Global Pediatric Oncology: Lessons From Partnerships Between High-Income Countries and Low- to Mid-Income Countries

Enhancement of paediatric oncology pharmacy practices in a low-middle-income country through teaching and training using the My Child Matters Grant

The development of a successful oncology pharmacy system includes competency training, cost-efficient procurement, proper storage, preparation and administration of chemotherapy, and appropriate waste disposal. Low-middle-income countries such as Pakistan face several challenges within the realm of oncology pharmacy such as the unavailability of training programmes, resources and financial support, and inconsistencies in the safe handling of cytotoxic drugs. The Indus Hospital and Health Network (IHHN) is among the pioneers of oncology pharmacy practices in Pakistan, with a well-established Oncology Pharmacy Team and chemotherapy preparation in accordance with the United States Pharmacopeia 797 and 800 safety guidelines. The My Child Matters Grant was awarded by the Sanofi Espoir Foundation to the Department of Paediatric Hematology and Oncology at IHHN for holistic improvement in childhood cancer care through teaching, training and capacity building. Partnerships were formed with five public-sector paediatric oncology units nationwide. Initiatives were taken to improve oncology pharmacy practices including teaching and training courses, in-person assessment visits, and mentorship and liaison efforts. Despite prevailing challenges, promising improvements were noted at each centre. However, Pakistan needs to establish a national plan for childhood cancer with the creation of regional organisations for the training and monitoring of oncology pharmacists. Centralisation of pharmacy operations within hospitals is essential to maintain the availability, storage, preparation and administration standards of chemotherapy.

Impact of a Regional Pediatric Hematology/Oncology Fellowship Program in Guatemala

PURPOSE

This study aimed to describe and assess the regional experience of a pediatric hematology/oncology fellowship program based in Guatemala.

METHODS

The Unidad Nacional de Oncología Pediátrica (UNOP) in Guatemala City, Guatemala, is the only hospital in Central America dedicated exclusively to childhood and adolescent cancer. To address the regional need for specialists, a fellowship program in pediatric hematology/oncology was launched in 2003. The UNOP fellowship program comprises 3 years of training. Although the program is based at UNOP, it also includes rotations locally and internationally to enhance clinical exposure. The curriculum is based on international standards to cover clinical expertise, research, professionalism, communication, and health advocacy. Trainees are selected according to country or facility-level need for pediatric hematologists/oncologists, with a plan for them to be hired immediately after completing their training.

RESULTS

Forty physicians from 10 countries in Latin America have completed training. In addition, there are currently 13 fellows from five countries in training. Of the graduates, 39 (98%) are now practicing in pediatric hematology/oncology in Latin America. Moreover, many of them have leadership positions within their institutions and participate in research, advocacy, and policy making. Graduates from the UNOP program contribute to institutions by providing care for an increasing number of patients with pediatric cancer. The UNOP program is the first pediatric hematology/oncology fellowship program in the world to be accredited by Accreditation Council for Graduate Medical Education-International, an international body accrediting clinical training programs.

CONCLUSION

The UNOP program has trained specialists to increase the available care for children with cancer in Latin America. This regional approach to specialist training can maximize resources and serve as a model for other programs and regions.

Psychosocial services for pediatric oncology patients in low- and middle-income countries from health care providers' perspectives: A survey-based report from the SIOP Global Health Network Psychosocial Working Group

OBJECTIVES

While pediatric cancer survival rates have improved in high-income countries, they remain much lower in low- and middle-income countries (L/MICs). While much focus in recent years has been on remediating the survivorship gap, less is known about the psychosocial needs and availability of psychosocial services for this population.

METHODS

A questionnaire was created by the SIOP Global Health Network Psychosocial Working Group to assess psychosocial needs and services in L/MIC. The questionnaire was distributed to pediatric oncology professionals, both in-person at the SIOP Annual Congress in Lyon (2019) conference and then electronically. Individuals not part of SIOP were also invited to participate via social media posts.

RESULTS

Sixty-six respondents from 31 countries completed the questionnaire. The majority of participants were physicians, followed by nurses. Participants from low- and lower-middle-income countries (L/LMICs) perceived patients as having higher rates of anxiety and caregivers as having higher rates of depression as compared to those in upper-middle-income countries (UMICs). Across all L/MICs represented, 85% of physicians reported that psychosocial issues sometimes, frequently, or always affect their clinical obligations. Participants reflected on the availability of professionals who treat mental health concerns; the availability of social workers, psychologists, and non-professional volunteers differed significantly between L/LMICs and UMICs. Treatment abandonment and myths/disinformation were highlighted as the most pressing psychosocial priorities.

CONCLUSION

Our study highlights pediatric oncology providers' perceptions of psychosocial concerns. Based on responses, proposals for minimum standards of care are made, as well as the importance of training existing providers and funding additional psychosocially-focused professionals.

Advances in the Global Initiative for Childhood Cancer: implementation in Latin America and the Caribbean

This report describes the status of childhood cancer control initiatives in Latin America and the Caribbean (LAC). Progress between 2017 and 2023 is measured using the outcome indicators from the Pan American Health Organization (PAHO) childhood cancer logic model aligned with the World Health Organization Global Initiative for Childhood Cancer (GICC). This report also describes the advances, barriers, and facilitators for the implementation of the GICC at the Regional level. Methods used in this report encompassed a comprehensive approach, incorporating a literature review, interviews, surveys, and a Delphi study developed by the technical team of the PAHO Non-Communicable Diseases and Mental Health Department and by the GICC LAC working group. Since 2017, there has been a substantial increase in the number of countries that have included childhood cancer in their national regulations. Currently, 21 LAC countries are involved in the GICC implementation, activities, and dialogues. However, the objectives for 2030 will only be achieved if Member States overcome the barriers to accelerating the pace of initiative implementation. There is an urgent need to increase the efforts in childhood cancer control in LAC, especially regarding the prioritization of timely detection, essential diagnostics, access to cancer treatment, palliative care, and close follow-up of children and adolescents with cancer.

Financial costs of pediatric cancer management in Africa: systematic review

The high costs of cancer treatment and the lack of investment in health care are significant barriers to public health on the African continent. The objective of this study was to investigate the financial cost of children cancer treating in sub-Saharan Africa. We systematically searched PubMed, Cochrane, and Google Scholar to identify relevant studies between March 2000 and December 2022. We selected articles that specifically addressed the US dollar financial costs of childhood cancer in African countries. Medians and interquartile ranges (IQR) were calculated. We also calculated the economic burden of childhood cancer at the individual level, by dividing the direct costs of cancer per patient by the GDP per capita, PPP of the country studied. The quality of economic studies was assessed using the CHEERS (2022) 28-point checklist. A total of 17 studies met our eligibility criteria. The median (IQR) of total childhood cancer costs by region was $909.5 ($455.3-$1,765) and ranged from $88803.10 for neuroblastoma to $163.80 for lymphoma. No significant differences (p < 0.05) were observed for comparisons of the direct cost of childhood cancer between the geopolitical zone of sub-Saharan Africa. Differences in the direct costs of childhood cancer were significant for different cancer types (p < 0.05). In the majority of 17 out of 54 countries on Africa the continent, the economic burden of childhood cancer exceeds 80% of GDP per capita, PPP, up to 345.38% of Nigeria's GDP for Rhabdomyosarcoma. The cost of treating childhood cancers is high in Africa is catastrophic, if not downright prohibitive for households in Sub-Saharan Africa. We believe that the data from our study will be able to help make different objective advocacy allowing it to be provided with funds based of the evidence that can strengthen this program in order to install cancerology structures in the countries and by following the system plan. Cost reduction in the treatment of childhood cancer in particular and in general all types of cancer.

