Tackling child cancer in Africa

By TIM EDEN

Outcomes for victims of child cancer remain poor in Africa, raising important questions about medicines access and funding

The death rates for children under five years old have almost halved since 1995 thanks to the global efforts inspired by theMillennium Development Goals. Most of the remaining 6.9 million annual mortalities occur in Africa, and most are caused by preventable or treatable communicable infections. Globally, only an estimated 0.14 per 1,000 of those deaths are caused by cancer. So why focus on this disease?

Scant resources mean survival rates for cancer patients in developing countries are poor. In high-income nations 80 percent of children with the disease can expect to be cured, but in developing African countries survival is at best 10 percent. In fact, more than three quarters of the children who die from cancer every year live in low-income countries. Most are not diagnosed or are diagnosed too late to save and very few receive relief of symptoms, especially of pain. Worryingly, as socio-economic conditions improve in developing African countries, the size of the cancer burden is growing, as it did in the developed world 50-60 years ago.

It is not impossible to change that. Endemic Burkitt lymphoma (the single most common tumour in sub-Saharan countries), which is associated with failure to clear the Epstein-Barr virus, chronic malarial infection and malnutrition, is curable for as little as $60.

Yet the challenges facing the sector in developing countries are considerable. Firstly, there is low public and professional awareness of the meaning of disease signs and symptoms leading to missed or late diagnosis. Hospitals often lack trained staff with the experience and resources to diagnose, treat or even relieve symptoms. In most African countries families are required to pay for some or all drug costs. The price of the essential drugs (all off-patent) required to treat most childhood cancers is relatively cheap but not if you live on less than $2 a day, so treatment refusal or abandonment rates are high (15-50 percent). Because infections are common, toxicity and death rates during cancer treatment are high. All children, irrespective of where they live, deserve better from the global community.

International twinning cancer partnerships can provide a way to effectively transfer the expertise, skills and knowledge acquired in developed countries over the last few decades. They can assist those in developing nations by improving the speed and accuracy of diagnosis, raising awareness, training and retaining staff, setting up reliable data registration (to document workload and outcomes), and optimising supportive, palliative and curative care. Locally affordable but effective treatment plans can be developed jointly by teams from developed and developing nation partners. Such twinning must involve local recognition, strong local leadership and the creation of a team to deliver care and support families. Local ownership and empowerment is crucial for long-term success. Affordability is another major issue. Subsidies for drug costs, family transport and accommodation costs during hospitalisation may be necessary especially where no national health insurance scheme is in place.

World Child Cancer (WCC) was created in 2007 to promote twinning, and raise the money to facilitate partnerships between established children’s cancer units and the developing peers who request assistance. WCC now has eight projects, open or in advanced stage of development, half of which are in sub-Saharan Africa. Each one includes the key elements of awareness, speedy diagnosis, staff training, subsidies for out-of-pocket family costs, development of parent groups and, where required, refurbishment of units to make them fit for purpose. Even relatively small amounts of money (£30 - £45,000 per year) can make a major difference. Yet strict clinical and financial governance is crucial to success, and reporting via an in-country sustainability plan is essential.

Long-term reliance on aid can de-motivate and demoralise, but self-reliance takes a variable time from country to country. The success of these partnerships requires sustained friendship, enthusiasm and commitment from both sides and, of course, initial philanthropy if we are to offer relief or cure to suffering children.

This is only part of the answer. The global medical and pharmaceutical community also needs to address the question of how we can ensure consistent production, importation and distribution of the drugs needed to cure children’s cancer. The drugs are all generic and off-patent and on the World Health Organisation’s essential list – but they still do not get to all who need them. It is a great tragedy that few children in Africa receive adequate pain relief because of a failure to import, prescribe and dispense the required powerful analgesics. We must do better to overcome these challenges and ensure that no child suffers unnecessarily.