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The Practice of Paediatric Radiation Oncology in Low-and Middle- income Countries: Outcomes of an International Atomic Energy Agency Study-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/)
Abstract
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.
... Childhood cancer is prevalent throughout the world. 1 With modern technologies and therapies, high-income countries (HICs) now report cure rates as high as 80% for children with cancer. 2,3 However, low-and middle-income countries (LMICs) struggle with lack of health care resources and infrastructure, resulting in upward of 90% of pediatric oncologic deaths occurring in these countries. [2][3][4] As radiotherapy is a critical component of care for children with malignancies, improving quality and access to pediatric radiotherapy services in LMICs is vital. ...
... 2,3 However, low-and middle-income countries (LMICs) struggle with lack of health care resources and infrastructure, resulting in upward of 90% of pediatric oncologic deaths occurring in these countries. [2][3][4] As radiotherapy is a critical component of care for children with malignancies, improving quality and access to pediatric radiotherapy services in LMICs is vital. 5 Ethiopia is a low-income country (LIC) in sub-Saharan Africa with a multitude of distinct ethnic groups, languages, and religions. ...
... Previous literature regarding pediatric radiotherapy in LMICs focus on epidemiology, barriers to radiotherapy delivery, and patterns of care. [2][3][4][5][6][7][8][9][10] Data regarding solutions to these challenges are limited; however, institutional partnerships between radiotherapy departments represent one such avenue. Twinning partnerships have been effectively implemented in other medical specialties, including emergency medicine, psychiatry, and infectious diseases. ...
PURPOSE
Pediatric radiotherapy is a necessary and challenging component of oncologic care for children in low- and middle-income countries (LMICs). Collaboration between institutions in LMICs and high-income countries (HICs) has been shown to be effective in improving oncologic treatment outcomes; however, literature regarding pediatric radiotherapy twinning partnerships is limited.
METHODS
Emory University has a long-standing twinning collaboration with Tikur Anbessa Specialized Hospital (TASH) for certain medical specialties. After securing institutional funding, a faculty member and a resident from the Emory University Department of Radiation Oncology set out to establish a twinning program with TASH for pediatric radiotherapy.
RESULTS
Emory and TASH faculty and residents established initial communications virtually via email and video correspondence. TASH residents and faculty completed surveys regarding pediatric radiotherapy institutional and educational needs to outline goals of collaboration. Five lectures and case-based practicums were identified focused on Wilms tumor, medulloblastoma, rhabdomyosarcoma, Hodgkin lymphoma, and palliative radiotherapy. The Emory team then conducted a visit to TASH during which lectures and practicums were delivered. The Emory team directly observed and guided simulation and treatment planning procedures. TASH residents practiced decision making, simulation, contouring, and field placement for Wilms tumor cases on the basis of didactics and feedback provided by the Emory team. Additionally, a needs assessment regarding pediatric oncologic resources was completed. Clinical care pathways and standard operating procedures were drafted by collaborators. Virtual peer-review sessions were established to continue collaborations abroad and plan for next in-person visit.
CONCLUSION
Collaborative efforts by global experts have helped to establish and improve treatment protocols for childhood cancer. The presented twinning experience may serve as a model for other LMIC and HIC centers for establishing similar partnerships.
... These potential risks are magnified in the use of modern radiation therapy techniques such as IMRT, image-guided RT, and stereotactic radiosurgery that represent an entirely new paradigm that also requires extensive knowledge and understanding of the latest imaging systems, set up uncertainties, radiobiological response of healthy tissues, 3D dose calculations, optimization of variable intensity beam delivery, and internal organ motion. 22 More than 75% of the RT centers in our survey lacked all the necessary equipment to deliver treatment with complex advanced RT techniques. Our findings are supported by other studies. ...
... 25 The high cost of RT treatment has been a major challenge for patients in accessing RT treatment when the treatment machines are operational, a status often jeopardized by frequent breakdown of RT machines. 22 To improve access to RT, we recommend that the cost of RT services be subsidized in Governmentfunded and PPP RT centers, and there is a need for a new model where availability and affordability needs can be met while maintaining high standard of care. ...
Purpose:
Access to radiotherapy (RT) is now one of the stark examples of global cancer inequities. More than 800,000 new cancer cases require potentially curative or palliative RT services in Africa, arguably <15% of these patients currently have access to this important service. For a population of more than 206 million, Nigeria requires a minimum of 280 RT machines for the increasing number of cancer cases. Painfully, the country has only eight Government-funded RT machines. This study aimed to evaluate the status of the eight Government-funded RT services in Nigeria and their ability to deliver effective RT to their patients.
Methods:
A survey addressing 10 critical areas was used to assess the eight Government-funded RT services in Nigeria.
Results:
Unfortunately, six of the eight centers (75%) surveyed have not treated patients with RT because they do not have functioning teletherapy machines in 2021. Only two RT centers have the capability of treating patients using advanced RT techniques. There is no positron emission tomography-computed tomography scan in any of the Government-funded RT centers. The workforce capacity and infrastructure across the eight centers are limited. All of the centers lack residency training programs for medical physicists and radiation therapy technologists resulting in very few well-trained staff.
Conclusion:
As the Nigerian Government plans for the new National Cancer Control Plan, there is an urgent need to scale up access to RT by upgrading the RT equipment, workforce, and infrastructure to meet the current needs of Nigerian patients with cancer. Although the shortfall is apparent from a variety of RT-capacity databases, this detailed analysis provides essential information for an implementation plan involving solutions from within Nigeria and with global partners.
... These potential risks are magnified in the use of modern radiation therapy techniques such as IMRT, image-guided RT, and stereotactic radiosurgery that represent an entirely new paradigm that also requires extensive knowledge and understanding of the latest imaging systems, set up uncertainties, radiobiological response of healthy tissues, 3D dose calculations, optimization of variable intensity beam delivery, and internal organ motion. 22 More than 75% of the RT centers in our survey lacked all the necessary equipment to deliver treatment with complex advanced RT techniques. Our findings are supported by other studies. ...
... 25 The high cost of RT treatment has been a major challenge for patients in accessing RT treatment when the treatment machines are operational, a status often jeopardized by frequent breakdown of RT machines. 22 To improve access to RT, we recommend that the cost of RT services be subsidized in Governmentfunded and PPP RT centers, and there is a need for a new model where availability and affordability needs can be met while maintaining high standard of care. ...