Systematic review registration

Approval of the study was given by the ethics committee of the Faculty of Medicine of the University of Lubumbashi (UNILU/CEM/135/2018) and (UNILU/CEM/096/2019).

Impact of Physician Dual Practices on a Pediatric-Oncology Outreach-Program

OBJECTIVE

Physician dual practices (PDP) can be defined as 'doctors combining clinical work in public and private health-sector.' This study explores the impact of PDP on a long-term pediatric-oncology outreach-program between large referral hospitals in the Netherlands, Indonesia and Kenya.

METHODS

This cross-sectional descriptive study used a self-administered semi-structured survey.  The most senior doctor from each partner site was interviewed in June 2022. The survey contained 70 closed-ended and 7 open-ended questions and took 30-45 minutes to complete. Closed-ended questions were evaluated on 2-5 point rating scales. Informed consent was acquired and respondents endorsed the final report.

RESULTS

In the Netherlands an estimated 0-20% of senior doctors combine work in public and private-sector, while 60-80% do so in Indonesia and Kenya according to the respondents. In Indonesia and Kenya, most of doctors are involved in PDP to augment low government salaries. Impact of PDP on pediatric-oncology care is minimal in the Netherlands, but detrimental in Indonesia and Kenya: shortage of experienced doctors, limited supervision of junior staff, slow diagnostics and delays in chemotherapy administration ultimately lead to undermining of the quality of care and adverse patient outcomes.

CONCLUSIONS

PDP adversely impact patient care at the Indonesian and Kenyan partner sites of a pediatric-oncology outreach-program. Strategies addressing PDP in resource-poor settings are required to improve treatment outcomes and survival of children with cancer.

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.

Targeting DNA polymerase β elicits synthetic lethality with mismatch repair deficiency in acute lymphoblastic leukemia

Mismatch repair (MMR) deficiency has been linked to thiopurine resistance and hypermutation in relapsed acute lymphoblastic leukemia (ALL). However, the repair mechanism of thiopurine-induced DNA damage in the absence of MMR remains unclear. Here, we provide evidence that DNA polymerase β (POLB) of base excision repair (BER) pathway plays a critical role in the survival and thiopurine resistance of MMR-deficient ALL cells. In these aggressive resistant ALL cells, POLB depletion and its inhibitor oleanolic acid (OA) treatment result in synthetic lethality with MMR deficiency through increased cellular apurinic/apyrimidinic (AP) sites, DNA strand breaks and apoptosis. POLB depletion increases thiopurine sensitivities of resistant cells, and OA synergizes with thiopurine to kill these cells in ALL cell lines, patient-derived xenograft (PDX) cells and xenograft mouse models. Our findings suggest BER and POLB's roles in the process of repairing thiopurine-induced DNA damage in MMR-deficient ALL cells, and implicate their potentials as therapeutic targets against aggressive ALL progression.

Determinants of delayed childhood cancer care in low- and middle-income countries: A systematic review

Early access to care is essential to improve survival rates for childhood cancer. This study evaluates the determinants of delays in childhood cancer care in low- and middle-income countries (LMICs) through a systematic review of the literature. We proposed a novel Three-Delay framework specific to childhood cancer in LMICs by summarizing 43 determinants and 24 risk factors of delayed cancer care from 95 studies. Traditional medicine, household income, lack of transportation, rural population, parental education, and travel distance influenced most domains of our framework. Our novel framework can be used as a policy tool toward improving cancer care and outcomes for children in LMICs.

How should childhood acute lymphoblastic leukemia relapses in low-income and middle-income countries be managed: The AHOPCA-ALL study group experience

BACKGROUND

Children with relapsed acute lymphoblastic leukemia (ALL) in low-income and middle-income countries rarely survive. The Pediatric Hematology-Oncology Association of Central America (AHOPCA) developed the AHOPCA-ALL REC 2014 protocol to improve outcomes in resource-constrained settings without access to stem cell transplantation.

METHODS

The AHOPCA-ALL REC 2014 protocol was based on a modified frontline induction phase 1A, a consolidation therapy with six modified R-blocks derived from the ALL-Berlin-Frankfurt-Munster REZ 2002 protocol and intermittent maintenance therapy. Children with B-lineage ALL were eligible after a late medullary relapse, an early or late combined relapse, or any extramedullary relapses. Those with T-lineage ALL were eligible after early and late extramedullary relapses, as were those with both B-lineage and T-lineage relapses occurring at least 3 months after therapy abandonment.

RESULTS

The study population included 190 patients with T-lineage (n = 3) and B-lineage (n = 187) ALL. Of those with B-lineage ALL, 25 patients had a very early extramedullary relapse, 40 had an early relapse (32 extramedullary and 8 combined), and 125 had a late relapse (34 extramedullary, 19 combined, and 72 medullary). The main cause of treatment failure was second relapse (52.1%). The 3-year event-free survival rate (± standard error) was 25.9% ± 3.5%, and the 3-year overall survival rate was 36.7% ± 3.8%. The 3-year event-free survival rate was 47.2% ± 4.7% for late relapses. The most frequently reported toxicity was grade 3 or 4 infection. Mortality during treatment occurred in 17 patients (8.9%), in most cases because of infectious complications.

CONCLUSIONS

Selected children with relapsed ALL in Central America can be cured with second-line regimens even without access to consolidation with stem cell transplantation. Children in low-income and middle-income countries who have lower risk relapses of ALL should be treated with curative intent.

A Hematopoietic Stem Cell Transplantation Startup in Iraqi Kurdistan: Results in Thalassemia Patients and Analysis of the Methodology

In hemoglobinopathy-prone regions, like the Middle East, thalassemia is the most prevalent noncommunicable life-threatening disorder of children and is highly curable by hematopoietic stem cell transplantation (HSCT). Moreover, transplantation is very cost-effective, and HSCT programs can be established directly in middle-income countries (MICs) at a reduced cost while maintaining quality standards and outcomes consistent with international ones. The aim of the present study was to review and verify the efficacy of the applied methodology through the analysis of 47 consecutive matched-related HSCTs in children with thalassemia. In 2016, the first HSCT unit for adults and children with both malignant and nonmalignant diseases was developed in Iraqi Kurdistan, thanks to a capacity building project funded by the Italian Agency for Development Cooperation. Data on clinical activity were obtained from a cohort of patients treated in the newly established HSCT unit. Primary endpoints were overall survival (OS) and thalassemia-free survival (TFS). Startup of the HSCT unit was completed over a 3-year period. Assessing and meeting minimum requirements were crucial for the startup; moreover, a team of international health care professionals (HCPs), all experts in the field of HSCT, conducted the education and training phase, involving all the clinical and nonclinical professionals in the program. At a median follow-up of 2.6 years, the 3-year TFS and OS were 82.8% (SE, 5.5%) and 87.1% (SE, 4.9%), respectively. TFS and graft-versus-host-disease-free composite survival was 80.6% (SE, 5.8%). At present, the HSCT service is completely autonomous, and more than 250 transplants have been done in both adults and children. The minimal essential requirements for an HSCT startup may be affordable in many MICs. Our results for thalassemia are comparable with international data. A twinning program with an international group of experts and a capacity-building approach is crucial for the success of the program, a strategy that allows for rapid development of HSCT units.

