Sustainable care for children with cancer: a Lancet Oncology Commission.

We estimate that there will be 13·7 million new cases of childhood cancer globally between 2020 and 2050. At current levels of health system performance (including access and referral), 6·1 million (44·9%) of these children will be undiagnosed. Between 2020 and 2050, 11·1 million children will die from cancer if no additional investments are made to improve access to health-care services or childhood cancer treatment. Of this total, 9·3 million children (84·1%) will be in low-income and lower-middle-income countries. This burden could be vastly reduced with new funding to scale up cost-effective interventions. Simultaneous comprehensive scale-up of interventions could avert 6·2 million deaths in children with cancer in this period, more than half (56·1%) of the total number of deaths otherwise projected. Taking excess mortality risk into consideration, this reduction in the number of deaths is projected to produce a gain of 318 million life-years. In addition, the global lifetime productivity gains of US$2580 billion in 2020-50 would be four times greater than the cumulative treatment costs of $594 billion, producing a net benefit of $1986 billion on the global investment: a net return of $3 for every $1 invested. In sum, the burden of childhood cancer, which has been grossly underestimated in the past, can be effectively diminished to realise massive health and economic benefits and to avert millions of needless deaths.

[Retinoblastoma in Senegal: Pathologist's view]. / Le rétinoblastome au Sénégal : point de vue du pathologiste.

OBJECTIVES: Describe the macroscopic and microscopic profiles of the retinoblastoma (RB) in Senegal and correlate histological criteria to evolution to emerge severity factors. METHODOLOGY: We realized a retrospective study on 10years (January 2005-December 2014). Only patients (n=67) who performed a histological analysis of the enucleation specimen (n=68) were followed until the end of the study. RESULTS: The tumor measured an average of 3.8cm (2/4.5). Endophytic tumor development was in 55 cases (80.8%), exophytic in 6 cases (8.9%) and mixed in 7 cases (10.3%). Extra-retinal form was present in 13 cases (19.2%). The RB was well differentiated in 11 cases (16.2%), moderately differentiated in 31 cases (45.6%) and undifferentiated in 26 cases. The invasion of optic nerve (ON) was present in 18 cases (26.5%). The tumor was extra-retinal in 37 cases (54.4%). The anterior chamber was invaded in 6 cases (8.8%). The global survival at 2years was 84% and 70% at 5years. In multivariate analysis, well tumor differentiation and stage pT1 were associated with remission. The other-laminar of ON invasion, the massive invasion of the choroid and pT3 stage were recurrence risk factors. The undifferentiating tumor, invasion of the ON section, tumor sclera crossing and pT4 stage were predictive death. CONCLUSION: The RB histological prognostic factors should be clearly identified in the pathological reports as they guide the after surgical period care and follow-up management strategy.

The My Child Matters programme: effect of public-private partnerships on paediatric cancer care in low-income and middle-income countries.

In low-income and middle-income countries, an excess in treatment failure for children with cancer usually results from misdiagnosis, inadequate access to treatment, death from toxicity, treatment abandonment, and relapse. The My Child Matters programme of the Sanofi Espoir Foundation has funded 55 paediatric cancer projects in low-income and middle-income countries over 10 years. We assessed the impact of the projects in these regions by using baseline assessments that were done in 2006. Based on these data, estimated 5-year survival in 2016 increased by a median of 5·1%, ranging from -1·5% in Venezuela to 17·5% in Ukraine. Of the 26 861 children per year who develop cancer in the ten index countries with My Child Matters projects that were evaluated in 2006, an estimated additional 1343 children can now expect an increase in survival outcome. For example, in Paraguay, a network of paediatric oncology satellite clinics was established and scaled up to a national level and has managed 884 patients since initiation in 2006. Additionally, the African Retinoblastoma Network was scaled up from a demonstration project in Mali to a network of retinoblastoma referral centres in five sub-Saharan African countries, and the African School of Paediatric Oncology has trained 42 physicians and 100 nurses from 16 countries. The My Child Matters programme has catalysed improvements in cancer care and has complemented the efforts of government, civil society, and the private sector to sustain and scale improvements in health care to a national level. Key elements of successful interventions include strong and sustained local leadership, community engagement, international engagement, and capacity building and support from government.

