ArticleLiterature Review

Challenge of pediatric oncology in Africa

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Abstract

The care of children with malignant solid tumors in sub-Saharan Africa is compromised by resource deficiencies that range from inadequate healthcare budgets and a paucity of appropriately trained personnel, to scarce laboratory facilities and inconsistent drug supplies. Patients face difficulties accessing healthcare, affording investigational and treatment protocols, and attending follow-up. Children routinely present with advanced local and metastatic disease and many children cannot be offered any effective treatment. Additionally, multiple comorbidities, including malaria, tuberculosis, and HIV when added to acute on chronic malnutrition, compound treatment-related toxicities. Survival rates are poor. Pediatric surgical oncology is not yet regarded as a health care priority by governments struggling to achieve their millennium goals. The patterns of childhood solid malignant tumors in Africa are discussed, and the difficulties encountered in their management are highlighted. Three pediatric surgeons from different regions of Africa reflect on their experiences and review the available literature. The overall incidence of pediatric solid malignant tumor is difficult to estimate in Africa because of lack of vital hospital statistics and national cancer registries in most of countries. The reported incidences vary between 5% and 15.5% of all malignant tumors. Throughout the continent, patterns of malignant disease vary with an obvious increase in the prevalence of Burkitt lymphoma (BL) and Kaposi sarcoma in response-increased prevalence of HIV disease. In northern Africa, the most common malignant tumor is leukemia, followed by brain tumors and nephroblastoma or neuroblastoma. In sub-Saharan countries, BL is the commonest tumor followed by nephroblastoma, non-Hodgkin lymphoma, and rhabdomyosarcoma. The overall 5-years survival varied between 5% (in Côte d'Ivoire before 2001) to 34% in Egypt and up to 70% in South Africa. In many reports, the survival rate of patients is not mentioned but is clearly very low in many sub-Saharan Africa countries (Sudan, Nigeria). Late presentation was observed for many tumors like nephroblastoma in Nigeria, 72% were stages III and IV or BL stages III and IV were observed in 40% and 30%, respectively. Africa bears a great burden of childhood cancer. Cancer is now curable in developed countries as survival rates approach 80%, but in Africa, >80% of children still die without access to adequate treatment. Sharpening the needlepoint of surgical expertise will, of itself, not compensate for the major infrastructural deficiencies, but must proceed in tandem with resource development and allow heath planners to realize that pediatric surgical oncology is a cost-effective service that can uplift regional services.

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... 5 In Africa, over 58,000 childhood cancers and over 18,000 deaths were recorded in 2018, 1 and >80% of these children still die without access to adequate treatment; in many reports, the five-year survival rates vary from as low as 5% to 70%. 6 The disparity in survival rates is compounded by barriers in all steps of cancer care from late presentation, co-morbidity (especially malnutrition), lack of affordability and restricted access to both supportive and empirical anti-cancer treatments. 6 Despite the widespread use of anti-retroviral therapy, human immunodeficiency virus (HIV)associated cancers such as Burkitt's lymphoma (BL) and other non-Hodgkin's lymphoma (NHL), Kaposi's sarcoma are common among children living with HIV in sub-Saharan Africa (SSA). ...
... 5 In Africa, over 58,000 childhood cancers and over 18,000 deaths were recorded in 2018, 1 and >80% of these children still die without access to adequate treatment; in many reports, the five-year survival rates vary from as low as 5% to 70%. 6 The disparity in survival rates is compounded by barriers in all steps of cancer care from late presentation, co-morbidity (especially malnutrition), lack of affordability and restricted access to both supportive and empirical anti-cancer treatments. 6 Despite the widespread use of anti-retroviral therapy, human immunodeficiency virus (HIV)associated cancers such as Burkitt's lymphoma (BL) and other non-Hodgkin's lymphoma (NHL), Kaposi's sarcoma are common among children living with HIV in sub-Saharan Africa (SSA). 6,7 Spontaneous tumour lysis syndrome (STLS), a rare but life-threatening metabolic oncological emergency, is known to complicate high-grade tumours such as BL, NHL and the acute leukaemias. ...
... 6 Despite the widespread use of anti-retroviral therapy, human immunodeficiency virus (HIV)associated cancers such as Burkitt's lymphoma (BL) and other non-Hodgkin's lymphoma (NHL), Kaposi's sarcoma are common among children living with HIV in sub-Saharan Africa (SSA). 6,7 Spontaneous tumour lysis syndrome (STLS), a rare but life-threatening metabolic oncological emergency, is known to complicate high-grade tumours such as BL, NHL and the acute leukaemias. [8][9][10] This is noted to occur, however, in Malawi, Zimbabwe and Uganda, in >50% of these high-grade malignancies among African children. ...
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High-grade malignancy is endemic in sub-Saharan Africa and is prone to the spontaneous tumour lysis syndrome. However, data on spontaneous tumour lysis syndrome remain scanty in our setting. We sought to determine the prevalence and factors associated with laboratory spontaneous tumour lysis syndrome in children in Uganda. We conducted a cross-sectional study among children <18 years old with histologically confirmed high-grade malignancy between October 2013 and April 2014. Laboratory spontaneous tumour lysis syndrome was defined as the presence of 2 of each of hyperkalaemia, hypocalcaemia, hyperuricaemia and hyperphosphatemia prior to administration of chemo-therapy when alternative diagnoses had been excluded. A p < 0.05 was considered statistically significant. Of 108 children , of median age 7.7 years, where boys outnumbered girls 2:1, high-grade, malignancy included Burkitt's lymphoma, acute lymphoblastic leukaemia, non-Hodgkin's lymphoma, acute myeloid leukaemia and Burkitt's leukaemia, with 14 suffering with laboratory spontaneous tumour lysis syndrome. Hypocalcaemia was its most common electrolyte imbalance ; and four children died prior to commencement of chemotherapy. Bulky disease, lactate dehydrogenase levels 500 iu/l and serum creatinine levels >1.2 mg/dl were associated with laboratory spontaneous tumour lysis syndrome. However, only bulky disease was significantly predictive of laboratory spontaneous tumour lysis syndrome. Such children would benefit from routine screening.
... Paediatric surgical oncology is at the moment not regarded as a health care priority by policy makers in LMICs and sub-Saharan Africa (SSA). 4 Although the fourth millennium development goal (MDG) was to reduce child mortality, 11 most attention, research and resources were channelled towards the reduction of communicable diseases such as HIV and TB, which have been, for years, the leading causes of childhood mortality. 5,12 With the reduction in these diseases, attention now also needs to be focused on non-communicable diseases (NCDs) including malignancies, which are emerging as a significant cause of childhood mortality in keeping with the World Cancer Declaration of the Union of International Cancer Control (UICC). ...
... 1,2,3 In low-and middle-income countries (LMICs), cancer deaths contribute a small percentage to childhood mortality; the leading causes of death remain diarrhoeal illnesses, pneumonia and other infectious diseases such as human immunodeficiency virus (HIV) and tuberculosis (TB). 4,5 The incidence of childhood cancer in LMICs is quoted at 4% -15% of all cancers, which is significantly higher than that in HICs, probably owing to the greater proportion of children in LMICs. 6,7,8,9,10 statistics in such NCDs makes it difficult to fully appreciate their burden and prioritise resources accordingly. ...
... 6,7,8,9,10 statistics in such NCDs makes it difficult to fully appreciate their burden and prioritise resources accordingly. 4,12 There is a paucity of literature on childhood cancer in LMICs in general, 4,5,13 and studies that have been published focused mainly on paediatric medical oncological cancers. The publication from the South African children's tumour registry (SACTR) reported on the incidence of different paediatric cancers, 14 but no study in South Africa has focused on STs in detail. ...
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Background: There are few modifiable risk factors for solid tumours (STs) in children, except in the presence of a predisposing condition, and prevention is usually not possible; therefore, early diagnosis and prompt treatment are important in improving survival. Reporting the incidence, demographic data, presentation and outcomes of these STs improves awareness and allocation of resources for their management. There is a paucity of literature on the incidence, prevalence, demographics and treatment of paediatric STs in low- and middle-income countries (LMICs) including South Africa. Aim: The aim of this study was to describe the demographics and spectrum of childhood STs at Chris Hani Baragwanath Academic Hospital (CHBAH). Setting: The study was conducted at the Departments of Paediatric Surgery and Oncology at CHBAH. Methods: A retrospective review of the records of children below 16 years of age with STs seen at CHBAH and managed by paediatric surgeons and oncologists from 01 January 2007 to 31 December 2016 was undertaken. The central nervous system, eye, bone and exclusively medically managed tumours were excluded. Results: The solid tumours accounted for 33% of all paediatric oncology cases. The three most common malignant tumours were: Wilms’ tumour (32.7%), rhabdomyosarcoma (18.2%) and neuroblastoma (13.6%). Solid tumours were most common in the 1 to 5-year age group and most presented with advanced disease. An average of 30 oncological surgeries were performed per year. Conclusion: The solid tumours studied represented a third of all oncology cases encountered in children; therefore, early diagnosis, early referral and prompt management of STs could improve childhood cancer survival.
... Population-based cancer registries around the world report overall incidence rates for childhood cancer (cancer in children aged 0-14 years) that vary by a factor of about four, between less than 60 to more than 200 per million per year (12,17). The socioeconomic development of a population seems to be associated with the reported incidence of childhood cancer in the respective country (18,19). This is reflected in the higher incidence rates reported for HICs, particularly for acute lymphoblastic leukemia, the most common cancer type in children in HICs (12), and for cancer in infants (below 1 year), compared to low-and middle-income countries (LMICs) (12,18,(20)(21)(22)(23)(24). ...
... The empirically reported differences may thus ultimately be related to inequities in access, utilization and quality of health care services including "missed diagnosis" (22,24,25), high prevalence of other infectious diseases (e.g., malaria, tuberculosis, HIV/AIDS), high proportions of deaths from unknown causes and differences in (childhood) cancer reporting standards (115). Registries in LMICs are often facing substantial challenges with respect to reporting information on cases and linkage between cancer registries (if they exist); appropriate diagnostic and health care facilities are not always in place or available only at central level (18,19,116). ...
... An unknown but high proportion of children in LMICs with potentially curable cancer never receives contemporary therapy or, may even not be able to access basic health care services provided by a trained oncologist (34,117,118). Primary healthcare facilities and local/regional hospitals may lack awareness of and experience in diagnosing pediatric cancer (18,19,114) and the non-specific nature of many early symptoms for some cancer types (e.g., leukemia which often presents with symptoms similar to those of infections) may result in delayed diagnosis or failure to detect the disease at all (34,115). Even if a childhood cancer is diagnosed, childhood cancers are complex diseases and risk group adapted therapy is crucial (34,119). ...
Article
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Inequalities in health according to social conditions are regarded as unnecessary and unjust. There is a large body of evidence on inequalities in adult cancer, observable throughout the societies on a national level as well as on a global scale. Socioeconomic influences on health matter at all ages including childhood, for which childhood cancer is the leading cause of disease related death in high-income countries (HICs). Substantial differences in the reported incidence of childhood cancers have been observed globally by socioeconomic development of a population. This is reflected in the higher incidence rates reported for HICs, particularly for acute lymphoblastic leukemia, and for cancer in infants (below 1 year), compared to low- and middle-income countries (LMICs). Considerable inequalities between populations and degree of socioeconomic development are also noted for survival from childhood cancer, with substantially lower survival rates seen in most LMICs compared to HICs. With respect to inequalities by socioeconomic position (SEP) within countries, findings of an association between SEP and childhood cancer risk are diverse and limited to studies from HICs. On the contrary, observations on social inequalities in survival within countries are accumulating and indicate that survival inequalities do not only concern resource-poor countries but also high-income populations including European countries. In turn, a childhood cancer diagnosis in itself may have implications on the parents' socioeconomic situation as well as on the later socioeconomic life after having survived the disease. The underlying mechanisms and causal pathways of these empirically demonstrated social inequalities are poorly understood, although it is of significant public health relevance for any actions or strategies to reduce childhood cancer-related inequity. We propose a conceptual framework on potential underlying mechanism and pathways specifically addressing social inequalities in childhood cancer and after childhood cancer to (i) illustrate potential pathways by which social determinants may create health inequities at different points of the childhood cancer continuum; (ii) illustrate potential pathways by which a childhood cancer diagnosis may impact the socioeconomic situation of the concerned family or the later life of a childhood survivor; and (iii) point out how major determinants may relate to each other.
... The formation of collaborative study groups and multimodal therapy has led to significant progress in the management of WT [29]. However, in developing countries, late presentation, malnutrition, poverty and lack of multidisciplinary cooperation affect treatment outcomes for children with WT [30,31]. The two comprehensive collaborating groups that studied WT were the Pediatric Oncology Group (COG) and the International Society of Pediatric Oncology (SIOP). ...
... The predominance of females recorded in this study is in agreement with the reports of Breslow et al. [32] and Kaste et al. [33] where female children were more prevalent in Wilm's tumors than male patients. However, Hadley et al. [31] Davidson et al. [34] studies in Africa did not agree with current findings indicating a nearly identical incidence of Wilm's tumor in both sexes. Male/female predominance may depend on the geographical area of study. ...
