact of changes on the patient care was recorded.

Results

Thirty-three sets of written minutes (covering 161 cases) in the middle era and 32 sets of written minutes (covering 122 cases) in the last era were compared with the initial experience (20 meetings, 72 cases). Running costs of these conferences has dropped from $360/h to < $40/h. Important concepts were introduced, such as multidisciplinary teamwork, second-look surgery, and early referral. Suggestions for plan changes have decreased from 44% to 30% and 24% in the respective consecutive eras. Most recommendations involved alternative intervention modalities or pathology review. Most of these recommendations were followed.

Conclusion

Video-teleconferencing in neuro-oncology is feasible and sustainable. With time, team experience is built while the percentage and the type of treatment modifications change. Commitment and motivation helped maintain this initiative rather than availability of financial resources. Improvement in patients’ care was achieved, in particular, with the implementation of a multidisciplinary team and the continuous effort to implement recommendations.

Disparities in Retinoblastoma Presentation, Treatment, and Outcomes in Developed and Less-Developed Countries

Retinoblastoma (RB) is the most common intraocular malignancy in children. In the past century, RB survival rates in developed countries (DCs) have improved from <5% to as high as 99%. In contrast, in less developed countries (LDCs) where the tumor burden is greatest, survival rates remain poor, with some countries reporting survival rates as low as 0-5%. In addition, there are disparities between DCs and LDCs in RB presentation, treatment modalities, and prognosis. These disparities are due to many underlying causes, including delays in diagnosis, access to medical care, patient and physician familiarity with the disease, availability and cost of treatment, and patient acceptance of enucleation. It is our belief that attempts to extend the improvements in prognosis achieved in DCs to various LDCs must be culturally sensitive and tailored to each country's specific challenges, and thus, a "one-size-fits-all" approach to improving patient outcomes in LDCs is unlikely to work well. We discuss several culturally sensitive approaches that have been successfully implemented in various LDCs, including those that make use of telemedicine and "twinning" with centers of excellence around the world.

Retinoblastoma

Retinoblastoma is a rare cancer of the infant retina that is diagnosed in approximately 8,000 children each year worldwide. It forms when both retinoblastoma gene (RB1) alleles are mutated in a susceptible retinal cell, probably a cone photoreceptor precursor. Loss of the tumour-suppressive functions of the retinoblastoma protein (pRB) leads to uncontrolled cell division and recurrent genomic changes during tumour progression. Although pRB is expressed in almost all tissues, cone precursors have biochemical and molecular features that may sensitize them to RB1 loss and enable tumorigenesis. Patient survival is >95% in high-income countries but <30% globally. However, outcomes are improving owing to increased disease awareness for earlier diagnosis, application of new guidelines and sharing of expertise. Intra-arterial and intravitreal chemotherapy have emerged as promising methods to salvage eyes that with conventional treatment might have been lost. Ongoing international collaborations will replace the multiple different classifications of eye involvement with standardized definitions to consistently assess the eligibility, efficacy and safety of treatment options. Life-long follow-up is warranted, as survivors of heritable retinoblastoma are at risk for developing second cancers. Defining the molecular consequences of RB1 loss in diverse tissues may open new avenues for treatment and prevention of retinoblastoma, as well as second cancers, in patients with germline RB1 mutations.

Histopathologic Diagnosis of Pediatric Neoplasms: A Review of International Consultations

Context.—Correct histopathologic diagnosis is fundamental to defining proper treatment and improving outcomes in children with malignancies. The Department of Pathology at St. Jude Children's Research Hospital (SJCRH) has collaborated with SJCRH International Outreach Program partner sites to improve the accuracy of histopathologic diagnoses in countries with limited resources. Pathologists at SJCRH provide review and evaluation of cases that are considered difficult or complex.

Objectives.—To determine the quality of pathology diagnosis and to identify areas for improvement in our international partner sites, we retrospectively analyzed all the international cases that were submitted for review. A comparison of our data with selected reports of surgical pathology error rates published in the medical literature was performed.

Design.—From January 2009 through December 2011, SJCRH received 763 cases submitted by international pathologists from 37 countries for histopathologic review and evaluation. Of 763 cases reviewed, 705 (92.4%) met the criteria for inclusion in this study. Rates of concordance between the submitted diagnoses and SJCRH reviewed diagnoses were analyzed.

Results.—Overall concordance, minor disagreement, and major disagreement rates between submitted diagnoses and SJCRH reviewed diagnoses were 430 (61.0%), 98 (13.9%), and 177 (25.1%) of the cases, respectively. Major disagreement rates ranged from 13.7% to 37.1% among studied countries.