SIOP PODC: clinical guidelines for the management of children with Wilms tumour in a low income setting.

Wilms tumour is a relatively common and curable paediatric tumour. Known challenges to cure in low income countries are late presentation with advanced disease, malnutrition, failure to complete treatment and limited facilities. In this article, management recommendations are given for a low income setting where only the minimal requirements for treatment with curative intent are available (setting 1). These include general management, supportive care, social support and registration of patients. Recommendations specific for Wilms tumour care include diagnostic procedures with emphasis on the role of ultrasonography, preoperative chemotherapy with a reduced dosage for malnourished children and postoperative chemotherapy based on surgical staging.

Treatment of nephroblastoma in Africa: results of the first French African pediatric oncology group (GFAOP) study.

BACKGROUND: The multidisciplinary management of nephroblastoma has been defined through multicentric prospective studies and an average 90% of patients cured expected. In Africa, such studies are uncommon and results are fragmentary or unknown in most of the countries. We report the results of the GFAOPNEPHRO 01 study using SIOP 2001 protocol approach. PROCEDURE: From April 1, 2001 to March 31, 2004, 8 African Pilot Units were selected to participate in a nonrandomized prospective study. All patients referred with a clinical and radiological diagnosis of nephroblastoma were registered, those aged over 6 months and less than 18 years with a unilateral tumor not previously treated were included in this study and received preoperative chemotherapy. Patients with unfavorable histology or with a tumor other than Wilms tumor, and those with stage IV tumor and persistent disease after surgery were secondarily excluded. RESULTS: Of the 229 patients initially registered, 166 were included and finally 133 retained in the study, after surgery. Tumor rupture occurred in 7.5% of the patients. Thirty-five percent were stage I, 22% stage II, 23% stage III, and 18% stage IV. Two-year disease-free survival and 5-year survival are, respectively: 77.9% and 76.7% for localized tumors, 72.7% and 71.6% for all study patients. CONCLUSIONS: It is possible to conduct African multicentric therapeutic studies within the framework of GFAOP. Results in terms of event-free survival and survival are satisfactory. Improvements with respect to procedure, data collection, and outcome are expected in a new study.

Cyclophosphamide monotherapy in children with Burkitt lymphoma: a study from the French-African Pediatric Oncology Group (GFAOP).

BACKGROUND: The French African Group of Pediatric Oncology was set-up to improve quality of care for children with cancer. Preliminary observations on the efficacy in Burkitt lymphoma (BL) of a cyclophosphamide monotherapy (CPM) have been published. We report the results of a multicentric prospective study combining first-line CPM and a multidrug second-line chemotherapy (SC) for refractory/relapsed patients. PROCEDURE: Patients ≤ 18 years with Burkitt or Burkitt-like lymphoma, were included in six countries (Burkina-Faso, Cameroon, Ivory Coast, Madagascar, Mali, and Senegal). All patients received three weekly CPM courses (1.2 g/m(2) IV with intrathecal methotrexate and hydrocortisone), stage 3/4 patients received three further courses. SC added methotrexate, vincristine, cytarabine, and prednisone. RESULTS: There were 178 patients included (42 stage 1/2, 134 stage 3/4, and 2 unknown). Isolated facial localization was found in 41 patients, diffuse abdominal involvement in 120 patients including 65 with both. Nine early deaths were reported, toxicity occurred in 136/743 courses (83 patients) and was predominantly hematological. After CPM, complete remission (CR) rate was 47% with a 33% EFS. Because of rapid progression 76/108 eligible patients (85 primary refractory and 23 relapses) received SC resulting in 35.7% CR but a 21% toxic death rate. The OS of the whole strategy was 50.5% and correlated to stage. CONCLUSION: A prospective multicentric study on BL was feasible in very low-income countries. CPM can be recommended in stage 1-2 because of optimal cost/benefit ratio. However, more intensive strategies, still adapted to socio-economic conditions, are required for advanced stages 3 and 4.

