The outcome and cost of a capacity-building training programme on the early recognition and referral of childhood cancer for healthcare workers in North-West Cameroon.

Aim: Early cancer diagnosis is necessary to improve survival rates. The aim of this study was to assess the outcome and cost of the childhood cancer training programme amongst healthcare workers. Design: This was a prospective pre-post study design, using questionnaires for pre- and post-training testing. The warning signs of childhood cancer were used as the main teaching content to improve recognition and early diagnosis. Methods: Pre-training and post-training knowledge, as well as attitude questionnaires, was administered at the beginning and at the end of each training workshop. Paired samples t test and chi-square were used to compare the change in knowledge and differences between groups. Results: The overall percentage knowledge score increased from 51%-85% (p < .001). The doctors had a better knowledge score than the nurses in the pre-test (70% versus 50%, p = .008), but there was no significant difference in the post-test scores. The cost of training was €25.06 per healthcare worker. Conclusion: We recommend similar training programmes in public health to improve early diagnosis of childhood cancer.

Destitution, treatment adherence and survival of children with Burkitt lymphoma in a twinning programme in Northwest Cameroon.

BACKGROUND: Burkitt lymphoma (BL) is a curable childhood cancer. Treatment adherence is crucial for a good outcome, but is potentially problematic in low- and middle-income countries owing to parental financial constraints. AIMS: To investigate the association of destitution with treatment adherence and its effect on the survival of patients with BL. METHODS: Patients received free medical treatment from a twinning programme at two Cameroon Baptist hospitals. A destitution assessment questionnaire, based on socioeconomic status, was completed at diagnosis. Medical records were reviewed for treatment adherence and survival. Chi-squared and Fisher's exact tests were used to compare groups. Kaplan-Meier plots were used to calculate overall survival, and log-rank chi-squared tests when comparing survival rates between patient subgroups. Significance was measured at P < .05. RESULTS: The 225 children with BL had a mean age of 8.2 years (median 8.0) and the overall survival was 52%. The mean family destitution score was 56% on a linear scale. Few (8%) patients delayed treatment appointments. A quarter (25%) experienced more than a 1-week follow-up delay and 9.8% absconded within 1 year. The destitution score was not significantly associated with delay of treatment, but with delay in follow-up (P < .001). Guardian relationship (single mother) and patient's age were significantly associated with overall survival (P = .025). CONCLUSIONS: Though linked to poor follow-up, destitution was not significantly associated with absconding patients, poor outcome or poor adherence to treatment, probably due to comprehensive financial support from the international twinning programme. However, additional support for single mothers should be considered.

The role of traditional healers in the diagnosis and management of Burkitt lymphoma in Cameroon: understanding the challenges and moving forward.

BACKGROUND: Burkittlymphoma(BL) is the most common childhood cancer in Cameroon with a reported incidence of 3 per 100,000 children under 15 years in the Northwest region. Treatment at three Baptist mission hospitals has a recorded cure rate of over 50%. Traditional medicine(TM) is recognized by the national health system, but its scope is undefined and entraps children with BL. The aim of this study was to investigate the attitudes and practices of parents and traditional healers (TH) towards TM in children with BL in order to develop recommendations for an integrative approach and improved access to life-saving treatment for children with BL. METHODS: This is a descriptive case series of children diagnosed with BL treated at Banso, Mbingo, and Mutengene Baptist Hospitals between 2003 and 2014. A questionnaire was used to obtain the following information: demographic information, religion, the rate of use of TM, reasons why guardians chose to use TM, the diagnoses made by the TH, treatment offered, and the type of payment requested, based on the accounts of patient caregivers. Data was analyzed using Center for Disease Control Epi Info 7. RESULTS: Three hundred eighty-seven questionnaires were completed by parents/guardians. 55% had consulted a TH, of whom 76.1% consulted the TH as first choice. Common diagnoses provided by TH included liver problem, abscess, witchcraft, poison, hernia, side pain, mushroom in the belly and toothache. Methods of management included massage, cuts, concoctions, and incantations. The fee for these services included chickens, farm tools, and cash ranging from 200FCFA (0.4USD) to 100,000FCFA(200USD). The choice of TM was based on accessibility, failed clinic/hospital attendance, recommendation of relatives, and belief in TM. CONCLUSIONS: TH are involved in BL management in Cameroon. TH are ignorant about BL, resulting in non-referral, and thus delay in diagnosis and treatment. Collaboration with TH could reduce late diagnosis and improve cure rates of BL and other childhood cancers.