PURPOSE: Access to radiotherapy (RT) is now one of the stark examples of global cancer inequities. Over 800,000 new cancer cases require potentially curative or palliative RT services in Africa, arguably less than 15% of these patients currently have access to this important service. For a population of over 200 million, Nigeria requires a minimum of 280 RT machines for the increasing number of cancer cases. Painfully the country has only 8 government-funded radiotherapy machines. This study aimed to evaluate the status of the eight (8) Government-funded RT centres in Nigeria regarding RT equipment, workforce and infrastructure to quantify their ability to deliver effective RT to their patients.
METHODS: A survey addressing ten (10) critical areas was used to assess the eight (8) Government-funded RT centres in Nigeria.
RESULTS: Unfortunately, 6 of the 8 centres (75%) surveyed have not treated patients with RT over the last 2 years because they do not have functioning teletherapy machines. Only 2 RT centres have the capability of treating patients using advanced RT techniques. There is no PET-CT scan in any of the Government-funded RTcentres. The workforce capacity and infrastructure across the 8 centres are limited. All of the centres lack residency training programmes for medical physicists and radiation therapy technologists (RTTs) resulting in very few well-trained staff.
CONCLUSION: As the Nigeria government plans for the new National Cancer Control Plan, there is an urgent need to scale up access to radiotherapy by upgrading the RT equipment, workforce and infrastructure to meet the current needs of Nigerian cancer patients. While the shortfall is apparent from a variety of radiotherapy-capacity data bases, this detailed analysis provides essential information for an implementation plan involving solutions from within Nigeria and with global partners.
Citation Format: Simeon C. Aruah, Runcie C. Chidebe, Tochukwu C. Orjiakor, Fatima Uba, Uchechukwu Shagaya, Charles Ugwanyi, Aisha A. Umar, Taofeeq Ige, Obinna C. Asogwa, Oiza T. Ahmadu, Musa Ali-Gombe, Alabi Adewumi, Vitalis C. Okwor, Mutiu A. Jimoh, Basheer Bello, Lucy O. Eriba, Yusuf A. Ahmed, Awwal Bisalla, Ukamaka Itanyi, Ramatallah A. Balogun, Suleiman Alabi, David Pistenmaa, Coleman C. Norman, Dosanjh Manjit. The status of Government-funded radiotherapy centres in Nigeria [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1111.
... These potential risks are magnified in the use of modern radiation therapy techniques such as IMRT, image-guided RT, and stereotactic radiosurgery that represent an entirely new paradigm that also requires extensive knowledge and understanding of the latest imaging systems, set up uncertainties, radiobiological response of healthy tissues, 3D dose calculations, optimization of variable intensity beam delivery, and internal organ motion. 22 More than 75% of the RT centers in our survey lacked all the necessary equipment to deliver treatment with complex advanced RT techniques. Our findings are supported by other studies. ...
... 25 The high cost of RT treatment has been a major challenge for patients in accessing RT treatment when the treatment machines are operational, a status often jeopardized by frequent breakdown of RT machines. 22 To improve access to RT, we recommend that the cost of RT services be subsidized in Governmentfunded and PPP RT centers, and there is a need for a new model where availability and affordability needs can be met while maintaining high standard of care. ...
Purpose: Access to radiotherapy (RT) is now one of the stark examples of global cancer inequities. Over 800,000 new cancer cases require potentially curative or palliative RT services in Africa, arguably less than 15% of these patients currently have access to this important service. For a population of over 200 million, Nigeria requires a minimum of 280 RT machines for the increasing number of cancer cases. Painfully the country has only 8 government-funded radiotherapy machines. This study aimed to evaluate the status of the eight (8) Government-funded RT centres in Nigeria regarding RT equipment, workforce and infrastructure to quantify their ability to deliver effective RT to their patients.
Methods: A survey addressing ten (10) critical areas was used to assess the eight (8) Government-funded RT centres in Nigeria.
Results: Unfortunately, 6 of the 8 centres (75%) surveyed have not treated patients with RT over the last 2 years because they do not have functioning teletherapy machines. Only 2 RT centres have the capability of treating patients using advanced RT techniques. There is no PET-CT scan in any of the Government-funded RTcentres. The workforce capacity and infrastructure across the 8 centres are limited. All of the centres lack residency training programmes for medical physicists and radiation therapy technologists (RTTs) resulting in very few well-trained staff.
Conclusion: As the Nigeria government plans for the new National Cancer Control Plan, there is an urgent need to scale up access to radiotherapy by upgrading the RT equipment, workforce and infrastructure to meet the current needs of Nigerian cancer patients. While the shortfall is apparent from a variety of radiotherapy-capacity data bases, this detailed analysis provides essential information for an implementation plan involving solutions from within Nigeria and with global partners.
Citation Format: Runcie C.W. Chidebe, Chinedu S. Aruah, Tochukwu C. Orjiakor, Fatima Uba, Uchechukwu N Shagaya, Charles Ugwanyi, Aisha A Umar, Taofeeq Ige, Obinna C. Asogwa, Oiza T Ahmadu, Musa Ali-Gombe, Alabi Adewumi, Vitalis C. Okwor, Mutiu A Jimoh, Basheer Bello, Lucy O. Eriba, Yusuf A. Ahmed, Awwal Bisalla, Ukamaka Itanyi, Ramatallah A Balogun, Suleiman Alabi, David Pistenmaa, Coleman C. Norman, Dosanjh Manjit. The Status of Government-Funded Radiotherapy Centres in Nigeria [abstract]. In: Proceedings of the 11th Annual Symposium on Global Cancer Research; Closing the Research-to-Implementation Gap; 2023 Apr 4-6. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(6_Suppl):Abstract nr 86.
... 29 A review of 34 cancer treatment institutions in SSA showed that the majority of these centers offered surgical and chemotherapy services, whereas only 18 of them had RT facilities available for use. 30 In a 2020 evaluation of pediatric RT facilities by Anacak et al, 31 it was observed that only 53% of children were treated with an intent to cure in low-income countries, as opposed to over 80% in high-income countries. Underutilization of RT in SSA can be attributed to various limitations, including limited specialized workforce and infrastructure, inaccessibility of health care centers, and lack of health insurance. ...