Cost-effectiveness of childhood cancer treatment in Egypt: Lessons to promote high-value care in a resource-limited setting based on real-world evidence

BACKGROUND

Childhood cancer in low-and middle-income countries is a global health priority, however, the perception that treatment is unaffordable has potentially led to scarce investment in resources, contributing to inferior survival. In this study, we analysed real-world data about the cost-effectiveness of treating 8886 children with cancer at a large resource-limited paediatric oncology setting in Egypt, between 2013 and 2017, stratified by cancer type, stage/risk, and disease status.

METHODS

Childhood cancer costs (USD 2019) were calculated from a health-system perspective, and 5-year overall survival was used to represent clinical effectiveness. We estimated cost-effectiveness as the cost per disability-adjusted life-year (cost/DALY) averted, adjusted for utility decrement for late-effect morbidity and mortality.

FINDINGS

For all cancers combined, cost/DALY averted was $1384 (0.5 × GDP/capita), which is very cost-effective according to WHO-CHOICE thresholds. Ratio of cost/DALY averted to GDP/capita varied by cancer type/sub-type and disease severity (range: 0.1-1.6), where it was lowest for Hodgkin lymphoma, and retinoblastoma, and highest for high-risk acute leukaemia, and high-risk neuroblastoma. Treatment was cost-effective (ratio <3 × GDP/capita) for all cancer types/subtypes and risk/stage groups, except for relapsed/refractory acute leukaemia, and relapsed/progressive patients with brain tumours, hepatoblastoma, Ewing sarcoma, and neuroblastoma. Treatment cost-effectiveness was affected by the high costs and inferior survival of advanced-stage/high-risk and relapsed/progressive cancers.

INTERPRETATION

Childhood cancer treatment is cost-effective in a resource-limited setting in Egypt, except for some relapsed/progressive cancer groups. We present evidence-based recommendations and lessons to promote high-value in care delivery, with implications on practice and policy.

FUNDING

Egypt Cancer Network; NIHR School for Primary Care Research; ALSAC.

Childhood acute promyelocytic leukemia in a pediatric cancer referral center in Baghdad, Iraq. Improved results with ATRA extended consolidation

Modern treatments have dramatically improved the prognosis of childhood acute promyelocytic leukemia (APL). This progress has not yielded equivalent benefit in developing countries, where biological studies and supportive cares are insufficient and often unavailable. Since 2003, an all-trans retinoic (ATRA)-based, risk-adapted protocol was initiated in Baghdad. Patients were defined: high-risk with WBC ≥10 × 10⁹/L and standard-risk with WBC <10 × 10⁹/L. ATRA was included in induction and maintenance and, from 2010, in consolidation. Of 429 pediatric acute myeloid leukemia (September 2003-August 2019), 118 (27.5%) were APL. Six children died before therapy, 4 refused; 94/108 (87%) achieved a remission; 12 (11%) died early and 2 abandoned. The 5-year overall survival and event-free survival are 61.8% and 55.5% for all patients, 51.7% and 43.6% for first protocol, 68.4% and 63.9% for second one. Baseline WBC count was a risk factor for induction mortality; early hemorrhagic death remains a major cause of failure. ATRA extended consolidation improved results.

Factors influencing outcomes of older children with medulloblastoma over 15 years in Peru, a resource-limited setting

BACKGROUND

Medulloblastoma is the most common malignant brain tumor in children. While survival has improved in high-income countries (HIC), the outcomes for patients in low-to-middle-income countries (LMIC) are unclear. Therefore, we sought to determine the survival of children with medulloblastoma at the Instituto Nacional de Enfermedades Neoplasicas (INEN) between 1997 and 2013 in Peru.

METHODS

Between 1997 and 2013, data from 103 children older than 3 years with medulloblastoma were analyzed. Fourteen patients were excluded. The patients were split into two distinct cohorts, 1997-2008 and 2009-2013, corresponding with chemotherapy regimen changes. Event-free (EFS) and overall survival (OS) were calculated using the Kaplan-Meier method, whereas prognostic factors were determined by univariate analysis (log-rank test).

RESULTS

Eighty-nine patients were included; median age was 8.1 years (range: 3-13.9 years). The 5-year OS was 62% (95% CI: 53%-74%), while EFS was 57% (95% CI: 48%-69%). The variables adversely affecting survival were anaplastic histology (compared to desmoplastic; OS: HR = 3.4, p = .03), metastasis (OS: HR = 3.5, p = .01; EFS: HR = 4.3, p = .004), delay in radiation therapy of 31-60 days (compared to ≤30 days; EFS: HR = 2.1, p = .04), and treatment 2009-2013 cohort (OS: HR = 2.2, p = .02; EFS: HR = 2.0, p = .03).

CONCLUSIONS

Outcomes for medulloblastoma at INEN were low compared with HIC. Anaplastic subtype, metastasis at diagnosis, delay in radiation therapy, and treatment in the period 2009-2013 negatively affected the outcomes in our study. Multidisciplinary teamwork, timely delivery of treatment, and partnerships with loco-regional groups and colleagues in HIC is likely beneficial.

Cancer treatment decision-making among parents of paediatric oncology patients in Guatemala: a mixed-methods study

OBJECTIVES

To examine treatment decision-making priorities and experiences among parents of children with cancer in Guatemala.

SETTING

This study was conducted at Guatemala's National Pediatric Cancer Center in Guatemala City.

PARTICIPANTS

Spanish-speaking parents of paediatric patients (≤18 years of age) diagnosed with any form of cancer within the 8 weeks prior to study enrolment. The quantitative portion of this study included 100 parent participants; the qualitative component included 20 parents. Most participants were Catholic or Evangelical Spanish-speaking mothers.

OUTCOMES

Priorities and experiences of cancer treatment decision-making including decision-making role and experienced regret.

RESULTS

A range of paediatric ages and cancer diagnoses were included. Most Guatemalan parents surveyed (70%) made decisions about their child's cancer together and almost all (94%) without input from their community. Surveyed parents predominately preferred shared decision-making with their child's oncologist (76%), however 69% agreed it was best not to be provided with many options. Two-thirds of surveyed parents (65%) held their preferred role in decision-making, with fathers more likely to hold their preferred role than mothers (p=0.02). A small number of parents (11%) experienced heightened decisional regret, which did not correlate with socio-demographic characteristics or preferred decision-making role. Qualitative results supported quantitative findings, demonstrating a decision-making process that emphasised trust and honesty.