Conclusions.—The major disagreement rate between referring international sites and SJCRH was substantially higher than the major disagreement rate among US institutions. Lack of the availability of immunohistochemistry and the training of pathologists in the diagnosis of pediatric neoplasms may have contributed to the discrepancies.

SIOP-PODC recommendations for graduated-intensity treatment of retinoblastoma in developing countries

Retinoblastoma remains incurable in many regions of the world. The major obstacles to cure are delayed diagnosis, poor treatment compliance, and lack of evidence-based recommendations for clinical management. Although enucleation is curative for intraocular disease, in developing countries retinoblastoma is often diagnosed after the disease has disseminated beyond the eye. A SIOP-PODC committee generated guidelines for the clinical management of retinoblastoma in developing countries and developed a classification system based on the resources available in those settings. Recommendations are provided for staging and treatment of unilateral and bilateral retinoblastoma and counseling of families for whom compliance is an issue.

"Retinoblastoma survival disparity": The expanding horizon in developing countries

The patients' survival for the most common intraocular tumor in children, retinoblastoma, has a wide spectrum among the world countries. This study was conducted to provide an overview of the retinoblastoma survival disparity worldwide by discussing the trends of patients' survival, as well as recent advances in the management of retinoblastoma. The design of this study was literature review and commentary. Selected articles from PubMed (except one) including both developing and developed countries regarding the patients' survival in retinoblastoma were considered and reviewed critically. An analysis of 47 articles was performed. In conclusion, in spite of an obvious contrast of retinoblastoma survival disparity in the world, the expanding horizons in developing countries are promising and continuing on all fronts and results are hope-inspiring.

Practical steps for establishing ocular plaque therapy in developing countries

INTRODUCTION

Retinoblastoma and uveal melanoma are the most common ocular tumors in children and adults, respectively. Enucleation and external beam radiation therapy are integral in the management of ocular tumors. However, these tumors could also be treated effectively by plaque therapy, which has the potential of preserving the globe and maintaining vision.

METHODS AND MATERIALS

We reviewed our experience with the introduction of this technique to our center. Furthermore, we highlighted the critical role of a specialized multidisciplinary team in the successful implementation of this procedure.

DISCUSSION

This review represents a detailed report addressing the practical steps for successfully establishing plaque therapy in developing countries.

RESULTS

Plaque therapy was successfully implemented at our center in 1.5 years. Integration with an advanced cancer center is crucial for the correct transfer of this complex technology.

CONCLUSION

Complex brachytherapy procedures could be successfully established and implemented in developing countries.

Tele-practice guidelines for the symptom management of children undergoing cancer treatment

The provision of tele-practice symptom management is often without the provision of evidence-based guidelines. Under the auspices of the Pediatric Oncology Group of Ontario, a nursing task force was established to appraise the evidence and develop guidelines. Promising new efforts to enhance symptom management through tele-practice are emerging. Seven guidelines and one documentation tool were created from evidence compiled from case reports, clinical examples, and nonexperimental studies. The symptom management guidelines contribute to the paucity of literature and may serve as a useful resource for health professionals providing telephone advice and conducting tele-practice symptom management assessments.

Clinical presentation and outcome of retinoblastoma among children treated at the National Cancer Institute (NCI) in Gezira, Sudan: a single Institution experience

BACKGROUND

Retinoblastoma (RB) is a rare and unique cancer that affects the eyes of very young children. There are few reports on RB in Sudan.

MATERIALS AND METHODS

We performed a retrospective study of data from patients diagnosed with retinoblastoma between January 1999 and December 2009 at the National Cancer Institute in Gezira (NCI-Gezira).

RESULTS

Of the 519 cases of childhood cancer treated at NCI-Gezira during the study period, 25 (4.8%) were retinoblastoma. Of these 25 patients with retinoblastoma, there were 13 boys and 19 cases were unilateral. The median age at diagnosis was 36 months (range, 8-60 months). The disease was localized in 9 patients, regional in 5 patients, and metastatic in 11 patients. The most frequent symptoms were enlarged eye (n = 14) and leukocoria (n = 8). Nine patients (36%) have been lost to follow-up; 9 were alive at last follow-up (7 in remission, 2 progressed); and 7 have died (5 from disease and 2 from unrelated causes). Twenty-two eyes were enucleated in 16 patients (6 bilateral and 10 unilateral). Pathologic examination of the enucleated eyes could only be completed in 11 patients. Diagnostic imaging in the form of computerized tomography scans or ultrasonography of the brain and orbit was done for 10 patients (40%).