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ABSTRACT Background: Wilms' tumor is a malignant tumor that contains metanephric blastema, stromal and epithelial derivatives. The characteristic is the presence of abortive tubules and glomeruli surrounded by the stroma of a spindle cell. The stroma may include striated muscle, cartilage, bone, adipose tissue, and fibrous tissue. Aims: The study aimed to describe the age, sex and histology distribution of Wilms’ tumor and its association with age groups, sex and the side affected by the kidneys. Subjects and methods: A retrospective observational study was performed on renal masses patients who were consequently diagnosed selectively by histopathological study in the National Center for Public Health Laboratories (NCPHL) at the Department of Pathology, and the Department of Pathology in Al-Thorah university hospital, Sana'a, Yemen, over a period of 18 years from January 1, 2004 to December 31, 2021. Data were collected from hospital records. The study variables were lesions histological types, benign, malignancy, non-neoplastic lesions, sex, grades and age. The whole data were analyzed by IBM SPSS Statistics 22.Ink. The outcomes for variables were given in the form of rates (%). Chi Square was used for categorical variables that measured association among categorical variables. P-values less than 0.05 were considered significant. Results: Wilms tumors counting 47/282 (16.7%) of total diagnostic malignant tumors. The female cases were 29/47 (61.7%) more than male cases 18/47 (38.3%) with M:F ratio equal to 1.0: 1.6. The mean age of the Wilms’ patients was 5.3 years with SD equal to 3.6 years and ages ranged from 9 months to 15 years. Most of the Wilms’ patients were in age group 1-5 years 31/47(66%) followed by 6-10 years (25.5%). Favorable histology (FVH) Wilms’ tumors with better prognosis counting 42/47 (89.4%) while unfavorable histology (UFVH) with poor prognosis only counting 5/47 (10.6%). There was no significant association between Wilms’ tumor and gender while there was a highly significant association of Wilms’ tumor with 1-5 years group (rate = 77.5%, OR=48.6, CI =19.8-119, p <0.001) and with 6-10 years group (rate= 80%, OR=26.6, CI=7.1 – 98.7, p <0.001). There was no significant association between Wilms’ tumors with kidney side in which roughly equal rates were present in both side. Conclusion: Wilms' tumors in Yemeni children appear at an early age and peak in the first 5 years of life with an increased incidence among females with predominantly FVH. The current study provided much needed information about the burden of Wilms' cancer in Yemen, to enable Yemen to better plan to address the burden. Further studies are necessary to determine the exact incidence and trend of Wilms' cancer and risk factors in Yemen. Keywords: children cancers, kidney cancers, Sana’a city, Wilms' tumor (WT), degree of anaplasia, Yemen
... Formation of collaborative study groups and multimodal therapy has made dramatic advances in the management of WT [8]. However, in developing countries, late presentation, malnutrition, poverty and lack of multidisciplinary collaboration aff ect the treatment outcome of children that have WT [9,10]. Th e two comprehensive collaborative groups that have studied WT are the Children's Oncology Group (COG) and International Society of Paediatric Oncology (SIOP). ...
... Female predominance recorded in the present study is consistent with the report of other studies [11,12]. However, other studies are not in agreement with this fi nding [10,13]. Th e male/female predominance may depend on geographical area of study. ...
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Objective: The objective of this study was to evaluate the profi le and management outcome of children treated for Wilms' Tumor (WT) in a developing country. Methodology: This was a retrospective study of children that were treated for WT at the pediatric surgery unit of Enugu State University Teaching Hospital (ESUTH), Enugu, Nigeria. Medical records of children who underwent treatment for WT over a 5-year period were evaluated. Results: Twenty one cases of WT were treated during the study period with an age range of 3-12 years (median 4.5 years) and male to female ratio of 1:1.3. The median duration of symptoms prior to presentation was 6 months and the mean duration of hospital stay was 24.2 days. All the patients presented with abdominal mass and they all had abdominal ultrasound and chest x-ray. Five (23.8%) patients had metastasis at presentation and majority of the patients were in stage 3. Surgery with adjuvant chemotherapy plus radiotherapy was received by most of the patients. Survival rate as at 5 years follow up period was 66.7%. Conclusion: There is still signifi cant morbidity and mortality associated with the management of WT in resource-constrained environment.
... Neuf leucémies ont été observées, soit 3 % des cancers de l'enfant. Cette fréquence est légèrement supérieure à celle rapportée par Margaron (1,8 %) au Kenya, mais nettement inférieure à celle des auteurs occidentaux (40 %) [5,9]. Cette différence pourrait s'expliquer par une insuffisance de moyens de diagnostic précoce dans les pays africains [9]. ...
... Cette fréquence est légèrement supérieure à celle rapportée par Margaron (1,8 %) au Kenya, mais nettement inférieure à celle des auteurs occidentaux (40 %) [5,9]. Cette différence pourrait s'expliquer par une insuffisance de moyens de diagnostic précoce dans les pays africains [9]. ...
... The care of children with malignant solid tumours in sub-Saharan Africa is compromised by resource deficiencies that range from inadequate healthcare budgets and a paucity of appropriately trained personnel, to scarce laboratory facilities and inconsistent drug supplies. Patients face difficulties accessing healthcare, affording investigational and treatment protocols and attending follow-up [46,47]. Children routinely present with advanced local and metastatic disease and many children cannot be offered any effective treatment [46]. ...
... Patients face difficulties accessing healthcare, affording investigational and treatment protocols and attending follow-up [46,47]. Children routinely present with advanced local and metastatic disease and many children cannot be offered any effective treatment [46]. While available evidence suggests that children are a low-risk population for COVID-19 susceptibility, and complications, the public health and social distancing measures that have been implemented to curb the spread of COVID-19 have had their collateral effect on the paediatric cancer diagnosis, treatment and care in many countries [48][49][50][51]. ...
Article
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The coronavirus disease 2019 (COVID-19) pandemic has immensely disrupted health care services globally. The pandemic has been particularly disruptive for cancer services and more so in low-resource settings. In this narrative review, we highlight the reported impact of the COVID-19 pandemic on cancer prevention, screening, diagnosis, treatment and research across the African continent. We also explore ways in which identified structural and contextual constraints can be navigated for the re-escalation of oncological activities, while discussing how the pandemic has necessitated the reimagination of how oncology services can be delivered now and in the future. We conducted a literature search of MEDLINE (via PubMed) and Scopus for relevant articles and synthesised the findings thematically. In spite of the dearth of data, available evidence suggests a substantial impact of the pandemic on the various aspects of cancer management in African countries. Aggravating factors include pre-existing health system and cancer management gaps in many countries within the region, which are typically faced with inadequate availability of oncology resources, oncologists and other vital resources; in addition to the acute and lingering consequences of social distancing, movement restrictions and other public health measures implemented to contain the spread of the virus. As the pandemic evolves and movement restrictions are eased, there is a need for the timely and safe return to normal oncological care. This will require a risk-adjusted and multidisciplinary approach, with the aim of mitigating the further impact of the disruption on cancer patients, their families and healthcare providers.
... 11,12 There is scant information on childhood CNS tumour incidence in Africa. 13 Although we can compare and contrast incidence across studies, drawing firm conclusions around international variation in childhood CNS tumour incidence remains challenging as studies in lower income nations are scarce and studies often include different histologic subtypes and time periods. ...
... We conducted analyses stratified by HDI level to make inferences about changes in exposures and access to advanced medical care inlcuding the potential introduction and use of neuroimaging technologies, which occurred in the 1980s-90s in the USA and continues to increase in lower-income nations. 13,[25][26][27] When considering 2012 HDI levels, we observed increasing incidence over the study period for low and medium HDI among ependymal tumours, glioma of uncertain origin and other embryonal tumours (Supplementary Tables S7 and S8, available as Supplementary data at IJE online). In contrast, medulloblastoma incidence increased exclusively in countries with higher HDI, which also showed increases in glioma of uncertain origin and ependymal tumours. ...
Article
Background Central nervous system (CNS) tumours comprise 20% of childhood cancers worldwide. Whether childhood CNS tumour incidence has increased over time across geographic regions remains to be explored. Methods We identified CNS cancers in the Cancer in Five Continents (CI5) data and estimated age standardized incidence rates (ASRs; cases/million children) and 95% confidence intervals (95% CI), male-to-female incidence rate ratios (IRR; 95% CI) and average annual percent change in incidence (AAPC; 95% CI) by geographic region for children aged 0–19 years where data were available using Poisson regression and generalized estimating equations (GEE). Cancers included: astrocytic tumours, medulloblastoma, ependymal, oligodendroglial and mixed glioma, glioma of uncertain origin, and other embryonal tumours. Geographic regions were defined using the United Nations geoscheme. Results There were 56 468 CNS cancers included in the study. ASRs were highest for astrocytic tumours globally in 2012 (ASR: 5.83; 95% CI: 5.68–5.99). Globally, all cancers exhibited a male excess in incidence. Regionally, only medulloblastoma had a consistently elevated male-to-female IRR at 1.4–2.2. Globally, incidence decreased for astrocytic tumours in GEE models (AAPC: −1.66; 95% CI: −3.04 to −0.26) and increased for medulloblastoma (AAPC 0.66; 95% CI: 0.19–1.14), ependymal tumours (AAPC: 1.49; 95% CI: 1.49; 95%: 0.69–2.30), glioma of uncertain origin (AAPC: 4.76; 95% CI: 1.17–1.14) and other embryonal tumours (AAPC: 3.58; 95% CI: 2.03–5.15). Regional variation in incidence trends was observed. Countries moving from lower to higher Human Development Index (HDI) over time did not appear to drive observed incidence trends. Conclusions Epidemiologic and molecular studies on underlying mechanisms for changes in the global incidence of CNS tumours are necessary.
... Black children of sub-Saharan African ancestry consistently show the highest incidence of WT worldwide at 11 cases per million (1). In sub-Saharan Africa, WT is reported as the second or third most common pediatric malignancy, which differs from its North American incidence (2). With the advent of cooperative trials, multimodal treatment regimens, and multidisciplinary care models, overall survival at 5-years for patients with WT in developed nations is now greater than 90% (3). ...
... However, alarming disparities in outcomes persist for children with WT residing in sub-Saharan African nations, with overall survival at 5-years as low as 25% (4). Over the past 50 years, basic descriptions of WT prevalence, treatment challenges, and poor outcomes for children living in resource-limited settings of sub-Saharan Africa have been published, with the principal focus in more recent years on social determinants of health as contributing factors to this profound cancer disparity (2,(5)(6)(7). Only in the last decade has examination of WT biology as a molecular determinant of health in these austere contexts begun to gain momentum (8)(9)(10)(11). ...
Article
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Wilms tumor (WT) is the most common renal malignancy of childhood. Global disparities in WT have been reported with the highest incidence and lowest overall survival occurring in sub-Saharan African nations. After a detailed search of PubMed, we reviewed available literature on WT in sub-Saharan Africa and summarized findings that explore biologic and social factors contributing to this alarming cancer health disparity. Access to care and treatment abandonment are the most frequently reported factors associated with decreased outcomes. Implementation of multidisciplinary teams, collaborative networks, and financial support has improved overall survival in some nations. However, treatment abandonment remains a challenge. In high-income countries globally, WT therapy now is risk-stratified according to biology and histology. To a significantly lesser extent, biologic features have been studied only recently in sub-Saharan African WT, yet unique molecular and genetic signatures, including congenital anomaly-associated syndromes and biomarkers associated with treatment-resistance and poor prognosis have been identified. Together, challenges with access to and delivery of health care in addition to adverse biologic features likely contribute to increased burden of disease in sub-Saharan African children having WT. Publications on biologic features of WT that inform treatment stratification and personalized therapy in resource-limited regions of sub-Saharan Africa have lagged in comparison to publications that discuss social determinants of health. Further efforts to understand both WT biology and social factors relevant to appropriate treatment delivery should be prioritized in order to reduce health disparities for children residing in resource-limited areas of sub-Saharan Africa battling this lethal childhood cancer.
... We expected smaller impairments of HRQOL in children with chronic conditions from economically developed countries than among peers from other countries because of better availability of medical and psychosocial services (Hadley et al., 2012), which could reduce negative consequences of the medical condition. ...
... This result may be based on gender differences in coping (e.g., girls are more likely to seek support than boys) and actual support receipt (Miller and LaGreca, 2009). The larger decline of HRQOL observed in children with chronic conditions from economically less developed countries could be due to lower availability of medical and psychosocial services (Hadley et al., 2012). In addition, some chronic conditions with above-average decline of HRQOL, such as spina bifida and sickle cell disease, are more common in economically less developed regions, partially due to less preventive efforts (such as mandatory folic acid fortification for reducing the spina bifida risk) (Atta et al., 2016). ...
Article
Objective: The aim of this meta-analysis was to compare levels of health-related quality of life (HRQOL) among children with and without chronic physical and/or sensory conditions, based on PedsQL 4.0 General Core Scales. Methods: Studies were identified with electronic databases (CINAHL, PSYCINFO, MEDLINE, Google Scholar, PSYNDEX) and from the PedsQL website. We included controlled studies that compared PedsQL scores of children (mean age < 18 years) with and without chronic physical and/or sensory conditions and uncontrolled studies on children with chronic physical and/or sensory conditions from countries where data from peers without chronic conditions have been published. Random-effects meta-analyses were computed. Results: In total, 1,231 studies fulfilled the inclusion criteria. There were large declines of the total and physical score as well as medium-sized declines of psychosocial health and its subscales, based on criteria of interpreting effect sizes by Cohen [Cohen, J. (1992). A power primer. Psychological Bulletin, 112, 155-159]. Children with cerebral palsy and spina bifida showed the largest declines across all scales, but significant declines emerged in all compared 29 chronic conditions. We identified moderating effects of duration of the chronic condition, rater, child gender, country, sociodemographic equivalence of the compared groups, type of control condition, and publication status. Conclusions: Young people with chronic health conditions should be screened for HRQOL, and the profile across different domains should be preferred over the use of a sum score. Child self-reports are particularly relevant for assessing emotional and social functioning. Effective measures aimed at improving HRQOL are needed, especially if the chronic condition leads to severe declines of physical functioning.
... Le cancer est une maladie grave et constitue une cause importante de décès chez les enfants et les adolescents dans le monde avec une incidence estimée à 140.6 cas par million d'enfants par an [1]. Sur les 200000 cas de cancers survenant dans le monde en moyenne chaque année chez les enfants de moins de 15 ans, 70 à 80% surviennent dans les pays à revenu faible ou intermédiaire [2][3][4][5]. La majorité de ces cancers sont de bon pronostic avec un même rapport coût efficacité quel que soit le niveau de revenu du pays. Dans les pays développés les taux de survie sont proches de 80% [6]. ...
... En Afrique, l'incidence des cancers de l'enfant reste encore est mal connue. La plupart des pays ne possédant pas de registre de cancer [1,2,6]. Au Bénin les données concernant le cancer pédiatrique sont rares. ...
Article
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SUMMARY Epidemiology of childhood cancer at Pediatric Unit of Borgou/Alibori Regional Teaching Hospi-tal in Bénin Introduction: Childhood cancers are rare, but they are an important cause of death. Benin has lack of data on pediatric cancer. The objective of this work was to study the epidemiology of childhood cancer in the pediatric unit of CHUD B / A. Patients and Method: This was a retrospective study conducted in the pediatric ward of CHUD B /A from January 2014 to January 2019. It included all children with diag-nosed cancer following clinical and paraclinical arguments. The variables studied were epidemiological, diagnostic and evolutionary. Results: Of 22279 children admitted during the study period, 40 had can-cer, a frequency of 0.18%. The mean age of patients was 8.8 +/- 4, 64 years (11months and16years) and the sex ratio M / F of 3. Lymphomas were the most represented (40%), followed by leukemia (17.5%). %), neuroblastoma (17.5%), nephrobalstoma (7.5%). The intra-hospital mortality rate was 22.5%. Conclusion: Childhood cancer at CHUD B /A deserves more attention. The establishment of a pediatric oncology unit should be considered for case management. Keywords: Childhood cancer- Benin.
