Delayed referral and treatment of paediatric cancer in Nigeria: Time to stop blaming the victim

Background: Caregiver delay in presentation has been cited as a major contributor to poor prognosis of paediatric cancers in low-middle income countries like Nigeria. This study explored the time duration between onset of symptoms and presentation to healthcare facilities, diagnosis, and referral for specialist care. Methods: Data were compiled from caregivers of newly registered children at a teaching hospital in Nigeria. Sociodemographic and clinical history of the child were taken. Type of cancer, date of diagnosis, centre where the diagnosis was made, treatment start date, and duration of symptoms until treatment were elicited from consenting caregivers and documented. Results: Acute lymphoblastic leukaemia was the most prevalent cancer type among the patients. The mean time from first symptom to presentation was 15 weeks and from presentation at any health care facility to specialist referral and diagnosis was 38 and 39 weeks, respectively. Time from diagnosis to treatment was a mean of 8 weeks (range: 1 to 27 weeks) Conclusion: Delayed presentation has become a commonly cited factor for poor cancer outcomes in Nigeria and may often inaccurately assign blame to the patient/caregivers. The results of this study point to delayed detection, delayed diagnosis and delayed referral for specialist care, as more accurate contributors to late-stage presentation and consequently worse outcomes of paediatric cancers in Nigeria. Strengthening of community and primary level healthcare professionals’ understanding of paediatric cancers, establishment of simple detection algorithms and national implementation of efficient referral protocols will potentially reduce delays in specialist attention and improve outcomes

Early Detection of Paediatric Cancer: Equipping Primary Health‑Care Workers in Nigeria

Background: Paediatric cancer patients in Nigeria continue to arrive at specialist centers with advanced‑stage disease. The reasons for this are myriad, not least of which are delays in detection, diagnosis, and referral for treatment. While delayed presentation has often been reported from the perspective of delays from caregivers’ decisions, institutional deficiencies in the health care system may account for an unmeasured portion of the factors leading to delayed presentation. This project centered around training of health‑care professionals at community level to detect potential paediatric cancer signs and refer appropriately. Aim: The aim of the study is to access the immediate impact of training on early detection and referral of possible paediatric cancer cases in the community and primary level health care workers and professionals in the Southwest Nigeria. Materials and Methods: This was a retrospective review of the training impact in three South‑Western states in Nigeria. Scores before and after the training were analyzed using the IBM SPSS statistics, version 23 (IBM, Armonk, NY, USA). Results: A total of 732 primary health care workers were trained. In the pre assessment evaluations, 44.8% of participants reported that cancer did not occur in children, 47.2% did not know any referral pathway for a child suspected of cancer. The post training assessment indicated an improvement in participants’ understanding of common paediatric cancers types and how to refer a suspected case for specialist diagnosis and attention. Mean scores before and after the training were 3.5/15 and 12.5/15, respectively. Conclusion: Training health-care professionals working at the community level can have an immediate and measurable impact on early detection and referral for paediatric cancers, as seen by the difference in pre training and post training assessment scores. There remains a need for continuous training to ensure early referral and ultimately increase survival indices of children diagnosed with cancer in Nigeria

The global retinoblastoma outcome study : a prospective, cluster-based analysis of 4064 patients from 149 countries

DATA SHARING : The study data will become available online once all analyses are complete.BACKGROUND : Retinoblastoma is the most common intraocular cancer worldwide. There is some evidence to suggest that major differences exist in treatment outcomes for children with retinoblastoma from different regions, but these differences have not been assessed on a global scale. We aimed to report 3-year outcomes for children with retinoblastoma globally and to investigate factors associated with survival. METHODS : We did a prospective cluster-based analysis of treatment-naive patients with retinoblastoma who were diagnosed between Jan 1, 2017, and Dec 31, 2017, then treated and followed up for 3 years. Patients were recruited from 260 specialised treatment centres worldwide. Data were obtained from participating centres on primary and additional treatments, duration of follow-up, metastasis, eye globe salvage, and survival outcome. We analysed time to death and time to enucleation with Cox regression models. FINDINGS : The cohort included 4064 children from 149 countries. The median age at diagnosis was 23·2 months (IQR 11·0–36·5). Extraocular tumour spread (cT4 of the cTNMH classification) at diagnosis was reported in five (0·8%) of 636 children from high-income countries, 55 (5·4%) of 1027 children from upper-middle-income countries, 342 (19·7%) of 1738 children from lower-middle-income countries, and 196 (42·9%) of 457 children from low-income countries. Enucleation surgery was available for all children and intravenous chemotherapy was available for 4014 (98·8%) of 4064 children. The 3-year survival rate was 99·5% (95% CI 98·8–100·0) for children from high-income countries, 91·2% (89·5–93·0) for children from upper-middle-income countries, 80·3% (78·3–82·3) for children from lower-middle-income countries, and 57·3% (52·1-63·0) for children from low-income countries. On analysis, independent factors for worse survival were residence in low-income countries compared to high-income countries (hazard ratio 16·67; 95% CI 4·76–50·00), cT4 advanced tumour compared to cT1 (8·98; 4·44–18·18), and older age at diagnosis in children up to 3 years (1·38 per year; 1·23–1·56). For children aged 3–7 years, the mortality risk decreased slightly (p=0·0104 for the change in slope). INTERPRETATION : This study, estimated to include approximately half of all new retinoblastoma cases worldwide in 2017, shows profound inequity in survival of children depending on the national income level of their country of residence. In high-income countries, death from retinoblastoma is rare, whereas in low-income countries estimated 3-year survival is just over 50%. Although essential treatments are available in nearly all countries, early diagnosis and treatment in low-income countries are key to improving survival outcomes.The Queen Elizabeth Diamond Jubilee Trust and the Wellcome Trust.https://www.thelancet.com/journals/langlo/homeam2023Paediatrics and Child Healt

