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Challenges for paediatric oncology in Africa

A recent short article has been publisehd in the Lancet Oncology (Volume 14, Issue 4, Pages 279 - 281, April 2013) entitled Challenges for paediatric oncology in Africa

The authors Mhamed Harif , Fousseyni Traoré, Laila Hessissen, Claude Moreira, Jean-Jacques Atteby are all members of the GFAOP and 2 are member of MGHI

Tremendous progress has been made in cancer care for children in high-income countries, which has led to overall survival of 75—80%.1 However, 75—80% of children now live in parts of the world (low-income and most middle-income countries) where they have much less chance of being cured because of inadequate resources for treatment and care, and poor organisation.2, 3 In Africa, large areas of the continent have no available care for children with cancer. This situation reflects the difficulties faced in the building of complex and expensive cancer care programmes. Mortality in children younger than 5 years in Africa is more than 15 times higher than in Europe or North America because of infection and malnutrition.4 Political instability also has negative effects on the sustainability of health-related development programmes in the continent. In this context, in April, 2000, physicians from France (led by Jean Lemerle) and Africa decided to work together in a joint effort to develop an infrastructure for paediatric cancer care in Africa. The resultant Groupe Franco—Africain d’Oncologie Pédiatrique (GFAOP; French—African Paediatric Oncology Group) planned to work together to adapt methods to diagnose and treat childhood cancer in Africa and to share their data in a prospective way. Six countries were initially involved: Algeria, Cameroon, Madagascar, Morocco, Senegal, and Tunisia.5 In north Africa, paediatric oncology services were already in place, but physicians in these services were asked to participate to share their experience and to put in place clinical research programmes. The first six countries were subsequently joined by Burkina Faso, Côte d’Ivoire, Mali, Mauritania, the Democratic Republic of the Congo, and Togo. Support was given to local teams to provide education, drugs, and medical supplies. Regular meetings, programme assessments, and educational programmes targeted nurses, laboratory technicians, pathologists, and paediatricians. Patients with B-cell lymphoma and those with Wilms’ tumour were the first to be enrolled. B-cell lymphoma is the most common childhood cancer in Africa and has been the subject of several GFAOP studies, which aimed either to reproduce the good results obtained in high-income countries or to test approaches designed for endemic Burkitt’s lymphoma. Diagnosis of Burkitt’s lymphoma is mainly based on cytology. The first series of patients were treated according to a regimen derived from the French LMB89 protocol.6 3-year overall survival from 306 enrolled patients was 61%. Notably, during these first few years, survival increased from 54% in the first year to 73% in the third year. Overall survival at 18 months was 75·2% in the north African countries, where treatment was more intensive, and 55·6% in the newly established units in the sub-Saharan countries. Besides diagnostic delay, many patients died in the initial phase of care because of metabolic disturbances and infections. Survival in the north African units was 56% before their host countries joined the GFAOP.7 The second GFAOP study into Burkitt’s lymphoma was designed for sub-Saharan countries (Burkina Faso, Cameroon, Côte d’Ivoire, Mali, Madagascar, and Senegal). The primary objective was to reproduce the results reported by Hesseling and colleagues8 from Malawi, but with a less intensive regimen. Treatment consisted of 3-weekly cyclophosphamide courses with intrathecal methotrexate. A more intensive, second-line, regimen based on the LMB89 regimen6 was introduced for patients with an insufficient response during or at the end of cyclophosphamide monotherapy, or after relapse. 2-year overall survival for 178 enrolled patients (108 of whom needed to be given the second-line treatment) was 50·5%.9 Survival in patients with stage I—II disease was 75·0%. This approach showed that early rescue is a good strategy, particularly for stage I and II disease. Wilms’ tumour is a difficult cancer to treat in developing countries because of the need for different competences, including imaging, surgery, and pathology, together with a multidisciplinary approach. The GFAOP proposed a regimen based on SIOP 2001,10 with preoperative chemotherapy for all patients and postoperative treatment adapted on the basis of the extent of disease. 2-year event-free survival was 46·7% in the 32 patients from the sub-Saharan region and 86·6% in the 101 patients from north Africa during the first period (an improvement from 77·4% in the period before the GFAOP project).11, 12 The effect of radiotherapy is probably the main reason for this difference in outcome between north and sub-Saharan Africa. The GFAOP programme has recently been extended to cover Hodgkin’s lymphoma, acute lymphoblastic leukaemia, and retinoblastoma. The proposed regimen for Hodgkin’s lymphoma uses chemotherapy (COPP/ABVD) alone, tailored according to disease stage. For standard-risk acute lymphoblastic leukaemia, the programme consists of three-drug induction, consolidation, intensification and maintenance, without high-dose methotrexate. A programme for non-metastatic retinoblastoma has been set up at the Bamako (Mali) unit and is being extended to other units. The GFAOP experience shows that even in difficult economic and social contexts it is possible, as paediatric oncology teams are established and gain experience, to improve survival outcomes for many patients. The best approaches are based on local leadership and appropriate education programmes. The group has also successfully created clinical research programmes at several centres. In north African units, clinical research has been shown to be a good approach to improve the quality of care. In some countries, local and national authorities are aware of these achievements and so are more involved in the group’s work. For example, in Bamako, a project to house the parents of paediatric patients with cancer is being implemented with the support of the national government and a local non-governmental organisation. However, treated patients make up only a small proportion of children with cancer in Africa. Many children with cancer never access care, and many abandon treatment because of inadequate social support. Mortality from the toxic effects of treatment also remains high, and improvements in supportive care are needed. The GFAOP now faces new challenges. These include the improvement of quality of care in already established units to reduce preventable morbidity and mortality, the setting up of satellite clinics to improve access to care and reduce rates of abandonment, and the opening of units in additional countries. To achieve these objectives, the group is setting up several programmes, including projects to improve data collection by use of local data managers and the introduction of adapted patient information systems. To help to work towards the improvement of health-care provider qualifications, the GFAOP is setting up an African School of Pediatric Oncology in Marrakesh, Morocco. This school is developing programmes not only for physicians and nurses, but also for pathologists, surgeons, and technicians. To make progress in such ambitious projects, local and international support is needed. All authors are board members of Groupe Franco—Africain d’Oncologie Pédiatrique; MH is president and LH is general secretary of the group. We declare that we have no conflicts of interest.

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