CONCLUSIONS

Although these findings are not surprising, and similar to reports from other developing countries, we hope our work will provide a foundation for strategies to improve outcome for retinoblastoma in our center such as proper training, public awareness, team approach, and twinning.

Strategies to manage retinoblastoma in developing countries

Survival of retinoblastoma is >90% in developed countries but there are significant differences with developing countries in stage at presentation, available treatment options, family compliance, and survival. In low-income countries (LICs), children present with advanced disease, and the reasons are socioeconomic and cultural. In middle-income countries (MICs), survival rates are better (>70%), but there is a high prevalence of microscopically disseminated extraocular disease. Programs for eye preservation have been developed, but toxicity-related mortality is higher. Although effective treatment of microscopically extraocular disease improved the outcome, worldwide survival will be increased only by earlier diagnosis and better treatment adherence.

Teleoncology: current and future applications for improving cancer care globally

Access to quality cancer care is often unavailable in low-income and middle-income countries, and also in rural or remote areas of high-income countries. Teleoncology-oncology applications of medical telecommunications, including pathology, radiology, and other related disciplines-has the potential to enhance access to and quality of clinical cancer care, and to improve education and training. Implementation of teleoncology in the developing world requires an approach tailored to priorities, resources, and needs. Teleoncology can best achieve its proposed goals through consistent and long-term application. We review teleoncology initiatives that have the potential to decrease cancer-care inequality between resource-poor and resource-rich institutions and offer guidelines for the development of teleoncology programmes in low-income and middle-income countries.

Familial retinoblastoma in developing countries

BACKGROUND

Although screening for familial retinoblastoma has been shown to be beneficial we suspected that such screening programs may be less than optimal in developing countries (DC).

METHODS

Retrospective cohort study comparing patients with familial retinoblastoma from five centers in DC (Argentina, Brazil, Turkey, Jordan, and Venezuela) versus a reference center in the USA.

RESULTS

Ninety-two (32 from the USA and 60 from DC) patients were included. Forty-one (44.6%) patients avoided enucleation, 42 (45.7%) had 1 eye removed, and 9 (9.8%) underwent bilateral enucleation. Eleven (11.9%) had major pathology risk factors at enucleation. There were no cases of metastatic disease at diagnosis. Detection via screening was significantly less common in DC than in the USA (23.3% vs. 71.8%, P < 0.0001). Patients in DC were diagnosed at a significantly later age and with more advanced intraocular disease that led to increased risk of bilateral enucleation. Patients detected by screening in DC were significantly younger at diagnosis, had less advanced intraocular disease, better ocular preservation rates and survival results than those whose retinoblastoma was not detected via early screening. Five-year pEFS was 0.92 for the patients treated in the USA and 0.81 for the patients in DC (P = 0.42). Seven events occurred (extraocular relapse four in patients from DC and second malignancies in three).

CONCLUSIONS

Patients with familial retinoblastoma are less likely to be diagnosed by screening in DC and had higher morbidity and mortality caused by recurrent extraocular retinoblastoma.

Retinoblastoma: the challenges of management in Ibadan, Nigeria

BACKGROUND

Retinoblastoma is a common highly malignant tumor of the eye. Late presentation leads to poor survival rate in many developing countries.

OBJECTIVE

To identify problems associated with management of retinoblastoma.

METHODS

A retrospective review of cases of retinoblastoma at the University College Hospital, Ibadan, between January 1992 and December 2007.

RESULTS

A total of 32 eyes of 26 patients were studied. Sixteen were males and 10 were females. Minimum age at presentation was 4 months and maximum age was 60 months (mean 30.69+/-14.2 mo). Over 90% presented after 1 month of onset. Reasons for late diagnosis included late presentation for unknown reasons, missed diagnosis, and mismanagement in a previous hospital. Eleven of 26 patients defaulted to avoid removal of the eye, and treatment was only completed in 5 patients. Problems included financial constraint regarding investigations and procurement of drugs, as well as availability of the chemotherapy.

CONCLUSIONS

Retinoblastoma is a problematic malignancy of childhood associated with management problems often related to difficulty with patients accepting removal of the affected eye and financial constraint for treatment.

