The problem of treatment abandonment in children from developing countries with cancer

BACKGROUND: There is an inequality gap between the outcome of childhood cancer in resource, rich and limited countries. Abandonment of treatment is one of the reasons for this. PROCEDURE: We searched the medical literature for evidence on abandonment, its causes, and any preventative interventions. RESULTS: Abandonment is a very real problem all across the developing world. Cancers associated with poorer prognosis seem to have higher abandonment rates. It is also related to the socio-economic and educational status of parents, travel time to treatment centers, and affordable, locally available treatment. CONCLUSIONS: Twinning between institutions, which includes several preventative interventions, has clearly been shown to work.     

A practical approach to reporting treatment abandonment in pediatric chronic conditions

Treatment abandonment, the failure to complete therapy that is required for definitive disease control, frequently causes treatment failure for pediatric patients in low‐ and middle‐income countries with chronic conditions, particularly cancer. Other forms of incomplete treatment affecting children in all settings, such as nonadherence and loss to follow‐up, are often confused with treatment abandonment. Unclear definitions of incomplete treatment dramatically affect reported outcomes. To facilitate disease‐specific and cross‐sector analyses, we outline a practical approach to categorize forms of incomplete treatment, present distinct semantic categories with case examples and provide an algorithm that could be tailored to disease‐ and context‐specific needs. Pediatr Blood Cancer 2015;62:565–570. © 2015 Wiley Periodicals, Inc.     

Childhood cancer in developing countries

The problem of childhood cancer cannot be evaluated separately from developmental levels and states of health of the countries. Rapid increase in population, poverty, poor hygiene, lack of education, and multitude health problems impede the development of pediatric oncology and success of the management of childhood cancer in developing countries. More than 85% pediatric cancer cases occur in developing countries that use less than 5% of world resources. The rate will exceed 90% in the next two decades, due to the increase of youth population in favor of developing countries. Incidence rates, pathology, and clinical characteristics of various cancers seem different in developing and developed countries. Different environments, life styles, dietary habits, and hygienic conditions are the main reasons for those differences. Unprecedented changes in diagnostic techniques, treatment methods and supportive care have occurred during the last decades. Consequently, management has improved and the mortality rates have decreased. Most of the children with cancer living in developing countries could not profit from those advances in pediatric oncology because of the cost.     

Scaling up cancer care for children without medical insurance in developing countries: The case of Mexico

Background

In 2006, the Mexican government launched the Fund for Protection Against Catastrophic Expenditures (FPGC) to support financially healthcare of high cost illnesses. This study aimed at answering the question whether FPGC improved coverage for cancer care and to measure survival of FPGC affiliated children with cancer.

Procedure

A retrospective cohort study (2006–2009) was conducted in 47 public hospitals. Information of children and adolescents with cancer was analyzed. The coverage was estimated in accordance with expected number of incident cases and those registered at FPGC. The survival was analyzed by using Kaplan–Meier survival curves and Cox proportional hazards regression modeling.

Results

The study included 3,821 patients. From 2006 to 2009, coverage of new cancer cases increased from 3.3% to 55.3%. Principal diagnoses were acute lymphoblastic leukemia (ALL, 46.4%), central nervous system (CNS) tumors (8.2%), and acute myeloid leukemia (AML, 7.4%). The survival rates at 36 months were ALL (50%), AML (30.5%), Hodgkin lymphoma (74.5%), Non‐Hodgkin lymphoma (40.1%), CNS tumors (32.8%), renal tumors (58.4%), bone tumors (33.4%), retinoblastoma (59.2%), and other solid tumors (52.6%). The 3‐year overall survival rates varied among the regions; children between the east and south‐southeast had the higher risks (hazard ratio 3.0; 95% CI: 2.3–3.9) and 2.4; 95% CI: 2.0–2.8) of death from disease when compared with those from the central region.

Conclusion

FPGC has increased coverage of cancer cases. Survival rates were different throughout the country. It is necessary to evaluate the effectiveness of this policy to increase access and identify opportunities to reduce the differences in survival. Pediatr Blood Cancer 2013;60:196–203. © 2012 Wiley Periodicals, Inc.     

The outcome of childhood adrenocortical carcinoma in Egypt: A model from developing countries

Abstract

Adrenocortical carcinoma (ACC) is a rare, aggressive endocrine neoplasm. Complete surgical resection is the single most important treatment. Most available information has been learned from experience with its more frequent adult counterpart. In this study, we assessed the features and survival outcome of patients with ACC at Children’s Cancer Hospital Egypt (CCHE). Patients diagnosed at CCHE between July 2007 and November 2016 were followed up on until November 2018. Patients with stages I and II were operated upon, while stages III and IV had received combinations of doxorubicin, etoposide, platinol, and mitotane (DEPM) beside the attempt to conduct surgery when feasible. Data belonging to 18 patients (7 men and 11 women) were analyzed; median age at diagnosis was 48.5?months. Sixteen patients had presented with secreting tumors. Six patients were diagnosed with stage I disease; four with stage II; three with stage III; and five with stage IV carcinoma. By the end of this study, 10 patients have survived; five-year overall survival of 66.3%. Surviving patients were all of stage I or II diseases and were all in remission. Seven patients who did not survive died due to tumor progression, while one patient died after chemotherapy. The prognosis of ACC is essentially dependent on a successful complete resection of the tumor and thus on the initial tumor stage. The mitotane and DEP protocols may help control tumor growth in the advanced stages for only short periods.