Pattern of presentation, treatment, and determinants of outcome of pediatric oncology cases at a tertiary institution in Lagos

Background: Cancers in children are increasing all over the globe, however, the outcome in LMICs is still quite poor due to a myriad of factors. Aim: This review focused on pattern of admissions in a pediatric oncology unit in Lagos, Nigeria and the determinants of outcome. Settings and Design: This was a retrospective descriptive study at the Lagos University Teaching Hospital from January 2015 to July 2017. Common treatment protocols like UKALL, NWTSG etc are adapted for use in the unit. Data Analysis: This was done using SPSS version 22. Results: A total of 178 children were seen at the oncology unit with a slight male preponderance of 1.4:1. The most common malignancy seen was acute lymphoblastic leukemia (20.8%) while retinoblastoma was the commonest solid tumor (19.6%). Mortality rate observed in the period under review was 45% and a large number of patients (22%) abandoned treatment. Conclusion: The management of childhood cancers is still a big challenge in resource constrained settings and a robust health insurance policy will improve outcomes

Oncology Education in the Nigerian Medical Curriculum: A cross-sectional review

No Abstract

Increasing pediatric radiation oncology capacity in sub-saharan Africa using technology: a pilot of a pediatric radiation oncology virtual training course

Abstract Background The shortage of skilled healthcare professionals in pediatric oncology and the limited access to training programs remain significant challenges in Nigeria and sub-Saharan Africa. The the Pediatric Radiation Oncology (Virtual) Course, ‘PedROC’ project aims to contribute to improving pediatric cancer outcomes in Nigeria by increasing the capacity of radiation oncology professionals. To address the gap in access to pediatric radiation oncology professional development, the PedROC project was created, harnessing technology to improve radiation oncology training via a curriculum delivered through web-conferencing. This study aimed to evaluate the effectiveness of the PedROC pilot in enhancing the capacity, confidence, and skill of radiation oncologists in decision-making, prescribing, and treatment planning of radiotherapy for children diagnosed with cancer. Methods A multidisciplinary faculty of specialists in radiation oncology, pediatric oncology, oncology nursing, radiation therapy technology, and medical physics collaborated to identify the key learning needs in pediatric radiation oncology in the country. The team collaborated to develop a comprehensive curriculum covering the most common pediatric cancers in sub-Saharan Africa for the training program. The training course was conducted over two days, delivering twenty-four half-hour sessions for a total of 12 h, from July 31 to August 01, 2021. Results Analysis of pre and post - training surveys showed a significant increase in self-reported confidence measures across all domains among radiation oncologists. The program successfully improved participants’ knowledge and confidence levels in managing common pediatric cancers using radiotherapy, particularly addressing radiotherapy-specific issues such as appropriate dose, target volume delineation, treatment planning, dose constraints, and plan evaluation. Conclusion The PedROC pilot showed the efficacy of this model in enhancing the capacity and confidence of radiation oncology professionals involved in the treatment of pediatric cancer. The findings indicate that technology holds significant potential to increase pediatric radiation oncology capacity in Africa, ensuring improved access to proper treatment and ultimately improving pediatric cancer outcomes

Impact of the COVID-19 pandemic on patients with paediatric cancer in low-income, middle-income and high-income countries: a multicentre, international, observational cohort study