Development of retinoblastoma programs in Central America

BACKGROUND

Retinoblastoma, a curable eye tumor, is associated with poor survival in Central America (CA). To develop a retinoblastoma program in El Salvador, Guatemala, and Honduras, twinning initiatives were undertaken between local pediatric oncology centers, nonprofit foundations, St. Jude Children's Research Hospital, and the University of Tennessee Hamilton Eye Institute.

PROCEDURE

The retinoblastoma program focused on developing early diagnosis programs in Honduras with national vaccination campaigns, developing treatment protocols suited to local conditions, building local networks of oncologists and ophthalmologists, training local healthcare providers, using modern donated equipment for diagnosis and treatment, and the ORBIS Cybersight consultation program and Internet meetings to further education and share expertise. Pediatric ophthalmologists and oncologists worked with foundations to treat patients locally with donated equipment and Internet consultations, or at the center in Guatemala.

RESULTS

Number of patients successfully treated increased after the program was introduced. For 2000-2003 and 2004-2007, patients abandoning/refusing treatment decreased in Guatemala from 20 of 95 (21%) to 14 of 123 (11%) and in Honduras from 13 of 37 (35%) to 7 of 37 (19%). Survival in El Salvador was good and abandonment/refusal low for both periods. Of 18 patients receiving focal therapy for advanced disease, 14 have single remaining eyes.

CONCLUSION

Development of the program in CA has decreased abandonment/refusal and enabled ophthalmologists at local centers to use modern equipment to provide better treatment. This approach might serve as a guide for developing other multispecialty programs.

Diffuse pontine glioma in Jordan and impact of up-front prognosis disclosure with parents and families

For patients with diffuse pontine glioma, our institution offers local radiotherapy and supportive care only. The prognosis and do-not-resuscitate orders are discussed upfront with patients' parents. To investigate the effectiveness of this policy, we retrospectively reviewed records of patients with diffuse pontine glioma treated at the institution over a 49-month period. This study included 19 children (16 girls and 3 boys). The median age at diagnosis was 7 years. One patient remained alive at the end of the study, 2 were lost to follow-up, and 16 were confirmed dead. The median survival was 8.2 months. Do-not-resuscitate discussion was documented for 14 patients and successfully initiated for 11. None of those confirmed dead had been offered life support. Contrary to the common belief, our study showed that do not resuscitate should be addressed in Muslim patients with high-risk malignancies. We also found that diffuse pontine glioma warrants further study in developing countries.

Clinical nurse coordinators: a new generation of highly specialized oncology nursing in Jordan

Despite the important role of nurses in a pediatric oncology team, the marginalization of nursing is common, especially in developing countries. At the King Hussein Cancer Center (KHCC) in Jordan, the position of the clinical nurse coordinator (CNC) was created in the pediatric neuro-oncology and ocular oncology services to empower the role of nursing. Our advanced nursing practice is based on the domains of the Strong Model of Advanced Practice, which are direct patient care, support of systems, education, research and publications, and professional leadership. There is strong involvement of the CNC in clinical care, patient education, follow-up, and interdisciplinary collaboration, which has resulted in improved survival, reduced morbidity, and increased compliance of patients and also their successful reintegration into society. The coordination of twinning initiatives and telemedicine activities has helped ensure the quality of treatment and supported research initiatives in the services. Such a positive impact has led to a significant increase in the recruitment of CNCs at KHCC. We propose that the role of nursing be strengthened in developing countries to improve the level of care provided to patients and their families.

Retinoblastoma: what is new in 2007-2008

PURPOSE OF REVIEW

This review highlights many of the most important articles published from June 2007 to May 2008 on retinoblastoma. Significant advances in molecular biology, translational research, and clinical reports are detailed.

RECENT FINDINGS

The most significant recent findings in the molecular biology of retinoblastoma include the evidence for aneuploidy and genomic instability as cancer causes rather than the long-held Knudson's 'two-hit' hypothesis; the evidence that retinoma may represent a precursor lesion for retinoblastoma prior to the acquisition of genomic instability; and the evidence that a horizontal interneuron may be the cell of origin in murine knockout retinoblastoma and may be capable of clonal expansion after differentiation. Translational studies also demonstrate promise for the use of topotecan and 2-deoxy-D-glucose in children. Finally, the introduction of intraarterial chemotherapy for human intraocular retinoblastoma appears to be safe and effective and may eliminate the need for enucleation in many patients.

SUMMARY

Exciting new advances in both the basic science and clinical applications of new therapies continue to emerge for this rare disease. We expect that local control rates even for advanced intraocular retinoblastoma will soon reach 100% in the developed world as a result of new findings in the clinic and in the laboratory.