Pediatric ependymoma: A single-center experience from a developing country

Adjuvant therapy for brain tumors in LMICs: A systematic review of barriers and possible solutions

BACKGROUND

Adjuvant therapy is an important tool in the arsenal of brain tumor management and can improve patients' outcomes significantly but low- and middle-income countries (LMICs) often face challenges in provision. Therefore, our study aims to highlight barriers and strategies to adjuvant therapy of brain tumors in low-resource settings.

METHOD

A comprehensive search of literature was conducted using PubMed, CINAHL, Google Scholar, and Scopus, from inception to October 20, 2022. The review included studies on adjuvant therapy for brain tumors in LMICs and identified themes using the National Surgical, Obstetric, and Anesthesia Plan (NSOAP) domains.

RESULTS

32 studies were included in the review. The most reported barriers to adjuvant care were limited access to healthcare (14 %), limited access to chemotherapy and radiation equipment (25 %), and traditional or alternative medications (11 %). Strategies for improvement include improving the availability of specialized radiation oncology training (8 %) and improving access to neuro-diagnostics and neurotherapeutics (12 %). In addition, efforts to subsidize treatment (4 %) and provide financial coverage through the Ministry of Health (4 %) can help to address the high cost of care and improve access to funding for chemotherapy. Finally, establishing documentation systems and registries (16 %), implementing standardized national treatment guidelines (8 %) can help to improve overall care for brain tumor patients in LMICs.

CONCLUSION

A multimodal approach of strategies targeting workforce, infrastructure, service delivery, financing, and information management is needed to improve adjuvant care for brain tumors. International collaboration and partnerships can also play a key role in addressing barriers and improving care in LMICs.

Barriers to Neurosurgical Care of Brain Tumors in Low- and Middle-Income Countries: A Systematic Review of the Service Delivery Challenges

INTRODUCTION

Brain tumors pose a major challenge in low- and middle-income countries (LMICs) due to limited resources and high costs, resulting in hampered service delivery of neurosurgical care and significant disparities in patient outcomes compared to high-income nations. Therefore, our systematic review aims to identify barriers to service delivery in providing adequate surgical care for the management of brain tumors in LMICs.

METHODS

We searched Scopus, PubMed, Google Scholar, and CINAHL, from inception to October 20, 2022. The data from the eligible studies were extracted and analyzed qualitatively.

RESULTS

The final analysis included 35 articles, which highlighted significant challenges in providing adequate surgical care for brain tumors in LMICs. Among the cited studies, 10% reported lack of multidisciplinary team structures, 61% noted delayed patient presentation, 16% highlighted delays in neuroimaging, 10% reported delays in scheduling surgery, lack of training for specialized surgery (3%), lack of intra-operative facilities (19%), power supply interruption (6%), and lack of advanced diagnostic and specialized surgery facilities (19%). Strategies for addressing these challenges include cross-border collaboration (7%), public education, and awareness (13%), establishing multidisciplinary teams (20%), utilizing alternative surgical techniques (13%), 7% intraoperative ultrasound, 13% intraoperative cytology smear), and establishing satellite hospitals for low-risk care (7%), standard operating procedure and infection control (13%).

CONCLUSION

Targeted interventions considering economic constraints are essential to improve the availability, affordability, and quality of neuro-oncologic services in developing countries. International collaborations and building capacity are vital for improving patient outcomes and service delivery, as well as forming multidisciplinary teams and utilizing resource-saving, innovative methods.

Workforce Challenges for the Neurosurgical Care of Brain Tumors in Low- and Middle-Income Countries: A Scoping Review

Limited neurosurgical workforces remain one of the critical problems experienced in low resource settings. Therefore, our study aims to explore and summarize the key challenges to neurosurgical care of brain tumors in terms of workforce in LMICs. A comprehensive literature search was conducted using Scopus, PubMed, CINAHL, and Google Scholar from inception to October 20, 2022. All extracted data were screened independently by 2 reviewers and thematically analyzed. We found and screened 3764 articles, of which 33 studies were included in our final analysis as per our inclusion criteria. Among the studies included, 33% highlighted the limited number of neurosurgeons, 39% emphasized the absence of specialized surgical teams, 7% pointed out a shortage of nursing staff, and 4% noted suboptimal anesthesia teams. The study uncovered the need for improved training programs in neuro-oncology (32%) and neuro-anesthesia (3%), as well as improved collaboration (32%), and multidisciplinary team structures (15%), are essential for tackling these workforce challenges and improving patient outcomes. It is crucial to implement targeted interventions and policy changes to address the barriers to the workforce in providing effective neurosurgical care to patients with brain tumors in developing countries. This might entail capacity building and training programs for healthcare professionals. Policymakers should consider allocating resources and funding for workforce development and making neurosurgical care a priority in healthcare plans.

