Interventions to improve early detection of childhood cancer in low- and middle-income countries: A systematic review

Childhood Cancer Awareness Program in Bungoma County, Kenya

BACKGROUND

Awareness could play a key role in reducing underdiagnosis and accelerating referral of childhood cancer in low- and middle-income countries and ultimately improve outcomes. This study describes the implementation of a childhood cancer awareness program in Bungoma County in Kenya, containing five components: (1) baseline data collection of primary healthcare facilities; (2) live training session for healthcare providers (HCP); (3) early warning signs posters; (4) online SMS course for HCP; and (5) radio campaign.

METHODS

This study was conducted between January and June 2023. All 144 primary healthcare facilities (level 2 and 3 health facilities) within Bungoma County were visited by the field team.

RESULTS

All 125 level 2 (87%) and 19 level 3 (13%) facilities participated in the study. National Health Insurance Fund (NHIF) failed to cover services in 37 (26%) facilities. HCP were more often reported absent at level 3 (89%) than level 2 (64%) facilities (P = 0.034). The 144 live training sessions were attended by over 2000 HCP. Distribution of 144 early warning signs posters resulted in 50 phone calls about suspected childhood cancer cases. Sixteen children were later confirmed with childhood cancer and treated. Online SMS learning was completed by 890 HCP. Knowledge mean scores improved between pre-test (7.1) and post-test (8.1; P < 0.001). Finally, 540 radio messages about childhood cancer and a live question-and-answer session were broadcasted.

CONCLUSION

This study described the implementation of a childhood cancer awareness program in Kenya involving both HCP and the general public. The program improved HCP's knowledge and increased the number of referrals for children with cancer.

Stigma in Pediatric Cancer: An Exploratory Study of Osteosarcoma and Retinoblastoma in Guatemala, Jordan, and Zimbabwe

PURPOSE

Stigma is an understudied barrier to health care acceptance in pediatric oncology. We sought to explore the stigma experience, including its impact on cancer treatment decision making, and identify strategies to mitigate stigma for patients with osteosarcoma and retinoblastoma in Guatemala, Jordan, and Zimbabwe.

METHODS

Participants included caregivers, adolescent patients (age 12-19 years), and health care clinicians. A semistructured interview guide based on The Health Stigma and Discrimination Framework (HSDF) was adapted for use at each site. Interviews were conducted in English, Spanish, Arabic, or Shona, audio-recorded, translated, and transcribed. Thematic analysis focused on stigma practices, experiences, outcomes, drivers, mitigators, and interventions.

RESULTS

We conducted 56 interviews (28 caregivers, 19 health care clinicians, nine patients; 20 in Guatemala, 21 in Jordan, 15 in Zimbabwe). Major themes were organized into categories used to adapt the HSDF to global pediatric cancer care. Themes were described similarly across all sites, ages, and diagnoses, with specific cultural nuances noted. Pediatric cancer stigma was depicted as an isolating and emotional experience beginning at diagnosis and including internalized and associative stigma. Stigma affected decision making and contributed to negative outcomes including delayed diagnosis, treatment abandonment, regret, and psychosocial fragility. Overcoming stigma led to positive outcomes including resilience, treatment adherence, pride, and advocacy. Identified stigma drivers and mitigators were linked to potential interventions.

CONCLUSION

Participants describe a shared stigma experience that transcends geography, cultural context, age, and diagnosis. Stigma manifestations have the potential to impact medical decision making and affect long-term psychological outcomes. Stigma assessment tools and interventions aimed at stigma mitigation including educational initiatives and support groups specific to pediatric cancer should be the focus of future research.

