Pediatric oncology in Morocco: achievements and challenges

Cancer in children is quickly becoming one of the leading causes of non traumatic death among children. In pediatric oncology, palliative care is a primary component of the cancer control plan. In low income countries also known as emerging nations or developing countries access to adequate care remains a challenge for most pediatric oncology patients. In Morocco the situation has dramatically improved in the last few years as both the government and NGOs have become more aware of the importance and urgency of the issue. The incidence of cancer in patients under 15 years of age in Morocco is estimated to be 1000 new cases per year and the incidence of leukemia to be 100 new cases diagnosed per year. Pediatric cancer patients are mostly managed by public hospitals. Thus they are highly influenced by the Moroccan public health system, which is now considering cancer management a priority. Since health cover is very limited, most chemotherapy drugs were purchased by local parent associations. Recently, a new large Moroccan NGO (ALSC) provides anti-cancer drugs to all government-run oncology units. Despite all the progress, Morocco has witnessed in the pediatric oncology field, the palliative aspect of the care is not yet organized. Pediatric oncology is supported by the work of the National Society of Pediatric Oncolgy. The opioide therapy is available. However its use is strongly limited by the current restrictive and obsolete legislation which represents a major barrier to care. Despite the latest progress, pediatric oncology in Morocco still needs to improve in order to achieve performances comparable to those of the developed world. These improvements include better survival rates, less treatment abandonment, developing new techniques, improving quality of life and creating data collection teams. In order for this action to succeed all the stakeholders (government, NGOs, medical societies, oncology teams) must work together and coordinate their efforts.     

Current status of pediatric hematology/oncology and palliative care in Lebanon: a physician's perspective

Children with cancer suffer a lot, especially those in developing countries with limited health resources. Although pediatric hematology/oncology has become a well-developed subspecialty in Lebanon, pediatric palliative care is still underrecognized. The current pediatric hematology/oncology and palliative care services in Lebanon are reviewed in this article. We stress upon the adverse consequences of absence of well-defined pediatric palliative care in order for it to be recognized and integrated as a new discipline.     

The international scandal of defective asparaginase: A blight on children with cancer

Acute lymphoblastic leukemia is the commonest form of cancer in children and adolescents worldwide, and asparaginase is an essential component of successful chemotherapy for this disease associated with long-term survival rates often exceeding 90% in high-income countries. Demonstrably defective preparations of asparaginase, distributed from China and India, increase the burden of morbidity and mortality, reducing attainable survival rates. This adverse outcome is enabled by inadequate regulation and oversight, especially in resource-poor settings in low- and middle-income countries where the great majority of children and adolescents with cancer live. The pediatric oncology community must rise to the challenge.     

Challenge of pediatric oncology in Africa

The care of children with malignant solid tumors in sub-Saharan Africa is compromised by resource deficiencies that range from inadequate healthcare budgets and a paucity of appropriately trained personnel, to scarce laboratory facilities and inconsistent drug supplies. Patients face difficulties accessing healthcare, affording investigational and treatment protocols, and attending follow-up. Children routinely present with advanced local and metastatic disease and many children cannot be offered any effective treatment. Additionally, multiple comorbidities, including malaria, tuberculosis, and HIV when added to acute on chronic malnutrition, compound treatment-related toxicities. Survival rates are poor. Pediatric surgical oncology is not yet regarded as a health care priority by governments struggling to achieve their millennium goals. The patterns of childhood solid malignant tumors in Africa are discussed, and the difficulties encountered in their management are highlighted. Three pediatric surgeons from different regions of Africa reflect on their experiences and review the available literature. The overall incidence of pediatric solid malignant tumor is difficult to estimate in Africa because of lack of vital hospital statistics and national cancer registries in most of countries. The reported incidences vary between 5% and 15.5% of all malignant tumors. Throughout the continent, patterns of malignant disease vary with an obvious increase in the prevalence of Burkitt lymphoma (BL) and Kaposi sarcoma in response-increased prevalence of HIV disease. In northern Africa, the most common malignant tumor is leukemia, followed by brain tumors and nephroblastoma or neuroblastoma. In sub-Saharan countries, BL is the commonest tumor followed by nephroblastoma, non-Hodgkin lymphoma, and rhabdomyosarcoma. The overall 5-years survival varied between 5% (in C?te d'Ivoire before 2001) to 34% in Egypt and up to 70% in South Africa. In many reports, the survival rate of patients is not mentioned but is clearly very low in many sub-Saharan Africa countries (Sudan, Nigeria). Late presentation was observed for many tumors like nephroblastoma in Nigeria, 72% were stages III and IV or BL stages III and IV were observed in 40% and 30%, respectively. Africa bears a great burden of childhood cancer. Cancer is now curable in developed countries as survival rates approach 80%, but in Africa, >80% of children still die without access to adequate treatment. Sharpening the needlepoint of surgical expertise will, of itself, not compensate for the major infrastructural deficiencies, but must proceed in tandem with resource development and allow heath planners to realize that pediatric surgical oncology is a cost-effective service that can uplift regional services.     

