Initiating Childhood Cancer Treatment in Rural Rwanda: A Partnership-Based Approach

Abstract

Background. More than 85% of pediatric cancer cases and 95% of deaths occur in resource-poor countries that use less than 5% of the world's health resources. In the developed world, approximately 81% of children with cancer can be cured. Models applicable in the most resource-poor settings are needed to address global inequities in pediatric cancer treatment. Procedure. Between 2006 and 2011, a cohort of children received cancer therapy using a new approach in rural Rwanda. Children were managed by a team of a Rwandan generalist doctor, Rwandan nurse case manager, Rwandabased US-trained pediatrician, and US-based pediatric oncologist. Biopsies and staging studies were obtained in-country. Pathologic diagnoses were made at US or European laboratories. Rwanda-based clinicians and the pediatric oncologist jointly generated treatment plans by telephone and email. Results. Treatment was provided to 24 patients. Diagnoses included lymphomas (n = 10), sarcomas (n = 9), leukemias (n = 2), and other malignancies (n = 3). Standard chemotherapy regimens included CHOP, ABVD, VA, COP/COMP, and actino-VAC. Thirteen patients were in remission at the completion of data collection. Two succumbed to treatment complications and nine had progressive disease. There were no patients who abandoned treatment. The mean overall survival was 31 months and mean disease-free survival was 18 months. Conclusions. These data suggest that chemotherapy can be administered with curative intent to a subset of cancer patients in this setting. This approach provides a platform for pediatric cancer care models, relying on local physicians collaborating with remote specialist consultants to deliver subspecialty care in resource-poor settings.

Leveraging International Expertise for Cancer Care in LMICs

“…The shortage of multidisciplinary oncology subspecialists is a challenge that some centers in LMICs have attempted to overcome by seeking the support of multidisciplinary expertise through the creation of international partnerships and utilization of remote communication technologies [9][10][11][12]. In our research we have found that leveraging existing communication technology-such as email-facilitates access to the needed expertise across international lines.…”

“…Many of these partnerships have included the use of email or videoconferencing technology to facilitate knowledge sharing and multidisciplinary discussions in addition to investment in specialized oncology education [9][10][11][12][19][20][21][22] However, email communication for the coordination of multidisciplinary care is associated with the difficulties we have described above, and attempting to arrange videoconferencing-or teleconferencing-based MDCs is associated with significant logistical barriers such as potential time zone differences and scheduling conflicts [23]. Other technologies exist for long-distance coordination of medical diagnostics and treatment planning, collectively described as telemedicine.…”

The role of twinning in sustainable care for children with cancer: A TIPPing point? SIOP PODC Working Group on Twinning, Collaboration, and Support

“…This assessment can establish realistic goals for a strategic TIPP plan, and determine where to allocate financial and human resources 6 . The resulting road map, with clearly delineated roles, responsibilities, timeline, and deliverables contemplated, allows the LMIC partner to own the project 5,6,16 . It is vital at this stage that the LMIC partner not feel intimidated about asking awkward questions, which typically involve clarifying issues of finance and autonomy, including what will happen if the TIPP fails.…”

“…Written formalization of the partnership with a memorandum of understanding (MOU) is essential 16,17 . The MOU provides, for both internal and external stakeholders, a high‐level guiding framework for the intended collaboration that is clear and unambiguous and permits easy review and updating (Table 3).…”

Lessons From Pediatric HIV: A Case for Curative Intent in Pediatric Cancer in LMICs

“…10 In Rwanda, investment in the health system to combat HIV/AIDS has strengthened cancer management, including the treatment of childhood malignancies in rural areas. 11 In each positive example, a shared commitment among governments and other stakeholders, domestic and international, to improve both the access to and the quality of cancer care has led to progress despite many challenges.…”