CONCLUSIONS

Guatemalan parents preferred to make decisions with their medical team and appreciated providers who were honest and inclusive, but directive about decisions. This study reinforces the importance of the provider-parent relationship and encourages clinicians in all settings to ask about and honour each parent's desired role in decision-making.

Global, regional, and national childhood cancer burden, 1990-2019: An analysis based on the Global Burden of Disease Study 2019

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We provided a comprehensive and the latest evaluation of the global childhood cancer burden.

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The childhood cancer burden has been decreasing globally over the last 30 years.

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Age-standardized incidence and prevalence rates of childhood cancer were more notable in higher SDI quintiles.

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Age-standardized death and disability-adjusted life year rates of childhood cancer decreased with SDI.

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Leukemia was still the most common cancer and the leading cause of death among children.

Introduction

Cancer is the leading cause of death among children.

Objectives

We report on the latest estimates of the burden of cancer among children at the global, regional, and national levels from 1990 to 2019.

Methods

Based on the Global Burden of Disease Study 2019, children’s cancer data were analyzed by sex, age, year, and location. Age-standardized rates were used to compare the burdens among regions and nations. Joinpoint analysis was applied to assess the temporal trend of the global childhood cancer burden.

Results

In 2019, 291,319 (95% uncertainty interval [UI], 254,239 to 331,993) new cases and 98,834 (86,124 to 113,581) deaths from childhood cancer were documented globally. Further, 8,302,464 (7,230,447 to 9,555,118) DALYs and 1,806,630 (1,567,808 to 2,089,668) prevalent cases were recorded in the same year. Age-standardized incidence and prevalence rates of childhood cancer were greatest in higher SDI settings and increased most significantly in Australasia and Southern Latin America over the last 30 years. However, although age-standardized death and DALY rates of childhood cancer have remarkably decreased in all regions since 1990, countries with a lower SDI showed the highest rates in 2019, particularly in countries in Eastern Sub-Saharan Africa. Among all cancers, leukemia has shown the largest decrease in burden since 1990. Despite this, leukemia was still the most common cancer and the leading cause of death among children in 2019, followed by brain and central nervous system cancer.

Conclusions

On a global scale, the childhood cancer burden has significantly fallen over the last 30 years, but is still higher in lower SDI countries. Effective interventions and collaborations among nations should be facilitated to improve healthcare among children with cancer in countries with lower SDI.

Cancer in sub-Saharan Africa: a Lancet Oncology Commission

In sub-Saharan Africa (SSA), urgent action is needed to curb a growing crisis in cancer incidence and mortality. Without rapid interventions, data estimates show a major increase in cancer mortality from 520 348 in 2020 to about 1 million deaths per year by 2030. Here, we detail the state of cancer in SSA, recommend key actions on the basis of analysis, and highlight case studies and successful models that can be emulated, adapted, or improved across the region to reduce the growing cancer crises. Recommended actions begin with the need to develop or update national cancer control plans in each country. Plans must include childhood cancer plans, managing comorbidities such as HIV and malnutrition, a reliable and predictable supply of medication, and the provision of psychosocial, supportive, and palliative care. Plans should also engage traditional, complementary, and alternative medical practices employed by more than 80% of SSA populations and pathways to reduce missed diagnoses and late referrals. More substantial investment is needed in developing cancer registries and cancer diagnostics for core cancer tests. We show that investments in, and increased adoption of, some approaches used during the COVID-19 pandemic, such as hypofractionated radiotherapy and telehealth, can substantially increase access to cancer care in Africa, accelerate cancer prevention and control efforts, increase survival, and save billions of US dollars over the next decade. The involvement of African First Ladies in cancer prevention efforts represents one practical approach that should be amplified across SSA. Moreover, investments in workforce training are crucial to prevent millions of avoidable deaths by 2030. We present a framework that can be used to strategically plan cancer research enhancement in SSA, with investments in research that can produce a return on investment and help drive policy and effective collaborations. Expansion of universal health coverage to incorporate cancer into essential benefits packages is also vital. Implementation of the recommended actions in this Commission will be crucial for reducing the growing cancer crises in SSA and achieving political commitments to the UN Sustainable Development Goals to reduce premature mortality from non-communicable diseases by a third by 2030.

Impact of COVID‐19 Measures on a Paediatric Oncology Outreach‐Program INVESTIGATORS & INSTITUTIONAL AFFILIATION

Paediatric oncology outreach‐programs have been effective development interventions to reduce inequalities in healthcare between high‐income countries (HIC) versus low and middle‐income countries (LMIC). Little is known about their sustainability during times of a pandemic

This study assesses the impact of COVID‐19 government measures on a paediatric oncology outreach‐program between three large referral hospitals in Netherlands (HIC), Indonesia (LMIC) and Kenya (LMIC)

COVID‐19 government measures have impacted childhood cancer care at all three hospitals. However, disruptions in services are more prominent at partner sites in LMIC, increasing existing inequalities

COVID‐19 government measures have adversely affected the wellbeing of children with cancer in both HIC and LMIC, and the chances of survival of children with cancer in LMIC

Government leaders and policy makers should take collateral damage of their COVID‐19 policies and local settings into account to protect children with cancer in LMIC

The development of an international childhood cancer hospital register database in 13 African countries. A project of the French African Pediatric Oncology Group (GFAOP)

BACKGROUND AND AIM

The establishment of an international hospital-based register (HBR) for the French African Pediatric Oncology Group (GFAOP) was a necessary step in the group's clinical research program. With help from the Sanofi Espoir Foundation's "My Child Matters" program, the GFAOP resolved to develop an international HBR network to collect quality data on children attending the Pediatric Oncology Units (POUs).

METHODS

All children entering POUs from January 2016 to December 2018 were registered using an online questionnaire. Data collection included information on diagnosis, disease stage, demographics, socioeconomic status, and outcome. An intensive training program was developed to improve both data quality and quantity.

RESULTS

Among the 3348 children registered, 3230 had a suspected cancer, 681 were not confirmed. A diagnosis was confirmed on radiological, clinical, or histological examination for 2549 children including Burkitt lymphoma (516: 20%)-the most frequent diagnosis, Wilms' tumor (459: 18%), retinoblastoma (357: 14%), and acute lymphoblastic leukemia (345: 13%). Of these, 2187 children were treated. Early deaths, abandonment, economic difficulties, and lack of equipment were some of the reasons offered to explain the numbers of undiagnosed and untreated children. Vital status is known for 1994 children: 1187 died and 807 were alive, 551 of these with a follow-up > 12 months.

CONCLUSION

This work has provided reliable data on children attending the POUs, especially clarifying reasons and occasions for care rupture. The data will help to identify material, human resources, and staff training needs, to evaluate progress, and to encourage consideration of pediatric cancer in national cancer plans.

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.