OBJECTIVES: Paediatric cancer is a leading cause of death for children. Children in low-income and middle-income countries (LMICs) were four times more likely to die than children in high-income countries (HICs). This study aimed to test the hypothesis that the COVID-19 pandemic had affected the delivery of healthcare services worldwide, and exacerbated the disparity in paediatric cancer outcomes between LMICs and HICs. DESIGN: A multicentre, international, collaborative cohort study. SETTING: 91 hospitals and cancer centres in 39 countries providing cancer treatment to paediatric patients between March and December 2020. PARTICIPANTS: Patients were included if they were under the age of 18 years, and newly diagnosed with or undergoing active cancer treatment for Acute lymphoblastic leukaemia, non-Hodgkin's lymphoma, Hodgkin lymphoma, Wilms' tumour, sarcoma, retinoblastoma, gliomas, medulloblastomas or neuroblastomas, in keeping with the WHO Global Initiative for Childhood Cancer. MAIN OUTCOME MEASURE: All-cause mortality at 30 days and 90 days. RESULTS: 1660 patients were recruited. 219 children had changes to their treatment due to the pandemic. Patients in LMICs were primarily affected (n=182/219, 83.1%). Relative to patients with paediatric cancer in HICs, patients with paediatric cancer in LMICs had 12.1 (95% CI 2.93 to 50.3) and 7.9 (95% CI 3.2 to 19.7) times the odds of death at 30 days and 90 days, respectively, after presentation during the COVID-19 pandemic (p<0.001). After adjusting for confounders, patients with paediatric cancer in LMICs had 15.6 (95% CI 3.7 to 65.8) times the odds of death at 30 days (p<0.001). CONCLUSIONS: The COVID-19 pandemic has affected paediatric oncology service provision. It has disproportionately affected patients in LMICs, highlighting and compounding existing disparities in healthcare systems globally that need addressing urgently. However, many patients with paediatric cancer continued to receive their normal standard of care. This speaks to the adaptability and resilience of healthcare systems and healthcare workers globally

The Global Retinoblastoma Outcome Study: a prospective, cluster-based analysis of 4064 patients from 149 countries

Background Retinoblastoma is the most common intraocular cancer worldwide. There is some evidence to suggest that major differences exist in treatment outcomes for children with retinoblastoma from different regions, but these differences have not been assessed on a global scale. We aimed to report 3-year outcomes for children with retinoblastoma globally and to investigate factors associated with survival. Methods We did a prospective cluster-based analysis of treatment-naive patients with retinoblastoma who were diagnosed between Jan 1,2017, and Dec 31,2017, then treated and followed up for 3 years. Patients were recruited from 260 specialised treatment centres worldwide. Data were obtained from participating centres on primary and additional treatments, duration of follow-up, metastasis, eye globe salvage, and survival outcome. We analysed time to death and time to enucleation with Cox regression models. Findings The cohort included 4064 children from 149 countries. The median age at diagnosis was 23.2 months (IQR 11.0-36.5). Extraocular tumour spread (cT4 of the cTNMH classification) at diagnosis was reported in five (0.8%) of 636 children from high-income countries, 55 (5.4%) of 1027 children from upper-middle-income countries, 342 (19. 7%) of 1738 children from lower-middle-income countries, and 196 (42.9%) of 457 children from low-income countries. Enudeation surgery was available for all children and intravenous chemotherapy was available for 4014 (98.8%) of 4064 children. The 3-year survival rate was 99.5% (95% CI 98.8-100.0) for children from high-income countries, 91.2% (89.5-93.0) for children from upper-middle-income countries, 80.3% (78.3-82.3) for children from lower-middle-income countries, and 57.3% (524-63-0) for children from low-income countries. On analysis, independent factors for worse survival were residence in low-income countries compared to high-income countries (hazard ratio 16.67; 95% CI 4.76-50.00), cT4 advanced tumour compared to cT1 (8.98; 4.44-18.18), and older age at diagnosis in children up to 3 years (1.38 per year; 1.23-1.56). For children aged 3-7 years, the mortality risk decreased slightly (p=0.0104 for the change in slope). Interpretation This study, estimated to include approximately half of all new retinoblastoma cases worldwide in 2017, shows profound inequity in survival of children depending on the national income level of their country of residence. In high-income countries, death from retinoblastoma is rare, whereas in low-income countries estimated 3-year survival is just over 50%. Although essential treatments are available in nearly all countries, early diagnosis and treatment in low-income countries are key to improving survival outcomes. Copyright (C) 2022 The Author(s). Published by Elsevier Ltd.Y

Twelve-month observational study of children with cancer in 41 countries during the COVID-19 pandemic

Childhood cancer is a leading cause of death. It is unclear whether the COVID-19 pandemic has impacted childhood cancer mortality. In this study, we aimed to establish all-cause mortality rates for childhood cancers during the COVID-19 pandemic and determine the factors associated with mortality