Optimizing outcomes for children with non‐Hodgkin lymphoma in low‐ and middle‐income countries by early correct diagnosis, reducing toxic death and preventing abandonment

Abstract

In high-income countries, more than 90% of children with mature B-cell lymphomas are cured with frontline therapy. However, cure requires prompt and correct diagnosis, careful risk stratification, very intense chemotherapy and meticulous supportive care, together with logistical support for patients who live far from the cancer centre or face financial barriers to receiving care. In low-and middle-income countries (LMIC), cure rates range from 20% to 70% because of lack of diagnosis, misdiagnosis, abandonment of treatment, toxic death and excess relapse with reduced-intensity regimens. Fortunately, a wide range of successful interventions in LMIC have reduced these causes of avoidable treatment failure. Public awareness campaigns have led to societal awareness of childhood cancer; telepathology has improved diagnosis, even in remote areas; subsidized chemotherapy, transportation, housing and food have reduced abandonment; and hand hygiene, nurse training programmes and health system improvements have reduced toxic death. These interventions can be deployed everywhere and at low cost, so are highly scalable. Children and adolescents with Burkitt lymphoma can be cured in all countries by making a timely correct diagnosis, applying protocols adapted to the local context, preventing abandonment of therapy and avoiding toxic death. Reducing these causes of treatment failure is feasible and highly cost-effective everywhere.

Science and health for all children with cancer

“…There is no health for all unless there is also science for all. * The expected number of cancer cases per year (170/million) is calculated by applying the mean agespecific annual incidence rates of all high-income countries from Globocan (http://gco.iarc.fr/today/online-analysis-table) to the population of each country (8,108). The incidences in each pediatric age cohort are 200/million among 0 to 4 year olds, 135/million among 5 to 9 year olds, 135/million among among 10 to 14 year olds, and 211/million among 15 to 19 year olds.…”

Re-evaluation of challenging telepathological diagnoses in support of a hospital in Tanzania

“…In particular, in the case of lymphomas, the problems are well known from other studies. 11 Carey et al. found a correct diagnosis from the field of haemato-oncology in 52% of samples; 46/197 investigated cases showed discordant results, and in 38 cases, either the local or distant teams were unable to make a diagnosis.…”

Effect of Second Cycle Pre-induction Chemotherapy in Critically Ill Burkitt’s Lymphoma Children

“…Toxic death in the first month of therapy can be as high as 10% [16], but it may be up to 30% in higher-risk patients in LMIC (low middle income countries) [17]. Patients whose diagnosis is delayed present with more advanced disease and a higher risk of malnutrition, TLS, comorbid infections and great risk for early toxic death.…”

“…2-5% of patients died within a few hours of arrival to the hospital before even completing staging evaluation [15]. Nutritional deficiencies in some settings may also increase the risk of early toxicity, and chemotherapy dose modifications may be necessary in these cases [17].…”