Global Health Education and Best Practices for Neonatal-Perinatal Medicine Trainees

Neonatal-perinatal medicine (NPM) trainees are expressing an increased interest in global health. NPM fellowship programs are tasked with ensuring that interested fellows receive appropriate training and mentorship to participate in the global health arena. Global health engagement during fellowship varies based on a trainee's experience level, career goals, and academic interests. Some trainees may seek active learning opportunities through clinical rotations abroad whereas others may desire engagement through research or quality improvement partnerships. To accommodate these varying interests, NPM fellows and training programs may choose to explore institutional partnerships, opportunities through national organizations with global collaborators, or domestic opportunities with high-risk populations. During any global health project, the NPM trainee needs robust mentorship from professionals at both their home institution and their partner international site. Trainees intending to use their global health project to fulfill the American Board of Pediatrics (ABP) scholarly activity requirement must also pay particular attention to selecting a project that is feasible during fellowship and also meets ABP criteria for board eligibility. Above all, NPM fellows and training programs should strive to ensure equitable, sustainable, and mutually beneficial collaborations.

Pediatric oncology infrastructure and workforce training needs: A report from the Pediatric Oncology East and Mediterranean (POEM) Group

BACKGROUND

Inadequate numbers of trained health care providers (HCPs) contribute to poor pediatric oncology (PO) outcomes, particularly in low- and lower middle-income countries (L/LMICs). An understanding of the characteristics of the workforce challenges is vital for addressing these problems.

METHODS

The Pediatric Oncology East and Mediterranean (POEM) Group surveyed PO centers in countries of North Africa, Middle East, Central Asia, and Indian subcontinent on infrastructure and workforce capacity, service availability, and training opportunities for HCPs. Participating centers were categorized by the World Bank income levels for their countries and correlated with services, workload and staffing characteristics, and training needs.

RESULTS

Fifty of 82 member centers (61%) from 21 countries responded to the survey. Two hundred ninety-nine pediatric oncologists and 1176 nurses treated 12 496 new PO patients/year, with a 1451-bed utilization. The majority (71%) of new cases occurred in L/LMICs. The availability of HCPs correlated with country income level, as did pediatric subspecialty access, while availability of support services was unrelated. Twenty-five centers in 11 countries offered PO fellowship training for physicians, whereas 13 PO nurse training centers in nine countries had the capacity to train 273 nurses annually. The survey respondents indicated that, among their existing workforce, an average of 3.5 physicians and 14 nurses per institution would benefit from additional PO training opportunities.

CONCLUSIONS

The participating centers exhibited intraregional heterogeneity in financial resources, infrastructure, workload, workforce, and medical services. Our findings provide insight into the disparities and regional resources available to POEM, which can be mobilized to rectify specific deficiencies.

Treatment of childhood acute lymphoblastic leukemia in Iraq: a 17-year experience from a single center

We performed a retrospective analysis of 1415 acute lymphoblastic leukemia children diagnosed between January 2000 and December 2016 at Children Welfare Teaching Hospital, Baghdad, Iraq. Patients were divided into three cohorts according to treatment period (2000-2005; 2006-2011; 2012-2016). Treatments were based on modified-UKALL protocols; a steroid-pre-phase was introduced from September 2008. The overall complete remission was 86%, increased from 80% to 91% in the last period. Early deaths occurred in 10%, decreasing to 6%, overtime. Relapses were 23%; toxic deaths and abandonment 8% and 13%, respectively. At a median follow-up of 65.3 months, with abandonment considered as an event, the 5-year overall survival (OS) and event-free survival were 62.2% and 46.3%, statistically influenced by treatment period (5-year OS 62.6%, 59.1%, 66.3%; p=.057, respectively). Though pediatric ALL survival in Iraq is still below that observed in high income countries, survival rates progressively improved. Toxic deaths remain an important cause of failure.

A single assessment of methotrexate levels at 42 hours permits safe administration and early discharge in children with lymphoblastic lymphoma and leukemia receiving high-dose methotrexate

High-dose methotrexate (HDMTX) is an important component of treatment in pediatric acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LL). Optimal rescue therapy is essential for the safe administration of HDMTX. A cost-effective strategy that does not compromise safety is necessary for low- and middle-income countries. Consecutive admissions for HDMTX in children with ALL and LL over 12 months were analyzed. The dose of HDMTX was 3 g/m² in B-ALL and B-LL and 5 g/m² in T-ALL and T-LL. A methotrexate level was measured at 42 hours of starting HDMTX infusion (T42-MTX). Three doses of folinic acid at T42, T48, and T54 and alkalinized hydration till T54 were administered if T42-MTX <1 µM. A total of 282 cycles of HDMTX that were administered in 71 patients were analyzed. T42-MTX was <1 µM in 266 (94.3%) cycles. T42-MTX was ≥1 µM in 12% and 3% of cycles of HDMTX administered at a dose of 5 g/m2 and 3 g/m2, respectively (p = .074). The median duration of hospitalization for HDM was three days and did not differ with the dose of HDMTX administered (p = .427). Mucositis, delayed recovery of blood counts, and hospitalization for reversible toxicity occurred after 21 (7.4%), 28 (9.9%), and 19 (6.7%) cycles of HDMTX, respectively. Mucositis was greater following the administration of 5 g/m² of HDMTX. A single T42-MTX measurement permits the safe administration of HDMTX and an expedited discharge from the hospital within three days in more than 90% of children with ALL/LL.

Pediatric Oncology Clinical Trials and Collaborative Research in Africa: Current Landscape and Future Perspectives

PURPOSE

Adequate clinical services have yet to be established in the majority of African countries, where childhood cancer survival rates vary from 8.1% to 30.3%. The aim of this review is to describe the landscape of pediatric oncology trials in Africa, identify challenges, and offer future opportunities for research collaborations.

METHODS

The study includes data from the International Pediatric Oncology Society (SIOP) global mapping survey, meta-research identifying trials in Africa in ClinicalTrials.gov, and a literature overview of publications on the subject of pediatric oncology clinical research supported by expert opinions on the current situation and challenges.

RESULTS

The SIOP global mapping survey received responses from 47 of 54 African countries, of which 23 have active clinical research programs. A preliminary search of ClinicalTrials.gov showed that only 105 (12.1%) of 868 African oncology studies included children and adolescents. Of these, 53 (50.5%) were interventional trials according to the registry’s classification. The small number of African trials for children and adolescents included palliative care and leukemia trials. In African oncology journals and international pediatric oncology journals, < 1% of the pediatric oncology publications come from Africa. Services and research were strengthened by international collaboration. National studies focused on clinical needs, local challenges, or interventional priorities. Both the literature review and the expert opinions highlight the need to expand clinical research in Africa, despite ongoing regional instability and lack of resources.

CONCLUSION

While a low number of pediatric clinical treatment trials are open to African children and adolescents, clinical research of high quality is being done in Africa. Several initiatives are stimulating the development of the research capacity across the continent, which should increase the publication output.

Palliative Care Nursing Development in the Middle East and Northeast Africa: Lessons From Oman

Nurses are on the frontline of palliative care, and in some countries, are the only contact for patients and families facing life-threatening illness. The Oman Cancer Association in the Sultanate of Oman, in collaboration with the Middle Eastern Cancer Consortium and the Oncology Nursing Society, led a palliative care initiative over the past decade to better integrate palliative care into the health care system. Components of this initiative include integrating palliative care into the health care curricula and providing palliative care education to over 400 nurses and other health care professionals within Oman. The four-part education series includes the following courses: (1) Foundations of Palliative Care, (2) Advanced Concepts in Palliative Care, (3) Palliative Care Leadership, and (4) Palliative Care Research. Additional participants from 17 different countries in the Middle East and northern Africa also attended the training. Twenty of the trainees who were considered palliative care leaders in their countries then participated in a Train the Trainer course. This group trained the last cohort of health care professionals in Oman and then took learned concepts and strategies back to their respective countries in order to provide country-wide education and build palliative care capacity in the region. Outcomes include the development of palliative care units, quality improvement projects that improved care, and advocacy projects to increase opioid availability within some countries. The collaborative continues its work and connections through social medial, email, and virtual collaboration. Other countries can use this model to permeate palliative care within their regions.