Determining the cost and cost-effectiveness of childhood cancer treatment in Haiti

Haiti is a low-income country with one of the lowest human development index rankings in the world. Its childhood cancer services are provided by a single hospital with the only dedicated paediatric oncology department in the country. Our objective was to assess the cost and cost-effectiveness of all types of childhood cancer in Haiti to help prioritise investments and to support national cancer control planning. All costing data were collected from the year 2017 or 2018 hospital records. Costs were classified into 11 cost categories, and the proportion of the overall budget represented by each was calculated and converted from Haitian Gourde to United States dollars. The 5-year survival rate was retrieved from hospital records and used to calculate the cost-effectiveness of disability-adjusted life year (DALY) averted, using a healthcare costing perspective. Additional sensitivity analyses were conducted accounting for late-effect morbidity and early mortality and discounting rates of 0%, 3% and 6%. The annual cost of operating a paediatric oncology unit in Haiti treating 74 patients with newly diagnosed cancer was $803,184 overall or $10,854 per patient. The largest cost category was pharmacy, constituting 25% of the overall budget, followed by medical personnel (20%) and administration (12%). The cost per DALY averted in the base-case scenario was $1,128, which is 76% of the gross domestic product per capita, demonstrating that treating children with cancer in Haiti is very cost-effective according to the World Health Organisation Choosing Interventions that are Cost-Effective (WHO-CHOICE) threshold. In the most conservative scenario, the cost per DALY averted was cost-effective by WHO-CHOICE criteria. Our data will add to the growing body of literature illustrating a positive return on investment associated with diagnosing and treating children with cancer in even the most resource-limited environments. We anticipate that these data will aid local stakeholders and policymakers when identifying cancer control priorities and making budgetary decisions.

Collaboration for success: the Global Initiative for Childhood Cancer in Latin America

The Global Initiative for Childhood Cancer (GICC) aims to increase the cure rate for children with cancer globally by improving healthcare access and quality. The Pan American Health Organization (PAHO), St. Jude Children's Research Hospital (St. Jude), and collaborators have joined efforts to improve outcomes of children with cancer in Latin America and the Caribbean (LAC) using the CureAll framework. In this article, we describe the process of developing regional resources aimed at accelerating the GICC implementation in LAC. In March 2021, PAHO formed regional working groups to develop core projects aligned with CureAll pillars and enablers. Seven working groups emerged from regional dialogues: early detection, nursing, psychosocial, nutrition, supportive care, treatment abandonment, and palliative care. PAHO arranged regular online meetings under the mentorship and support of St. Jude regional/transversal programs and international mentors. Between April and December 2021, 202 multidisciplinary experts attended 43 online meetings to promote the dialogue between stakeholders to improve childhood cancer outcomes. Fourteen technical outputs were produced: four regional snapshots, four technical documents, two virtual courses, one set of epidemiological country profiles, one educational content series for parents/caregivers, and two communication campaigns. The ongoing dialogue and commitment of PAHO, St. Jude, LAC working committees, and international collaborators are essential foundations to successfully accelerate GICC implementation. This is achievable through the development of materials of regional and global relevance. Further research and evaluation are needed to determine the impact of these strategies and resources on childhood cancer outcomes in LAC and other regions.

Late Effects of Childhood Cancer Survivors in Africa: a Scoping Review

INTRODUCTION

The number of children surviving cancer in Africa is increasing. Knowledge about late effects of survivors is lacking. Our study maps literature regarding late effects of childhood cancer survivors in Africa.

METHODS

Scoping review was performed following JBI-guidelines. Systematic literature search was conducted in: Medline, Embase, African Index Medicus, Web of Science, Scopus, Psycinfo. Titles and abstracts were screened by two reviewers, followed by full-text analysis by the lead reviewer.

RESULTS

Sixty-eight studies were included for content analysis. Studies originated from 10 of 54 African countries. Most studies had retrospective study design, 2-5 years follow-up, solely chemotherapy as treatment modality, Egypt as country of origin. Fifty-three studies described physical, and seventeen studies described psychosocial late effects.

CONCLUSION

Literature concerning late effects is available from a limited number of African countries. Psychosocial domain lacks attention compared to the physical domain. More countries should report on this topic to prevent, identify and monitor late effects.