• Key points

• Initial stage and resectability are the main indicators of outcomes in adrenocortical carcinoma.

• Chemotherapeutic agents used in developed countries did not achieve the same outcomes.

• Further molecular-pharmacology differentiation is needed for various ethnic populations.

     

Second neoplasms after treatment of childhood cancer in Slovenia

BACKGROUND: The number of long time survivors of childhood cancer treatment is constantly increasing over the last decades as a result of advances in diagnosis and treatment. The occurrence of second neoplasms is one of most serious late effects observed in cancer survivors. METHODS: The risk of secondary neoplasm was studied in a cohort of 1,577 patients treated for childhood cancer registered in the Cancer Registry of Slovenia (CRS) between 1961 and 2000. The time at risk was defined from the date of diagnosis of first malignancy to the time of death or the end of the study. RESULTS: The most frequent primary malignancies were: acute leukemia 28.5%, central nervous system (CNS) tumors 21.3%, and lymphomas 16.6%. Median observation time was 7.8 years. Forty-eight patients developed second neoplasms. CNS tumors, acute leukemias, and thyroid carcinoma were most frequent second neoplasms. The cumulative risk for second neoplasm in the entire cohort was 0.06% at 5 years, 5.1% at 15 years, and 12.6% at 25 years after diagnosis of first cancer. The overall survival after second neoplasm was 65% 10 years after the diagnosis of second neoplasm. CONCLUSIONS: Patients after treatment of childhood cancer are at special risk for subsequent neoplasms and long-term follow-up is mandatory.     

Smoking habits in survivors of childhood and adolescent cancer

Because of their increased risk for second cancers, childhood cancer survivors are people who really should not smoke, but available evidence suggests that they do. We studied the smoking habits of long-term childhood cancer survivors in data collected from 1289 adult survivors of childhood cancer and 1930 of their sibling controls. Survivors were diagnosed with cancer between 1945 and 1974 when they were less than 20 years old. Using matched analyses that controlled for the influence of family, survivors were 8% less likely than controls to be current smokers, 13% less likely to be eversmokers, but 12% less likely to have quit smoking; these differences were not statistically significant. In a logistic regression analysis there was a significant difference by year of diagnosis for current smoking rate ratios (RR); survivors were less likely to be current smokers if diagnosed in recent years (RR = 0.76; 95% confidence intervals = 0.58–0.98, between 1965–74) and quite similar to controls if diagnosed in earlier years (RR = 1.05 between 1945 and 1954). In our group of long-term cancer survivors, the reduction in current smoking came about because survivors were more inclined never to start smoking than controls. Once addicted to tobacco, they were less likely to quit. While the fact that survivors are less likely to start smoking is encouraging, the persistence of smoking habits strongly suggests the need for continuing efforts to prevent smoking in this most vulnerable group. © 1992 Wiley-Liss, Inc.     

Understanding refusal and abandonment in the treatment of childhood cancer

Treatment refusal and abandonment is the principal cause of therapy failure in children with cancer in the developing world. A complex interplay of biological, socio-economic and treatment-related factors underlies this problem. Interventions are likely to succeed when they try and address all of these issues simultaneously, as exemplified by the success of twinning programs linking resource-rich and resource-limited countries. Hitherto, there has been no systematic attempt to understand and address this problem in India. Based on the knowledge gained from research in other parts of the developing world, we offer suggestions for dealing with this problem.     

Adverse childhood experiences and resilience in childhood and adolescent and young adult cancer patients

Childhood and adolescent and young adult (AYA) cancer survivors experience poor health outcomes in adulthood. Adverse childhood experiences (ACEs) also portend poor health outcomes for the general population. Resilience can mitigate effects of ACEs. We examined the feasibility of assessing ACEs and resilience in childhood and AYA cancer patients. We also described occurrences of ACEs, resilience, and poor health outcomes. Of 52 participants, most rated their study experience favorably, with privacy in answering sensitive questions. Half reported ACEs, and those with ACEs had lower resilience; X²(3, N = 52) = 9.4, p = .02. Further investigations of ACEs and resilience in larger cohorts are warranted to delineate associations with long-term health outcomes.     

Effective childhood cancer treatment: The impact of large scale clinical trials in Germany and Austria

In Germany and Austria, more than 90% of pediatric cancer patients are enrolled into nationwide disease‐specific first‐line clinical trials or interim registries. Essential components are a pediatric cancer registry and centralized reference laboratories, imaging review, and tumor board assistance. The five‐year overall survival rate in countries where such infrastructures are established has improved from <20% before 1950 to >80% since 1995. Today, treatment intensity is tailored to the individual patient's risk to provide the highest chances of survival while minimizing deleterious late effects. Multicenter clinical trials are internationalized and serve as platforms for further improvements by novel drugs and biologicals. Pediatr Blood Cancer 2013;60:1574–1581. © 2013 Wiley Periodicals, Inc.