Identifying opportunities to bridge disparity gaps in curing childhood cancer in Malawi: Malignancies with excellent curative potential account for the majority of diagnoses

Abstract

The majority of African children with cancer die without access to resources. We describe efforts to build a public treatment program with curative intent for childhood cancer in Lilongwe, Malawi despite severe limitations in diagnostic and therapeutic resources. We retrospectively analyzed a cohort of childhood cancer patients at Kamuzu Central Hospital from 12/2011-6/2013. Consistently available chemotherapeutic agents were limited to cyclophosphamide, vincristine, doxorubicin, bleomycin, methotrexate, and prednisone. Of 258 newly diagnosed childhood malignancies, 17 patients with retinoblastoma were excluded from clinical analyses due to insufficient clinical data. Among the remainder of the cohort (n = 241), 42% were female with median age 8.4 years (range 0.6-17.9). Forty-six (19%) were HIV-infected (42 Kaposi sarcoma, 3 Burkitt lymphoma, 1 Hodgkin lymphoma). The most common clinical presentations were palpable abdominal mass (41%), peripheral lymphadenopathy (33%), and jaw mass (17%). Nearly two-thirds of total diagnoses were accounted for by Burkitt lymphoma (n = 74), Kaposi sarcoma (n = 52), Hodgkin lymphoma (n = 21), and Wilms tumor (n = 19). Twelve-month overall survival for these 4 most common diagnoses was 54% (95% confidence interval 46-61) versus 19% (95% confidence interval 11-30) for all other diagnoses (median follow-up 19 months). Treatment-related mortality was highest in patients with non-Wilms solid tumors of the abdomen (48% versus 10% for the overall cohort, p < 0.001), while treatment abandonment was highest in patients with bone and soft-tissue sarcomas (29% versus 14% overall, p = 0.05). Childhood cancers with excellent curative potential accounted for the majority of patients, establishing an opportunity to build treatment programs with curative intent despite severe limitations.

Pediatric Kaposi sarcoma in context of the HIV epidemic in sub-Saharan Africa: current perspectives

“…Prevalence of HIV negative patients among pediatric KS cases ranges from 10–14% in Malawi to 22% in Uganda. 7 , 22 , 24 , 43 , 44 Outside of Africa, HIV-unrelated pediatric KS in the form of transplantation-related and classic disease is extremely rare and has been reported in fewer than 50 patients. 45 …”

“… 51 Ultimately, KS is among the top three most-common childhood malignancies overall in numerous countries in central, eastern, and southern Africa, where it carries a disease burden greater than that of childhood acute lymphoblastic leukemia in the US. 8 , 34 , 43 , 50 , 52 …”

“…The overall treatment-related mortality was 7%, which compared favorably to the 10% treatment-related mortality among all pediatric oncology patients in Lilongwe, establishing BV as a relatively safe first-line chemotherapeutic option. 23 , 43 …”

Investigating Wilms’ Tumours Worldwide: A Report of the OxPLORE Collaboration—A Cross‐Sectional Observational Study

“…The majority of African children with cancer die without access to healthcare resources [23]. These same childhood cancers have excellent curative potential given the ideal treatment programmes, thus presenting an opportunity for improvement [33]. We recommend interventions at all stages of the child cancer journey, with focus on: early access to diagnosis; treatment in a multidisciplinary setting (involving surgical expertise, histology services, specialised nursing, pharmacy, laboratories, radiology, palliative care, infectious diseases, critical care and nutrition) via a standardised protocol and measures to address abandonment of treatment and loss to follow-up ( Fig.…”

Suubi4Cancer: A protocol for an innovative combination intervention to improve access to pediatric cancer services and treatment adherence among children living with HIV/AIDS in Uganda

“…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]]. Although financial barriers have been commonly identified [[20], [21], [22]], we know of no interventions addressing financial stress faced by families of youth with a suspected cancer who are seeking diagnosis and treatment.…”