Family knowledge about the legal rights of children and adolescents with cancer

OBJECTIVE

Identify the knowledge of family members of children and adolescents with cancer about their legal rights, difficulties, and concessions to ensure them.

METHOD

Quantitative study, survey type, of intersectional design. A questionnaire drawn up by the researchers was applied in order to characterize the minor and their family and also to identify the family's knowledge about legal rights. Descriptive statistics were used to analyze data.

RESULTS

61 family members who participated know some more rights to the detriment of others and are especially motivated to search for information when negative impacts on the financial life increase, with repercussions beyond family health.

CONCLUSION

the studied population requires more information and demands knowledge about some rights guaranteed by law. Guidance on rights empowers the family and guarantees the necessary care, searching to have an intersectoral action qualify care and assist in restructuring family dynamics to deal with chronic conditions.

Performance of PRISM III and PIM 2 scores in a cancer pediatric intensive care unit

Objective

To assess the performance of Pediatric Risk of Mortality (PRISM) III and Pediatric Index of Mortality (PIM) 2 scores in the pediatric intensive care unit.

Methods

A retrospective cohort study. Data were retrospectively collected from medical records of all patients admitted to the pediatric intensive care unit of a cancer hospital from January 2017 to June 2018.

Results

The mean PRISM III score was 15, and PIM 2, 24%. From the 338 studied patients, 62 (18.34%) died. The PRISM III estimated mortality was 79.52 patients (23.52%) and for PIM 2 80.19 patients (23.72%), corresponding to a standardized mortality ratio (95% confidence interval: 0.78 for PRISM II and 0.77 for PIM 2). The Hosmer-Lemeshow chi-square test was 11.56, 8df, 0.975 for PRISM II and 0.48, 8df, p = 0.999 for PIM 2. The area under the Receiver Operating Characteristic curve was 0.71 for PRISM III and 0.76 for PIM 2.

Conclusion

Both scores overestimated mortality and have shown a regular ability to discriminate between survivors and non-survivors. Models should be developed to quantify the severity of cancer pediatric patients in Pediatric Intensive Care Units and to predict the mortality risk accounting for their peculiarities.

Reduced-intensity therapy for pediatric lymphoblastic leukemia: impact of residual disease early in remission induction

Legacy data show that ∼40% of children with acute lymphoblastic leukemia (ALL) were cured with limited antimetabolite-based chemotherapy regimens. However, identifying patients with very-low-risk (VLR) ALL remains imprecise. Patients selected based on a combination of presenting features and a minimal residual disease (MRD) level <0.01% on day 19 of induction therapy had excellent outcomes with low-intensity treatment. We investigated the impact of MRD levels between 0.001% and <0.01% early in remission induction on the outcome of VLR ALL treated with a low-intensity regimen. Between October of 2011 and September of 2015, 200 consecutive patients with B-precursor ALL with favorable clinicopathologic features and MRD levels <0.01%, as assessed by flow cytometry in the bone marrow on day 19 and at the end of induction therapy, received reduced-intensity therapy. The 5-year event-free survival was 89.5% (± 2.2% standard error [SE]), and the overall survival was 95.5% (± 1.5% SE). The 5-year cumulative incidence of relapse (CIR) was 7% (95% confidence interval, 4-11%). MRD levels were between 0.001% and <0.01% on day 19 in 29 patients. These patients had a 5-year CIR that was significantly higher than that of patients with undetectable residual leukemia (17.2% ± 7.2% vs 5.3% ± 1.7%, respectively; P = .02). Our study shows that children with VLR ALL can be treated successfully with decreased-intensity therapy, and it suggests that the classification criteria for VLR can be further refined by using a more sensitive MRD assay.

Childhood Acute Leukemias in Developing Nations: Successes and Challenges

PURPOSE OF REVIEW

Acute leukemias represent a tremendous threat to public health around the globe and the main cause of death due to disease in scholar age children from developing nations. Here, we review their current status in Mexico, as a paradigm of study, and the major challenges to control systemic diseases like childhood cancer.

RECENT FINDINGS

A unique molecular epidemiology, late/low precision diagnosis, limited access to treatment, toxicity associated with therapy, continuous exposure to environmental risk factors, and the high frequency of early relapses are some of the factors cooperating to low rates of survival in low-to-medium-income countries. Deliberative dialogues and exhaustive programs have emerged as promising means of advancing evidence-informed policy, by providing a structured forum for key stakeholders to integrate scientific and pragmatic knowledge about complex health concerns. A system-wide strategy based on the comprehensive leukemia identity is essential for a meaningful decline in early childhood mortality.

Australia and New Zealand's responsibilities in improving oncology services in the Asia-Pacific: A call to action

AIM

To review the expected increasing demand for cancer services among low and middle-income countries (LMICs) in the Asia-Pacific (APAC), and to describe ways in which Australia and New Zealand (ANZ) can provide support to improve cancer outcomes in our region.

METHODS

We first review the current and projected incidence of cancer within the APAC between 2018 and 2040, and the estimated demand for chemotherapy, radiotherapy and surgery. We then explore potential ways in which ANZ can increase regional collaborations to improve cancer outcomes.

RESULTS

We identify 6 ways that ANZ can collaborate with LMICs to improve cancer care in the APAC through the ANZ Regional Oncology Collaboration Strategy: Increasing education and institutional collaborations in the APAC region through in-country training, twinning partnerships, observerships and formalised training programs in order to increase cancer care quality and capacity. Promoting and assisting in the establishment and maintenance of population-based cancer registries in LMICs. Increasing research capacity in LMICs through collaboration and promoting high quality global oncology research within ANZ. Engaging and training Australian and New Zealand clinicians in global oncology, increasing awareness of this important career path, and increasing health policy engagement. Increasing web-based endeavours through virtual tumour boards, web-based advocacy platforms and web-based teaching programs. Continuing to leverage for funding through professional bodies, government, industry, not-for-profit organisations and local hospital funds.

CONCLUSION

We propose the creation of an Australian and New Zealand Interest Group to provide formalised and sustained collaboration between researchers, clinicians and stakeholders.

Improving Peripheral Intravenous Catheter Care for Children with Cancer Receiving Chemotherapy in Malawi

PURPOSE

To change pediatric oncology nursing management of peripheral intravenous catheter (PIVC) insertion and care based on current best evidence.

DESIGN AND METHODS

Practice change strategies were developed, and nurses completed education on proper PIVC insertion, dressing placement, and ongoing PIVC assessment with emphasis on preventing chemotherapy extravasation. Nurses also completed a chemotherapy course as part of their orientation program. The plan for PIVC practice change was based on evidence from published research and established PIVC care guidelines. Pre-assessment data revealed numerous PIVC attempts and a high incidence of extravasation (42%) in children with cancer receiving treatment in Malawi.