Radiation therapy (RT) is an essential part of the multidisciplinary treatment of pediatric cancer. Over the past five decades, significant advances have been made in the delivery of RT, with better dose delivery to disease targets while minimizing exposure to nearby organs at risk. These advances have led to improved treatment outcomes, increased survival, and reduced treatment-related toxicities. Advanced treatment techniques, however, require significant investment in infrastructural and personnel resources. This review documents what is currently available regarding expertise and infrastructure for pediatric radiation oncology practice in Nigeria. It was performed to serve as a foundation for the creation and design of tailored solutions (initiatives and policies) to increase pediatric radiation availability, accessibility, and equity in Nigeria and ultimately improve pediatric cancer treatment outcomes in the region.
... Provision of sustainable and effective cancer services in any country, to any population of patients, requires a clear understanding of the national treatment healthcare infrastructure, financial support and reimbursement mechanisms, distribution of services and expertise, and access to clinical trials [9][10][11]. Paediatric oncology provision in eastern European countries have been previously described, identifying discrepancies in outcomes, variations in access to specialised services for children and adolescents, and unequal use and distribution of expertise [3,6,[12][13][14]. ...
Introduction: Significant differences in outcome and survivorship in childhood cancer still exist across Europe,
with poorer results in eastern regions. We aimed to map the provision of paediatric radiotherapy in Romania,
identifying the key future requirements and main challenges.
Methods: An online survey supported by SIOP Europe was distributed to all 33 (13 public, 20 private) radio-
therapy departments operating across Romania. The questionnaire contained 22 open-ended and multiple-
choice questions, exploring resources, clinical trial participation, patient referral practice, and Radiotherapy
Quality Assurance (RTQA).
Results: Nineteen centres (58%) responded to the survey, ten of which treat children and seven having desig-
nated radiation oncologists for paediatric patients. While access to advanced photon techniques is high (16/19
with IMRT/IMAT), only six centres report availability of general anaesthesia. Participants agree that challenges
include a lack of national/regional specialised paediatric radiotherapy centres, limited access to mentors or
training opportunities, and availability of robust multidisciplinary tumour boards. Only one centre reports
participating in paediatric radiotherapy clinical trials; likely attributable to a lack of national trial infrastructure
and poor local engagement. Physicians in 16 centres refer children for proton therapy but find the long waiting
time and laborious paperwork difficult. Sixteen responders considered paediatric RTQA essential; agreeing that a
(inter)national RTQA programme is needed and would benefit patients.
Conclusions: While advanced radiotherapy techniques are widely available for children in Romania, the lack of
centralised and harmonised practice, scarce training opportunities, underdeveloped clinical trial infrastructure,
and laborious proton referral process highlighted by the survey, describe a complex landscape. Future im-
provements are required, including establishing strategic national and international multi-stakeholder colla-
borations
... time with the advent of effective chemotherapeutics and enhanced surgical techniques. To our knowledge there are only limited studies, which studied the radiotherapy practices in pediatric malignancies in general [8,9]. With this study we wanted to analyze the radiotherapy practices in pediatric malignancies in our institution. ...
Background: Incidences of pediatric malignancies are increasing. In management of various childhood malignancies like hematological, bone and soft tissue tumors radiotherapy plays a crucial role. RT treatment planning and delivery poses a challenge to clinicians. Hence with this study we wanted to know the radiotherapy practices in our institution. Materials and Methods: This was a retrospective study analyzing case records and RT charts of all pediatric malignancies who received radiation treatment for a period of 3 years from January 2018 to December 2021. Demographic details, RT details, toxicity details were carefully recorded. Results: Details of 73 pediatric malignancy cases who received RT were analyzed. Median age was 10 years and the majority were males (66%). Commonest malignancies which received RT treatment were ALL (30%), Brain tumors (26%) and bone and soft tissue tumors (22%). Radiotherapy was given as a part of radical intent treatment including neo adjuvant, definitive, adjuvant and prophylactic in 92% of patients. Conformal RT techniques in the form of 3DCRT and VMAT were used in majority (91%) cases. A significant proportion (27%) of cases required anesthesia for RT treatment delivery. 16% of patients had treatment break and common reasons for treatment break being infections (COVID, respiratory) and neutropenia. Grade 3 or more acute toxicities were observed in 14% of patients and hematological toxicity was the most frequent. Conclusion: Hematological and bone & soft tissue tumors are the most common pediatric malignancies requiring RT as a part of multimodality treatment. For RT treatment delivery anesthesia services may be required in pediatric malignancies. Acute Grade 3 or more toxicities and treatment breaks are a concern and these pediatric cases require a properly coordinated supportive care during treatment.
... Not unexpectedly, discussion of GBCs at HPB specific MDTs (or "tumour boards") happened more frequently in units performing high volumes of liver resections, commensurate with the need for subspecialised MDTs due to greater case volumes. 10 Despite recommendations for routine staging laparoscopy in consensus guidelines, less than one third of respondents overall and less than one fourth of respondents from high volume centres performed this routinely, while MRI and PET CT were in turn underutilised as staging investigations in low volume centres. 1,[7][8][9] Ensuring consistent discussion of GBCs in HPB MDTs may overcome some of these differences in practice, and prove a helpful endeavour towards more uniform and evidence-based staging approaches in the workup of GBC. ...
... Not unexpectedly, discussion of GBCs at HPB specific MDTs (or "tumour boards") happened more frequently in units performing high volumes of liver resections, commensurate with the need for subspecialised MDTs due to greater case volumes. 10 Despite recommendations for routine staging laparoscopy in consensus guidelines, less than one third of respondents overall and less than one fourth of respondents from high volume centres performed this routinely, while MRI and PET CT were in turn underutilised as staging investigations in low volume centres. 1,[7][8][9] Ensuring consistent discussion of GBCs in HPB MDTs may overcome some of these differences in practice, and prove a helpful endeavour towards more uniform and evidence-based staging approaches in the workup of GBC. ...
... Not unexpectedly, discussion of GBCs at HPB specific MDTs (or "tumour boards") happened more frequently in units performing high volumes of liver resections, commensurate with the need for subspecialised MDTs due to greater case volumes. 10 Despite recommendations for routine staging laparoscopy in consensus guidelines, less than one third of respondents overall and less than one fourth of respondents from high volume centres performed this routinely, while MRI and PET CT were in turn underutilised as staging investigations in low volume centres. 1,[7][8][9] Ensuring consistent discussion of GBCs in HPB MDTs may overcome some of these differences in practice, and prove a helpful endeavour towards more uniform and evidence-based staging approaches in the workup of GBC. ...