Attitudes and practices of pediatric oncology providers regarding fertility issues

PURPOSE: Given the higher survival rates of childhood cancer, health care providers must be aware of the side effects of cancer therapies to educate patients and provide appropriate interventions to reduce cancer-related morbidity. To understand the current practices and attitudes in a pediatric hematology/oncology clinic, health care providers were surveyed regarding fertility issues pertinent to their patient care. PARTICIPANTS AND INSTRUMENTS: In this study, 93.8% (30/32) health care providers in one pediatric hematology/oncology department completed a 44-item survey assessing knowledge, current practices, obstacles to current practices, perceptions of patient differences, and improvements to future practice. RESULTS: The majority of health care providers were aware of the adverse effects of alkylating agents (90.7%) and of abdominal and pelvic radiation (100.0%) on fertility. However, only half were aware of gender differences in gonadotoxicity (50.0%) or knowledgeable of current research and technology in fertility preservation (53.3%). While only 34.6% of providers currently consulted with specialists, nearly all (92.8%) indicated a desire to do so in the future, but 64.3% indicated difficulties in finding proper facilities and specialists for their patients. Almost all (96.6%) agreed that providers and patient families need more information regarding the effects of cancer therapy on fertility. CONCLUSIONS: Surveyed pediatric oncology providers considered fertility to be an important issue for childhood cancer patients and desired more resources regarding effects on fertility and fertility preservation. Greater communication needs to be established between pediatric oncology providers and specialists in reproductive medicine and endocrinology to ensure adequate professional collaboration and patient referrals.     

AMOR: a proposed cooperative effort to improve outcomes of childhood cancer in Central America

The dramatic reduction of pediatric cancer mortality rates has been one of the greatest accomplishments of contemporary medicine. About 80% of children with cancer are now expected to be cured by current therapies. However, most of the world's children have no access to cancer treatment. The translation of effective pediatric cancer therapies to impoverished regions of the world presents an enormous challenge to the health care profession. Over the past 20 years, efforts have been under way to extend adequate cancer treatment to an increasing number of children in developing countries. These initiatives, collectively designated "twinning programs," consist essentially of a partnership between a pediatric cancer unit in a developing country and a group of health care providers in the developed world. Here we review the twinning programs that have been implemented in Central America, discuss their impact on the development of local resources and the outcome of childhood cancer, and propose a collaborative research initiative aimed at improving the international dissemination of progress in pediatric hematology-oncology.     

Psychosexual functioning in cancer survivorship: What the pediatric oncologist needs to know

Sexual health may be disrupted in adolescents and young adults (AYAs) both during and after cancer treatment, irrespective of whether they are diagnosed in childhood, adolescence, or young adulthood. Unfortunately, oncology providers often underestimate the relevance of psychosexual issues for AYAs and underprioritize sexual health throughout treatment and survivorship. The purpose of this narrative review is to provide information on (a) the etiology of psychosexual dysfunction in childhood, adolescent, and young adult cancer patients and young adult survivors of childhood cancer; (b) strategies for communicating and evaluating potential sexual health issues of AYA patients/survivors; and (c) guidance for the practicing pediatric oncologist on how to address sexual health concerns with patients.     

Unique Factors Affecting the Management and Prevention of Caries in the Childhood Cancer Survivor

Childhood cancer survivors are at high risk for a myriad of complications secondary to oncologic treatment regimens. Caries is one of the major sequela of oncologic treatment that place the childhood cancer survivor at risk for complications in adulthood. Dental caries can be prevented with optimum dental care, early identification, and patient education. A barrier to their prevention is the lack of routine dental care received by this population. Health care providers are in a prime position to remedy this problem through their frequent contact with the childhood cancer survivor during sick and well-child office visits. The purpose of this article is to convey information and tools related to dental caries in the pediatric cancer survivor younger than 18 years to enhance primary care providers’, acute care pediatric nurse practitioners’, and oncology providers’ knowledge of risk stratification, early identification, and treatment regimens for caries in the childhood cancer survivor.     