... This study investigates the influence of health insurance status on the outcome of childhood cancer at MTRH. The four prevalent cancers are similar to those reported in other sub-Saharan African countries with relatively few cases of acute leukemia and brain tumors [23,24]. Treatment abandonment was the most common reason for treatment failure with overall event-free survival at 3 years relatively low (18%) when compared with international data [25,26]. ...
... In this study, we observed that there were equally as many cases of solid tumors as there were hematological tumors (Fig. 1). The high incidence of non-Hodgkin lymphoma, particularly Burkitt lymphoma, Wilm's tumor, and Kaposi sarcoma, with low incidences of leukemia and brain tumors has been reported in many countries within sub-Saharan Africa [23,24]. ...
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Background: Survival of childhood cancer in high-income countries is approximately 80%, whereas in low-income countries, it is less than 10%. Limited access to health insurance in low-income settings may contribute to poor survival rates. This study evaluates the influence of health insurance status on childhood cancer treatment in a Kenyan academic hospital. Methods: This was a retrospective study. All children diagnosed with a malignancy from 2010 until 2012 were included. Data on treatment outcomes and health insurance status at diagnosis were abstracted from patient charts. Results: Of 280 patients, 34% abandoned treatment, 19% died, and 18% had progressive or relapsed disease resulting in 29% event-free survival. The majority of patients (65%) did not have health insurance at diagnosis. Treatment results differed significantly between patients with different health insurance status at diagnosis; 37% of uninsured versus 28% of insured patients abandoned treatment, and 24% of uninsured versus 37% of insured patients had event-free survival. The event-free survival estimate was significantly higher for patients with health insurance at diagnosis compared with those without (P = 0.004). Of patients without health insurance at diagnosis, 77% enrolled during treatment. Among those patients who later enrolled in health insurance, frequency of progressive or relapsed disease and deaths was significantly lower (P = 0.013, P < 0.001, respectively), while the event-free survival estimate was significantly higher (P < 0.001) compared with those who never enrolled. Conclusion: Childhood cancer event-free survival was 29% at a Kenyan hospital. Children without health insurance had significant lower chance of event-free survival. Childhood cancer treatment outcomes could be ameliorated by strategies that prevent treatment abandonment and improve access to health insurance.
... Globally, some of the worst pediatric cancer survival rates are in SSA, with a majority dying from their disease [16,17]. These dismal odds are influenced by barriers to accessing cancer services and staying in treatment, including cultural misconceptions about cancer, and inadequate patient/family level resources [18][19][20]. ...
... Some of the worst pediatric cancer survival rates are in SSA, with a majority dying from their disease [16,17]. Recent reviews hightlight the urgent need for "better data" and the "paucity of epidemiologic information" on pediatric cancer in HIV-infected youth from regions with a high burden of HIV/AIDS [3,49]. ...
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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).
... As for germ cell tumors, it would be mixed in the suspected 32.71% because the assay of Alpha-feto-protein (AFP) and Betha HCG in two patients was negative. This distribution of histogenesis is different in Western countries demonstrated by Hadley L.G, et al. [17]. This difference can be explained by the presence of sufficient technical facilities in the West to make early diagnosis of certain tumors that are difficult to detect. ...
... Ja et al(2013) however found that seventy ve cases (23.1%) were seen in the 0-4 year age group, 118 cases (36.4%) in the[5][6][7][8][9] year age group while 131 cases (40.4%) were seen in the[10][11][12][13][14][15] year age group. Contrary to present study ndings Rajpal Singh15 Punia et al (2014) observed that highest number of cases were in the16 age group of 10-14 year. ...
... Many children with cancers in low-income countries still die without access to proper therapy, and the overall 5-year survival is considerably poor in most sub-Saharan African countries [3][4][5]. ...
Article
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Introduction: The burden of childhood cancer is an important child health concern globally. Several million new cases are diagnosed annually, but the greatest burden is borne by developing countries. The management of paediatric cancer patients in these settings is fraught with several challenges, which can significantly affect outcome. Aim: To identify the various challenges in management of children with cancers in the University of Uyo Teaching Hospital Uyo, Nigeria and proffer interventions which may impact positively on their long term survival and quality of life. Methods: A three year retrospective study of children admitted with cancers was carried out at the Haemato-Oncology unit of the department of Paediatrics, University of Uyo Teaching Hospital, Uyo Nigeria, from January 2019 and December 2021. The available records of their admission, treatment process, progress and outcome were reviewed. Results: Of the thirty-eight (38) patients seen, all presented at a late stage of disease. The socio-economic class of parents were mostly low (81.6%) and all treatments were self-sponsored, with 44.7% discharging against medical advice due to financial constraints. Conclusion: The challenges in the management of paediatric cancer patients included late presentation, late diagnosis, financial constraints/poverty, burn-out of caregivers, with a resultant high frequency of discharge against medical advice. Greater awareness about childhood cancers, increased advocacy for governmental input by way of resources, infrastructure and health insurance policies would improve outcome.
... Neuroblastoma, arising from neural crest cells [3], accounts for 15% paediatric tumour-related deaths worldwide [4][5][6]. Factors including late presentation of disease and abandonment of treatment have been outlined as impeding good outcomes [7][8][9]. ...
Article
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Background Cancer is a major global health concern and a leading cause of death in paediatric populations worldwide. Malnutrition contributes to a poor prognosis and remains the most common comorbidity leading to death in children with cancer. This retrospective study was developed through Oxford Paediatrics Linking Oncology Research with Electives (OxPLORE)—a medical student-led collaboration of paediatric surgeons and oncologists from low- and middle-income (LMIC) and high-income (HIC) countries. The aim of this study was twofold; firstly, to investigate the nutritional status and outcomes of neuroblastoma paediatric patients in two OxPLORE centres. Secondly, to facilitate the development of research skills of medical students as part of the OxPLORE initiative. Results Nine neuroblastoma patients were identified (YY, n = 4, XX, n = 5) over the study period. Nutritional status was poorer in YY patients (median z -score − 1.57 cf. − 0.7, t = 1.16, p = 0.28), which correlated with poorer survival in the YY cohort (75%), as compared to the XX cohort (100%). YY patients were older at presentation than the XX cohort (57 cf. 13 months, t = 1.959 p = 0.09). Further, tumour presentation was at a later stage in the YY group (75% stage IV). Conclusion This collaboration has shown a correlation in disparities in nutritional status and outcome of neuroblastoma in paediatric populations in YY and XX. These findings can inform institutional quality improvement. Further, this pilot study has highlighted the potential for medical students to undertake international research collaborations.
... Poor health-seeking behavior, geographic inaccessibility, financial unaffordability of care, infrastructural deficiencies, deficient diagnostic capability and equipping of health workers, and specialist care unavailability have been documented as some of the causes. [6,7] Several studies have also reported the role of delayed presentation in impacting survival rates. [8] Often, these studies have quite accurately blamed delayed presentation on factors such as lack of awareness, poor health-seeking behavior, [9] stigma, and sociocultural/religious beliefs of patients, [10] or in the case of paediatric patients, the parents, or caregivers. ...
Article
Background: Paediatric cancer patients in Nigeria continue to arrive at specialist centers with advanced-stage disease. The reasons for this are myriad, not least of which are delays in detection, diagnosis, and referral for treatment. While delayed presentation has often been reported from the perspective of delays from caregivers' decisions, institutional deficiencies in the health care system may account for an unmeasured portion of the factors leading to delayed presentation. This project centered around training of health-care professionals at community level to detect potential paediatric cancer signs and refer appropriately. Aim: The aim of the study is to access the immediate impact of training on early detection and referral of possible paediatric cancer cases in the community and primary level health care workers and professionals in the Southwest Nigeria. Materials and Methods: This was a retrospective review of the training impact in three South-Western states in Nigeria. Scores before and after the training were analyzed using the IBM SPSS statistics, version 23 (IBM, Armonk, NY, USA). Results: A total of 732 primary health care workers were trained. In the pre assessment evaluations, 44.8% of participants reported that cancer did not occur in children, 47.2% did not know any referral pathway for a child suspected of cancer. The post training assessment indicated an improvement in participants' understanding of common paediatric cancers types and how to refer a suspected case for specialist diagnosis and attention. Mean scores before and after the training were 3.5/15 and 12.5/15, respectively. Conclusion: Training health-care professionals working at the community level can have an immediate and measurable impact on early detection and referral for paediatric cancers, as seen by the difference in pre training and post training assessment scores. There remains a need for continuous training to ensure early referral and ultimately increase survival indices of children diagnosed with cancer in Nigeria.
... [26,27] In LMICs, the advanced disease stages seen in patients are likely due to late diagnosis and late referral. [28,29] In our series, 44% of patients were identified to be in stage IIIB, and the group with an unfavourable prognosis (G2) accounted for 85.8% of patients. In studies from Brazil and India, stages III and IV accounted for ~50% of patients. ...
Article
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Hodgkin lymphoma
... Menos de 20% das crianças/adolescentes têm acesso ao tratamento curativo. Consequentemente, a sobrevivência de crianças com câncer na África é significativamente menor do que nos países desenvolvidos, onde a sobrevida global em 5 anos é de 70 a 80% (Hadley, Rouma & Saad-Eldin, 2012). ...
Article
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Trata-se de uma revisão narrativa com objetivo de evidenciar repercussões psicossociais do câncer na vida de crianças/ adolescentes adoecidos e familiares/cuidadores. Os dados encontrados na literatura científica demonstram que o câncer é um evento complexo e amplo, marcado por determinantes subjetivos e sociais, sendo os aspectos psicológicos, financeiros, disparidades no acesso ao tratamento em contexto global e a escolarização, socialização as principais dimensões que sofrem interferência do processo de adoecimento/tratamento. A compreensão das implicações psicossociais torna-se essencial para a prestação de um cuidado integral em saúde, uma vez que esse evento afeta o modo de vida da pessoa adoecida e a dinâmica familiar. Abstract: It is a narrative review with the objective of showing psychosocial repercussions of cancer in the lives of sick chil-dren/adolescents and family members/caregivers. The data found in the scientific literature demonstrate that cancer is a complex and broad event, marked by subjective and social determinants, with psychological, financial aspects, disparities in access to treatment in a global context and schooling, socialization the main dimensions that suffer interference of the illness/treatment process. Understanding the psychosocial implications becomes essential for the provision of comprehensive health care, since this event affects the sick person's way of life and family dynamics.
... African countries, whereas it ranks fifth in North America. 3 Moreover, survival rates of 25%-53% in low-income countries have been reported as opposed to 70%-97% in high-income countries. 2 In 2018, the WHO set a global survival target of 60% for children with cancer by 2030. ...
Article
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Background/objectives Wilms tumor (WT) is a curable type of cancer with 5-year survival rates of over 90% in high-income countries, whereas this is less than 50% in low- and middle-income countries. We assessed treatment outcomes of children with WT treated at a large Kenyan teaching and referral hospital. Design/methods We conducted a retrospective record review of children diagnosed with WT between 2013 and 2016. Treatment protocol consisted of 6 weeks of preoperative chemotherapy and surgery, and 4–18 weeks of postoperative chemotherapy depending on disease stage. Probability of event-free survival (pEFS) and overall survival (pOS) was assessed using Kaplan–Meier method with Cox regression analysis. Competing events were analyzed with cumulative incidences and Fine–Gray regression analysis. Results Of the 92 diagnosed patients, 69% presented with high-stage disease. Two-year observed EFS and OS were, respectively, 43.5% and 67%. Twenty-seven percent of children died, 19% abandoned treatment, and 11% suffered from progressive or relapsed disease. Patients who were diagnosed in 2015–2016 compared to 2013–2014 showed higher pEFS. They less often had progressive or relapsed disease (p = .015) and borderline significant less often abandonment of treatment (p = .09). Twenty-nine children received radiotherapy, and 2-year pEFS in this group was 86%. Conclusion Outcome of children with WT improved over the years despite advanced stage at presentation. Survival probabilities of patients receiving comprehensive therapy including radiation are approaching those of patients in high-income countries. Additional improvement could be achieved by ensuring that patients receive all required treatment and working on earlier diagnosis strategies.
... 1,2 The incidence of WT is highest among African American children, followed by Caucasian children, and then Asian children. [3][4][5][6] Five-year survival is more than 90% for children with all stages of favorable histology WT (FHWT) who receive appropriate treatment. [7][8][9][10] However, survival remains poor for children with higherstage diffuse anaplastic WT. 11,12 Most children present with resectable disease in one kidney, and upfront unilateral nephrectomy is recommended for most children. ...
Article
The NCCN Guidelines for Wilms Tumor focus on the screening, diagnosis, staging, treatment, and management of Wilms tumor (WT, also known as nephroblastoma). WT is the most common primary renal tumor in children. Five-year survival is more than 90% for children with all stages of favorable histology WT who receive appropriate treatment. All patients with WT should be managed by a multidisciplinary team with experience in managing renal tumors; consulting a pediatric oncologist is strongly encouraged. Treatment of WT includes surgery, neoadjuvant or adjuvant chemotherapy, and radiation therapy (RT) if needed. Careful use of available therapies is necessary to maximize cure and minimize long-term toxicities. This article discusses the NCCN Guidelines recommendations for favorable histology WT.
... For example, in Africa, the survival outcomes of children with brain tumors remain poor, and priority must be given to access to care before organizing an effective transitional care for AYA patients. [25][26][27] ...