RESULTS

Post-assessment data nine months later resulted in a reduced extravasation rate from 42% to 4% using point prevalence assessments. PIVC insertion attempts reduced following education and guideline implementation; 81% of children required more than 3 PIVC insertion attempts before the practice change. Only 1% of PIVC insertions required more than 3 attempts after education and practice change implementation. Nurses completed a 32-item written examination before the chemotherapy course; the mean score was 50/100. Upon completion of the chemotherapy course, nurses obtained a mean score of 97/100 on the written examination.

CONCLUSIONS

Using an organized approach to nursing practice change improved PIVC care in children with cancer.

PRACTICE IMPLICATIONS

This project provides evidence that nursing practice change strategies can be used in any setting including countries like Malawi with limited resources.

The burgeoning role of global health diplomacy to alleviate suffering of cancer patients in low- and middle-income countries

The science of global health diplomacy (GHD) consists of cross-disciplinary, multistakeholder credentials comprised of national security, public health, international affairs, management, law, economics and trade policy. GHD is well placed to bring about better and improved multilateral stakeholder leverage and outcomes in the prevention and control of cancer. It is important to create an evidence base that provides clear and specific guidance for health practitioners in low- and middle-income countries (LMICs) through involvement of all stakeholders. GHD can assist LMICs to negotiate across multilateral stakeholders to integrate prevention, treatment and palliative care of cancer into their commercial and trade policies.

The role of twinning in sustainable care for children with cancer: A TIPPing point? SIOP PODC Working Group on Twinning, Collaboration, and Support

With the World Health Organization (WHO) Global Initiative for Childhood Cancer, there is renewed interest in sustainable interventions to improve childhood cancer care in low-/middle-income countries (LMICs). Practitioners in LMICs have traditionally practiced "twinning," i.e., targeted international pediatric oncology partnerships (TIPPs) between one or more institutions in a high-income country (HIC) and an LMIC, to improve care for children with cancer in the latter. The International Society of Paediatric Oncology Committee for Paediatric Oncology in Developing Countries Working Group on Twinning, Collaboration, and Support reviewed guidelines from https://cancerpointe.com and the current literature, gathered input from practitioners in LMICs, and in this article discuss the role of TIPPs in the WHO initiative.

Infection Prevention and Control Measures at the Children Hospital Lahore: A My Child Matters Collaborative Project

PURPOSE

Infection prevention among children with cancer is a major challenge at Children Hospital Lahore (CHL), a public health care facility in Pakistan with 1,000 new pediatric cancer admissions annually. The objective has been to reduce infections through collaboration between CHL and the St Jude Children's Hospital Global Infectious Disease program via a grant by the Sanofi Espoir foundation through the My Child Matters program. The aim of the current study was to describe the effect of the collaborative improvement strategy on existing infection prevention and control (IPC) standards at CHL.

MATERIALS AND METHODS

Our work was a prospective before-and-after study to improve IPC standards. We compared the WHO Hand Hygiene Self-Assessment Framework and four modules of the St Jude modified Infection Control Assessment Tool (ICAT) scores over a 3-year period. Our strategy included creating a multidisciplinary team of pediatric oncologists, infectious disease physicians, nurses, a microbiologist, and a data manager; engaging in monthly online IPC mentoring sessions with St Jude Children's Hospital Global Infectious Disease program and My Child Matters mentors; performing daily inpatient health care-associated infection surveillance rounds; and performing regular hand hygiene training and compliance audits.

RESULTS

Baseline needs assessment showed health care-associated infections identified by positive blood cultures as 8.7 infections per 1,000 patient-days. Deficient hand hygiene supplies, health education measures, and bed sharing of neutropenic patients were identified as major challenges. Our hand hygiene facility level, per WHO scores, increased from Inadequate to Intermediate/Consolidation by the end of the 3-year implementation (122 v 352 WHO Hand Hygiene Self-Assessment Framework scores). The sink:bed and hand sanitizer:bed ratios improved to 1:6 and 1:1, respectively. The ICAT general infection control module increased by 40% (45 v 78 ICAT scores) and hygiene compliance improved by 20%.

CONCLUSION

Implementing a collaborative improvement strategy improved IPC standards in our center, which can be easily replicated in other pediatric oncology centers in lower- and middle-income countries.

Challenges and opportunities for managing pediatric central nervous system tumors in China

Central nervous system (CNS) tumors represent the most deadly cancer in pediatric age group. In China, thousands of children are diagnosed with CNS tumors every year. Despite the improving socioeconomic status and availability of medical expertise within the country, unique challenges remain for the delivery of pediatric neuro-oncology service. In this review, we discuss the existing hurdles for improving the outcome of children with CNS tumors in China. Need for precise disease burden estimation, lack of intra- and inter-hospital collaborative networks, high probability of treatment abandonment, along with financial toxicities from treatment represent the key challenges that Chinese healthcare providers encounter. The tremendous opportunities for advancing the status of pediatric neuro-oncology care in and beyond the country are explored.

FPGS relapse-specific mutations in relapsed childhood acute lymphoblastic leukemia

Although the cure rate for childhood acute lymphoblastic leukemia (ALL) has exceeded 80% with contemporary therapy, relapsed ALL remains a leading cause of cancer-related death in children. Relapse-specific mutations can be identified by comprehensive genome sequencing and might have clinical significance. Applying whole-exome sequencing to eight triplicate samples, we identified in one patient relapse-specific mutations in the folylpolyglutamate synthetase (FPGS) gene, whose product catalyzes the addition of multiple glutamate residues (polyglutamation) to methotrexate upon their entry into the cells. To determine the prevalence of mutations of the FPGS mutations, and those of two important genes in the thiopurine pathway, NT5C2 and PRPS1, we studied 299 diagnostic and 73 relapsed samples in 372 patients. Three more FPGS mutants were identified in two patients, NT5C2 mutations in six patients, and PRPS1 mutants in two patients. One patient had both NT5C2 and PRPS1 mutants. None of these alterations were detected at diagnosis with a sequencing depth of 1000X, suggesting that treatment pressure led to increased prevalence of mutations during therapy. Functional characterization of the FPGS mutants showed that they directly resulted in decreased enzymatic activity, leading to significant reduction in methotrexate polyglutamation, and therefore likely contributed to drug resistance and relapse in these cases. Thus, besides genomic alterations in thiopurine metabolizing enzymes, the relapse-specific mutations of FPGS represent another critical mechanism of acquired antimetabolite drug resistance in relapsed childhood ALL.

