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

Prevalence and risk factors of asymptomatic bacteriuria among children living with HIV in Lagos, Nigeria

Introduction: HIV/AIDS has gradually become a chronic disorder following the success of combination chemotherapy. As a result of the persisting immune deficiency, certain risk factors predispose affected individuals to infections. The aim of the study was to determine the prevalence and identify risk factors of asymptomatic bacteriuria among HIV infected children. Methods: this was a case control study conducted at the Lagos University Teaching Hospital from July 2010 to June 2011.Eighty-five children living with HIV were consecutively selected from the HIV clinic of the Lagos University Teaching Hospital and compared with 85 age and sex matched HIV negative controls for the occurrence of asymptomatic bacteriuria. Mid-stream urine samples were obtained from the participants and the samples were analyzed for microscopy, culture and sensitivity. Demographic and clinical data was obtained from the caregivers and clinical notes respectively. Data were analyzed utilizing SPSS version 17. Results: the prevalence of asymptomatic bacteriuria was 24.7% among children living with HIV and 8.2% among un-infected children (p value 0.004). The stage of the disease, CD4 count, sex as well as age were risk factors for asymptomatic bacteriuria among children living with HIV. Conclusion: asymptomatic bacteriuria is a prevalent problem among children living with HIV infection and urinary screening should be routine in the work up of febrile children living with HIV

Spectrum of Thyroid Abnormalities among Children Living with HIV in Lagos, Nigeria

Thyroid disorders have been described in an adult population but are underreported in the pediatric population. The aim of this study was to determine the prevalence and describe the spectrum of thyroid abnormalities among HIV infected children on Highly Active Antiretroviral Therapy (HAART) in Lagos, Nigeria. This was a cross-sectional study carried out at a teaching hospital with an antiretroviral therapy (ART) center. Serum levels of thyroid stimulating hormone (TSH), free triiodothyronine (fT3), and free thyroxine (fT4) were analyzed in 83 children living with HIV on HAART and 51 controls. The prevalence of thyroid dysfunction and correlation of fT3, fT4, and TSH with duration on HAART, age, CD4 count, and nutritional status were assessed. Thyroid abnormalities were seen in 9.6% of the children living with HIV comprising subclinical hypothyroidism in 6%, euthyroid sick syndrome in 2.4%, and overt hypothyroidism in 1.2% as compared to 2% subclinical thyroid disease among the controls (p= 0.15). Hypothyroidism was correlated with CD4 count and viral load. None of the patients had clinical features of thyroid disease. Thyroid abnormalities were more prevalent among children living with HIV and yearly screening with follow-up is advocated

Childhood cancer in Nigeria: The effect of a handbook in the experiences of caregivers

Background: Parents of children diagnosed with cancer are handed a frightening diagnosis, with attendant emotional, social, and financial challenges. They often have many questions that remain unanswered by busy doctors and nurses, who are themselves overwhelmed by the challenges of caring for cancer patients in resource-constrained circumstances. The objective of this study is to evaluate the impact of a childhood cancer handbook on the experience of caregivers of children diagnosed with paediatric cancer in Nigeria.Methodology: A series of focus group discussions involving caregivers of children with histologically diagnosed cancer were held. A childhood cancer handbook was given to each participant to read. Data was collected four weeks later and analysed using qualitative content analysis.Results: In general, 91.7% of focus group participants reported that they found the handbook useful and having it at diagnosis would have significantly increased their level of information and made dealing with the diagnosis more tolerable. However, many of the participants reported that while the book completely catered to their informational and emotional needs, it did not adequately address certain practical needs such as paying for cancer treatment.Conclusion: Many Nigerian families go through the entire paediatric cancer journey, feeling like they are stumbling in the dark. No dedicated information resource on paediatric cancer exists in Nigeria. The provision of a detailed handbook at diagnosis may reduce the psychological and emotional toll of a cancer diagnosis on parents and family of a child diagnosed with cancer

Health insurance and the financial implications of sickle cell disease among parents of affected children attending a tertiary facility in Lagos, south-west Nigeria

Introduction: there is a paucity of data on the financial implications of sickle cell disease on households of affected children and their use of health insurance in Nigeria. This study assessed the awareness of health insurance, patterns of health service utilization and financial implications of sickle cell disease among children seeking care at a tertiary facility in Nigeria. Methods: a structured questionnaire was administered to parents of 314 children with sickle cell disease attending the pediatric hematology unit of the Lagos University Teaching Hospital between May and December 2019. Results: mean age of the children was 91.5 ± 43.1 months. M:F was 1.17:1. 45.5% of households earned above NGN 150,000 (USD 417) monthly. 71.3% of the parents had heard of health insurance but only 20.7% were enrolled in a health insurance scheme. Awareness of health insurance was significantly associated with social class (p=0.000) and monthly household income (p=0.000). 60.8% of the parents preferred pre-facility treatment. Social class (p=0.01) and monthly household income (p=0.001) were significantly associated with home treatment. Time on admission ranged from 2-18 days with an average of 4.31 days. Average cost of hospitalization was USD 148 ± USD 14.2 and total cost of care incurred was USD 20,787. Neither age of child (p=0.857), estimated household income (p=0.863) nor social class (p=0.397) was associated with cost of care. Conclusion: a high cost of care was observed in our study population underscoring the need for increased awareness and access to health insurance for households of children with sickle cell disease

Challenges of retinoblastoma management in a Nigerian tertiary eye care facility

Background: Retinoblastoma is the most common intraocular childhood malignancy. Its management is, however, not without challenges especially in a developing country like Nigeria. This study sought to present the clinical profile and treatment outcome of patients with retinoblastoma managed in a Nigerian tertiary eye care facility highlighting the challenges with a view to improving the management of the disease. Materials and Methods: A retrospective, single-institution, and institutional review board-approved review of all patients diagnosed with retinoblastoma between January 2012 and December 2015 was done. Data obtained from case files of patients include demographic characteristics, presenting complaint, laterality of disease, tumor stage using the International Intraocular Retinoblastoma Classification, treatment, and outcome. Information obtained from phone calls to the caregivers were also summarized. Results: The review included 54 eyes of 41 patients between the ages of 2 months and 5 years. The mean age at presentation was 24.4 ± 11.4 months. There were 18 males (43.9%). Duration of symptoms before presentation ranged from 2 weeks to 2 years. Tumor was bilateral in 13 (31.7%) patients. Leukocoria was the most common presenting complaint observed in 32 (59.2%) eyes. Groups D and E were the most common intraocular tumor stage documented in 16 (29.7%) and 15 (27.8%) eyes, respectively. Most patients (29, 70.7%) defaulted from treatment after the first or second presentation. Only 6 (21.4%) of 28 patients offered enucleation or modified exenteration either at presentation (Class E) or after chemoreduction (orbital disease) consented. Conclusion: Late presentation, high default rate, and noncompletion of treatment were the major challenges facing retinoblastoma management in this center

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

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