Article
Objective: Transitional care in surgical neurooncology is poorly studied. However, this period is pivotal, since it allows the patient to be empowered in his or her disease management. Here, the authors describe the experience of the Necker-Enfants Malades and the Sainte-Anne Hospital collaboration. Methods: The mixed transitional consultations started in September 2019 in a dedicated space for transitional care, named the "La Suite" department, located in the Necker-Enfants Malades Hospital, Paris, France. The authors organized planned consultations to schedule the clinical and radiological follow-up in the adult neurosurgical department but also emergency consultations to manage tumor recurrence in young adult patients. Transitional care was performed jointly by pediatric and adult neurosurgeons who have developed clinical and research skills in the field of surgical neurooncology. Neuropathological analysis was performed by a neuropathologist who is specialized in pediatric and adult neurooncology. Results: Fourteen patients benefited from a mixed transitional consultation. All of them accepted to start their management in an adult neurosurgical environment. Eleven patients (78.6%) for whom the disease was controlled benefited from a planned consultation. Three patients (21.4%) required rapid neurosurgical management for a tumor recurrence (n = 2) or for a new primary CNS tumor (n = 1) and benefited from an emergency consultation. Conclusions: For adult patients harboring a brain tumor during childhood or adolescence, the authors suggest that neurosurgeons specialized in adult surgical neurooncology with a full knowledge in pediatric neurooncology will combine the required skills to optimize care management for these patients within a dedicated multidisciplinary organization framework.
... Cancer is now curable in developed countries as survival rates approach 80%, but in Africa,>80% of children still die without access to adequate treatment (2) .The costs of treatment, diagnostic investigations, meals and hospital stay are borne by patients and their families. Because no coordinated cancer registry exists in Ethiopia, few studies have explored the incidence of pediatric malignancies and to our knowledge none have reported outcomes from our region. ...
... All the authors recommend alternative solutions which do not involve ionizing radiation [13][14][15][16][17]. This is all the more valid in Africa, which contains 80% of the world's children and where cancer care is still a dilemma [18][19][20]. ...
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Background Abdominal trauma are a common cause of infant morbidity and mortality. Aim To assess the relevance of computed tomography scan for the management of abdominal trauma in children in countries with limited resources. Patients and method It was a retrospective and descriptive study over 5 years in patients aged 0 to 15 years. Results Twenty four cases of abdominal trauma were collected. There were 14 boys and 10 girls with a sex ratio of 1.4. The average age was 8.7 years with extremes of 18 months and 15 years. The causes found were: road accidents (14 cases), home accident (6 cases), gambling accidents (3 cases) and one aggression. Traumas were divided into 83.3% (20 cases) of abdominal blunt and 16.7% (4 cases) of abdominal wound. Polytrauma accounted for 41.7% (10 cases). No computed tomography scan was ordered. The spleen was the most injured organ (11 cases) followed by the intestines (6 cases). The average length of hospital stay was 12.3 days with extremes of 3 and 15 days. The treatment was non-operative in 13 patients (54.2%) and surgical in 11 ones (45.8%). No deaths were noted in our series. Conclusion Abdominal trauma in children are potentially serious injuries. The treatment depends on the damaged organ and the patient's hemodynamic status. Computed tomography scan does not appear to be indispensable in the management of traumatized children in countries with limited resources.
... The causes of this global disparity in survival among patients with pediatric cancer are multifactorial, but delayed presentation to treatment is a major contributing factor. [6][7][8][9][10] In sub-Saharan Africa (SSA), delayed presentation has been recognized as an important barrier to effective care since cancer care efforts began in the region in the 1960s. [11][12][13][14][15] A multisite study in SSA estimated that 50%-80% of patients with pediatric cancer present at an advanced stage because of presentation delays. ...
Article
PURPOSE It is estimated that 50%-80% of patients with pediatric cancer in sub-Saharan Africa present at an advanced stage. Delays can occur at any time during the care-seeking process from symptom onset to treatment initiation. Referral delay, the time from first presentation at a health facility to oncologist evaluation, is a key component of total delay that has not been evaluated in sub-Saharan Africa. METHODS Over a 3-month period, caregivers of children diagnosed with cancer at a regional cancer center (Bugando Medical Centre [BMC]) in Tanzania were consecutively surveyed to determine the number and type of health facilities visited before presentation, interventions received, and transportation used to reach each facility. RESULTS Forty-nine caregivers were consented and included in the review. A total of 124 facilities were visited before BMC, with 31% of visits (n = 38) resulting in a referral. The median referral delay was 89 days (mean, 122 days), with a median of two facilities (mean, 2.5 facilities) visited before presentation to BMC. Visiting a traditional healer first significantly increased the time taken to reach BMC compared with starting at a health center/dispensary (103 v 236 days; P = .02). Facility visits in which a patient received a referral to a higher-level facility led to significantly decreased time to reach BMC ( P < .0001). Only 36% of visits to district hospitals and 20.6% of visits to health centers/dispensaries yielded a referral, however. CONCLUSION The majority of patients were delayed during the referral process, but receipt of a referral to a higher-level facility significantly shortened delay time. Referral delay for pediatric patients with cancer could be decreased by raising awareness of cancer and strengthening the referral process from lower-level to higher-level facilities.
... [26,27] In LMICs, the advanced disease stages seen in patients are likely due to late diagnosis and late referral. [28,29] In our series, 44% of patients were identified to be in stage IIIB, and the group with an unfavourable prognosis (G2) accounted for 85.8% of patients. In studies from Brazil and India, stages III and IV accounted for ~50% of patients. ...
... Moreover, an important role may be performed by differences in registration techniques and the availability and access to data sources (Steliarova, 2017). Besides, incidence registration and consequently incidence rates may be affected by the availability of diagnostic facilities (Amayiri, 2014;Hadley, 2012) and once available, by socioeconomic barriers to their access (Magrath, 2013, Steliarova, 2017 (Parkin, 1994). Ajiki has also proposed an original formula for such a method (Ajiki, 1998 This method compares the result of the registration procedure with an independent cancer case-series. ...
Thesis
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Introduction The activity of cancer registries represents a multistep process that starts by gathering information from a variety of sources. Such information is checked, linked, enriched and handled to produce high-quality original data capable of being informative enough to prove useful in answering specific epidemiological and clinical questions. This thesis is part of a PhD by Prior Publication grounded in six published papers. These papers deal with different steps in the production of cancer registry data, enhancing the contribution of registries to cancer epidemiology. Skin melanoma has been used as an example, but all the presented methods and concepts apply to any cancer type. Materials and methods 1. The first paper (related to cancer registry data quality) tests the hypothesis whether the distribution of the first digit (from one to nine) of crude incidence rates obeys Benford law. Pearson’s coefficient of correlation and different distance measures were applied to compare the theoretical distribution to the observed one in a sample of 43 population-based cancer registry populations randomly drawn from the volume X of Cancer Incidence in 5 Continents. 2. In the second paper, an innovative index for measuring the amount of internal variability among the sub-areas underlying an overall incidence rate is presented. The measure is a ratio, where the numerator is the difference between the highest and the lowest age-adjusted standardised rate in sub-areas. The denominator is the overall area age-adjusted standardised rate. Such measure was applied to age-standardised incidence rates for ‘all cancer sites excluding non-melanoma skin cancer’, for men, in 2014, for Nordic countries as a whole, for each country (Denmark, Faroe Islands, Finland, Greenland, Iceland, Sweden and Norway) and their regions. 3. In paper three, to make cancer registry data useful in the clinical setting, melanoma incidence during 1985–2004 in the Tuscan cancer registry (Italy) was analysed including both standard (site, morphology, sex, age, calendar period) and clinically relevant variables, as in situ melanoma and Breslow’s thickness. For the time trend analysis, the annual percent change (APC) of the rates was computed. 4. Paper 4 presents the results of an age-period-cohort model applied to 1977 skin melanomas, incident in the Tuscan cancer registry. Such a method allows us to understand the time trend better and to forecast future change. Moreover, a non-linear regression model was applied to estimate the expected number of new cases in a more recent period. 5. Paper 5 shows a skin melanoma survival analysis based on 1403 patients from two Italian registries (Tuscan and Reggio-Emilia). The focus was on two different approaches: the multivariate Cox proportional hazard model and the Classification And Regression Trees analysis. The latter is an automatic method that splits data through a recursive process creating a ‘tree’ of groups with different profiles of risk of death. Both ways were applied to the following variables: age, sex, Breslow thickness, Clark level, Registry, sub-site and morphologic type. 6. In Paper 6, the quality of melanoma diagnosis and care in the Tuscan region is measured based on 13 newly realised process indicators, which encompassed early diagnosis, pathology reporting and surgical treatment. We evaluated the clinical adherence to these indicators in two years: 2004 and 2008, using a population-based series of incident skin melanomas, measuring the possible changes in the indexes following the implementation of specific regional recommendations. Results 1. The distribution of the first significant digits of cancer incidence rates was shown to belong to numbers that abide by Benford law, in the whole dataset (146,590 rates) by sex and cancer registries. The correlation coefficient between observed and expected distributions was extremely high (0.999), and the distance measures very small. 2. The index for internal variability highlighted a quite relevant heterogeneity among Nordic countries (index 57.1% = the difference between the Nordic country with the highest and the one with the lowest rate is 57.1% of the Nordic overall age-adjusted rate). Within countries, the variability was negligible in Iceland (9.6%), and high in Sweden (37.1%). 3. During the four analysed periods standardized melanoma incidence rose significantly, for both invasive (APC = + 5.1%) and in situ lesions (APC = + 11.1). Over time, the median value of thickness decreased from 1.68 to 0.8 mm (P < 0.001), but only for <=1.00 mm melanomas. Although the rates of thin melanoma have increased, rates for thick ones did not decrease. 4. The model that best fitted the data included age and ‘drift’. The linear effect (‘drift’) showed, in each age group, an increase of the risk of malignant melanoma diagnosis of about 36.6% every five years of period or cohort. For the period 2002–2006, 1112 new cases were predicted with a standardised rate (age 15–84 years) of 19.2 × 100.000. In the Tuscany Cancer Registry area, no clues for malignant melanoma incidence rates levelling off were documented. Growing rates and numbers of malignant melanoma are expected soon. 5. The Cox proportional hazard model found sex, age, Breslow thickness, Clark and morphologic type to have a significant independent prognostic value. The Classification And Regression Trees analysis identified six groups of different risks based on Breslow thickness, age and sex. The best prognostic group (5-year observed survival, 98.1%) included those subjects with Breslow less than 0.94 mm and age 19–44 years. The same thickness but an older age (50–69 years) was associated with a statistically significant different prognosis (5-year observed survival, 92.8%). 6. As regards the quality of care, there were statistically significant increases in the percentage of thin (<= 1 mm) melanomas from 2004 to 2008 (from 50.7 to 61.3%) and in the number of pathology reports that mentioned ulceration (from 61.4 to 84.6%) and margin statuses (from 76.8 to 84.3%). The percentage of patients staged by sentinel lymph node biopsy was stable (63%) and was higher for patients younger than 75 years of age (74%). The number of lymph nodes almost invariably exceeded the proposed site-specific cut-off reference, and, in 2008, the number of nodes removed was always reported for lymphadenectomy. From 2004 to 2008, surgical and pathological waiting times increased. Conclusions The six presented papers cope cohesively with consecutive steps in the procedure of cancer registration. 1. The check for Benford law abidance may become a preliminary test in the process of data quality. 2. The heterogeneity index offers a new, simple (to be produced and to be understood) and noteworthy information. 3. The analysis of some clinically crucial variables raises the interest of clinicians and makes cancer registries closer to the real world. 4. The use of methods with higher statistical involvement, e.g., the age-period-cohort model, provided further information on melanoma time trends in the area. Moreover, estimates were projected to a more recent period bridging the Registry’s timeliness gap. 5. Prognosis is a piece of vital information for both patients and clinicians. Hazard ratios and patients grouping showed almost the same risk patterns but conveyed by a different message (relative vs absolute), with a different understandability. 6. Population-based quality indexes allow to check the practical application of guidelines and recommendations, highlighting critical situations to be improved. Cancer registration is a unique process made by different but connected steps. The improvement of each of them positively affects others. It is a sort of virtuous circle in which new methods, new uses and new users are all involved in a common aim: exploiting cancer registries’ activity. Registries can have a real informative power only if the whole process, from the collection of raw data to the provision of relevant information for various stakeholders, is accomplished.
... Management of WT in developing countries provides well-known challenges such as late presentations particularly in malnourished children, failure or abandonment of therapy, insufficient capacity of specialized hospitals, and deficiency in treatment facilities [11,12]. Some experts analyzed that primary surgery might be unsuitable to be practiced in resource-constrained settings due to the aforementioned problems; therefore, delayed resection should be the principal modality [13]. ...
Article
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Background Wilms tumor is the commonest malignant renal neoplasm in children. Surgery plays a pivotal role in the management, and evidence-based guidelines for surgical resection have been established by the major international groups. Any deviation from the protocol is considered as a violation. The goal of this study was to evaluate outcomes of the patients with unilateral Wilms tumor treated at a developing country and to analyze surgical violations (SV) and their impact on the prognosis. A retrospective review was conducted for 37 patients who were presented to our hospitals and underwent nephrectomy for WT from January 2016 to December 2018. All participating centers adopt Children’s Oncology Group protocol. The SV were analyzed by logistic regression. Overall survival (OS) and event-free survival (EFS) were estimated by the Kaplan-Meier method. Results There were 12 (32.4%), 11 (29.7%), 10 (27%), and 4 (10.8%) stages I, II, III, and IV, respectively. Their median age at time of diagnosis was 3.1 years. Upfront nephrectomy was performed for 30 cases. Six patients had tumor relapse (2 lungs and 4 local recurrences) at a median follow-up of 15.7 months. Out of the relapsed patients, two had unfavorable histology, and regarding their staging, four were stage III, one was stage II, and one was stage IV. Thirty-month OS and EFS were 84.3% and 81.1%, respectively. Twenty-seven SV occurred within 25 patients. Lack or inadequate lymph node sampling represented 74.07% (20/27), intraoperative tumor rupture and spillage accounted for 18.52% (5/27), and unwarranted preoperative biopsy happened in 7.41% (2/27). The SV were not correlated with mortality (p value = 0.381); however, they had a significant impact on the relapse (p value = 0.001). On further analysis; tumor rupture and spillage was a predictor for recurrence reaching a statistical significance (p value = 0.003), whereas the other violations were not. Conclusions Favorable outcomes could be achieved by compliance with evidence-based guidelines even in a resource-limited country like ours. Violations were correlated with relapse; however, only tumor rupture and spillage was of statistical significance in multivariate analysis. Failure of lymph node documentation was the main problem encountered, and it should be avoidable in future practice.