An evaluation of a palliative care outreach programme for children with Burkitt lymphoma in rural Cameroon.

BACKGROUND: Palliative care (PC) is the most appropriate treatment for patients with life-limiting, incurable diseases, but it is a relatively new concept in sub-Saharan Africa (SSA). A lack of curative treatment options for some conditions creates a great need for PC, but such services are rarely provided in SSA. More research into PC in SSA is urgently needed to create an evidence base to confirm the importance of appropriate PC services. OBJECTIVES: To gain a better understanding of the needs of patients and their families visited by a children's PC nurse in Cameroon and to identify aspects of the service that can be improved. METHODOLOGY: A qualitative study design with semi-structured interviews was used. Tape-recorded interviews were transcribed and thematically analysed. RESULTS: Twelve interviews were conducted with patients, carers and nurses. Financial aid, general disease improvement and prayers were the directly expressed needs of service recipients. Specialist training in children's PC was the main need expressed by the nurses. Open communication about clinical status and treatment failure, more detailed counselling, more distraction for patients and respite for carers were identified as underlying needs. CONCLUSION: It is possible to provide an effective children's PC service that meets the most urgent needs of recipients in a rural setting in SSA. Recommendations include improved counselling, specialist education for staff, expansion of local support networks and more frequent home visits. More studies are needed to help define the need for PC in children with life-limiting diseases.

The Collaborative Wilms Tumour Africa Project; baseline evaluation of Wilms tumour treatment and outcome in eight institutes in sub-Saharan Africa.

AIM: Reported survival of Wilms tumour in sub-Saharan Africa is below 50%. A published International Society of Pediatric Oncology (SIOP) Pediatric Oncology in Developing Countries (PODC) consensus adapted treatment guideline is implemented as a multi-centre prospective clinical trial at eight centres in sub-Saharan Africa. A baseline evaluation has been done to help decide on priorities to improve outcome and to assess improvements over time. METHODS: A retrospective chart review was performed of patients admitted with Wilms tumour in the three years (2011-2013) preceding the collaborative trial. Patient outcome at the end of treatment was documented for all patients diagnosed in 2011 and 2012. Outcome was classified as (1) alive, no evidence of disease; (2) alive with disease; (3) died during treatment and (4) incomplete treatment. Details on treatment facilities, staff and estimated cost of treatment are documented. RESULTS: Every year 114-130 patients are diagnosed. The mean survival at end of treatment is 39% (69/176) ranging from 11% to 61%. Incomplete treatment is the most common cause of treatment failure with 31% (54/176), ranging from 14% to 48% between centres. Twenty-six percent (46/176) of patients died during treatment, ranging from 13% to 37%. Estimated cost of treatment for parents ranged from 100 US$ to 1100 US$ and was considered an important cause of failure to complete treatment. CONCLUSION: Overall two year survival is estimated at 25%. Prevention of incomplete treatment is possible and will positively affect outcome. Sharing similar local challenges in this regional collaborative project helps to identify and implement feasible, sustainable and successful strategies.

An interinstitutional review of the value of FNAB in pediatric oncology in resource-limited countries.

