Stigma in Pediatric Cancer: An Exploratory Study of Osteosarcoma and Retinoblastoma in Guatemala, Jordan, and Zimbabwe.

PURPOSE: Stigma is an understudied barrier to health care acceptance in pediatric oncology. We sought to explore the stigma experience, including its impact on cancer treatment decision making, and identify strategies to mitigate stigma for patients with osteosarcoma and retinoblastoma in Guatemala, Jordan, and Zimbabwe. METHODS: Participants included caregivers, adolescent patients (age 12-19 years), and health care clinicians. A semistructured interview guide based on The Health Stigma and Discrimination Framework (HSDF) was adapted for use at each site. Interviews were conducted in English, Spanish, Arabic, or Shona, audio-recorded, translated, and transcribed. Thematic analysis focused on stigma practices, experiences, outcomes, drivers, mitigators, and interventions. RESULTS: We conducted 56 interviews (28 caregivers, 19 health care clinicians, nine patients; 20 in Guatemala, 21 in Jordan, 15 in Zimbabwe). Major themes were organized into categories used to adapt the HSDF to global pediatric cancer care. Themes were described similarly across all sites, ages, and diagnoses, with specific cultural nuances noted. Pediatric cancer stigma was depicted as an isolating and emotional experience beginning at diagnosis and including internalized and associative stigma. Stigma affected decision making and contributed to negative outcomes including delayed diagnosis, treatment abandonment, regret, and psychosocial fragility. Overcoming stigma led to positive outcomes including resilience, treatment adherence, pride, and advocacy. Identified stigma drivers and mitigators were linked to potential interventions. CONCLUSION: Participants describe a shared stigma experience that transcends geography, cultural context, age, and diagnosis. Stigma manifestations have the potential to impact medical decision making and affect long-term psychological outcomes. Stigma assessment tools and interventions aimed at stigma mitigation including educational initiatives and support groups specific to pediatric cancer should be the focus of future research.

Síndrome de burnout en cirujanos generales en tiempos de la pandemia COVID-19 / Burnout syndrome in general surgeons in time of the COVID-19 pandemic

Objetivo: Evaluar el síndrome de burnout (SB) en cirujanos generales. Material y Método: Se realizó un estudio de corte transversal en nuestro centro hospitalario, en agosto de 2021. La muestra estuvo formada por 56 profesionales de la salud que incluyeron a residentes y especialistas en cirugia general quienes prestaron servicio en el contexto de la COVID-19. Resultados: La prevalencia del burnout fue del 71%, la edad media fue de 34 años y los residentes fueron los más afectados (62,5%). La distribución por sexo fue de 82,5% en masculinos y 17,5% en el sexo femenino. Del total de evaluados, 23 son casados y 17 solteros, predominando los cirujanos con hijos (60%). Discusión: Entre los pocos estudios publicados sobre el SB en trabajadores de la salud en tiempos de COVID-19 se ubican como posibles factores predisponentes: a las privaciones de sueño, el riesgo biológico ocupacional intrínseco, la cuarentena obligada a la que tienen que someterse los trabajadores de la salud fuera de casa y los dilemas éticos en la toma de decisiones de atención a pacientes. Sin embargo, un estudio ha mostrado que los estresores vinculados al SB más importantes son la falta de equipo de protección personal, el miedo al contagio de COVID-19 y el miedo de contagiar a los familiares. Conclusión: Existe una alta prevalencia del SB en cirujanos generales en el contexto de la pandemia COVID-19. Los más afectados fueron residentes jóvenes de sexo masculino, casados, con hijos y con bajos ingresos económicos.

Objective: To evaluate the burnout syndrome (BS) in general surgeons. Material and Method: A cross-sectional study was carried out in our hospital in August 2021. The sample consisted of 56 health professionals that included residents and specialists in general surgery who provided service in the context of COVID-19 Results: The prevalence of burnout was 71%, the mean age was 34 years and the residents were the most affected (62.5%). Sex was 82.5% in males and 17.5% in females. Of the total evaluated, 23 are married and 17 are single, with a predominance of surgeons with children (60%). Discussion: Among the few studies published on BS in health workers in times of COVID-19, the following are located as possible predisposing factors: sleep deprivation, intrinsic occupational biological risk, the forced quarantine that patients have to undergo. out-of-home health workers and ethical dilemmas in patient care decision-making. However, a study has shown that the most important stressors linked to BS are the lack of personal protective equipment, the fear of contagion of COVID-19 and the fear of infecting family members. Conclusion: There is a high prevalence of BS in general surgeons in the context of the COVID-19 pandemic. The most affected were young male residents, married, with children and with low income.

Phase I clinical trial of ifosfamide, oxaliplatin, and etoposide (IOE) in pediatric patients with refractory solid tumors.