The relevance of nutrition to pediatric oncology: A cancer control perspective

It is indisputable that adequate and appropriate nutrition is fundamental to the health, growth, and development of infants, children, and adolescents, including those with cancer. Nutrition has a role in most of the accepted components of the cancer control spectrum, from prevention through to palliation. The science of nutrigenomics, nutrigenetics, and bioactive foods (phytochemicals), and how nutrition affects cancer biology and cancer treatment, is growing. Nutritional epigenetics is giving us an understanding that there are possible primary prevention strategies for pediatric cancers, especially during conception and pregnancy, which need to be studied. Primary prevention of cancer in adults, such as colorectal cancer, should commence early in childhood, given the long gestation of nutritionally related cancers. Obesity avoidance is definitely a target for both pediatric and adult cancer prevention, commencing in childhood. There is now compelling evidence that the nutritional status of children with cancer, both overweight and underweight, does affect cancer outcomes. This is a potentially modifiable prognostic factor. Consistent longitudinal nutritional assessment of patients from diagnosis through treatment and long‐term follow‐up is required so that interventions can be implemented and evaluated. While improving, there remains a dearth of basic and clinical nutritional research in pediatric oncology. The perspective of evaluating nutrition as a cancer control factor is discussed in this article.     

Specific Deficit Analyses in Motor Performance and Quality of Life of Pediatric Cancer Patients—A Cross-Sectional Pilot Study

Although survival rates in childhood cancer have distinctly improved, pediatric cancer patients often experience various disease- and treatment-related side effects with long-term consequences. Despite current studies investigating inactivity and limitations in physical functioning and quality of life in pediatric cancer patients, only little information regarding specific deficits in physical functioning and quality of life has been available until now. No study has yet analyzed these parameters from a global perspective and then identified specific deficits in a mixed childhood cancer population. Within this cross-sectional pilot study, motor performance and quality of life of 26 pediatric cancer patients were assessed after inpatient medical treatment, using standardized motor test batteries (MOT 4–6; DMT 6–18) and a quality of life questionnaire (KINDL®). Reference data have been mainly provided by the German “Children and Young People Health Survey” (KiGGS). Patients achieved lower motor performance scores (p = .000) (more than 27% below the average of healthy peers). Specific deficits were identified in motor speed and motor control (4–6 years), as well as in endurance, strength and coordination under time pressure (6–17 years). In terms of quality of life, no significant differences were examined compared to healthy children of the same age. The results of this study confirm that children with oncological diseases frequently have specific motor problems. Future research in pediatric oncology must investigate the impact of targeted, individualized exercise interventions addressing these specific deficits.     

The role of hormones in breast carcinogenesis: Issues of relevance to female childhood cancer survivors*

Breast cancer is the most common cancer among women in Western industrialized countries, and is an important potential second cancer to consider in young women who are survivors of childhood or adolescent cancers. This paper reviews the relationship between hormones and breast biology, cancer treatment factors that may increase or reduce the risk of breast cancer in female survivors of childhood cancer, the treatment of ovarian failure in these survivors, and the potential for preventive strategies in this population. The expanding numbers of female childhood cancer survivors increase the need for health care providers to understand the late health effects of treatments on reproductive health and breast cancer risk. Med. Pediatr. Oncol. 36:514–518, 2001. © 2001 Wiley‐Liss, Inc.     

Rituximab for Child with Chronic Relapsing Autoimmune Hemolytic Anemia

Childhood cancer is a leading cause of childhood mortality in developed countries though ranks lower than infections in developing countries. Most patients with malignancies present late to hospital with consequent adverse outcome. Early diagnosis, therefore, is an important requirement in pediatric oncology as delayed diagnosis is associated with poor prognosis and huge economic cost. The study aims to identify factors associated with delay in the diagnosis of childhood cancer at University of Nigeria Teaching Hospital, Enugu.Children aged 0–17 years with admitting diagnosis of cancer which was histologically confirmed were reviewed prospectively over a 3-year period. An interviewer structured questionnaire was administered to patients or parents/caregivers to obtain information on patients’ biodata, their symptoms as well as visit to health professionals or alternative health care providers before presentation at this hospital.Ninety patients were confirmed to have cancer. Overall median lag time (LT) was 15.7 weeks. Major contributors to delay were parents and the type of cancer patients presented with. Acute lymphoblastic leukemia (ALL) had the shortest median LT of 4.2 weeks while Hodgkin's disease had the longest median LT of 53.6 weeks (p = 0.01, Mann-Whitney test, 2-tailed). The median parent's delay was 12.3 weeks and health system delay was 3.6 weeks showing a significant difference in the two categories of delay (p < 0.0001, Mann-Whitney test, 2-tailed). The median treatment delay was 5 days.Public awareness and health system reform is imperative in reducing the delay in diagnosis of childhood cancer in our environment.     