A retrospective study of malaria in pediatric oncology patients in Senegal.

We retrospectively studied the outcome of malaria infection in pediatric oncology patients presenting to a single institution in Senegal, West Africa over a 10-year period (2000 to 2009). We investigated whether myelosuppression (secondary to chemotherapy) was associated with increased case fatality from malaria. Anonymized clinical and laboratory data were recorded. Severe anemia was defined as hemoglobin less than 6 g/dL, leucopenia as total white blood cell count less than 4×109/L, neutropenia as less than 1×109/L, and "lymphopenia" as non-neutrophil component less than 2.5×109/L. Primary outcome was death within 1 month of malaria diagnosis, from coma or multiple organ failure, in the absence of another infectious cause. Data analysis was carried out with SPSS (v16.0) using Fisher exact test (P<0.05, significant). Fifty-five malarial cases were confirmed in 54 patients (total 400 patients; overall incidence 14%). Four cases were excluded because of lack of outcome data. Of the remaining 51 episodes, at 1 month after malaria diagnosis, 46 recovered (90.2%) and 5 died (9.8%). There was no association with severe anemia, leucopenia, neutropenia, or lymphopenia (P=1.00, P=0.28, P=0.53, and P=0.22, respectively). Despite the high incidence of myelosuppression in pediatric oncology patients, we found no evidence that this was associated with increased fatality of malaria episodes.

Retinoblastoma in children: a case series from Senegal.

Retinoblastoma is the most common tumor of the eye in Senegalese children. Diagnosis occurs often at a late stage, when enucleation is unavoidable. In this report, we describe all recorded cases occurring in Senegal over a 10-year period (2005-14). For the 106 cases clinically and radiological identified, the mean age at diagnosis was 30 months (2 months / 10 years). Leucocoria (74.6%) and exophthalmos (42.3%) were common signs of the disease. For the 67 cases identified through patient-file examination, extra-ocular forms were present in 30% of cases at the time of diagnosis and retinal detachment in 19% of cases. Chemotherapy and surgery were the only available therapeutic methods. Overall survival at 5 years was 70%. Retinoblastoma is a serious illness that threatens the lives and sight of affected children. There are about 10 cases per year in Senegal. Management can be enhanced by improving existing technical platforms and training medical staff.

Advanced Burkitt Lymphoma in Sub-Saharan Africa Pediatric Units: Results of the Third Prospective Multicenter Study of the Groupe Franco-Africain d'Oncologie Pédiatrique.

PURPOSE: To evaluate the results of an intensive polychemotherapy regimen for Burkitt lymphoma (BL) in sub-Saharan African pediatric centers. PATIENTS AND METHODS: Children with advanced-stage BL (stages II bulky, III, and IV) treated with the GFAOP-Lymphomes Malins B (GFALMB) 2009 protocol in 7 centers between April 2009 and September 2015 were prospectively registered. Treatment regimen contained a prephase with cyclophosphamide followed by 2 induction courses (cyclophosphamide, vincristine, prednisone, high-dose methotrexate [HDMTX]), 2 consolidation courses (cytarabine, HDMTX), and a maintenance phase only for stage IV. HDMTX was given at the dose of 3 g/m2. RESULTS: Four hundred patients were analyzed: 7% had stage II bulky, 76% stage III, and 17% stage IV disease. Median age was 7.3 years, and sex ratio was 1.9:1 (male:female). A total of 221 patients received the whole protocol treatment and 195 achieved complete remission (CR), 11 of them after a second-line treatment. Treatment abandonment rate was 22%. One hundred twenty-five patients died, of whom 49 deaths were related to treatment toxicity. A total of 275 patients are alive, including 25 despite treatment abandonment, but only 110 are known to be in CR with a follow-up > 1 year, indicating a high rate of loss to follow-up. Twelve-month overall survival (OS) was 60% (95% CI, 54% to 66%) and 63%, 60%, and 31%, respectively, for stage II bulky, III, and IV. Patients with stage III disease who started second induction course within 34 days had OS of 76%, versus 57% (P = .0062) beyond 34 days. CONCLUSION: The GFA-LMB2009 protocol improved patients' survival. Early dose intensity of treatment is a strong prognostic factor. Improving supportive care and decreasing loss to follow-up are crucial.

