Barriers to effective treatment of pediatric solid tumors in middle‐income countries: Can we make sense of the spectrum of nonbiologic factors that influence outcomes?

Abstract

Background Delivery of effective treatment for pediatric solid tumors poses a particular challenge to centers in middle-income countries (MIC) already vigorously addressing pediatric cancer. This study aimed to improve our understanding of barriers to effective treatment of pediatric solid tumors in MICs. Methods An ecological model centering in pediatric sarcoma and expanding to country as the environment were used as benchmark for studying delivery of solid tumor care in MICs. Data on resources was gathered from seven centers members of the Central American Association of Pediatric Hematologists and Oncologists (AHOPCA) using an infrastructure assessment tool. Pediatric sarcoma outcomes data was available and retrieved from hospital-based cancer registries for six of the seven centers and analyzed by country. Patients diagnosed from 1/1/2000-12/31/2009 with osteosarcoma, Ewing sarcoma, rhabdomyosarcoma, and other soft tissue sarcomas were included in the analysis. In order to explore correlations between resources and outcomes a pilot performance-index was created. Findings Results identified specific human resources, communication, quality and infrastructure deficits. Treatment abandonment rate, metastatic disease at diagnosis, relapse rate and 4-year abandonment-sensitive overall survival (AOS) varied considerably by country (1-38%, 15-54%, 24-52%, 21-51%, respectively). Treatment abandonment rate correlated inversely with health economic expenditure per capita (r= −0.86, p=0.03) and life expectancy at birth (r = −0.93, p=0.007). Four-year AOS correlated inversely with under-5 mortality rate (r= −0.80, p=0.05) and directly with the pilot performance-index (r =0.98, p=0.005). Interpretation Initiatives to improve treatment effectiveness of pediatric solid tumor care in MIC and pediatric sarcoma in particular are warranted. Building capacity and infrastructure, improving supportive care and communication, and fostering comprehensive multidisciplinary teams are identified as keystones in Central America. A measure that meaningfully describes performance in delivering pediatric cancer care is feasible and needed to advance comparative prospective analysis of pediatric cancer care and define resource-clusters internationally.

Preventing treatment abandonment for children with solid tumors: A single‐center experience in Brazil

“…To identify possible risk factors for abandonment, we considered that the type of malignancy could be a risk factor. In our cohort, a higher rate was found for retinoblastoma, compared with other solid tumors . Similarly, Vasquez et al, in 2018 in Peru, found a significant association between a higher risk of abandonment in patients with retinoblastoma .…”

“…Treatment abandonment has been addressed in Latin America, especially in patients with childhood cancer and leukemia as an important cause of treatment failure, and strategies to overcome this problem have been implemented. However, fewer studies have focused specifically on solid tumors . Therefore, the aim of this study was to describe strategies to prevent treatment abandonment in children diagnosed with solid tumors in one reference center in Brazil, and to report its prevalence and associated factors.…”

Carboplatin in the treatment of Ewing sarcoma: Results of the first Brazilian Collaborative Study Group for Ewing Sarcoma Family Tumors-EWING1

“…The development of multimodal therapy with chemotherapy, irradiation, and surgery has increased current long‐term survival rates for children with cancer to greater than 70% in state of the art treatment centers in high‐income countries . Patients in countries with limited resources typically present with high rates of locally advanced and/or metastatic disease, which influences their prognosis . Resource‐specific validation and adaptation of the state of the art treatment regimens is required in order to make advances widely generalizable.…”

In the realms of future: new frontiers of ‘techno-oncology’ as a platform for global improvement in the outcomes of childhood cancer

“…Financial challenges are a major impediment to development of sustainable cancer treatment centers in LMICs [18]. Due consideration needs to be given to generation of local funding through novel ideas and concepts that tap into local resources [19].…”