Pediatric trauma care in Africa: the evolution and challenges

Childhood trauma is one of the major health problems in the world. Although pediatric trauma is a global phenomenon in low- and middle-income countries, sub-Saharan countries are disproportionally affected. We reviewed the available literature relevant to pediatric trauma in Africa using the MEDLINE database, local libraries, and personal contacts. A critical review of all cited sources was performed with an emphasis on the progress made over the past decades as well as the ongoing challenges in the prevention and management of childhood trauma. After discussing the epidemiology and spectrum of pediatric trauma, we focus on the way forward to reduce the burden of childhood injuries and improve the management and outcome of injured children in Africa.     

Challenges to the measurement of health-related quality of life in children receiving cancer therapy

Measures of health-related quality of life (HRQL) assess those areas of a patient's functioning that are affected by their cancer and its therapy. Although HRQL measures are integrated frequently into studies of survivors of childhood cancer, their use in the assessment of children receiving therapy has been limited by several methodological challenges. These arise from issues specific to measuring HRQL in young children, who comprise a large proportion of the pediatric oncology population, and from issues associated with assessing HRQL during therapy, when the patient's health status is in constant flux. This study summarizes the commonly used HRQL measures, and examines factors that impact their broad application. These include the influence of developmental changes on the content and format of HRQL measures, the role of proxy assessors, the important characteristics of measurement tools used to assess patients receiving active therapy, and the issues related to the ideal timing of serial HRQL assessments in prospective trials.     

Novel insights in the management of sickle cell disease in childhood

Sickle cell disease (SCD) is a life-threatening genetic disorder characterized by chronic hemolytic anemia, vascular injury and multiorgan dysfunctions. Over the last few decades, there have been significant improvements in SCD management in Western countries, especially in pediatric population. An early onset of prophylaxis with Penicillin and a proper treatment of the infections have increased the overall survival in childhood. Nevertheless, management of painful episodes and prevention of organ damage are still challenging and more efforts are needed to better understand the mechanisms behind the development of chronic organ damages. Hydroxyurea (Hydroxycarbamide, HU), the only medication approved as a disease-modifying agent by the United States Food and Drug Administration and the European Medicines Agency, is usually under-used, especially in developing countries. Currently, hematopoietic stem-cell transplantation is considered the only curative option, although its use is limited by lack of donors and transplant-related toxicity. SCD symptoms are similar in children and adults, but complications and systemic organ damages increase with age, leading to early mortality worldwide. Experts in comprehensive care of young patients with SCD, especially those approaching the transition age to adulthood, are missing, leading people to rely on urgent care, increasing health care utilization costs and inappropriate treatments. It would be important to establish programs of comprehensive healthcare for patients with SCD from birth to adulthood, to improve their quality and expectancy of life.     

A questionnaire based review of long-term follow-up programs for survivors of childhood cancer in Canada

Background

Major advances have been made in the treatment of childhood cancer; however, survivors of childhood cancer are at increased risk for morbidity and mortality. There is little literature regarding available long‐term follow‐up programs for survivors of childhood cancer.

Procedure

In March 2007, 16 surveys were sent to pediatric hematology/oncology programs across Canada to determine what programs were available for survivors of childhood cancer, and the nature of such programs.

Results

Of 15 participating centers, 13 (87%) have multi‐disciplinary programs for the long‐term follow‐up of pediatric cancer survivors. Research databases were documented in 9/15 (60%) of centers to document late effects. Dedicated programs for adult survivors of childhood cancer were established in 8/15 (53%) of centers. Access to subspecialty care for survivors was rated as quite good. Concerns were raised by many participants about patients being lost to follow‐up. Respondents indicated that primary care physicians appear to be under‐represented within dedicated long‐term follow‐up programs.

Conclusion

Long‐term follow‐up programs for survivors of childhood cancer are available in 87% of Canadian pediatric oncology centers. While programs reported good access to care for childhood survivors, many adult survivors of childhood cancer have more limited timely access to services and patients are often lost to follow‐up. New models of care incorporating primary care physicians are necessary due to growing numbers of survivors. Pediatr Blood Cancer 2009;52:113–115. © 2008 Wiley‐Liss, Inc.     