Treatment of Wilms Tumor in Sub-Saharan Africa: Results of the Second French African Pediatric Oncology Group Study.

PURPOSE: Multidisciplinary management of Wilms tumor has been defined through multicenter prospective studies and an average expected patient cure rate of 90%. In sub-Saharan Africa, such studies are uncommon. After the encouraging results of the first Groupe Franco-Africain d'Oncologie Pédiatrique (GFAOP) study, we report the results of the GFAOP-NEPHRO-02 study using an adaptation of the International Society of Paediatric Oncology 2001 protocol. PATIENTS AND METHODS: From April 1, 2005, to March 31, 2011, seven African units participated in a nonrandomized prospective study. All patients who were referred with a clinical and radiologic diagnosis of renal tumor were screened. Those older than age 6 months and younger than 18 years with a unilateral tumor previously untreated were pre-included and received preoperative chemotherapy. Patients with unfavorable histology or with a tumor other than Wilms, or with a nonresponding stage IV tumor were excluded secondarily. RESULTS: Three hundred thirteen patients were initially screened. Two hundred fifty-seven patients were pre-included and 169 with histologic confirmation of intermediate-risk nephroblastoma were registered in the study and administered postoperative treatment. Thirty-one percent of patients were classified as stage I, 38% stage II, 24% stage III, and 7% stage IV. Radiotherapy was not available for any stage III patients. Three-year overall survival rate was 72% for all study patients and 73% for those with localized disease. CONCLUSION: It was possible to conduct sub-Saharan African multicenter therapeutic studies within the framework of GFAOP. Survival results were satisfactory. Improvements in procedure, data collection, and outcome are expected in a new study. Radiotherapy is needed to reduce the relapse rate in patients with stage III disease.

Continuous ambulatory peritoneal dialysis (CAPD) in children: a successful case for a bright future in a developing country.

The authors report the first case of successful peritoneal dialysis (PD) in a developing country performed about a 13-year-old adolescent followed-up for stage V chronic kidney disease (CKD) with anuria. After 3 months of hemodialysis, the parents opted for continuous ambulatory peritoneal dialysis (CAPD) as they wished to return home located 121km from Dakar. After PD catheter insertion, the plan proposed to the patient consisted 3-4 hours stasis of isotonic dialysate during the day and a night stasis of 8 hours of icodextrin for an injection volume of 1L per session. The patient and his mother were trained and assessed on the PD technique. After dialysis adequacy was tested while hospitalised, they were able to return home and continued the sessions following the same plan prescribed and while keeping in touch, by telephone, with the medical team. The technique assessment at the day hospital every 2 weeks revealed dialysis adequacy and satisfactory tolerance of PD at home after 04 months of observation. It was the first case of successful CAPD in the pediatrics unit in this context. Scaling this technique is a challenge for the pediatric nephrologist in developing countries like Senegal.

Treatment of B-cell lymphoma with LMB modified protocols in Africa--report of the French-African Pediatric Oncology Group (GFAOP).