... In the first report on cancer incidence in Sudan (2009)(2010), by the National Cancer Registry, leukaemia was described as the most common cancer among children in Khartoum state with an incidence rate of 10 per 100,000 [4]. Similarly, in northern Africa, it is the most common malignancy in children [5]. Sixty five percent of patients with leukaemia, when revised in the course of their disease, demonstrated oral signs or symptoms [6]. ...
... In the first report on cancer incidence in Sudan (2009)(2010), by the National Cancer Registry, leukaemia was described as the most common cancer among children in Khartoum state with an incidence rate of 10 per 100,000 [4]. Similarly, in northern Africa, it is the most common malignancy in children [5]. Sixty five percent of patients with leukaemia, when revised in the course of their disease, demonstrated oral signs or symptoms [6]. ...
Article
Full-text available
The burden of oral health diseases in children with leukaemia and the impact of cancer treatment on their oral health have not been studied in Sudan. The present study assesses the oral health status of leukemic children through measuring caries experience, gingival status, oral hygiene status and mucositis. It also explores the association between the oral health status of children with leukaemia and their parental education, oral hygiene habits, treatment stage and type of leukaemia. A cross sectional hospital-based study was conducted at the Radiation and Isotope Center Khartoum, Khartoum State. A total of 87 children were included in this study. Data were collected by interviewer questionnaire and clinical examination. The oral health status revealed high prevalence of untreated dental caries (37.9%) and the majority (67.9%) of children had poor oral hygiene. Nearly, all children with leukaemia (93.1%) had never visited a dental health facility in their lives. Regarding the treatment stages of leukaemia, the severity of dental caries was found to be more significant in the maintenance phase, while oral mucositis was more significant in the induction phase.
... This has resulted in therapy only being given to those with the finances to pay for therapy and to those able to travel to the treatment center. 14,20,30 Coinciding with the medical management of Wilms tumor, surgical resection is necessary for survival. A study assessing pediatric surgeon distribution across the world noted a correlation between national income and the number of trained pediatric surgeons within a population. ...
... Acute lymphoblastic leukemia (ALL) is the most common pediatric cancer, nearly, accounting 80% of childhood cancers [1]. Epidemiological data report 2900 new diagnoses of childhood ALL per year in the USA [2] and about 50 new cases per million per year in Europe [3], with different ethnicities sharing such a high incidence [4]. ...
Article
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Childhood acute lymphoblastic leukemia (ALL) peaks around age 2–4, and in utero genetic epigenetic mother-fetus crosstalk might tune ALL onset during childhood life. Folate genes variably interact with vitamin status on ALL risk and prognosis. We investigated DHFR and MTHFR gene variants in 235 ALL children and their mothers to disclose their role in determining ALL onset age and survival. Pyrosequence of DHFR 19bp ins/del (rs70991108; W/D), MTHFR C677T (rs1801133; C>T), and MTHFR A1298C (rs1801131; A>C) was assessed in children and in 72% of mothers for dyad-analysis comparison. DHFR DD-children had delayed ALL onset compared to WW-children (7.5 ± 4.8 vs. 5.2 ± 3.7 years; P = 0.002) as well as MTHFR 1298 CC-children compared to AA-children (8.03 ± 4.8 vs. 5.78 ± 4.1 years; P = 0.006), and according to the strong linkage disequilibrium between MTHFR 677 T-allele and 1298C-allele, MTHFR TT-children showed early mean age of onset though not significant. Offspring of MTHFR 677 TT-mothers had earlier ALL onset compared to offspring of 677 CC-mothers (5.4 ± 3.3 vs. 7 ± 5.3 years; P = 0.017). DHFR/MTHFR 677 polymorphism combination influenced onset age by comparing DD/CC vs. WW/TT children (8.1 ± 5.7 vs. 4.7 ± 2.1 years; P = 0.017). Moreover, mother-child genotype combination gave 5.5-years delayed onset age in favor of DD-offspring of 677 CC-mothers vs. WW-offspring of 677 TT-mothers, and it was further confirmed including any D-carrier children and any 677 T-carrier mothers (P = 0.00052). Correction for multiple comparisons maintained statistical significance for DHFR ins/del and MTHFR A1298C polymorphisms. Unexpectedly, among the very-early onset group (<2.89 years; 25th), DD-genotype inversely clustered in children and mothers (4.8% vs. 23.8% respectively), and accordingly ALL offspring of homozygous DD-mothers had increased risk to have early-onset (adjusted OR (odds ratio) = 3.08; 1.1–8.6; P = 0.03). The opposite effect DHFR promoter variant has in tuning ALL onset-time depending on who is the carrier (i.e., mother or child) might suggest a parent-origin-effect of the D-allele or a two-faced epigenetic role driven by unbalanced folate isoform availability during the in-utero leukemogenesis responsible for the wide postnatal childhood ALL latency.
... As a result, more than 90% of children in Africa who develop cancer die without access to adequate treatment, compared with an 80% survival rate for children in high-income countries. [4][5][6] The poor survival rate in African countries is due to numerous factors including poverty 7,8 ; competing health priorities 9 ; poor cancer diagnostic capacity 10 ; inability to recognize signs and symptoms, thus leading to no or delayed referral to a tertiary facility 11 ; and insufficient access to diagnostic and treatment facilities. 7 Substantial improvements for cancer diagnosis and treatment have been made in Tanzania over the last decade. ...
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Background Cancer in children in Tanzania is a concerning health issue, yet there is a shortage of information about the experiences of the guardians of children who receive cancer treatment. Objective To explore concerns and needs of support among guardians of children on cancer treatment in Dar es Salaam, Tanzania. Method Using a qualitative design, 3 focus group discussions were held with 22 guardians of children aged 9 to 17 years. Guardians were recruited from Muhimbili National Hospital, Dar es Salaam, where their children were receiving cancer treatment. Data were analyzed using thematic content analysis. Results Guardians experienced several issues during the initial stages of their child’s cancer treatment, including the process of seeking a diagnosis, and experiences with care at the peripheral (regional) hospitals and national hospital. They also shared what they felt would lessen their difficult experiences. Seven themes emerged in this study: financial concerns, emotional concerns, barriers to cancer care, need for improved cancer care, need for information, need for tangible support, and gratitude and hope. Conclusion Guardians of children with cancer experience challenges during initial stages when seeking a diagnosis and have concerns and needs related to cancer care and treatment. Implications for practice Improvements are needed regarding care at regional hospitals, the cancer diagnosis, and the recognition of early signs of cancer and quick referral to diagnostic centers, compassionate caring behaviors by healthcare workers, budgetary support from the government to meet the medication supply demands, and meeting stakeholders’ support needs.
... 3 However, further recent literature on bone tumors in Africa is scarce, given the low priority given to surgical oncology in Africa and the lack of cancer registries in most countries. 4 Michelle Ghert, MD Presentation with advanced stage osteosarcoma has been reported to be associated with a low socioeconomic status. 5 In poor countries such as Tanzania, advanced presentation of disease and the lack resources for limb salvage generally result in the need for amputation, which is a notable burden on families and the ability of the patient to function in society. 6,7 In less developed countries such as those in sub-Saharan Africa, standard treatment regimens may not be available or financially feasible, and logistic barriers to treatment lead to poor outcomes in pediatric cancer. ...
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Bone tumors account for a small fraction of childhood cancers. Most published reports are from developed countries. The purpose of this study was to review the primary bone tumors in children and adolescents treated at a referral center in Northern Tanzania. We completed a 10-year hospital-based cross-sectional study in which all patients younger than 20 years diagnosed with a primary bone tumor at the Kilimanjaro Christian Medical Center Orthopaedic Department from January 2006 to December 2015 were identified and reviewed. Of the 80 identified patients, 15 (18.8%) were aged 5 to 8 years, and 65 (81%) were aged 9 to 19 years. Forty-seven males (59%) and 33 females (41%) were identified. The most common tumor locations were the femur, tibia, and humerus. Osteosarcoma was the most common malignant diagnosis (49 patients, 61%). No cases of Ewing sarcoma were reported. The most common tribal origins of the patients were Chagga and Maasai. Most primary bone tumors treated at a referral center in Northern Tanzania are malignant, with osteosarcoma representing the vast majority. No cases of Ewing sarcoma were identified in this tertiary referral hospital–based database. This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
... África soporta una gran carga relacionada con la patología oncológica infantil, donde menos del 20% de los niños tienen acceso a un tratamiento curativo (13) , particularmente en los países sub-saharianos, donde además se suma el problema de la falta en el registro, lo que dificulta el conocimiento real de su incidencia y comportamiento. La escasez de centros oncológicos apropiados que cuenten con personal cualificado forman parte principal de los resultados desesperanzadores de estos pacientes, unido a la búsqueda tardía de atención sanitaria ante la progresión inminente de la enfermedad, una vez agotados los tratamientos locales tradicionales. ...
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A pesar de que en los países empobrecidos la universalización del acceso a la asistencia sanitaria y a los tratamientos considerados básicos es todavía un objetivo pendiente, actualmente la mejora en área de la nutrición y la atención de la salud se ha traducido en una reducción de la tasa de mortalidad en niños menores de 5 años (TMM5). En los últimos años, las familias africanas de la clase media urbana se han visto favorecidas de la educación de la mujer, una mejor nutrición infantil e higiene y, por lo tanto, una TMM5 inferior al promedio regional. No obstante, la asistencia sanitaria en estas regiones es un reto, y las especialidades que requieren profesionales altamente capacitados y un acceso suficiente a los equipos y materiales caros son mucho menos alcanzables que en los países en desarrollo. En este sentido, las cifras hablan por sí solas: un estudio patrocinado por la Organización Mundial de la Salud (OMS) en 1998, reveló la existencia de solo 79 neurocirujanos en el África subsahariana, la proporción de 1 profesional para asistir a una población de 3.600.000 habitantes, mientras que la proporción mundial sería de 1 neurocirujano para 230.000 habitantes.
... The overall incidence of pediatric solid malignant tumor is difficult to estimate in these poor nations because of lack of vital hospital statistics and national cancer registries in some of these countries. [4] Cancer registries ensure cancer surveillance, thus providing the basis for research as well as policy decisions. [5] The management of childhood tumors faces several challenges in countries with limited resources. ...
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Cancer is relatively rare in childhood, but it contributes considerably to childhood mortality, years of life lost per person and late effects in survivors. Childhood cancers are life-threatening diseases that are universally distressing and potentially traumatic for children and their families at diagnosis, during treatment, and beyond. These cancers have different characteristics than those occurring among adults and described as cancers occurring below 15 years of age. In developed countries, its incidence is relatively rare but it's a leading cause of death. More than 80% of the childhood cancers are occurring in low and middle income countries where paediatric oncology facilities continue to face several challenges. There is an urgent need to overcome these barriers to improve the quality of life of childhood cancer patients and their care givers. These patients should be managed multimodally by pediatric oncologists, surgeons, radiation oncologists, nurses, psychologists, social workers, nutritionists, and occupational therapists.
... They also expressed a desire for more local cancer centers; currently there are only five cancer centres in Tanzania, two located in Dar es Salaam and one each in Mwanza, Kilimanjaro, and Mbeya, all of which are at far distances from the rural areas with limited services. Tanzania currently has a limited number of healthcare providers and similar to other African countries, the burden of other diseases such as malaria, HIV/AIDS, and tuberculous place a significant strain on the healthcare system [33]. ...
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Background Cancer is one of the leading causes of morbidity and mortality worldwide. Seventy percent of deaths of cancer occur in low or middle-income countries, where the resources to provide cancer treatment and care are minimal. Tanzania currently has very inadequate facilities for cancer treatment as there are only five sites, some with limited services; two are in Dar es Salaam and one each in Mwanza, Kilimanjaro and Mbeya that offer cancer treatment. Despite cancer being a prevalent problem in Tanzania, there is a significant shortage of information on the experiences of young people who receive cancer treatment and care. The aim of this study was to explore cancer-related concerns and needs of care and support among young adults and children who are receiving cancer treatment in Dar es Salaam, Tanzania. Methods Using an explorative, qualitative design, two focus group discussions (FGDs) with young adults (18 to 25 years) and four FGDs with children (9 to 17 years) were held. Data were transcribed into English and analyzed using content analysis. Results Identified concerns included physical effects, emotional effects, financial impacts, poor early care, and poor treatment. Identified needs included the need for improved care in hospital by the staff, need for community support, financial needs, needs for improved cancer care and treatment in the hospitals, and the need for increased education about cancer. Resilience was identified, particularly around hope or faith, having hope to be healed, and receiving good care from staff. Conclusion Young adults and children receiving cancer treatment in Tanzania have many needs and concerns. Improvements with regard to the care provided in hospital by the staff, the cancer care and treatment in the hospital, and population-wide education about cancer are necessary to address the identified needs and concerns. Further studies on specific approaches to address the concerns and needs are also warranted.
Article
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.
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BACKGROUND Research in Namibia has come a long way over the past two decades. Even so, research in the field of paediatric oncology is still lagging behind. Therefore, this study looked at the pattern of paediatric cancer patient over a ten-year period. METHODS A cross-sectional study was done to analyse the paediatric oncology cases that were admitted to the paediatric oncology unit (ward 8 west) at Windhoek Central Hospital (WCH) between 01 January 2011 and 31 December 2020. The study analysed the files of paediatric patients admitted with a paediatric cancer diagnosis from the age of 0 to 16 years. RESULTS A total of 174 paediatric cancer patient files met the inclusion criteria. Haematopoietic cancers were the most commonly occurring diagnosis of a paediatric cancer type in the study population (44.8%), of which leukaemias were the most common type of haematopoietic cancer. The other types of cancer apart from haematopoietic cancers consisted of embryonal cancers (37.9%), soft tissue and bone sarcomas (13.8%), and brain or CNS cancers (3.4%). The median age at diagnosis was 5.13 years with an age range of 0 to 15 years. HIV exposure had an incidence of 6.4%. CONCLUSIONS Haematopoietic cancers remains the number one most common type in Namibia. However, there has been a change in the ranking of the other childhood cancer subtypes over the last 3 decades. The recommendation is that there be better recordkeeping of cancer patient files to capture important information. For follow-up studies, prospective studies are recommended in the future.