Oxaliplatin, although related to cisplatin and carboplatin, has a more favorable toxicity profile and may offer advantages in combination regimens. We combined oxaliplatin, ifosfamide, and etoposide (IOE) and estimated the regimen's maximum tolerated dose (MTD) in children with refractory solid tumors. Dose-limiting toxicity (DLT) and MTD were assessed at 3 dose levels in a 21-day regimen: day 1, oxaliplatin 130 mg/m (consistent dose); days 1 to 3, ifosfamide 1200 mg/m/d (level 0) or 1500 mg/m/d (levels 1 and 2) and etoposide 75 mg/m/d (levels 0 and 1) or 100 mg/m/d (level 2). Course 1 filgrastim/pegfilgrastim was permitted after initial DLT determination, if neutropenia was dose limiting. Seventeen patients received 59 courses. Without filgrastim (n=9), DLT was neutropenia in 2 patients at dose level 1. No DLT was observed after adding filgrastim (n=8). There was no ototoxicity, nephrotoxicity >grade 1, or neurotoxicity >grade 2. One patient experienced a partial response and 9 had stable disease after 2 courses. In conclusion, the IOE regimen was well tolerated. Without filgrastim, neutropenia was dose limiting with MTD at ifosfamide 1200 mg/m/d and etoposide 75 mg/m/d. The MTD with filgrastim was not defined due to early study closure. Filgrastim allowed ifosfamide and etoposide dose escalation and should be included in future studies.

Cisplatin and etoposide in childhood germ cell tumor: brazilian pediatric oncology society protocol GCT-91.

PURPOSE: In 1988, we formed a consortium of Brazilian institutions to develop uniform standards for the diagnostic assessment and multidisciplinary treatment of children and adolescents with germ cell tumors. We also implemented the first childhood Brazilian germ cell tumor protocol, GCT-91, evaluating two-agent chemotherapy with cisplatin and etoposide (PE). We now report on the clinical characteristics and survival of children and adolescents with germ cell tumors treated on this protocol. PATIENTS AND METHODS: From May 1991 to April 2000, 115 patients (106 assessable patients) were enrolled onto the Brazilian protocol with a diagnosis of germ cell tumor. RESULTS: Patients were treated with surgery only (n = 35) and chemotherapy (n = 71). Important prognostic factors included stage (P = .025), surgical procedure at diagnosis according to resectability (P < .032), and abnormal lactate dehydrogenase value at diagnosis (P < .001). CONCLUSION: The improvement in survival by the introduction of a standard protocol is an important achievement. This is of particular importance for smaller institutions with previous limited experience in the treatment of childhood germ cell tumors. In addition, the results of a two-agent regimen with PE were favorable (5-year overall survival rate is 83.3% for patients in the high-risk group [n = 36] who received PE v 58.8% for patients in the high-risk patients group who received PE plus ifosfamide, vinblastine, and bleomycin [n = 17; P = .017]). Thus for selected patients, complex three-agent regimens may not be necessary to achieve long-term survival, even for some patients with advanced disease.

Transfer of complex frontline anticancer therapy to a developing country: the St. Jude osteosarcoma experience in Chile.

BACKGROUND: A frontline protocol for newly diagnosed osteosarcoma was conducted simultaneously at St. Jude Children's Research Hospital (sponsor) and Calvo Mackenna Hospital (CMH, partner), a public pediatric hospital and national center for the treatment of bone tumors in Santiago, Chile. PROCEDURE: Of 72 eligible patients, 22 (31%) were enrolled and managed in Santiago, without travel to Memphis. Pathology specimens and imaging material were centrally reviewed at St. Jude. Patients received 12 intensive courses of systemic chemotherapy with hematopoietic growth factor support over 35 weeks, and amputation or limb-salvage surgery as indicated for local control. The sponsor assisted the partner site to establish a clinical research infrastructure and obtain hematopoietic growth factor. Communication among medical and nursing teams was maintained throughout the study. Patient-care and protocol issues were discussed frequently between the two centers via scheduled videoconferences and electronic communications. Auditors monitored appropriate study conduct at the international site. RESULTS: No major discrepancies were identified in histologic findings, staging, or imaging studies. Preliminary results demonstrated similar outcome and treatment tolerance; the 2-year event-free survival estimate was 78.5% (95% CI, 51-100%) for patients treated at CMH (median follow-up, 1.6 years) and 74.3% (95% CI, 62-87%) for patients treated at St. Jude (median follow-up, 4 years). Overall per-patient costs were significantly lower in Chile. CONCLUSIONS: Through a twinning mechanism, it is feasible to simultaneously conduct complex front-line osteosarcoma clinical trials at two institutions in countries with different levels of resources.