BACKGROUND: The French African Paediatric Oncology Group (GFAOP) was set up in October 2000 to improve the quality of care of children with cancer in Africa. Eight pediatric oncology units from Algeria, Cameroon, Madagascar, Morocco, Tunisia, and Senegal have been involved. METHODS: Patients less than 18 years with cytology or histology proven B-cell non-Hodgkin lymphoma were included. Two LMB89 modified regimens were proposed (MAT and GFA). RESULTS: From April 2001 to April 2004, 343 cases were registered. Thirty seven patients were excluded. Thirteen patients were stage I, 26 stage II, 209 stage III and 50 stage IV including 8 L3 acute lymphoblastic leukemia (ALL3) cases. Three year OS of the whole population of patients is 61%. In GFA group 36 months OS is 63.6% in stages I/II, 51.6% in stage III and 35.8% in stage IV. In MAT group, the OS is 84.4% in stages I/II, 76.2% in stage III and 55.6% in stage IV. Seventy one patients died during treatment, 32 at pre-induction phase, 27 at induction and 12 at consolidation. Treatment related mortality decreased during the 3-year inclusion period (first year: 25.7%, second year: 19.1%, third year: 11.6%). The improvement of supportive care translated into an increase of the overall survival rates from 54% in the first year to 73% in the third year. CONCLUSION: These data demonstrate the feasibility of prospective multicentric studies in Africa. An improvement of quality of care has been noticed during the 3 first years.

[Idiopathic nephrotic syndrome (INS) in children in Dakar: about 40 cases]. / Le syndrome néphrotique idiopathique (SNI) de l'enfant à Dakar: à propos de 40 cas.

INTRODUCTION: This study aimed to analyze the diagnostic, therapeutic, and evolutionary features of nephrosis in children in a pediatric department in Dakar. METHODS: The study was carried out in the Department of Pediatrics at the Aristide Le Dantec Hospital. We conducted a retrospective study over a period of 3 years from 1 January 2012 to 31 December 2014. All patients aged 2-12 years with idiopathic nephrotic syndrome were included in the study. RESULTS: Forty cases of nephrosis were collected, that is to say a prevalence of 23% among patients with kidney disease treated in the Department of Pediatrics. The average age was 7.11 ± 3.14 years. 72.5% (n=29) of patients suffered from pure nephrotic syndrome. Lower limb edema was present in 100% of patients, oliguria in 55% (n=22) and high blood pressure (HBP) in 5% (n=2) of cases. Median proteinuria was 145,05 ± 85,54 mg/kg/24 hours. Median protidemia was 46,42 ±7.88 g/L and median albumin was 17.90 ± 7.15 g/L. Thirty nine patients were treated with prednisone-based corticosteroid therapy. Corticosensitivity was retained in 77% (n=30) patients and corticoresistance in 13% (n=5) of cases. The factor of poor response after corticosteroid therapy was initial proteinuria greater than 150 mg/kg/day (p = 0.024). Renal biopsy was performed in 18% (n=7) of patients which showed focal and segmental hyalinosis in 57.2% (n=4). Cyclophosphamide and azathioprine were associated with corticosteroids in 10% (n=4) of cases respectively. The overall remission rate was 89.8%. The evolution toward chronic renal failure was observed in three patients. CONCLUSION: Nephrosis accounted for almost one quarter of all cases of kidney disease treated in our Department. It has high overall remission rate. The only factor contributing to poor response after corticosteroid therapy was high levels of initial proteinuria. Focal and segmental hyalinosis was the most frequently found lesion diagnosed by renal biopsy.

[Review of the management of enuresis in a Senegalese hospital]. / Réflexions sur la prise en charge de l'énurésie dans un centre hospitalier au Sénégal.

The profile of enuretic patients consulting a hospital urology department was reviewed over a period of 15 months based on 102 cases. The study concerned 47 male subjects and 55female subjects with a mean age of 15 +/- 5.3 years. The mean weekly frequency of enuresis was 5.2 +/- 1.9 and enuresis occurred more than once a night for 41.6% of patients. Enuresis was primary in almost 67% of cases. Various aetiological factors for enuresis were identified from analysis of the clinical data and were generally associated: sleep factor (n=93), bladder factor (n=84), hormonalfactor (n=52). Patients were managed as a function of the factors identified. With a mean follow-up of 6 +/- 2.1 months, cure was obtained in 30.4% of cases and improvement was obtained in 24.5%. The various management problems are discussed as a function of socio-economic realities in Senegal and the authors emphasize the need for a multifactorial approach.