Measurement of health-related quality of life in survivors of cancer in childhood in Central America: feasibility, reliability, and validity

Cancer is the commonest cause of disease-related death in children over 5 years of age in various parts of Latin America, but the survival rates are improving. This study assessed the health status and health-related quality of life (HRQL) of more than 200 survivors of cancer in childhood in the countries of a Central American consortium devoted to pediatric hematology-oncology. Patients' self-reports and parental proxy assessments were collected using interviewer-administered Spanish-language questionnaires, and physicians provided assessments using self-complete questionnaires, based on the complementary Health Utilities Index (HUI) Mark 2 (HUI2) and Mark 3 (HUI3) health status classification systems. Inter-rater agreement, measured by intra-class correlation (ICC), was fair to moderate (0.340.60) for all 3 pairs of assessors for readily assessable attributes: HUI2 sensation, HUI3 vision, HUI3 hearing, and HUI3 ambulation. Less than 40% of the patients reported being in perfect health. More than 20% reported being in health states with HRQL scores corresponding to moderate or severe disability, notably in the attributes of emotion and cognition. The results reflect a common profile in survivors of cancer in childhood, including those from industrialized societies. This study illustrates the feasibility of collecting reliable and valid information on HRQL in the developing country context, raising the prospect that such information could be used to influence clinical practice.     

Models of care for survivors of childhood cancer

With improvements in therapy for childhood cancer, the expectation that most childhood cancer patients will survive and enter adulthood is a reality. There is clear evidence that survivors are at risk for adverse health-related long-term sequelae associated with their cancer and its treatment, requiring appropriate health care resources. What is less clear is how this health care should optimally be delivered. We review the functional and operational needs for long-term follow-up for childhood cancer survivors and present alternatives for models of care. Programs for childhood cancer survivors should provide mechanisms for monitoring and management of late effects, as well as support and advocacy for addressing psychosocial issues, health education, and assistance with financial concerns. Access to research is an important component as clinical care and research are integrally related. A multidisciplinary model that provides continuity of care throughout the disease course is optimal, providing transitions from acute anti-neoplastic therapy to follow-up and primary care, as well as from pediatric care to adult-oriented care. There is no single best model of care for all childhood cancer survivors. In evaluating different models, considerations include available resources as well as the particular cancer population being served. Not all survivors require the same level of services and the service level requirement for individual patients may change with time. As outcome research progresses for childhood cancer survivors, methodological issues of optimal health care delivery for this population deserve to be the subject of such research.     

Pediatric oncology in Turkey

The survival of children with cancer has increased dramatically in the last decades, as a result of advances in diagnosis, treatment and supportive care. Each year in Turkey, 2500-3000 new childhood cancer cases are expected. According to the Turkish Pediatric Oncology Group and Turkish Pediatric Hematology Societies Registry, about 2000 new pediatric cancer cases are reported each year. The population in Turkey is relatively young. One fourth of the population is younger than 15 years of age. According to childhood mortality, cancer is the fourth cause of death (7.2%) after infections, cardiac deaths and accidents. The major cancers in children in Turkey are leukemia (31%), lymphoma (19%), central nervous system (CNS) neoplasms (13%), neuroblastomas (7%), bone tumors (6.1%), soft tissue sarcomas (6%), followed by renal tumors, germ cell tumors, retinoblastoma, carcinomas-epithelial neoplasms, hepatic tumors and others. Lymphomas rank second in frequency as in many developing countries in contrast to West Europe or USA, where CNS neoplasms rank second in frequency. The seven-year survival rate in children with malignancies in Turkey is 65.8%. The history of modern Pediatric Oncology in Turkey dates back to the 1970's. Pediatric Oncology has been accepted as a subspecialty in Turkey since 1983. Pediatric Oncologists are all well trained and dedicated. All costs for the diagnosis and treatment of children with cancer is covered by the government. Education and infrastructure for palliative care needs improvement.     

Children's Oncology Group's 2013 blueprint for research: Behavioral science

Behavioral science has long played a central role in pediatric oncology clinical service and research. Early work focused on symptom relief related to side effects of chemotherapy and pain management related to invasive medical procedures. As survival rates improved, the focused has shifted to examination of the psychosocial impact, during and after treatment, of pediatric cancer and its treatment on children and their families. The success of the clinical trials networks related to survivorship highlights an even more critical role in numerous domains of psychosocial research and care. Within the cooperative group setting, the field of behavioral science includes psychologists, social workers, physicians, nurses, and parent advisors. The research agenda of this group of experts needs to focus on utilization of psychometrically robust measures to evaluate the impact of treatment on children with cancer and their families during and after treatment ends. Over the next 5 years, the field of behavioral science will need to develop and implement initiatives to expand use of standardized neurocognitive and behavior batteries; increase assessment of neurocognition using technology; early identification of at‐risk children/families; establish standards for evidence‐based psychosocial care; and leverage linkages with the broader behavioral health pediatric oncology community to translate empirically supported research clinical trials care to practice. Pediatr Blood Cancer 2013; 60: 1048–1054. © 2012 Wiley Periodicals, Inc.