Every year, according to the World Health Organization, an estimated 400 000 children and adolescents of 0-19 years old develop cancer. Leukaemias, brain cancers, lymphomas, and solid tumours, such as neuroblastoma and Wilms tumours are the most common childhood cancers. Cure rates in high-income countries (HICs) with 20% of the world’s children with cancer exceed 80%, while only 30% in low- and middle-income countries (LMICs) are cured.
The survival rate of childhood cancer in South Africa is around 55-60% and seems to be on the rise.
The economies of most LMICs are at an early stage of development; stages characterised by poverty, shortages of health-care workers, weak health systems, low education levels, poor access to modern technology, and a paucity of health care facilities. LMICs also have younger populations and therefore a larger proportion of children with cancer than HICs. Additionally, interventions such as public health campaigns which impact on early diagnosis and referral which translate into improved outcomes for adults may have limited impact on decreasing the incidence of paediatric malignancies are not related to modifiable risk factors. However, a few LMICs have seen declines in childhood mortality because of improvements in infectious diseases control. Consequently, noncommunicable disease such as childhood cancer are on the rise and it is likely that the Covid-19 pandemic will reverse gains made in some countries or further exacerbate progress due to resource constraints experienced from a health system – based, supply perspective.
While there is an overall need to strengthen systems to improve diagnostics and treatment for patients of all ages with cancer, dedicated centres for childhood cancer treatment require specialized diagnostic and therapeutic capabilities, and the ability to manage complications. Childhood cancer care should ideally be managed in a limited number of treatment centres in which multi-disciplinary resources and expertise are concentrated with good satellite centres who can deliver some treatment, thereby decreasing the burden on families, providing rapid management of complications, and decreasing abandonment of treatment. Intensive care units (ICUs) are imperative for the delivery of intensive chemotherapy, but centres lacking ICUs will also be able to cure a portion of children. Stable drug supplies are mandatory as drug shortages impact negatively on survival. Nutritional support is particularly important in LMICs where malnutrition at diagnosis or during treatment is prevalent with an adverse impact on outcome.
It is essential to have individuals trained in paediatric oncology i.e., paediatric oncologists, surgeons, pathologists, radiation oncologists, radiologists, pharmacists, nurses palliative care and allied care workers. Inpatient and outpatient beds preferably designated for paediatric oncology patients is essential. Infection control methods such as a hand hygiene programme, isolation capabilities, and a strong anti-microbial stewardship programme are desirable. Basic haematologic, biochemical, microbiologic, and pathologic laboratory services capable of timely turnaround is vital to the successful delivery of cancer care. Although advanced diagnostic modalities, such as flow cytometry and cytogenetics, are available in HICs, their absence does not preclude the establishment of a paediatric oncology centre.
Diagnostic imaging capabilities are necessary. Advanced modalities such as computerized tomography and magnetic resonance imaging are ideal, but basic modalities, such as plain radiographs and ultrasonography are sufficient to begin treating childhood cancer. Reliable supplies of chemotherapeutic agents and supportive care medications, such as antimicrobials, antiemetics, and analgesics, are crucial. According to the WHO only 29% of low-income countries report that cancer medicines are available to their populations compared to 96% of high-income countries. Blood product availability is vital as treatment protocols may cause bone marrow suppression, necessitating the timely and reliable delivery of safe blood products. However, this is not the case for all chemotherapies; treatment for several malignancies requires minimal transfusion support.
Abandonment of therapy is a significant cause of treatment failure in many LMICs. Financial support, provision of transport and accommodation decreases the risk of abandonment and must be considered an essential part of oncology care in LMICs. Many factors contribute to treatment abandonment, including a lack of financial resources, poor disease comprehension, cultural factors, belief in alternative medicines, fear of treatment toxicity, inadequate care on the part of health care workers, and decreased awareness. just as some level of basic supportive care capacity is necessary to treat children with cancer, basic educational and aid programs aimed at preventing abandonment are also imperative. Addressing the emotional, social, financial, and spiritual needs of children and families facilitates adherence to treatment, improves quality of life, and reduces the risk of abandonment.
Surgery is a vital component for diagnosis and treatment of many paediatric malignancies, e.g., Wilms tumour but many cancers are curable without surgical intervention. Similarly, radiation therapy is used for a variety of paediatric malignancies e.g., Hodgkin lymphoma, Wilms tumour, and sarcomas. However, in some cases, substituting additional chemotherapy or surgery can result in cure.
Different childhood cancers require different treatment intensities for maximum cure rates; for example, the chemotherapy for Wilms tumour is far less intense than for acute myeloid leukemia. Risk stratification systems is one of the major achievements in paediatric oncology where treatment intensity is matched to the disease and the disease risk, reducing both over- and under-treatment. It is imperative to avoid overtreatment in LMICs, as it contributes to an increase in treatment-related mortality. The balance point for each malignancy is essential to optimize therapy and curing the maximum number of children possible. The availability of supportive care is key to the balanced approach.
Collaboration with centres of excellence in HICs allows multi-disciplinary expertise with local knowledge and capabilities.
Collection of basic data on patient demographics, disease characteristics, and treatment outcomes, including cause of death, allows for evaluation of specific treatment protocols, and allows for modification of therapy. Many factors contribute to morbidity and mortality, e.g., treatment-related mortality, relapse, or treatment abandonment. Health care workers in many LMICs lack the time to collect, review, and analyse outcome information. In most settings, a resolute data manager with sufficient training, infrastructure, and support is needed to ensure accurate and timely data entry. Collection and analysis of data are neither academic research nor a luxury, but outcome monitoring is essential to improving the care and outcomes of children with cancer. Quality improvement efforts in LMICs make the difference between life and death.
Most LMICs lack policies to ensure good paediatric oncology care, and do not have a National Cancer Plan (NCP), a public health programme aimed at increasing the diagnosis, reducing the number of deaths and improving the quality of life of cancer patients, through the implementation of evidence-based strategies for the prevention, early detection, diagnosis, treatment, palliation, and research for innovative solutions and evaluation of outcomes. An NCP is to promote the implementation of cost-effective measures beneficial for the maximum number of persons in the population. NCPs promote the development of management guidelines, emphasise early with easy referral pathways, lowers the morbidity and mortality, and improves the quality of life of cancer patients, no matter where they are born.
Leaving no one behind includes government’s commitment to all children and their families including our most vulnerable children with non-communicable, long-term conditions.
Professor Gita Naidu Chair: South African Children’s Cancer Study Group
Sandhya Singh Director, Non-Communicable Diseases National Department of Health
Hedley Lewis Chief Executive Officer of CHOC Childhood Cancer Foundation South Africa
For Media Queries contact Hedley Lewis: 0829947655 – [email protected]