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

AIMS

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Global Collaborations for Cervical Cancer: Can the East-West Alliance Facilitate Treatment for all?

Despite the advances in the primary prevention of cervical cancer, there is an absolute increase in the incidence of cervical cancer as a result of an increase in world population. A vast majority of patients in low and low-middle income countries continue to present at a locally advanced stage, necessitating treatment with chemoradiation and brachytherapy. There is a dearth of equipment and trained professionals for the treatment of cervical cancer, especially in low and low-middle income countries. There is an urgent need to improve treatment availability and develop better treatments. Worldwide trends, however, reveal a low number of therapeutic and innovative research trials in cervical cancer. The present article elucidates the existing challenges and provides solutions to improve outcomes. The proposed strategies hinge on strengthening collaborations for global advocacy.

Developing National Cancer Guideline: A Step Toward Standardized Multidisciplinary Management in Indonesia

Background and context: Along with the development and advancement of cancer management, multidisciplinary approach has been an essential part to achieve a better patient outcome. However, to ensure the best management for cancer patients, national clinical guidelines should be established. Clinical practice guidelines serve a great role in translating evidence from bench to bedside, as well as improving the quality of medical care throughout the country. Until 2014 , before the establishment of National Cancer Control Committee (NCCC), there have been several hospital-based and society-based guidelines, but no national guidelines available. Aim: The development of national cancer guideline aims to ensure best clinical practice on cancer in Indonesia. Strategy/Tactics: The guidelines were developed based on the strategic objective of NCCC-Ministry of Health (MoH) Republic of Indonesia and the Decree of Minister of Health Number 1438/MENKES/Per/IX/2010 about the standard of medical services. Program/Policy process: Under the decree of Minister of Health and NCCC-MoH, all cancer-related discipline represented by expert from each discipline´s professional society were gathered in a “Guideline Development Team” to develop national cancer guidelines. First, there was a discussion on the outline. Then, each specialist/discipline would develop their own management based on the related knowledge. Finally, everyone will discuss together to finalize the compiled guidelines. Outcomes: Eight national guidelines were developed in three years after NCCC established, including breast cancer, cervical cancer, lung cancer, colorectal cancer, nasopharyngeal cancer, brain tumor, prostate cancer and osteosarcoma. Experts of the related discipline were involved in writing the guidelines. Various obstacles occurred during the process of writing the guidelines, including multidiscipline teams involvement and the geographical problem of being an archipelago country. But, having one vision to develop the best medical management for cancer patients, the national guidelines were finally published on the Web site of NCCC and currently waiting for Minister of Health approval. What was learned: Gathering multidisciplinary teams to develop national guidelines was not an easy task. However, by having the same vision and inviting all cancer-related societies, we can make this achievement. Moreover, the decree of Minister of Health was also an essential part to push everyone moving forward.

The Role of Multisectoral Collaboration in Indonesia for Successful Health Promotion