Background: Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multi- centre studies.
Methods: A 34-question online survey was disseminated to members of the European-African Hepa- topancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia–Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.
Results: Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.
Conclusion: Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.
... along with aspects of quality, such as inputs of interdisciplinary RT teams, treatment planning protocols and quality assurance. 3,4 This is an underresearched area in low-and middle-income countries (LMIC) including India, where most of the childhood cancer cases occur. ...
Background
Planning and coordination of the delivery of radiation therapy (RT) can be challenging in resource-limited settings. In this retrospective study, we describe the profile of children undergoing radiation and analyze deviation from some accepted norms.
Procedure
Data on all children (<18 years of age) with cancer who completed RT from January 2009 to December 2019 were retrieved. Diagnostic groups with more than five patients were included in the analysis for deviations in RT (time to start [TTS]; total dose delivered [TDD] in gray; and time to complete [TTC]). We investigated reasons for deviation.
Results
Two hundred seven children received RT as front-line treatment (68% Indian, 59% male). Most common diagnoses were brain tumors (44%), lymphomas (13%), leukemias, and soft tissue sarcomas (10% each). TTS deviation was seen in 23.6%, TTD in 6.0%, and TTC in 24.7%, while 43.4% had at least one deviation in any of these three parameters. Deviation in TTS varied significantly by location of preceding treatment and by cancer (greatest deviation in sarcomas), with issues around access to health care being the most common reason. Deviation in TTC varied significantly by cancer (greatest deviation in sarcomas and medulloblastoma), with myelotoxicity being the most common reason.
Conclusions
Our study adds to the limited literature on RT quality for children with cancer in resource-limited settings. Certain cancers (sarcomas and medulloblastomas) and patient groups (preceding treatment outside our institute) had the maximum deviation. Barriers to accessing care and myelotoxicity were the two main reasons for this deviation.
... This is because globally access to RT is not uniform and there are deficiencies in availability of RT machines, trained staff, as well as aspects of quality like input of interdisciplinary RT teams, treatment planning protocols, and quality assurance. (3,4) This is an under-researched area in low and middleincome countries (LMIC) including India where most of the childhood cancer cases occur. ...
Background The delivery of Radiation therapy (RT) needs a level of coordination and planning which can be challenging in resource-limited settings. In this retrospective study we describe the profile of children undergoing radiation and analyze deviation from accepted norms. Procedure Data on all children (< 18 years age) with cancer who completed RT from Jan 2009 to Dec 2019 were retrieved. Diagnostic groups with more than 5 patients, were included in the analysis for deviations in RT (Time to start (TTS); total dose delivered (TDD) in Grays; and time to complete (TTC)). We investigated reasons for deviation. Results 207 received RT as front-line treatment (68% Indian, 59% male and 32% received treatment preceding RT outside). Most common diagnosis were brain tumors (44%), lymphoma (13%). leukemia and soft tissue sarcoma (10% each). 23.6% had deviation in TTS, 6.0% in TDD and 24.7% in TTC while 43.4% had at least one deviation in any of these three parameters. Deviation in TTS varied significantly by location of preceding treatment and by cancer (greatest deviation in sarcomas) with issues around access to healthcare the most common reason. Deviation in TTC varied significantly by cancer (greatest deviation in sarcomas and medulloblastoma) with myelotoxicity the most common reason. Conclusions Our study adds to the limited literature on RT quality for children with cancer in LMIC. Certain cancers (sarcomas and medulloblastoma) and patient groups (preceding treatment outside our institute) had the maximum deviation. Barriers to accessing care and myelotoxicity were the two main reasons for this deviation.
Radiotherapy plays an important role in the multimodal treatment of childhood cancer. Our objective was to provide an analysis of pediatric oncology patients treated with radiotherapy in a national referral institution in Serbia. A retrospective chart review of children treated with radiotherapy between January 2007 and July 2018 was conducted. Of the 806 patients who were identified, 767 formed the basis of this study. CNS tumors (31.2%) were the most common tumors followed by leukemias (17.3%) and bone tumors (14.3%). The most common indication for radiotherapy was in adjuvant setting (69.1%). Anesthesia or sedation was performed on 115 patients. The 5-year and 10-year overall survival rates were 65.7% and 62.1%, respectively. A significant difference in survival in relation to tumor type was seen. The best survival rates were obtained in patients with retinoblastoma, followed by lymphomas and nephroblastoma, while patients with bone sarcomas had the worst survival. The intent of radiotherapy treatment was also a parameter associated with survival. Patients treated with palliative and definitive intent lived shorter than patients treated with prophylactic and adjuvant intent. Our study showed that good treatment outcomes can be achieved in specialized centers with an experienced team of professionals who are dedicated to pediatric oncology.
Purpose:
No published study to date has examined total cost and cost-effectiveness of maintaining a pediatric oncology treatment center in an African setting, thus limiting childhood cancer advocacy and policy efforts.
Methods:
Within the Korle Bu Teaching Hospital in Accra, Ghana, costing data were gathered for all inputs related to operating a pediatric cancer unit. Cost and volume data for relevant clinical services (eg, laboratory, pathology, medications) were obtained retrospectively or prospectively. Salaries were determined and multiplied by proportion of time dedicated toward pediatric patients with cancer. Costs associated with inpatient bed use, outpatient clinic use, administrative fees, and overhead were estimated. Costs were summed for a total annual operating cost. Cost-effectiveness was calculated based on annual patients with newly diagnosed disease, survival rates, and life expectancy.
Results:
The Korle Bu Teaching Hospital pediatric cancer unit treats on average 170 new diagnoses annually. Total operating cost was $1.7 million/y. Personnel salaries and operating room costs were the most expensive inputs, contributing 45% and 21% of total costs. Together, medications, imaging, radiation, and pathology services accounted for 7%. The cost per disability-adjusted life-year averted was $1,034, less than the Ghanaian per capita income, and thus considered very cost effective as per WHO-CHOICE methodology.
Conclusion:
To our knowledge, this study is the first to examine institution-level costs and cost-effectiveness of a childhood cancer program in an African setting, demonstrating that operating such a program in this setting is very cost effective. These results will inform national childhood cancer strategies in Africa and other low- and middle-income country settings.