Chapter
Wilms’ tumor is the most common renal tumor of childhood, affecting seven to eight cases per million person years in children. It accounts for 95% of all pediatric renal cancers and 6% of all cancers below 15 years of age. The gender-specific incidence is almost similar with slight female preponderance. The mean age of diagnosis is 41.6 months in boys and 46.9 months in girls for unilateral disease. The patients with bilateral disease present approximately 1 year before those with unilateral disease. The recent data has revealed the difference in incidence between different geographic regions and ethnic groups within that geographic region. Various case control studies have been conducted to study the role of paternal occupational exposure and maternal occupational and hormonal exposure during pregnancy. There have been inconsistencies in the pattern of exposure, and it seems unlikely that environmental exposure has any significant role to play in the pathogenesis of Wilms’ tumor. This chapter discusses the epidemiology of Wilms’ tumor in particular relation to the incidence of the tumor, geographic and ethnic variations, causative hypothesis, role of environmental factors in causation, pertinent issues in low-income countries, and the role of tumor registries.KeywordsWilms tumorEpidemiologyIncidence
Article
The need for paediatric urological care in low- and middle-income countries in sub-Saharan Africa (SSA) is enormous due to a burgeoning paediatric-aged population and a disproportionate burden of congenital malformations. There are formidable challenges in the provision of a skilled workforce and appropriate infrastructure, resulting in a huge unmet need with consequent effects on the long-term health and prosperity of the population. Constraints of funding, geography, culture, surgical and anaesthetic skills, and instrumentation means that many conditions present late and with complications that could have been avoided by an earlier attendance. It also means that the management of congenital malformations, e.g., bladder exstrophy and congenital obstructive posterior urethral membrane, differ substantially from that seen in the developed world, with the outlook for children with renal failure being particularly bleak. Collaborations between paediatric urologists from high- and low-income countries are beginning to help with the development of a surgical infrastructure customised to paediatric care, and with the training of specific paediatric urological knowledge and skills. These collaborations, whilst welcome, still require substantial expansion to achieve more equitable access to appropriate paediatric urological care for children in SSA. Future efforts have to focus on the creation of sustainable and equal partnerships between urologists from low- and high-income healthcare environments, with an emphasis on providing sustainable management, appropriate to local need and available resources. The provision of shared learning, utilising the benefits of global digital communication, will improve mutual understanding of needs in a resource-poor environment and the involvement of trainees from both income settings can help perpetuate long-term collaborations.
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Background The rarity and heterogeneity of pediatric cancers make it difficult to assess risk factors associated with the development of cancer in this group. This also determines the quantity and quality of evidence for etiological factors linked to pediatric cancers. Evidence on the risk factors associated with pediatric cancers is scarce; however, it has been accumulating slowly over the years. As the disease burden shifts from communicable to non-communicable diseases, most of these low- to middle-income countries (LMICs) find themselves overburdened with changing health care priorities and needs. In sub-Saharan Africa, it is of major importance to pay particular attention to risk factors associated with pediatric cancer. Objective To map evidence on risk factors associated with pediatric cancers in sub-Saharan Africa (SSA). Methods This review was guided by Arksey and O’Malley’s framework for conducting scoping reviews. Four electronic databases were searched in December 2018, and another manual search was conducted in February 2022 to include newly published eligible articles. The databases searched included PubMed and Health Source: Nursing/Academic Edition. We also searched articles from an academic search engine, Google scholar. This review included articles reporting the relevant outcomes of this study and articles reporting cancers in children in the 0–15 years age range. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews (PRISMA-ScR): checklist and explanation. Results We retrieved 7391 articles from the initial database. The final number of studies that were included for data extraction was 15. Evidence from the retrieved studies suggests that most childhood cancers in the SSA region are infection-induced. The type of cancer mostly reported is Burkitt Lymphoma and is diagnosed mostly in the tropical region of SSA. The type of risk factors was divided into three types: infection-induced, genetic, and demographic risk factors. Overall, based on the articles retrieved, there was limited evidence on the risk factors associated with pediatric cancers in SSA. Conclusion The limited evidence on the risk factors coupled with the lack of evidence on the true burden of these malignancies in the SSA hampers efforts to set priorities for childhood cancer control. Formulation of effective preventative (where possible) measures and treatment regimens will need proper assessment of risk factors.
Article
Background: Significant disparities exist for timely access to cancer care for children, with the highest disparities in low- and middle-income countries (LMICs). This study aims to conduct a systematic review that identifies the factors contributing to delayed care of childhood cancers in LMICs. Methods: We will conduct a systematic review with search strings compliant with the PICO framework: (1) the Population-children (aged 0-18 years) from LMICs; (2) the Exposure-factors contributing to timely childhood cancer care; (3) the Outcome-delays in childhood cancer care. Discussion: Our study is an essential step to guide strategic interventions to assess the myriad of factors that prevent children from accessing timely cancer care in LMICs. The results will be submitted for publication in a peer-reviewed journal and shared with institutions related to the field.
Article
Background: Unaffordable health-care costs are a critical factor in poor cancer care in low and middle-income countries. Net costs of treating childhood cancer in Nigeria are largely undocumented. This study sought to define the direct cost of pediatric cancer treatment in Lagos, Nigeria, to address this knowledge gap. Methods: This was a longitudinal study design targeting determination of cost of cancer-related care delivered to newly diagnosed childhood cancer patients at the Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria, from January 2017 to January 2020. Study participants included children with histologically confirmed diagnoses. All direct costs associated with care from the time of diagnosis until either remission or death were documented based on a parental survey at each patient encounter. Results: Among 46 enrolled participants (median age of 6 years), leukemia was the most common diagnosis. The median duration from diagnosis to last assessment was 11 months, and the average cost directly related from diagnosis to remission or death was NGN 5,064,700 (USD 13,876). The highest cost of care was associated with rhabdomyosarcoma, with an average cost of ₦6,798,635 ($18,678). These costs were juxtaposed to the average monthly family earning of NGN 115,228 (USD 316). Conclusion: This study revealed the direct cost of managing childhood cancer in Lagos, Nigeria, which proved unaffordable for most caregivers. Policies are needed to improve the affordability of health-care delivery for childhood cancer, including a focus on the adequacy of health insurance coverage and public health-related policies governing financial support targeting health-care delivery in the context of childhood cancer to improve outcomes.
Article
Background: Wilms tumor (WT) represents around 85% of pediatric renal tumors. In high-income countries, 5-years survival of WT is above 90% but survival in developing countries is inferior. Objective: To identify the predictors of treatment outcome of WT in a developing country. Methods: A retrospective study conducted at the pediatric oncology department, Combined Military Hospital Rawalpindi, Pakistan. All newly diagnosed WT cases from 1st January 2012 who completed their treatment before 31st August 2019 were evaluated. Treatment was based on SIOP Wilms Tumour 2001/UK version 5. Patients presenting before nephrectomy received pre-operative chemotherapy. The postoperative chemotherapy regimen was decided according to the stage, risk stratification and metastatic status of the patient. Results: Data of 84 cases, including 40 (47.6%) males and 44 (52.4%) females was analyzed. The mean diagnostic age was 38.87 ± 28.66 months and 68 (81%) cases were less than five years of age. The commonest presenting features were abdominal mass in 75 (89.3%) cases. The right kidney was affected in 43 (51.2%) cases. Stage I disease was documented in 27 (32.1%) cases, stage II in 25 (29.8%), stage III in 13 (15.5%), and stage IV in 17 (20.2%) cases. In univariate analysis, advanced stage (P = < 0.001) and metastatic disease (P=< 0.001) adversely affected the treatment outcome. Multivariate analysis demonstrated that advanced stage WT was associated with the worst outcome (P= < 0.05). Four (4.8%) cases had treatment-related mortality (TRM). With a median follow-up time of 28.26 ± 23.03 months, OS and EFS were 66 (78.6%) and 63 (75.0%) respectively. Discussion: Delayed presentation with advanced-stage metastatic disease is quite common in the developing courtiers and is the major contributor to decreased EFS and OS. In the present study, 20.2% cases had metastatic disease, which is similar to reported from other developing countries. OS decreased from 92.6% in stage I to 47.1% in stage IV disease (P=< 0.001) and EFS decreased from 92.6% in stage I to 43.8% in stage IV disease (P=< 0.001). Very similar results are reported by a regional study [17]. Results in stage I and II disease are comparable to documented in the western world and inferior in advanced-stage disease. The strength of the present study is that multiple factors, affecting the treatment outcome of WT over almost seven years period were evaluated. Conclusions: Stage of the disease is the most important prognostic factor. Delayed presentation with metastatic disease has a poor outcome.
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Introduction A major barrier to improving childhood cancer survival is the perception that paediatric oncology services are too costly for low-income and middle-income country (LMIC) health systems. We conducted a systematic review to synthesise existing evidence on the costs and cost-effectiveness of treating childhood cancers in LMICs. Methods We searched multiple databases from their inception to March 2019. All studies reporting costs or cost-effectiveness of treating any childhood cancer in an LMIC were included. We appraised included articles using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Where possible, we extracted or calculated the cost per disability-adjusted life year (DALY) averted using reported survival and country-specific life expectancy. Cost/DALY averted was compared with per capita gross domestic product (GDP) as per WHO-Choosing Interventions that are Cost-Effective guidelines to determine cost-effectiveness. Results Of 2802 studies identified, 30 met inclusion criteria. Studies represented 22 countries and nine different malignancies. The most commonly studied cancers were acute lymphoblastic leukaemia (n=10), Burkitt lymphoma (n=4) and Wilms tumour (n=3). The median CHEERS checklist score was 18 of 24. Many studies omitted key cost inputs. Notably, only 11 studies included healthcare worker salaries. Cost/DALY averted was extracted or calculated for 12 studies and ranged from US$22 to US$4475, although the lower-end costs were primarily from studies that omitted key cost components. In all 12, cost/DALY averted through treatment was substantially less than country per capita GDP, and therefore considered very cost-effective. Conclusion Many included studies did not account for key cost inputs, thus underestimating true treatment costs. Costs/DALY averted were nonetheless substantially lower than per capita GDP, suggesting that even if all relevant inputs are included, LMIC childhood cancer treatment is consistently very cost-effective. While additional rigorous economic evaluations are required, our results can inform the development of LMIC national childhood cancer strategies.
Article
Objective: Chronic health conditions are often associated with uncertainty and threats which may cause anxiety in the family members. The present meta-analysis analyzed whether parents of children with chronic physical diseases and/or sensory/physical disabilities show higher anxiety levels than parents of healthy/nondisabled children or test norms. Methods: The databases PSYCINFO, MEDLINE, Google Scholar, CINAHL, and PSYNDEX were searched for relevant studies. In total, 486 studies were identified that fulfilled the inclusion criteria. Results: We found moderate elevations of anxiety symptoms in parents of young people with chronic conditions (g = .54 standard deviation units). About 16% of the parents fulfilled the criteria for an anxiety disorder. Parents of young people with neuromuscular disorders, HIV-infection/AIDS, and cancer during active treatment showed large elevations of anxiety symptoms. Elevations of anxiety symptoms were smaller in the cases of longer lasting chronic conditions, longer time since the end of active treatment, in families of older children, in samples with lower percentages of mothers, and in studies from economically developed countries compared to less developed countries. Conclusion: Measures for preventing and reducing anxiety symptoms in parents of young people with neuromuscular disorders, HIV-infection/AIDS, and those undergoing cancer treatments are particularly needed.
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AIM: To assess survival outcome of pediatric patients with localized osteosarcoma of the extremities in Upper Egypt, identify factors of prognostic significance for survival, and to determine factors predictive of surgical methods employed in these patients, and developing a clinical model for risk prediction. METHODS: A retrospective analysis of data assembled from medical records of 30 pediatric patients with a histologically-verified non-metastatic osteosarcoma of the extremities treated at South Egypt Cancer Institute with a unified chemotherapy protocol between January 2001 and December 2015 was carried out. Prognostic factors were determined using univariable and multivariable methods. A model for surgical outcomes in these patients based on the baseline clinical factors, and the parameters predictive of their tumor response to chemotherapy was developed. RESULTS: With a median follow-up of 63 months for the study population, the estimates for EFS & OS at 3 and 5 years were 69.5% & 79% and 65.2% & 65.3%, respectively. Age ≥16 was independently associated with both worse MFS (HR 6.05, 95%CI 1.43-25.6, p = 0.015) and OS (HR 7.9, 95%CI 1.71-36.2; P = 0.008). In the multivariable analysis, a proximal location within the limb gained a statistical significance to be independently associated with worse OS (HR 2.4, 95%CI 1.13-22.1; P = 0.003). Poor response to chemotherapy was marginally associated with worse MFS (HR 4.9, 95%CI 1.02-23.8; P = 0.047) only in the univariable analysis. The patients found to be more likely would undergo an amputation surgery (OR 14.1, 95%CI 1.34-149.4, p = 0.028) those in whom a tumor was poorly responding to chemotherapy. CONCLUSION: In Upper Egypt, despite the reasonable survival outcomes in non-metastatic osteosarcoma, a relatively high limb amputation rate has been encountered. The development of a clinical prediction model for future planning of possible outcome improvement in these patients, however, is still feasible.
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Despite the high prevalence of infection by the Human Immunodeficiency Virus (HIV) in South Africa, information on its association with cancer is sparse. Our study was carried out to examine the relationship between HIV and a number of cancer types or sites that are common in South Africa. A total of 4,883 subjects, presenting with a cancer or cardiovascular disease at the 3 tertiary referral hospitals in Johannesburg, were interviewed and had blood tested for HIV. Odds ratios associated with HIV infection were calculated by using unconditional logistic regression models for 16 major cancer types where data was available for 50 or more patients. In the comparison group, the prevalence of HIV infection was 8.3% in males and 9.1% in females. Significant excess risks associated with HIV infection were found for Kaposi's sarcoma (OR=21.9, 95% CI=12.5–38.6), non‐Hodgkin lymphoma (OR=5.0, 95%CI=2.7–9.5), vulval cancer (OR=4.8, 95%CI=1.9–12.2) and cervical cancer (OR=1.6, 95%CI=1.1–2.3) but not for any of the other major cancer types examined, including Hodgkin disease, multiple myeloma and lung cancer. In Johannesburg, South Africa, HIV infection was associated with significantly increased risks of Kaposi's sarcoma, non‐Hodgkin lymphoma and cancers of the cervix and the vulva. The relative risks for Kaposi's sarcoma and non‐Hodgkin lymphoma associated with HIV infection were substantially lower than those found in the West. Int. J. Cancer 88:489–492, 2000. © 2000 Wiley‐Liss, Inc.
