Challenges in the Management of Wilms Tumor in a Developing Country: A Twenty Years’ Experience From a Single Center in Pakistan

Abstract

Background: Wilms Tumor (WT) is one of the most curable childhood cancers. High cure rates seen in the developed countries are not reproduced in developing countries. Lack of access to cancer treatment facilities, financial constraints, late presentation, and abandonment have previously been described. We reviewed our data over the last 20 years to highlight some of these challenges. Methods: This is a retrospective chart review of children with WT at our center up to the age of 18 years between 1 November 1997 and 30 November 2017. Demographic details, presentation characteristics and treatment details were recorded. Factors associated with poor outcome were analyzed. Results: Two hundred eleven children were registered; 117(55.5%) were males. Median age at presentation was 3 (range 0 to 18) years. Presentation data were available for 184/211 patients, staging details for 159/211 and metastatic status for 178/211. Of the available dataset, 60% presented without prior treatment, whereas 40% presented atleast after primary surgical excision. High-stage (stage III or above) disease was present in 79 (49.7%) patients; 61 (34.3%) was presented with metastases or recurrence; 63 (29.8%) abandoned or refused treatment; 99/172 (57.6%) patients finished treatment, 23 (13.4%) died during treatment, and 6 died before treatment. Of the 99 patients who finished treatment 83 (83.8%) are well off therapy; 15(15.2%) relapsed; 6 (40%) are alive after salvage therapy, while 9 (60%) died. Conclusions: Our data highlights the challenges of managing WT in resource poor environments. Prior surgery, incomplete staging work-up and abandonment are some of the most frequently encountered barriers. A multipronged approach is required to overcome these challenges.

Prognostic impact of pre‐referral tumor resection in unilateral Wilms tumor: A single‐institute experience from a lower middle‐income country

“…In another study from Karachi, Pakistan, Khan et al. reported OS and EFS were 66.7% and 56.9%, respectively, at 100 months 20 . In our study, patients with metastatic disease had a dismal outcome compared to those with localized tumors.…”

“…The male‐to‐female ratio in our study was 1.6:1. Though WT is reported to be more common in females than in males, more prevelance in males has been described in some studies from Asia 18–20 . This difference may be due to the ethnic differences or the preferential seeking of medical treatment for males over females.…”

“…Intraoperative tumor rupture/spillage are also considered predictors of poor outcomes. 19,20,28 In the PTR subset, the renal capsule had ruptured in 14 patients, whereas its status was unknown in 24 patients. 20 In our study, patients with metastatic disease had a dismal outcome compared to those with localized tumors.…”

“…Though WT is reported to be more common in females than in males, more prevelance in males has been described in some studies from Asia. [18][19][20] This difference may be due to the ethnic differences or the preferential seeking of medical treatment for males over females. Regardless of the initial treatment approach, NWTS/COG employing upfront sur-gical resection, and SIOP using preoperative chemotherapy before nephrectomy, equivalent survival outcomes have been reported in Western Europe and North America.…”

“…19,20,28 In the PTR subset, the renal capsule had ruptured in 14 patients, whereas its status was unknown in 24 patients. 20 In our study, patients with metastatic disease had a dismal outcome compared to those with localized tumors. This finding is also consistent with other studies in both HICs and LMICs.…”