Volume 3, Cancer, presents the complex patterns of cancer incidence and death around the world and evidence on effective and cost-effective ways to control cancers. The DCP3 evaluation of cancer will indicate where cancer treatment is ineffective and wasteful, and offer alternative cancer care packages that are cost-effective and suited to low-resource settings. Main messages from the volume include:
-Quality matters in all aspects of cancer treatment and palliation.
-Cancer registries that track incidence, mortality, and survival †“ paired with systems to capture causes of death are important to understanding the national cancer burden and the effect of interventions over time.
-Effective interventions exist at a range of prices. Adopting ‘resource appropriate’ measures which allow the most effective treatment for the greatest number of people will be advantageous to countries.
-Prioritizing resources toward early stage and curable cancers is likely to have the greatest health impact in low income settings.
-Research prioritization is no longer just a global responsibility.
Providing cancer treatment requires adequate numbers of trained healthcare professionals and infrastructure beyond what is available in most LMICs, especially low income countries. Careful patient monitoring is a requirement of good quality cancer care and this often involves laboratory tests in addition to clinical examination. Even if financing were immediately available to build or expand a cancer control system, reaching capacity will take many years.
The cancer burden in low- and middle-income countries (LMIC) is substantial. The purpose of this study was to identify and describe country and region-specific patterns of radiotherapy (RT) facilities in LMIC.
A systematic review of the literature was undertaken. A search strategy was developed to include articles on radiation capacity in LMIC from the following databases: PubMed, Embase, CINAHL Plus, Global Health, and the Latin American and Caribbean System on Health Sciences Information. Searches included all literature up to April 2013.
A total of 49 articles were included in the review. Studies reviewed were divided into one of four regions: Africa, Asia, Eastern Europe, and South America. The African continent has the least amount of resources for RT. Furthermore, a wide disparity exists, as 60% of all machines on the continent are concentrated in Egypt and South Africa while 29 countries in Africa are still lacking any RT resource. A significant heterogeneity also exists across Southeast Asia despite a threefold increase in megavoltage teletherapy machines from 1976 to 1999, which corresponds with a rise in economic status. In LMIC of the Americas, only Uruguay met the International Atomic Energy Agency recommendations of 4 MV/million population, whereas Bolivia and Venezuela had the most radiation oncologists (>1 per 1000 new cancer cases). The main concern with the review of RT resources in Eastern Europe was the lack of data.
There is a dearth of publications on RT therapy infrastructure in LMIC. However, based on limited published data, availability of RT resources reflects the countries' economic status. The challenges to delivering radiation in the discussed regions are multidimensional and include lack of physical resources, lack of human personnel, and lack of data. Furthermore, access to existing RT and affordability of care remains a large problem.
About 57% of the total number of cancer cases occur in low and middle income countries. Radiotherapy is one of the main components of cancer treatment and requires substantial initial investment in infrastructure and training. Many departments continue to have basic facilities and to use simple techniques, while modern technologies have only been installed in big cities in upper-middle income countries. More than 50% of cancer patients requiring radiotherapy in low and middle income countries lack access to treatment. The situation is dramatic in low income countries, where the proportion is higher than 90%. The overall number of additional teletherapy units needed corresponds to about twice the installed capacity in Europe. The figures for different income level groups clearly show the correlation between gross national income per capita and the availability of services. The range of radiotherapy needs currently covered varies from 0% and 3–4% in low income countries in Latin America and Africa up to 59–79% in upper-middle income countries in Europe and Central Asia. The number of additional radiation oncologists, medical physicist, dosimetrists and radiation therapists (RTTs) required to operate additional radiotherapy departments needed is 43 200 professionals. Training and education programmes are not available in every developing country and in many cases the only option is sending trainees abroad, which is not a cost-effective solution. The implementation of adequate local training should be the following step after establishing the first radiotherapy facility in any country. Joint efforts should be made to establish at least one radiotherapy facility in countries where they do not exist, in order to create radiotherapy communities that could be the base for future expansion.
Effective treatment of children with medulloblastoma requires a functioning multi-disciplinary team with adequate neurosurgical, neuroradiological, pathological, radiotherapy and chemotherapy facilities and personnel. In addition the treating centre should have the capacity to effectively screen and manage any tumour and treatment-associated complications. These requirements have made it difficult for many low and middle-income countries (LMIC) centres to offer curative treatment. This article provides management recommendations for children with standard-risk medulloblastoma (localised tumours in children over the age of 3–5 years) according to the level of facilities available. Pediatr Blood Cancer © 2014 Wiley Periodicals, Inc.
Wilms tumour is a relatively common and curable paediatric tumour. Known challenges to cure in low income countries are late presentation with advanced disease, malnutrition, failure to complete treatment and limited facilities. In this article, management recommendations are given for a low income setting where only the minimal requirements for treatment with curative intent are available (setting 1). These include general management, supportive care, social support and registration of patients. Recommendations specific for Wilms tumour care include diagnostic procedures with emphasis on the role of ultrasonography, preoperative chemotherapy with a reduced dosage for malnourished children and postoperative chemotherapy based on surgical staging. Pediatr Blood Cancer © 2012 Wiley Periodicals, Inc.
Global studies of childhood cancer provide clues to cancer etiology, facilitate prevention and early diagnosis, identify biologic differences, improve survival rates in low-income countries (LIC) by facilitating quality improvement initiatives, and improve outcomes in high-income countries (HIC) through studies of tumor biology and collaborative clinical trials. Incidence rates of cancer differ between various ethnic groups within a single country and between various countries with similar ethnic compositions. Such differences may be the result of genetic predisposition, early or delayed exposure to infectious diseases, and other environmental factors. The reported incidence of childhood leukemia is lower in LIC than in more prosperous countries. Registration of childhood leukemia requires recognition of symptoms, rapid access to primary and tertiary medical care (a pediatric cancer unit), a correct diagnosis, and a data management infrastructure. In LIC, where these services are lacking, some children with leukemia may die before diagnosis and registration. In this environment, epidemiologic studies would seem to be an unaffordable luxury, but in reality represent a key element for progress. Hospital-based registries are both feasible and essential in LIC, and can be developed using available training programs for data managers and the free online Pediatric Oncology Networked Data Base (www.POND4kids.org), which allows collection, analysis, and sharing of data.