Pediatric neurosurgical medulloblastoma outcomes in La Paz, Bolivia: How a Lower Middle-Income Country (LMIC) institution in South America compares to the United States

BACKGROUND

How pediatric medulloblastoma patients fare in Lower Middle-Income Country (LMICs) in South America is not well understood. Correspondingly, the aim of this study was to summarize the pediatric neurosurgical experience of an institution in La Paz, and compare outcomes to that of a generalized High Income Country (HIC) United States (US) experience.

METHODS

A retrospective review of all pediatric neurosurgical medulloblastoma patients at the Children's Hospital of La Paz, Bolivia (Hospital del Niño "Dr. Ovidio Aliaga Uria") between 2014 and 2023 was conducted and compared to a generalized US experience abstracted from the US National Cancer Database (NCDB) and National Inpatient Sample (NIS) databases. Categorical, continuous and survival data were statistically summarized and compared.

RESULTS

A total of 24 pediatric medulloblastoma patients underwent neurosurgical treatment at the Hospital del Niño. In this La Paz cohort, there were 15 (63%) males and 9 (38%) females, with a mean age of 5.6 years old at diagnosis. The majority of patients underwent subtotal resection (STR, 79%), while the remaining patients underwent biopsy only. Ten (42%) patients expired during their hospitalization, and mean length of stay overall was 39 days. Only 8 (33%) patients received adjuvant treatment after surgery. Median overall survival from diagnosis in the La Paz cohort was 1.9 months. Compared to the US databases, the La Paz cohort experienced significantly more emergency room admissions for surgery, less gross total resection, more STR, more return to operating room for ventriculoperitoneal shunting, more bacteremia, more tracheostomy procedures, more percutaneous gastrostomy placements, longer lengths of stay, less adjuvant chemotherapy, less radiation therapy, shorter follow-up, and ultimately, significantly shorter overall survival (all P < 0.050).

CONCLUSIONS

Pediatric neurosurgical medulloblastoma outcomes at the Children's Hospital of La Paz, Bolivia are significantly inferior to that of a generalized US experience. Future research is required to identify institution- and country-specific initiatives to improve discrepancies between institutions in LMICs in South America compared to HICs.

Prognostic factors of pediatric ependymomas at a National Cancer Reference Center in Peru

Background

Ependymomas are central nervous system tumors that significantly impact the quality of life and carry a high mortality rate. Both the disease itself and its treatment cause significant morbidity. At a national level in Peru, there are no reports on clinical characteristics of the disease.

Methods

This retrospective study captured patient aged less than 19 years with a diagnosis of ependymoma from 2012 to 2022 at a tertiary center in Lima.

Results

85 patients were included with a median follow-up time was 51.6 months. The 5-year overall survival and progression-free survival were 55.89% (95% CI: 44.28 - 65.99) and 37.71% (95% CI: 26,21-49,16) respectively. The main prognostic factors identified were completed treatment (p=0.019), adjuvant chemotherapy (p=0.048), presence of metastasis (p=0.012), and disease recurrence (p=0.02).

Conclusions

The survival of patients with ependymoma is below that reported in high-income countries. Incomplete treatment and treatment abandonment are factors that negatively impact the prognosis. Further studies are needed to identify barriers in the referral and treatment process for patients with ependymoma.

Workflow in a pediatric neuro-oncology center

Introduction

Medical workflow is defined as task, process and medical staff working together in a specialized multidisciplinary team to deliver proper healthcare and achieve patient satisfaction with good patient experience such as in neuro-oncology centers which deal with central nervous system tumors. The aim of this article is to review workflow of a neuro-oncology center focusing on how to maintain patient satisfaction with the best health care outcome.

Main body

An organized workflow system in a neuro-oncology center is based on a multidisciplinary team of specialized and experienced neurosurgeons, pediatric oncologist, neuroradiologist, neuropathologist and radiotherapy oncologist where the patient is assigned to a primary oncologist and the decision regarding the surgical intervention is decided first by the pediatric neurosurgeon. The optimum workflow in a high flow neuro-oncology center starts with screening of all the referred cases to select those who match the mission and resources of the center to avoid overloading that affects the time and quality for care giving. Admission protocols must differentiate between elective and emergent admissions, centralization of caseload and proper scheduling of operations and outpatient visits. Clinical documentation is mandatory, and the efficiency and effectiveness of electronic health records (EHR) allows for tracing the work and tasks, proper coordination between multidisciplinary teams and generation of national cancer registries. Surgical intervention is followed by chemotherapy and/or radiotherapy according to pre-planned protocols for every specific pathology that is diagnosed by the neuropathologist. As the management of many neuro-oncology cases is complex and may require individualization, multidisciplinary team meetings involving extensive discussions are analysis for the best management plan.

Conclusion

A high flow neuro-oncology center requires a well-planned, and organized multidisciplinary team maintaining workflow system to improve the health outcome, and patient’s compliance and experience.