Evaluation of a Health Care Worker Training Intervention to Improve the Early Diagnosis and Referral of Childhood Cancers in Ghana: A Qualitative Descriptive Study

PURPOSE

This study sought to (1) evaluate the perceived effectiveness of an early childhood cancer warning signs and symptoms (EWSS) training intervention on health care worker (HCW) knowledge, attitudes, and clinical practice; (2) evaluate the ease of implementation of training received, including potential barriers and facilitators; and (3) provide insights into program improvements for future iterations of the intervention.

METHOD

Using a qualitative descriptive study design, we conducted in-depth, semistructured interviews with 23 purposively sampled Ghanaian HCW recipients of the EWSS training intervention. We undertook iterative thematic analysis of data concurrently with interviews and used a modified version of the theoretical framework of acceptability to guide the evaluation of the training intervention.

RESULTS

We identified six themes-affective attitude, burden, intervention coherence, perceived effectiveness, self-efficacy, and quality improvement-that structure participant perceptions of the effectiveness of the EWSS training. Participants generally had a positive attitude to the training intervention, found the content relatively easy to understand, and communicated the positive impacts of the training on their day-to-day practice. However, they also identified patient- and system-level challenges to the real-world implementation of intervention components, including patients' cultural and religious beliefs about illnesses, patients' financial constraints, and inadequately funded health systems.

CONCLUSION

Our findings suggest that although an HCW-focused training intervention has the potential to improve timely diagnosis and referral for childhood cancers in Ghana and comparable health system contexts, complementary interventions to address patient- and system-level implementation challenges are required to translate improvements in HCW knowledge to sustained impact on health outcomes for children with cancer.

Economic Perspective of Cancer Care and Its Consequences for Vulnerable Groups

Simple Summary

For cancer patients, many different reasons can cause financial burdens and economic threads. Sociodemographic factors, rural/remote location and income are known determinants for these vulnerable groups. This economic vulnerability is related to the reduced utilization of cancer care and the impact on outcome. Financial burden has been reported in many countries throughout the world and needs to be addressed as part of the sufficient quality of cancer care.

Abstract

Within healthcare systems in all countries, vulnerable groups of patients can be identified and are characterized by the reduced utilization of available healthcare. Many different reasons can be attributed to this observation, summarized as implementation barriers involving acceptance, accessibility, affordability, acceptability and quality of care. For many patients, cancer care is specifically associated with the occurrence of vulnerability due to the complex disease, very different target groups and delivery situations (from prevention to palliative care) as well as cost-intensive care. Sociodemographic factors, such as educational level, rural/remote location and income, are known determinants for these vulnerable groups. However, different forms of financial burdens likely influence this vulnerability in cancer care delivery in a distinct manner. In a narrative review, these socioeconomic challenges are summarized regarding their occurrence and consequences to current cancer care. Overall, besides direct costs such as for treatment, many facets of indirect costs including survivorship costs for the cancer patients and their social environment need to be considered regarding the impact on vulnerability, treatment compliance and abundance. In addition, individual cancer-related financial burden might also affect the society due to the loss of productivity and workforce availability. Healthcare providers are requested to address this vulnerability during the treatment of cancer patients.

Prevention and Management of High-Burden Noncommunicable Diseases in School-Age Children: A Systematic Review

BACKGROUND AND OBJECTIVES

Noncommunicable diseases (NCDs) are chronic conditions requiring health care, education, social and community services, addressing prevention, treatment, and management. This review aimed to summarize and synthesize the available evidence on interventions from systematic reviews of high-burden NCDs and risk factors among school-aged children.

METHODS

The following databases were used for this research: Medline, Embase, The Cochrane Library, and the Campbell library. The search dates were from 2000 to 2021. We included systematic reviews that synthesized studies to evaluate intervention effectiveness in children aged 5 to 19 years globally. Two reviewers independently extracted data and assessed methodological quality of included reviews using the AMSTAR 2 tool.