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Background: Red blood cells and platelet concentrates are frequently used in paediatric oncology. There is little literature on the indications and costs of this adjuvant therapy. Aim: To retrospectively evaluate the indications, amounts and costs of transfusing blood products in 2008 in the Depart-ment of Paediatric Oncology at Tygerberg Children's Hospital, Cape Town. Material and Method: The patient records were analyzed for age, sex, disease and stage, indications for transfusion and type of blood product as well as amount. The costs were obtained from the Blood Bank for each item released for every patient. Results: Thirty-nine children with cancer were transfused, between one unit and 34 units of blood products per patient, during their treatment in 2008. The total cost of this therapy in 2008 was ZAR 941,966 = USD 125,595 = EUR 89,711. The maximum cost per patient amounted to ZAR 70,682 = USD 9,424 = EUR 6,731 and the minimum ZAR 914 = USD 121 = EUR 87. The average expenditure per patient was ZAR 24,125 = USD 3,216 = EUR 2,297. The management of leukemia required the highest usage of blood products per patient. Conclusion: The use of blood products is indispensable during the treatment of numerous haematology – oncology diseases. Their indications should be specified in internal protocols and their actual use should be audited frequently due to the considerable costs.
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Africa has one of the highest neonatal mortalities in the world, for which the commonest causes do not include surgical conditions such as some congenital anomalies that are amenable to surgery but are not often operated on because of a number of challenges. These challenges include cultural beliefs and practices, dearth of human resource capacity, inadequate laboratory and imaging support and lack of consumables and intensive or high dependency care facilities. Some of these challenges will be examined and highlighted using the acronym "ASKS" in this article.
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Childhood cancer is fast becoming an important paediatric problem in Nigeria and several parts of Africa, with the progressive decline of infectious and nutritional diseases. The following study was a 5-year retrospective review of paediatric solid tumours as seen at the Jos University Teaching Hospital, Nigeria. To determine the relative frequencies of childhood solid malignant tumours in Jos, Central Nigeria and compare with reports of previous studies both locally and abroad. Cancer registers and medical records of patients were used to extract demographic data, specimen number and/or codes. Archival materials were retrieved from the histopathology laboratory and sections were made from paraffin embedded blocks of these specimens. Slides of these histological sections were reviewed and reclassified where necessary. The relative frequencies were then determined. One hundred and eighty one solid tumours of children were diagnosed within the study period. Ninety-four (51%) were benign and 87 (49%) malignant. Male: Female ratio was 1.3:1. The commonest malignant tumour diagnosed was rhabdomyosarcoma which accounted for 27 (31%), comprising of 15 (55.6%), 11 (40.7%) and 1 (3.7%) embryonal, alveolar and pleomorphic rhabdomyosarcomas, respectively. Non Hodgkin lymphoma and Burkitt lymphoma accounted for 17 (19.5%) and 12 (13.8%), respectively. Based on the result of our study, we conclude that the commonest solid malignancy of childhood in Jos, Nigeria is rhabdomyosarcoma. This has implications for diagnosis, management and prognosis of theses soft tissue sarcomas in our paediatric population.
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Advances in paediatric oncology has tremendously improved the outcome in children with nephroblastoma. In most developing countries, however, the survival rate is still very low. Objective: To study the outcome and the impediments to the management of nephroblastoma in Southeast Nigeria. Analysis of 42 children managed for nephroblastoma over a 10-year period (January 1995-December 2004) at the University of Nigeria Teaching Hospital, Enugu, Nigeria is made. Diagnosis was based on clinical, radiologic and histologic evaluation. The peak age incidence was 2-5 years with a male:female ratio of 1.1:1. Abdominal mass was the main presentation in all the children. Treatment consisted of nephroureterectomy followed by adjuvant chemotherapy with Vincristine, Actinomycin D and Cyclophosphamide. Adriamycin was added for metastatic disease. Twenty-two children (52.3%) had stage III disease, 13 (31.0%) had stage IV, while the remaining seven (16.7%) children had stage II. Stage I disease was not encountered. Seven children had inoperable tumor requiring pre-operative chemotherapy. While 25 children were available for evaluation, 17 were lost to follow up. Four children died of complications of treatment, while 11 relapsed with poor outcome. With a mean follow up of 21 months, the 5-year survival rate is 40%. Morbidity and mortality with nephroblastoma is high in our environment. Late presentation, poverty, ignorance and poor compliance to treatment constitute a great challenge to the paediatric oncologist in a developing country. Solutions may lie in improving health funding and health information in the health care delivery system. Free health care for children with malignancy is advocated. Collaboration with institutions in the privileged parts of the world may help.
Article
Context.—Histopathology, like other branches of medicine in West Africa, has suffered largely from economic, political, social, and infrastructural problems, becoming a shadow of the top quality that had been obtained in the past. To address the prevailing problems, one needs to attempt defining them. Objective.—The existing structure of training and practice are discussed, highlighting the author's perception of the problems and suggesting practical ways to address these while identifying potential roles for North American pathology organizations. Design.—The author's past and ongoing association with pathology practice in Nigeria forms the basis for this review. Results.—Pathology practice is largely restricted to academic medical centers. The largest of academic centers each accession around 4000 or fewer surgical specimens per year to train 9 to 12 residents. Histopathology largely uses hematoxylin-eosin routine stains, sometimes with histochemistry but rarely immunohistochemistry. Pathologists depend largely on their skills in morphology (with its limitations) to classify and subclassify tumors on routine stains, including soft tissue and hematolymphoid malignancies. Immunofluorescence, intraoperative frozen section diagnosis, electronic laboratory system, and gross and microscopic imaging facilities are generally not available for clinical use. Conclusion.—The existing facilities and infrastructure can be augmented with provision of material and professional assistance from other pathology associations in more developed countries and should, among other things, focus on supplementing residency education. Virtual residency programs, short-visit observerships, development of simple but practical laboratory information systems, and closer ties with pathologists in these countries are some of the suggested steps in achieving this goal.
Article
From 1961 to 1986, 29 patients with pelvic rhabdomyosarcoma (including pelvic retroperitoneal rhabdomyosarcoma) were admitted to the paediatric surgical service at the Red Cross Children's Hospital, Cape Town. During the period 1961–1970, the mainstay of treatment was radical surgery with or without subsquent chemotheraphy and radiotherapy. Of the 13 patients, only 2 have survived long-term (15%). From 1971 a new management policy of pre-treatment with chemotherapy and in some instances radiotherapy followed by conservative limited surgery was commenced. Twelve of the 16 patients have survived (75%). One patient with stage III prostatic tumour had treatment with only chemotherapy and radiotherapy and is surviving 8 years after diagnosis; another with a vaginal tumour, also stage III, whose parents refused surgery is alive tumour-free 4 years after similar treatment. Chemotherapy has not only significantly improved survival in pelvic rhabdomyosarcoma but has permitted limited surgery and in some instances has resulted in survival without surgical excision.
Article
Background Wilms tumor has a survival rate of 85–90% in well resourced countries but in low income countries survival is lower. Malawi is a country with very limited resources. We studied the feasibility, toxicity and efficacy of preoperative chemotherapy for Wilms tumor in Malawian children.Methods All patients diagnosed with a Wilms tumor, admitted in Blantyre, Malawi, from 2006 to 2008, were included. These patients received SIOP-based preoperative chemotherapy followed by surgery and risk-stratified post-operative chemotherapy. Social support and counseling were provided to prevent abandonment of treatment.ResultsTwenty patients were included. Mean tumor volume at diagnosis was 2,500 ml and eight patients (40%) had metastases. Ninety-five percent of patients presented with hypertension, 80% with microscopic hematuria and 60% with a raised platelet count. Preoperative chemotherapy resulted in >50% tumor reduction in 55% of patients with localized disease and 75% of patients with metastatic disease. During preoperative chemotherapy, 11 of 18 patients experienced ≥ grade 3 anaemia, 7 patients experienced ≥ grade 3 neutropenia. In 12 patients the tumor was resected. Reasons of treatment failure were: abandonment of treatment (N = 3), death during anaesthesia induction (N = 1), inoperability (N = 5, due to metastatic disease in N = 4) and relapse (N = 2). One patient died of malaria 2 months after completion of chemotherapy. Eight patients (40%) are alive with a median follow up of 8 months (range 0–1.5 years).Conclusion Preoperative chemotherapy for Wilms tumor is feasible, tolerated and efficacious in Malawi. Continued efforts are needed to encourage early presentation and to prevent abandonment. Pediatr Blood Cancer 2009;53:584–589. © 2009 Wiley-Liss, Inc.
Article
Despite the high prevalence of infection by the Human Immunodeficiency Virus (HIV) in South Africa, information on its association with cancer is sparse. Our study was carried out to examine the relationship between HIV and a number of cancer types or sites that are common in South Africa. A total of 4,883 subjects, presenting with a cancer or cardiovascular disease at the 3 tertiary referral hospitals in Johannesburg, were interviewed and had blood tested for HIV. Odds ratios associated with HIV infection were calculated by using unconditional logistic regression models for 16 major cancer types where data was available for 50 or more patients. In the comparison group, the prevalence of HIV infection was 8.3% in males and 9.1% in females. Significant excess risks associated with HIV infection were found for Kaposi's sarcoma (OR=21.9, 95% CI=12.5–38.6), non-Hodgkin lymphoma (OR=5.0, 95%CI=2.7–9.5), vulval cancer (OR=4.8, 95%CI=1.9–12.2) and cervical cancer (OR=1.6, 95%CI=1.1–2.3) but not for any of the other major cancer types examined, including Hodgkin disease, multiple myeloma and lung cancer. In Johannesburg, South Africa, HIV infection was associated with significantly increased risks of Kaposi's sarcoma, non-Hodgkin lymphoma and cancers of the cervix and the vulva. The relative risks for Kaposi's sarcoma and non-Hodgkin lymphoma associated with HIV infection were substantially lower than those found in the West. Int. J. Cancer 88:489–492, 2000. © 2000 Wiley-Liss, Inc.
Article
Background Wilms tumour is one of the commonest childhood solid tumours which has an excellent outlook in the developed world with 5-year overall survival exceeding 90%. There is little information from Sudan regarding Wilms tumour.ProcedureRecords of patients with Wilms tumour diagnosed and treated at Institute of Nuclear Medicine, Molecular Biology and Oncology (INMO) in the University of Gezira from May 1999 to June 2007 were reviewed.ResultsThirty-seven children presented at a mean age of 4.1 years (range 2 months–13 years). The male to female ratio was 0.9–1. Abdominal swelling or mass was the commonest symptom. There was 1 child with Stage I (2.7%), 7 with stage II (18.9%), 25 with Stage III (67.6%) and 4 with Stage IV (10.8%). Following diagnosis 27% of children did not receive further treatment (5.4% died prior to treatment, 5.4% were not able to finance treatment and for the rest 16.2% no cause was identified). More than half of the children did not have a nephrectomy and only 4 (11%) completed treatment.Conclusions The poor outlook is related to several factors. Delayed presentation, poor awareness of treatment options, lack of finances, no provision of food, lodging and transport, absence of paediatric trained staff are the obstacles to better outcomes. Empowering parents with information, giving chemotherapy prior to nephrectomy, training staff and establishing links with a tertiary cancer centre in the developed world are some of the options to improve survival. Pediatr Blood Cancer 2008;50:1135–1137. © 2008 Wiley-Liss, Inc.
Article
Thirty-eight cases of a sarcoma involving the jaws of African children are described. This is a syndrome which has not previously been fully recognized. It is by far the commonest malignant tumour of childhood seen at Mulago Hospital.
Article
Histopathology, like other branches of medicine in West Africa, has suffered largely from economic, political, social, and infrastructural problems, becoming a shadow of the top quality that had been obtained in the past. To address the prevailing problems, one needs to attempt defining them. The existing structure of training and practice are discussed, highlighting the author's perception of the problems and suggesting practical ways to address these while identifying potential roles for North American pathology organizations. The author's past and ongoing association with pathology practice in Nigeria forms the basis for this review. Pathology practice is largely restricted to academic medical centers. The largest of academic centers each accession around 4000 or fewer surgical specimens per year to train 9 to 12 residents. Histopathology largely uses hematoxylin-eosin routine stains, sometimes with histochemistry but rarely immunohistochemistry. Pathologists depend largely on their skills in morphology (with its limitations) to classify and subclassify tumors on routine stains, including soft tissue and hematolymphoid malignancies. Immunofluorescence, intraoperative frozen section diagnosis, electronic laboratory system, and gross and microscopic imaging facilities are generally not available for clinical use. The existing facilities and infrastructure can be augmented with provision of material and professional assistance from other pathology associations in more developed countries and should, among other things, focus on supplementing residency education. Virtual residency programs, short-visit observerships, development of simple but practical laboratory information systems, and closer ties with pathologists in these countries are some of the suggested steps in achieving this goal.
Article
This is a review of recently published literature on surgery in tropical Africa. It presents the current state of surgical need and surgical practice on the continent. We discuss the enormous burden of surgical pathology (as far as it is known) and the access to and acceptability of surgery. We also describe the available facilities in terms of equipment and manpower. The study looked at the effects of the human immunodeficiency virus, the role of traditional healers, anesthesia, and the economics of surgery. Medical training and research are discussed, as are medical migration out of Africa and the concept of task shifting, where surgical procedures are performed by others when surgeons are not available. It closes with recommendations for involvement and action in this area of great global need.
Article
The French African Group of Pediatric Oncology was set-up to improve quality of care for children with cancer. Preliminary observations on the efficacy in Burkitt lymphoma (BL) of a cyclophosphamide monotherapy (CPM) have been published. We report the results of a multicentric prospective study combining first-line CPM and a multidrug second-line chemotherapy (SC) for refractory/relapsed patients. Patients ≤ 18 years with Burkitt or Burkitt-like lymphoma, were included in six countries (Burkina-Faso, Cameroon, Ivory Coast, Madagascar, Mali, and Senegal). All patients received three weekly CPM courses (1.2 g/m(2) IV with intrathecal methotrexate and hydrocortisone), stage 3/4 patients received three further courses. SC added methotrexate, vincristine, cytarabine, and prednisone. There were 178 patients included (42 stage 1/2, 134 stage 3/4, and 2 unknown). Isolated facial localization was found in 41 patients, diffuse abdominal involvement in 120 patients including 65 with both. Nine early deaths were reported, toxicity occurred in 136/743 courses (83 patients) and was predominantly hematological. After CPM, complete remission (CR) rate was 47% with a 33% EFS. Because of rapid progression 76/108 eligible patients (85 primary refractory and 23 relapses) received SC resulting in 35.7% CR but a 21% toxic death rate. The OS of the whole strategy was 50.5% and correlated to stage. A prospective multicentric study on BL was feasible in very low-income countries. CPM can be recommended in stage 1-2 because of optimal cost/benefit ratio. However, more intensive strategies, still adapted to socio-economic conditions, are required for advanced stages 3 and 4.
