ISH 2016

Oncology for children: what can be done when resources are scarce?

Prof Elizabeth Molyneux - Queen Elizabeth Central Hospital, Blantyre, Malawi

I was asked to talk about really what can be done for children, because I’m a paediatrician, children with cancer where they have very little resources. So really it’s a question of looking at what is feasible, what is safe and what is simple. Many of our children come from very far away, from rural areas. The mothers will have left a lot at home that they’re worried about so they don’t want to stay in hospital too long and yet, obviously, we want to cure the children. We’re fortunate in that probably our most common tumour is Burkitt’s lymphoma which is highly chemosensitive because we don’t actually have radiotherapy in the country. So we’ve tried to give our best shot to things that are common and things that are curable and don’t have too prolonged treatment courses. So, for instance, ALL which has been such a success story over in the West is a struggle for us to treat because treatments are very toxic and the treatments are also very prolonged.

So we started by trying to modify some of the protocols that have been used in the West and we thought we were modifying them down to something that was safe and quickly learned that it wasn’t. Our children are malnourished, our children often have comorbidities. What was being done in the ‘60s and the ‘70s and the ‘80s from which we can learn? Start, one step at a time, try something, see if it works and then add to that because everything you add is going to add toxicity. By adding one thing at a time, or certainly taking one step at a time, not necessarily one particular drug, we’ve built confidence both in ourselves and in what we can do but also in the patients who we look after. So, for instance, with Burkitt’s lymphoma we’ve now got a treatment protocol which the actual drugs cost about $70-80 for the whole treatment course and we’ve got 70% one year survival all stages. So we’re very excited because we started with something like 25% or 40% success. So really what we’re trying to do and trying to show is that there’s never nothing you can do, you can always care for children; whether they have a short life or a long life care is absolutely vital. Secondly, there’s an awful lot you can do with fairly simple treatments.

What are some of the treatments that you have been using?

We use the very old-fashioned drugs, drugs that are reasonable in cost and have been around for a long time, so cyclophosphamide, vincristine, prednisolone, doxorubicin, some methotrexate, we certainly use intrathecal methotrexate. We try and use oral drugs where we can because it’s much easier for everybody, it’s probably safer. For instance, a child who is on oral etoposide can go home whereas if you’ve got to give them intravenous treatment then they’ve got to stay in hospital.

How do you manage toxicities in such young and vulnerable patients?

Toxicities are important so we are careful with fluids. Actually we give extra nutrition to all the children, therapeutic nutrition. We use something called Plumpy’Nut which the children like, it’s based on peanuts. We have a very simple fever protocol, we treat very quickly any child who gets a fever. We look for malaria because malaria is common. So I think we try and jump on to something as quickly as possible and that goes, actually, a bit against the grain because in general paediatrics you tend to wait a little bit. Possibly we jump a bit too quickly but we’d rather do that than have to wait. Our real difficulty sometimes is trying to feed children because we can’t feed parenterally; parents really do not like nasogastric tubes so we have to try and encourage these children to drink or, indeed, to persuade a parent that the NG tube is the only way.

How do you think your practices can influence the western world?

I don’t think it hurts any of us to go back to basics and I suppose we’re in the privileged position, in a way, that we can use smaller doses and hopefully succeed. I think in some of the cases of treatments here in the West it’s very difficult to say well, I’m going to reduce treatments because you’re getting such success with the treatment that you’re actually getting whereas actually we can’t afford to give that very toxic treatment, nor can the children afford to receive it from a physical point of view, they will not tolerate it. So we are in a position to say, well, actually in certain instances less works.

Are there any trials to validate your points?

Yes, we’ve done a series of studies, particularly with Burkitt’s lymphoma, over the years. We started with something quite toxic and then re-evaluated what we were doing and slowly have increased the toxicity but not too much. As I say, we’re getting good success. Wilms’ tumour, we have a modified CEOP protocol and we have a Wilms’ collaboration which is wonderful, that’s between several countries, it’s led by Dr Tren Israel who is now based in the Netherlands. Because that’s a platform on which several centres who work perhaps in quite isolated environments in Africa can work together to produce protocols fairly quickly based on evidence. We’ve done things for Kaposi’s sarcoma and when you look in the literature nothing has been done. So we did a randomised trial and were pleased with some of the results we got but now we’re modifying that to try and improve outcomes for children with Kaposi’s.

What are your future plans?

Yes, there are tumours that we need to do much better with and I think, for instance, of retinoblastomas. What we’ve really got to do is advocate for early diagnosis, not only early diagnosis, good diagnosis. The sort of tests that can be done in the West that are taken for granted we can’t do. We’re relying on very simple morphology and therefore maybe making mistakes. So the whole early presentation which means the public being aware and also the healthcare people and following that we need to make a really good diagnosis and get our treatments in as soon as possible. But you can’t improve one thing without another. These children are poor and these children are often malnourished and they have other diseases. We need to raise everything together to really help them.

What is your take-home message?

In low income countries the priorities are trying to manage the children with the most common diseases and those are infectious. And also those don’t require per individual a big investment, financial investment. So it’s not surprising really that perhaps children with cancer have not received the attention that we would want them to but they need advocates. So I think there need to be people who advocate for them. Secondly, I think you shouldn’t look at your environment and say, ‘I can’t do anything’ because you are trying to compare yourself with Great Ormond Street or somewhere that has everything. Everybody can do something, however simple it is, and much of it will be successful.