CITATION: Chitsike, I., et al. 2020. Working together to build a better future for children with cancer in Africa. JCO Global Oncology, 6:1076-1078.The original publication is available at https://ascopubs.org/doi/10.1200/GO.20.00170ENGLISH ABSTRACT: No abstract availablehttps://ascopubs.org/doi/10.1200/GO.20.00170Publisher's versio

Afungchwi, Glenn M.

Chagaluka, George

Chitsike, Inam

Hesseling, Peter B.

Hessissen, Laila

Ilbawi, Andre

Israels, Trijn

Kaspers, Gertjan

Kouya, Francine

Mavinkurve-Groothuis, Annelies

Molyneux, Elizabeth

Njuguna, Festus

Paintsil, Vivian

Pritchard-Jones, Kathy

Renner, Lorna

Sung, Lillian

Stellenbosch University SUNScholar Repository

SPECIAL SERIES: ONCOLOGY CLINICAL TRIALS IN AFRICA: THE LANDSCAPE AND UPDATESreviewarticlesWorking Together to Build a Better Future forChildren With Cancer in AfricaInam Chitsike, MD1; Vivian Paintsil, MD2; Lillian Sung, MD, PhD3; Festus Njuguna, MD, PhD4; Annelies Mavinkurve-Groothuis, MD, PhD5;Francine Kouya, MD6; Peter Hesseling, MBChB, MMed, MD7; Gertjan Kaspers, MD, PhD5,8; Glenn M. Afungchwi, RN, MPH6;Andre Ilbawi, MD9; Lorna Renner, MBChB, MPH10; Kathy Pritchard-Jones, MD, PhD11; Laila Hessissen, MD12;Elizabeth Molyneux, MBBS13; George Chagaluka, MBBs, MMED13; and Trijn Israels, MD, PhD5There has been substantial improvement in survival ofchildren with cancer in high-income countries. How-ever, great challenges remain in low- and middle-income countries, where . 80% of children withcancer live.1 Survival in many countries in Africa, forexample, is estimated to be , 20%.2 The WHO re-cently launched the Global Initiative for ChildhoodCancer (GICC), which aims to increase survival ofchildren with cancers worldwide to. 60% by 2030 bypromoting access to high-quality cancer care for allchildren and with an initial focus on common andcurable cancer types.3As a group of pediatricians caring for children withcancer in Africa, we recognized the need to focus on 3activities—quality service provision, local data, andlocally relevant clinical research—to allow us to im-prove outcomes together. We realized that serviceprovision would not improve if we continued to rely onfragmented protocol development and outcome as-sessment at separate units. We required local data todevelop locally relevant, collaborative studies to findsustainable solutions to local challenges that will resultin substantial and sustained long-term gains. On thebasis of these 3 pillars of quality service, local data, andlocally relevant research, we are committed to co-ordinate research to establish and promote bestpractices within our network.Oncology units in well-resourced settings have benefit-ted greatly from multicenter collaborations in all aspectof cancer care delivery, resulting in improved outcomesfor children with cancer. Multicenter collaborations canand should be global in their design and value.4 Ac-curate local data on numbers of patients on treatment,accuracy of diagnosis, causes of treatment failure, andthe efficacy of specific interventions are required to in-form the strategies for improved care and outcomes.Our aim is to increase the survival of children withcommon and curable cancers in Africa to exceed60%, in line with the WHO GICC.With the same goal in mind, the Collaborative WilmsTumor Africa project was formed in 2014 and hasbeen implementing a consensus-adapted treatmentguideline in 8 centers in sub-Saharan Africa asa multicenter clinical trial.5 This guideline wasdeveloped by the Committee for Pediatric Oncologyin Developing Countries (PODC) of the InternationalSociety of Paediatric Oncology (SIOP).6,7 Currentlyparticipating centers are in Blantyre (Malawi); Eldoret(Kenya); Accra and Kumasi (Ghana); Mbingo, Banso,and Mutengene (Cameroon); and Harare (Zimbabwe).Funding was received from SIOP and World ChildCancer and distributed to all participating centers tocover treatment, travel, and other associated costs forpatients.In the first 4 years of the trial (2014-2018), 201 pa-tients were included. After