Reduced-dose intensity therapy for pediatric lymphoblastic leukemia: long-term results of the Recife RELLA05 pilot study

Treatment-related mortality is common among children with acute lymphoblastic leukemia (ALL) treated in poor-resource settings. We applied a simplified flow cytometric assay to identify patients with precursor B-cell ALL (B-ALL) at very low risk (VLR) of relapse and treated them with a reduced-intensity treatment plan (RELLA05). VLR criteria include favorable presenting features (age ≥ 1 and < 10 years), white blood cell count of <50 ×109/L, lack of extramedullary leukemia, and minimal residual disease level of <0.01% on remission induction day 19. Except for 2 doses of daunorubicin, treatment of patients with VLR B-ALL consisted of a combination of agents with relatively low myelotoxicity profiles, including corticosteroids, vincristine, L-asparaginase, methotrexate, and 6-mercaptopurine. Cyclophosphamide, systemic cytarabine, and central nervous system radiotherapy were not used. Of 454 patients with ALL treated at the Instituto de Medicina Integral Professor Fernando Figueira in Recife, Brazil, between December 2005 and June 2015, 101 were classified as having VLR B-ALL. There were no cases of death resulting from toxicity or treatment abandonment during remission induction. At a median follow-up of 6.6 years, there were 8 major adverse events: 6 relapses, 1 treatment-related death (from septicemia) during remission, and 1 secondary myeloid leukemia. The estimated 5-year event-free and overall survival rates were 92.0% ± 3.9% and 96.0% ± 2.8%, respectively. The 5-year cumulative risk of relapse was 4.24% ± 2.0%. The treatment was well tolerated. Episodes of neutropenia were of short duration. Patients with B-ALL selected by a combination of presenting features and degree of early response can be successfully treated with a mildly myelosuppressive chemotherapy regimen.

Sustainable care for children with cancer: a Lancet Oncology Commission

We estimate that there will be 13·7 million new cases of childhood cancer globally between 2020 and 2050. At current levels of health system performance (including access and referral), 6·1 million (44·9%) of these children will be undiagnosed. Between 2020 and 2050, 11·1 million children will die from cancer if no additional investments are made to improve access to health-care services or childhood cancer treatment. Of this total, 9·3 million children (84·1%) will be in low-income and lower-middle-income countries. This burden could be vastly reduced with new funding to scale up cost-effective interventions. Simultaneous comprehensive scale-up of interventions could avert 6·2 million deaths in children with cancer in this period, more than half (56·1%) of the total number of deaths otherwise projected. Taking excess mortality risk into consideration, this reduction in the number of deaths is projected to produce a gain of 318 million life-years. In addition, the global lifetime productivity gains of US$2580 billion in 2020-50 would be four times greater than the cumulative treatment costs of $594 billion, producing a net benefit of $1986 billion on the global investment: a net return of $3 for every $1 invested. In sum, the burden of childhood cancer, which has been grossly underestimated in the past, can be effectively diminished to realise massive health and economic benefits and to avert millions of needless deaths.

Therapy-induced mutations drive the genomic landscape of relapsed acute lymphoblastic leukemia

To study the mechanisms of relapse in acute lymphoblastic leukemia (ALL), we performed whole-genome sequencing of 103 diagnosis-relapse-germline trios and ultra-deep sequencing of 208 serial samples in 16 patients. Relapse-specific somatic alterations were enriched in 12 genes (NR3C1, NR3C2, TP53, NT5C2, FPGS, CREBBP, MSH2, MSH6, PMS2, WHSC1, PRPS1, and PRPS2) involved in drug response. Their prevalence was 17% in very early relapse (<9 months from diagnosis), 65% in early relapse (9-36 months), and 32% in late relapse (>36 months) groups. Convergent evolution, in which multiple subclones harbor mutations in the same drug resistance gene, was observed in 6 relapses and confirmed by single-cell sequencing in 1 case. Mathematical modeling and mutational signature analysis indicated that early relapse resistance acquisition was frequently a 2-step process in which a persistent clone survived initial therapy and later acquired bona fide resistance mutations during therapy. In contrast, very early relapses arose from preexisting resistant clone(s). Two novel relapse-specific mutational signatures, one of which was caused by thiopurine treatment based on in vitro drug exposure experiments, were identified in early and late relapses but were absent from 2540 pan-cancer diagnosis samples and 129 non-ALL relapses. The novel signatures were detected in 27% of relapsed ALLs and were responsible for 46% of acquired resistance mutations in NT5C2, PRPS1, NR3C1, and TP53. These results suggest that chemotherapy-induced drug resistance mutations facilitate a subset of pediatric ALL relapses.

Suubi4Cancer: A protocol for an innovative combination intervention to improve access to pediatric cancer services and treatment adherence among children living with HIV/AIDS in Uganda

Youth Living with HIV (YLWHIV) are at high risk for cancer. Sub-Saharan Africa (SSA) has some of the worst pediatric cancer survival rates due to barriers to accessing cancer services and treatment adherence. This protocol describes a study that aims at: 1) Identifying confirmed and suspected cancer cases in a cohort of >3000 HIV positive youth; 2) Examining the short-term preliminary outcomes of an evidence-based Economic Empowerment (EE) intervention, Suubi (“hope” in a local Ugandan language), on access to pediatric cancer diagnosis and care, and treatment adherence among YLWHIV with suspected cancers in Uganda; and 3) Exploring multi-level factors impacting intervention participation and experiences. The proposed Suubi4Cancer intervention combines savings-led EE through family development accounts (FDA) with financial literacy and management (FLM) and cancer education (CE). The study will review medical charts in 39 clinics in Southwest Uganda to identify confirmed and suspected cancer cases. Subsequently, Suubi4Cancer will be evaluated via a randomized-controlled trial design (FDA + FLM + CE versus Usual Care) targeting a total of 78 youth ages 10-to-24 and their caregivers. Assessments at baseline and 9 months will examine change in cancer treatment access; cancer treatment adherence; and knowledge, attitudes, and beliefs about cancer and cancer treatment. Semi-structured interviews with the intervention group will explore their intervention experiences. To our knowledge, Suubi4Cancer will be the first study to test the preliminary impact and acceptability of a combination intervention to increase access to cancer diagnosis and treatment services for YLWHIV.

Trial registration

Clinical Trials NCT03916783 (Registered: 04/16/19).

Establishing Cancer Treatment Programs in Resource-Limited Settings: Lessons Learned From Guatemala, Rwanda, and Vietnam

Purpose

The global burden of cancer is slated to reach 21.4 million new cases in 2030 alone, and the majority of those cases occur in under-resourced settings. Formidable changes to health care delivery systems must occur to meet this demand. Although significant policy advances have been made and documented at the international level, less is known about the efforts to create national systems to combat cancer in such settings.

Methods

With case reports and data from authors who are clinicians and policymakers in three financially constrained countries in different regions of the world—Guatemala, Rwanda, and Vietnam, we examined cancer care programs to identify principles that lead to robust care delivery platforms as well as challenges faced in each setting.

Results

The findings demonstrate that successful programs derive from equitably constructed and durable interventions focused on advancement of local clinical capacity and the prioritization of geographic and financial accessibility. In addition, a committed local response to the increasing cancer burden facilitates engagement of partners who become vital catalysts for launching treatment cascades. Also, clinical education in each setting was buttressed by international expertise, which aided both professional development and retention of staff.

Conclusion

All three countries demonstrate that excellent cancer care can and should be provided to all, including those who are impoverished or marginalized, without acceptance of a double standard. In this article, we call on governments and program leaders to report on successes and challenges in their own settings to allow for informed progression toward the 2025 global policy goals.