Background: Cancer had caused 14,067,900 people suffered in 2012. In Indonesia, with 357,000 cases, added by mortality and morbidity, cancer has added the country double burden of disease. Thus, preventive measure should be done to tackle the problem. One of the best ways is health promotion through the massive campaign and multisectoral collaboration using the momentum of annual World Cancer Day (WCD). Annual WCD has been held by National Cancer Control Committee (NCCC)-Ministry of Health (MoH), however, 2017 is the kick-off event which engages multisector to promote cancer awareness and knowledge. Aim: This campaign aims to increase awareness and knowledge about cancer (including the healthy lifestyle, detection program and treatment) among Indonesian. Strategy: The national action was planned based on the strategic objective of NCCC. The campaign was coordinated by NCCC-MoH of Indonesia and implemented throughout the country. The local situation, condition and creativity were encouraged to ensure the successful campaign. Program process: Initial coordination was made by NCCC. The proposal was disseminated to the centers across Indonesia. Then, centers would carry out the event and report to the NCCC. Meanwhile, a massive campaign in Jakarta was held by NCCC. Outcomes: There were 25 out of 34 provinces, consisted of 18 nongovernmental organizations (NGOs), 20 professional societies, 37 hospitals and 25 provincial public health service involved in the WCD campaign. This WCD was held under decree of Minister of Health. Several programs in the WCD were press briefing, seminars, talk show, fun campaign in public areas (i.e., celebrity performance, yoga), promotion via local television/newspaper and social media; early detection such as Papanicolaou test, mobile mammography, breast ultrasound, clinical breast examination and visual inspection of acetic acid. The impact of WCD 2017 was tremendous compared with previous year, with multisectoral involvement, overloaded participants and broke the World of Record Museum-Indonesia (MURI) with the most dancer involved dance for the cancer survivor. In addition, the impact can be seen in 2018, when no decree of the minister and national movement provided. In 2018, NCCC only organized a training of trainer with the hope of having an extension of the hand to deliver knowledge and awareness. Nevertheless, each part of Indonesia was commemorating their own WCD without any coordination. These evidence showed that NCCC had been successful to increase awareness and knowledge about cancer. What was learned: Many people were involved in the preparation, starting from doctors, local government, NGOs, hospitals, MoH, companies, survivors and celebrities. Moreover, social media campaign and celebrities played a great role in making this event succeed. Therefore, multisector collaboration is an essential part of raising awareness and knowledge about cancer.

Epstein-Barr virus latent membrane protein 1 (EBV-LMP1) and tumor proliferation rate as predictive factors of nasopharyngeal cancer (NPC) radiation response

BACKGROUND

Irradiation is still the treatment of choice in NPC treatment as one of highest malignancy in Indonesia as well as in Southeast Asia. Up to now there is no accurate predictor on radiation response, since that the similar histo-morphological pattern, as a well-known prognostic factor can revealed a wide range of treatment outcomes. Purpose of the study is to established the influence of EBV-LMP 1 as the most important protein expressed by EBV oncogenes in cellular behaviour such as proliferation rate, tumor aggressivity in NPC and to find out the role of both, proliferation rate and EBV-LMP1 expression as a predictor on NPC radiation response.

MATERIALS AND METHODS

172 paraffin-embedded biopsy specimens from NPC patients were analysed flow-cytometrically to obtain the S-phase fraction value as the proliferation parameter. From this group of patients, 81 fresh specimen biopsies could be collected, and the EBV-LMP 1 expression were detected by western blotting technique (mAB S12--Karolinska Instituet) could be done. Several variables such as clinical stage, pathology pattern and radiation response were also collected. The radiation responses were established clinically (by nasopharyngoscopy), by CT scanning and pathologically.

RESULTS

Sixty-five percent of our patients belong to the T3 and T4, whereby the N2-3 group consists 75% of them. Fourteen percent of the patients are Hsu type I, 48% are Hs type II and the rest belong to Hsu type III. Our study revealed that the mean SPF value was 14.62% (10.18%, which correlated (p < 0.05) with the tumor and nodal sizes. The rate of positive expression of the EBV-LMP1 was 50%, and did not show a correlation with the proliferation activity as well as the radiation response. However, it showed a significant correlation with the tumor and nodal size. There was a significant correlation between this proliferation value with the radiation response calculated by both, bivariate as well as by multivariate analysis. The complete and incomplete response group of patients has a SPF mean value of 10.1% +/- 9% and 17.1% +/- 9.3% respectively, with the SPF cut off value of 11%. There is no correlation between the proliferation rate with the histology pattern of NPC, as well as this radiation response with the histology pattern.

CONCLUSIONS

It is assumed that the expression of EBV-LMP1 prevents the apoptosis process through increasing the level of A20 protein, rather than inducing the expression of the EGFR in the proliferation pathway. SPF, one of the proliferation rate parameters, was the only factor that can be used as a radiation response predictor of NPC. It is assumed that the patients with high proliferation rate (SPF > 13%) should be irradiated in the unconventional irradiation scheme such as hyper-fractionated irradiation, or combined with another modality that will enhance the radiation effect, since the proliferation is too fast for once-a-day irradiation scheme. There were no correlations among pathology pattern, the proliferation rate and radiation response in NPC.