In low-income and middle-income countries, an excess in treatment failure for children with cancer usually results from misdiagnosis, inadequate access to treatment, death from toxicity, treatment abandonment, and relapse. The My Child Matters programme of the Sanofi Espoir Foundation has funded 55 paediatric cancer projects in low-income and middle-income countries over 10 years. We assessed the impact of the projects in these regions by using baseline assessments that were done in 2006. Based on these data, estimated 5-year survival in 2016 increased by a median of 5·1%, ranging from −1·5% in Venezuela to 17·5% in Ukraine. Of the 26 861 children per year who develop cancer in the ten index countries with My Child Matters projects that were evaluated in 2006, an estimated additional 1343 children can now expect an increase in survival outcome. For example, in Paraguay, a network of paediatric oncology satellite clinics was established and scaled up to a national level and has managed 884 patients since initiation in 2006. Additionally, the African Retinoblastoma Network was scaled up from a demonstration project in Mali to a network of retinoblastoma referral centres in five sub-Saharan African countries, and the African School of Paediatric Oncology has trained 42 physicians and 100 nurses from 16 countries. The My Child Matters programme has catalysed improvements in cancer care and has complemented the efforts of government, civil society, and the private sector to sustain and scale improvements in health care to a national level. Key elements of successful interventions include strong and sustained local leadership, community engagement, international engagement, and capacity building and support from government.
Many children with cancer in low- and middle-income countries are treated in hospitals lacking key infrastructure, including diagnostic capabilities, imaging modalities, treatment components, supportive care, and personnel. Childhood cancer treatment regimens adapted to local conditions provide an opportunity to cure as many children as possible with the available resources, while working to improve services and supportive care. This paper from the Adapted Treatment Regimens Working Group of the Pediatric Oncology in Developing Countries committee of the International Society of Pediatric Oncology outlines the design, development, implementation, and evaluation of adapted regimens and specifies levels of services needed to deliver them.
Background:
Optimal cancer care requires a multidisciplinary approach. The purpose of the current study was to evaluate the impact of a multidisciplinary tumor board on the treatment plans of children with solid tumors.
Procedures:
The records of 158 consecutive patients discussed at a formal multidisciplinary pediatric tumor board between July 2012 and April 2014 were reviewed. Treatment plans were based on clinical practice guidelines and on current Children's Oncology Group protocols. Alterations in radiologic, pathologic, surgical, and medical interpretations were analyzed to determine the impact on changes in recommendations for clinical management.
Results:
Overall, 55 of 158 children (35%) had alterations in radiologic, pathologic, medical, or surgical interpretation of clinical data following multidisciplinary discussion. Of these, 64% had changes to the initial recommendation for clinical management. Review of imaging studies resulted in interpretation changes in 30 of 158 patients studied (19%), with 12 clinical management changes. Six of 158 patients (3.9%) had changes in pathologic interpretation, with four patients (2.5%) requiring treatment changes. In eight patients (5%), a change in medical management was recommended, while in 11 patients (7%) there were changes in surgical management that were based solely on discussion and not on interpretation of imaging or pathology.
Conclusions:
Formal multidisciplinary review led to alterations in interpretation of clinical data in 35% of patients, and the majority led to changes in recommendations for treatment. Comprehensive multidisciplinary tumor board incorporated into the care of children with cancer provides additional perspectives for families and care providers when delineating optimal treatment plans.
There is growing consensus that Information and Communication Technologies (ICTs) have tremendous potential to catalyze global health collaborations. Advanced ICTs can be employed to leverage the recent major upsurge in Global Health interest into greater space-time flexible collaborative action against cancer and for enhancing greater effectiveness of existing global health initiatives. The recent call for greater action in closing the cancer divide through collaborations, including that in the Red Journal, inspired the 2015 Global Health Catalyst cancer summit, which brought together a unique combination of global oncology leaders, Diaspora leaders, ICT and palliative care experts, industry, nonprofits, and policy makers. The summit provided a forum for networking, knowledge sharing and discussion of some of the emerging models for ICT-powered global health collaborations in radiation oncology care, research, and education, as well as avenues for complementary outreach, including engagement with the Diaspora. This article summarizes the discussions/recommendations from the summit and highlights the emerging ICT-powered models for Radiation oncology Global Health, avenues for greater outreach (Ubuntu) for greater impact and sustainability, as well as emerging areas for scale-up and increased action towards closing the cancer divide.
Radiotherapy is a critical and inseparable component of comprehensive cancer treatment and care. For many of the most common cancers in low-income and middle-income countries, radiotherapy is essential for effective treatment. In high-income countries, radiotherapy is used in more than half of all cases of cancer to cure localised disease, palliate symptoms, and control disease in incurable cancers. Yet, in planning and building treatment capacity for cancer, radiotherapy is frequently the last resource to be considered. Consequently, worldwide access to radiotherapy is unacceptably low. We present a new body of evidence that quantifies the worldwide coverage of radiotherapy services by country. We show the shortfall in access to radiotherapy by country and globally for 2015-35 based on current and projected need, and show substantial health and economic benefits to investing in radiotherapy. The cost of scaling up radiotherapy in the nominal model in 2015-35 is US$26.6 billion in low-income countries, $62.6 billion in lower-middle-income countries, and $94.8 billion in upper-middle-income countries, which amounts to $184.0 billion across all low-income and middle-income countries. In the efficiency model the costs were lower: $14.1 billion in low-income, $33.3 billion in lower-middle-income, and $49.4 billion in upper-middle-income countries-a total of $96.8 billion. Scale-up of radiotherapy capacity in 2015-35 from current levels could lead to saving of 26.9 million life-years in low-income and middle-income countries over the lifetime of the patients who received treatment. The economic benefits of investment in radiotherapy are very substantial. Using the nominal cost model could produce a net benefit of $278.1 billion in 2015-35 ($265.2 million in low-income countries, $38.5 billion in lower-middle-income countries, and $239.3 billion in upper-middle-income countries). Investment in the efficiency model would produce in the same period an even greater total benefit of $365.4 billion ($12.8 billion in low-income countries, $67.7 billion in lower-middle-income countries, and $284.7 billion in upper-middle-income countries). The returns, by the human-capital approach, are projected to be less with the nominal cost model, amounting to $16.9 billion in 2015-35 (-$14.9 billion in low-income countries; -$18.7 billion in lower-middle-income countries, and $50.5 billion in upper-middle-income countries). The returns with the efficiency model were projected to be greater, however, amounting to $104.2 billion (-$2.4 billion in low-income countries, $10.7 billion in lower-middle-income countries, and $95.9 billion in upper-middle-income countries). Our results provide compelling evidence that investment in radiotherapy not only enables treatment of large numbers of cancer cases to save lives, but also brings positive economic benefits.