implementation, comparedwith the baseline evaluation, survival without evidenceof disease at the end of treatment increased (69% v52%, respectively; P = .002), abandonment of treat-ment declined (12% v 23%, respectively; P = .009),and fewer patients died during treatment (13% v 21%,respectively; P = .06).8 Two-year event-free survivalwas 49.9% 6 3.8% in this patient cohort whenabandonment of treatment was considered an event.9The Collaborative Wilms Tumor Africa Project Phase IIis planned to start in the second half of 2020 andaims to improve survival further. There are minor revi-sions to the comprehensive adapted treatment guide-line based on lessons learned in Phase I.10After establishing, implementing, and evaluatinginitial treatment guidelines, we analyzed clinical dataand recognized that the major barrier to using moreintensive treatment regimens was the lack of opti-mal supportive care.9 In 2019, Supportive Care forChildren With Cancer in Africa (SUCCOUR) wasinitiated, with a goal to improve supportive care andreduce treatment-related mortality further. Buildingon the regional network of the Collaborative WilmsTumor Africa Project and the lessons learned,SUCCOUR aims to promote improvements in sup-portive care for every child in Africa to be able to becured from cancer.We are currently conducting a baseline evaluation ofcurrent practices and outcomes in the following im-portant areas of supportive care: malnutrition, febrileneutropenia, abandonment, and treatment-relatedmortality. This baseline evaluation will be fundamen-tal to understanding the current situation and willAuthor affiliationsand supportinformation (ifapplicable) appear atthe end of thisarticle.Accepted on June 2,2020 and published atascopubs.org/journal/go on July 16, 2020:DOI https://doi.org/10.1200/GO.20.00170Licensed under theCreative CommonsAttribution 4.0License1076facilitate the development and prioritization of supportivecare interventions. It will provide a benchmark for futureevaluation of the impact of implemented interventions.Abandonment, or incomplete treatment, is known to be animportant problem in our centers, and our goal will be toreduce it to zero. Hence, the third project, Toward ZeroPercent Abandonment, was started in Blantyre, Malawi, in2019. It aims to eliminate incomplete treatment. Aban-donment of treatment is a known common and preventablecause of treatment failure in low-income countries.11 Thebaseline evaluation of this project in Malawi documen-ted that 49 (19%) of 264 patients diagnosed in 2018 and2019 with common and curable cancers had abandonedtreatment.12 Interventions in Malawi to prevent abandon-ment include full coverage of treatment, accommodationand transport costs, a tracking system to remind patients ofappointments, and more systematic and improved coun-seling of parents of the need to complete treatment. Weintend to introduce this project in all participating centersover the next 1-3 years.The Collaborative Wilms Tumor Africa Project, SUCCOUR,and Toward Zero Percent Abandonment form the currentcore of the Collaborative African Network of Clinical Careand Research for Childhood Cancer (CANCaRe Africa). Wesee the network as a platform on which to build thesecollaborative studies with the intention that other studiescan and will be added to create change. The vision ofCANCaRe Africa is that children with common and curablecancers in sub-Saharan Africa will achieve survival rates. 