RESULTS

Fifty studies were included. Asthma had the highest number of eligible reviews (n = 19). Of the reviews reporting the delivery platform, 27% (n = 16) reported outpatient settings, 13% (n = 8) home and community-based respectively, and 8% (n = 5) school-based platforms. Included reviews primarily (69%) reported high-income country data. This may limit the results' generalizability for school-aged children and adolescents in low- and middle- income countries.

CONCLUSIONS

School-aged children and adolescents affected by NCDs require access to quality care, treatment, and support to effectively manage their diseases into adulthood. Strengthening research and the capacity of countries, especially low- and middle- income countries, for early screening, risk education and management of disease are crucial for NCD prevention and control.

Adolescent and young adult cancers in India-Findings from the National Cancer Registry Programme

BACKGROUND

The adolescent and young adult (AYA) age group is a bridge between pediatric and adult age groups. The present study describes the epidemiology of cancers in the AYA age group in India.

METHODS

The data of primary site cancers in the age group of 15-39 years from the 28 Population Based Cancer Registries (PBCRs') and 58 Hospital Based Cancer Registries under the National Cancer Registry Programme for the reporting year 2012-2016 was analysed.

RESULTS

The median age adjusted incidence rate (AAR) was 22.2 per 100,000 among males and 29.2 per 100,000 among females. The age-specific incidence rate increased with increasing age in both genders with the highest recorded numbers in the 35-39 age group. The proportion of myeloid leukaemia and non-Hodgkin's lymphoma was highest in the 15-24 age group. Cancers of the breast, thyroid, mouth and tongue constituted the leading sites between 30 and 39 years. There was a significant increase in the incidence among AYA males (APC=0.9) between 1985 and 2015, while a decline in incidence was observed for females, which was not significant (APC=-0.2). The majority of patients had locoregional spread of cancer at the time of diagnosis. The projected number of cancer cases in both genders are expected to increase to 178,617 in 2025.

CONCLUSION

Cancers in the AYA population are a concern in India. Since AYA oncology appears to be evolving in India, a robust health care system and suitable AYA cancer care policies and programmes are strongly needed to improve disease outcomes and survival.

Malnutrition in paediatric patients with leukaemia and lymphoma: a retrospective cohort study

Introduction

Paediatric cancer is a potentially curable disease and its prognosis has been linked to several factors, such as nutritional status. The impact of malnutrition on these patients, either by overnutrition or undernutrition, varies and its relationship with outcomes is inconsistent. This study was conducted in order to determine the frequency of malnutrition in children with haematolymphoid malignancies at the time of diagnosis, as well as during treatment and to also investigate its relationship with the development of infections and death.

Materials and Methods

A retrospective cohort study of 191 children with a recent diagnosis of a haematolymphoid malignancy. The risks and nutritional classification were determined using anthropometry, follow-ups were conducted for up to 24 months and the presentation and frequency of infections and/or death were also recorded. Bivariate and multivariate analyses were conducted using binomial logistic regressions, for death and infection outcomes during follow-up. Survival analysis was conducted for various factors and types of cancer.

Results

83.7% of children had a sufficient nutritional classification at diagnosis, 6.8% had malnutrition by undernutrition and 9.4% by overnutrition. 83.8% had at least one infectious complication during follow-up and 47.1% had ≥ 3. This percentage increased to 69.2% when configuring it in the malnutrition by undernutrition group. 18.3% of patients died. When configuring the mortality, the percentage was greater in patients with Acute Myeloid Leukaemia (AML) (57.1%) and malnutrition by undernutrition (30.7%). The multivariate analysis for the outcome of death, only showed a statistically significant variable (AML odds ratio = 26.52; confidence interval = 1.09–643.24; p = 0.04).

Conclusion

No statistically significant relationship was found between the nutritional status of children with haematolymphoid neoplasms, and outcomes such as infections or death. The differences in the results obtained in these investigations may be related to the varied nutritional status definitions and the ways of measuring them, thus limiting comparisons between them.