In response to a world in which cancer is a growing global health challenge, leaders in cancer policy from the United States and 14 economically diverse countries recently concluded that successful campaigns to control cancers and improve current strategies will increasingly depend on concerted international collaborations (1). Highlighting urgency for such collaborations, the 2014 World Health Organization Cancer Report (2) describes the growing cancer burden as alarming and a major obstacle to human development and well-being, with a growing annual economic cost of approximately 1.16 trillion US$. The report also highlights major global cancer disparities, with more than 60% of 14 million new cases and 70% of 8.2 million deaths per year occurring in low- and middle-income countries (LMICs), some of which, sadly, are the least capable of dealing with cancer without some form of collaboration. These major disparities in cancer deaths are in part a reflection of poignant underlying disparities in radiation oncology services. For example, radiation therapy, which is needed in the treatment of more than 50% of cancer patients (3), is not available in 31 of Africa’s 54 countries (4), and 55 of 139 LMICs reportedly (5) have no radiation therapy services at present. Therefore, having cancer in many LMICs often leads to a painful and distressing death.
Retinoblastoma remains incurable in many regions of the world. The major obstacles to cure are delayed diagnosis, poor treatment compliance, and lack of evidence-based recommendations for clinical management. Although enucleation is curative for intraocular disease, in developing countries retinoblastoma is often diagnosed after the disease has disseminated beyond the eye. A SIOP-PODC committee generated guidelines for the clinical management of retinoblastoma in developing countries and developed a classification system based on the resources available in those settings. Recommendations are provided for staging and treatment of unilateral and bilateral retinoblastoma and counseling of families for whom compliance is an issue. Pediatr Blood Cancer © 2013 Wiley Periodicals, Inc.
Background:
The high-cure rates of 90% in retinoblastoma are not replicated in developing countries due to late presentation and poor compliance to treatment. The present study takes a closer look at causes of abandonment of therapy and effectiveness of counselling in reducing abandonment.
Procedure:
A retrospective study of children with retinoblastoma registered at our centre from March 2008 through August 2011.
Results:
Fifty (49.50%) of 101 children registered for treatment abandoned therapy. Abandonment rates were significantly higher in rural as compared to urban children (P = 0.02). There was no significant difference in rate of abandonment between stages or laterality of disease and other socio-demographic factors. Telephone calls were more effective than letters in tracing patients (31.2% vs. 2.4%). Major reasons cited behind abandonment were financial problems (30%) and unwillingness to enucleate (20%). Of the 12 children who returned and were retreated 6 (50%) died of progressive disease. Nineteen (73%) of those who did not return died at home. Abandonment rates steadily declined from 71.42% in 2008 to 16.66% in 2011 (P = 0.01) due to effective pre-abandonment counselling by a support team under the National Retinoblastoma Registry of India from 2009.
Conclusions:
Abandonment rates for children with retinoblastoma continue to be unacceptably high. Rural background, financial constraints and hesitancy to enucleate were important causes behind abandonment. Outcome of patients who abandoned treatment was uniformly dismal. Inclusion of support team and intensified initial counselling helped in improving compliance.
The Pediatric Oncology Network Database, POND4Kids (www.pond4kids.org, POND), is an online, multilingual clinical database created for use by pediatric oncology units in countries with limited resources to meet various clinical data management needs including cancer registration, data collection and changes in treatment outcome. Established as a part of the International Outreach Program at St. Jude Children's Research Hospital in Memphis, Tennessee, POND aims to provide oncology units a tool to store patient data for easy retrieval and analysis and to achieve uniform data collection to facilitate meaningful comparison of information among centers. Currently, POND is being used to store clinical data on thousands of patients and measure their treatment improvement over a period of time. In 2009 POND included more than 100 pediatric oncology units; each has its own virtual private area. A case study of the UNOP Guatemala Clinic's use of POND is presented. On-going challenges at partner sites include inconsistent data collection methods, missing records, training for data managers, and slow or unreliable internet connections.
The article summarises the current use of radiotherapy (RT) in childhood cancer and suggests methods to improve current practice in regions where outcomes of paediatric cancer patients are inferior to those of high-income countries.
The International Atomic Energy Agency (IAEA) is supporting low- and mid-income countries (LMICs) in upgrading cancer care where nuclear applications, particularly RT, are used. A consensus meeting of experts was invited to advise IAEA on the needs for RT in paediatric cancer patients. The current indications for RT were reviewed, together with regional differences in access, practice and outcome.
Regional variations in the use of evidence-based multidisciplinary care including RT were associated with varying outcomes of paediatric cancer patients. The contribution of modern and investigational technology to these differences is uncertain and should be determined in clinical trials. Adequate resources are required to support children through the acute phase of treatment and to permit early recognition and management of late effects. An IAEA sponsored project for prospective data collection to assess the current and future status of radiation treatment in childhood cancer in LMICs has commenced.
RT remains an essential component of the multidisciplinary management of many paediatric cancers. Excessive variations in outcome are inappropriate and call for action on harmonising training programmes and compliance with evidence-based recommendations. Training projects targeting paediatric cancer care are being implemented and clinical studies comparing new technologies against evidence-based approaches are needed to achieve this goal. The IAEA has an important role in these activities and has commenced prospective data collection in 13 LMICs to monitor trends in treatment techniques and outcomes.
The developing countries bear the greatest burden of childhood cancers as over 90% of the world's children live in these countries. Childhood cancer in most instances is curable, but many children die from cancer because most children live in developing countries without access to adequate treatment due to high cost of treatment and poor organization in these countries. Initiatives to increase cancer care in developing countries would therefore include establishment of standard cancer care centres, manpower training, establishment of standardized management protocols, procurements of standard drugs and collaboration with international organizations.