60%-70%, in line with the GICC. The mission is to achievethis by reducing treatment-related deaths to , 10%; re-ducing abandonment of treatment to , 10%; and de-veloping, implementing, and evaluating locally appropriatetreatment guidelines.CANCaRe Africa has collaborated and aligned with othernational and international initiatives. We are sharing ourbest practices with the WHO GICC, allowing our platform,experience, and knowledge to serve the broader com-munity. Collaborative research and innovation are essentialto achieving the targets established by the WHO initiative,and we are actively supporting these WHO workstreams.Collaborative research and innovation are essential toachieving the targets established by the WHO GICC; we areactively supporting WHO workstreams related to estab-lishing treatment standards, to incorporating supportivecare programs as part of universal health coverage, andto defining core indicators used in monitoring programsand research. SIOP, including SIOP Africa and SIOPPODC, is the global scientific pediatric oncology umbrellaorganization.13 We collaborate within the SIOP communityto learn from other groups, develop our guidelines, andimplement and evaluate them according to robust scientificstandards. We also work closely with our national gov-ernments, allowing for sustainable uptake of our programsin the public sector. Current funding for the activities of thisregional network comes from SIOP, World Child Cancer,and the Sanofi Espoir Foundation, who share our vision. Wehope to expand these partnerships and include others tohave sustainable and hopefully increased funding to deliveron our aims and objectives.Over the past few years, we have learned many lessons.14We do work according to a shared vision, mission, andprinciples by designing feasible interventions, achievingincremental steps, and ensuring long-term sustained im-pact. We give priority to interventions with the highestexpected impact on child survival, cognizant of the currentprofound inequalities. Our philosophy is that local leadersare in the best position to assess feasibility of interventionsand set priorities. Transparency, trust, and a shared pur-pose are essential. We work through national institutionalreview boards, ensure the validity of our results, and rou-tinely report successes and challenges internally and ex-ternally. Friendship, good communication, and comraderyare facilitators in achieving our vision and at the core of oursuccess.We have established an active regional network for child-hood cancer that can be a platform for further initiatives toimprove care and survival, including but not limited to theWHO GICC. This is only the beginning of our work. To-gether, we are finding sustainable solutions to shared localchallenges for children with cancer in our community andaround the world.AFFILIATIONS1Department of Pediatrics, College of Health Sciences, Harare,Zimbabwe2Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi,Ghana3The Hospital for Sick Children, Toronto, Ontario, Canada4Moi University/Moi Teaching and Referral Hospital, Eldoret, Kenya5Princess Máxima Center for Pediatric Oncology, Utrecht, theNetherlands6Department of Pediatric Oncology, Mbingo Baptist Convention Hospital,Mbingo, Cameroon7Department of Pediatrics and Child Health, Stellenbosch University,South Africa8Emma Children’s Hospital, Amsterdam UMC, Vrije UniversiteitAmsterdam, Pediatric Oncology, Amsterdam, the Netherlands9Global Initiative for Childhood Cancer, WHO, Geneva, Switzerland10Department of Child Health, University of Ghana Medical School,Accra, Ghana11University College London, London, United Kingdom12Pediatric Hematology and Oncology Center, Mohamed V University,Rabat, Morocco13Department of Pediatrics, College of Medicine, Blantyre, MalawiCollaborative Childhood Cancer Clinical Research in AfricaJCO Global Oncology 1077CORRESPONDING AUTHORTrijn Israels, MD, Princess Máxima Center for Paediatric Oncology,Heidelberglaan 25, 3584 CS Utrecht, The Netherlands; Twitter:@AfricaCancare; e-mail: T.Israels-3@prinsesmaximacentrum.nl.SUPPORTSupported by the International Society of Paediatric Oncology, WorldChild Cancer, and the Sanofi Espoir Foundation.AUTHOR CONTRIBUTIONSConception and design: Inam Chitsike, Vivian Paintsil, Festus Njuguna,Gertjan Kaspers, Kathy Pritchard-Jones, Laila Hessissen, ElizabethMolyneux, George Chagaluka, Trijn IsraelsFinancial support: Gertjan KaspersProvision of study materials or patients: Inam Chitsike, Peter Hesseling,Lorna RennerCollection and assembly of data: Inam Chitsike, Vivian Paintsil, FrancineKouya, Peter