Article
Co-morbidities introduce confounding variables into investigational protocols and complicate both diagnosis and management of children with malignant solid tumours. Such patients who are coincidentally HIV infected and who also have pulmonary or abdominal tuberculosis pose a particular challenge. The purpose of this report is to describe the diagnostic and management difficulties encountered in a small cadre of 18 HIV-infected children with solid tumours presenting to the Department of Paediatric Surgery. A retrospective descriptive study of HIV-infected children with malignant solid tumours. 18 HIV-infected children were identified with a variety of primary tumours. 11 children had confirmed pulmonary or abdominal tuberculosis and in 4 the diagnosis was suspected. Neoadjuvant chemotherapy was used when possible to provide a window of opportunity to investigate co-morbidity and improve health status, inter alia, improving the patients' nutritional status. FDG-PET scanning proved unreliable in discriminating between malignant and inflammatory pathology. Overall survival was 33%. The coincidence of malignancy, HIV infection and tuberculosis carries a high mortality independent of the primary tumour type.
Tumors arising from the soft tissues are uncommon in children, accounting for about 6% of all childhood malignancies. More than half (53%) of these originate from the striated muscles and are called rhabdomyosarcomas (RMS) the remaining are nonrhabdomyosarcoma soft tissue sarcomas (NRSTS). Almost two-thirds of RMS cases are diagnosed in children < 6 years of age. They can arise at varied locations like the head and neck region, genitourinary tract, extremities, trunk and retroperitoneum. Pathologically RMS is now classified as superior, intermediate and poor outcome histologies. For stratification of treatment and also comparison of results the RMS are now staged both by the clinical grouping and the TNM staging systems. The ultimate outcome depends on the site, extent of disease and histology. Currently, approximately 70% of the patients survive for 5 years or more and are probably cured. This is credited to the use of multi-modal, risk-adapted therapy, refinements in tumor grouping and better supportive care which has emerged out of cooperative studies like Intergroup Rhabdomyosarcoma Study (IRS) and the International Society of Pediatric Oncology studies (SIOP). The treatment involves chemotherapy, radiotherapy and organ/function preserving surgery. The gold standard chemotherapy is still vincristine, actinomycin D and cyclophosphamide (VAC) regime with high doses of intensity bone marrow rescue with colony stimulating factors. The NRSTS are rare and of heterogenous histologies and so it has been difficult to arrive at a treatment strategy for these. What is definitely understood is that these are usually immature and poorly differentiated tumors that respond poorly to chemotherapy and so surgical resection forms the mainstay of treatment with adjuvant radiotherapy and chemotherapy to prevent local recurrences. In all likelihood, the molecular analysis of RMS will further refine current classification schemes and knowledge of genetic features of the tumors will significantly improve the ability of investigators to identify patients at lower or higher risk of treatment failures, thus paving the way for advances in risk-based therapy.
Article
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.
Article
Malnutrition at diagnosis is found in 10-50% of children with cancer in industrialized countries. In developing countries a large proportion of the normal paediatric population is undernourished and children with cancer often present late with advanced disease. Therefore it would be expected that many children with cancer are malnourished at admission. Malnutrition is associated with more severe chemotherapy toxicity and infectious complications. All new paediatric oncology patients admitted in the Queen Elizabeth Central Hospital, Blantyre, Malawi between 1, January 2007 and 1, January 2008 were included. We documented age, clinical diagnosis, HIV status, weight, height, mid-upper-arm-circumference (MUAC) and triceps skinfold (TSF), and calculated arm muscle area (AMA). Nutritional data were compared with the 1978 NCHS growth curves. Of 128 children, 70 (55.1%) had an AMA for age <5th percentile and 76 (59.3%) had a TSF and MUAC below the 5th percentile, both parameters indicating acute malnutrition. Fifty seven patients (44.5%) had a height for age <-2 SD (indicative of stunting), and 22 patients (17.2%) had a weight for height (WFH) <-2 SD. Arm anthropometry shows that more than half of Malawian children with cancer are severely acutely malnourished at diagnosis. WFH, in children with large tumour masses, is less sensitive than arm anthropometry in detecting acute malnutrition. Forty-five percent of paediatric oncology patients in Malawi are stunted, making interpretation of weight for age (WFA) very difficult.
Article
Childhood cancer is fast becoming an important pediatric problem in several parts of Africa, with the progressive decline of infectious and nutritional diseases. The present study analyzes 1325 Nigerian children with neoplasms diagnosed over a 13-year period (1960-1972). It accounted for 12.5% of all tumors registered in our Cancer Registery over the period of study. The commonest type of malignant tumor in the Nigerian child was solid lymphoma, of which Burkitt's tumor predominated. The overall pattern of tumors in these children was strikingly different in certain aspects from what obtains in the Caucasian child. When four main groups of tumors were considered, the ratio frequency pattern in Nigerian children was one of high lymphoma, high orbital, low leukemia, low glioma type. In the Caucasian child, the ratio frequency pattern is usually one of high leukemia, high glioma, low lymphoma, low orbital type. The observed differences in frequencies of childhood tumors between population groups require further studies.
Article
The pattern of childhood malignancies in the developing countries of Africa is characterized by a high incidence of lymphoma and a low incidence of leukaemia. The converse is the case in the developed countries of Europe and North America. A high incidence of lymphoma with low incidence of leukaemia has been associated with poor living standards. The clinical records of 257 children admitted with malignant disease to the University of Nigeria Teaching Hospital, Enugu between January 1978 and December 1982 were studied retrospectively to determine the pattern of malignant diseases amongst these children. The lymphomas were the commonest tumours, constituting nearly 40% of the total, followed by Wilm's tumour (14.0%), leukaemia (12.9%) and CNS tumours (9.7%). However, the incidence of lymphoma was lower while the incidence of leukaemia was higher than in previous reports from other parts of Nigeria and Africa. The rarity of Ewing's tumour, histocytosis-X and testicular tumours in African children is confirmed in the present study.
Article
Data from the cancer register in the Department of Child Health, Korle Bu Teaching Hospital Accra, Ghana was reviewed in order to document the pattern of malignancies seen in children. Out of a total of 15,200 admissions over a 40 month period there were 254 malignancies diagnosed constituting 1.67% of all admission. Lymphoma was the commonest tumour constituting 67% with Burkitt's Lymphoma being the commonest subtype. This was followed by Retinoblastoma (8.6%), Leukaemia (8.2%) and Wilms tumour (7.8%). This trend is similar to the picture seen in other developing countries in Africa where there is a high incidence of lymphoma and a low incidence of leukaemia, the converse being the case in Europe and North America.
Article
Despite the high prevalence of infection by the Human Immunodeficiency Virus (HIV) in South Africa, information on its association with cancer is sparse. Our study was carried out to examine the relationship between HIV and a number of cancer types or sites that are common in South Africa. A total of 4,883 subjects, presenting with a cancer or cardiovascular disease at the 3 tertiary referral hospitals in Johannesburg, were interviewed and had blood tested for HIV. Odds ratios associated with HIV infection were calculated by using unconditional logistic regression models for 16 major cancer types where data was available for 50 or more patients. In the comparison group, the prevalence of HIV infection was 8.3% in males and 9.1% in females. Significant excess risks associated with HIV infection were found for Kaposi's sarcoma (OR=21.9, 95% CI=12.5-38.6), non-Hodgkin lymphoma (OR=5.0, 95%CI=2.7-9.5), vulval cancer (OR=4.8, 95%CI= 1.9-12.2) and cervical cancer (OR= 1.6, 95%CI= 1.1-2.3) but not for any of the other major cancer types examined, including Hodgkin disease, multiple myeloma and lung cancer. In Johannesburg, South Africa, HIV infection was associated with significantly increased risks of Kaposi's sarcoma, non-Hodgkin lymphoma and cancers of the cervix and the vulva. The relative risks for Kaposi's sarcoma and non-Hodgkin lymphoma associated with HIV infection were substantially lower than those found in the West.
Article
With 90% of world children living in developing countries and a rising cancer incidence, the third world bears the greatest burden of pediatric cancer. Pediatric cancers today are highly treatable, but 80% of children with malignancies die because they live in the developing countries where access to medical care is inadequate. Pediatric cancer care is expensive and available at only a few centers, which deal with excessive patient numbers and are staffed by inadequate numbers of physicians and nurses. There are marked geographic variations in incidences and presentations observed in the spectrum of pediatric malignancies. Initiatives to improve cancer care include setting up worldwide pediatric care units; establishing standard guidelines for treating patients; undertaking research and lobbying international organizations like the World Health Organization, United Nations Children's Emergency Fund (UNICEF), International Union Against Cancer (UICC), and the International Society of Pediatric Oncology (SIOP); to make chemotherapy, supportive care drugs, and opioids for palliation uniformly available. New outreach training programs would alleviate manpower shortages by linking centers from the two world regions for training and facilitate collaboration with international organizations.
Article
To review the clinical presentation and management of children with nephroplastoma and the factors influencing the outcome at Kenyatta National Referral and Teaching Hospital (KNH). This was a retrospective case series study based on secondary data accumulated between 1990 and 1996. The relevant data were extracted from records of all children aged 12 years and below, admitted for cancer at KNH, Nairobi. Out of 803 children with cancer, 71 (8.8%) had histologically proven nephroblastoma. At presentation, 1.5% were in stage I, 13.2% stage II, 36.8% stage III, 41.2% stage IV and 7.4% stage V. Eighty five per cent presented with stage III-V disease. Ninety five per cent had nepherectomy and received chemotherapy. Radiotherapy was given to 50.7% of the patients. Nine patients died before commencement of chemotherapy, two of whom died in the immediate post-operative period. The median duration between admission and surgery was 41 days. Pre-operative chemotherapy was given to 42% of the patients. Approximately 25.5% of the patients received little or no induction chemotherapy due to unavailability of drugs while only 2.8% received the prescribed maintenance treatment with the remainder getting erratic or no treatment. Overall, only 34.7% remained disease free two years from time of diagnosis. Late presentation, poor availability of cytotoxic drugs and frequent treatment interruptions for various reasons have contributed to the poor outcome of nephroblastoma in Kenya.
Article
To determine the frequency distribution of malignant tumours of childhood aged 0-14 years. A retrospective histopathological review of 541 cases of malignant tumours of childhood. Cancer Registry, Department of Histopathology, Muhimbili Medical Centre, Dar es Salaam, Tanzania. Malignant tumours of childhood accounted for 11.5% of all malignant tumours recorded in the cancer registry. Commonest malignant tumours were lymphomas (53%), of which 31.4% were Burkitt's lymphoma (BL), 14.9% Hodgkin's disease (HD), and 6.6% Non-Hodgkin's lymphoma (NHL). Others were retinoblastoma (12.9%), carcinoma (9%), nephroblastoma and soft tissue sarcoma each 6.7% and Kaposi's sarcoma (5.9%). Bone, germ cell and nervous system tumours were rare. These findings may act as a basis for which further studies on malignant tumours of childhood in Tanzania could be carried out.
Article
Child survival efforts can be effective only if they are based on accurate information about causes of deaths. Here, we report on a 4-year effort by WHO to improve the accuracy of this information. WHO established the external Child Health Epidemiology Reference Group (CHERG) in 2001 to develop estimates of the proportion of deaths in children younger than age 5 years attributable to pneumonia, diarrhoea, malaria, measles, and the major causes of death in the first 28 days of life. Various methods, including single-cause and multi-cause proportionate mortality models, were used. The role of undernutrition as an underlying cause of death was estimated in collaboration with CHERG. In 2000-03, six causes accounted for 73% of the 10.6 million yearly deaths in children younger than age 5 years: pneumonia (19%), diarrhoea (18%), malaria (8%), neonatal pneumonia or sepsis (10%), preterm delivery (10%), and asphyxia at birth (8%). The four communicable disease categories account for more than half (54%) of all child deaths. The greatest communicable disease killers are similar in all WHO regions with the exception of malaria; 94% of global deaths attributable to this disease occur in the Africa region. Undernutrition is an underlying cause of 53% of all deaths in children younger than age 5 years. Achievement of the millennium development goal of reducing child mortality by two-thirds from the 1990 rate will depend on renewed efforts to prevent and control pneumonia, diarrhoea, and undernutrition in all WHO regions, and malaria in the Africa region. In all regions, deaths in the neonatal period, primarily due to preterm delivery, sepsis or pneumonia, and birth asphyxia should also be addressed. These estimates of the causes of child deaths should be used to guide public-health policies and programmes.
Article
Juvenile rhabdomyosarcoma (JRMS) though rare, is the most common soft tissue malignancy of childhood that exhibits bimodal age distribution pattern. Review the pattern of JRMS in Port Harcourt based on sex, age, tumor sites and histologic types. A retrospective descriptive study. The study was conducted in the University of Port Harcourt Teaching Hospital (UPTH), Port Harcourt, Nigeria over 12 years. We studied 21 juvenile rhabdomyosarcomas during the period under review. The hematoxylin and eosin stained histological slides were retrieved and reviewed to confirm previous diagnosis and histologically typed for the study. The sex, age and tumor sites were retrieved from the histology consultation forms, These tumors were diagnosed from patients aged 0 - 20 years with the highest frequencies (38.1% each) occurring at 0 - 5 and 16 - 20 years age group. Males are more affected with a ratio 3.2:1. The trunk is the most common site of occurrence (47.7%) of which the genitourinary system is the most affected (23.8%) in this study. The most common histologic type is the embryonal rhabdomyosarcoma (71.5%). Alveolar rhabdomyosarcoma accounted for (19%) and the sarcoma botryoides (9.5%). The age of presentation and anatomic sites of the tumor are important in the diagnosis of these tumors. If a tumor histologically shows as small round blue cells, rhabdomyosarcoma should be considered as a differential diagnosis.