The Children's Oncology Group (COG) recently celebrated the milestone of 50 years of pediatric clinical trials and collaborative research in oncology. Our group had its origins in the four legacy pediatric clinical trials groups: the Children's Cancer Group (CCG), the Pediatric Oncology Group (POG), the National Wilms' Tumor Study Group (NWTS), and the Intergroup Rhabdomyosarcoma Study Group (IRSG), which merged in 2000 to form the COG. Over the last 50 years, the survival rates for childhood cancer have risen from 10% to almost 80%. Outcome in acute lymphoblastic leukemia (ALL) has gone from a 6-month median survival to an 80% overall cure rate. We have modified therapies in most major diseases to induce remission with the fewest long-term sequelae. Here we look back on our advances but also look forward to the next 50 years, which will produce even more successful treatments that will be tailored to the specific patient, translating the tools of molecular genetics. Experience has clearly proven that everything we know about the diagnosis and management of childhood cancer is a result of research and the dramatic historical decrease in mortality from childhood cancer is directly related to cooperative group clinical research.
Despite increasing globalisation, international mobility and economic interdependence, 9.7 million children aged less than 5 years in low income countries will die this year, almost all from preventable or treatable diseases. Diarrhoea, pneumonia and malaria account for 5 million of these deaths each year, compared to about 150,000 deaths from childhood cancer in low- and middle-income countries. In high-income countries, 80% of the 50,000 children diagnosed with cancer each year survive, yet cancer remains the leading disease-related cause of childhood death. In low- and middle-income countries, where 80% of children live, the 200,000 children diagnosed with cancer each year have limited access to curative treatment, and only about 25% survive. Some might argue that death from paediatric cancer in poor countries is insignificant compared to death from other causes, and that scarce health resources may be better used in other areas of public health. Is there a role for the treatment of children with cancer in these regions? Do international partnerships or 'twinning' programmes enhance local health care or detract from other public health priorities? What is ethical and what is possible? This review examines the health challenges faced by infants and children in low-income countries, and assesses the role and impact of international paediatric oncology collaboration to improve childhood cancer care worldwide.
Background:
Childhood-cancer survival is dismal in most low-income countries, but initiatives for treating paediatric cancer have substantially improved care in some of these countries. The My Child Matters programme was launched to fund projects aimed at controlling paediatric cancer in low-income and mid-income countries. We aimed to assess baseline status of paediatric cancer care in ten countries that were receiving support (Bangladesh, Egypt, Honduras, Morocco, the Philippines, Senegal, Tanzania, Ukraine, Venezuela, and Vietnam).
Methods:
Between Sept 5, 2005, and May 26, 2006, qualitative face-to-face interviews with clinicians, hospital managers, health officials, and other health-care professionals were done by a multidisciplinary public-health research company as a field survey. Estimates of expected numbers of patients with paediatric cancer from population-based data were used to project the number of current and future patients for comparison with survey-based data. 5-year survival was postulated on the basis of the findings of the interviews. Data from the field survey were statistically compared with demographic, health, and socioeconomic data from global health organisations. The main outcomes were to assess baseline status of paediatric cancer care in the countries and postulated 5-year survival.
Findings:
The baseline status of paediatric oncology care varied substantially between the surveyed countries. The number of patients reportedly receiving medical care (obtained from survey data) differed markedly from that predicted by population-based incidence data. Management of paediatric cancer and access to care were poor or deficient (ie, nonexistent, unavailable, or inconsistent access for most children with cancer) in seven of the ten countries surveyed, and accurate baseline data on incidence and outcome were very sparse. Postulated 5-year survival were: 5-10% in Bangladesh, the Philippines, Senegal, Tanzania, and Vietnam; 30% in Morocco; and 40-60% in Egypt, Honduras, Ukraine, and Venezuela. Postulated 5-year survival was directly proportional to several health indicators (per capita annual total health-care expenditure [Pearson's r(2)=0.760, p=0.001], per capita gross domestic product [r(2)=0.603, p=0.008], per capita gross national income [r(2)=0.572, p=0.011], number of physicians [r(2)=0.560, p=0.013] and nurses [r(2)=0.506, p=0.032] per 1000 population, and most significantly, annual government health-care expenditure per capita [r(2)=0.882, p<0.0001]).
Interpretation:
Detailed surveys can provide useful data for baseline assessment of the status of paediatric oncology, but cannot substitute for national cancer registration. Alliances between public, private, and international agencies might rapidly improve the outcome of children with cancer in these countries.
The four national paediatric cancer clinical trials organisations in the United States—the Children's Cancer Group, the National Wilms' Tumor Study Group, the Intergroup Rhabdomyosarcoma Study Group and the Pediatric Oncology Group—were formed in 1955, 1969, 1972 and 1979, respectively. Together, the Children's Cancer Group and Pediatric Oncology Group serve as a national registry of nearly all childhood cancers in the United States, provide a national network of communication for researchers, care providers and families of paediatric patients with malignant disease and conduct laboratory investigations and clinical trials of new treatments of cancers in infants, children, adolescents and young adults. Nearly 95% of patients with cancer in the United States who are below 15 years of age are registered by the Children's Cancer Group and the Pediatric Oncology Group and more than half of American children with cancer are entered into at least one trial by a paediatric group. Improved survival of children receiving treatment according to well-defined protocols in specialised children's centres, in contrast to children who received treatment outside of these centres, has been shown for those with acute lymphoblastic leukaemia, lymphoma, Wilms' tumour, medulloblastoma, rhabdomyosarcoma and Ewing's sarcoma.
The difference in survival for children diagnosed with cancer between high- and low-income countries (LIC) continues to widen as curative therapies are developed in the former but not implemented in the latter. In 1996, the Monza International School of Pediatric Hematology/Oncology (MISPHO) was founded in an attempt to narrow this survival gap. During its sixth and seventh meetings, members recognized the problem of lack of affordability of essential drugs to treat childhood cancer in many LIC, and initiated an advocacy program. In 1998, MISPHO spawned a collaboration of Central American pediatric oncology centers: the Asociación de Hemato-Oncología Pediátrica Centroamericana (AHOPCA). AHOPCA members reported preliminary findings from several of the 10 cooperative protocols that are currently in progress. In 2003, a second regional collaborative group was formed that includes seven centers in South America. Twinning programs between MISPHO centers and centers in high-income countries (HIC) have proven invaluable to harness the resources of these centers to improve pediatric oncology care in LIC. MISPHO educational efforts include oncology nursing, supportive care, cancer-specific updates, epidemiology, and clinical research methods. Educational efforts are facilitated by educational content and online conferencing via www.cure4kids.org. Identifying preventable causes of abandonment of therapy and documenting the nutritional status of patients treated at MISPHO centers are areas of active research.
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Special Issue: Radiotherapy in low and middle income countries
Special Issue: Radiotherapy in low and middle income
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