Hesseling, Glenn M. Afungchwi, Lorna Renner, GeorgeChagalukaData analysis and interpretation: Inam Chitsike, Vivian Paintsil, LillianSung, Annelies Mavinkurve-Groothuis, Andre Ilbawi, Laila Hessissen,George ChagalukaManuscript writing: All authorsFinal approval of manuscript: All authorsAccountable for all aspects of the work: All authorsAUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OFINTERESTThe following represents disclosure information provided by authors ofthis manuscript. All relationships are considered compensated unlessotherwise noted. Relationships are self-held unless noted. I = ImmediateFamily Member, Inst = My Institution. Relationships may not relate to thesubject matter of this manuscript. For more information about ASCO’sconflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/go/site/misc/authors.html.Open Payments is a public database containing information reported bycompanies about payments made to US-licensed physicians (OpenPayments).Gertjan KaspersConsulting or Advisory Role: Helsinn Healthcare, AbbVie, BoehringerIngelheim, Medix Medical Services ASIA, AgiosNo other potential conflicts of interest were reported.REFERENCES1. Lam CG, Howard SC, Bouffet E, et al: Science and health for all children with cancer. Science 363:1182-1186, 20192. Ribeiro RC, Steliarova-Foucher E, Magrath I, et al: Baseline status of paediatric oncology care in ten low-income or mid-income countries receiving My ChildMatters support: A descriptive study. Lancet Oncol 9:721-729, 20083. WHO: The Global Initiative for Childhood Cancer, 2019. https://www.who.int/cancer/childhood-cancer/en/4. Rodriguez-Galindo C, Friedrich P, Alcasabas P, et al: Toward the cure of all children with cancer through collaborative efforts: Pediatric oncology as a globalchallenge. J Clin Oncol 33:3065-3073, 20155. Israëls T, Kambugu J, Kouya F, et al: Clinical trials to improve childhood cancer care and survival in sub-Saharan Africa. Nat Rev Clin Oncol 10:599-604, 20136. Israels T, Moreira C, Scanlan T, et al: SIOP PODC: Clinical guidelines for the management of children with Wilms tumour in a low income setting. Pediatr BloodCancer 60:5-11, 20137. Israels T, Renner L, Hendricks M, et al: SIOP PODC: Recommendations for supportive care of children with cancer in a low-income setting. Pediatr BloodCancer 60:899-904, 20138. Paintsil V, David H, Kambugu J, et al: The Collaborative Wilms Tumour Africa Project: Baseline evaluation of Wilms tumour treatment and outcome in eightinstitutes in sub-Saharan Africa. Eur J Cancer 51:84-91, 20159. Chagaluka G, Paintsil V, Renner L, et al: Improvement of overall survival in the Collaborative Wilms Tumour Africa Project. Pediatr Blood Cancer 11:e28383,202010. Israels T, Paintsil V, Chitsike I, et al: Treatment guidelines: Collaborative Wilms Tumour Africa Project Phase II. https://siop-online.org/wp-content/uploads/2020/04/Treatment-Guidelines-Collaborative-Wilms-Tumour-Africa-Project-Phase-II-doc-v1.8-FINAL.pdf11. Friedrich P, Lam CG, Itriago E, et al: Magnitude of treatment abandonment in childhood cancer. PLoS One 10:e0135230, 201512. Chakumatha E, Weijers J, Banda K, et al: Outcome at the end of treatment of patients with common and curable childhood cancer types in Blantyre, Malawi.Pediatr Blood Cancer 67:e28322, 202013. Khalek ER, Afungchwi GM, Beltagy ME, et al: Highlights from the 13th African Continental Meeting of the International Society of Paediatric Oncology (SIOP), 6-9 March 2019, Cairo, Egypt. Ecancermedicalscience 13:932, 201914. Israels T, Molyneux EM, SIOP Africa-PODC Collaborative Wilms Tumour Project Group: Lessons learned from a multicentre clinical trial in Africa. Nat Rev ClinOncol 16:211-212, 2019n n nChitsike et al1078 © 2020 by American Society of Clinical Oncology

Working together to build a better future for children with cancer in Africa

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Working together to build a better future for children with cancer in Africa

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