Fine-needle aspiration biopsy (FNAB) has been widely accepted as a reliable diagnostic modality in the general pediatric population, but its role in pediatric oncology still remains elusive. With new treatment protocols subscribing to preoperative chemotherapy, the need for a quick, minimally invasive, and accurate diagnostic procedure has arisen. This study assesses the feasibility of FNAB in childhood malignancies to render a specific diagnosis on which treatment can be initiated. An 11-year retrospective study was done on FNABs in patients 19 years and under referred for clinically malignant mass lesions. Cases were confirmed with histology, immunocytochemistry, flow cytometry, or clinical follow-up. Of the 357 patients referred for FNABs, 36 patients were lost to follow-up and 31 FNABS were inadequate. A total of 290 cases were included in the study, of which 68 (23%) cases were benign and 222 (77%) were malignant. The most frequently occurring tumors were nephroblastoma (68), non-Hodgkin's lymphoma (39), rhabdomyosarcoma (22), Hodgkin's lymphoma (22), and neuroblastoma (22). The sensitivity of the procedure for neoplasia was 96.6%, the specificity 97.0%, positive predictive value 99.0%, and negative predictive value 90.1%, with a diagnostic accuracy of 96.7%. The ability of FNAB to enable a specific diagnosis to be made, that is correct and accurate subtyping of the tumor on which chemotherapy or radiotherapy could be commenced was 75.7%. This study shows that FNAB can be used with confidence to confirm malignancy in children. With clinicoradiological correlation and the aid of ancillary techniques, FNAB allows a rapid and accurate preoperative diagnosis for definitive therapy commencement in most cases.

Meeting the challenge of hematologic malignancies in sub-Saharan Africa.

Cancer is a leading cause of death and disability in sub-Saharan Africa and will eclipse infectious diseases within the next several decades if current trends continue. Hematologic malignancies, including non-Hodgkin lymphoma, leukemia, Hodgkin lymphoma, and multiple myeloma, account for nearly 10% of the overall cancer burden in the region, and the incidence of non-Hodgkin lymphoma and Hodgkin lymphoma is rapidly increasing as a result of HIV. Despite an increasing burden, mechanisms for diagnosing, treating, and palliating malignant hematologic disorders are inadequate. In this review, we describe the scope of the problem, including the impact of endemic infections, such as HIV, Epstein-Barr virus, malaria, and Kaposi sarcoma-associated herpesvirus. We additionally describe current limitations in hematopathology, chemotherapy, radiotherapy, hematopoietic stem cell transplantation, and supportive care and palliation. We review contemporary treatment and outcomes of hematologic malignancies in the region and outline a clinical service and research agenda, which builds on recent global health successes combating HIV and other infectious diseases. Achieving similar progress against hematologic cancers in sub-Saharan Africa will require the sustained collaboration and advocacy of the entire global cancer community.

Malawi pilot study of Burkitt lymphoma treatment.

BACKGROUND: Burkitt lymphoma (BL) accounts for 50% of childhood cancer in Malawi. Lack of resources precludes the use of new successful treatment approaches such as the LMB 89 group B protocol, which cures >80% of children with stage III BL with high dose chemotherapy and matching supportive care. Our objective was to achieve a good cure rate in Murphy stage I-III BL with manageable toxicity in Malawi at a drug cost of <1000 US dollars per patient. PROCEDURE: The intensity and toxicity of the LMB 89 group B protocol was reduced and adapted to Malawi realities. All stages received the same treatment. Children with suspected BL in the period July 1997-November 1999 were subjected to abdominal ultrasound, a tumor biopsy and/or fine needle aspirate (FNA) and bone marrow (BM), cerebrospinal fluid (CSF), and peripheral blood examination. HIV seropositive children were excluded. Endpoints are projected event free survival (EFS) at minimum 1 year, blood and gastro-intestinal tract toxicity, and risk for and severity of infections. RESULTS: Forty-four children were eligible for treatment and analysis. Their median age was 7.2 years, M:F ratio 1.4:1 with 10 stage I, 5 stage II, and 29 stage III patients. Projected Kaplan-Meier EFS for all was 57% (CI 41-73) at 1 year with 90% EFS in stage I and 52% EFS in stage III. The survival curve remained stable at 500 days. Toxicity and delays in appropriate supportive care contributed to ten deaths during treatment. Local recurrent tumor caused five and CNS recurrence one death. Two children died from progressive disease. The incidence of severe (grade 3 and/or 4) hematologic toxicity varied from 13% to 36%, gastro-intestinal toxicity (GIT) from 2% to 17%, and infections from 7% to 41% per chemotherapy module. CONCLUSIONS: It is possible to administer less intense and less costly multiagent chemotherapy to children with BL in a developing society with acceptable EFS rates. Adequate supportive care of the at-times associated severe toxicity must be made available to better the results.